Evelyn Lewis and the War Against Health Disparity for Veterans, African Americans

, reviewing yet another study on a disease’s unique effects on African American patients. Rather than getting excited about the new data points it uncovered, Lewis was feeling numb. In her 25 years in healthcare, she’d reviewed so many of these studies, and each reiterated a health disparity that, as she puts it, “goes all the way back to W.E.B. Du Bois.”

But when the speaker explained that the study was proven successful based on results showing that fewer patients eventually sought care, Lewis had had enough.

“I raised my hand and asked, ‘How do you know you’re successful? How do you know what you’re doing is the reason they’re not coming back to your ER?’,” Lewis told MD Magazine®.

Lewis suggested a few more likely explanations: Maybe the patients never returned because they were treated poorly by providers. Maybe they didn’t have access to transportation. Maybe they never received a follow-up. Maybe the study was unsuccessful.

Once it was clear the communication line was broken between patient and physician, a study could not be a success, she said. Physicians carry not only the opportunity to connect with their patients and improve their care, but the responsibility to keep that connection open. Lewis has seen too many clinical efforts come and go in response to this gap to just sit back herself and watch as medicine continues on the same misguided path.

Healthcare has lost its personal touch, Lewis said, and the first ones to suffer are the populations of patients who need personalized care.

A Doctor for the Warriors

Evelyn Lewis, MD

“Segmenting a conversation about something specific to [a patient’s] community or family should be much less uncomfortable for a provider than dismissing this person’s level of injury, illness or pain because of what they look like,” Lewis said. “And we know we have that because of the presence of health disparity.”Cultural comprehension in health care is Lewis’ great fight—on 2 levels, really. She’s served in various capacities with the American Academy of Family Physicians, the National Medical Association, the American Medical Association, and the Commission to End Healthcare Disparities. But she’s also a 25-year retired veteran of the US Navy, a decorated service member who’s dedicated the latter half of her career to making sure her compatriots are treated well.

Lewis currently works as the chief medical officer of Warrior Centric Health (WCH), a for-profit corporation that addresses special healthcare needs in veterans and their families. The organization was founded about 10 years ago, after Lewis and eventual chief executive officer Ronald J. Steptoe read a RAND Corporation report called “Invisible Wounds of War,” which detailed the rate of post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) in veterans at the height of the Iran and Iraq wars.

About 19% of all returning service members reported experiencing possible TBI while deployed, and another 7% reported a combination of probable TBI and PTSD/depression. Despite those significant rates, just 53% with PTSD or depression reported having sought help in that past year — and another half of those treated considered their care minimally adequate.

“We actually read that from the beginning to the end, dissecting that document,” Lewis said. “And it literally spelled out what we’re seeing now, in terms of injuries, illnesses, and the kinds of things that are the results of our engagement in that conflict.”

Realistic Education

Again, Lewis was faced with reports and results, but no answers. She and Steptoe worked to bridge the void between veterans and healthcare in the civilian setting. One of their first steps was in setting some facts straight: This isn’t the job of the US Department of Veterans Affairs (VA), nor should it be.“The VA was never intended to take care of every veteran. They don’t have the resources for that,” Lewis said. “They’ve never been appropriately resourced to even take care of 5-7 million veterans that they do take care of. That’s where the big problem lies.”

More than three-quarters of US military veterans receive all their healthcare in the civilian sector, Lewis said. Less than one-quarter receives any care at all from the VA, and an even smaller portion receives all their care from the federal department. The misconception that the VA can do it all, Lewis noted, is widespread.

After awareness campaigns, Lewis and Steptoe formed focus groups consisting of both active duty and retired service members, veterans from wars ranging from conflicts in the Middle East to Vietnam. “We did a broad sweep so as to become a part of this issue and find what was missing, what we could do,” Lewis said.

These discussions shaped WCH’s modules of focus: military culture, cultural competency of the military setting, patient-provider communication, and the neurobiology of PTSD and TBI. If Lewis could better instruct both physicians and veterans on these gaps of knowledge, they would be closer to solutions.

Before moving to the commercial market, WCH sampled their strategies with active duty soldiers. They traveled to military sites and bases across the country—at one point finding themselves discussing the significance of neurological health at Fort Hood, shortly after a US Army major and civilian psychiatrist fatally shot 13 people and injured 30-plus people under debated motives at the Texas base.

Treating the Individual

If that wasn’t indicative of the necessity of Lewis’ work, the response from civilian healthcare organizations certainly was. To date, WCH has partnered with a few dozen organizations and institutions, set up across the academic, research & design, continuing medical education, and policy-making fronts of healthcare.The reality is that Lewis’s message and goal is transferrable across many populations in healthcare: she found a particular issue affecting a particular population, she found the problems in care which prevented the issue from being resolved originally, and she gave doctors the information and confidence they would need to hold their own in addressing the affected population.

“One of the ways in which we looked at talking about cultural competence is by demonstrating what it means within a subpopulation of people, being veterans,” Lewis said. “People assume they’re all the same. Even the branches are all different subpopulations of patients. The way you would address any of them on any disease is dependent on that distinction, and how they will respond to your questioning, and what they will tell you as a result of that.”

Lewis joked that a Marine could lose a limb and still insist it doesn’t hurt, while a member of the Army could complain about a bothersome fingernail. In its simplest comparison, this is cultural difference. The remedy to this is more questioning from healthcare providers: “You served in the military? What branch? What did you do?”

Since retiring from the Navy in 2003, Lewis has sought medical attention dozens of times. Not once did a provider ask her if she ever served.

“When we talk about culturally competent care, we know providers get uncomfortable about that,” Lewis said. “But we segment how we talk to men versus women, someone in grade school versus college. We segment all the time.”

Lewis points to the longer and longer list of clinical trials focused on African-American patients to demonstrate this fact. The rates of diabetes and cardiovascular disease in this community has been distinguished as a public health crisis for so long that it’s always been the norm in Lewis’ life.

Yet, the studies persist, like a cultural RAND report that’s stuck on repeat: “Diabetes is still rampant; cardiovascular disease is getting even worse in these communities.” Lewis is still waiting for people to realize it’s not just that population’s burden. “This is everybody’s problem,” Lewis said. “It is a role we all have a part in. Until we accept that, until we do it, I think we’re going to keep having the same conversations.”

It takes education on the facts surrounding the issue—that the VA isn’t taking care of everyone, just as no entity will suddenly treat all the black patients. Realistically, the best contribution an organization can make is in bridging the gap between a community and a doctor.

“These problems can be solved,” Lewis said. “We all have that power, and we all should have that commitment to do it. It won’t be the government that does it. It has to be done in our communities.”