Publications by authors named "Michelle Morse"

19 Publications

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Reparations for Black American descendants of persons enslaved in the U.S. and their potential impact on SARS-CoV-2 transmission.

Soc Sci Med 2021 05 9;276:113741. Epub 2021 Feb 9.

Department of Earth System Science, Stanford University, Stanford, CA, USA.

Background: In the United States, Black Americans are suffering from a significantly disproportionate incidence of COVID-19. Going beyond mere epidemiological tallying, the potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored.

Methods: We compared the COVID-19 time-varying R curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates β for 4 cells of the simplified next-generation matrix (from which R is calculated for structured models) for the outbreak in Louisiana. Lastly, we considered the potential structural effects monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention β and consequently R.

Results: Once their respective epidemics begin to propagate, Louisiana displays R values with an absolute difference of 1.3-2.5 compared to South Korea. It also takes Louisiana more than twice as long to bring R below 1. Reasoning through the consequences of increased equity via matrix transmission models, we demonstrate how the benefits of a successful reparations program (reflected in the ratio β/β) could reduce R by 31-68%.

Discussion: While there are compelling moral and historical arguments for racial-injustice interventions such as reparations, our study considers potential health benefits in the form of reduced SARS-CoV-2 transmission risk. A restitutive program targeted towards Black individuals would not only decrease COVID-19 risk for recipients of the wealth redistribution; the mitigating effects would also be distributed across racial groups, benefiting the population at large.
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http://dx.doi.org/10.1016/j.socscimed.2021.113741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871902PMC
May 2021

Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities.

Cureus 2021 Feb 16;13(2):e13381. Epub 2021 Feb 16.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.

Background Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood. Methodology This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record. Results Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient's outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069). Conclusions Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.
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http://dx.doi.org/10.7759/cureus.13381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891794PMC
February 2021

Revitalizing Graduate Medical Education in Global Settings: Lessons From Post-Earthquake Haiti.

Acad Med 2021 03;96(3):368-374

P.E. Farmer is internist, infectious disease specialist, and anthropologist, Kolokotrones University, professor of global health and social medicine, Harvard Medical School, chief, Division of Global Health Equity, Brigham and Women's Hospital, and founder and chief strategist, Partners In Health, Boston, Massachusetts.

Following the massive 7.0-magnitude earthquake that devastated much of the Haitian capital city of Port-au-Prince on January 12, 2010, the Haitian health system and its medical education programs were fragmented, fragile, and facing a significant, overwhelming demand for clinical care. In response, the authors of this paper and the institutions they represent supported the development of a teaching hospital that could fill the void in academic training capacity while prioritizing the health of Haiti's rural poor-goals aligned with the Haitian Ministry of Health (MOH) strategy. This bold initiative aimed to address both the immediate and long-term health care needs within post-disaster Haiti through a strategic investment in graduate medical education (GME). Here, the authors describe their approach, which included building consensus, aspiring to international standards, and investing in shared governance structures under Haitian leadership. The Haitian MOH strategy and priorities guided the development, implementation, and expansion of solutions to the ongoing crisis in human resources for health within the acute context. Local leadership of this initiative ensured a sustained and transformative model of GME that has carried Haiti beyond acute relief and toward a more reliable health system. The enduring success can be measured through sustained governance systems, graduates who have remained in Haiti, standardized curricula, a culture of continuous improvement, and the historic achievement of international accreditation. While ongoing challenges persist, Haiti has demonstrated that the strategy of investing in GME in response to acute disasters should be considered in other global settings to support the revitalization of tenuous health systems.
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http://dx.doi.org/10.1097/ACM.0000000000003857DOI Listing
March 2021

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes.

J Gen Intern Med 2021 02 15;36(2):464-471. Epub 2020 Oct 15.

Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record-based registries enable population-based examination of care across racial groups.

Objective: To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery.

Design: Cross-sectional study SETTING: Two large academic medical centers and affiliated community primary care and specialty practices.

Participants: A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American.

Measurements: Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement.

Results: Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m to eGFR ≤ 20 ml/min/1.73 m, meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m with the default CKD-EPI equation.

Limitations: Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability.

Conclusions: Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population.
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http://dx.doi.org/10.1007/s11606-020-06280-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878608PMC
February 2021

Racial Disparities in Rheumatology Through the Lens of Critical Race Theory.

Rheum Dis Clin North Am 2020 11;46(4):605-612

Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Office #6016P, Boston, MA 02115, USA.

According to critical race theory (CRT), racism is ubiquitous in society. In the field of medicine, systems of racism are subtly interwoven with patient care, medical education, and medical research. Public health critical race praxis (PHCRP) is a tool that allows researchers to apply CRT to research. This article discusses the application of CRT and PHCRP to 3 race-related misconceptions in rheumatology: (1) giant cell arteritis is rare in non-White populations; (2) Black patients are less likely to undergo knee replacement because of patient preference; and (3) HLA-B*5801 screening should only be performed for patients of Asian descent.
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http://dx.doi.org/10.1016/j.rdc.2020.07.001DOI Listing
November 2020

Creating Real Change at Academic Medical Centers - How Social Movements Can Be Timely Catalysts.

N Engl J Med 2020 Jul 10;383(3):199-201. Epub 2020 Jun 10.

From the Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School - both in Boston.

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http://dx.doi.org/10.1056/NEJMp2002502DOI Listing
July 2020

Misdiagnosis, Mistreatment, and Harm - When Medical Care Ignores Social Forces.

N Engl J Med 2020 Mar;382(12):1083-1086

From the University of California Berkeley, Berkeley, and the University of California San Francisco, San Francisco (S.M.H.); New York University, New York (H.H.); the University of California Irvine, Irvine (A.J.); the University of Michigan, Ann Arbor (S.D.S.); Brigham and Women's Hospital and Harvard Medical School - both in Boston (M.M., P.E.F.); Johns Hopkins University, Baltimore (J.A.G.); Princeton University, Princeton, NJ (K.A.W.); and University College London, London (M.G.M.).

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http://dx.doi.org/10.1056/NEJMp1916269DOI Listing
March 2020

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

Circ Heart Fail 2019 11 29;12(11):e006214. Epub 2019 Oct 29.

Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183732PMC
November 2019

Democratizing Evidence Production - A 51-Year-Old Man with Sudden Onset of Dense Hemiparesis.

N Engl J Med 2019 Oct;381(16):1501-1505

From Jan Swasthya Sahyog (the People's Health Support Group), Ganiyari, Chhattisgarh, India (S.C., T.L., Y.J.); the HEAL Initiative, University of California, San Francisco, San Francisco, and Columbia University Medical Center, New York (T.L.); Brigham and Women's Hospital, Boston, and EqualHealth, Brookline (M.M.) - both in Massachusetts; the University of California, Irvine (A.J.); and the University of Michigan, Ann Arbor (S.S.).

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http://dx.doi.org/10.1056/NEJMp1907988DOI Listing
October 2019

Development of a neurology training program in Haiti.

Neurology 2019 02;92(8):391-394

From Partners in Health/Zanmi Lasante (K.I., L.M., M.E.M., A.L.B.), Hôpital Universitaire de Mirebalais, Haiti; Dartmouth College (S.M.S.), Hanover, NH; Faculté de Médecine et de Pharmacie de l'Universite d'Etat d'Haiti (S.P.), Port-au-Prince, Haiti; and Division of Global Health Equity, Department of Medicine (M.E.M.), and Department of Neurology (A.L.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1212/WNL.0000000000006960DOI Listing
February 2019

Health equity in Israel.

Lancet 2018 02;391(10120):534

Brigham and Women's Hospital, Boston, MA 02116, USA.

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http://dx.doi.org/10.1016/S0140-6736(17)32171-2DOI Listing
February 2018

Where We Fall Down: Tensions in Teaching Social Medicine and Global Health.

Ann Glob Health 2017 Mar - Apr;83(2):347-355. Epub 2017 May 16.

SocMed, Minneapolis, MN; EqualHealth, Boston, MA; Department of Medicine, Global Health Pathway, University of Minnesota, Minneapolis, MN; Center for International Health, St. Paul, MN.

Background: As global health interest has risen, so too has the relevance of education on the social determinants of health and health equity. Social medicine offers a particularly salient framework for educating on the social determinants of health, health disparities, and health equity. SocMed and EqualHealth, 2 unique but related organizations, offer annual global health courses in Uganda, Haiti, and the United States, which train students to understand and respond to the social determinants of health through praxis, self-reflection and self-awareness, and building collaborative partnerships across difference.

Objectives: The aim of this paper is to describe an innovative pedagogical approach to teaching social medicine and global health. We draw on the notion of praxis, which illuminates the value of iterative reflection and action, to critically examine our points of weakness as educators in order to derive lessons with broad applicability for those engaged in global health work.

Methods: The data for this paper were collected through an autoethnography of teaching 10 global health social medicine courses in Uganda and Haiti since 2010. It draws on revealing descriptions from participant observation, student feedback collected in anonymous course evaluations, and ongoing relationships with alumni.

Findings: Critical analysis reveals 3 significant and complicated tensions raised by our courses. The first point of weakness pertains to issues of course ownership by North American outsiders. The second tension emerges from explicit acknowledgment of social and economic inequities among our students and faculty. Finally, there are ongoing challenges of sustaining positive momentum toward social change after transformative course experiences.

Conclusions: Although successful in generating transformative learning experiences, these courses expose significant fracture points worth interrogating as educators, activists, and global health practitioners. Ultimately, we have identified a need for building equitable partnerships and intentional community, embracing discomfort, and moving beyond reflection to praxis in global health education.
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http://dx.doi.org/10.1016/j.aogh.2017.03.515DOI Listing
May 2018

Health Information and Global Health Inequity: Point-of-Care Knowledge Systems as a Foundation for Progress.

J Gen Intern Med 2017 May 31;32(5):572-575. Epub 2016 Oct 31.

Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.

Point-of-care clinical knowledge systems play an increasingly important role in providing information for health care providers in high-resource settings, and there is evidence of strong interest among providers within low-resource settings. Unfortunately, systems developed for high-resource settings have a range of elements that make them suboptimal for low-resource settings. We discuss what a point-of-care clinical knowledge system designed for low-resource settings would ideally contain, and argue that such a system is worthy of further study and funding, towards the overarching goal of reducing global health inequity.
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http://dx.doi.org/10.1007/s11606-016-3909-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400756PMC
May 2017

Medical Education and Global Health Equity.

AMA J Ethics 2016 Jul 1;18(7):702-9. Epub 2016 Jul 1.

Deputy chief medical officer at Partners In Health, an assistant program director for the internal medicine residency program at Brigham and Women's Hospital, and instructor in medicine at Harvard Medical School in Boston, and a visiting professor at the University of Global Health Equity.

Recent efforts to expand medical training in resource-constrained settings are laudable, but change that transforms health systems will require new educational approaches. Today's physician-leaders need to leverage clinical and global health knowledge with a nuanced understanding of the social forces that impact health, the ability to marshal political will, and the capacity to manage dynamic programs and institutions. In establishing the University of Global Health Equity, we have identified three reform principles. First, equipping medical schools with the tools and technology to deliver is imperative. Second, the mismatch between the skills taught in most medical schools and those needed to improve fragile health systems must be addressed. Finally, medical schools that strive to eliminate health inequities should "walk the walk," adopting progressive practices to institutionalize equity.
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http://dx.doi.org/10.1001/journalofethics.2016.18.7.medu1-1607DOI Listing
July 2016

Development of a neurology rotation for internal medicine residents in Haiti.

J Neurol Sci 2016 Jan 3;360:158-60. Epub 2015 Dec 3.

Hôpital Universitaire de Mirebalais, Partners in Health/Zanmi Lasante, Mirebalais, Haiti.

In many low-income countries where there are few or no neurologists, patients with neurologic diseases are cared for by primary care physicians who receive no formal training in neurology. Here, we report our experience creating a neurology rotation for internal medicine residents in rural Haiti through a collaboration between a public academic medical center in Haiti and a visiting neurologist. We describe the structure of the rotation and the factors that led to its development.
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http://dx.doi.org/10.1016/j.jns.2015.12.003DOI Listing
January 2016

A needs and resource assessment of continuing medical education in Haiti.

Ann Glob Health 2015 Mar-Apr;81(2):248-54

EqualHealth, Brookline, MA; University of Miami Miller School of Medicine, Miami, FL.

Background: Haiti has a chronic physician shortage, and the country has been facing an increased disease burden since the 2010 earthquake and the subsequent introduction of cholera. In such resource-challenged settings, access to postgraduate medical education often is limited due to inadequate financial, structural, and academic resources. A crucial component to improved health in Haiti is the expansion of continuing medical education (CME). To our knowledge there have been no previous studies investigating the continuing professional development needs of Haitian physicians working in this context.

Objective: The objectives of this study are to describe the educational resources available to Haitian physicians and to understand their continuing professional development needs.

Methods: We performed a needs and resource assessment of CME available to Haitian physicians using surveys and focus groups. We surveyed 62 physicians and led 3 focus groups. Questions gathered data on physicians' access to educational resources. Descriptive statistics were calculated from surveys, and focus group transcripts were manually reviewed for themes.

Findings: In all, 82 conference attendees were invited to participate. Of these, 62 physicians completed the needs and resource assessment survey. Of the participants, 16% had a medical library at work and 31% had access to a computer at work. Educational conferences were available at work for 27% of participants, and 50% attended conferences outside of work. Less than half (45%) identified a clinical mentor. Focus group participants described inadequate tangible and reference resources, lack of colleague support, and lack of avenues for specialty training and employment.

Conclusions: In this needs assessment, Haitian physicians identified lack of support for clinical decision making, poor access to CME activities, limited professional development, and absence of employment opportunities as key areas of need in support of their clinical and professional work.
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http://dx.doi.org/10.1016/j.aogh.2015.03.003DOI Listing
December 2016