Anne Gaglioti: “The way out of inequity is not the same way as the way in.”

Anne Gaglioti

The Center for Community Health Integration is delighted to welcome Anne Gaglioti, MD, MS, FAAFP to our faculty. Anne is an Associate Professor in MetroHealth Medical Center’s Department of Family Medicine, Population Health Research Institute, and Center for Health Care Research and Policy, and at the National Center for Primary Care at Morehouse School of Medicine, where she directs the Southeast Regional Clinicians Network and serves as Senior Strategic Advisor. As a self-described family physician researcher and concerned citizen, her work brings together family medicine, health equity, community engagement, and practice-based research. Anne grew up in Cleveland Heights, Ohio and recently moved back to the area.

Q: What was your path to medical school?

A: I wanted to be a physician from the time I was a young child. In my senior year of high school, I shadowed Frank Klamet. Dr Klamet was a priest at Holy Rosary Parish and had done a lot of work in El Salvador in the ‘70s with the Ursuline nuns and then did mission work, living in community there. He realized people needed medical care, so he went to medical school. He did his residency at Case Western, and I shadowed him. I met him when I was helping care for a neighbor who was ill. His approach was really interesting. He would do home visits on folks, and the line between social medicine and spiritual medicine and family medicine was really very blurred. That's when I decided that I wanted to do family medicine, after working with him.

Q: So your interests in health equity and community have long roots.

A: Yes, absolutely. Social justice and health have always been really important to me. As a kid, my mom was very active in the women's movement and the anti-war movement in the ‘60s, so I was raised on those principles.

Q: In your work there's primary care, health equity, community engagement - those are all near and dear to your heart. How do those pieces fit together in your mind? What's that intersection like?

A: I think that health care is a human right that many people are not afforded. To me, the most fundamental part of health care is being in a healing relationship with someone you trust. In this country, the way people get to have a primary care relationship looks very different based on the situation you’re born into and where you live and what your skin color is. And it’s tied to socioeconomic advantage.

I think primary care, health equity and community engagement really should be the same thing -- different branches of the same tree.

If you’re doing equity research or trying to create change at a population level, you have to scale those relationship skills that are the basis of the primary care relationship to the community level. I think family doctors and primary care doctors are good at that kind of research because they know how to build trusting relationships. It's just a natural extension of our skill set in some ways.

What I really struggle with is whether I’m helping people, because the research, or even implementation work, is really slow. You're doing things on a larger scale, but it's very difficult to see the impact of what you're doing, because often you don't know the impact and often it's just so far removed from what you're doing. When I help one person at a time, I always know that I can see the impact, and you get a little glimpse of that when you're doing community engaged work and when people tell you what it means to them.

Q: How do you describe your research interests?

A: I try to be practical and useful. Working in a health equity space, so much time has been spent documenting disparities that it's been hard to understand drivers of equity. We've done so much work studying gaps that we haven't really done the best job of understanding how to get out of the hole that we've dug ourselves. By definition, the way out of the hole, the way out of inequity, is not the same way as the way in, and so I think it requires something else. I struggle with that, especially in a reductionist model of research. I think that's the big question: where is equity, how do we recognize it and measure it? How do we understand the path in and the path out, and how does primary care support or threaten equity? There are probably spaces where primary care does both. Some of the work we've done with big data is about how we characterize the relationship between people and places and health, because that's often done in a very siloed reductionist way that's not always helpful. So another thing we try to do is really understand all the complex aspects of place, whether that's policies, or access to care, or the demographic composition of a place, and understand how that impacts health and how primary care fits into the health landscape of a place.

Q: It’s interesting how things shift when you think about equity as opposed to inequity.

A: Yeah, we've made some progress but it’s not great. We just published a paper looking at equity in maternal morbidity rates among Black and white women across a big sample of 29 different states, looking at Medicaid claims which account for about 40% of births in the United States. These are women who are poor and equally insured and have the same access to health care. We didn't find any place that was achieving equity. We were really hopeful that we'd be able to say, this place is it. But we were able to characterize the places and the Medicaid populations that were closer [to equity] than others. They also had more equitable outcomes across race groups with respect to wealth and educational attainment, so equity was more likely to be occurring in multiple domains or trends towards that. I think that really makes a difference. So it’s not just race disparities in health outcomes, but it's all these other factors that travel with it.

Q: How does your interest in community engagement relate to your research?

A: As director of a practice-based research network, I have a really engaged and vocal patient and stakeholder advisory board, about 20 people from across the southeast region. They are the ones who develop our research agenda for the network. I try to use my community engaged work to inform our other work as well, to use some of the broad ideas of what's important to community members to support all of the work that we do. The goal is to be able to have those things feeding into each other.

We did a really interesting project in Atlanta, which has a high rate of Black-white breast cancer mortality disparities. We've done some big data work on breast cancer mortality disparities and some place-based research, and we essentially brought the work to patients and primary care doctors in federally qualified health centers and said, Are you aware of these disparities? What do you think about them and why do you think they exist? What do you think are the pathways out of this? So we use population-level research as a community engagement tool to get people to discuss the causal pathways that they think are important and what might be a solution.

I think that's a good example where that works well. But community engagement can come in on both sides: what you should be working on should be meaningful to people. In our research network we have oversight on all steps of our research process. We won't send out a survey unless we get feedback from the community. We also ask them, “What do these results mean to you?” I think that's a great way to engage community and also get some different answers, because,

a bunch of academics have been looking at these kinds of numbers for a long time and haven’t made much headway. Sometimes you need the lived experience to understand what it means.

Q: What in your work is energizing for you? What gets your juices flowing?

A: I really do love seeing patients, always. I really do love team science, and thinking through hard problems, and trying to think of creative ways to move forward and move the needle. I really like the rare time when someone says, thank you for doing this work, we used it in this way. 

I really get excited when we learn something new, and sometimes I get excited when we get rejected for what we're doing. I think that's always a good sign. It's often a sign you're doing the right thing if it's hard.