Graduation Date

Spring 5-7-2022

Document Type

Honors Thesis

Degree Name

Doctor of Medicine

Department

College of Medicine

First Advisor

Jasmine R. Marcelin, MD and Sara H. Bares, MD

Second Advisor

Ishani Ganguli, MD, MPH

Third Advisor

Kathleen A. McManus, MD, MSc

Abstract

Over the last four years, I have developed a research focus examining the intersections of race, place, and health. My M.D. Honors Thesis reflects a snapshot of these efforts. In this collection of brief research reports, I leverage area-based measures to investigate structural inequities in three contexts: the HIV epidemic in our hyperlocal community, the early stages of the COVID-19 pandemic, and clinical trials for novel COVID-19 therapeutics. I apply novel social epidemiologic tools to measure and explore disparate outcomes. And, in reflecting upon my findings, I discuss concrete implications for clinicians, researchers, and policymakers alike.

Chapter 1: Neighborhood-Level Deprivation and Racial Inequities in HIV Viral Suppression
Human immunodeficiency virus (HIV) is a treatable chronic disease. Yet, geographic and racial inequities across the HIV care continuum are persistent, even in the U.S. Midwest. Using the Area Deprivation Index, a novel measure of neighborhood-level disadvantage, I showed that Black-White disparities in HIV viral suppression among our clinic population are explained by neighborhood deprivation. Our findings highlighted how structural racism, through longstanding place-based disinvestment, directly contributes to disparate HIV outcomes.

Chapter 2: County-Level Social Vulnerability and COVID-19 Cases & Deaths
While it is now widely recognized that the COVID-19 pandemic has had an outsized impact on marginalized and minoritized communities, the pandemic’s inequitable trajectory was not as obvious during the early stages. Leveraging publicly available data as of mid-April 2020 and the validated CDC/ATSDR Social Vulnerability Index, I showed how greater prevalence of population-level characteristics like racial/ethnic minority status, limited English proficiency, poverty, unemployment, crowded housing, and poor transportation access are directly associated with disease incidence and death. Our findings informed risk prioritization efforts across the country and offer an evidence-based framework for allocation of scarce resources.

Chapter 3: Census Tract-Level Inequities in Access to COVID-19 Therapeutic Trials
Geography is a key determinant of access to health care yet is often unexplored as a determinant of clinical trial enrollment. Using publicly available data from ClinicalTrials.gov, I geocoded the locations of 2,095 COVID-19 biomedical trial sites and calculated the driving distance from each U.S. Census tract center of population to the nearest site. I identified that nearly one-third of the overall US population, over one-half of the Native American population, and over three-fourths of the rural population lived more than an hour away from the nearest trial site. Of further concern, Black and Hispanic populations lived closer to trial sites than other populations, yet several studies highlighted the underrepresentation of these populations in major COVID-19 trials. Our findings demonstrated that geographic accessibility alone may not improve representative trial enrollment in the absence of additional structural interventions.

Comments

If interested in citing this work, please consider referencing one or more of the following peer-reviewed publications relevant to the content herein. The manuscripts published which directly represent the content of this honors thesis include references 1-4, whereas, the subsequent citations include related works which were cited but not directly discussed in this thesis.

1. Khazanchi R, Sayles H, Bares SH, Swindells S, Marcelin JR. Neighborhood Deprivation and Racial/Ethnic Disparities in HIV Viral Suppression: A Single-Center Cross-Sectional Study in the U.S. Midwest. Clin Infect Dis. 2020;72(10):e642-e645. doi:10.1093/cid/ciaa1254

2. Khazanchi R, Beiter ER, Gondi S, Beckman AL, Bilinski A, Ganguli I. County-Level Association of Social Vulnerability with COVID-19 Cases and Deaths in the USA. J Gen Intern Med. 2020;35(9):2784-2787. doi:10.1007/s11606-020-05882-3

3. Khazanchi R, Beiter ER, Ganguli I. Methodological Considerations for Modeling Social Vulnerability and COVID-19 Risk—Response to Nayak et al. J Gen Intern Med. 2021;36(4):1115-1116. doi:10.1007/s11606-021-06601-2

4. Khazanchi R, Powers SD, Rogawski McQuade ET, McManus KA. Inequities in the Geographic Accessibility of COVID-19 Biomedical Therapeutic Trials in the United States. J Gen Intern Med. 2021;36(11):3650-3653. doi:10.1007/s11606-021-07081-0

5. Chen J, Khazanchi R, Bearman G, Marcelin JR. Racial/Ethnic Inequities in Healthcare-associated Infections Under the Shadow of Structural Racism: Narrative Review and Call to Action. Curr Infect Dis Rep. 2021;23(10):17. doi:10.1007/s11908-021-00758-x

6. Khazanchi R, Evans CT, Marcelin JR. Racism, Not Race, Drives Inequity Across the COVID-19 Continuum. JAMA Network Open. 2020;3(9):e2019933. doi:10.1001/jamanetworkopen.2020.19933

7. Khazanchi R, Winkelman TNA, Pandita D, Jelinek R, Shearer RD, Bodurtha PJ. Patient Characteristics and Subsequent Health Care Use by Location of SARS-CoV-2 Testing Initiation in a Safety-Net Health System. JAMA Netw Open. 2021;4(6):e2112857. doi:10.1001/jamanetworkopen.2021.12857

8. Khazanchi R, Crittenden F, Heffron AS, Cleveland Manchanda EC, Sivashanker K, Maybank A. Beyond Declarative Advocacy: Moving Organized Medicine And Policy Makers From Position Statements To Anti-Racist Praxis. Health Affairs Forefront. Published February 25, 2021. Accessed February 26, 2021. https://www.healthaffairs.org/do/10.1377/hblog20210219.107221/full/

9. Tsai J, Cerdeña JP, Khazanchi R, et al. There is no “African American physiology”: The fallacy of racial essentialism. Journal of Internal Medicine. 2020;288(3):368-370. doi:10.1111/joim.13153

10. Khazanchi R. On Student Advocacy, Syndemics, & Structural Racism. The Advocate: Nebraska Medical Association’s Magazine. 2020;20(3):14-15, 22-23.

11. Thakore N, Khazanchi R, Orav EJ, Ganguli I. Association of social vulnerability, COVID-19 vaccine site density, and vaccination rates in the United States. Healthcare. 2021;9(4):100583. doi:10.1016/j.hjdsi.2021.100583

12. Khazanchi R, Marcelin J, Abdul-Mutakkabir J, Essien U. Race, Racism, Civil Rights Law, And The Equitable Allocation Of Scarce COVID-19 Treatments. Health Affairs Forefront. Published February 10, 2022. Accessed February 26, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20220208.453850

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