Health disparities in the news

Mom’s immune system and microbiome may help predict premature birth

Roughly 10 percent of children worldwide — an estimated 15 million babies — are born prematurely, or before 37 weeks gestation, each year. In developed countries, surviving an early birth has become more likely, thanks to the availability of intensive medical care. More than 98 percent of U.S. preemies survive infancy, according to a study published in the American Journal of Obstetrics and Gynecology in 2016, though as many as 44 percent of the youngest preemies don’t make it. Survival is least likely in nations with the fewest resources. Worldwide, complications associated with preterm birth are the leading cause of death in children younger than 5 years old. Some of the signs of inflammation linked to preterm birth differ from those found during full-term birth, says Nardhy Gomez-Lopez, a reproductive immunologist at Wayne State University. For example, in 2017, she and colleagues reported in the American Journal of Reproductive Immunology that some proteins involved in inflammation, called cytokines, were present at higher than normal levels in amniotic fluid from a subset of women who delivered preterm. The earlier the women delivered their babies, the higher the cytokine levels. Infections, which are present in at least a quarter of preterm births, could be the cause, but inflammation and cytokine levels were also elevated when no infection was found. Part of the problem with developing a predictive test is that preterm labor isn’t just one condition. Thirty years ago, preterm labor was viewed simply as regular labor that happened early, says perinatologist Roberto Romero at Wayne State, who directs the perinatology research branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Although scientists now recognize that the biology of preterm labor is distinct, they still have to grapple with the reality that it varies depending on the underlying cause. Wayne State and NICHD recently released gene activity data from the whole blood of 150 Detroit women, 71 of whom delivered preterm, and encouraged researchers to use the data to find predictors of preterm labor, as part of a crowdsourcing collaboration called the DREAM challenge. The challenge is expected to be completed in January 2020. “We are at the beginning of an exciting period,” says Romero at Wayne State. The field is now equipped to start studying preterm birth as a collection of several different syndromes and seek out treatments to address each one, he says.

Why are uterine cancer rates rising so drastically in black women?

According to a December 2018 report from the CDC, the number of new uterine cancer diagnoses increased an average of 0.7 percent per year between 1999 and 2015, resulting in an overall 12 percent rise. Rates of endometrial cancer, specifically, jumped 4.5 percent per year on average. The uterine cancer mortality rate increased 1.1 percent per year on average between 1999 and 2016, amounting to a 21 percent leap overall. What’s more, the burden of uterine cancer is greatest for black women, and the disparity is increasing with time. While that same CDC report found that non-Hispanic white and black women had similar incidences of uterine cancer (about 27 cases out of 100,000 people), black women were more likely to be diagnosed with uterine sarcoma, the most aggressive form of uterine cancer, than women of other races, and also more likely to be diagnosed at a later stage than women of other races. Teasing apart the potential reasons behind this disparity is a complex task. The puzzle pieces start to come together when you look at some of the major risk factors for developing uterine cancer. Let’s start with endometrial cancer risk factors. “We do know that obesity is one risk factor,” Michele L. Cote, Ph.D., a professor of Oncology at Wayne State University and associate center director of Cancer Research Career Enhancement, tells SELF. This is because it’s a health condition that can increase the amount of estrogen in your body. Another endometrial cancer risk factor revolves around children. “The more children you have, the lower your risk,” Cote says. Pregnancy increases your output of progesterone, so you might benefit from its protective effects against this cancer. But people are generally having fewer kids these days, Cote explains, including black women. “Unfortunately, we don’t have a lot of research data yet on why black women are more likely to have a more aggressive form of uterine cancer,” Cote says.
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Medical students take to the streets to give free care to Detroit's homeless

Armed with care packages, clothes and clinical supplies, medical students in Detroit are learning outside the classroom. They are putting their knowledge and boots to the pavement, providing free health care to the city's homeless. Each week, students under the supervision of a registered physician or nurse practitioner get on their bikes and look for those in need. Programs such as Michigan State University's Detroit Street Care, Wayne State University's Street Medicine Detroit and the University of Michigan's Wolverine Street Medicine work together to treat as many of the city's homeless as possible. Jedidiah Bell, a fourth-year med student at Wayne State University and president of Street Medicine Detroit, says seeing issues from lack of health care access in his home country of Zimbabwe made him want to participate. "When I moved to the states for university and medical school, I saw the similar things [lack of access] with the homeless population," said Bell. "When I saw street medicine, I appreciated the model of how can we take medical care to the street and build up trust to bridge the gap between the homeless and the medical world." While the programs provide a vital service to the community, Bell says the real-world experience teaches students things the classroom or clinic can't. "It teaches medical students to hone-in on, not just medical conditions of patients, but to be able to sit down and form relationships and discuss other things that might be contributing to [patients'] health but might not come up during a traditional medical encounter." Bell says there's a widespread belief that the "students take away more from people on the streets than they take away from us." Anneliese Petersen, a second-year medical student at Wayne State University and volunteer with Street Medicine Detroit, says the experience also shows upcoming medical professionals another side of health -- the social determinants. "Things that are not strictly medical-based but have a strong impact on health and well-being. Income, access to health care, access to medication, being able to eat well, sleep well, to be able to relax and not be under chronic stress."
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AG's office: Make Your Date didn't pay staff to raise funds

The state Attorney General's Office has found that a nonprofit for a program linked to Mayor Mike Duggan did not compensate staff or contractors to raise money nor did it take in enough funds to require state registration. Attorney General Dana Nessel's Charitable Trust division delved into the fundraising practices of the nonprofit Make Your Date, Inc. The single-page finding issued Tuesday by the Attorney General's Office notes that "it appears this organization does not compensate staff or independent contractors for services related to fundraising." "Additionally, this organization does not solicit or receive contributions in excess of $25,000 in a 12-month period," the letter notes, adding that based on the finding and state laws for charities, registration under the Charitable Organizations and Solicitations Act was not required. Wayne State University noted in a Thursday statement that the attorney general office's analysis included interviews and inspection of documents and "confirmed that its registration exemption status was proper. The attorney general confirmed that the separate nonprofit had not spent or received in excess of $25,000 in a 12-month period," the university's statement reads. "In fact, it spent or received no money." Wayne State on Thursday said that the report reaffirms that the university is the only entity operating the program. "Wayne State is proud of Make Your Date, which a recent study has shown has reduced preterm birth among the program’s clients by up to 37%," the university wrote. "Wayne State University will continue to execute and expand the Make Your Date Program to further reduce preterm birth and improve pregnancy outcomes for women and children in the City of Detroit and beyond."
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Wayne State University pediatrician and professor helps develop policy recognizing racism as a health factor

A Wayne State University pediatrician played a critical role in developing a national policy statement that recognizes for the first time the impact racism has on the health of American children and teens. Lynn Smitherman, M.D., FAAP, assistant professor of WSU Pediatrics, is a member of the American Academy of Pediatrics’ Task Force Addressing Bias and Discrimination. The task force’s work contributed to the policy statement, “The Impact of Racism on Child and Adolescent Health,” issued by the AAP on July 30. The statement is a call for action by the nation’s pediatricians to reduce the impact of racism and improve the health of American children. The AAP believes that racism has a significant impact on children’s health. The academy says that pediatricians must play a part in improving the health condition of children through listening to families, creating “culturally safe medical homes” and by becoming advocates for social justice in their communities. “Eliminating discrimination, racism and bias in the care of our most valuable resource, our children, is a basic tenet to any civil society. Participating in the AAP’s Task Force on Addressing Bias and Discrimination in the care of children was one of the many highlights of my professional career,” said Smitherman, who also chairs the National Medical Association’s Pediatric Section and is the vice chair of Medical Education for the WSU Department of Pediatrics. “Any activity to bring people together and heal the divides of this country are critically important to the well-being and health of the society in general. I was very proud that the AAP took this important position and that I, as a WSU faculty member, was able to contribute.”
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Wayne State/Henry Ford Health System Lead $4 Million Detroit-Based NIH HEAL Initiative

The National Institutes of Health launched the “Helping to End Addiction Long-term Initiative” in April 2018 to improve prevention and treatment strategies for opioid misuse and addiction and to enhance pain management. This initiative aims to improve treatments for chronic pain, curb the rates of opioid use disorder and overdose, and achieve long-term recovery from opioid addiction. A team of researchers led by Wayne State University this week received one of 375 grant awards across 41 states made by the National Institutes of Health in fiscal year 2019 to apply scientific solutions to reverse the national opioid crisis. This $4 million award, “Dual-orexin antagonism as a mechanism for improving sleep and drug abstinence in opioid use disorder,” will bring together a research team from Wayne State University and Henry Ford Health System to investigate a rigorous treatment method that may offer a new therapeutic approach to reduce opioid addiction relapse. According to Mark Greenwald, Ph.D., principal investigator on Wayne State’s grant and professor and associate chair of research and director of the Substance Abuse Research Division in the Wayne State School of Medicine’s Department of Psychiatry and Behavioral Neurosciences, insomnia is common in opioid addictions and is a major predictor of potential relapse. Current medications to treat insomnia have limited results on relapse and may produce unwanted side effects. “There are FDA-approved medications for treatment of insomnia, but there is an unmet need for alternatives, especially to aid in preventing opioid addiction relapses,” said Greenwald. “The Orexin (OX) system plays a key role in sleep and substance use, and offers promise as a potential alternative to other medications currently used to treat insomnia.
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$3.1 million NIH grant to improve quality of life for African American cancer survivors

African Americans have the lowest survival rate of any racial or ethnic group in the United States for most cancers – a problem that is magnified in southeast Michigan. These differences are often due to socioeconomic disparities that result in unequal access to medical care, health insurance, healthy food and more. African Americans who survive cancer also have the shortest survival of any racial/ethnic group in the United States for most cancers, according to the American Cancer Society. A team of researchers from Wayne State University and the Barbara Ann Karmanos Cancer Institute are investigating the combined role that community, interpersonal and individual influences have on the health-related quality of life for African American cancer survivors, and how those influences create racial health disparities between African Americans and white survivors. The team includes Felicity W.K. Harper, Ph.D., associate professor of oncology in the Wayne State School of Medicine and the Karmanos Cancer Institute; Malcolm P. Cutchin, Ph.D., professor in the Institute of Gerontology and the Department of Health Care Sciences in Wayne State’s Eugene Applebaum College of Pharmacy and Health Sciences; and Hayley Thompson, Ph.D., professor of oncology in the School of Medicine and associate center director for community outreach and engagement at Karmanos. The study, “ARISE: African American Resilience in Surviving Cancer,” is a five-year, $3.1 million project funded by the National Cancer Institute of the National Institutes of Health that aims to identify targets of change and inform the development of interventions to address causes of poorer health-related quality of life experienced by African American cancer survivors.
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Make Your Date Detroit delivers results

Detroit has one of the worst (highest) preterm birth and infant mortality rates in the country, equal to that of some third world countries. With a preterm birth rate of 14.5 percent, Detroit earned an “F” among major U.S. cities for premature births according to the 2018 Premature Birth Report Card from the March of Dimes, the nation’s leading maternal and infant health nonprofit organization. Research has shown that disparities such as racial inequity, poverty, stress, food insecurity, lack of education, and limited access to transportation or health care can contribute to poor health outcomes for mothers and babies. In efforts to quell this epidemic, the city of Detroit has welcomed several initiatives geared towards reducing the city’s infant mortality rate. One such initiative is the Make Your Date Detroit program. Make Your Date Detroit is a Wayne State University organization that is fighting to turn the tide against premature births in Detroit. “African American infants are at a 50 percent greater risk of preterm birth compared to white infants. As a result, African American infants are now more than twice as likely to die as white infants,” says Marisa Rodriquez, director of strategic operations of the Office of Women’s Health at Wayne State University. “African American women are three to four times more likely to die in pregnancy than white mothers. Hispanic mothers and infants are also at greater risk when compared to white women. There are tests and treatments that exist to reduce preterm birth, but many pregnant women do not have access to them. Our program works to make these lifesaving approaches available. What our program and others provide is important in the fight to reduce the very substantial racial and ethnic health disparities that are seen in pregnancy.” Rodriquez says that the Make Your Date program has already begun saving infant lives in a short period. “Make Your Date has been so successful that participating mothers are 37 percent less likely to deliver at under 32 weeks and 28 percent are less likely to deliver at under 34 weeks,” she said. “In a city with such high rates of preterm birth and infant mortality, these results are remarkable. We are very proud that women are delivering healthy babies as a result of this program.”  
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Wayne State looks to ‘reboot’ urban pediatrics program

Wayne State University has created a new practice plan called Wayne Pediatrics, according to Dr. Herman Gray, chair of the new Wayne Pediatrics department. Gray says the department is taking advantage of this opportunity to reimagine how care is delivered to children and their families in an urban setting. As part of that effort, Wayne Pediatrics has created the Urban Children’s Health Collaborative, an initiative to connect urban kids with better health care. Gray also talked about the wider health care disparities that exist, both in Detroit and around the country. “Certainly, poverty and racism are pretty much universally acknowledged as the foundational components of societal disparities,” says Gray. “We believe that being minimized, being disrespected, being uncertain of your place in society induces toxic stress.”
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Michigan doctors reach out to LGBTQ community to narrow health disparities

Roughly 1 in 6 LBGTQ people nationwide report being discriminated against when visiting a doctor or health clinic, while 1 in 5 say they’ve avoided health care because of discrimination fears, according to a 2017 survey of  lesbian, gay, bisexual, transgender, and queer adults. That, in turn, deepens health disparities over a lifetime as patients skip screenings and get less help for chronic conditions and poor health habits, according to an overview of health research by the U.S. Office of Disease Prevention and Health Promotion. From public health clinics to large hospital systems, Michigan’s health care industry is reaching out to close such disparities, from updating forms to accommodate genders beyond “male and female” to adding LGBTQ-specific services. Among the most tangible efforts is the Corktown Health Center in Detroit, which opened in 2017 as Michigan’s first nonprofit health center with a focus on LGBTQ patients. It’s also one of only a few dozen such centers nationwide. As vice chair of education at Wayne State University’s Department of Internal Medicine, which helped establish Corktown Health Center,  Dr. Diane Levine is helping Wayne State’s medical school incorporate coursework, clinical teaching, and even residency slots at Corktown so that medical students today are more aware of the needs of LGBTQ patients tomorrow. The curriculum will mean that new medical students will go from “about two hours” of focus on LGBTQ health in the classroom, to about two dozen hours, she said. Among her presentations, she said, is the genderbread person, to prompt discussion on the interplay of the mind, heart, and reproductive organs. Understanding these basics, she said, is a first step in understanding a patient, she said. “And that,” she said, “is really Doctoring 101.”
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Wayne State develops novel geocoded map to improve health outcomes

If you live in southeast Michigan, your ZIP code may determine how long you live. Live in the 48236 ZIP of Grosse Pointe and at birth you can expect to live to an average of 82 years. Just a few short miles away, however, if you’re born and live in the Detroit ZIP of 48201, you can shave 13 years off that respectable mark. The 13-year loss can be attributed to numerous factors, including a lack of access to healthy food, health care and safe places to exercise. Resource limitations and socioeconomic disparities in the 48201 ZIP code also contribute to soaring levels of toxic stress and poor health. That stress often manifests in the form of disproportionate levels of high blood pressure, which, if uncontrolled, brings on a host of illness guaranteed to shorten lifespan. That’s the bad news.
The good news, as attendees of the Detroit Regional Chamber’s annual Mackinac Policy Conference heard Thursday morning, is that a radically new form of mapping health data by census tract may give policymakers, researchers and health care providers the information they need to design targeted efforts to improve health in areas with a long history of worse outcomes. The goal, said Phillip Levy, assistant vice president of Translational Science and Clinical Research Innovation for Wayne State University, is to develop a precision approach to population health, guided by data provided by drilling down as far as possible, perhaps even to individual neighborhoods.
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Addressing mental health key to improving criminal justice system

Diverting individuals with mental health disorders into treatment programs rather than simply jailing them not only significantly reduces the jail population but also lowers the chances of recidivism among offenders, according to a five-year study conducted by the Center for Behavioral Health and Justice at Wayne State University’s School of Social Work and released by the state of Michigan. According to the study, 54 percent of all individuals booked into jails in the target counties reported some variation of a substance abuse problem, while 45 percent described themselves as housing insecure and 42 percent said they had been recently incarcerated. Meanwhile, 34 percent had some indication of mental illness. “More than just a collection of data, this report offers us an early roadmap to drastic improvements in how our criminal justice system handles issues of mental illness and substance abuse,” said Sheryl Kubiak, dean of the Wayne State School of Social Work and the principal investigator for the study. “In addressing these issues, we also give ourselves opportunity to address many of the problems that these issues underlie, including jail overcrowding, poor access to mental health, and drug treatment and recidivism.” Drug abuse presented an equally thorny problem for many jails, said Kubiak. “Most jails have little therapy or protocols for inmates suffering withdrawals,” she said. “Some just hand out blankets and Gatorade and think that’s enough.” Kubiak concludes: “As the study proves, when we simply lock up mentally ill or addicted individuals with no real plan to get them help, we’re only prolonging and exacerbating problems that we have the tools to effectively address.”  
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High blood pressure is rampant in Michigan. Better data may lead to a cure

“You can throw all the medicines you want at the [hypertension] problem, but if you can’t fix the upstream social determinants, you’ll never solve it,” said Dr. Phillip Levy, an emergency room physician at Detroit Receiving Hospital and cardiovascular researcher who developed the tool. Levy’s work will be presented Thursday at the Detroit Regional Chamber Mackinac Policy Conference. If all goes well, the map could one day address health disparities at the street level throughout Michigan, combining neighborhood health data with demographic information such as age, race, demographics, income, insurance coverage, pollutants, access to transportation, fresh food and more. “This is about using information to address adverse health outcomes of the state. We know that heart disease disproportionately affects Detroit, so it makes sense to start there,” he said. Levy’s work is part of an emerging focus in health care on “precision public health, as more practitioners, public health advocates, and even community leaders and businesses better understand that certain demographics and neighborhoods carry more “disease burden” than others.
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How technology bridges gaps between healthcare and underserved populations

Steven Ondersma discovered that "only a very small proportion, maybe 10 percent" of the people who need professional care realize that need and have the means to address it. "I've just become really interested in having whole-population effects, rather than helping a few people who might be ready to make use of the treatment and have access to that treatment," says Ondersma, deputy director of the Merrill Palmer Skillman Institute at Wayne State University. Ondersma and others in Michigan who are interested in addressing the social determinants of health have increasingly turned to technology as an answer to that question. Weisong Shi, professor of computer science at Wayne State envisions the potential for technology to bring a doctor's office to those more remote patients. He proposes a vehicle, "just like an ice cream truck," that would allow people to get basic physical tests in their communities, with the results being transmitted back to a provider's office. Asthma disproportionately affects African-Americans nationwide, but in Detroit the problem is particularly pronounced – and often an emergency situation. Karen MacDonell, associate professor in Wayne State’s School of Medicine, has been using technology to improve those outcomes with the Detroit Young Adult Asthma Project. Funded by a series of National Institutes of Health grants, MacDonell began the project over 10 years ago by interviewing young African-American Detroiters about their asthma. She asked participants what strategies would help them adhere to their medication before an emergency arose. "Long story short, they wanted something using technology – something they could have with them, something easy to manage, something brief," she says. MacDonell developed a text messaging program that collects information about a patient's asthma and then sends the patient conversational messages encouraging medication use.
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How technology is bridging gaps between healthcare and underserved populations

Steven Ondersma discovered that "only a very small proportion, maybe 10 percent" of the people who need professional care realize that need and have the means to address it. "I've just become really interested in having whole-population effects, rather than helping a few people who might be ready to make use of the treatment and have access to that treatment," says Ondersma, deputy director of the Merrill Palmer Skillman Institute at Wayne State University. Ondersma and others in Michigan who are interested in addressing the social determinants of health have increasingly turned to technology as an answer to that question. Weisong Shi, professor of computer science at Wayne State envisions the potential for technology to bring a doctor's office to those more remote patients. He proposes a vehicle, "just like an ice cream truck," that would allow people to get basic physical tests in their communities, with the results being transmitted back to a provider's office. "You can go to this rural area and ... run these checks without asking these people to drive about 50 miles away to go to a hospital to do this kind of test," Shi says. Asthma disproportionately affects African-Americans nationwide, but in Detroit the problem is particularly pronounced – and often an emergency situation. Karen MacDonell, associate professor in Wayne State’s School of Medicine, has been using technology to improve those outcomes with the Detroit Young Adult Asthma Project. Funded by a series of National Institutes of Health grants, MacDonell began the project over 10 years ago by interviewing young African-American Detroiters about their asthma. She asked participants what strategies would help them adhere to their medication before an emergency arose. "Long story short, they wanted something using technology – something they could have with them, something easy to manage, something brief," she says. MacDonell developed a text messaging program that collects information about a patient's asthma and then sends the patient conversational messages encouraging medication use.
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Age of fraud: are seniors more vulnerable to financial scams?

Scientists looking into age-related financial vulnerability are very interested in physical changes to the aging brain, the way eyesight and hearing can get less keen. In some cases, a new pattern of making mistakes with money may be a harbinger of cognitive bad things to come, the “first thing to go,” as it were. McGill University neuroscientist Nathan Spreng was able to track down 13 elderly scam victims and 13 others equivalent in age, gender and education who had successfully fended off a scam. Spreng’s research found the brains of the two groups were physically different. He noticed this thinning of the part of the brain called the “insula,” which, along with a lot of other things, may help us trigger our “spidey sense,” the hunch that can warn us away from dicey financial situations. Some experts are skeptical about practical applications of research like Spreng’s. Peter Lichtenberg, director of the Institute of Gerontology at Wayne State University, is not a neuroscientist but a psychologist who studies financial decision-making capacity. While he sees the brain scanning as promising, his experience tells him financial acumen and scam-spotting are really complex matters. “There is no one aging pattern,” Lichtenberg said. “You know, some older adults are as good as they were in their fifties and sixties. Others are showing a more significant decline.” Lichtenberg says he has data showing 20 percent of older people admit when they do talk about money with others, it’s out of loneliness. That is, people might engage with a scammer because they want to talk to someone, anyone.
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Wayne State to form new pediatrics group, work closely with Henry Ford pediatricians

Wayne State University School of Medicine announced Monday the formation of Wayne Pediatrics, a new clinical service group of the university's medical school, that is intended to replace its longtime pediatrics group, University Pediatricians, which has left Wayne State and signed an affiliation agreement with Central Michigan University. Under the proposal, Wayne Pediatrics would become the clinical arm of the 130-physician Wayne State department of pediatrics, many of whom are also affiliated with 280-member University Pediatricians. Wayne Pediatrics also is discussing a partnership with the pediatrics department of Henry Ford Medical Group that would provide a continuum of primary and specialty pediatric services, said Herman Gray, M.D., chair of the department of pediatrics at Wayne State medical school. Gray said the Henry Ford partnership would also focus on improving the health of children and such social determinants of health as lack of access to quality housing, healthy food and transportation. Last week, a larger affiliation fell through between Henry Ford and Wayne State over a split on the unfolding arrangement by the university board of governors. Both WSU President M. Roy Wilson, M.D., and HFHS CEO Wright Lassiter III said they looked forward to resuming master affiliation talks sometime in the future, but would continue to work together on existing academic and clinical collaborations. The formation of Wayne Pediatrics is expected to cause Wayne State faculty pediatricians, many whom also belong with University Pediatricians, to choose between Wayne State and Central Michigan for their faculty affiliation. University Pediatricians, which is now a private-practice group that is affiliated with DMC Children's Hospital of Michigan, recently signed an affiliation with Central Michigan. It is expected that the UP pediatricians will become full-time faculty members faculty members with the six-year-old Mt. Pleasant medical school.
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Addressing rural Michigan's high infant mortality and poor maternal health

Michigan’s rural areas have high infant mortality and poor maternal health, fueled in part by substance abuse, lack of access to healthy food, and dwindling birthing hospitals and OB-GYNs. The root causes may be different from those in Michigan's urban communities, but the results are the same: Michigan's African-American and American Indian babies are three times likelier than white babies to die in their first year of life. Addiction is one of the biggest challenges for Michigan's rural mothers and infants. In Michigan’s rural areas, more pregnant women smoke cigarettes and abuse opioids than pregnant women in urban areas. "Cigarettes are the most commonly used substance during pregnancy and are at least as powerful a contributor to infant mortality as any of the other substances," says Dr. Steven Ondersma, a professor in Wayne State University's departments of psychiatry and behavioral neurosciences and obstetrics and gynecology. 
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Med students learn empathy and skills in Detroit street care programs

The Michigan State Medical School's Detroit Street Care program and Wayne State University's Street Medicine Detroit are helping medical students see past stereotypes to build relationships between homeless people and medical professionals to improve their quality of care, put them in touch with other resources like housing, and overcome some of the structural problems that make being homeless in Detroit especially deadly. In the process, the students themselves are engaging in a form of back to basics medicine that puts patients first. These programs allow medical students to reach out to homeless people on the street, carrying backpacks with medicine and diagnostic equipment, as well as necessities like hats, gloves, and food. They also meet with patients at places like the Tumaini Center, working under the tutelage of other medical students, nurse practitioners and doctors. On the street, they go out with a "peer support specialist," a formerly homeless person who helps them approach people.