The art of caring includes the desire to understand and reckon with the social forces and economic realities that, for better or worse, shape our health and well-being. 

The mission of Micah Foster, MS ’18, PA-C, is embodied in many of the patients he sees as an urgent care clinician in Grand Rapids, MI, including a 6-year-old girl with a dry cough and wheezing. 

The girl’s worried mother reports that for the past two weeks “Karla” has not slept through the night. She tires while playing. Theraflu hasn’t helped. A three-week wait for a primary care appointment detours mother and daughter to an urgent care clinic, where Karla is diagnosed with reactive airway disease. DuoNeb is administered. An albuterol inhaler is prescribed. A brief talk on symptom management is delivered. Follow-up with the primary care provider is strongly advised. And Karla and her mother disappear into the night.

Mr. Foster, who last summer presented Karla as a patient case study to students in RFU’s physician assistant program, is not satisfied.

“What is missing?” he asks. “Yes, Karla received a diagnosis. But urgent care can’t fix her problem. Where is it fixed? It can begin to be fixed in primary care. In three weeks.”

A true fix for Karla’s asthma, and the asthma that disproportionately affects black children and other non-white children living in urban areas and in poverty, is in understanding and acting upon the causal relationship between the social determinants of health and disease. 

This is what brings Mr. Foster back to RFU and what drives his work as executive director of the Grand Rapids African American Health Institute (GRAAHI). The institute works to promote healthcare parity in the local African-American community through advocacy, education and research aimed at achieving positive health outcomes.

The social determinants of health (SDOH) — the conditions in which people are born, grow, work, live and age — are shaped by the distribution of money, power and resources at global, national and local levels. While every life is influenced by SDOH, Mr. Foster offers his as a case in point.

Born and raised in Grand Rapids, he notes that the city is ranked 13th in the U.S. News & World Report’s 2019 “Best Places to Live in the U.S.,” before directing students’ attention to a 2016 study of life expectancy in the Grand Rapids area across incomes. 

“If you’re at the top of income earners, congratulations,” he said. “You have 10 years of living over the poor. Just remember: No one in this room chose where or to whom they were born. You can control all the variables in the world, but if you are poor, you don’t live as long. Think about that in the context of generations, how it’s a barrier to generational health and wealth.”

Mr. Foster was raised by caring parents along with eight siblings. The family relied on government assistance. College was never a consideration. 

“My goal was to finish high school, get a job and make money,” he said. “I was one of just a few African Americans in my school. I learned from the social isolation, the microaggressions, that the educational process was not for me.”

The first time he encountered overt racism was in the fourth grade.

“Some kids called me the N word,” he said. “When my younger son was first called the N word, he was also in the fourth grade. Our society has made significant gains since the 1990s in cultural awareness and respect for diversity. While we have made some surface changes in our city, the underlying social context of structural and institutional racism is firmly embedded. It’s something most African Americans have to deal with every day of their lives.”

Married with two sons, now ages 13 and 15, Mr. Foster worked in financial services and sales until the economic downturn in 2008 caused him to pursue higher education and a career in health care. His mission to improve the health of the African-American population in his hometown sustained him during his studies at RFU and during long drives home every other weekend to visit his family. Long before PA school, he witnessed how inequities in housing, education and income harmed the health of his neighbors. He saw that those inequities were fueled by a racism that he said “doesn’t go away, but adapts to the times.” 

“These forces,” he said, “come together like a tornado around many of our patients.”

The stress of racism causes wear and tear on immune, inflammatory and metabolic functions. The chronic stress response, studies show, causes damage to blood vessels and arteries, increases blood pressure and raises the risk of heart attack and stroke. 

“When we really begin to see our patients — the housing and income and environmental factors within their zip codes — we start to understand it’s not their fault. And that’s one of the most important lessons you can learn as a health professional and as a human being.”

GRAAHI is working in numerous ways to improve health among African Americans who comprise 20 percent of the population of Grand Rapids. The city has ranked poorly on measures of economic opportunity for its black population, including homeownership, entrepreneurship and median household income.

Mr. Foster is overseeing his agency’s Pathways to Careers in Health Care initiative, funded by a $400,000 planning grant from the W.K. Kellogg Foundation, which aims to increase the pipeline of students of color into the health professions. GRAAHI is partnering with seven West Michigan colleges and universities to create academic pathways, increase awareness, mentorship and K-12 education opportunities, all aimed at dismantling barriers to a diverse healthcare workforce.

“There are a lot of reasons we want to diversify all aspects of health care, but a big, big driver is the power of income,” Mr. Foster said. “We already have a group of individuals with an inclination toward health care, who practice it in entry-level positions, like CNAs, lab techs, phlebotomists. They have the ability, with proper support, to increase their education and income and improve their well-being. That can change their families for generations to come.”

A healthcare workforce reflective of the population it serves, research shows, can also improve health outcomes. Mr. Foster points to a lack of trust in the health system that manifests in patients’ skepticism of medicine and lack of desire for follow-up.

“We can write our patient a prescription,” he said. “But will they trust it’s what they need? Do they have the ability to fill it? Can they adhere to the medication protocol?”

The skills of caring — communication, empathy, shared decision-making and team-building — help build trust. Behind the asthma exacerbation, the high A1C level or blood pressure, is often a lack of knowledge of the disease state and barriers to health in home and community. 

“We learn the science of medicine, but once we begin practice we quickly realize we need more than the pathology of disease and pharmacology to treat our patients,” Mr. Foster said. “We need to advocate for them, find the resources they need, sell them on the idea that their health can improve and their quality of life can be better.”