Fostering Equitable Change During COVID-19

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: from the tragedy of a relentless pandemic to the opportunity its devastation makes obvious, the nation finally sees the inequities that public health teams have been talking about for decades.

DR. JONEIGH KHALDUN:
I've heard people say or somehow try to blame communities of color for the circumstances that they're in, or to somehow—inaccurately—try to make some connection to genetics and race. Unfortunately, I think that it's just a sign of the systemic racism that exists in our society.

DR. NICOLE ALEXANDER-SCOTT:
We need to make sure that the communities of color—the communities that are disadvantaged, communities where there are undocumented citizens, immigrant communities—have what they need to fight the fight the same way the other communities are.

RUDY MACKLIN:
Trust is the big factor here. To go in different areas with people of color, you have to have a relationship with the people in those communities. And that's where we come in—we have relationships in those communities.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, health inequities across the United States are severely exposed by the COVID-19 virus as minority, ethnic, and low-income populations continue to suffer the most, losing loved ones at rates higher than the general population.

With the nation's eyes opened, public health leaders have an opportunity to pursue overdue reforms. We're talking about those opportunities today with a group of public health leaders who have been working on these issues long before the virus attacked.

Dr. Nicole Alexander Scott is director of the Rhode Island Department of Health. She joins us to talk about the impact health equity zones have had on her state's pandemic response.

Also, Rudy Macklin talks about the importance of gaining the trust of communities he serves as director of Louisiana's Bureau of Minority Health Access and Promotions.

But first, we hear from Dr. Joneigh Khaldun, chief medical executive and chief deputy director for health at the Michigan Department of Health and Human Services.

KHALDUN:
I don't think we should be surprised. Disparities in access to care, access to quality education, and higher paying jobs, high-quality housing—it's a known issue in the United States.

With COVID-19, it's led to a disproportionate number of people of color having chronic medical conditions, which we know makes them more likely to be susceptible to severe disease, like COVID-19.

And—I think it's important to note—more likely to be living on low-wage jobs. And so, things like being able to work from home, or being able to effectively isolate yourself from others, are just not realistic for many people of color.

So, I think it's certainly not a surprise at all that COVID-19 is impacting communities of color more.

JOHNSON:
Do you think people at large are coming around to these inequities now that they've seen them firsthand, up close?

KHALDUN:
I think that there will always be some people who want to deny that there are health inequities or that disparities exists.

I've heard people say or somehow try to blame communities of color for the circumstances that they're in, or to somehow—inaccurately—try to make some connection to genetics and race. Unfortunately, I think that it's just a sign of the systemic racism that exists in our society.

But for those of us who look at data, who respect data, who understand how policy impacts health, I think there is absolutely no denying the reality of health inequities in this country.

JOHNSON:
Obviously, we can't go back. But we can look forward.

How do you think public health leaders ought to use this moment to bring about the change that will prepare us for the next public health emergency?

KHALDUN:
Yes, there's so much going on in our society right now, and I think it's most important that we move beyond speeches, we move beyond op-eds.

I think it's great that more and more states and the CDC are pulsing the data and talking about it, but we need policy change. We need to be looking at the composition of our public health executive leadership teams—are they reflective of the communities that we're serving?

I think we need to build a public health infrastructure. So, we know public health has been underfunded for decades in this country, but can we now work to build up the data and the IT systems so that we can appropriately understand, track, and respond to public health challenges?

I think we should be engaging with communities of color, making sure we're not just telling them about the problems in their communities; but also, I think, focusing on the strengths and the resilience in communities of color, and making sure that we're bringing them in to be a part of developing the solutions to the problems we're facing.

JOHNSON:
That's a long list, and there's still a lot of work to do in terms of dealing with the virus itself.

Have you started work on any of these issues there in Michigan?

KHALDUN:
Absolutely. And, again, still a lot of work to be done. But Michigan was one of the first states to pulse cases and deaths from COVID-19 publicly and to really begin focusing on understanding why those disparities exist, and then doing something about it.

Governor Whitmer, with the leadership of our lieutenant governor Garlin Gilchrist, started the coronavirus disparities task force, which is led by the lieutenant governor but also includes many community leaders, academic partners, public health leaders from across the state to really start thinking about how can we address this problem?

So, we've been working on things like implicit bias in the healthcare community, making sure that we have equitable access to testing in communities of color or across the state, and also developing pilots so that we can make sure people have equitable access to isolation—so isolation hotels if they need support with being able to isolate effectively—but much more to do.

That's just a few of the things we're working on here in Michigan.

JOHNSON:
Are you reaching out to your colleagues who lead other departments in Michigan for help on these issues?

KHALDUN:
Oh, absolutely. I mean, that's how public health works. Public health does not just belong in the public health department, so absolutely.

We have our environmental department who's at the table. We work very closely with our licensing agencies in the state as well. Housing, of course, as you mentioned. So, absolutely it's a collaborative effort—and not just government.

So, we're working with others in the community—which I think is really, really important, that we get out of our offices and engage the community that is most impacted. Because the best solutions really will come up from the community, and we need to support that.

JOHNSON:
A lot of people are still working from home. Offices haven't fully re-opened in many places around the country.

How are you achieving these new partnerships and conversations during this period of staying at home?

KHALDUN:
It's certainly still challenging.

We, like many people across the country, are still using Microsoft Teams, and Zoom, and all those other platforms to try to bring folks together. I think it's not ideal; but, of course, we know it's the safest thing right now because we shouldn't be gathering in large groups.

That is primarily how we're doing our work, but also having a lot of live community events and making sure that we're engaging communities across the state well.

JOHNSON:
If you're in a state and you've not had a chance to do anything other than deal with the virus itself, where would you start in this process of moving forward?

KHALDUN:
I think that there's an opportunity for us to have conversations.

I think, first and foremost—especially when we talk about racism and systemic racism across the country—you could start with just a conversation. You don't have to know everything, but we do expect you to listen.

I think it's also important that you take a look not only at the community that you serve but also look internally at your own departments. What are some things that you can do to really bring about change and make sure that the policies that you are putting forward are not creating even more problems for the communities that you are serving.

So, again, looking at the diversity in your leadership structure, making sure your policies are moving forward in a way that promotes health equity, looking at the way you put money out of the door—are you looking at the grant proposals that come to you with a health equity lens and making sure that you're getting money out of the door in a way that promotes health equity as well?

JOHNSON:
What about your work so far has you most excited?

KHALDUN:
I'm excited about just bringing about change; and the dedication, and knowledge, and expertise that exists in not just in our department, but in the communities. I think it's a really unique opportunity for us to be able to elevate voices that have not had an opportunity to be at the table in the past.

It's really an opportunity for us to bring about change that I think we haven't been able to previously because it hasn't been at the forefront of people's minds: systemic racism as an issue—we've got governors across the country who are now paying attention and listening; public health funding—COVID 19 has really brought to bear the fact that public health systems have been underfunded for decades, so let's really start talking about how we can appropriately fund public health so that when the next public health crisis comes, we can all respond as quickly as possible so we can prevent the spread.

JOHNSON:
Is there any fear in your mind that we could forget this opportunity too soon or miss it altogether?

KHALDUN:
Yes, I'm certainly very concerned. Again, I think oftentimes initially when something happens, there's a lot of speeches, people march, there's op-eds, but no real policy change comes out of the situation.

And I think that's something I'm very concerned about and something I lose sleep about, which is why I think we need to make sure we're using this time to actually make policy change.

When it's no longer exciting for folks who don't think about this every day—and a lot of people do, even before COVID-19, and before the recent police murders across the country—there are people who've been talking about this and thinking about it and advocating for change for some time.

So, how can we capitalize on that, and really just create structural changes and policies—again, hiring, how money goes out the door, how we're looking at data, and working with communities.

If we can make that part of the way we do our work, I think we'll be able to see long-term change.

JOHNSON:
How do you get the motivation to keep that fire burning?

KHALDUN:
Just looking around. Just looking around in my community.

I'm an African American woman whose family is from Detroit, so the issue of disparities and systemic racism is something that's very close to me. It's impacted many of the experiences in my life. So, that's motivation enough.

Just living, quite frankly, for me is motivation enough.

JOHNSON:
And for people in your position who don't have those connections, what should be their motivation?

KHALDUN:
I think when you're in public health, you come into public health because you want to serve and, really, I think that's all you have to remember.

Just listen. No one expects you to really understand experiences that you have not had—no one expects that—but we do expect you to listen. We expect you to be able to use your platform and the power that you have to be able to impact change.

And I think it's something very simple that people in positions of power can do. And they don't have to have the same experiences as others, but they do have to listen.

JOHNSON:
Ask Google to define a health equity zone and the search results are impressive. Page after page of articles and other entries focused on the work of one state—Rhode Island.

Dr. Nicole Alexander-Scott heads the effort there, leading a pandemic response thats benefited from communities prepared to address health inequities.

I feel like you had a head start on this issue because of your health equity zones.

How have they performed during these last few months?

ALEXANDER-SCOTT:
Health equity zones have been critical to our response. Our partnership really allowed for the community-led, equity-focused collaborations that we have through the HEZ.

Being able to fulfill the need to engage community residents and partners, make sure that their needs are elevated, that their voices are heard about what's needed for contact tracing, for expanded testing, or support services to do quarantine in isolation—all of that needs to really wrap around the communities most disproportionately impacted. And the infrastructure of health equity zones is already in place and ready to act in helping to address those root causes of health in our local communities.

So, we've talked about the fact that this is the time. This is why health equity zones are here: to help address the adversities that are occurring—whether through a pandemic crisis or through what's happening in the everyday in their communities—and helping them make sure that we bounce forward.

JOHNSON:
If a state doesn't have health equity zones but now sees the value in having that process, can they get it going even if they're in the middle of this pandemic response?

ALEXANDER-SCOTT:
Absolutely. It's really about engaging with the community.

We in Rhode Island have ready-made documents to help them, but it's about organizing around the communities in locations—because it's geographically-based—helping them set up an organization that can help them drive forward and set certain goals, lay those out, all of which are key public health principles.

Need to have a data-driven action plan, then focus on helping them implement it and, over time, be able to evaluate the outcomes and do an assessment on what changes need to be done.

It is certainly helpful to have these infrastructures in place in advance so that they are ready to go in the midst of a pandemic response, but it's never too late to really redirect our approach and make sure that the community's voice is first, help them organize to guide us in providing them what they need.

JOHNSON:
Have you ever wondered how your response to COVID might have been different had you not established those health equity zones so long ago?

ALEXANDER-SCOTT:
Yeah, we would really be starting from scratch in a challenging way. Communities disproportionately impacted are struggling.

It's clear—the data with cases, the data with hospitalizations, and the data, unfortunately, with death, and the multi-pronged effort that we need to address.

Because we have the health equity zones infrastructure in place and now our focus is able to be health equity zones, you go out and connect with those community members whose voice is really needing to be elevated and is struggling, bring them in.

And so, we can use the infrastructure of the health equity zones to get the funding to them that we need to do.

JOHNSON:
What's been the reaction of the community partners who are involved in this process with you?

How are they feeling about the zones now that all of this has been taking place?

ALEXANDER-SCOTT:
There's a mixed reaction.

At this point, urgency and impact is needed. We need to see swift action and that comes with resources and funding. So, as we are able to leverage this mechanism or funding to get out to the communities quickly and effectively, we're going to continue to see the positive response.

If we didn't have that infrastructure and mechanism, I am sure that we would have a greater outcry and even more concerns. But knowing that that is an option for us to deliver swift action and get resources out to the community that we need is an excellent positive.

Now is the time that we want to deliver, and our health equity zones are at the ready to do so.

JOHNSON:
When you finally have time—and we don't know when that will be—what changes do you think you might like to see to this program going forward? Version 2.0, if you will.

ALEXANDER-SCOTT:
We want more health equity zones. We want greater investment—and it's really to be able to leverage. That's been our focus. And there are pockets of investments going out to communities, and what we've seen over the years is they act, then, in silos and do a little bit here and a little bit there.

The health equity zones' focus is to galvanize that together so that we can really see true movement in one direction. It's not to take away, but it's to coordinate them to integrate and to really have movement in the direction that we need to go. So, we want to continue see the momentum built and have the sustainable change, the sustainable improvement, bouncing forward to community resiliency that allows for economic resiliency and improvement, employment improvements, housing, access to transportation, fresh fruits and vegetables.

That takes a galvanizing of resources and activities moving in that direction. That's what we want to continue to elevate and make sure that the community's voices, the ones that may be most overlooked or are most harmed by this, are elevated most effectively through this process.

So, this is our time to respond, and through that we can see where else do we need to make the improvements? How else can we push the investments? And how else can we really get the sustainable policy and system change that we need that addresses root causes, takes racism, and sexism, and other isms head on, and addresses the other structural causes that have led to the disparities that we're seeing exposed through COVID-19?

JOHNSON:
Are those the best arguments for getting zones in place around the country?

ALEXANDER-SCOTT:
Absolutely, absolutely.

It's being able to have a ready-made infrastructure in place in advance of a crisis like this so that you can hit the ground running. Also in place during and after a crisis so that you have less of a negative impact from a crisis the way we are seeing this time.

So, the more we can leverage our funding to build those resources, the more resilient we can support a community in doing so that they are not hit as hard disproportionately compared to other communities and that they're able to bounce forward to a better place—unlike what we have seen with disasters in the past where the disadvantaged communities ended up worse after the crisis.

There is so much work for us to do to make sure that doesn't happen again now, and having infrastructures like health equity zones—that are ready-made, led by a community, data-driven—so that you cannot have to start from scratch, but can hit the ground running. Everyone is working hard during this pandemic.

We need to make sure that the communities of color—the communities that are disadvantaged, communities where there are undocumented citizens, immigrant communities—have what they need to fight the fight the same way the other communities are, and don't then experience the disproportionately higher rates and percentages of cases and hospitalizations that have been seen.

JOHNSON:
When you created this program, did you ever imagine that it would be tested like this?

ALEXANDER-SCOTT:
I had the sense that it's tested like this every day. Imagining whether or not a pandemic such as this would ever occur, certainly had not.

But my sense is we are seeing the full exposure of the types of challenges that communities deal with every day. Everyone is getting to see that because of what the data is showing. I don't think it's as much of a surprise for the communities dealing with it because that's what they face every single day.

And so, putting the infrastructure and the resources behind it in place give communities the opportunity to fight the way they need to, as opposed to tying their hands behind their back, and wrapping their legs, and cutting out their knees from underneath them, and telling them, "Why don't you fight?"

It's really giving them that ability to stand strong, and move forward, and change the policies and the systems that inhibit that. That's what we want to really use this opportunity and infrastructures like the health equity zones initiative to help fight back.

JOHNSON:
Rudy Macklin is director of Louisiana's Bureau of Minority Health Access and Promotions. Today, he helps communities in his state address a number of daunting challenges: a pandemic, health inequities, and racism.

MACKLIN:
The Bureau of Minority Health Access—we deal with health disparities in an effort to improve health equity. It's the way we do it because health disparities was the buzz word back then, when I first started in 1994, and now it's health equity.

And the way to achieve health equity, you're going to have to reduce health disparities first. And there's two fronts when it comes to the health disparities and achieving health equity.

One is you deal with systemic problems of social determinants of health. When it deals with your environment—you know, poverty, unemployment, education attainment, you know, and red lining in different neighborhoods, racial segregation—all of those systemic problems does affect health.

But there's another section—or another component, I should say—that deals with health equity, and it's the personal responsibility of the person. And that's what my office focuses on more than anything because we've done all the studies, and conferences, and workshops, and research on the other burdens that affect health—such as social determinants of health—but we found that the greater burden was on the responsibility of the person, or the people in the communities, by healthy, active lifestyle choices, physical activity, and nutrition.

That, to me and to us, is the greater partner when it comes to achieving health equity.

JOHNSON:
Health equity has gotten a lot of attention during the pandemic.

How are people in positions like yours helping support the response?

MACKLIN:
When it comes to COVID-19 during this pandemic, disproportionately people of color—Brown and Black people—have really suffered the most because they're on the front lines. It mostly comes to different occupations—service providers, custodial workers, people who work at different occupations that are on the front lines—that will be exposed more than anyone else.

And also, when it comes to them getting testing—really, at one time, it was tough for them to get tested, and have transportation, getting to the healthcare facilities, and things like that got in their way.

My role, and others like us in our department, we try to eliminate those barriers for people of color and disadvantaged whites to make sure that they get good healthcare and are also able to get tested. Also, whatever help they need in order to help them live better.

It's an ongoing struggle because, you know, you just have to make sure you have the right people in those areas that they trust. Trust is the big factor here. To go in different areas with people of color, you have to have a relationship with the people in those communities. And that's where we come in—we have relationships in those communities.

JOHNSON:
It's hard to imagine that any state would not include people from its health equity office in the pandemic response.

But if that is the case, what's the argument for rolling your work into the effort to deal with COVID-19?

MACKLIN:
The argument is, like I said previously, relationships. We have a network of relationships around the state in hard-to-reach areas most people won't go. We go to those areas.

We spend time in those areas, and the best time to really get to know how people live is to go after 5:00 PM. And we go out of the 5:00 PM and on weekends, we get to know the peoples in those areas. And when we come back and we want to do some work in those areas, then they trust us.

When they bring us in, like the health equity task force for COVID-19, the governor has leaned on us and other offices like mine and other organizations like mine that have relationships in those hard-to-reach areas.

Even like, for example, the Hispanic community. You know, it takes trust to get in there; and if you don't have a relationship with the people in the Hispanic community, they're not going to trust you, and you're not going to get in. Or Native American communities, it's the same thing, or the Asian and Pacific Islanders.

So, they lean on us during this time of pandemic to use our relationship skills to get those people to be cooperative with the work that they're trying to do with them.

JOHNSON:
The other big issue facing the country right now is this question, this debate, this national reckoning over systemic racism.

How do people in your positions help address those issues in the communities?

MACKLIN:
Any plan you may have for that particular community when it comes to health and healthcare, you have to have the people that are from there—from the grassroots community—at the table. If you don't include them at the table, you're not going to get anything done.

Some of the decision-making processes that an organization or a state agency may have—if you try to pass some type of new policy or procedures without the people you're going to serve at the table to give you input, it's going to fail. And so, if you don't have people—grassroots people, organizers—at the table in the areas where they're from, you are not going to get anything done.

So, that's the best way to eliminate that systemic racism because you got people of all colors and backgrounds at the table to make sure that their voices are heard. In any type of policy you put together or set forth, their input is included.

JOHNSON:
Does that inclusion help build trust?

MACKLIN:
Exactly. It all goes back to trust. You have to establish trust first in those communities, build a relationship all the time, then you can get better cooperation.

Because if I'm here in Baton Rouge and I'm trying to reach people in four hours away in Shreveport, Louisiana, and I don't have the relationships like the people there, and I want to make a policy from here that will effect the people there, I have to go there and really get to know those people over a period of time in order to get their cooperation.

JOHNSON:
Still talking about addressing the issues of systemic racism in America—is this debate an opportunity to make lasting policy change, from your perspective?

MACKLIN:
This is nothing new. We've been fighting this battle even before I was born. Coming up in the civil rights movement in '68—when I was, what, about eight years old, maybe—we saw these things. My father was a member of the NAACP and he was active. My brother was active.

These things still been going on, and we have these conversations all the time. But when will conversations become a reality? When will they turn it into policy? And when will they turn into the things that we can enact or implement to eliminate the systemic racism? Because right now, it seems like all we have are conversations. So, how are we going to move forward beyond talking about this problem? Could we keep talking about this problem every time?

And then, when there's a big event, or issue, or a disastrous thing that happened to George Floyd or Breonna Taylor, then, all of a sudden, everybody wants to have this conversation again. And then when those events come and go, the conversations are still left behind, and the recommendations are not implemented.

And so, hopefully this time we can get some type of implementation to eliminate the systemic racism, but it's going to take help. It's going to take political will, which is a problem. And the country's divided right now, and so it's really going to be tough to eliminate that right now.

JOHNSON:
How can people in positions like yours around the country help keep that conversation going, moving it from talk to action?

MACKLIN:
We're going to have to have a relationship with the powers that be in each state: with our state representatives, with our senators, and also our congressmen in Washington, D.C. It's going to be up to the people from the grassroots to my office, to the state legislature, to the congressmen and women to keep that conversation alive.

We sometimes get isolated into our own silos and start doing our own thing until we kind of forget about those table issues that are important when it comes to racism itself. And so, keeping it alive—it's just something we're just going to have to do.

The pandemic, hopefully, will go away one day soon, and Breonna Taylor and George Floyd will get their justice. And then what happens after that? We're going to still keep talking? Or are we just going to go back into our silos?

And so, we're going to have to make sure we keep everybody in the loop all the time to talk about these important issues.

JOHNSON:
What do you hope will come from these two national crises we face right now—the pandemic and the debate over racism?

MACKLIN:
Well, I hope to see that we don't go back to what we call "our normal," because the normal wasn't quite work.

We need a new normal, and we have to deal with the health issue first and try to keep politics out of this health issue because everybody going to have to adhere to the policies and procedures. Wear the masks and also social distance in order to get this pandemic under control because it's the people that are keeping it alive.

And the racism part, I think we have an opportunity because of the pandemic. It should be able to bring us together to eliminate the pandemic. That can help eliminate some racism because when people work together on an issue that's important to everybody, then everybody will get to know one another and work together, and that can help eliminate the racism.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.