The Health Equity Divide: Chronic Disease and COVID-19

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode, people with chronic diseases have suffered the most during the pandemic. We find out how public health plans to address this growing health equity divide.

DR. KAREN HACKER:
This has really put chronic diseases front and center, both in terms of inequities across the nation in chronic disease, but also in the impact of mortality and morbidity from COVID-19.

DR. NORMAN OLIVER:
The pandemic has laid bare this fact that people with chronic disease are hit hardest by COVID-19.

DR. SUSAN KANSAGRA:
The challenge is really an opportunity for chronic disease directors across the country to advance racial equity, to achieve and close disparities in chronic disease outcomes.

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, we examine the plan to reduce disparities in communities of color and rural parts of the country where people suffer more from chronic disease and have been hit hardest by COVID-19.

Our guests on this episode are working on solutions to help close the health equity divide. It's one that always existed but was made even worse during the pandemic.

Dr. Norman Oliver is a family physician who is now Virginia's state health commissioner. His approach is informed by years of treating patients with chronic illnesses made worse by poor living conditions and other challenges.

Dr. Susan Kansagra is section chief of the Chronic Disease and Injury Section within the North Carolina Department of Health and Human Services. She also is board president of the National Association of Chronic Disease Directors. She joins us to talk about her President's Challenge.

But first, we hear from Dr. Karen Hacker, director of the CDC's National Center for Chronic Disease Prevention and Health Promotion, about the federal strategy to address chronic disease post pandemic.

HACKER:
So, first of all, this has been a historic and unprecedented time with COVID-19. And, in particular, the fact that COVID-19 has affected disproportionately individuals with chronic disease has had great impact on our center.

As you know, chronic diseases placed people at increased risk for COVID-19, in particular for severe illness, but also some of the risk factors that we cover such as smoking and poor eating habits, obesity, pregnancy, all of which are within the center. So, this has really put chronic diseases front and center, both in terms of inequities across the nation in chronic disease, but also in the impact of mortality and morbidity from COVID-19.

We are very concerned about what this impact actually looks like. We know, for example, that there has been a decrease in the number of visits to care providers, so we know that there's been missed screenings, cancer screenings, for example, and a lack of preventive care.

But we also know that habits have changed—people's ability to exercise, for example, or to get access to healthy food. And particularly given that we've seen people lose their jobs, we've seen people have more difficulty paying their rent and things like that.

And we also know that the emotional toll that this pandemic has had on individuals in general, but certainly on people with chronic disease, is very concerning to us.

We are now thinking a lot more about those particular elements—we call them the social determinants of health. We know, for example, that particular groups, racial and ethnic minorities, rural populations, are experiencing a variety of problems from COVID-19 in addition to things like homelessness.

And we have spent a lot of time starting to think about what do we do now to try to mitigate the factors, influencing people with chronic disease, but also what are we going to do post-pandemic to try to catch up given that we know that there are going to be a large number of deficits, both some that we know and some that we yet have found out about.

JOHNSON:
Many long-standing inequities have been made worse by the virus—you've already talked about that.

So, after all that the country has suffered, is there any doubt that chronic disease and health equity are connected?

HACKER:
No, absolutely not.

But we knew that, before the pandemic, we have had wide inequalities in chronic disease burden across the country in particular geographic distribution, but also, in particular, historically disadvantaged communities such as Alaskan Natives, American Indians, African Americans, Latinx or Hispanics, and then Asian and Pacific Islanders.

So, what we are now seeing is that this pandemic has just exacerbated those existing inequalities because of many of those external pieces that I mentioned such as economic strain, loss of jobs, problems getting healthy foods or inability to exercise based on where you live, access to a whole variety of those contextual factors.

And we also know that things like what type of job you have would likely make a difference. If you can't stay at home, if you can't quarantine, for example. So, the types of things that we're seeing during this pandemic really just feel like they are adding fuel to an existing fire as far as I'm concerned.

And now, with COVID-19 increasingly being seen as having increased risks for those same populations, in part because of many of the things that I've mentioned, but also because of that underpinning of a high level of chronic disease to begin with. So, we really are going to have to work to get back not just to where we want to be, but to an increase beyond that because where we were already meant that there were inequalities, we have a lot of work to do.

JOHNSON:
So, what would you like to see states and territories do to address these inequities as they do their own post-pandemic planning?

HACKER:
Well, this is a public health crisis certainly like no other that we've seen in certainly my lifetime, and knowing how much it has worsened health inequities and the conditions in which people live, learn, work, and play also means that we're going to have to address some of these root causes or, as we mentioned before, those social determinants of health.

So, as we come out of this pandemic and look at the actual scenarios, we're going to have to understand how the structural issues such as structural racism, for example, have lead to the inequities that we're seeing and how are we going to address these as a community, as a group, because none of these are going to be able to be solved by one organization.

Our center is focusing on health inequities for a very long time. We're going to continue to do that, but we're going to now be looking at things, I think, through a health equity lens, almost doing a health equity assessment of the programmatic initiatives that we take on.

And with the social determinants of health, we are now focusing on five specific areas which we think are very, very pertinent to chronic disease, and those include food and nutrition insecurity, the built environment, tobacco policy, social connectedness, and clinical community linkages.

There are many other social determinants, but these are some of the ones that we've been already working in and think we can have some influence over, recognizing that any approach needs to be a multi-sector approach if we're going to address these issues and develop solutions.

And as we look at these social determinants of health, we've got to encourage our own grantees—our own awardees in the field—to do the same, to bring partners together and be very deliberate in thinking about what problems they want to tackle and how they plan to tackle them. Our goal is to really change these environmental factors influencing health, and make sure that every community in the long run has access to all of the options to live the healthiest lives that they can live.

In terms of what we're doing now, we've been working with both ASTHO and NACCHO in trying to identify best practices, because we know many communities are already doing this work and have had great impact and we need to learn from them.

Recently, in the budget, there is actually funding for communities to develop what are called social determinants of health accelerator plans. And we are working on a grant specifically focused on that. And then about a week ago, we released a new notice of funding offer, and that was for community health workers to build capacity and training. In terms of that workforce, recognizing how important they are to achieving some of these goals.

JOHNSON:
It sounds like the CDC has a lot of new programs or new ideas in the works.

HACKER:
Absolutely. I think, well, we want to make sure that the work we're doing is going in the right direction and our colleagues in the state and local areas we hope will see this as initiatives that help them as well.

Many of our awardees already are focused, as I mentioned, on these types of priorities and on chronic disease priorities. And so, as we work with partners to support our colleagues at the state and territorial and tribal level, we want to acknowledge how important chronic disease is, given what we've learned throughout this pandemic about the risk factors.

And then, we want to assist them in thinking through the resources, both that we've given them but also the resources that they have where they are, because we know that they are leading the way and, in many cases, what happens on the ground is not something that we're always privy to. And again, we can learn from them and they can teach one another.

We want to be able to provide them with some flexibilities so that they can use technology, that they can get access to the data that they might need. We have learned from our own staff and from the field about the types of initiatives that are really critical during and hopefully after this pandemic.

And, as we move out of the pandemic, we need to work with our colleagues to think really creatively about achieving all of these goals. We can't do things exactly the way we were doing them before, because we are living in a different world now. We've got to be able to build back better, but we've got to address these inequities and address population health changes.

So, with ASTHO and NACCHO—they speak to so many of their constituents and thinking through what communities can do, and we're right in there with them.

In terms of health equity data, we just recently released our places data from our behavioral risk factor surveillance system. This data is now available at a very granular level, which is exactly what communities need to have in order to understand the level of chronic disease in their communities. And that will hopefully help them think through their own innovations and changes in programming that they can be doing at the ground level.

And, again, I'll mention that community health worker NOFA that we just released. It's really looking at how community health workers can both help with COVID-19, but also with chronic disease and connecting individuals in need to the care and resources that they must have.

JOHNSON:
In its response to COVID-19, Congress has given us a lot of flexibility with federal programs and funding. Of all that's been achieved on this front, what changes do you hope will stay in place post-pandemic?

HACKER:
Well, I think first of all, there's going to be enormous lessons learned. The pandemic has really shone a light on these inequities that we knew existed and particularly vis-a-vis individuals with chronic conditions. So, we've got to figure out how to increase the resiliency of populations, and we've got to be thinking about how do we do that in a way that is equitable and that really changes the scenario so that we don't end up in a situation like this in the future.

How our programming can help to prevent chronic disease and also help individuals with chronic disease manage their conditions to the best of their ability will be very, very important. And we know that things like technology and clinical systems and medical advances and the delivery of care are going to be very important to track and understand.

We've got to be more innovative in the way that we're measuring our impact as we go along, particularly vis-a-vis health equity, and we need to immediately implement the innovations so that we can break down barriers and really solve some of these problems that are now so dramatically underlined as a result of this pandemic. Ultimately, we really want to be impactful and our partners want to be impactful and together there is a pressing need to be so.

JOHNSON:
How would you characterize the opportunity we've been given to make lasting changes in the way this country approaches public health?

HACKER:
Well, I think I've said some of this already, but the fact is I think we got into this situation with public health and not a very good situation. And, again, as a past health department director, it's very clear that the resources just were never available. And now, as we come out of this pandemic, we've got to rebuild that infrastructure.

And as it pertains to a chronic disease, it's even more critical because we know that this population is more vulnerable. And then if we subdivide that population into ethnic and racial groups, we know that certain groups are even more vulnerable to conditions such as this pandemic has presented us with. So, as we come out of this, I think our challenge is going to be can we keep these efforts afloat or do we forget about them in a couple of years and just move on? So, for example, community health workers, are they just for COVID or they're really going to be integrated into our systems and to our public health in our health care systems so that they can be there in the future to make sure that we are improving the health of communities?

JOHNSON:
Dr. Norman Oliver leads Virginia's public health department. For him, any plan to address chronic disease must include strategies to address the social determinants of health.

OLIVER:
I think one of the things that we have to do is redouble our efforts to try to, first of all, prevent chronic disease. There's a lot of prevention work that public health departments across the country are doing. I think we need to step it up, do even more of it.

The other thing that I think we need to do is, even in the context of fighting the COVID-19 pandemic, we need to be mindful of these other issues and make part of our response not just testing and case investigation, contact tracing, and now, of course, vaccinating people, but also addressing these chronic elements and helping people, you know, and get treatment and dealing with the health related social needs that are connected to these chronic illnesses.

JOHNSON:
Now, before COVID, communities of color and people living in rural areas might have already been having trouble getting access to treatment for some of these chronic conditions, and there is some evidence that the same is true when it comes to COVID testing and vaccinations.

Have you noticed or recognized any of those problems in the Commonwealth of Virginia?

OLIVER:
Most definitely. And when I talk about health inequities, like I often speak about Black and Brown communities, but the point you raised is really true.

We should also talk about rural communities who face many of the same kinds of inequities in health. All the stuff I just said about diabetes and so on, you can say to the same thing about rural America.

And yes, it's a problem of access to care and that's multifactorial, right? The healthcare workforce is now distributed so that it's concentrated in urban areas, and in the urban areas that tends to be more concentrated in the suburban areas of the urban cities. There's a problem with accessing it that way.

Insurance—health insurance coverage is much lower among African Americans, Latinos, and other communities of color. The issue of income drives a lot of that. These are poor communities, and that's certainly true, not only of Black and Brown communities but of rural America as well—Southwest Virginia, it's old coal country. Those coal mines are no longer there, so this is a very poor area of the state.

And so, all of those things combine together to give you a population that has much less access to healthcare than others. That leads to getting not the kind of treatment that they need to get for their chronic illnesses.

JOHNSON:
So, how are you addressing these challenges as they relate to chronic disease and COVID?

OLIVER:
A lot of the things that I just said are factors that lead to the increased amount of chronic disease in these communities are structural or economic factors.

I think that at an individual level, when someone with diabetes that, say, someone who lives in Appalachia or is African American and from inner city Richmond, or Latino and Fairfax out on Route One, they come into your clinic and their diabetes is completely out of control. And you're trying to help them manage their diabetes.

And quite often, those of us who've taken care of patients like this will tell you that it's not a problem with the medicine. It's a problem with their living conditions, right? They don't have enough food to eat or the right kinds of food.

I remember I had a patient once who I thought was a horribly brutal diabetic and turned out he was functionally homeless, right? He was couch surfing from one relative to another. He didn't have a refrigerator to keep his insulin in. You couldn't keep control of his diabetes.

As soon as we got him a place to live, his diabetes was perfectly under control, right? So, his problem wasn't his diabetes—his problem was his lack of affordable housing. Some cases it's food insecurity, or they need a job, a good paying job, and that solves their health problem.

So here in Virginia, we have put together an organization called Partnering for Healthy Virginia, includes a lot of state agencies, so the Virginia Department of Health, the Department of Behavioral Health, the Department of Social Services, our Medicaid agency DMAS, and a number of community organizations, several large philanthropies, some faith-based organizations, and lots of hospitals. And we built that coalition as a collaborative to work on these sorts of issues.

One of the first things that we've been able to do is to put together a network of what we call Unite Virginia. It's a cloud-based network that allows you, at any point of entry, to connect people with the social services that they need.

So, someone who's visiting a doctor's office but needs help obtaining nutritious food, right from that office you can connect them to the appropriate places where he can go. And if you were at the food bank and it was discovered he needed behavioral health, counseling or whatever, that person there could connect them to the needed service.

And we're standing this up across the entire Commonwealth, and we've gotten a pretty broad network already. I think by the end of this year, it'll be connected all across the state.

JOHNSON:
This network helps address the determinants. It gets agencies and organizations talking to each other so they can help people when they come into the system.

Does it have any impact on this idea of structural racism? Does it help you address that problem at all?

OLIVER:
I think what it's addressing is the symptoms of structural racism. But, to address structural racism—first of all, what is structural racism?

When most people think about racist, they think, you know, KKK, neo-fascist, white supremacists, and those folks that are definitely racist, but that's sort of a personally-mediated kind of racism. When we talk about structural racism, we talk about the inequities that are hardwired into our society.

So, the fact that the schools in Black and Latino communities are under-resourced leads to poor educational achievement. The poor educational achievement then sets those people off for the situation that they get, as a general rule, in more low paying jobs than others would get. And that, of course, leads to less income, or they’re working in situations where the employer doesn't provide them with health insurance.

So, all of that is what we refer to as a structural racism, because it's something that happens to Black and Brown communities, and doesn't happen in white communities. Now, how do you address those sorts of issues? That's where I think you need to get into the policy kinds of things.

As I said, we did work with these other agencies and partners in setting up a partnering for a Healthy Virginia. We were trying to begin addressing some of those policy sorts of questions at the state level, and I think that's where we'll be headed on this coming out of the pandemic.

There was some work that actually was done during the pandemic because on all of these fronts, everything got worse. So, people who are struggling with maintaining a roof over their head during the pandemic, we saw a sharp increase in evictions. The state, the North administration was able to ensure that people could get relief from that and would not be evicted, so that was an immediate response around that.

Food insecurity has increased—around 10% of the population would say that they aren't a hundred percent sure where their next meal is coming from. That was before COVID-19—it almost doubled during the pandemic. So, we've worked with the Department of Social Services, the Department of Agriculture, and others on trying to get more money to food banks and other institutions that are trying to feed the hungry in the Commonwealth.

Things like that are happening now in the pandemic, and what we want to do is to continue that as part of the recovery. You know, once the pandemic is behind us, there's going to be a need for economic recovery, there's going to be in need for recovery in terms of feeding people and getting them jobs and addressing any number of other needs, like housing and so on.

And so, our hope is that this partnership that we've built will be able to find ways to leverage what we're doing into some real demonstrable projects along these lines.

So, for example, on housing, I would love to see us do something like a reinvestment project into some of these disinvested communities and build housing that's connected to healthcare and food supply and help build up those communities as part of the recovery. This, to me, is something where we need to reinvest in these communities and build up their infrastructure.

And it's not just the roads, it's the economy, it's the food supply, it's housing, transportation, all of these things need to be invested in. So, that's going to take that kind of effort, I believe.

JOHNSON:
How do you feel about the effort to address chronic disease in the context of the pandemic? Do you think that you have the awareness and the support of the people that you need in order to make some progress on those issues? Not just now, but beyond the pandemic?

OLIVER:
I think that it could be easy for some to get so focused on the immediate work around battling COVID-19 that you could forget about chronic disease. "We just need to get everybody vaccinated, that's all there is to it."

But, I think as we were talking about earlier, the pandemic has laid bare the fact that people with chronic disease are hit hardest by COVID-19. So, it immediately becomes connected and you have to deal with both.

Our healthcare system is fractured, public health is fractured, the healthcare system as a whole is fractured. But I think what this tells us is that we need to bring all those pieces together and work as a united team.

JOHNSON:
Dr. Susan Kansagra runs point on chronic disease concerns for the state of North Carolina. Currently, she also is board president of the National Association of Chronic Disease Directors. Her challenge to its members—advance racial equity in chronic disease programs.

KANSAGRA:
Yeah, the challenge is really an opportunity for chronic disease directors across the country to advance racial equity, to achieve enclosed disparities in chronic disease outcomes—and really this has been incredibly important now, more than ever, as we're seeing the impact, for example, of COVID-19 and the disparities that we are seeing in health outcomes due to COVID-19.

And so, it was really an opportunity to recommit ourselves to that challenge. And it asks chronic disease directors around the country to commit to taking certain action steps to advance racial equity in their programs. Things from, for example, training of their staff to things like evaluating their programs and budgets using a racial equity framework.

So, you know, that challenge leads out broad action steps that chronic disease directors can commit themselves too. So far, we have over 20 states signed on and more signing on every day. So, I'm really excited about it, and I think it's just another opportunity to continue to elevate and create a focus on this.

JOHNSON:
How did the pandemic influence the construct of the challenge?

KANSAGRA:
Well, the pandemic has showed us across the country public health disparities, you know, in pretty stark outcomes.

We can see already the differences in hospitalization and death rates among African American and Latinx populations are many-fold higher than they are than white populations through COVID-19. And we already know that those that have chronic conditions and disease puts them at higher risk of COVID-19 complications. And so, you know, that's one of the things we're seeing play out.

Certainly, we're also seeing the impact of racism and structural racism throughout society and seeing a call-to-action there. And so, it was really, you know, many things that have come to play over the course of the last year that has really a renewed that elevation and the idea of recommitting ourselves as chronic disease directors in what we can do in our programs to advance both health equity and specifically racial equity.

JOHNSON:
The virus seems to have made your case about the importance of addressing chronic diseases. Do you agree?

KANSAGRA:
Well, we have seen something we've already known, which is that chronic disease—and specifically having a healthy and resilient population that's free of chronic disease—is really important, whether it's for this public health threat or the next public health threat. And with COVID-19, of course, that conversation has been elevated and people can see the direct impact.

But if you think about also what's creating those disparities in chronic disease outcomes for certain populations, we know that, you know, there are root causes that are both driving the disparities in COVID-19 outcomes, but that are also driving disparities in chronic disease conditions that we're seeing across, you know, our populations, things like diabetes, hypertension.

So, those things are really connected, but the most important thing, I think, that this is really laying out there is when it comes to chronic disease, prevention and control is so important. Whether we're talking about COVID-19 or another public health threat, having a healthy and resilient population is important, you know, at baseline for any future threat we might face.

JOHNSON:
Can you share any examples of states or territories integrating health and racial equity in chronic disease programs?

KANSAGRA:
Yeah, so some of the things that are occurring across states are on, I would say, three different buckets of work.

One of those buckets is around training and really ensuring that our own public health staff and workforce is aware around issues of racial equity and racial justice and how to incorporate those things into our programmatic work, and also making sure that the partners we work with, you know, are also trained and educated.

And so, a lot of training going on in the National Association of Chronic Disease Directors specifically does a lot of great work with chronic disease programs and offering those trainings. There's also great things available through PHA and other public health organizations as well. So, you know, that's one piece of it, the training.

The other piece of it is around data. Being able to examine your own data from a state perspective and collecting data that can help inform actions to take.

And so, for example, one of the things we're doing in North Carolina is we are incorporating a module into our state surveillance system, our BRFSS survey called Reaction to Race to give us more information on the impact of race and inequity through that data that we'll be collecting. So, we don't have it yet, but that's something we will have, and a number of other states are also looking at that and how to incorporate some of those questions into their surveillance data.

We also, when it comes to, for example, COVID-19, we are one of the few states right now that's collecting information on race and ethnicity around vaccine distribution. That's something we are seeing so much discussion about now, how do we ensure equitable access to vaccine across different populations? So, you know, to be able to ensure you were doing that, first you'll have to collect the data and that is what informs action. And so, I know more states are thinking about how they can do that as well.

And then lastly, the last bucket is around really evaluating your own programs and policies using a racial equity tool. Again, the National Association of Chronic Disease Directors has a really great tool around advancing equity that can be used to evaluate those programs, those budgets, evaluating your, for example, taskforces, to understand what partners you are bringing to the table, and really taking that intentionality.

And I think that is what's so important—being intentional at every decision point and in every step of the way and using some of these tools to help create that discipline, focus, to think about equity when we're making these key public health decisions.

JOHNSON:
Is leadership training for people at the local level part of this program?

KANSAGRA:
Well, training is certainly a key component of it. As I mentioned before, there are some really great resources out there for training around health equity and racial equity as well, and also incorporating racial justice into how we think about chronic disease and public health programming. So, that is a key factor. You know, we need to educate ourselves as a public health workforce before we can necessarily incorporate this into, you know, programs or work with other external partners. And so, there are a number of resources that are available through that challenge and that the National Association of Chronic Disease Directors is creating as well to be able to offer back to the states and public health workforce.

JOHNSON:
Why is it important in your view that states and territories address this issue if they are not signed on to the challenge? Does that mean that they're not taking a look at this or maybe they've got their own program already in place?

KANSAGRA:
No, many states have been doing this work for a long time, and I think this is continued evolution of our work. You know, one of the things that we've seen public health is this desire to work upstream as we think about how we best promote health. And, you know, if you think about where we were decades ago, you know, health was really focused on healthcare. It still sometimes is, but treatment of disease and gradually public health helped move the thinking behind that upstream.

So, initially thinking about, okay, what drives disease? Well, it's risk factors for disease like physical activity and poor nutrition and tobacco use. And then, you know, addressing those risk factors, then going a little bit further upstream to think about, well, what drives those risk factors? Well, we know it's things in the community, things like access to physical activity, access to healthy food, environmental exposure, and then other environmental factors as well, for example, access to transportation and housing.

So, you know, public health has always had this history of driving further upstream. And I think this is another example of where, especially when we talk about equity, you know, we're seeing also another push further upstream to look at other factors, you know, institutional factors, structural factors that lead to inequity, you know, whether that's racial inequity, gender inequity, but there's, again, that push further upstream. And I think this is that continued drive that many health departments across the country are making in continuing to work on.

JOHNSON:
Is there any way in your mind, as a medical doctor yourself, that we can battle a virus like the COVID-19 virus without addressing chronic diseases in the communities?

KANSAGRA:
Well, I think both those things go hand in hand. You know, again, we know there's certain things that we think about when we think about respiratory diseases, the things that we've been talking about around making sure that you're wearing a mask and making sure you're washing your hands and social distancing, getting the vaccine, we know that there's those tools.

But also, there's tools to make sure that we again have a healthy and resilient community to begin with that decreases the risk that any one public health threat can lead to further adverse reaction. And so, that's where I think we have an opportunity to connect chronic disease and communicable disease and think about how we really promote this also as an opportunity for people to think about, you know, if you've been thinking about quitting smoking, well now is a great time to take that step.

If you are, you know, thinking about other changes that will help better control or prevent chronic disease, well, now is a really good time. Again, whether it's for COVID-19 or the next public health threat, being healthy now puts you in a better position. So, I think that's one of the things containing to emphasize. And again, aside from the personal aspect, thinking back to our communities, what we can do to ensure a healthy infrastructure so everybody has the ability to have a healthy and live a healthy life. I think that's what's also a commonality between, you know, communicable disease and what we're seeing in chronic disease that really, going back to the community infrastructure, how do we create a healthy environment, that is just so important, whether it's around COVID-19 or a chronic disease.

JOHNSON:
So, this work really can help create resilient communities.

KANSAGRA:
Exactly. You know, creating resilient communities—again, doesn't matter the threat—but creating a resilient community starts with the community. It starts with us addressing root causes, going back to those things that are fundamental.

Again, looking at our institutional and social factors and policies, looking at how communities are designed and are we ensuring that all communities have access to those key things, you know, like transportation and, you know, healthy foods and places for physical activity.

If we can ensure our communities have those and naturally, you know, our populations would have more access to that, that would lead to greater equity in our chronic disease outcomes, or, you know, any outcomes down the road.

So, starting with healthy communities and resilient communities is key.

JOHNSON:
The president's challenge lasts for one year and then another president will have another challenge.

What's your hope for the lasting impact of your challenge on the health of communities across this country?

KANSAGRA:
Well, you know, my hope is really that this becomes something where we don't need a challenge, that this is incorporated into our daily way of work and our daily thinking and, again, that intentionality is there at every step of the way so we don't need to think about this as a separate effort, really, that should be incorporated into our work.

But, you know, given we still have a long way to go and given what we're seeing now and disparities, we know that we have quite a bit of work ahead of us and this provides another opportunity to recommit ourselves and elevate this within our own programs.

And so, I hope that this will give the opportunity for people to continue to have the conversation, to have that dialogue with your communities and to take concrete actions, steps that will help embed this into their daily way of working into the future.

JOHNSON:
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.