Ep. 21: Daniel Dawes, JD, Executive Director of the Morehouse School of Medicine. Topic: Political Determinants of Health
Kathy: Welcome to Episode 21 of the Smarter Healthcare Podcast. Our guest is Daniel Dawes, a widely respected scholar, researcher, educator, and leader in the health equity, health reform and mental health movements. He is executive director of the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, Georgia, and a professor of health law, policy, and management.
Daniel is also co-founder of the Health Equity Leadership and Exchange Network, and he is author of two books – 150 Years of Obamacare and The Political Determinants of Health.
In this conversation, we talk about the political determinants of health and health equity. This was a fabulous conversation – I hope you enjoy.
Kathy: Hi Daniel, thank you so much for joining me on the podcast today. Could you start by sharing with us a little bit about your background in health policy?
Daniel: Sure. Well it’s great to be with you today Kathy. And I’ll just start with an episode, an experience that I had, about twenty years ago, that really fueled my desire to get involved in health policy. At that time – it involved a woman who was a patient in the emergency department at a major hospital in south Florida. And I had convinced the CEO at the time to let me volunteer with the hospital to actually shadow some of his executives, and to get a feel for why it is that I had observed in my own family inequities from generation to generation that I wanted to understand, what were the barriers that were preventing my family members from being able to achieve optimal health, essentially. So he allowed me to shadow some of his executives, and the first place they put me was the emergency department. And at that time there was a woman who had been, she had been brought to the emergency department on a gurney, and you could tell that she was in a lot of pain, she was writhing in pain, and I thought, “I wonder what’s wrong with her.” And you could see the triage nurse at the time trying to communicate, but was having a difficult time communicating, and so she sent for another nurse, apparently this patient had immigrated from Haiti and spoke limited English. She spoke Haitian Creole. And so she sent over for a nurse who she suspected could communicate with this patient, and it took maybe not even ten seconds before that nurse went over to the triage nurse and said, “I don’t understand what she’s saying. I have no idea what she’s saying. I don’t speak French or Haitian Creole. I speak English.” And as they were arguing, I thought, “Huh. I wonder how many times this happens in healthcare entities across the United States. Not just here in south Florida, but in New York City; California; in Omaha, Nebraska; Chicago; Denver; you name it. And it was really that moment that I recognized that patients could be extremely vulnerable in our health system. But the providers, right, are having to deal with very diverse, when you talk about limited English proficient patients, how difficult it could be to provide health services to these patients. So it really was a complex health system that we were operating in with multiple dimensions that had to be addressed. So that really got me excited and interested to understand what had been done to address the issue, or these issues that I had observed, and I started researching and exploring and I recognized at the time that in the late 1990s, you had Dr. David Satcher, who was then the assistant Secretary of Health and Human Services, and the sixteenth U.S. Surgeon General, leading a campaign to address racial and ethnic health disparities in the country. And I thought, “Oh, this is fascinating.” After that, Congress had actually authorized the Agency for Healthcare Research and Quality, to create a national healthcare disparities and a national quality report, and in addition to that they authorized the National Academy of Medicine to conduct a study looking at the unequal treatment in this country when it comes to racial and ethnic minority patients. So once those reports came out, you can imagine, I read them from cover to cover to learn what the experts were saying was occurring in other hospitals, and other clinics, and federally qualified health centers and so forth across the country. I felt those reports, as groundbreaking as they were, didn’t quite get to the root cause of these issues. And I decided to enroll myself, or apply really, to a leadership development program with a major health system now outside of south Florida, this time in Orlando, Florida, and I made the case to these executives that I really wanted to do something about it. I wanted to create a program that would bolster cultural competency in their health system. That would help to eliminate any disparities among their patient population groups. And I thought they would have opened up their arms to me, they would have said, “Yes! We certainly welcome you and we want to do something.” But instead quite the opposite happened. They said, “Daniel, we don’t discriminate against patients. We don’t have any disparate treatment or care in this health system.” And I said, “But how can that be? You’re one of the largest Medicare providers in the country, one of the largest health systems, and you serve a very diverse patient population, and yet all of these studies - at that time, you’re talking about over 6,000 peer-reviewed journal articles documenting disparities in healthcare. How is it that you have none? Really? That’s interesting.” Well, I tied my argument to one that was an economic argument and said, “Listen, if you give me the chance, let me figure out where there may be some issues. Let me conduct surveys with prospective patients and former patients, let me talk to providers inside and outside the system, as well as leaders in the community that you serve. I want to really understand if they see it the same way you do. At least give me that chance.” And I said, in addition to that, “What we create, if there is no issue, then fine. But if there is an issue, or there are issues that are preventing members of the community from going to your health system, let us create a solution to that that would afford you a competitive advantage over your competitors.” So that actually seemed to have resonated and it at least gave me the opportunity to conduct these surveys and these interviews and then after that, yes, the data did show there were issues – not everyone saw the system the way that the executives had, and right after that, immediately, I went about creating a cultural competency toolkit. For the nurses, for the doctors, for the staff, in the system that was then not only used throughout their central Florida market, but then in hospitals throughout the United States, which I was really excited about. Well during that episode, every time I tried to create this toolkit, I came up against lawyers who kept saying to me, “No you can’t do this project,” for one legal reason after another. And I kept saying to myself, “Well, gee, I’m only a sophomore in college, I don’t have the power of a legal knowledge to push back, so I can’t really defend what I’m doing, because I don’t have that knowledge base or that expertise.” And instead of going into healthcare administration I decided at that point that, you know what, I need to go to law school. And I need to immerse myself in these health laws and in these civil rights laws, the anti-discrimination laws, to understand why is it, then, that these lawyers at the health system would continue to rail against efforts to address health inequities in our hospitals. That didn’t make any sense. Why would the law allow the status quo, right? So it brought me to law school, and there I got really excited what we talked about the public policy arguments, and I had the opportunity, it really afforded me the opportunity to delve deeper into these laws, into these policies, and the more I did, the more frustrated I became. So after that I thought, “You know what, instead of going into, let’s say, hospital administration and maybe a legal department in a hospital, I would like to go and find out how this sausage is made. I want to understand what this process entails, and why is it that every time I read a law I just got more frustrated.” Thinking to myself, “Did these people not realize when they were writing such and such law that it would negatively impact certain groups? Or did they? Was it intentional, or unintentional, and if so, what could we do to rectify it?” So that brought me then, after law school, to Congress. And I had the opportunity to work with congresswoman Donna Christensen, who was the first female physician member of Congress in its history. She was the chair of the Congressional Black Caucus health braintrust at the time, and she mentored me and helped me to understand how this process really works. And from there she also allowed me to take some of the ideas that I wanted to work on from law school into Congress, and to develop legislation that would address not only health disparities, but emergency preparedness, because around that time we had Katrina, we had the anthrax scare, so bioterrorism was a major issue, and others. So I got to work on the things that I was really passionate about, as well as other topics and issues that opened up my eyes to a – I guess to the bigger picture of why some of these things were happening. Well, after that, there was an opening in Senator Edward Kennedy’s office, on his committee, rather, the Senate Health, Education, Labor, and Pensions Committee, he was the chair of the committee, and Senator Enzi from Wyoming was the ranking, and they were interested, both leaders were interested, in working on legislation to bolster mental health parity. They had worked on one in 1996, but employers and others and the Supreme Court, even with the Americans With Disabilities Act, had actually undermined many of the protections in these bills for consumers. And so they wanted to work on strengthening those laws and to fill the loopholes that were in these laws. And they needed someone with ERISA law experience. And I was the only one in my class that would dare take ERISA law. Very complex employee benefits law. But I did it, and I could see how it paid off in the long run because now they were really eager to get somebody who can understand employee benefits, and health policy. So I started immediately after talking with them and got to work on the mental health parity act, which we worked on for two years and we finally got passed, President George W. Bush signed it into law. We worked on the Americans With Disabilities Act Amendments Act, to again strengthen protections for people with disabilities. That passed as well, and President Bush signed it into law. And then we worked on the Genetic Information Non-Discrimination Act, as well as reauthorizations of various agencies – FDA, SAMHSA, NIH, CDC, you name it. So really an exciting time to get involved in policy, but again when I was there it was an even more frustrating experience, because every time that I tried to take an equity lens to this, you could see how it bothered some individuals. To talk about how laws may negatively impact certain groups. They wanted to really approach it with a one size fits all approach, which I didn’t think was appropriate. Because not everyone is in a similar situation. They’re not similarly situated. So you have to employ the type of resources that will help each group reach equity. If we care about helping them reach their optimal health, then we have to understand, what are those barriers and challenges that they’re confronted with. And not every single community is confronted by the same challenges and barriers, right? So after that now, Senators Barack Obama and Hillary Clinton were running for president, along with John McCain. And all three of them had been very interested in health reform. So we approached all three and we talked about what are your priorities for health reform? What are you going to do to really expand coverage and access to vital health services? And everyone said of course I want to do such and such and such, but we then asked them, how can we ensure that you will prioritize the advancement of health equity and the elimination of health disparities within your bills, your respective policies? And they said, well we would love to work with you on creating such a prioritization. And we said sure that sounds great. Barack Obama, though, was the only one to explicitly incorporate the elimination of health disparities as a key component of health reform negotiations that he wanted to pursue should he win office. And we were excited about that because it was the first time in U.S. history that you had a presidential candidate interested in addressing this and explicitly putting it on their campaign platform. So with all of that said now, I know I can go on and on, Kathy, but I’ll just say, after that, we knew that the political stars were going to align. Because when I talked about the frustration of trying to pass more equity-focused policies, in my reading of history and in my research, what I’d come to understand is how difficult it can be to take an equity lens to these policies. Moreso than not, people have used the levers of policy and politics to hinder the advancement of health equity, and only on rare occasions had we been successful in this country in using policy to prioritize not only the elimination of health disparities, but the prioritization and the advancement of health equity. So knowing that, I then was really interested, as we were working on these bills, which were, I would call them limited insurance reform bills, Mental Health Parity and GINA and so forth, we wanted to work on more comprehensive and inclusive health reform, and we just knew that in 2008, whoever won, right after that, we would be afforded an opportunity of a lifetime to work on a historical health policy, to advance health equity, to reform our health system, to ensure that we were, again, giving people what they needed, when they need it, in the amount that they need to reach their full health potential. And so at that point I started to lead a group of about 300 national organizations committed – these are a very diverse group of folks, from women’s groups to children’s advocacy groups, to racial and ethnic minority groups to faith-based groups, LGBTQ+ groups, older adults, veterans, you name it. All these disparate population groups, vulnerable and oftentimes marginalized groups. Brought them together to help us develop a comprehensive policy solution, one that was for the people by the people. We took aims and made sure that we took the affirmative steps to bring in these individuals to that policy table to help us work on this. We wanted their unique lens on this bill. Because our idea on equity is that the people who are closest to the pain, closest to the problems of health inequities in our society, should be the ones to help us lead the solutions, right? They really should be leading the solutions, and we work in tandem with them to ensure that it is codified into law. And so really looking at this notion that only policy can fix what policy has created, we leveraged that lever of policy, we leveraged the power of trans-disciplinary collaboration, and together we created, we worked on, America’s most comprehensive and inclusive health reform law that took us 150 years to realize in this country. It is the most equity-focused health reform law ever created by the United States government post-Reconstruction. So I was extremely honored and privileged to have had that opportunity to leverage that moment in time to work on a bill that we knew was going to positively influence not just millions, but practically every single individual living in this country.
Kathy: That was all so fascinating. I feel like we could take this interview in a hundred different directions right now. But I did want to talk about the book that you wrote last year. So we’ve heard a lot about social determinants of health over the last couple of years, but you wrote a book about the political determinants of health. So could you explain what that means and what the difference is between the two of them?
Daniel: Oh absolutely. So we have been, for the last, I want to say since 2008, actually when we started working on health reform, there was a commission that was established by the World Health Organization, to look at these social determinants of health, as Sir Michael Marmot, as Doctor David Williams at Harvard, Paula Braveman at the University of California-San Francisco and others have really opened our eyes to. And at that point it was really interesting to hear that there are these forces, these determinants, these drivers of inequities that are outside the walls of a hospital or clinic or practice that we need to take into consideration as we think about the health outcomes that we are trying to tackle. And it was a fascinating idea, I thought, to think about these multiple interacting determinants outside of healthcare that actually lead to the results that we see downstream. So through Michael Marmot and others, David Williams, they helped us coin this term of the social determinants of health. These structural and economic conditions in which people are born into, they live in and they die in, that affect all aspects of health. These are education; the more education, usually the healthier the individual. The issue of transportation. If you think about Katrina, for instance. I was speaking with Doctor David Satcher earlier today and he was reminding me during his work to address the devastation of the toll that Katrina had on population groups within New Orleans, that 30% of Black individuals who were living in New Orleans could not leave and seek protection from the storm because they didn’t have transportation. They didn’t have a car, they didn’t have a vehicle, they didn’t have access to the bus or whatever. So transportation as we know is a critical social determinant of health. And you go on, you think about all of these other issues, from employment to fresh fruits and vegetables, fresh foods, to the issue of racism, and how racism really does take a toll on our overall health and well-being. And it not only just impacts the victims, but also the perpetrators, as we’ve seen with the declines in life expectancy in this country. So it’s been a fascinating journey, to understand the social determinants of health, but I’ve long been troubled that when you think about the structural conditions that these individuals find themselves in, we have to ask ourselves, how did they come to be in the first place? How did they originate? And I felt like the equation – it wasn’t complete yet. Until we understood what were the instigators, the originators, of these social determinants of health? So, for instance, if you think about it in this way: Let’s think about many Black and Brown communities in the United States. And if you go in many of these communities you may have often noticed that right through these communities are a major highway, splitting the communities in half. Or railroad tracks, cutting the communities again in half. You may have noticed that there are a disproportionate number of bus depots in certain communities, right, Black and Brown communities versus white communities. And you have to ask yourself, how did they come to be in the first place? Well, we know through public health research that many communities of color have the highest rates of asthma. They have higher rates of asthma than the rest of the population. Through public health research we’ve been able to connect that to the fact that they’re breathing in some of the most polluted air in this country. But then again, we have to ask ourselves, where did that polluted air come from? Well we can of course now tie it, as a result of our public health researchers, to this infrastructure that was created in their own backyards. The highways that have elevated the pollution, air pollution, smog. We know, too, that in many instances, the railroad tracks, of course, have also led to higher rates of pollution. The bus depots, with the smog, have created air that is hard to breathe in. So we know that you can tie it to these infrastructure. But that doesn’t help us to really understand what created, has been perpetuating, and then of course exacerbating these health inequities. So we gotta take it one step further and connect it to the political determinant that created that social determinant, or those structural conditions. So when you do that, you recognize that for every single one of these social determinants, there was a political action or inaction that led to that mid-stream, and then of course downstream impacts that we see today, or experience today quite frankly. So the notion is that preceding every social determinant of health is a legal, regulatory, an ordinance, legislation, or other policy that basically led to that result. So the way I define this now, as I was researching this, to understand this more, and understand how politics and policy has been used over time to create this, I went back 400 years, and I don’t go back to 1619, I’ll go back to 1641, and I thought it was fascinating to see exactly how this worked. So in 1641, when the abolitionists had been pushing back on this evil institution of slavery, and seemed to be winning the debate of the time, the business interests that wanted to maintain and sustain their business model of slavery, then strategized and approached the policymakers in these early colonies with the idea of legalizing this terrible institution. So they went to the policymakers in Massachusetts, they went to policymakers in Connecticut, and New York, and others, and said, “We want to draft legislation with you, we need to do that in order to sustain this. It’ll have a detrimental impact on commerce,” they made the argument, “if you don’t sustain this evil institution.” And so these policymakers said, “You’re absolutely right.” And they started working and negotiating, and then implementing, they passed and then implemented and enforced these policies. But that wasn’t enough for them. Instead they even went further by developing and negotiating and passing and implementing additional policies that were designed to prevent Black and Indigenous population groups from being able to earn their own money, the laws were explicitly prohibiting such, they were explicitly prohibiting them from raising their own food, from learning to read and write, from being educated, they were prohibited from socializing with one another, in many of the colonies they also created policies that again were recycled from one colony to the next or one generation to the next that explicitly prohibited these Black and Indigenous populations from moving, talk about exercise now, how important that is, and in many respects they couldn’t go beyond a one-mile radius without either a lantern if it was at nighttime or passes from their masters or from certain white leaders. It was fascinating to see how these laws were developed back then in the early 1600s and then how over time they were then being recycled again like I said from one generation into the next century into another century, and all the way up until today. And I found it really fascinating how that was done and how strategic opponents of health equity have been in their efforts to really leverage these policy levers. So after looking at the evidence, after really scouring through laws and policies over the centuries, and understanding how this system works, the political process, the political system, and these other systems, how they’ve worked in tandem, I thought, well, I’m seeing a pattern here now, I’m seeing a trend. And so as I was trying to help folks understand how this has worked, I decided to define it. How do I define political determinants of health so it makes sense? And I defined it as the – it really involves a systematic process of, one, structuring relationships, two, distributing resources, and three, administering power, operating simultaneously in ways to mutually reinforce one another or influence one another to advance or hinder health equity. And so as I started looking at this now I thought well this might be an easy way for health equity leaders and champions, as they are looking at the effects of existing policies, and as they are thinking about how to create new policies, here is what we can do by looking at these three different buckets. So as you look at existing laws like the Homeowners Loan Corporation Act that intentionally redlined America in the early 1930s, we’ve moved away from explicitly racist laws from the 16-, 17-, and 1800s, but into the early 1900s civil rights lawyers and others said, “Wait a second this is a violation of the Equal Protection clause.” So we saw many racist leaders becoming a lot more savvy in creating and adopting more facially neutral policies, but once they were implemented they had the same racist effect. So Homeowners Loan Corporation Act is one of those facially neutral policies that when it was created and once they were going out into communities to rate them on a scale of A, B, C, or D, and to then use those reports to determine additional policies such as who should get VA and FHA home mortgage loans, you can see the impact that that’s had in structuring relationships, by redlining and starving communities of resources that they needed to thrive. Essentially keeping them put. If you think about blood quantum requirement laws, again, designed to prevent Black, white, Indigenous populations from mixing, or the anti-miscegenation laws in this country that again were designed to separate the population groups, you can see how those work. But then think about it when it’s not as explicit. The notion of accessible housing, for instance. The fact that you see ordinances making it difficult for folks. Again, you have to really think more strategically about how these structural relationships and you kind of see what you need to do to not go down that rabbit hole. The same thing with distribution of resources. We know there’s been a dearth of health services. You talk about, in COVID, testing kits and vaccinations, early on in many Black and Brown communities. Again, when you look at the appropriations process, discretionary and non-discretionary-funded programs, you get to see then how these communities were starved of the resources that they needed not only to survive pandemics, or other crises, but also thrive in our society that continues to intentionally put up barrier after barrier to stifle their ability to reach health equity. And then lastly when you think about the administration of power and how that’s been used, every single time in this country when folks have tried to give and share power – President Abraham Lincoln and his supporters at the time during the Civil War, worked on a policy and worked on additional policies to expand civil rights to newly-freed people and to poor whites who had been displaced as a result of the Civil War, and to give them greater protections for voting and so forth. Well, every time that we see these marginalized groups getting access to greater power, and then sharing that power, then the political forces slam back and then enact policies or overturn those policies that would give them the ability to basically advocate for themselves, their families, and their communities. And so you see how together it's worked to prevent folks from reaching their optimal health. Now, if I could quickly, Kathy, I don’t know if I have time, but I’d like to also talk about it in the context of my model, my political determinants of health model, is that OK?
Kathy: Sure, go ahead.
Daniel: OK, so in the model now, what I’ve done is to pull together from a historical lens, but also a political science, legal, and public health lens what really has been used in terms of the interventions and the barriers to advance health equity or hinder them. What’s worked? And how can we think about this more strategically? So my political determinants of health model really looks at these levers and these tools that have been leveraged over time. And the idea here is that once health equity is identified, a perceived health equity is identified, the idea here is that you must conduct your due diligence to ascertain whether the health outcome is – what? – systemic? Is it avoidable? And is it unjust? How far can you venture to understand whether it is an institutional or structural barrier that created this inequity, or is perpetuating and exacerbating the inequity that you seek to address? And what is the policy change that you desire, and can you demonstrate the value of investing in change? Because, as I mentioned earlier in our interview, usually policy has been used to maintain the status quo. So it was initially used forcefully to create these disparate health outcomes, but then it has been used to maintain status quo. How in the world can you leverage this then, to show the value of investing in the kind of change then that will disrupt the status quo? So that’s important. And in our country, in the United States, leaders, advocates have to realize and understand the disquieting and harsh truth that the political determinants of health inequities have rarely been addressed unless their reduction or elimination served other purposes. So I think it’s important to understand that the success of any advocacy effort, at least, for the time period since I can’t go into everything, depends on how palatable they are to a commercial interest, and a government investment value. If you can tie your policy agenda to those, the chances of your policy getting over the finish line and getting implemented, are a lot higher. And it was in those rare instances where health equity leaders in this country, whether mental health reformers, minority health leaders, universal healthcare leaders and others – those leaders who realized that truth and leveraged as such, were the ones that were able to get their policy implemented. So it’s really a fascinating look at, again, how this is done, what has worked, what hasn’t, and why.
Kathy: Now the COVID-19 pandemic – we saw a lot of these health inequities come into focus. You mentioned before asthma, and how that affected people, or just the fact that a lot of people in Black and Brown communities didn’t have the option of staying at home and had to work and thus were more susceptible to the disease. So, I guess, what are some of the lessons that we’ve learned from that, or what do we have to think about from a health policy standpoint moving forward to address some of these issues?
Daniel: Oh, my gosh, absolutely. So number one lesson that I think we’re learning is that COVID-19 hasn’t been striking all groups equally because our social and economic policies haven’t been benefitting all groups equally in this country. It’s also very clear that the nation’s health is not an organic outcome. It is not a coincidence that these racial and ethnic minority groups and other marginalized groups have been suffering tremendously during this quadruple pandemic, quite frankly, that we’re in. And it’s owing again to decisions from the past that continue to haunt us and continue to find their way in our current policies as well as proposed policies. So we’ve gotta be mindful of how this whole occurrence happened in the first place. The other lessons that we’ve come to realize too as we were trying to mitigate the impact of COVID-19 in these vulnerable communities was that when we looked back – we went back all the way to 1793 – intentionally, because this constitutional republic of ours was formed in – what - 1789, right? We established our government, started meeting in 1789. There was a major epidemic that struck the United States, yellow fever, back in 1793, but once you go back that far, and you’re coming all the way again throughout history you realize that it’s the same groups of people who are most negatively impacted during these times. Right? Racial and ethnic minority groups. Immigrant communities. Lower socio-economic status white individuals. And people with disabilities. They are most negatively impacted. And so if we know that to be the case, right, why is it that we see the same result over and over and over again? That is unacceptable, right? Especially we saw it in 2020, with all the technological capability and knowledge that we have on infectious diseases, on healthcare, on health equity, certainly we can stem the tide of this pandemic and realize for the first time in U.S. history an equitable response. But my goodness what I have learned is how challenging, right, that can be. Especially during a pandemic. It was hard before a pandemic, but even more so during a pandemic, where you have misinformation running rampant, where you have fear that is higher than ever, and all these other variables that you might not necessarily see before a pandemic. So it was interesting for us as we looked and we thought, “Well, what can we actually do that is within our power? And within the limited bandwidth that we have. How can we realize an equitable response, if not during this time, perhaps for future pandemics?” So we looked back and it was clear to us that data had always been an issue. And accessing the data during moments of pandemics and epidemics were an issue. And it wasn’t until post-event – once an epidemic or a pandemic subsided – that you were able to get access, researchers were able to get access to the data to again confirm that it’s the same groups of people that are most negatively impacted. Well, we wanted to do something differently. We wanted to be able to understand in as close to real time where those challenges were, which population groups and geographic regions of the country were disproportionately impacted by COVID-19. We wanted to know where supplies were going? Where were the testing kits going to? The vaccines? Ventilators and others. Again, were communities - lower socio-economic status communities, other marginalized communities – were we going to see the same result, or could we then develop a tool that would hold our leaders accountable, and share with them at least so they can’t avoid, because in the past the argument was, well, we don’t know who’s most negatively impacted because we don’t have that data right now, right? So it was a very convenient argument to make when data was harder to get hold of. Well, on the front end what we decided to do was to help work within a coalition called “We Must Count.” And in that coalition we worked to ensure that data was being collected, but it was also being reported, and being disaggregated by at least race and ethnicity. We’d love for people – by disability status, and other statuses if possible, but at least by race and ethnicity, and geographic region, so we could tell where the problems were greatest. Well, from that effort, we did get policymakers who were averse at first – they did not want to give that data. They did not want to show those data because they were fearful that it might show that the state is discriminating against one group versus another. Again, a similar argument if you recall from the beginning with the hospital executives that I worked with who didn’t want to share that data. They didn’t want to go there because they were fearful that it would show some disparity. Well, we thankfully, in 2020 now, had health equity-minded leaders in positions of power who said, “This is unacceptable. We’re not going to allow that to continue. We’re going to release the data and we’re going to ensure that policies are created and resources are sent to groups that really need it right now to survive.” And we got that. In addition to getting them to release the data, we then thought it would be important to create a comprehensive – the nation’s first health equity tracker. So that policy influencers, these are your advocates, your researchers, your policymakers, anyone who really cares about advancing health equity, would have access to the data – the system that we created, the data platform – the data is completely democratized. So you’re able to pull it, and do your own analysis if you’re in a state or a county and you’re interested in understanding what has been happening relative to COVID, but even beyond that. How about the co-morbidities that strike disproportionately, you’re then also able to track those, diabetes, COPD, but we also wanted to make sure – you heard me mention this is a health equity tracker – we didn’t just want a health disparities tracker, we wanted a health equity tracker. And we wanted to again help people connect the dots to what were fueling these poor health outcomes among these population groups. And so we are overlaying the data with very social determinants of health data, but then also taking it a step further through our legal epidemiology data sets that are being created by legal epidemiology team members to show the political determinants of health connection as well. So that they can understand which policies have been mitigating or exacerbating these health inequities. And COVID-19 cases and hospitalizations and so forth. So it’s called Health Equity Tracker, it’s at healthequitytracker.org, data platform and folks are welcome to come on it, we welcome folks to join, and help us think about other variables. We’re going to be adding mental and behavioral health factors, six of them, from Alzheimer’s to addiction to suicidality, anxiety, depression, trauma, you name it. We want to continue developing that phase of the tracker because we think it’s important to show how important mental health is to systemic health moving forward and how these other social and political variables impact such.
Kathy: A lot of the discussion that I’ve heard around social determinants of health recently has centered around, yes, we understand this is an issue, but for hospital leaders they feel like they don’t quite know what to do about it. So do you have any practical advice for them as to how their organizations can deal with some of these issues?
Daniel: Yeah, absolutely. I think first you got to acknowledge that there is a problem. I think that’s the first step in moving forward. There are a lot of folks who still deny the existence of health inequities. They continue to put their heads in the sand to avoid what is an inevitable conversation. And we need to recognize that we’re on borrowed time right now. So those health leaders that actually care enough to begin with, and have the courage to move beyond merely nibbling around the edges of the problem of health inequities, who want to do something substantive around this issue, they are the ones that will be rewarded in the end because of what we are seeing in terms of demographic shifts in this country. We are becoming a more racially pluralistic society. Over the next several decades we know that we will continue to see increased diversity in this country, and if these racial and ethnic minority children…first of all, think about in 2020 – 2020 was a very interesting year, not only because of COVID, but that was the first time in U.S. history now that you saw the number of children of color outnumbering white children in terms of their birth rates. And it’s been fascinating to see that trend. Well, if these children are coming from families and communities that are sicker and dying younger, prematurely, well it raises all sorts of economic and national security issues for the nation. And I think this is what leaders now are recognizing at various levels of government. Locally, state, nationally, and even internationally, why it is important to really tackle these health inequities. So how do you practically do this? We talked about acknowledging it. But in addition to acknowledging it, you gotta learn, you gotta understand these drivers of inequities. You gotta understand these political determinants of health, quite frankly. And understand what has been fueling these results. And then from there you have to understand that this is an issue, as contentious as it is, I mean health policy alone is contentious, you talk about adding an equity lens to this work, my gosh it’s equally or doubly contentious. So it’s going to take tremendous courage to do so because this movement to advance health equity really is not for the faint of heart. It’s going to take people who have courage and who can persevere until the job is done. It’s a very tiring process. As you can see it took us 75 years from the first time that the government was formed, the United States was formed as a constitutional government, basically from 1789 to about 1865 before we were able to realize America’s first major health policy that was signed into law by President Abraham Lincoln, but then was dismantled seven years after by folks – opponents of this agenda. It would take us 150 years after that again to be able to work on health policies that took an equity lens through the Affordable Care Act, or Obamacare. So can we wait 300 more years before we’re able to realize something? We don’t have that time anymore. We’re really on borrowed time, and if we truly believe in creating a society that is healthier, more inclusive and more equitable, then we’ve got to act now. So we’ve got to address not only the social determinants of health, which are becoming a lot more palatable for leaders, but we have to take that step further and address the political determinants of health inequities that have been really the instigators of this. We also need to understand and research the histories of our communities that we serve in and understand the barriers, the challenges that they’ve been confronting. I think it’s very important that we understand that at the community level it’s so easy to make judgments, to make assumptions about the people who reside in these communities without understanding the history and the facts that have driven the results that you see today. So I think that’s really important that they take that step. And then lastly I would say just understanding that this is a continuous process. Health equity is a journey and a destination. There’s an argument about is it just a journey and not a destination? Well I see it as both, because you really have to have something to strive for. There’s gotta be a goal. But understanding that even when you reach that goal, or try to, that goalpost is always moved. Over and over again. So it’s going to take a lot of political savvy, of policy acumen, in order to drive the results that we care so deeply about moving forward.
Kathy: Do you ever think that we’re going to reach the point where healthcare is not politicized? Is it possible to find any common ground when it comes to things like health inequity?
Daniel: Well, that is a great question, Kathy. And all I can say is that I would hope so. If we truly can get over the role that racism, sexism, ableism, homophobia plays in the creation of our policies. If we can truly educate the masses about these deleterious motives, and these destructive forces that really undergird our policies, then perhaps it wouldn’t be deemed as ‘politicized’. It wouldn’t be as politicized moving forward. But health policy has been, of all the public policy issues in this country, health policy is always the most contentious. Usually it’s the last one to be addressed from an appropriations standpoint. You add a layer of racial equity on that piece, and my goodness it becomes, like I said, doubly politicized. But if we can, as Martin Luther King, Junior, admonished us to do, not only look at the political aspect of these issues, but also work on the front end in educating people and sensitizing them to these issues, then maybe a few hundred years from now, it won’t be as politicized. But in the near-term, even in the intermediate term, I don’t see this not being a politicized issue. You have folks that are working to oppose any effort to advance this. You have opponents of health equity that have now been working and they are strategizing, they’ve come together, they’ve mobilized, and they are intent at pushing an ideology that is opposed to this notion of a more healthy and equitable and inclusive society. So as they continue to do that, they will continue to of course brainwash many people through their anti-intellectual efforts, and we now need to make sure that we are fighting, like those before us, who have fought and in many cases were in the minority, they were the dissenters, it wasn’t as popular as it is today, but still, as difficult as ever as we’ve seen. But we’ve got to keep pressing, and we’ve got to collectively come together and harness that power of collaboration to stomp out the inequities. Because I think the good news is that these structural barriers that we’ve been talking about almost for an hour now, they’re not permanent. They’re not permanent. And you heard me say that policy can fix what policy has created. But we’ve got to have the will, the political will and otherwise, to effect those changes. So we’ll continue to work on the hearts and the minds of many in our country, and hopefully that will translate throughout the process, this political process, from voting to government and policy in the long term.
Kathy: Well, Daniel, thank you so much. I learned so much from this conversation and I think my listeners probably did as well. Thank you.
Daniel: Thank you. My pleasure. Thanks for having me.
Kathy: Thank you for joining me for this episode of the Smarter Healthcare Podcast. If you’d like to learn more about Daniel, you can follow him on Twitter @DanielEDawes. You can follow me on Twitter @ksucich or @smarthcpodcast. Feel free to get in touch with comments or guest suggestions. To listen to more episodes, visit our website at www.smarthcpodcast.com or find us on your favorite podcast app. I’d appreciate if you would subscribe, rate, and review. Thanks for listening!
