Building Health Equity in an Unequal World: Practitioners Sharing Strategies

Building Health Equity in an Unequal World: Practitioners Sharing Strategies


CAROLINE KUO: Good
afternoon, everyone. Welcome. My name is Caroline
Kuo, and I serve as the Assistant Dean for
Diversity and Inclusion at the School of Public Health. Thank you for joining us today. It’s so great to
see all of you here. So today marks the second event
in a four-part series sponsored by the Center for the Study of
Race and Ethnicity in America and the School of Public Health,
with additional co-sponsorship from the president’s office,
from the Warren Alpert Medical School of Office of Diversity
and Multicultural Affairs, and also the Office of
Institutional Equity and Diversity. So I’d really like to
thank the leadership at those respective
offices, President Christina Paxson, Dean Joe Diaz, and the
Vice President of Social Equity Inclusion, Shontay Delalue. They all have been
incredible sources of support as we forge new
interdisciplinary collaboration across campus. And I think these collaborations
are exciting because they allow us to come together and to be
in scholarship around diversity and inclusion. Our Inaugural Dean, Dean
Fox, sitting here today in our new dean, Dean
Marcus, have also enthusiastically
supported this opportunity to bring our nation’s
leaders around innovations, around health equity, and
to bring conversations to Brown about how we can
overcome some major disparities in health. So welcome. In this particular partnership,
the School of Public Health has been so fortunate to partner
with the dynamic director of the Center for the
Study of Race and Ethnicity in America, Tricia Rose,
who’s also here today. Thanks, Tricia. It’s been so great
working with you. And her incredible
team, who are also here. I see them in the back. So I see Christina Downs,
Caitlin Scott, and also Stephanie LaRue. And I’d also like to
thank our team here at the School of Public Health. In the back, Joel
Hernandez, who’s really spearheaded this effort, with
Laura Joyce and Karen Scanlon. So thank you to all of you. So in this series, we
welcome an opportunity to engage with thought leaders
and champions of health equity from across our country. Last night, we launched a series
with a provoking conversation with Dr. Sherman James. He talked about the pernicious
social and structural barriers that we must collectively
tackle in order to ensure health for all. And today, we’re thrilled to
continue this conversation with experts, who are
dedicated to advancing health equity in their communities
and in underserved populations. They will be sharing the
innovative approaches they’re spearheading to
address health equity. And at this
historical crossroads, as we’re facing monumental
shifts in health care access in our
country, we do need to build innovative
approaches that close persistent but avoidable
gaps in health equity. So Dr. Aubert has the pleasure
of introducing our leaders here with us today in just a minute. But before he does that,
I want to invite you all to look forward to the spring
series, which is part two. We’ll be welcoming
Dr. Mona Attisha to talk about the lead
crisis in Michigan on March 1, followed by
another practitioner series later in April. So we hope to see
all of you there. So now I welcome Dr. Ron
Aubert to the podium. This wonderful series
is his brainchild. And we’re so happy to have
him introduce our speakers. RON AUBERT: Thank you, Caroline. Is this your phone? CAROLINE QUO: No. RON AUBERT: OK. OK, I’ll leave it here. All right, good. First of all, thank
you for coming out. We’ve had a really
tremendous kickoff. And first of all, it’s
very unusual for us to be able to put together
a panel and a speaker. These are all our first
choices, and I can’t tell you how hard that is to pull off. I mean, Caroline could
certainly tell you how hard that is to pull off. So we’re very, very
fortunate today to have all the people that
we’re going to hear from. My name is Ron Aubert. I’m the provost
visiting professor in the Center for the
Study of Race and Ethnicity in America in the
School of Public Health. So as part of this
series, one of the things that I wanted to do was
talking to Dr. [? Rose ?] and my colleagues at the
School of Public Health. I wanted to get
beyond measurement. I’ve seen a lot of
panels and discussions about the measurement of
health disparity and health and equality. Wanted to really also
focus on practice– what are people doing in
a public health practice to try and make a
more equitable world? And so we are very
delighted today to have the three
people that you will hear from very shortly. Let me just take a moment to
give a little bit about who you’re going to hear from. So Karen Hartfield
will start us off. Karen is a lecturer in the
Department of Health Services University of
Washington– that’s her academic affiliation. But she’s also the administrator
for the HIV STD program at public health in the
Seattle and King County Health Department. She has worked in
HIV prevention, communicable disease prevention,
immunization promotion, asthma prevention, family planning,
and public health settings for over 25 years, which
is hard to imagine when you see how youthful she looks. She is particularly interested
in how local public health departments address racial and
ethnic disparities in health outcomes and access to services. It is her belief that health
education and communication programs provide
opportunities to reach communities and
individuals who lack access to information and services. She is a native of Chicago. She holds a master’s
of public health degree from the University of North
Carolina at Chapel Hill. She will be followed by
Linda Goler Blount Brown, who is the president and CEO of the
Black Women’s Health Imperative and has been in that
position since 2014. As president and CEO,
Ms. Blount oversees the strategic direction
for the imperative and is responsible for moving
the organization forward in its mission to
achieve health equity, reproductive and social
justice for black women across the lifespan. Before joining the
imperative, Melinda served as vice president
of programmatic impact for the United Way
of Greater Atlanta. She was the first ever
national vice president of health disparities at
the American Cancer Society. With more than 25
years of experience in public, for-profit,
and nonprofit sectors, Linda has a
distinguished career that includes successful
tenures at the Coca-Cola Company and the US Centers
for Disease Control and Prevention– just to give
you two very diverse spans of institutions. She also has extensive
international experience and has served as a consultant
to government ministries in Germany, Barbados,
Malawi, Trinidad, and Tobago. She is a Michigan native. She holds a master’s degree in
public health and epidemiology from the University of Michigan. She also has a background
in computer science and engineering. So you’re going to see some
very interesting and impressive people today. And finally, one of our own– Nicole Alexander-Scott. Dr. Nicole Alexander-Scott has
been the director of the Rhode Island Department of
Health since May 2015 and Dr. Alexander-Scott
brings tremendous experience disposition from her
work as specialist in infectious diseases
for children and adults at hospitals in Rhode
Island affiliated with Brown University,
at the Rhode Island Department of Health. She is board certified in
pediatrics, internal medicine, pediatric infectious diseases,
and adult infectious diseases. She has a master’s
degree in public health from Brown University. She’s Assistant
Professor of Pediatrics and medicine in the Warren
Alpert Medical School at Brown University, and is
Assistant Professor of Health and Services Policy and
Practice at the Brown University School of Public Health. CAROLINE KUO:
Associate Professor. RON AUBERT: Excuse
me, make that change. Don’t want to cheat
her from her– NICOLE ALEXANDER-SCOTT:
It’s brand new. RON AUBERT: OK, great– anyway. But in her tenure as
Director of Public Health, the department’s
three leading parties are addressing the social
environmental determinants of health, eliminating
health disparities and promoting health
equity, and ensuring access to quality health services
for all Rhode Islanders, including the state’s
vulnerable population. So we have a really,
really good cast today of people who are really on
the front lines of making things happen. So without further ado, oh– one housekeeping matter. After the panel
discussion, we hope that you would join
us for refreshments, which are going to be in
the back, not [? Kaitlyn. ?] OK, great. So at this time, I’d like to
turn it over to Karen Hartfield to kick off today’s panel. KAREN HARTFIELD: Thank you, Ron. Ron and I have known each other
for actually over 30 years. So he’s just trying
to flatter me with that line about
how young I look. He knows the truth. OK, thank you so
much for inviting me. It’s really a privilege. I love talking to public
health students and faculty. So I’m going to talk
about the opioid crisis. You can’t open a
newspaper anymore without seeing
frightening articles about the opioid crisis. Lots of talk but what are
we going to do about it? And in this headline,
you’ll see down there Trump declares public
health emergency. And what does that mean? And everybody’s still like,
I don’t know what that means. It doesn’t mean money though. And how is it affecting
racial and ethnic minorities? I’m going to review
some barriers to reducing opioid use
and also King County’s innovative approaches to
the problem, some of which you may have been reading
about in the newspaper lately. So just to give you a little
bit of background– nationally, deaths involving heroin
and synthetic opioids quadrupled between 2010
and 2015 to the point now where overdose is
actually the leading cause of injury-related
death for 25 to 65-year-olds nationwide,
which is pretty astounding. It’s well established that
opioid use contributes to other public health
and social problems. So while we hear about
the results of overdoses and whatnot, probably
equally important is that opioid use is
associated with HIV, hepatitis C, other health
problems, and then a whole host of social
issues– poverty, family disintegration, justice system
involvement, and other issues. So Ron particularly wanted
me to address this point. How is the opioid crisis
connected to racial inequities and health disparities? I would argue that the opioid
crisis is an equity crisis, despite the fact that the
new face of the opioid user is mostly white. If you look at
overdose deaths, you’ll see that the rate of
deaths is more than twice as high nationally among whites
as among blacks and Latinos. And this disproportion
has been growing. Heroin use also is higher
among non-Hispanic whites. The opioid crisis, as
I’m sure you’ve read, has hit suburban and rural
areas particularly hard. Some speculate that the
new face of the opioid user is driving all of this
attention to the crisis, and you could spend
hours discussing that. But I think this masks
a very real impact of the crisis on racial
and ethnic minorities. Just a couple of examples. Opiate use is connected with
justice system involvement. More than 80% of those
convicted of heroin trafficking are black or Latino, though
all racial groups buy and sell drugs at roughly the same rates. And if you’ve read books
like The New Jim Crow, you’ll be familiar
with some of that data. Blacks are arrested
for drug crimes at twice the rate of whites. So even though the face that we
see in the newspaper is white, the impacts are very, very
significant in our community. There are also disparities
in access to drug treatment. Racial and ethnic minorities
are disproportionately uninsured and
underinsured, which makes accessing treatment difficult. So really quickly,
I’d like to just look at some of the main drivers of
the opioid epidemic prescribing practices for highly
addictive drugs. This has gotten a lot of press. Most experts believe that
overzealous prescribing practices in the early
2000s contributed heavily to the current crisis. Now since then, new guidelines
for prescribing opiates have led to a tighter market
for prescription opioids, while heroin is now
actually in some cases easier to get than oxycodone. And so it’s also less expensive. People who started out addicted
to prescription opiates seek heroin in synthetic
opioids as a substitute for the prescription drugs
they can no longer get, and that really is
a new phenomenon. Another driver is fentanyl,
which we hear about a lot. We heard about fentanyl killing
Prince and other celebrities. And fentanyl basically is an
opiate, but it’s so strong. It’s actually 50 times
stronger than heroin, and small amounts
of it can to death. And in some of the places
where the opioid overdose death rate is skyrocketing,
it is largely due to fentanyl, particularly in
the East Coast and Midwest. Stigma is an issue that’s
not talked about a lot, but I think it’s
really important that people remember that
using drugs is stigmatized. So people often delay
seeking treatment or say, well, I just
have a bad back, and that’s why I’m doing it. The longer people delay
getting treatment, of course, the harder it is
to get off of it. And in addition, they may
have developed other health problems. And then finally, what I call
is the very real difficulty of getting one’s life back
when you’re an opioid user. When you think about the
daily life of an opiate user, they need to dose
several times a day just to avoid feeling extremely
ill, sort of like the worst flu that you’ve ever had. And in order to
feel normal, you’re going to be using
several times a day. So you need to dose. You need to score the drugs. You need to get the
money to score the drugs. You need to find a
place to use the drugs, especially if you’re homeless. You need to have clean
supplies in order to avoid blood borne pathogens. And this cycle gets repeated
over and over again in a day. So turning to King County
now, just really quickly. King County, Washington is
where Seattle is located. So if I interchange
those words, forgive me. I live in the city, so
I’m a little city-centric. Some of the indicators in
Seattle and King County are heroin deaths tripling
between 2009 and 2014. Interestingly,
though, prescription opioid-related deaths decreased
over that same period, suggesting that persons
with substance use disorder in our area
are switching to heroin. Needle exchange volume has
tripled in the last 15 years, and drug treatment admissions
for heroin are skyrocketing. And this chart gives you
an idea of what it looks like in terms of drug costs. I think what’s interesting
here about this graph is that the sharpest
trend increase here is methamphetamine and coke. And I think that that’s actually
sort of unique to West Coast cities. I haven’t looked at the
data in other cities, but I suspect it’s similar. Still, as you can
see in 2016, we saw the most drug caused
deaths we’ve ever had. Oops– that correct? OK. These next few sides
highlight a couple of opioid-related
disparities, though. This slide shows you that
although nationally, you don’t really see this
picture, in King County, American Indian Alaskan natives
with a very wide confidence interval but blacks with a much
smaller confidence interval are actually overrepresented. The rates of drug-induced
deaths are actually higher. So I think in our
area, even though we have fewer blacks, Latinos,
American Indians, Alaska Natives, we need to
focus on the population. Another interesting
indicator is naloxone use. So naloxone is
also called Narcan, and that’s the drug
that reverses overdoses. You just– and you
come back to life. It’s kind of a miracle. So we distribute Narcan kits to
our needle exchange customers. And I took a look at
some of our survey data for the last three survey
cycles, which is actually over a six-year period. And what I discovered there
is that African-Americans are much less likely to have
a naloxone kit, and that’s a very troubling
trend because clearly, if people are injecting,
and then they’re impaired, and someone who has
naloxone it, and they can reduce their overdose. OK, this is interesting. Actually, when I took a
picture of this headline, I thought oh, these are all
public health headlines. King County– I just
want to mention– is like a tale of
two unequal cities. I don’t know if anyone
is from that area here. But on one hand, King County
is reaping the benefits of the economic boom
associated with companies like Microsoft and Amazon. We have the hottest housing
market in the whole country. The median home price
in Seattle is $700,000. It’s doubled in the
last five years. And with that, the concentration
of high-paying technology jobs has led to massive income
inequality in our area, housing unaffordability, and
migration out of urban areas into suburban areas
that are lower income and have less
access to services. So when you look at overall
indicators for Seattle and King County, it looks like the
healthiest place in the world. But when you look hard, you
will see the inequities there. So from how long will you live? It might depend on your
neighborhood– that’s a Kaiser study that demonstrated
that people in wealthier areas in King County live 14
to 18 years longer than those in poor areas. Homelessness, which
is clearly driven by our housing unaffordability,
is at an all-time high. And we know from our surveys
that 80% of our needle exchange clients are homeless. So you can put two and
two together there. This slide shows you a little
bit about African-Americans in King County. And all those green
areas are where African-Americans are living. Previously when the city
was more affordable, people lived more
in the central core. So if you were to superimpose
this map on other maps about cardiovascular disease,
obesity, and whatnot, you would see that the
green areas are poor and have worse
health indicators. I won’t go into
detail on this slide. But since you’re
public health students, I thought you’d be
interested in looking at the upstream-downstream
analogy. Have you all heard of that? Yeah, OK. Then I’m not going to
go into it too much. But King County, I would
say, is very, very committed at looking at upstream factors
that lead to conditions that lead to poor outcomes. And so when we develop
programs, we always try to look at
upstream factors that are contributing to what
is on the bottom there– the unhealthy stream. OK, so how many
of you have heard that Seattle is developing
safe consumption sites? Just a few? OK. Well, on a recent trip
to the other Washington, the hotel concierge asked
me where I was from. And I said, Seattle. And she said, oh, that’s
where it rains all the time and everyone works at Amazon. And you’re going to be
giving out heroin and letting people shoot up inside. And it was like
kind of, sort of. It is true that we
are working hard to establish what is commonly
known as a safe injection site and getting closer by the day. First of all, what is this
intervention all about? It’s clearly an
intervention that’s designed to reduce the negative
impacts of the opiate crisis. In King County, we’re choosing
to call them Community Health Engagement Locations
or CHELs, and that’s very, very deliberate. We’re not calling them safe
consumption or safe injection sites because what we feel
is that this service needs to be a wraparound
service, and we need to reduce stigma,
which is associated with using words like safe
consumption, safe injection. So there are no CHELs or safe
consumption sites in the United States at the moment, but
they are widely spread throughout Canada and Europe. So a CHEL is a harm reduction
approach, first and foremost. It is harm reduction. It is not a panacea or a cure. It provides multiple services
for persons with substance use disorder that they need
to stabilize their lives. At its core is providing
a space for injection drug users can inject
indoors under the supervision of a licensed health
care professional. But we believe we
need to provide other services at the CHEL. Supervised injection,
naloxone, syringe exchange, rapid linkage to drug
treatment, if it’s not on site, behavioral counseling,
and rapid linkage primary care, particularly for
wounds and abscesses. If we had all the money
that we would like to have, we would also provide
housing assistance because as you can
see, that’s really an issue– and legal assistance. But the vision for the CHEL
is keeping people alive today so they’re ready for
treatment tomorrow, next week, or next month, or maybe never. Some of the opponents
of safe injection sites say, well, you just need to put
all the money into treatment. And any of you who have
worked with substance users will know that not
everyone is ready for treatment wants treatment or
feels that they can access it. So this intervention is
really about keeping people alive and engaged in services. Ron, can you give
me a time check? Keep going? OK. So King County– this
is just a little graphic that we use to try to explain
to people that King County CHELs will have a positive
impact on both individuals and communities. So I already told you what
the primary goals were for individuals,
but the community is also going to benefit from
having CHELs because there will be a reduction in public
injecting, discarded needles on the street, which is a
very big issue in Seattle and in King County,
and reduce crime. And there are data
that actually back up that having a safe
injection site will have positive
impacts on the community. And of course,
society will benefit from reduced health inequities. So just to give you an example
of how it’s going to work, we’re studying Canadian
European models, and the one that we look at
the most is Vancouver insight. We convened a design team
to develop an implementation guide that’s available
on our website, if anyone is interested. There’s no
cookie-cutter approach, but I just want to show
you a little bit about how Insight works. Give you an idea of
what we’re trying to do. So this is where you
walk into Insight– the safe injection site. And this is the waiting area. And one of the things that
I learned when I was there is that the waiting
area itself needs to be really big because
most of the people coming in are homeless. And they need a place
to put shopping carts. They need a place to
put their bicycles. In addition, most of them
are coming in some form of being drug sick. And so having them all scrunched
together in a waiting room is not a good idea for
conflict resolution. Basically, Insight provides
an organized system for people to move through. The clients register,
wait to be called, wash up, and then go
to the injection booth. So this is what the supervised
consumption room looks like. These are all booths. They look kind of like
going to the hairdresser. There are mirrors, and
it’s very clean and nice. The mirrors are there
so that the injector can find a good vein,
and also so the nurse can see what’s going on. Because if there are 12
people in there and one nurse, it’s a little bit hard to
keep track of what’s going on. One common myth is that people
are allowed to share drugs. Insight and Seattle will not
allow people to share drugs, sell drugs, or help
each other inject. After people inject,
they’re strongly encouraged to move into what’s
called a chill space, where they can further be monitored
and recover and then go back out on the street. So what we’re
hoping in Seattle is to develop something similar. I’d like to highlight a
few challenges associated with CHEL startup
and reflect on issues specific to African-Americans. As you can imagine, there’s
a whole host of challenges. And again, that is a
topic for a whole seminar. But probably the
biggest challenge is siting and community impact. It’s absolutely critical to
place the CHEL in an area with a concentration
of injection drug users and also looking at
our surveillance data to find an area that has a
high rate of overdose deaths. In King County, as
you might guess, that’s the downtown
Seattle area. And with the slide I
showed you about how amazing and rich Seattle is,
you can imagine that business associations are very
opposed to adding this service in the middle
of the thriving condo market. So we’re facing major
challenges with where to put the safe injection site. The other issue is
legal challenges. And we don’t know
exactly where this is going, although we
just managed to get a positive decision on one. But the federal
government, of course, criminalizes drug
possession but also maintaining a
drug-involved premise. So people are familiar
with something that’s commonly called
the “crack house statute.” Basically, if the federal
government decided to, they could come and seize the
building that the CHEL is in. And so as you can
imagine, landlords are not super excited about
having us come and rent their space. We came very close
to finding a space, and then the
landlord pulled out. We think, though, that
there is a precedent in the state of Washington
for the local board of health to have broad
ability to preserve the life and health of people
within the jurisdiction. In addition, there
is a precedent set that with needle exchange,
a legal decision in Washington gave the health
officer the ability to implement a needle exchange,
despite illegal distribution of paraphernalia. Some people feel like
the safe injection site movement is like the
needle exchange movement. I don’t actually
think that’s true, but I think that it
is true that there is a precedent for
doing something that is illegal at the federal level. Finally, I want to
reflect on these issues with specific focus on the
African-American community. We have to make sure
the intervention is acceptable to the community. There could be a
lot of reasons why supervised injection is met with
skepticism in the community. This graphic here is
from a newspaper article in the black community
newspaper, which basically says that people
think it’s fine, but I have heard otherwise. So the issues I would
bring to the fore are the experimental nature
of this intervention could invoke the legacy of Tuskegee. And I think we have
to be really, really cognizant of that. Secondly, will the CHEL
help our community, get rid of the consequences
of substance use? But also the legal and
societal consequences. Some people feel
like, well, if you’re sort of condoning drug use
or making a place for people to use, then we’ll have
more people in prison, and we’ll have all of
the consequences that fall from that. Does the CHEL inadvertently
condone drug use in a community that’s
already ravaged by the effects of substance use? Could a CHEL exacerbate
the disproportionate impact of incarceration on
African-Americans? And from that needle exchange
survey I talked about, there actually are data that
show that African-Americans are less likely to plan
to use CHELs regularly than are Latinos and whites. So these are all
questions that I feel we have to really address. I’m going to skip over my
other intervention, which is about walk-in
access to buprenorphine medication-assisted treatment. We might have time for
that in the questions. And I just want to close by
showing you some street art that I saw in Vancouver,
when I was visiting Insight, and I think this really
kind of sums up why we’re doing this intervention. Thank you. RON AUBERT: Thank
you so much, Karen. Now we’ll have Linda Blount,
President and CEO of the Black Women’s Health Imperative. LINDA BLOUNT: Good afternoon. AUDIENCE: Good afternoon. LINDA BLOUNT: I’m going
to attempt to set a timer, but if it– OK. If it gets out of
control, just let me know. OK, well, as Ron said,
I’m the president and CEO of the Black Women’s
Health Imperative in DC, and I’m really happy to be
here to have a conversation kind of about what we
do and offer my thoughts on health equity. And I think I probably come at
it from a slightly different perspective. But I’ll start with my very
first experience with racism. I was in fourth grade. They had integrated
the elementary school, and we had a band. And I wanted to
play the clarinet. So you try out
different instruments. And as it happened,
the band director wrote on my sheet, “thick lips– recommend trombone.” And so I saw that but
then my friends saw it at the same time I
saw it, and I was just devastated because I interpreted
it as I wasn’t good enough to play the clarinet. But I stuck with it. I persisted as Sherman
James said and went on to play clarinet
right through college. And as Ron said, I did go to
the University of Michigan and studied epidemiology. And I used to hang
out at that place. And I heard that Brown’s
got a football team. I didn’t say it. So 35 years ago, Byllye Avery
founded the Black Women’s Health Imperative. She got a MacArthur
Genius Grant and brought 2,000 of her closest friends
together to Spelman’s campus to talk about self-care
and how black women should take care of themselves and
take care of each other. And so for 35 years, that’s
really sort of been our focus. And now we kind of
organized this way– wellness. We’ve got a CDC grant
for diabetes prevention, which will be expanded to just
chronic disease prevention. Do a lot of research. I’ll talk a little
bit about that. Reproductive justice is huge. HIV prevention– don’t have to
tell you all the statistics. And then our policy
focus is around enrolling women in health
insurance and clinical research participation. But also, looking at
preventive services, particularly the
essential health benefits and maintaining HBCU funding. So after 50 years, here we are. So 1962, Gloria Richardson
started the Cambridge movement in Cambridge, Maryland. She was the first woman to
lead a civil rights movement, and this was two years ago. So we still have that
same kind of imagery. So what is it that we actually
know about black women? And I’ll start with what we
call the negative narrative. And you’ve seen these
kinds of images. Black women are
considered hypersexual. There are plenty of studies that
look at medical school students and particularly around
prescriptions of Truvada. And they’re less likely
to prescribe Truvada to black women
because they think they’re going to engage in
risky or sexual behavior. Black women are angry. I’ve been called the
angry black women. Probably some of you have. As my friends say,
there’s nothing worse than a smart black
woman with an opinion. Black women are attitudinal. We’ve been certainly called
that and then manipulated. This had black Twitter
abuzz last week with this model’s hair
and the perspectives on what did and did not
happen with her hair. But of course, you remember the
Dove commercials and the Pepsi commercials. And so you always sort of
wonder who was in the room when the ad agency said
this would be a great idea. And then there’s the
science narrative. These are the statistics
that we hear all the time. We are overweight or obese. 50% of the incoming
freshman class at Spelman is hypertensive or pre-diabetic,
and about half of them are overweight or obese. We know the mortality
rates around breast cancer differences. We get breast cancer younger. We get a more aggressive
form of breast cancer. Breast cancer
incidences are actually increasing among black women. So you kind of wonder then with
the US Preventive Services Task Force, the American
Cancer Society recommending raising the
age of screening mammography to 50 and 45. Why that would happen? They were using
studies that took place in Canada and Sweden, where
there were no black women. And of course, my colleagues
say, what difference does it make? That’s genetics. There’s only 4%
difference between us all. But clearly,
something’s happening. And so why would you raise the
age of screening mammography to 50 if 18% of breast
cancers in black women occur under the age of 50? And black women have more
cortisol in their bloodstreams at any given point in time. And cortisol, as
we know triggers the inflammatory
response, raises our risk for a whole host of
metabolic disorders. And depending on who you
read, [? Tenay ?] Louis, Alfleeta Jackson,
David Williams, there are very real
physical consequences to elevated and chronic
stress, and we’ll talk a little bit about that. And then there’s
everything else. All these other things that we
talk about, and you all study, and the physicians treat. And so the question is,
what is behind all of this? I’m trained to
report on statistics, and I can do that really well. But then the question
is, is that it? Is that all we do? We just name it and describe it. And obviously, we’ve been at
interventions for a long time. The first report on
minority health in 1985– so 30 years ago. But things are,
in many instances, worse now than they were then. So I just want to
talk a little bit about perception and practice. When I first started at
the Black Women’s Health Imperative, we did a study,
and we asked black women to define health. Purely qualitative we just said
give us words and phrases– whatever health means to you. 80% to 85% of the words and
phrases that black women use– and we’re up to about
300 respondents now– were psychosocial. I’m at peace. I’m calm. I’m in control. About 10% of the
words and phrases black women use to define
health were financial. I can keep a roof over my head. I can take care of my children. I can pay my bills. Only about 5% of the
words that black women use to define health had
anything to do with disease state or physical health. So that suggested to
me that maybe the way we’ve been going about
this is backwards because we treat in
community-based programs, in the exam room, in research
as if preventing diabetes was really the most
important thing. And while it is important, it’s
not the most important thing. So we just had to take
an asset-based approach. Instead of talking about
what’s wrong with black women, why not come at their
health, at messaging, at imagery from a position
of asset, of strength, of positivity because we keep
sending black women a message every time we report
these statistics that something’s wrong with you. And that’s really not what
we’re trying to communicate. And so we have to
focus on it at my shop. And what we’re trying to
encourage the organizations we invest in to incorporate
the lived experiences of black women in their work. So it could be bench science. It could be community
research, programs policy. We have a tendency to
separate the people that we’re focused on from
all the environmental impacts. And if we don’t start looking
at how people actually live, my fear is 30 years
from now, we’ll be having the same conversation. And so what we engaged
in last year was a little bit of social listening
because black women are talking about what they think and
feel and believe and do about their health. So we looked at Twitter
and Facebook data to just kind of
get a sense of what was important to black women. And from October to
December of last year, we looked at what
women were saying. And no disease made it
to the top 10 list– not one. It was psychosocial. It was stressors. It was job-related
stuff, economic stuff. There wasn’t a single disease
in any of the top 10 issues on Twitter and Facebook. So we thought this maybe is an
opportunity to kind of rewind. And so we asked the researchers
at Boston University– the authors of the black
women’s health study– to go back and look
at the data and study women who reported their health
as very good or excellent. As it turned out, over 50%
of the women in the study– so you’re talking
60,000 women, and I think the study is in
its 23rd year now– report their health as
very good or excellent. So we wrote this report to
talk about what they do. How do they live? What are the things that
are important to them? Are there some
regional differences? What is it that we can actually
learn from healthy black women that we can employ in our work? And I’ve got a few
copies of this here. It’s on our website, bwahi.org. You can download it. But there are some implications
for all of these issues, whether you’re doing
programs or employee wellness programs,
policy, future research. Just by studying, what
women are saying about what they do that keeps them healthy
or what their lives are like. So for our shop for the
next couple of years, we’re focused on the
legislative agenda for black women’s health. One has never been done. You would think
so, but we’re going to produce the first
legislative agenda. We’re heavily engaged in
some data science work. And we’re going to look
at Google data next. So I’ve read Everybody
Lies earlier this year and just sort of
had this epiphany. I don’t know. If you haven’t read it, you
should definitely read it. It’s interesting. But on Google, women
have questions. They have problems
they’re trying to solve, like we all do. We want to know something. So if we can look at
Google data and figure out what it is about our health that
is a question, is a problem, what kind of answers
are we seeking? Then we can work with– we’ve got a team of
computing, data science, behavioral economists,
mindfulness folks, psychologists, epidemiologists. This interdisciplinary team
to create predictive behavior profiles. Because in public
health, we try to get people to go from
here to here when it comes to behavior change. But really we need to get people
to go from here to here to here because this never happens. So we’re going to create
predictive behavioral profiles and develop the programs,
the messaging, services, products that we can give to
our community organizations. We invest in, give
to corporations, or maybe sell to corporations,
make available to policymakers so that that work that’s
coming from black women themselves can actually
inform what we do and how we engage them. And they were aggressively
involved in untailoring. So we probably
get a call a month from an organization
very well intended who’s got an outreach program. Right now, It’s the ACA. And they say, we’ve got this
great messaging and imagery in this campaign. Could you tailor
this for black women? And my answer is always no
because if you didn’t design it with black women in mind in the
first place, changing a picture isn’t really going to
make any difference. So we actually for
the index, you’ll see the pictures of the women. We had a photo
shoot, and we asked women– we just put it
out on social media– come camera ready. We took pictures. Every picture in that
index is from women from the Washington DC area. I’m so tired of
stock photography I don’t know what to do. So we’re going to be
our own photo agency. But we’re also very much
involved in clinical trials, where we get calls also from
pharmaceutical companies, researchers. Could you give us 50
women for our trial? And again, the
answer is always no. What I say is can we
talk about why you’re calling us in the
first place to find the 50 women for your trial? And so far, nobody’s
been willing to engage in that conversation. Yeah, I’m hopeful. I’m persisting, as Sherman says. I’m steadfast in
my reluctance to– in a refusal to go
along with that. But we’ve got to
create a new evidence base for how we engage. And we talk about social
determinants of health all the time as though they
sit in this box over here, and that’s not where at all. So just a couple looks
at some of our materials that we developed. So this is around
HIV prevention. The DC government
had its own campaign that had black men
lying on the ground, and black women
standing over them, pointing at them menacingly
or pulling them by their tie. And I said that this
doesn’t resonate with us. And I was talking to
the women at the– well, yeah. I was talking to the
woman from the ad agency, and she gave me the classic
line, of course, which was, I talked to two black women,
and they said they like it. I said, OK. So about a year
after we launched this campaign, the person who
was running HIV for the DCL department pulled
me aside and said, can we use your
materials, please? Sure, no problem. And then this is one of the
pieces from the ACA enrollment that’s happening right now. So again, we were
given materials, and we said, sure, we’ll use
yours, but we’ll use ours. So two weeks ago,
when this rolled out, this one, within three days,
got shared 500,000 times. The one we were given by the ad
agency got shared three times. So I would say for all of you– I mean, obviously, we’re
talking about people here. And my assumption is the
people that you focus on. The people that I
focus on are not crazy. We do things for a reason. As we say, we do what we value. So we’re trying to get
people, and the women we serve, to value changing
whatever it is they need to change to be healthy
and make that a better cost equation than not doing it. Hey, I’m close. I don’t know how to turn it off. Oh, oh, you know that’s– OK. Who knows. Hopefully, it won’t do it again. I don’t know how to
operate the phone. But it’s a
cost-benefit equation. So how do we get
doing the things that we need to do to be
healthy to be as valuable or more than that not? So I would encourage
you– as you’re talking, as you’re writing. You’re doing your research. Think about that. People are not insane. And then we do things
that make sense for where we are right at the moment– keep those people in mind. And as we say, our work is
difficult, not impossible. But when it feels impossible,
we got Auntie Maxine. And if we don’t
have Auntie Maxine, we always have our attitude. So if you ever come
to Washington DC, stop by my office. I put Gloria Richardson
on office wall because I wanted to make
sure that not only I and the staff but anybody
who comes to visit us is reminded of why we are
coming into work every day– why we do what we do. This fight is still going on. So as Sherman says,
we will continue to persist so that
we’re 30 years from now, we’re not still having
this conversation. Thank you. RON AUBERT: Thank you, Linda. This persistence
thing keeps coming up. You that missed the talk last
night, it was a real doozy. So next, we have Dr.
Nicole Alexander-Scott. Brown’s own and so
without further ado– the final speaker,
and then we’ll move into the questions
and answer session. [INAUDIBLE] NICOLE ALEXANDER-SCOTT:
Such an honor to be here and associated with
such distinguished panel of colleagues having
learned so much. So thank you and thank you
for the invitation, Dr. Rose and Ron as well. Also an honor, and
I think the fact that you had all of your
initial invites immediately say yes certainly
is a reflection of who was asking as well. So thank you. Being able to share quickly, to
touch into what Ron mentioned about practice–
public health practice, and how we can put
this into practice is some of what I want
to share briefly today. The first few slides gives
us some purpose and reason for why. At the Department of Health
and on behalf of the state, we say we’re doing
what we’re doing. This highlights how much the
US spends on health care. That is certainly an outlier. It also highlights the lack of
return on investment compared to others, some of
whom spend half as much but are living longer. I often say, for those
that have heard this, that unless we are living
to 125 years of age, compared to other
countries, there’s a problem with how much we’re
spending on health care. This is a companion
slide that also offers some additional approaches. We also see the same
developed countries– many of whom have a
higher life expectancy but have to really also
highlight the difference. Here is the US, and the
blue part of the bar is how much we spend
on health care costs. And similar to the
previous slide, it’s the highest
blue bar on this. The red part of the
bar highlights how much we invest in social services. Social services can
fulfill the concept of the socioeconomic and
environmental determinants of health that we talk about,
what goes on in the community, and we have to, as we engage in
conversations about decreasing health care costs, we have
to together raise our voices and bring awareness to– it’s
not just decreasing costs, but it’s also
adjusting the ratio of spending to get the
better outcomes that we know are necessary. And this nails it
home with highlighting the different elements
that contribute to someone being healthy. What leads to someone’s
health outcomes? Clinical care, which is where
the blue part of this bar goes to. The 75% investment that
goes into 10% of what determines someone’s
health outcomes. I’m glad that this is a slide
that has genetics as just 10%. Other graphics have it
larger, and I believe that it’s this or smaller. And are the brunt of it– 80% is physical environment,
social and economic factors– both of which also
determine health behaviors. And we have to acknowledge that. So that’s the basis for which
the Department of Health has the three leading
priorities that Ron mentioned. Being able to make sure that we
are deliberate about addressing social, economic, and
environmental determinants of health. I’m going to share
a little bit more about the second
leading priority, eliminating
disparities of health and promoting health equity. I consider them as being
flip sides to the same coin. We have to expose the
problems, talk about them, make them clear when we
highlight disparities of health that exist. Racial and ethnic
disparities are prominent. They are real. Unfortunately, we have
to be clear about that. We have to talk also about
the structural factors that contribute to that
as well societally. So we systemically–
racism, sexism, so many of the other
isms that exist. While we talk
about the problems, we also have to put forth
solutions and take action on those solutions. Promoting health equity means
that regardless of the zip code you’re from, you
should have the right to live the healthiest
life you can live in the healthiest
community you can live in. We heard earlier about
Kings County and Seattle, and the differences in
life expectancy outcomes by the zip code. And then doing this two
helps us ensure access to quality health services. We’re deliberate about not just
saying health care services so that it’s clear the expanded
understanding of health means what goes on in
that health care setting, plus all of those
social, economic, and environmental conditions
that go on in the communities that we know make
the difference. And then also doing it for
our vulnerable populations. That means those that
may not have the voice to be able to advocate
for themselves. It could be the very
young, the very old, those who are
foreign-born, those who may not be able
to read or write, those who may be uninsured or
underinsured, incarcerated. It came to mind when
Karen was presenting on the racial-ethnic
disparities that exist within the
opioid epidemic, we often don’t speak of our
sickle cell community that is disproportionately
impacted by all of the opioid
prescribing limitation. They were already not
being appropriately treated for their pain. What does the sickle
cell community do now? That’s a vulnerable
population that we need to be able to advocate for. What we did was purposely
take our purposely broad three leading priorities
and focused them into five strategies, which
are still broad but have some direction that really look
at promoting healthy living. It looks at environmental
elements also promoting a comprehensive health system. Knowing that that
includes an oral health system, a behavioral health
system, and our physical health system. And we can all think of
someone that has had challenges navigating, accessing, or
forwarding something in one of those three health systems. Also doing what
public health is often known for in addressing health
hazards and emergent threats, while recognizing that an
emerging threat absolutely can include the overdose
epidemic that we’re in. And then taking what
public health does well, which is analyze data
but communicating it to drive action and to
improve someone’s health. And then what we’ve done–
and this is also online– is associated each of
those five strategies with 23 population health goals
that align with Healthy People 2020 goals or SMART objectives
and give us something to move forward with and target. And as a department, we’ve taken
those three leading priorities, five strategies, and
population health goals. And then on the
monthly basis, we look at metrics
and lead measures to see what are we doing as
programs and as individuals within the department,
as well as supporting the community in helping us
to reach those three leading priorities. And this is just a
snapshot of the great team of folks within
the department that range from our Division
of Policy Information and Communications
that includes our state medical examiners and then
also our division of customer services. That includes vital records
and our health facilities and health
professionals oversight. I show this because we need
to start within the department and help our staff that
are overseeing licensing and those that are
in the laboratory understand how what
they do can and does contribute to addressing
social, economic, and environmental
determinants of health. If the laboratory
isn’t testing for lead, we’re not able to see
the disparities that exist in communities that don’t
have their lead testing done as well. So that just is to briefly
show a snapshot of how we as a department should be
held accountable to applying public health practice. And then here are two ways that
we’re taking that foundation to advance statewide and
hopefully nationally health equity and health
system transformation. As I said, I would expand a
little bit more in that middle leaning priority. These are our
approaches at expanding the red part of the
bar and decreasing the blue part of the bar, as we
shift investments from health care into the community,
where we know we will have the greatest impact. So a place-based strategy
that we have in Rhode Island is health equity
zones initiative. It was the result of
years and years of leaders at the department, such as
Dr. Peter Simon and so many colleagues who recognize that
we were getting funding from our federal partners at CDC
and elsewhere and giving it to communities– those impacted
in the silos we were asked to give it to them– prevention for diabetes,
prevention for cancer, prevention for asthma,
prevention for others. And we noticed two things in
doing that over the years. One, the people on the other
end of each of those silos were the same people. And they weren’t breaking
themselves up into silos. And number two,
those same people weren’t getting any better. We were not seeing
the improvements. We were just continuing
to funnel money into those communities. So we’re taking years, even
up to a decade of working with our federal
partners, doing pilots, working with the communities,
we were able to convince. And since 2015, have now
had 10 health equity zones throughout Rhode Island. And what we have done is taken
funding from federal partners and as much flexible
funding as we could find to brade that
funding and be able to give it to the community
in a unified way to drive collective action with
authentic community engagement. What it required
was for community to define for themselves what
a health equity zone was. It needed to be a
geographic area that had a population
of at least 5,000 and known social, economic,
and environmental conditions that they wanted to be improved. And the sizes could
range, and they do for us. We have a health equity zone in
every county in Rhode Island. There are about five counties. There is one that’s the
size of a neighborhood. It’s not the size, but it is
a neighborhood– the health equity zone. There’s an Olneyville
health equity zone, and then there’s one
that’s a county– South County health equity zone. And what we required
for each zone is to form a community
collaborative that built on the assets
of that community. So it had to bring together
the residents of the community, businesses, municipal leaders,
transportation, and community plannings, health planners,
health system, the education system, law enforcement,
and so many more. Some of the collaborative
range in size from 20 to 30 to 50 to 60 that come together. And they had to have a backbone
agency that interfaces directly with us at the department on
behalf of that health equity zone and those collaborative. To start with developing
a community-led health needs assessment,
that not only included health care but the needs of
that community and then action plans that are specific,
that are smart, with objectives and measures of
how they’re moving towards it. Here are some examples of
the variety of elements and conditions that people
included within their health equity zones and
even further to show some of the specific examples. The backbone agencies
varied across each of the health equity zones. They continue to vary– not in past tense. This one of the Providence
ones– the backbone agency is the mayor’s office. They have a healthy
communities office, and their focus is on
tobacco-free environments, access to healthy
food and beverages, and access to physical
activity, and safe walking. Woonsocket in the northern
part of Rhode Island has their federally
qualified help center. Thundermist Health Associates
as the backbone agency, and their focus is on
substance abuse, trauma, and teen pregnancy. And then we have the
health equity zone that’s two cities combined of
Pawtucket and Central Falls with LISC as their
backbone agency and a number of key initiatives
that they’re working on. And our goal is twofold. One, that we’re able to
return to our federal partners and those that invest to say
not only have we addressed, the diabetes, the cancer,
the asthma and those that they wanted focused
on, but we’ve also tackled the social, economic,
and environmental conditions that we know directly
contribute to those outcomes. So if you go to our
website, you can find out more about the
health equity zones and let’s see if I
can show a brief video to be able to capture
it a little further. [MUSIC PLAYING] NICOLE ALEXANDER-SCOTT: Our
health equity zones initiative is a place-based initiative
that gets the community to come together
as a collaborative, involving partners that
never worked together before, whether it was law enforcement
and a community-based organization, school
administrations, our health systems, businesses, residents
come together, understand the challenges are
in their community, and with seed money from us,
be able to dedicate actions to addressing the comprehensive
needs of that community. NARRATOR: Health and the
opportunity for good health is not yet been
everyone’s reach. This means that some people
live sicker and die younger than their neighbors. That doesn’t have to happen. Good health comes
from more than genes and how people take
care of themselves. Where and how people
live plays a big role. Access to fresh, healthy
food, transportation, and mobility, safe
places to live and play and economic opportunity
all really matter. NICOLE ALEXANDER-SCOTT:
But we’ve also addressed those social and
environmental factors that we know directly impact them. It’s about people can have
better access to fruits and vegetables,
or that there are safe streets, or
complete streets so that there’s
easier accessibility and transportation. There’s improvement in the
housing in that neighborhood and community and
more job opportunities in that community, all of which
we know up to 80% actually determine someone’s
health outcomes. NARRATOR: Creating these
conditions for good health takes collective effort. It takes an entire
community working together. Rhode Island’s health
equity zone initiative provides opportunities
for communities to lead these efforts by
supporting strong community infrastructure to address the
determinants of health locally. These could be these
are transforming where and how people
live by focusing on the things that impact
health and economic success, such as access to healthy
foods through local community gardens, financial
management training, career development, the
creation of green spaces, and transportation
planning programs. By approaching community
development and partnerships with the residents and leaders
of these health equity zones, we are building healthier,
more equitable and resilient communities. NICOLE ALEXANDER-SCOTT: I love
to see empowered communities everywhere being able
to raise their voice and use it from a platform that
the health equity zones helped establish to make sure that
they called for, demanded, and received the services
that they know they need, and that they have access to
and can hold policymakers, administrators in
their community, public health officials
accountable to providing that and supporting that
community in doing it, but it’s community-driven. That’s what the vision is. So I am going to stop there and
acknowledge that and appreciate that the health equity
zone saw this and said we want even more of
us represented in this and to really advocate for this. These types of
initiatives are what we want to really
build the communities and make sure that things like
gentrification and others, as we work towards
these improvements, don’t lead to
relocation or removal, but there’s a voice
that’s maintained. So I’ll finish with saying
I’m grateful to have the honor to work with my
colleague in Washington as being President-elect
of the Association of State and Territorial
Health Officials, and he is president currently. The goal will be,
during this time, to bring attention to
building healthy communities and resilience and
demonstrating how these types of
place-based strategies are what’s going to be
needed to put public health practice into action
at the community level. So thank you. RON AUBERT: Please
come to the stage. All three of our speakers
were right on time. That’s great. That; a little unusual as well. So we’re going to have
a round of Q&A. I’m going to start with the
first couple questions, and I’ll open it up. I don’t want to spend
too much time taking away from the opportunity for
you to engage our panel. There’s so many
things that I could– OK, I’m going to calm down
and just try and keep it up– little bit focused. So one thing I wanted
to tackle first– I know, Linda, one
of the things you said rose to the
top of the surveys black women talked about
health was financial stability and then, Nicole,
you also talked about you have financial
training as part of services that you guys provided and
once maybe the two of you talk a little bit about that– one, the importance
of how you see, Linda, the link between just
financial or knowledge really and help. And then I want you
to follow up, Nicole, with what’s actually happening
as part of your activities around financial training– what that means. NICOLE ALEXANDER-SCOTT: Sure. LINDA BLOUNT: I don’t
know if this is on. So what we got
from the surveys is I mean, we all
understand the importance of having money and health. I mean, that’s been
talked about a lot. From the social
listening analysis, what we got was at the
heart of it was control. What women were saying
is if I have money, I can make decisions for
myself, for my family, for the people I care about. I can navigate this
world more predictably. So it really was about control. There are a lot of financial
literacy programs out there, and we’ve been asked
to partner with some. But and you need to know how to
manage your money, obviously. But if you don’t feel as though
you have a sense of agency, than a financial
literacy program is probably not going to
be all that helpful to you. So part of what we’re doing with
this ACA enrollment campaign is not only saying, yes, you should
enroll in health insurance, but here’s what it is. Here’s why it’s important. And here’s how you use it
so that we can hopefully get the women that we
served to understand that they do have some control. They can make some decisions. They do have agency
about their health and the health of
their families. And that goes back
to mental health and emotional wellness is
that people don’t feel as though they have any control. Then again, they’re
going to do whatever it is they think they
need to do to try to have some semblance of it. And we want those activities
to be healthy activities, not promoting
activities, and not the more self-defeating
activities that we see. NICOLE ALEXANDER-SCOTT: And one
of the most important elements for us, as I
mentioned, expanding the understanding of
health is to make sure that it’s clear that economic
stability, employment opportunities, economic
development, and stimulation are critical elements of help. And making sure that
the community understood that the investments that
were necessary and would also have the skills to
be able to lead that and drive it from
their perspective. So the financial
assistance element is to be able to work
one on one with someone in their individual
situation so that they get the tools for
being able to navigate in those specific situations. But we also have the
Pawtucket-Central Falls health equity zone has partnered with
the Central Falls Community Development Corporation
to be able to look at housing and health
system investment within that community. And everyone
recognizes that that’s a critical element of health. RON AUBERT: That’s great. Karen, very quickly– and this
is really for all of you guys, but we’ll start with Karen. You showed the headline of
this national emergency. You made the quick comment
of it doesn’t mean any money. And so I want you to
sort of address that. And then how is King
County and the state even sort of bracing
itself for what may be a reduction in funding
across the board for health departments? KAREN HARTFIELD: Right, well,
fortunately in King County in the state of
Washington, there’s pretty generous state funding,
and we have a really generous Medicaid expansion program. So the real scary
thing is what’s going to happen if
the Affordable Care Act falls apart? Because that’s funding
a lot of our treatment. And the fact that the
Trump administration got all excited about
the national emergency but didn’t talk
about money, I think, is really, really indicative
of this whole problem. So what are we doing to prepare? We’re trying to get as many
outside grants as we can get, and we’re trying to come up with
new treatment modalities that are a little bit less expensive
and better for the population, such as the buprenorphine
on-demand where an injection drug user can just walk
in, essentially be induced by a public health nurse, which
reduces the physician time, and then stay in the
program and be followed more like by case managers. So it’s a pretty
scary precarious time. RON AUBERT: Nicole, as
a state health director, how are you all preparing
or what strategies are you trying to
put in place to try to navigate these unknown
waters we’re in right now? NICOLE ALEXANDER-SCOTT: Well,
similar to what Karen said, the department
staff have heard me say that we need to continue
to look at ways of diversifying our funding portfolio. The other that’s an
interesting element in the midst of the
challenges that exist is figuring out how
to lead and keep your department and
colleagues focused on the prize in the
midst of uncertainty, questionable leadership, and
funding threats at every level. So it certainly
inspires me to see the commitment of the
staff and the communities that we’re serving to
move forward in spite of. But it’s made me feel very
strongly about the fact that civic engagement is
a public health issue. And so to every
extent that we can continue to keep
that at the forefront and make sure that
people have a voice and use that voice at every
level is beyond critical. RON AUBERT: So Linda how
much is your organization, another nonprofit, dependent on
federal funding versus others sources? And again, how does some
of this uncertainty impact your organization? NICOLE ALEXANDER-SCOTT: So
we are a lot less dependent on federal funding than
we were four years ago, and that’s by design. We’re still about
40% federally funded. I’d like to get that about 25%
because while the government certainly has a role, so
does the broader community. And if we’re really
going to, I think, address successfully these
health disparities issues, corporations need to have a
skin in the game– obviously, foundations do, individuals do. So we’re actually working with
some broader corporate partners to try to help them
understand that– and the women we’re talking
about are largely employed. And so it is in
their best interest to make sure they’re
as healthy as possible and giving them the
tools and resources so they know how
to go about that. Corporate wellness programs
attract a very tiny percentage of employees. So we need to figure out
a way to make wellness meaningful to the
broader employee base and then get those
services to them. RON AUBERT: So I
want to open it up at this point to
members of the– Dr. [? Rose, ?] absolutely,
take the first question. Got to get a boss
of a first question. AUDIENCE: Thank you so much. This was– whoa. OK, I don’t know how
they’re down there. This was amazing. I’m super inspired. There’s, of course, a little
sadness in all of the work everyone’s trying to do. But this is really
it’s not just inspiring but forcing me to
encourage researchers to think a little differently. So I want to ask
you about how we might be able to respond
to something you all really touched on, which is
the importance of taking communities we’re serving and
their experiences so seriously that we start with
where they are and what they know
as the answer. And how difficult
that is to do– that often that’s always what
we know, whoever the we is, and what ought to happen
because, of course, their vulnerability is
supposed to also mean they don’t have any idea
what the problems are. So in a roomful of
researchers, researchers to be, et cetera, what would
you say to researchers that would be the most
important kind of revision to the way we approach research
on vulnerable communities, whether it’s black
women in particular, whether it’s drug
users, whether it’s for people of color in general
and poor whites, et cetera. What can we do in terms of
how we approach research that would be most productive to help
the extraordinary work you all are doing? KAREN HARTFIELD: I’ve
got two ideas for you. One is hiring. I think making sure that your
qualitative researchers look like the people that
you’re talking to. It’s really important. And my second one would
be compensating people who are giving you their time. I mean, basically, we’re
privileged to hear from them. And so figuring out a way
to budget for incentives or get donations or
something like that, which is getting more
and more difficult. People don’t want to pay
people for interviews and focus groups and whatnot. But I believe that if we don’t
sort of treat our community partners and the community
members as equal participants, we’re not going to
make too much progress. LINDA BLOUNT: And that
I would say first start with looking at yourselves. As much as we want to believe
that science and analysis and the work that we do is
empirical– and I’m biased– it isn’t. You all bring everything
you have into your science, into the questions you ask,
into how you asked them, into who you ask, into how
you interpret the data. So there are ways to
be mindful of that. But the other thing is– and
I said it in my remarks– the people that you are
studying are not crazy. You may not agree with
what it is they’re doing. But they have a damn
good reason for doing it. It makes sense, given
where they are right now. So start there,
rather than start with you’ve got to be fixed,
and I’m here to do research. Participatory, though
it may be, to fix you, that’s not how they
see themselves. So if at all possible,
start with trying to see the people you’re
working with the way they see themselves and let that
drive your questions, let that drive your research,
let that drive your analysis. NICOLE ALEXANDER-SCOTT:
And I agree fully. I get to chuckle and credit
[? Dean ?] [? Whettel ?] and taking her community-based
participatory research qualitative research class
when I had obtained my MPH. To do that
authentically and to do it well takes patience,
energy, humility, and to make sure that
that is your number one approach in engaging
with the communities and to make sure that your
mindset is already clear, that they have the answer. Your job is really to help
facilitate them getting there, as opposed to there’s
a question that you have the answer to that
you’re bringing to them. I love the example that we have
a statewide research grant– clinical trial science
award that was awarded. And so we invited the
leadership of that grant to come speak to the
health equities zones because they had to do
community engagement. And the health equity
zones educated them on what their take was. What are we going
to get for this? How much have you got? A million dollars. How much of that is coming
to us in the community? How much is going to stay? And they had to turn
back around and go back. And they’re still working
and preparing to come back to the health equity zones. I’m helping them along. Whatever way you
like, but they are going to be the ones
that will decide. So continuing to really
have that type of approach is critical. LINDA BLOUNT: Good for you. AUDIENCE: I’m sorry, but I
have to ask about metrics. Is that OK if I ask
something about metrics? RON AUBERT: Absolutely. AUDIENCE: OK. KAREN HARTFIELD: Metrics. AUDIENCE: Yes. So Karen, what was the
unit of observation– the geographic unit
of observation– that you used to look at
who, what, where, when, how for the opioid epidemic? KAREN HARTFIELD: For
the safe injection? AUDIENCE: How did you examine? Do you have address data? Where did you get it? KAREN HARTFIELD: Yes. AUDIENCE: How did you map it? KAREN HARTFIELD: We have a
few different kinds of data. The Medical Examiner’s
Office is actually part of public health,
which is beneficial to us. So we have a lot
of data on deaths. But we also have some data now
that comes from EMS Emergency Medical Services so we
can look at overdoses and where they’re taking place. We have data on calls
to our recovery line. We have zip code data from
our needle exchanges, which are all around the county. So we really looked at all of
those things but primarily– AUDIENCE: Zip code was the
smallest area [INAUDIBLE] KAREN HARTFIELD: Yes,
we didn’t go smaller. AUDIENCE: Why is it? Why? KAREN HARTFIELD: Because I
think that we were mostly talking to individuals. So we didn’t want to get
their actual addresses. AUDIENCE: So you were afraid
that stigma would chase people off? KAREN HARTFIELD: Yeah, we have
a high-value needle exchange around confidentiality. We actually collect
no names or addresses or identifying information. AUDIENCE: So the zip code
is the smallest [INAUDIBLE] KAREN HARTFIELD: Yes. From the Medical
Examiner’s Office, we could actually
go smaller, but I think that in terms
of the raw numbers, I’m not really sure
where that would get us because we’re talking about
roughly 350 deaths a year. AUDIENCE: [INAUDIBLE] KAREN HARTFIELD: Right. I was intrigued by the theme
of strength-based approach, and resilience, and empowerment
that all three of you touched on. And I wondered if you could
give us a little bit more insight into why you think that
that particular approach is so conducive to a health equity
focus rather than a health disparity focus? And just give us a little bit
more insight in that theme. NICOLE ALEXANDER-SCOTT: I was
educated in my previous world as an adult and pediatric
infectious disease physician. I was just explaining
this yesterday to someone who asked me,
do I miss seeing patients. And I said I do miss
my patients very much. The lessons that they taught
me in terms of approach to life, especially
those with HIV for whom HIV was the
least of their problems. And but dealing with a
list of so many others– and I won’t get further
into the example of that. But that’s when I really– well, just over the course
of my medical career is where I really learned
about the resilience and that strength
and what it can do and how it’s so
underestimated and downplayed. If we look at and talk about
the different disparities that exists in affluent versus
disadvantaged communities, if you took a bunch of
the people who grew up in the affluent communities
and had the successes that they did and placed
them in those disadvantaged communities, you
could pretty much guarantee you wouldn’t
see the level of strength and accomplishment and
survival that people have maintained in spite of
what their environment is. So just imagine
what those people could accomplish being
offered or able to have those types of opportunities. That’s the driver
for me about why we have to look at the
strengths because it just gets overlooked. LINDA BLOUNT: And I would
say it only made sense. When we survey women, they
don’t see themselves as broken or broke down. That’s not how they
view themselves. Or why would we
approach them that way? We’d be completely out of sync. And also, I’m not a
behavioral economist. I’m definitely going to come
back as one in my next life. But negative doesn’t seem to
be as motivating as positive. People want to know they
can accomplish something. They want to know they
can succeed at something. And telling people,
you can’t do this. Your rates are worse than this. You’re never going to be– I, mean that’s just not
the way to inspire people. And so I think as my
father used to say, you can catch more flies
with honey than vinegar. It can’t hurt to try it a
different way certainly. KAREN HARTFIELD:
Yeah, I really loved the cover of the
report you showed us that with the healthy
black women in the pictures, and I think that is
really important. I know in my work in HIV with
men who have sex with men, we’ve also looked at this
sort of risk-based approach versus asset-based approach. And people are saying, well,
it’s just the opposite, basically. If a risk factor for HIV is
having 10 or more sex partners, than an asset-based approach
is having not so many sex partners, but it actually may
be related more to something like social connectivity, as
Linda was pointing out earlier. So I think it’s a really
important thing to do. It’s harder to measure,
I think, but it’s a really important frame. AUDIENCE: [INAUDIBLE] AUDIENCE: Oh, yeah, OK. I want to thank you so much
for the rich presentations. I learned a ton, and this
is of one of the best panels that I’ve been to at Brown. So thank you all. And this is a friendly
question, but it’s a question of sort of two parts. So briefly, it’s about poverty. So we talked about economic
stability, work, money, economic opportunity. But the word poverty
didn’t come up much, and I want to ask
about that in two ways. One, is strategic
in terms of what you need to do to
kind of stay away from that kind of terminology? And two, how do you think
about your work given the fact that we’ve got
say 14% of Americans– 50 million people–
trapped in conditions which are described as poverty. How do you imagine
your work to be able to succeed in spite
of that persistent fact? To go back to Brother Sherman
James last night and thank you. NICOLE ALEXANDER-SCOTT: So
for answering the first one, it wasn’t as if I was
avoiding the word poverty. But probably why
you heard me not say it– just happen to not say
it during this conversation– is that tendency to lean
towards the positive. The flip sides of
the coin, we have to expose what it is but
then come up with solutions. Solutions include making
sure that people are informed and equipped with
what they need to do to build their own employment
and economic opportunities, educational, and otherwise,
as well as the community is equipped to do that. And then for the
second question, how to accomplish this in
spite of the poverty for me goes back to the fact
that the economic element is a part of health. So I don’t see it as one or
the other or in spite of. But having solutions for
addressing the poverty piece has to be a part of addressing
and improving health. LINDA BLOUNT: And for me,
it’s deliberate in talking to the black women who
were in that survey and reading some
of the literature, the majority of poor
people believe they can not be poor at some point. And so they don’t want to be
reminded that they’re poor. So we use euphemisms–
low resource– whatever. I mean, there’s no term
that’s really great. But particularly if
I’m talking to women, I tend not to call them poor
because that doesn’t resonate. Even though they
are, they just don’t want to be reminded of it. The other point– the way that
we can try to deal with it, and we are trying to deal with
it is through policy work. We don’t deliver
services in communities. We’re not going to be a
financial literacy group, but we can work with lawmakers
and do at the federal and state level to try to address some
of these structural barriers. But what you’re talking
about requires an overhaul of our economic system. And if you’d like to come to DC. And you can look down the
street from our office and see that dome building. I’m happy to have you
go talk to those folks because we spend a
lot of time trying to get that message across. And it happens in
fits and starts. But we’re talking about
something pretty significant. KAREN HARTFIELD: Yeah,
and I would really echo what you said about people
don’t perceive themselves as being poor. And so when we call
people something that they don’t identify
with, we’ve kind of lost them. At the same time, we do look
at various socioeconomic indicators. I think it’s interesting
that you mentioned that. I’ve never thought about
literally staying away from the word poverty, but I
probably do for the reasons that Linda pointed out. RON AUBERT: Have a nice round
of applause for the panel again.

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