During a recent Stanford University symposium, speakers agreed that in thinking about health equity in response to the pandemic and chronic disease management, there are no quick fixes. Solutions will rely on building long-term trust with under-represented communities, and innovations must not solely focus on health delivery transformation, they said.
In one segment of the Stanford session, David Magnus, Ph.D., a professor of medicine and biomedical ethics at Stanford University, interviewed Marcella Nunez-Smith, M.D., senior adviser to the White House COVID-19 Response Team. In addition to a role at the White House, she's also associate dean for health equity research and professor of internal medicine, epidemiology and public health at the Yale School of Medicine.
In terms of building trust, Nunez-Smith said health systems might have to think differently about who comes to the decision-making table in terms of how they collect data, who governs it, how it is shared as well as in how they prioritize investments and deliver clinical care. “I think we have to push back on an instinct that the fixes are quick,” she said. Establishing trustworthiness requires patience and sincerity and is not performative, she said. “There is not a checkbox, where we can say ‘do these three things.’ But it is a process and if we can do more in partnership, genuinely, with the communities that have been most affected, that's how we begin to establish trustworthiness.”
She said that in many communities, as health systems and public health officials showed up with vaccination campaigns, “people rightly said, ‘Vaccines, where have you been? We have been struggling here with lack of housing, we've been struggling with limited economic opportunity. We've been struggling with community violence, for schools for our children. And now you care a lot and want to talk about vaccines and vaccination?’”
In her role with the White House, Nunez-Smith said she has conversations with many stakeholders across the country, and she stresses the conversations can’t be focused solely on vaccinations. Similarly, she added, if you are a healthcare system, the conversation can't be only about what happens in your hospital beds; it is how you show up as a member of that community.
On a separate panel focused on equity and chronic disease, David Saunders, director of the Office of Health Equity at the Pennsylvania Department of Health, described how his office has worked with the Department of Human Services in Pennsylvania to develop the Pennsylvania Health Equity Analysis Tool, that shows how policies such as redlining have impacted communities across many spectrums, not the least of which are health outcomes. “The good thing is we can change this phenomenon, and it begins with recognition, which this tool provides.”
It is not enough to say we know racism and discrimination are problematic, added Alyce Adams, Ph.D., professor of epidemiology and public health at Stanford, “because it is interwoven into the fabric of our policies and practices, and how we treat each other in ways that perpetuate themselves over time,” she said. “We have to think not only about how we stop overt discrimination and racism, but also how we weed it out within policies and change the power dynamics, such that those people who have not traditionally had a voice in this country are able to have that voice. Part of that, I believe, involves going back and providing a community's capacity to advocate for themselves. We also have to give them the capacity to advocate for themselves because it plays such a critical role in terms of disease prevention in the first place.”
Meena Seshamani, M.D., Ph.D., director of the Center for Medicine at the Centers for Medicare and Medicaid Services, spoke about some of the efforts at CMS to promote equity through value-based care and innovative payment programs. “We have to encourage innovation and transformation in care delivery, across the gamut from our payment rules to some care models that are operated out of the Center for Medicare, and also out of the Innovation Center, and being able to have shared learning collaboratives, so that we can evaluate and harness the lessons that we are learning, especially during this time,” she said. “We need to create partnerships and alignment where we can all learn together, we can understand where there's opportunities for improvement, understand what works and what doesn't, so that we're all rowing in the same direction, and we're all supporting our beneficiaries and providers, as care delivery is transformed on the ground.”
Adams said it is critical to engage communities and patients and other stakeholders in any interventions, because a lot of the work that has to happen actually happens outside of the healthcare system. “People who live in the communities are experts on the factors within their communities that adversely affect their health, so without that engagement, I worry that innovation only within the healthcare sector isn't going to get us to where we need to go.”
Pennsylvania has a health equity response team that has been meeting since April 2020, Saunders said. The group includes academia, healthcare, nonprofit organizations, and state agencies. “It does help to have all of us at the table and we're still meeting every other week. We share resources, but that alignment, that coordination, that continued perseverance is what will help prevent such disparity as it relates to chronic conditions in the future.”
