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With health equity, top-down answers won’t work, speakers say

In the second installment of “The Pandemic Puzzle: Lessons from COVID-19,” leaders and experts from government, academia, health care and business said the road to health equity begins and ends in the underserved communities.

- By Stephan Benzkofer

The health care system cannot heal itself. 

Hobbled by inefficiencies and undermined by systemic racism, the U.S. health care system will need innovative, tailored solutions to achieve equity — and those will have to come from the very communities that are now underserved.

That was the consensus among leaders from academia, government, medicine, public health and business who tackled the issue of an equitable pandemic recovery during the second installment of The Pandemic Puzzle: Lessons from COVID-19, a symposium series hosted by the Stanford School of Medicine and Stanford Graduate School of Business.

In addition, substantive progress will need to address societal factors — housing, employment, education, environment — that are critical to people’s health.

“To address the challenges of inequity and health disparities, we’ve got to think beyond our traditional approaches,” said Lloyd Minor, MD, dean of the School of Medicine. “And this, I believe, involves broadening our lens, our aperture, on what our responsibilities in health and health care are.”

Time and again, in session after session, the same idea was hammered home: The answers will come only in partnership with the communities that were hit hardest — primarily communities of color.

“Over the course of the pandemic, we’ve seen staggering disparities,” said Jonathan Levin, PhD, dean of the Graduate School of Business. “As we respond and rebuild, it’s critical that we understand the needs of these diverse populations and the ways the pandemic has impacted them.”

The vaccine rollout at once revealed the problem and a possible path forward. 

Marcella Nunez-Smith, MD, senior adviser to the White House COVID-19 Response Team, cautioned against pushing for quick fixes. She said that for many communities of color, the issue isn’t about regaining trust; it’s about establishing it in the first place. 

Patience, relationships and genuine partnerships will be essential, she said, and would have helped avoid the reactions that have met some health workers working on the vaccination campaign. 

Nunez-Smith said she understood the response of an often-ignored community. 

“People rightly said, ‘Vaccine? Where have you been?’” she said. “‘We have been struggling here with lack of housing. We’ve been struggling with limited economic opportunity. We’ve been struggling here with community violence. Poor schools for our children. And now you care a lot and want to talk about vaccines?’”

Recently, vaccine rates have started to improve among Black communities. Nunez-Smith credited partnerships between health care organizations and local institutions and businesses, such as Black-owned beauty salons and barbershops, that are deemed trustworthy sources of information among members of those communities.

“The theme across every one of these bright lights of innovation was partnership with the communities that have been most affected,” she said. “It was showing up with that spirit of humility and saying, ‘We don’t know the answer. You know the solutions. Help us.’”

Rooting out the causes of disease

Chronic diseases plague the United States. Half of U.S. adults live with a chronic condition, said Samantha Argita, vice president and director of the Racial Equity and Health Policy Program at the Kaiser Family Foundation. The cruel overlap between higher rates of chronic disease among communities of color and it being a major risk factor for severe COVID-19 drove higher mortality rates in nonwhite populations during the pandemic.

Compounding the problem, Black and Latino Americans are more likely to be diagnosed with chronic conditions at younger ages, creating financial burdens. Chronic conditions can reduce earning potential and result in medical debt, said Alyce Adams, MD, professor of epidemiology and public health at Stanford.

The problem has been generations in the making — the result of government policy and societal racism. Redlining is just one example of a policy that has had profound effects, said David Saunders, director of the Office of Health Equity at the Pennsylvania Department of Health. Redlining was the discriminatory practice by banks and real estate agents to prevent Blacks, Latinos and other minority groups from renting or buying homes in certain neighborhoods.

“If we are cordoned off and only can live in certain communities, our access to proper health care is harder to come by,” Saunders said. “The good thing is we can change this phenomenon, and it begins with recognition.”

Rooting out such policies and practices will require listening to and amplifying minority voices, Adams said. Again, partnership is critical. 

“It’s not enough for those of us outside the communities to advocate for them,” Adams said. “We also have to give them the capacity to advocate for themselves. It's matter of shifting the power dynamics such that we put more in the hands of communities so they can ... be equal partners in the work.”

Saunders agreed that community involvement is critical but said that long-term success requires buy-in at every level — what he called the “political determinants of health.”

“The fact is that at the federal, state and local levels, the decisions as to where funding goes is really the determining factor on the ground level as to how healthy a particular community is going to be,” he said.

More prevention-focused care will be foundational to stemming the epidemic of chronic diseases.

Meena Seshamani, MD, PhD, director of the Center for Medicine at the Centers for Medicare and Medicaid Services, noted that innovative, preventive-care programs that emphasized value-based care using a team model also proved effective during the recent crisis. 

“During the pandemic, a lot of these accountable care organizations quickly pivoted to providing telehealth and team-based services that were needed to address the range of issues that the pandemic created,” Seshamani said. “They invested in care managers, in community health workers, who could provide support that was so important for communities who were struggling to stay healthy during the pandemic.”

Can world’s nations respond as one?

Just as the pandemic revealed fault lines in the health care system, it also exposed weaknesses within societies and among nations.

The COVID-19 “infodemic” — the avalanche of information, much of it false or misleading, about the disease and vaccines — has undermined attempts to bring the pandemic under control in the United States and around the globe.

“I think we have learned we can have all the wealth, the technology, the incredible access to vaccines, but we have to deal with the human element,” said Michele Gelfand, professor of organizational behavior at Stanford.

The infodemic fuels uncertainty, which in turn leads people to latch onto conspiracy theories, she said.

Compounding that problem was political leadership that used the pandemic to excite nationalistic tendencies. “That really matters,” said Steve Davis, interim director of the Bill & Melinda Gates Foundation. “The correlation between political belief and vaccine hesitancy is very high.”

Having better organizations and structures in place before the next pandemic will be critical in avoiding a repeat of the last two years, which showed how difficult it is to create complex international agreements in the middle of a crisis.

“What I worry about is that we’re so quick to get over this, and fatigued, that we’re going to forget how important it is to double down now and invest in these systems,” said Davis, adding that organizations like the Gates Foundation and schools like Stanford have an important role in keeping these issues front and center.

Loyce Pace, director of the Office of Global Affairs at the U.S. Department of Health and Human Services, said the bottom line in preparing for the next pandemic is, “How are we positioned to ensure we can respond to protect the people most at risk. Period. I don’t want to have to work so hard to make a case for prevention and preparedness.”

The third installment of the four-part symposium, scheduled for Oct. 28, will focus on tracking and mitigating pandemics in the 21st century. Register here.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.

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