5

Working Toward Change in Communities

The workshop’s last session featured four presentations on translating diversity, equity, and inclusion (DEI) and health equity work into communities to foster change and engagement.

MOVING INTO THE COMMUNITY TO ADVANCE AND ACCELERATE DEI AND JUSTICE

Kimberlydawn Wisdom, senior vice president of community health and equity and chief wellness and diversity officer at Henry Ford Health, said that achieving equity is an important step, but the end goal is justice. She also reiterated the message that quality and equity go together, and that achieving quality requires equity to be at the core of any campaign. She said that when her organization started its equity work in 2007, the goal was to socialize the aspects of equity through the organization, with data driving that work.

As part of socializing equity aspects across the organization, Wisdom offered a variety of courses for which staff could earn continuing education credits. Ultimately, though, she realized that a more immersive experience was in order, so her team took mostly mid-level and midcareer individuals through a rigorous nine-month health care equity program that spent a half-day a month in the classroom and another half-day working on projects outside of the classroom. At graduation, the newly minted health care equity scholars presented posters of their work, with board members in attendance. This program helped drive home the mes-

sage that equity is important and needs to be integrated into everyday business.

In addition to its own efforts, Wisdom’s organization joined the American Hospital Association’s #123forEquity Pledge to Act campaign¹ and the Institute for Healthcare Improvement’s Pursuing Equity initiative. The latter program included visiting seven other health systems, which helped her organization’s journey, she said, given that it is not the type of activity that is easy to do in isolation. Regarding the organization’s work in the community, Wisdom said she and her colleagues went into middle and high schools to engage students in a deep immersion experience. Once a week, she and her team would meet with the students at 26 schools and provide coaching on leadership development, healthy eating, and health lifestyles. With its equity work over the past 16 years, Henry Ford Health has centered equity in its communities. One graduate of the program, Wisdom said, is now a state policy maker.

As an example of how her team is working with the community to increase equity in those communities, Wisdom discussed a community-based program—Sew Up the Safety Net for Women and Children—that she and her team developed with four competing health systems to reduce infant and maternal mortality. However, when the team went into the community, it failed to apply community-based participatory principles to its design efforts. One result of that failure was that the women in the community hated the program’s name because it was unclear what the title meant.

Eventually, the program team formed focus groups and met with the women, who told them they were resilient, resourceful winners and the keepers of their community. They renamed the program the Women-Inspired Neighborhood Network of Detroit² and began working on hard-wiring the safety net by including this program as part of the organization’s clinical model and forming partnerships with over 200 community organizations. Since 2016, the program has used the centering pregnancy model that has women coming in for their prenatal visits as a group. The program also used community health workers to visit the women in their homes between clinic visits. In over 700 births since the program began, there has been only one preventable infant death. Wisdom noted that the program is now available for other organizations to license.

MOVING TO A NEXT-GENERATION HEALTH PLAN

Alexander Li, chief health equity officer of L.A. Care Health Plan, said that California mandates that health systems, including the state’s

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¹ https://ifdhe.aha.org/123forequity (accessed November 21, 2023).

² winnetworkdetroit.org (accessed November 21, 2023).

Medicaid-managed care plans such as that of his organization, have a chief diversity officer in position. He cited data from a 2023 report showing that the percentage of companies in the S&P 500 with a chief diversity officer has increased from 48 percent in 2018 to 74 percent in 2022, though the average tenure for a chief diversity officer in those companies has declined from 37 months in 2018 to 30 months in 2022 (Palkeday et al., 2023). As Joel Weissman, deputy director and chief scientific officer of the Center for Surgery and Public Health at Brigham and Women’s Hospital, and professor of surgery in health policy at Harvard Medical School, noted in his presentation, chief health equity officers leave their positions because they are underappreciated, under-resourced, burned out, traumatized, and exhausted.

Li said that there are many definitions of health equity, and lacking clarity on that definition can cause someone to be unfocused about how to proceed, make change, and progress toward health equity. He also said that making progress is not a sprint but a marathon. Thus, chief health equity officers need to pace themselves and take care of themselves in the face of their overwhelming task. In his opinion, the chief health equity officer need not be a physician, but it has to be someone who understands and appreciates the public’s voice, who understands the available resources, and who has the authority to bend or break rules when appropriate. “You almost have to be the chief coordinator to make this work,” Li said, referring to the need to work with both the health care and social services systems.

When Li started his position, he said, he drafted a memo to his organization’s leadership team and his health equity team describing his plan for going about the work ahead. This exercise was intended to get buy-in from leadership and his team, ensure that everyone was on the same page, and help Li organize his thoughts. “I felt like I was getting pulled in all these different directions within my first two weeks, and I needed something just to anchor myself,” he said. In terms of creating a plan, he said it is important to hold oneself and the organization accountable to the plan. For example, the plan he crafted includes implementing initiatives to improve the health of Black birthing individuals and infants, with the accountable goal of supporting 500 or more Black birthing individuals in one or more of his organization’s programs by September 30, 2024.

Li discussed key initiatives and programs that are in play in California and the need to advocate for support. One initiative takes advantage of the 1115 waiver that allows Medicaid plans to modify Medicaid rules. The California Advancing and Innovating Medi-Cal program³ is designed to improve coordination across his organization’s fragmented health care

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³ https://www.chcf.org/publication/calaim-explained-five-year-plan-transform-medical/ (accessed November 21, 2023).

and social services systems and resources. A significant component of this program is directed at community support and uses money available for housing support, medically tailored meals, and short-term residency services such as recuperative care. Other initiatives call for expanding Medi-Cal to all people regardless of their immigration status and creating a managed care organization tax to increase payments for primary care providers to 87.5 percent of Medicare reimbursement rates.

Looking ahead, Li said, it is unclear if health equity efforts will be more of a local or national movement. He also listed questions whose answers would affect how health equity efforts move forward: Would the expansion of Medi-Cal to everyone regardless of immigration status be permanent? How can health systems define the value of health equity beyond financial return on investment? How can the systems measure progress? Can we be patient enough to undo the economic disparities, structural racism, and other barriers to achieve better health and health outcomes?

STANDING UP AND SPEAKING OUT TO SUPPORT DEI AND HEALTH EQUITY

Olveen Carrasquillo, associate dean for clinical and translational research at the University of Miami Miller School of Medicine, said that as a leader, he feels a responsibility to attend rallies and speak out against social injustice and misguided medical advice. For example, he has often spoken out at rallies and events in support of undocumented immigrants, against racial injustice, and against COVID-19 misinformation promoted by elected officials.

Carrasquillo explained that one of his responsibilities is to address diversity in clinical trial participation and at his institution. At present, 47 percent of such research participants are Hispanic, and 17 percent are Black. For COVID-19 vaccine trials, over 60 percent of study participants at his institution were members of a minoritized population, compared to 25 percent in the rest of the nation. “This does not happen by accident,” he said. “First you need robust community partnerships.” However, along with strong community partnerships, his efforts have also benefited from his institution’s long-standing commitment to DEI. Carrasquillo added that this includes high rates of faculty diversity. As an example, over half of the faculty of his division are members of an underrepresented minority. Such an environment, where many faculty and institutional leaders have championed DEI programs, is key for achieving success in diversity at all levels including in clinical trial participation, he said.

However, Carrasquillo noted that efforts to address and promote DEI in Florida are now being challenged due to attacks by the state’s governor,

presumably as part of his campaigning for the Republican nomination for president. In response to state-led anti-DEI initiatives, Carrasquillo and fellow faculty members and students at the University of Miami, along with faculty at Hispanic-serving Florida International University, have protested publicly and issued signed statements voicing strong opposition against these anti-DEI initiatives. However, he said, many faculty and students have been frustrated that as they were standing up for state DEI programs, the university’s leadership remained silent. As an example, he showed a newspaper article on the faculty- and student-led protests in support of DEI. Carrasquillo said the article noted that when the university was asked to comment on such protests, his institution’s spokesperson declined to respond. Other colleagues have told him the same was true at various campuses of the University of Florida, where institutional leaders also have not spoken out in support of DEI programs for fear of retaliation.

When Florida’s governor turned his attention to the state’s immigrant community, a bill was drafted that would require the state’s hospitals to collect information from patients to determine if they were undocumented immigrants.⁴ While Carrasquillo and a group of Florida health care providers criticized the bill because it would create a culture of fear that will keep some individuals from seeking needed care,⁵ he lamented that more health professionals and health care organizations were not speaking out against this legislation. He suggested that many hospitals likely stayed silent because they feared losing state funding.

The point, Carrasquillo said, is that he is an anomaly. At most Florida universities, only a few faculty members have been vocal critics of such discriminatory actions. Carrasquillo said many faculty, especially those at public universities, fear retaliation by the state government. He added that some institutions have also asked their faculty to stay silent about the end of DEI programs. He added that concerns about retaliation are real and that the state has already taken action against some doctors who expressed concerns about state policies, such as advising children not to get COVID-19 vaccines. Even private institutions such as his with a history of supporting DEI are now remaining silent or issuing vague statements on DEI so as not to upset the state leaders. “I think many of our faculty and staff, and certainly the community partners I work with on many projects, are disappointed by the lack of leadership on this issue,” Carrasquillo said.

Carrasquillo stated that some of the state’s institutions are now trying to find new names for DEI programs, hoping they will go unnoticed.

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⁴ https://www.flsenate.gov/Session/Bill/2023/1718 (accessed November 13, 2023).

⁵ https://news.yahoo.com/florida-hospitals-comply-immigration-law-090744557.html (accessed November 13, 2023).

However, Carrasquillo said his concern about how many traditional DEI champions and C-suites remain silent on the matter is that as history has taught us, such silence often equates to complicity. He also cautioned those at the workshop from other states to be prepared for anti-DEI efforts, such as those in Florida, to come to their states.

INDIGENOUS ENGAGEMENT WITH DEI

Valarie Blue Bird Jernigan, director of the Center for Indigenous Health Research and Policy and a professor in the Department of Rural Health within the Center for Health Sciences at Oklahoma State University, noted that Oklahoma State University was the first institution to open a college of medicine on a tribal reservation, as a strategy to increase the enrollment of Indigenous medical students. “This is an exciting experiment to see if that moves the needle at all in terms of getting more Natives into medicine,” Jernigan said.

An overview of Native nations that Jernigan provided illustrated that Native Americans are not just another racial or ethnic group and are citizens of three sovereigns: their tribal nation, the United States, and the states in which they live. She noted that treaties between the U.S. government and Native nations require the U.S. government to provide health care for Native people in exchange for Native land. One provision of the Affordable Care Act permanently reauthorized the Indian Health Care Improvement Act, which provides funds to the Indian Health Service (IHS) across three types of facilities: IHS facilities, tribal facilities, and urban health care centers. Today, IHS allocates approximately 1 percent of its budget to urban Indian health care centers, even though over 70 percent of Native people live in urban areas. This disparity, she said, exists by design—Congress, in 1953, established a new policy that eliminated much of the government’s support for Indian tribes. In addition, since urban Indian Health Centers are designated federally qualified health centers, they must also treat all comers, not just Native people.

DEI, said Jernigan, is a different issue for Native communities, given that they have no power and are rarely in positions of leadership outside of Indigenous spaces—and even there they are often not in leadership positions. DEI efforts in Indigenous health care facilities, she explained, are focused mostly on the diversity that exists among Native people.

Equity, Jernigan said, is a state in which everyone has a fair opportunity, an idea that should resonate with all people but is not resonating with Native communities. As one participant in a focus group she conducted said, “We don’t want equity. We don’t want what the rest of Americans have. I want to have, what we call in Anishinaabe, mino bimaadiziwn [living the good life and having good health].” From the Native perspective, the goal is not equity but self-determination. As Abi-

gail Echo-Hawk, director of the Urban Indian Health Institute, argues, health equity has been based on Western cultural norms that do not speak to Indigenous people, given that they are influenced by the same institutions and structures that created so much harm in the first place. The point, Jernigan said, is that not all people want the same thing regarding equity. Rather, there are unique goals that Native people have, and equity might not be a term that resonates.

Jernigan said that inclusion to Indigenous people is about building and fostering relationships with Indigenous people with other cultures. It is about creating a respectful environment to explore, learn, and communicate with a community that has been underrepresented for a long time. Most tribes, she said, believe in the concept of “all my relations,” which means being related to everything in the universe comes with the obligation to care for the land. “And so, inclusion is about recognizing that perspective, and it is also about truth and reconciliation,” Jernigan said. As one activist has stated, “We cannot have reconciliation without truth.”

Two primary practices that Jernigan said she would recommend when thinking about DEI and Native people are two-eyed seeing and cultural humility. Two-eyed seeing, she explained, “refers to learning to see from one eye with the strengths of Indigenous knowledge and ways of knowing, and from the other eye with the strengths of Western knowledge and ways of knowing, and to use this learning together for the benefit of all.” Cultural humility, which differs from cultural competence, is the personal, lifelong commitment to self-evaluation and self-critique in which the individual not only learns about another’s culture but also starts with an examination of one’s own beliefs and cultural identities (Tervalon and Murray-García, 1998). “I believe cultural humility is a key practice,” she said. “You can never be fully competent in anyone’s culture, even including your own.”

DISCUSSION

An audience member asked if there was one spark or catalyst that could help health care leaders start turning the ship toward envisioning health care and clinical goals when advancing and protecting public health at the society and population level. Li said that building relationships would be a good start, and Wisdom added that one spark could be proximity to the community that provides an ability to facilitate change. “The more that leadership can be proximal to what is happening in these communities,” she said, “there may be a greater openness to strategizing how to close the disparit[y] gaps, move toward equity, and ultimately move toward social justice.” Carrasquillo said that payment reform focused on value could be a catalyst for change.

CLOSING REMARKS

Winston Wong, workshop planning committee chair and scholar-in-residence at the UCLA Kaiser Permanente Center for Health Equity, commented that it is tough sledding for these groups of individuals who have taken up the position of being a DEI or health equity officer, who are at the vanguard and are the strength of this movement. “They are drawing on the strength of their predecessors in paving the road, but they are extremely vulnerable,” Wong said. Moving forward on DEI and health equity is not guaranteed to succeed, he added. Wong added that success will require fighting, ensuring the data exist to support these efforts, and committing to ensure these positions are protected throughout the organization and the community. As far as how to accomplish that, he said, the roundtable will try to address that over the coming year.