Latest / Health Ethics Podcast / Health Equity is the Goal, Health Justice is the Path

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Health Equity is the Goal, Health Justice is the Path · Health Ethics Podcast

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Welcome to the COVID Ethics Series podcast, a conversation with leading experts about bioethical
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issues that have been exacerbated due to the COVID nineteen pandemic. I'm Brian Pilkington,
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and I teach bioethics at Seatonhall University and at the Hackensack Marinian School of
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Medicine. I moderate the COVID Ethics Series in cooperation with the IHS Library and
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IHS Student Life. This podcast is a spin off collaboration with the IHS Library
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where we'll have the opportunity to go deep with the experts from our series.
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Thanks for joining our conversation. Welcome everyone to the COVID Ethics Series. I
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am Brian Pilkington and it is my great pleasure to be with doctor Phil Alberti
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for today's discussion. Doctor Albertie is the founding director of the Double AMC Center
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for Health Justice and Senior Director of Health Equity Research and Policy at the Double
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AMC. He is a population health scientist whose singular professional commitment to health equity
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research and action spans over two decades. He's widely published, a frequent public
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speaker, and has served on advisory boards and expert panels for numerous organizations,
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including the Center for Centers for Disease Control and Prevention, the National Institutes of
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Health, and the Centers for Medical Care and Medicaid Services. In twenty twenty
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one, doctor Albertie founded the Double AMC Center for Health Justice as focusing on
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order way to focus on building evidence in support of the structural changes needed to
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ensure that all communities thrive. It is such a pleasure to have you here,
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Philip, Thank you so much for joining me today. Thank you for
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the invite. Brian excited, excited to chat. So we're just going to
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get right into it. Health justice. This has been your jam for quite
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some time. It's gaining increasing popularity. And I'll do this a few times
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throughout our conversation. But the audience who usually turns into the COVID Ethics series
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will have touched on this a bitten conversation in our Vulnerability session with Nancy Berlinger
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and also in our session with schred hartvinkat to pour them on rights to health.
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But Philip tell us, because we have folks tuning in from all over
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the place, what is health justice? Sure? So at the Center we
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say that health equity is our goal and health justice is the path. So
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maybe it'll be clearer to define what health justice is kind of in light of
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what health equity is. Right. So we all know that CDC or the
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WHO or the World Health Organization definition of health equity. Right, every community,
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every person has a fair and just opportunity to attain their full health potention.
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Right, And it's a really important definition, but it's a little bit
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a little bit vague, and what does that feel like on the ground.
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How do you know when you've achieved right, that state of just opportunity.
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So there's this really great framework that is relatively new, I think, maybe
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just like maybe a year old, called the Vital Conditions for Health Framework.
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I promise I'm getting to the health justice question in a second. And what
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that framework is, it's kind of like a more asset based, positive alternative
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to the social determinants of health. Right. So rather than saying I want
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to intervene on housing, right, the Vital Conditions say we want all of
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our communities to have humane housing. Right. It's the goal of the work
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is that the default scenario, right when we think about health equity and the
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center, then it's really when every community kind of has and provides like as
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a default, without having to do anything right, the basic vital conditions that
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we all need to thrive, like humane housing or reliable transportation or clean air
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or freedom from racism and discrimination. These things that should just exist everywhere.
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So that's our goal for health equities. Every community has that. And then
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over the course of my career and thinking and doing in this space kind of
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health justice as a framework that was originally developed by Emily Benfer, who's a
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lawyer an incredible housing advocate back in twenty fifteen, we operationalize that framework in
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this way. We say health justice requires that we put one foot in community
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wisdom and multi sector partnership. So that's our process. But that's how we
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do the work of health justice right, grounding it in that community lived experience,
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and then we work in that collaboration to develop the kinds of evidence through
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research that we can embed into organizational, local, state, federal policy change
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that actually creates that health opportunity, that creates meaningful work or humane housing or
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reliable transportation right for communities all at once with a stroke of a pen.
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So it's really not about the work that takes place in a physician's offense.
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Although I think there's a real corollary that we can talk about maybe healthcare equity
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between patient populations, certainly, and of course the organizational work of equity,
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diversity and inclusion for medical schools and teaching hospitals. But the work of health
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equity is really located outside of the health system, of the healthcare systems walls,
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and health justice really demands that we dig pretty deeply to address and we
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can talk more about fundamental causes of disease if you're interested kind of what our
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fund and it kind of requires that we we dig our collaborative shovel pretty deeply
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to get to the root causes of the kinds of injustices that stand in the
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way of our communities having that ability to thrive. Thank you, really helpful
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framing, and I appreciate the imagery of the path toward the goal. Yeah,
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let's keep going. So say a little bit more about what those are
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and within the context of there being health related features outside of the physician's office,
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because this is a common conversation at the Hackensack Merinity in School of Medicine
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where I teach, and also at Seaton Hall where I teach thinking about health
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broadly, thinking about ethics broadly. The clinic is essential, but it's not
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exhaustive. So say more about this please, Well, so I'll say two
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things. So there's a framework that I kind of talk about a lot,
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and I think about three flavors of equity, right, and so I think
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about equity within an organization, right, between populations inside and organizations. So
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think about all the work at your institution around equity, diversity, and inclusion
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that looks like pay, equity promotion, equity representation, belonging, all of
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those structures and systems to ensure that learner populations, administrator populations, faculty populations
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have that same equitable opportunity to contribute and thrive, right. And of course,
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a healthcare organization that's really living that that EDI life, that's doing that
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well, is going to contribute to healthcare equity, right, which is equity
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between patient populations in a clinical setting, looking at access, so equitable access
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to care, but not any care, right, high quality clinical care.
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And so of course if the organization itself is characterized by equity and belonging,
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then of course they're going to be able to contribute to that equity between patient
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populations as well, and that's not just a product of EDI work. It's
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also a product of the shift from payments for volume of services to value,
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So this kind of change to value based purchasing, it's also quality improvement.
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It's also patient engagement. It's also all that important work that you're doing are
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on screening for patient level social needs and referring to community assets. So all
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of that goes into that healthcare equity bucket. But all population science tells us
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that medical care contributes like fifteen or twenty percent to what makes a person or
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a community healthy. So yes, we have to our members, medical schools,
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teaching hospitals, your institutions have to be committed to healthcare equity because you
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own it, right, it's kind of like your jam, Like if you're
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not going to do it, who's going to do it? But you have
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to be mindful that's not the full sum of the conversation because you know,
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those vital conditions for health that we just talked about, those live outside of
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the healthcare system. And it's really incredible. There's this beautiful wheel that represents
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the vital conditions, and one of the wedges of the pie is basic needs
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for health and safety, and clinical care is just one sliver of that piece
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of the pie. Because basic needs for health and safety also has to do
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with you know, clean air and potable water and freedom from things like gun
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violence. Right, all of that is in that pie wedge. And so
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I think there's a through line there. Of course, you know of that
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fifteen or twenty percent connecting the healthcarecterity to the broader health equity. But I
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mentioned vital conditions, and so now we'll kind of talk about how that connects
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to the outside of the healthcare system's walls and this kind of concept of health
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justice. So my training, and this is going way back in like you
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know, two thousand was in social factors as fundamental causes of disease. So
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social factors like racism, classism, sexism, homophobia, transphobia, zo fill
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in your isms and phobias, right, So, and the reason that these
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are positive to be fundamental causes of illness over three reasons. So one each
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of those things, each of those isms and phobias impacts multiple outcomes. I
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don't think we need to belabor that point. That's just the truth. They
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also can take many pathways to get to that downstream impact. Right, So
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imagine at and kind of walk through the hypothetical example, like, imagine you
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know that we in the healthcare system had were perfect at eliminating racism from all
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of our textbooks and algorithms and clinical interactions. Racism doesn't need healthcare to exert
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its influence. It can go through education, or the judicial system, or
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any other number of ways of processes, structures and systems to impact all of
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those downstream outcomes. So that's that's the second characteristics. So we've got many
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pathways, many outcomes, and those isms and phobias. The third, the
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third quality or criterion is that they control resources to health. I'm sorry,
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they control health promoting resources like money, information, power, beneficial social connections,
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right, And so and the conceptualization that I kind of walk around with,
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that's like the base of the pyramid. These fundamental causes then work their
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way into our But my friend Daniel DAWs would call political determinants of health,
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right, the policy choices we make or don't make, the actions we take
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or don't take, that then maldistribute across our communities those vital conditions for health.
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And I don't think we need to look very far in twenty twenty three
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to look at the way that racism impacts voting policy, or the way that
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transphobia impacts policies, trying to erase that entire community from the fabric of our
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nation right where that sexism impacts healthcare access around reproductive services and abortion care,
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etc. So the goal of health justice again is to dig that deeply,
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to really think about the kinds of movements that really exist in that anti racist,
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antidiscriminatory space that creates the power, that community centered power to think about
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the policies and policy changes again all levels organizational, all the way up to
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federal, that are going to frankly redistribute in a more equitable way those vital
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conditions for health so that every single community, every community benefits from a health
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equity agenda. And I want to be labor that point a little bit because
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I think there's a lot of harmful narrative out there, like we are trying
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to say, well, in order to achieve health equity, we need to
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steal health from community a right and give it to community B. That it's
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a false choice. The scarcity mindset doesn't have to exist in this nation at
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this time. We have the resources and the meanings to make sure that every
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community black, white, brown, gay, straight, rich, poor has
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these fundamental, these basic kind of conditions that we all need to thrive.
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And so that's where the health justice agenda lives. There's a lot of work
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to do in healthcare equity when it comes to health professions, education, and
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kind of the provision of care and clinical settings that is mindful of that broader
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context. But really for medicine to play that health equity game has to do
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with advocacy, right, advocating in solidarity and partnership across sectors for the kinds
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of policy changes that would benefit the communities and patient populations that we serve,
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I mean, super helpful. Deeper, we could spend hours talking and I
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have two sort of divergent paths, and so I'll mention them both, send
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you down one, and then we would come back together first as a sort
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of is a smaller nuts and bolts maybe even theoretical question about how how do
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you see relying on community wisdom given the diversity, the history, the context
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of different kinds of communities, especially within maybe a longer history and medicine of
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a certain kind of medical model that may not have been as open to other
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sorts of ways of knowing. Let's just say so that's a big question.
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And then the other question is, and you can pick. I mean,
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what you've said sounds wonderful to me. We'll get these vital conditions covered.
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I mean, this is great. But there are folks that are less interested
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and smart folks in talking about health justice or justice and health. They really
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want to talk about rights to health care, which is a more narrow approach.
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And I know that there's a big debate. So either if you can
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help you know the audience understand sort of thinking through community wisdom given the diversity
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of communities, or if you've given any thoughts to the I guess more narrow
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view of really focusing on rights to healthcare, even though it's only fifteen percent
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or the number you pulled. So take those as you would like. Yeah,
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those are huge. So let's let's start with the first one, because
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I love talking and we always start with community. And so there was a
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reason that the very first output of the Center for Health Justice was our Principles
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of Trustworthiness toolkit. And so you mentioned kind of historic. You were very
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polite, I would say, and framing the question kind of you know,
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it's not just the history of medicine and public health and kind of those historical
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abuses that we all know and talk about, whether it's Tuskegee or Mary and
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Emery and Sims or Henrietta Lacks, etc. There are lots of current examples
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as well, so we don't need to we don't need to go too far
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back in the history books for kind of real, you know, abuses at
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the hands of medicine and public health and so at the core of community engagement.
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And what I what I don't mean by community engagement is the way that
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it's often operationalized by kind of institutions with power and privilege, which is,
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you know, we've got a community advisory board or maybe hundreds of community advisory
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boards across hundreds of projects, and of course there's no coordination of them.
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But that's that's a separate conversation. But most people say, well, you
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know, here are our brilliant ideas. We're going to bring them to our
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community advisory board. We're going to get a thumbs up on our ideas,
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and then we'll check the box and say that we've engaged the community like that.
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That is not what we're talking about. So the principles of trustworthiness,
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we're really about, how can organizations like an academic medical center, like a
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public health department, like a police department. Right as opposed to demanding that
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communities get over their mistrust or distrust because quote unquote we're not like that anymore.
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As opposed to that, let's really put the onus where it belongs,
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on those institutions with power and privilege to demonstrate they are worthy of the community's
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trust. And so we partnered via our CHARGE Collaborative. So CHARGE is a
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group of about fourteen hundred health equity champions at the center has convened even before
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it was a center, so eight or nine years now, and we work
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with them in many ways. But in this instance they were conduits to local
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communities. So we work with nine members of that CHARGE group who represented seven
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different local communities, who then each went into their local communities. This is
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very early twenty twenty to interview three to five community members about what it would
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mean for these kinds of institutions to demonstrate that trustworthiness, like what concrete principles
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and related actions could we take, and then that full group of us or
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the Center team, those charge collaborators and all thirty plus community members co develop
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the work together, co develop that toolkit. And that's part of what I'm
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getting at of this process, right of health, justice, of doing this
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work in a truly aged way, where you mentioned kind of epistemological equity,
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where like knowledge is allowed to flourish in all different ways, and no one's
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knowledge trumps anyone else's. It's all important for the mix and the creation.
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And that's where that toolkit came from. And so the very first principle is
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so germane to what you said. It's the community is already educated, right,
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That's why it doesn't trust you, right. So it's about you have
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to acknowledge, take responsibility for those current and past actions. You have to
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be explicit about it, think about how you talk with the words that you
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use, How respectful are you in your conversations with community in that engagement process.
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And so I think, yes, our institutions haven't always been at the
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forefront. We are not always the most humble. We don't necessarily agree that
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others knowledge is as valuable as our own. And that is exactly kind of
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one of the goals of the Center. Is to help us get over that,
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because we are wrong on all counts. Communities that have been that have
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not only survived, but in many instances have been able to thrive in places
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where they are lacking those vital conditions, where they are faced with adverse political
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decisions and politicians who do not represent their own voices, their own constituents,
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we have seen communities thrive. So there is wisdom about what it takes to
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navigate those injustices that frankly, Brian folks like you and I are not going
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to know unless we are truly approaching the work as as humble kind of equal
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partners willing to learn. Because for health justice leadership is partnership, I mean,
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really helpful. And it's not every day I'll say that I get to
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talk epistemology. So this is this is why I mean, and again the
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for the audience of the books, you'll be aware of some of the sort
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of concerns are an epistemic injustice, which have popped up on a couple of
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podcasts, but just briefly, so I mean, is you got to exactly
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the core of the question I was thinking about, And now I want to
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push on to sort of the consideration of rights, which maybe it's ill fitting
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to ask now, given the sort of narrowness I keep saying that of you
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know, sort of rights to healthcare. I mean the following kinds of things
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you have a much, I mean, which I really appreciate. The breadth
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and the breadth and the expansiveness right of your health justice program, engagement with
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communities. I mean, this is huge. So any thoughts about rights to
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healthcare, rights to health? Is this useful for health justice? Is it
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too small? I mean, just any reflections of it's central. You can't
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I mean, if we could tomorrow snap our fingers and have twenty percent of
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inequities and health injustice disappear because medicine's gotten its act together, let's do it
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like let's go. And so I think, no, it's it's core.
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I think. The reason that I'm so careful about the distinction between health and
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healthcarecuity and using the words very precisely and with intention, because I think we
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also live in an environment where health has been medicalized, and so I don't
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want anyone to think that we can attain true health equity just through medical care.
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I don't want physicians and healthcare administrators to think that they are in charge
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of like health equity, and frankly that that means that I don't want healthcare
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organizations to become landlords or to become grossers. That's not the role either.
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And so I think, you know, centering that fifteen to twenty percent is
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key, And everything I said about community engagement I would double down on for
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patient engagement, right, And so I think, you know, there are
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some really important things. So how are we advocating for healthcare policies. I'm
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not going to name any explicit ones that truly are about expanding in an equitable
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way access to high quality healthcare. So I think that is where we have
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to start right conversations about healthcare equity and rights to healthcare. Interestingly, we
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did a poll that we just released maybe a week and a half ago of
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members of gen Z. I'm going to try to remember the exact figures.
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Those are nationally representative poll of eighteen to twenty four year olds, and the
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purpose of the poll is to find bipartisan support for a health equity agenda.
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So, yes, we have some divisions, but health justice is obviously a
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future oriented thing. We're not going to get there tomorrow, and so where
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are areas of agreement that we could be fostering right now, because the leaders
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of tomorrow are already there. And so when it came to like this question,
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it was something like either seventy five or seventy seven percent of self identified
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conservative members of gen Z said that healthcare is a human right right and that
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the federal government has a responsibility to ensure everyone has access to healthcare. So
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I think, you know, we have to ask ourselves when that kind of
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support exists, and I would say that it exists, maybe even an older
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generation, perhaps maybe not to that degree. Again, we come back to
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that vital conditions framework. At the center of that framework is civic muscle and
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belonging right. That's the core of this. So I think there are many
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instances, whether it's gun policy, healthcare policy, where the public and bipartisan
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consensus ways feel feel very strongly about something, including the right to healthcare,
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that maybe our elected officials are not mirroring in their votes and in their own
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and in their own work, and so that our civic muscle is somehow diminished.
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I think organizationally, there are two things that come to mind in the
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healthcare equity and even the health equity bucket. So one, of course,
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is that core commitment to equity, diversity, and inclusion that is so contributory
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to the kinds of care that is provided. The police's care is provided,
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the populations that feel welcomed and that ease and our healthcare settings. So that
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is a core commitment. But I also want to say a general infrastructure for
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the kind of patient and community engagement that is absent, I would say from
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almost one hundred percent of our academic medical center institutions right the work is siloed,
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it's not transparent, we don't know who's doing what. We're not fiscally
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ready to pay patients and communities for their wisdom like we would pay any other
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expert. So I think there's a lot of work both yes, in the
23:30
EDI space, but also in kind of organizing the practice and culture of medicine
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towards healthcare equity and the data we collect, the stratifications we conduct, the
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facilities we have or don't have, an engaging patients as equal partners in that
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work, and even designing the workflows that makes all patient populations feel that they
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can access healthcare like anyone else can I'm not sure if that answered that second
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request. Yes, yes, yeah, no, no, this was It's
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great and it's I mean, the poll was surprising to me, but super
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helpful, and I think you may be right in the suggestion it's more expensive.
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Actually, just before we were talking, I was speaking with my wonderful
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colleague Althia Joseph at Seaton Hall and very similar kinds of claims and thinking about
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rights to healthcare for everyone, and in conversations with members of communities outside of
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the US, it's actually been noted as sort of well, the moral leadership,
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and I don't really don't know how to think about more leadership on an
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international level, but more leadership may not be there because look, you're not
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taking care of folks, and it's just seen as obvious. So it's a
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it heartens me, and I think this poll, the poll is really helpful.
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And I take the points on organization, and I take the points of
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you know, thinking about gen Z the eighteen twenty four year old let's stick
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with those not always an age group of folks who go through medical school.
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I mean, how would you any reflections on what should be going on in
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medical schools? I mean, how are you folks at the Center for Health
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Justice Double AMC. How are we thinking about health justice within medical education?
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Yea, so full you know, full disclosure amount of physicians. So I've
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never been through medical schools, so I can't steak with any kind of that
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lived experience, but I'll answer in this way. I think there's a lot
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of work at the AMC. So we don't we don't develop curriculum, we
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don't mandate curriculum or curricular content. But we have recently, my colleagues,
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particularly in our academic affairs and our equity, diversity and Inclusion teams, have
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been producing these sets of competencies that really do speak to some of the skills
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and behaviors that we think, you know, entering residents, graduating residents,
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you know, full fledged physicians should have. So there's a great set of
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telehealth competencies that talks about telehealth or healthcare equity through telemedicine. There's a great
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set that I actually worked on a little bit a few years ago of quality
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improvement patient safety competencies and one of the domains is healthcare equity in QIPS.
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And then very recently there was a competency set around equity diversity and inclusion.
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That really is very, very expansive and well thought through. I think though
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it's like, for me, an overwhelming kind of amount of skills and competencies.
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And I don't necessarily know that that medicine as a field has landed on
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like the three or four core skills that every physician, every specialty right must
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have in order to promote a population health slash health equity agenda. Right,
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some folks are going to be like me. Some physicians are going to want
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to go full tilt boogie and like drive this and become physician public health advocates.
26:56
Fantastic, But that's not the expectation. I don't think that every physical
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needs to be a public health professional, because we have public health professionals.
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They don't all need to be population health scientists because folks like me are population
27:07
health scientists. The idea is to make them better partners and to really identify
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those core skills. And so when I thought about this, because I had
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a feeling you might ask me something about medical education, So I think,
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A, it's really crucial that every physician, no matter where they go to
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and no matter what kind of medicine they practice understands their place in the broadest
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system for health, like number one, not just the health care system,
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but where where does their cog fit in this machine? Right from fundamental causes
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all the way up through one on one clinical care. What is the role
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of a physician across those three flavors of equity? I think that's important,
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that kind of knowledge. I think active listening. It's probably a skill that
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every physician needs to contribute to this work, either in their nical work or
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in their advocacy work, like not just hearing the words coming out of a
28:03
patient or a family member or a caregiver, but then taking action right on
28:08
that work and then you know, tying those two together kind of their place
28:15
in the system, and that active listening, you know, the knowledge and
28:18
skill to be able to refer a patient a family to the right either healthcare
28:26
asset or community asset to expertly address whatever that health related social need. Now
28:33
we do that well with clinical needs. The physicians not the right person to
28:37
deal with all of this. They don't have the time, they don't have
28:40
the training we have. You know, I think about care teams, whether
28:44
it's you know, PAS nurses or community based practitioners like Dulas Putomatos community health
28:49
workers. Right, there are other experts back to the epistemology, right,
28:53
there are other experts whose knowledge and connections are more beneficial in kind of this
28:59
broader sense of like social care. So let the physicians, let that,
29:03
let that one specific expert do that expertise like listen, know their place,
29:10
know what connections are necessary, and then anything above that in terms of these
29:14
broader competencies, that's like cherries on top, that's gravy. That's you cultivating
29:18
a different kind of activist physician, which I'm here for all day because for
29:22
better or for worse, physicians have a louder voice at advocacy tables than folks,
29:29
like, no one wants to hear from the epidemiologist, right, No,
29:32
I trust me, no one wants to hear from me, But they
29:33
definitely want to hear you know, at local, state, and federal policy
29:37
tables. They're super interested, and not only what physicians have to say,
29:41
but what their patients have to say. Those stories combined with the data,
29:45
it's really powerful, and so we need some of those physicians. But I
29:51
am a full onbeliever medicine does not own health equity and physicians do not need
29:56
to be population health experts. And just because as you have, I'll be
30:00
quiet before I get myself in trouble. Those are my final thoughts on that.
30:04
No, no trouble, I mean super helpful, and I think the
30:10
would be Again, we have two non physicians talking about medical education. But
30:14
the amount that students working through medical school, working through health sciences programs,
30:21
whether they're eighties, otis pas, our colleagues and nursing, there is so
30:26
much. And as the importance of sort of health considerations beyond the clinic gets
30:33
raised, it can seem, at least to some like that's just more and
30:37
more. But it's a team effort. I mean that's a easy sort of
30:40
sports analogy, but there's and you don't need at all, right, you
30:44
need to be able to successfully navigate folks to the expert. And that's what
30:48
I really appreciate about your epistemological approach. I mean, it's proper deference to
30:52
expertise, but understanding that expertise comes in a variety of forms and you might
30:57
not yet be familiar with that, and you can lift it up so that
31:02
the what's required of an individual practitioner to make those connections and behave in those
31:07
spaces and those partnership like changes with this mindset. But we can lift that
31:11
and make a corollary to our organizations and talk about organizational competencies and the way
31:17
that our institutions behave in community partnerships. Right Oftentimes, the AMC, because
31:22
of its it's well resourced, you know, financial resources, clinical resources,
31:27
scientific resources, feels like it needs to be the lead in community coalitions,
31:33
like it needs to be the driver or the convener or the backbone I call
31:37
BS on that, right, So I think, you know, and I
31:40
don't think anyone's necessarily done the work to delineate and maybe we can start that
31:44
here. Kind of those organizational competencies, some of it's related to trustworth than
31:48
as some of it's related to what we've already talked about. You know,
31:52
what does it mean for a large academic medical center to behave in a multisector
31:57
community collaboration in ways that facilitate the multidirectional sharing of expertise and the creation of
32:06
solutions that are therefore just like inherently better Because they've centered that lived experience,
32:14
it resonates across sectors and everyone's contributing, it's like to the maximum ability of
32:20
their resources to that solution. And so I think there's there's a room to
32:25
grow thinking not just about team based care and that kind of epistemological difference,
32:30
but also that broader way that our institutions behave and in these collaboratives. But
32:38
yeah, I mean institutions, when they're working well and when they're thriving right,
32:43
they support the on the ground practices. And folks who are tuning into
32:47
this podcast will be aware of my usual line on bioethics, and I think
32:52
we can maybe expand this to considerations of health and help justice. You don't
32:57
solve tough ethical or bioethical issues if you don't have a bunch of folks from
33:01
different perspectives, different experiences, different disciplines working together. And that's where I
33:07
think that your points of what sort of navigation and active listening are broadly applicable.
33:12
So this is, yeah, maybe this is where really intentional. So
33:15
like some of the things that our center did, which was really innovative and
33:19
pushed the AMC mothership a little bit, you know, pushed not a little
33:22
bit a lot when we said, you know, we want an advisory group.
33:24
But we want our advisory group to only have, you know, to
33:28
have ten seats at the table, only one of which is reserved for a
33:31
physician. The other nine are going to be from the arts, and from
33:35
housing, and from civil rights and from food justice, and we're going to
33:37
pay them as experts for three years and they're actually going to co develop our
33:43
work. Well what's the work going to be? Well, I can't tell
33:45
you in advance because we were going to co develop it in real time together.
33:50
And so I think, you know, it's it's a heart it's a
33:52
big leap for institutions to make to have that kind of intentionality and then to
33:59
pony up the resources and the will to make that happen. And so I'm
34:02
super grateful for our for our double AMC leadership to let us kind of walk
34:07
the talk on some of these you know, health justice principles, because we
34:13
always say the process is as important as the product, right, and if
34:16
you don't do this in an authentic way, you will never attain the outputs
34:21
and outcomes that you want to attain. Yeah, I mean yeah, good
34:27
organizations need leadership that's open to trying new things and taking certain kinds of risks
34:32
here. I mean, you don't yeah, it's this is good. So
34:36
I want to so suppose of folks who are listening in they think, you
34:39
know, this resonates with their experience. They like this idea. Maybe they're
34:43
in medical education, health sciences education of some sort, and they think,
34:45
okay, yeah, Philips right about health justice the importance here. And you've
34:51
done, I mean, so much work and you can sort of jump up
34:53
to the higher level or sort of just keep it, you know, point
34:57
us to the right papers to follow up on. But how for folks who
35:00
are interested, what's the best way to start to bring public and population health
35:06
concepts which you've done so much work on, how do we bring those to
35:08
bear in medical practice, in healthcare education? I mean, what's the advice
35:15
for folks who are looking to sort of do some of this stuff. I'm
35:23
pausing because I'm trying to think of the best first step. So you know,
35:29
I think it depends on from where you are in that ecosystem, right,
35:34
So if you are, there are so many different entry points, so
35:40
I think you know, one one underutilized resource, particularly for not for profit
35:45
health systems, is the community health needs assessment. Right. And so if
35:52
if done in the spirit with which that regulation is intended, and by that
35:55
I mean done by the healthcare institution itself and not kind of farmed out to
36:00
a consultant, that could be and the organizing principle, or the ways in
36:07
which patients and communities are engaged in service of population and community health. It
36:13
could, you know, from the research questions that are asked, to the
36:15
experiential learning opportunities that are developed, right to the places and ways in which
36:21
clinical care is provided, you know, to the community based partnerships that are
36:24
better sparked. It really could be a guiding principle. So I'd say a
36:30
first step is maybe read your organization H and A right, learn first and
36:36
foremost what your communities are saying, are there prioritize needs, and then understand
36:42
how close or far from your community your institution's response to those community prioritize needs.
36:50
Is that strategy? So I take a look at that document. I
36:54
never wanted to, like go to the literature first, because what are you
36:59
going to get from a paper? Bat said, I will share with you,
37:02
Brian, this is going to sound so gross, especially given at that
37:06
intro. I'm going to share one of my own papers. I'll share it
37:08
with you after that. We actually just had published with lays out kind of
37:13
a framework. It's called a population health Impact Pyramid for healthcare and so what
37:20
it does. It takes a riff off of doctor Tom Frieden's public health Impact
37:22
Pyramid that he published in twenty ten. I kind of looked at the kinds
37:27
of interventions that are maximally impactful when it comes to public health interventions or at
37:31
the top was kind of individual education, at the bottom was addressing socioeconomic factors.
37:38
So our pyramid is really about what can the field of healthcare do to
37:44
truly impact population health? And I might get the order of the tiers wrong,
37:49
but I'll start at the bottom because we've already kind of gone through it.
37:52
So no surprise. Fundamental causes right of health and wellness, so being
37:55
explicitly anti racist, anti sexist, at set right political determinants of health.
38:01
So really thinking about the advocacy that you, as an individual or your institution
38:06
is engaged in the vital conditions of the multisector partnership, the local collaborations.
38:12
You know, your institutions anchor work are you are you contributing to the economic
38:16
development of your local community through procurement and hiring and investing in local businesses.
38:22
You know, the next level up is the healthcare context, which is everything
38:27
from EDI, So all of that core EDI work in that kind of within
38:32
the context of a system, all the way through the larger policy healthcare policy
38:37
changes around value based purchasing, etc. Right then thinking about the kinds of
38:43
organizational commitments that you're making to the data that you collect, to that infrastructure
38:46
for community and patient engagement. And then the next level up those socio clinical
38:52
interventions. So are you screening for health related social needs? Are you referring
38:57
do you have a medical legal partnership where you brought in a lawyer to the
39:00
care team to address health harming legal needs. And then the tip of the
39:04
pyramid, so maybe the least directly impactful full well knowing that all seven tiers
39:08
are essential is the health professions education. So making clear kind of what what
39:15
across any kind of practitioner has needed those skills, those confidencies to locate themselves
39:21
in that pyramid and to dig as deeply down to as fundamental roots as possible,
39:27
super healthful. And I mean, yeah, we've talked before so you
39:30
know, I'm excited now to read this paper, and it's great. We
39:32
have a number of students who listen from all walks of life. We have
39:37
philosophy, majors, medical, all sorts of folks. So I think the
39:39
paper is helpful. Though I take that open for all feedback because it's just
39:44
you know, two people's thoughts in the paper. So this is this may
39:49
be an assignment in the future if you get a bunch of papers that say,
39:52
you know, Professor Pilkinson's class on X, you went have a host
39:54
of responses, So I want to get you out. We'll have a positive
40:00
question right at the end. But one short one first. You mentioned once
40:04
or twice, and we've talked before about health challenges around gun violence, and
40:09
we've seen I mean recent events you should I can't not ask, so any
40:17
thoughts from all the work you've done on publishing, population health, work on
40:22
health justice, any reflections or opportunities for hope here. My first, like
40:29
gut response is just to repeat, it's the guns. So I'm just gonna
40:32
say that out loud. That's my personal bias. It's the guns. It's
40:36
not mental health. But as a red herring, I think it's just important
40:39
to say that loud as often as possible. But I'll bring it back to
40:45
the vital conditions for health, right, I think the bigger question is why
40:52
are people? Why are communities so afraid? Why are they so quick to
41:01
go to violence? Right? You know, if the goal of the vital
41:06
conditions for health is that all communities thrive, I think you know, United
41:12
States twenty twenty three. You can look at various metrics. We are so
41:15
far from a state where all communities are thriving, where it's almost like many
41:21
communities, if not most communities are building. Right, And so I think
41:23
when we are in a period of economic and like a guilting of the heart,
41:35
I don't know how to say it any other way. Right, when
41:37
when our communities are characterized by the lack of all those vital conditions, the
41:43
lack of meaningful work, the lack of reliable transportation, the lack of humane
41:47
housing, the lack of freedom for from racism and discrimination, it's it's no
41:54
surprise to me that when our basic needs, you can even get like Maslow
42:00
if you want, like our basic needs right aren't being met. And you
42:05
couple that with endemic miss and disinformation and fear mongering and putting up You know,
42:13
we could go through a history of the metamorphosis of the red herring or
42:17
the strong person. Right, So, whether it's the welfare queen that never
42:22
existed, to the groomers of today, to the terrorists from them, I
42:25
mean, take your pick, to the global corporatist that is just a stand
42:29
in for anti Semitism. I mean, I think we can go from straw
42:34
person to straw person, other to other that when paired with the lack of
42:38
our basic needs for safety being met, the lies being told in various venues
42:45
that create us versus them mentality, and frankly, more guns than people in
42:52
our country, it's just no surprise to me. So I'll go back to
42:54
that pole again. Right, So, there were some divisions. There were
42:59
some conservative liberal self identified conservative liberal divisions among generations Z, but overall,
43:07
seventy percent of that generation said that gun violence is a public health issue.
43:10
It's a pretty large majority, right in sixty percent, and this is where
43:15
there were pretty big political divisions, or at least ideological divisions. Sixty percent
43:21
that it said that it should be a top federal priority. So I'm also
43:25
reminded of another poll that just came out. I think it was like a
43:28
Fox News poll, but I can't believe they aired. But it was like
43:31
eighty eight percent pro background check, eighty seven percent pro all these common sense
43:37
gun control policies. This was a Fox News poll. And so again I
43:43
go back to a statement that I made earlier about the middle of that vital
43:45
conditions wheel being civic muscle and belonging. We are in a state right now
43:51
when almost everybody agreed with some of the kinds of policies that would be effective
43:58
not at eradicating this epidemic, this public health crisis, but if at least
44:05
mitigating it somewhat. And yet the folks that are decision makers and policymakers right
44:08
now ignore right, ignore that consensus, ignore their constituents. So again I
44:15
come back to health justice is a movement right If if our voices are not
44:21
being heard, we need to collectively find those areas of consensus, of nonpartisan,
44:27
bipartisan, all partisan agreement, and flex our civic muscle together and make
44:30
sure that are the people that are opportunity makers, are policymakers, etc.
44:37
Are listening right to where what we want and what we agree, and when
44:40
it comes to gun violence, we are we are so far from that.
44:46
I don't know. Those are some of my musings. No, I mean,
44:50
well put and I think, well, we'll wrap up there. I
44:53
mean, because that perfectly comes full circle. It sounds like, given the
44:58
consensus around the sort of key fact is related to gun violence and health,
45:01
to ignore this is to ignore the wisdom of many communities. I mean,
45:06
this is what it seems like, and it's so we've gotten Yeah, now,
45:08
Philip, thank you so much for your time. I've learned a ton
45:12
everyone. Thank you for tuning in, and we'll be sure to list a
45:15
number of doctor Albertie's papers, some of my favorites, as well as the
45:19
one you just mentioned, along with some other resources on our web page.
45:22
Again, I am Brian Pelton, and I've been being with doctor Philip Albertie,
45:27
founding director of the Association of American Medical College's Center for Health Justice and
45:31
Senior Director for Health Equity and Research and Policy there as well. Philip,
45:36
thank you so much for your time. Well, thank you, Brian.
45:39
Thank you for listening to this episode of the covid Ethics series podcast. Be
45:45
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45:51
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