Achieving Health Equity: What’s Next?

Sheree Crute (00:00:00):

Thank you. Hello, everyone. I'm Sheree Crute, director of communications at the National Institute for Health Care Management Foundation, NIHCM. Welcome, and thank you so much for joining us for today's webinar, Achieving Health Equity: What's Next? a close look at how we can improve health within info systems on the serious challenges facing black, Latino, Native American, and other underserved communities, drawing on history and the valuable lessons we've learned about public health in America over the last year.

Sheree Crute (00:00:36):

The pandemic has cast a spotlight on just how severe many longstanding health disparities are in our country. According to the Centers for Disease Control and Prevention, black, Latino, and Native American individuals were hospitalized with COVID-19 at 2.83 and 3.5 times the rate of white individuals, respectively, with similar disparities occurring in COVID-19 mortality rates along with barriers to high-quality treatments and the vaccine.

Sheree Crute (00:01:11):

As we learned more and more from the COVID-19 data, we also began to see a broad range of disparities increase across multiple determinants of health, including nutrition, housing insecurity, and access to clean air, showing us how important it is for us to address these issues if we ever hope to achieve health equity across all of our community. Today, our expert speakers are going to discuss some of what the nation has learned about these unmet health needs and ongoing health risks across communities of color and what can be done to implement effective solutions.

Sheree Crute (00:01:48):

Before I introduce our panel, I want to thank NIHCM's president and CEO, Nancy Chockley, and our NIHCM team for their help in convening today's event. In addition, you can find full biographies for our speakers along with today's agenda and copies of their slides on our website. We also invite you to live tweet if something excites you or interests you during today's event using the hashtag #HealthEquityNIHCM. That's health equity, N-I-H-C-M.

Sheree Crute (00:02:21):

We will also take as many questions as time will allow after our presentations have all completed. With that, I will introduce our first speaker, Bobby Watts. Mr. Watts is the CEO of the National Health Care for the Homeless Council and a member of the Biden Health Equity Task Force. The council supports 300 federally-funded Health Care for the Homeless Programs and 100 Medical Respite providers with training, technical assistance, sharing of best practices, research, active policy and advocacy work to eliminate homelessness. Mr. Watts has 25 years of experience in the direct service and implementation of homeless and health shelter services. Mr. Watts?

Bobby Watts (00:03:14):

Thank you very much. I'm very honored to be here. Thank the National Institute for Health Care Management Foundation for convening this important gathering. I'd like to first apologize to all those in attendance. I need to leave a little before the top of the hour. I was sent some of the questions that were submitted in advance, and we'll try to address those in my time. I'm glad I can at least stay to hear all of the other presentations.

Bobby Watts (00:03:41):

We'd like to begin by introducing very briefly what the council is, and the best way to do that is through our mission statement. We finished a strategic planning process about a year and a half, almost two years ago. One of the things that followed was a new mission statement.

Bobby Watts (00:03:59):

It is grounded in human rights and social justice. The National Health Care for the Homeless Council’s mission is to build an equitable, high-quality health care system through training, research, and advocacy in the movement to end homelessness. I want to point that out for a few reasons.

Bobby Watts (00:04:14):

Our mission statement says who we are, what we do, why we exist. We start off by talking about grounded in human rights and social justice. We view health care and housing as human rights and working to advance and to secure those rights as a matter of social justice.

Bobby Watts (00:04:32):

We also were careful in our words. We want to build an equitable, high-quality healthcare system. We believe that you can't really have high quality unless you have equity. High quality for some is not the high quality that we want, so it must be equitable.

Bobby Watts (00:04:51):

Then our main ways of supporting the 300 Health Care for the Homeless, Federally Qualified Health Centers, and 100 Medical Respite Program is through training, research, and advocacy. Our ultimate goal is to work to end homelessness. We know we can't do that by ourselves. We're part of a larger movement to do that.

Bobby Watts (00:05:13):

I want to talk a little bit, just very briefly, about the relationship between homelessness and health because you'll see tremendous disparities between the health status of people who are housed and those who are unhoused. One of the key things is just to understand that the connection between homelessness and health is a strong one. Homelessness can lead to poorer health. In many cases, poorer health leads to homelessness.

Bobby Watts (00:05:45):

We see this slide. The data on the left, really, is for single adults. When we look at homelessness, we will see there are a large number of single adults, but very significant number are those in families. They have somewhat different health profiles and dynamics affecting them experiencing homelessness.

Bobby Watts (00:06:08):

We'll see that higher rates of behavioral health, some of these life-controlling conditions that we now understand, more and more, are medical conditions and not matters of personal wills, mental illness, substance use disorders. Drug overdose, for many years, has been one of the greatest cause of death among single adults that experienced homelessness.

Bobby Watts (00:06:33):

When we look at the health status of people experiencing homelessness, we know that the best health status is among those who have been housed. Next is if you're in a shelter, your health is better but not as good as if you're housed. It's not unsurprising, or not surprising, that among those who are unsheltered, they are in the poorest health. They are two to four times more likely to die in a given age group than sheltered homelessness, than those who are sheltered, and 15 times more likely to die than the general population. These are age-adjusted mortality data.

Bobby Watts (00:07:15):

One of the most shocking things is that among those who are unsheltered, the average age of death of those who die while living on the streets, under bridges, in parks, in the richest nation on Earth is about 20 to 30 years younger than the general population. Generally, it's been around the late 40s to early 50s, while the average age of death among the general population is around 80, 78 to 80. We're losing 20 to 30 years of life.

Bobby Watts (00:07:53):

During COVID, there is a lot of missing data, and I will address missing data a little bit later. We don't collect homelessness data well. We don't collect mortality among people experiencing homelessness. Then there was the gap of COVID data among those populations, but we did have data, a national survey. They were of different cities where their data collected was differently. It found an average increased mortality rate of 30 to 40%.

Bobby Watts (00:08:30):

One of the places that has the best data is New York City, both housing data, and homeless data, and cause of death data among people experiencing homelessness. Through August of last year, so really, one of the early big parts of the pandemic, they found a 78% increased death rate. That's age-adjusted death rate from COVID among people experiencing homelessness.

Bobby Watts (00:08:58):

I want to just look at the composition of who is experiencing homelessness in the United States. There were almost 600,000 people that were estimated by the U.S. Department of Health and Urban Development, HUD, that were experiencing homelessness on a single night in 2020. This was in January, late January, early February, so before the pandemic.

Bobby Watts (00:09:25):

We see a few things when we're looking at the homeless status. We see that about 37% are those who are in families. More than a third of people experiencing homelessness are family members, are two parents with children, or a mom with children, or a single dad with children. Most of those who are in families are children. A tremendous amount of number of people who are experiencing homelessness are children.

Bobby Watts (00:09:56):

We also see that racial minorities are overrepresented among people experiencing homelessness. African Americans are between 12.5% and 13% of the general population but 40% of those experiencing homelessness. Likewise, Native American are also greatly overrepresented among people experiencing homelessness. Among those who are experiencing homelessness, we see more males than females.

Bobby Watts (00:10:31):

Want to talk next about equity. When we talk about equity, I want to make clear that not all disparity is necessarily due to inequity. I think it's important to look at our definition of equity. Many people have different definitions, which is why I didn't write mine down. In talking with a number of people, I've kind of come up with my own.

Bobby Watts (00:10:55):

At our national conference last year, I had a chance to have a conversation, viewed by our participants, with Dr. Ibram Kendi, the author of How to Be an Anti-racist, and stamped from the beginning, which won the national Book Award, and asked him what was his definition of equity. It's very similar to one I use, so I'm just going to adopt it. It is basically having what is needed for a fair opportunity at success. Having what is needed for a fair opportunity at success.

Bobby Watts (00:11:31):

Another way to put it is that people are given what is needed so that they have a fair opportunity at success. When we think of health equity, then we have to look at, then that means that people have what is needed for fair opportunity for health. We can see that as a nation, the amount of people that are experiencing homelessness in the richest country on Earth and the effects of that on their health... We can see that homelessness leads to health inequity.

Bobby Watts (00:12:13):

We are the only wealthy country in the world that has this kind of disparity, this number of people that were born and raised in this country that are experiencing homelessness. As was mentioned, it's not by accident that we find people of color, racial minorities, especially African Americans and Native Americans, among greatly overrepresented, among people experiencing homelessness.

Bobby Watts (00:12:44):

This is the result of structural inequity, structural racism from the beginning of our nation and that whose practices, not just the legacy, but the practices continue today with redlining how we choose to fund our schooling system, our education system, our policing practices. All of this leads to greater over-representation of people of color among those experiencing homelessness.

Bobby Watts (00:13:16):

One of the statistics I like to cite is that we see that marijuana usage among whites and blacks is almost exactly the same. Yet a African American is four times more likely to get arrested for marijuana possession than a white person. That is purely a function of policing practices. Where are the policing stopping people? In which neighborhoods? Which cars are they stopping? Which ones are they searching?

Bobby Watts (00:13:46):

We see that when police stop cars and search them, they find drugs at the same rates among blacks and whites. It is really a representation of inequitable practices that leads to homelessness, that leads to inequitable health outcomes, and therefore, health inequity.

Bobby Watts (00:14:06):

There are some ways we can get closer. What are some of the solutions? There are two buckets of solutions. One is universal. Again, other countries don't have this type of health disparity among people experiencing homelessness. They have universal health care. We don't have that in this country.

Bobby Watts (00:14:25):

We also don't have the type of homelessness. They are closer to recognizing housing as a human right and seeing it as the responsibility of the society to provide minimal, adequate housing for those in need. We saw some of that with the pandemic where the CDC said in order to protect people during this pandemic, there was a moratorium on evictions.

Bobby Watts (00:14:51):

Some universal ways can really just raise the floor for everyone and wipe out some health inequities. We have a natural experiment going on with the Affordable Care Act, and which states expanded Medicaid, and which states didn't. Among Health Care for the Homeless Programs, we've seen huge increase in access in Medicaid states versus those that don't.

Bobby Watts (00:15:16):

Now in the Health Care for the Homeless Program, as Federally Qualified Health Centers, they will serve everyone regardless of their Medicaid status, their ability to pay. The discrepancy comes when you need to refer someone to a substance abuse program, a mental health program, for a specialist to get their heart checked, or any medical condition. In the non-expansion states, that's much less access, and people are in poorer health.

Bobby Watts (00:15:43):

Another way is through tailored solutions. You can have special services. The whole Health Care for the Homeless movement realized that just creating the healthcare system did not mean that it was accessible to people experiencing homelessness. There are lots of barriers including mistrust by people experiencing homelessness because they had been mistreated by the healthcare system. We needed to have special outreach, special services, needed to make sure we were addressing the full person from the very beginning.

Bobby Watts (00:16:19):

This has been our model for 35 years. Integrated health with behavioral health, primary care, social services, addressing the social determinants of health, because you can treat someone's blood sugar, but if they're still sleeping out under a bridge, if they don't have a place to store their insulin, then you aren't really addressing them. We knew we had to treat the whole person. Special services. Also, all Health Care for the Homeless Programs have some kind of special outreach.

Bobby Watts (00:16:50):

One of the questions that came to me was, what can be done about homeless youth? I saw that previously, NIHCM did something with homeless youth. I wanted to drive this principle further, take it further. One way to address health inequity for youth experiencing homelessness is to have special services targeted to them. There are a number of special shelters for homeless youth, which is really important because they would not feel safe or welcome in a general shelter. They need special services. They need to make sure that they are being able to connect to school.

Bobby Watts (00:17:32):

LGBTQ's youth are at much higher risk of homelessness. You have to make sure that your services are friendly for them. Then we also have to take into account, where are they in their developmental continuum, with their developmental growth, and make sure the services are targeted for that. Two key ways to address to health inequity are universal, lifting the floor for everyone, that everyone has more of a minimal opportunity to get what they need for success or for health and then to make sure there are special targeted services.

Bobby Watts (00:18:10):

Oh, hit the wrong slide. I am done and just really want to thank all of you. I'm sorry I won't be able to stay for questions, but if some are emailed to me, I will do my best to answer them. I turn it back to our host. Thank you.

Sheree Crute (00:18:26):

Thank you so much, Mr. Watts, for giving us a full look at the scope of homelessness, and the impact of homelessness on so many people in America, and the barriers to change. We really appreciate it. Our next speaker, Rita Carreon, is Vice President for health at UnidosUS, a national Hispanic civil rights and advocacy organization based in Washington D.C.

Sheree Crute (00:18:54):

Ms. Carreon oversees the organization's strategic direction in health, including community engagement and programming, addressing the social determinants of health, and advancing health equity. She currently leads a team on the public health response for COVID-19 through UnidosUS's Esperanza Hope for All campaign. Ms. Carreon's expertise and interests include improving health and the quality of care for diverse communities. Ms. Carreon?

Rita Carreon (00:19:24):

Hi, Sheree. Thank you so much for inviting me at this table and for Bobby Watts, his leadership for Health Care for the Homeless work. I think a lot of the efforts that he's been leading ring true in terms of where our communities are at and how important it is for us to tailor our approaches in reaching out to the most needed populations. I'm happy to be here today.

Rita Carreon (00:19:53):

My focus today will be on moving toward health equity in the Latino community. For those of you who remember us, UnidosUS, we're formerly the National Council of La Raza. It's the nation's largest Latino civil rights and advocacy organization. Our purpose for why we exist is we want to create a world where there is no barriers for Latinos to reach their fullest potential. Really, our vision is to see a stronger America where economically, politically, and social advancement is really a reality for all Latinos.

Rita Carreon (00:20:28):

We want to make sure that Latinos thrive and are continuing to be contributors to this country and that those contributions are recognized. I wanted to start with our network of community-based organizations. We have nearly 300 community-based organizations. These are nonprofit, direct-service providers across all the states, including Federally Qualified Health Centers that Bobby Watts talked about, in addition to community-development organizations, charter schools, and community-based organizations.

Rita Carreon (00:21:06):

This also includes organizations or some networks of individuals that stem really deeply into specific areas. UnidosUS not only focuses on health, but we also focus on education, economic empowerment, housing, workforce development, immigration, and civic engagement. We lean on our Promotores de Salud, our Padres Comprometidos, which are parents who are leaders and ambassadors at the schools. We have a National Institute of Latino School Leaders. We have housing counselors. We're probably one of the biggest call centers in terms of helping Latinos get into homes. We also have financial coaches in addition to all the work that we did a year ago with trying to get our Latinos to register to vote and be engaged through our counselors.

Rita Carreon (00:22:02):

One of the things that I wanted to talk about today was before the pandemic and even in terms of our key priorities of where we stand as an organization in the component that we work on is really ensuring that we're shaping the public narrative that's positive about Latinos. We want to make sure that the leaders that we work with and the advocates that we work with have the skills base to continue to lead within their communities, that we know, where health happens, really.

Rita Carreon (00:22:36):

We know that in our community, when you're serving an individual, you're serving their full self as well as their family. A lot of our initiatives are focused around critical programs where we address the social determinants of health. We also want to create and share actionable knowledge. We believe data is important for us to be able to support and provide resources in the communities that is needed the most.

Rita Carreon (00:23:07):

Of course, meaningful and actionable access to quality, equitable health care is front and center for us. I think Latinos in general, with the ACA, have improved in terms of having more access to health insurance. We have seen within the pandemic that... We've also seen folks come off of it for a number of reasons.

Rita Carreon (00:23:33):

I wanted to kind of pull us back a little bit just because we've been in this space for a while. We have 50 years of experience as a civil rights or an advocacy organization. Back in 2016, we had done kind of an assessment of our Affiliates to kind of further understand where their current needs were at. This is pre-pandemic, right?

Rita Carreon (00:23:57):

As you can see, access job, and economics for opportunities, and having affordable food and affordable housing were just as critical for many of them. I just wanted to bring this up because I know it's a little bit old, but it just kind of rings a little bit true in terms of kind of where we are today. The factors in terms of where Latinos access our healthcare system and impact their wellbeing of their children and their families is still affordability. It's still coverage. It's still preventive services. It's having a workforce that understands their needs, their cultural dynamics as well as in language or language-appropriate care.

Rita Carreon (00:24:40):

This is just as critical for us. If I were to now do an assessment of our Affiliates, now post or in the current pandemic, you will see some of these things probably change across the notion based on what we've been hearing. I did want to note that before the pandemic and in many of our world and what we were already dealing with was really these anti-immigration policies that created a major fear among our Latinos.

Rita Carreon (00:25:16):

Very anti-immigrant, anti-families, that started to and seeing in many in terms of how we were accessing health care, education, our employment, in terms of discrimination, safety and violence within our communities, having a living wage, affordable housing, and food access, and being able to have access to food and be able to navigate any social support services.

Rita Carreon (00:25:51):

Why I put immigration policy in the middle in terms of the fear is that we were starting to see many of our community come off services that they were eligible for because of fear that folks would be penalized. This was something that we were working with and dealing with in trying to kind of elevate and protect our families and defend our families.

Rita Carreon (00:26:23):

Back a year ago, the pandemic, as we all know, and have seen, and how Sheree had mentioned, that it has impacted our community at an extraordinary bent. We're 60.6 million Latinos in this country. We make up about 18% of the population, but we were seeing... We weren't surprised about this, that the COVID cases were extraordinary in terms of our exposure to COVID but also, the deaths that are happening.

Rita Carreon (00:26:59):

Even at one point, we were seeing a lot of our kids getting COVID because many of them were largely in homes where we had essential workers that were going and still going to work to make a living, to be able to continue to run this country economically, and make sure that we all have food at the tables.

Rita Carreon (00:27:20):

One of the things that we focused on this year is to really try to increase access to vaccines and understanding about COVID through our public health response and through our Esperanza Hope for All. We saw through a poll that we had done with the COVID collaboratives and the NAACP was that 34% of Latinos have limited trust in terms of the vaccine being safe. 86% of them did not want to receive the vaccine as soon as possible.

Rita Carreon (00:27:52):

We got to work. We spent a number of months and really tried to advocate the importance of data and data collection across states, and with the federal government, and how important it was. Back in March of this year, we actually did another poll with our healthcare voters based on an October poll that we had done last year to really try to get a sense of where people were at in terms of COVID with Univision.

Rita Carreon (00:28:21):

This was with 2,200 Latinos, both Spanish and English speakers, and in emerging communities where they're often not approached. We started hearing from our communities that they were cautious about reopening because they wanted to put health first over their finances. It's largely because of just the number of losses that they were seeing. We still had a huge amount of Latinos that were hesitant about the vaccine, misinformation that was undermining our efforts, and really, the huge economic consequences, not only in the loss of jobs but health insurance, and closed businesses, and really, trouble keeping food on the table.

Rita Carreon (00:29:11):

UnidosUS launched... About a year ago, we launched our Esperanza Hope campaign. Then this year, we expanded our Esperanza Hope for All campaign with a major focus on vaccines. I want to reiterate that our Esperanza Hope for All efforts is not just vaccine related. It's really looking at and mitigating the impact that the health, economic, and educational impact that this pandemic has played on Latinos.

Rita Carreon (00:29:43):

It's ensuring not only the delivery in terms of access to the different vaccines but continuing the prevention, education, and testing efforts. Economically, it's really preserving Latino families' housing for renters and owners and preventing loss of home equity. On the education side, it's really mitigating the learning loss that were seen and continue to see among children who have had to do remote schooling.

Rita Carreon (00:30:10):

In this next slide, what I provide here is a little bit about how we're approaching this this year in terms of really reaching out to 20 million Latinos on public health information, trying to increase that confidence, and awareness, and education about the importance of how to take care of yourself and why the vaccines are safe and ethicable.

Rita Carreon (00:30:30):

At the same time, one of the things that we are focused on is also on nutrition. It's coupled with our work that we're doing on increasing coverage, special coverage, open enrollment until the 15th with our communities because many of them have lost jobs, so they may qualify for getting and accessing health insurance. On the economic and education side, it just shows to you that we've been both on the policy and the programmatic work advocating for fair housing, for making sure that folks are not getting... Their rights are protected.

Rita Carreon (00:31:14):

Bobby Watts mentioned a bit about how the CDC, I think in my lifetime, had put that parameter in place in terms of evictions and stuff. On the education side for our children, I think it continues to be a big issue, not only on the learning but also, their mental wellbeing. When we think about how will we move forward in equity and what does it look like for the next generation of our children in our future, I would recommend mental health as a critical priority and social and emotional wellbeing of our kids.

Rita Carreon (00:31:52):

The next slide just talks a little bit about kind of what we're calling our air game and our ground game on our campaign. We've been working in very multi-prong effort across the campaign. The reason why I lift up the vaccine campaign here today is because there isn't a one size fits all. If you're looking to work with a Latino community, there are a number of different ways to do that.

Rita Carreon (00:32:17):

It's both on the national lens, but also in the local capacity of our Affiliates. I think many of our Affiliates we saw early on that had to close their doors and others that kept open because they had a huge amount of community coming, and knocking doors, and trying to figure out what had just happened and how they need some cash assistance to pay their rent, or be able to get tested, or support in any other ways.

Rita Carreon (00:32:48):

We have launched, and we raised, I think, $1.5 million last year to try to support our Affiliates just for their own operations to have their technology in place. This year, a lot of our focus is working with some network of our Affiliates, both health centers and community-based organizations, to train local trusted messengers, to make sure that they are knocking on doors, and doing the outreach and education around the vaccines, and hosting vaccination events. It does take a lot. It's a lot of resources, a lot of workforce, and training, and data collection to be able to do some of this work.

Rita Carreon (00:33:31):

The other kind of air game that I wanted to mention is the different initiatives that we have. For us, we see the importance of being on the ground, being able to do a mobile-marketing tour or an educational tour to make sure that we are in neighborhood where some of these resources are not being brought. Even to this day, we hear that some of this information is not provided in the language that they speak.

Rita Carreon (00:33:58):

Our partnerships with different agencies, with our Affiliates, with corporate America, I think, is critical for us to be able to do this together, to be able to get out of this pandemic, be able to go back to lives that we cherish the most, but we have a long way to go in terms of major miss and disinformation that is happening across our country and utilizing influencers to be able to support some of that work.

Rita Carreon (00:34:32):

Obviously, this is not done alone. We have multiple partners that we partnered with, coalitions that we're a part of, foundations that have supported us along the way in thinking about how we are addressing COVID, how we're addressing the vaccine access. We'll continue to do that.

Rita Carreon (00:34:50):

What I do want to mention is that the mass majority of Latinos... This one's right before I say that. We are starting to turn the corner. I think that I mentioned yesterday when we were releasing a new video called The Conversation or La Conversacion, which are a series of short bits of Latino doctors, nurses, promotoras, to talk about the frequently asked questions.

Rita Carreon (00:35:16):

We also recognize that we are turning this corner, that we're hopeful every day, that hope is on the horizon, that Latinos want to get the vaccine. They just need to know where to get it, and how to get it, and that not other things are limiting their ability to be able to receive the vaccine.

Rita Carreon (00:35:37):

I bring this up largely because if you place some of these barriers that keep coming up in terms of your immigration status, or your insurance status, or your income, or the lack of ability of having paid leave to go and get a vaccine, or recover if you are feeling sick from it, these are things that are structural barriers that have been around for a number of years in terms of just how we think about the policies, the practice, the systemic racism that has occurred, and how we think about how we as our healthcare system is established and fragmented in the same boat, and how when we think about our communities, we've got to think much more broader, beyond the doctor's office, and where people are coming from in terms of their own experiences and ability to get treatment and care.

Rita Carreon (00:36:42):

We do need to recognize our blind spots. I do want to mention. The time that I have today with you all is just a little, [Spanish 00:36:53]... What do you say? Point that I can be able to just... nugget of information. I would encourage you to go to our website at unidosus.org.

Rita Carreon (00:37:05):

We have a number of different publications that we've recently pushed out. One was the 100 first days of the Biden administration in terms of our priority going forward, that we need to have equitable implementation of all the researches that are being put in place. Equitable representation, meaning we have our Proyecto 20, which is one-year long to make sure that Latinos are represented in this administration, and across different angles, and racial equity.

Rita Carreon (00:37:38):

We do have a paper that we released last month, or I think in April, around racial equity, and how you approach some of that work, and really trying to level the playing field. I think for us, having those that live in poverty, those that are imprisoned, those that receive low-quality education, unemployed can lead to poor health outcomes. For our community, we need to start building a better moral for us for tomorrow.

Rita Carreon (00:38:09):

I think a lot of the times, folks forget that Latinos have been contributors to this country. The vast majority of Latinos in the United States are American citizens. About 79% of Latinos living in this country are U.S. citizens, even our children. I think it's one in three children that are in schools are Latino. The majority of them, 90% of them, are U.S. citizen. I think when we're a very heterogeneous population, ensure that one unit, one community... You have one community. Those needs may change in how you approach it.

Rita Carreon (00:38:48):

My next and last slide is just, how to you lean in? How do you think about working with our Latino-led community-based organizations or even the community-based organizations that are in a large Latino community or diverse community. My first and foremost ask of you is to listen. Listen and hear them out in terms of, how do you amplify for systemic changes in polices and practice? What can you do as an organization and as an investor, as a partner to invest in this community, invest in in-language trusted messengers, or utilize multi-stakeholder approach?

Rita Carreon (00:39:29):

There isn't one size fits all, so we all have a stake in being able to elevate our voices, enhance the role of our local leaders because they have lived these experiences. The role of community health workers, the promotores, are significant. They have experienced some of this work for a number of years and during this pandemic. Hold them close. Center them. Center your children as well in regards to family and in our approach.

Rita Carreon (00:39:59):

I guess at the end of the day, I'm saying, be flexible. Be bold. Be collaborative. Disregard any potential ideas that you have of Latinos, but more of embracing the culture that has been a contributor to this country. With that, Sheree, I'm happy to send it back to you and answer any questions.

Sheree Crute (00:40:26):

Thank you so much, Ms. Carreon, for that great analysis of the complexity and of helping and improving health in Latino communities. Our third speaker today is Stacy Bohlen. Ms. Bohlen is the Chief Executive Officer of the National Indian Health Board, NIHB. With the support of a strong tribally-elected board of directors, Ms. Bohlen serviced NIHB, has contributed to the organization's successful work to establish and elevate the tribal presence for improving health care in the nation's capital, and promoted and strengthened the organization's service to all federally-recognized tribes. NIHB, a nonprofit, provides a number of services to tribes, including advocacy, health research, and policy analysis, and continually represents the tribal perspective while monitoring federal legislation and opportunities for them to work with national organizations on Indian healthcare issues. Ms. Bohlen?

Stacy Bohlen (00:41:34):

Thank you so much. [Foreign language 00:41:38]. Good afternoon. My Native name is Turtle Woman. That name requires of me the responsibility to speak the truth for all the people. My Anglo name is Stacy Bohlen. I am the CEO of the National Indian Health Board. I am a citizen of the Sault Ste. Marie Tribe of Chippewa Indians from Michigan.

Stacy Bohlen (00:42:00):

Thank you so much for inviting us to be here today. It's good to be part of this really important conversation, and more importantly than that, part of change that is necessary in the United States. I'm going to take a little bit of a different approach from my colleagues who have presented before me.

Stacy Bohlen (00:42:22):

There is a project that began about 10 or 12 years ago called Reclaiming Native Truths. It was an expansive undertaking to look at the knowledge, attitudes, and beliefs of Americans about American Indians and Alaskan Natives. At that time and because of that project, we learned that 80% of Americans know absolutely nothing about us. It's really quite something to be of the first people of this land and to be unknown to 80% of those how occupy it now.

Stacy Bohlen (00:43:03):

The position that I'm going to take without making an assumption that this esteemed group of people, and our listeners, and those who are experiencing this are among them. I think we'll probably talk to a very enlightened crowd. I'm taking the perspective of a historical walk-through on who we are and how we came to be where we are in being the perpetual winners of the race to the bottom when it comes by almost any measure: health care, health status, economics, et cetera.

Stacy Bohlen (00:43:42):

When the Europeans first arrived on the shores of what we now call the United States on the American continent, they encountered a land that much like their own was home to a multitude of civilizations, and cultures, and more than 20 million people. However, the Europeans who arrived on our shores did not share an interest in traditional diplomacy. They came for conquest.

Stacy Bohlen (00:44:10):

Shortly after Christopher Columbus's return to Spain, after his voyage to the Americas in 1492, the European power sought legal justification for what they were going to do to us for the future of colonization. To that end, in 1493, Pope Alexander the sixth issued a papal decree that authorized Spain and Portugal to take control of the Americas and rule over its people, the first indication of what would become known as the Doctrine of Discovery.

Stacy Bohlen (00:44:48):

This decree was followed by the 1494 Treaty of Tordesillas, which formally split newly discovered land of the Americas between Spain and Portugal. The foundation of both of these documents and the power that they assert are both derived from an idea that a Christian nation can assert sovereignty over their non-Christian counterparts. This idea would form the basis of the Doctrine of Discovery, which would form the underpinnings of colonization for the coming centuries.

Stacy Bohlen (00:45:23):

This method of engagement continues to have ramifications to this present day. The Doctrine of Discovery basically made it illegal for American Indians to own and occupy lands in what is now the United States. When American Indians found a loophole through which they could own land, then the papal decree became that you had to have a soul to own lands. American Indians don't have souls, so we therefore cannot own land.

Stacy Bohlen (00:45:57):

Recently, Rick Santorum, former senator from Pennsylvania, made a speech to a group of young Conservatives stating that his people had created America from nothing, that when they came to the shores, there was nothing here, and that Native Americans contribute nothing to American culture. I'm going to talk shortly about the idea of invisibility and cancel culture for Native Americans that's been the dominant culture toward our people since 1492. I'm going to ask you to join me in calling for the removal of Rick Santorum as a commentator at CNN because of these unbelievable statements that he has made about our people.

Stacy Bohlen (00:46:49):

If any other ethnicity or racial group people in the United States had had something similar asserted about them, he would already be gone, but we are not getting any traction. I'm going to ask for your help with that. The Doctrine of Discovery instrument undergirded the colonization of the United States. Some argue that it is an antiquated document that's lost to the annals of history, but our people bear witness to the ruthlessness with which it was used even in the way that COVID-19 responses played out in Indian country.

Stacy Bohlen (00:47:25):

As centuries passed, European powers continued their unrelenting march across the Americas. Native people, all of us, were displaced often by force or by the introduction of European diseases to which we had no resistance, such as smallpox. Some tribal nations were able to negotiate treaties before their lands were taken from them. Many of these treaties were negotiated under duress and often at the barrel of a gun. They are perhaps the earliest examples of the existence of a government-to-government relationship between European powers and tribal people of this land.

Stacy Bohlen (00:48:04):

That government-to-government relationship is the ground that we stand on as Native people, that distinguishes us from all other peoples in the United States of America because when the United States Constitution was written, it established a firm place for Native Americans in the American legal system. Article I, Section 8, Clause 3 of the United States Constitution provides that Congress may have the power, quote, "to regulate commerce with foreign nations, and among the several states, and with the Indian tribes."

Stacy Bohlen (00:48:41):

By including tribes as separate from foreign nationals, or nations rather, thus, framers also made it clear that tribes occupied a third legally ambiguous realm. Through our displacement, through the European or original folks' displacement by the English, the United States of America claimed land from the Atlantic Ocean to the Mississippi River. Among those possessions were the tribal nations. We were treated very much as possessions.

Stacy Bohlen (00:49:21):

I'm going to fast forward a little bit. I'm not going to stay too many hundreds of years in the past, but I'm just trying to form the basis of how we find ourselves where we find ourselves now in terms of the health equity question. In 1823, the Supreme Court Chief Justice John Marshall authored the majority opinion of Johnson v. McIntosh in which he codified the notion that the Doctrine of Discovery was in fact the basis of initial European settlements in the Americas.

Stacy Bohlen (00:50:01):

The court affirmed the idea of Indian title, which states that tribes can only sell their land to the United States government and not to private citizens. This is by virtue of having been discovered by the predecessors to the United States. We were only able to sell our land to them. Marshall was careful to mention that the United States inherited this construct and that the Doctrine of Discovery is never implicated as current United States policy. It's just framed in a way that it's used to claim sovereignty over the lands that passed to the United States of America.

Stacy Bohlen (00:50:51):

I'm going to forward. I had a couple more hundred years of history that I'm going to forward through, so just give me a second. I think people on this call may be familiar with the fact that most of the time, our relationship with the United States government was managed in the Department of War and later, to the U.S. Department of Interior where American Indian policy is largely addressed, including the Indian health system. It's a very unique position to be in.

Stacy Bohlen (00:51:25):

You may also be familiar with a Supreme Court case that led to the removal of the Cherokee nation from the East Coast of the United States. The earlier approach to Indian affairs was that it was remarkably antagonistic. As I said, the placement of the predecessor of the Bureau of Indian Affairs was the War Department that really embodies this fact. Most people are familiar with the Indian Removal Act, which was signed into law by Andrew Jackson in 1830.

Stacy Bohlen (00:51:59):

The act also provided for... Hold on one second here. The act also provided that backdrop. For an example, perhaps the most egregious one, American treaty-making, the lack of care to ensure that there were negotiations and ways to negotiate with those who are authorized to do that negotiating. In the Treaty of New Echota, the Cherokee nation allegedly ceded their claims in the Southeast voluntarily and chose to relocate to Oklahoma. However, the treaty was not signed by a party who was able to make that concession.

Stacy Bohlen (00:52:43):

While the Supreme Court protected the Cherokee nation, Andrew Jackson called out the calvary and said that if the Supreme Court wants to uphold the decision that those Indians can stay on the land, they can send their army to stop me. That was how the Cherokees were marched across country on foot in what became the Trail of Tears.

Stacy Bohlen (00:53:09):

There's a lot we can talk about with this, but this is the foundation of the United States of America in terms of our relationship as Native people. Colonization is like Foucault's pendulum, created in 1851 by the great French physicist, Leon Foucault. Once set in motion, it operates into perpetuity on the Earth's geomagnetic force that only slight encouragement needed to keep it going.

Stacy Bohlen (00:53:38):

We see colonization the same way. Its constructs were so elegant that once set in motion, they marched through history, perpetuating exploitation, injustice, and marginalization of indigenous people and peoples of color with a seemingly invisible hand, moving it forward. It is this very construct that makes it so effective.

Stacy Bohlen (00:54:03):

Despite the poor social determinants of health most frequently found in indigenous and other communities of color, the circumstances that proceed from hundreds of years of colonization can be blamed for these poor health outcomes, for adverse childhood experiences, for poverty, for the rates of homelessness that were described by Bobby, for the incredible year we had last year of racial reckoning at the beginning of it. It has to change because COVID-19 was simply an expected outcome of this historical plan that continues.

Stacy Bohlen (00:54:49):

We don't see this as a time of incremental change. We see this as a dual conversion of two crises: one that was spurred by the death of George Floyd and one by COVID-19, that convergence and the immigration crisis in this country, families being torn apart at the border for bargaining purposes. That is very similar to the boarding school era in the United States of America in which American Indians in the [inaudible 00:55:21] children were forcibly removed from their homes, put in boarding schools far, far away from home to both be a negotiating tool that would bring their parents and the leaders of their tribes to be more malleable in negotiating treaties, and to literally kill the Indian, and save the man.

Stacy Bohlen (00:55:48):

That era ended in 1970. What we have witnessed at our borders in the separation of children from their families for political outcome, a desired political outcome, America has seen before in Indian country. We found ourselves in this place of vulnerability with COVID-19. The gross underfunding of the Indian health system that has never exceeded 50% of need and the inherent vulnerabilities, the exact vulnerabilities that the CDC, the World Health Organization pointed out would be the people most likely to get this disease: people with diabetes, obesity, heart disease, overcrowding in housing. Wouldn't you know it? Lack of running water, so you can't really wash your hands.

Stacy Bohlen (00:56:44):

We have many Alaskan Native communities that have no sanitation systems. They have no running water. Because of the uranium mining that went on in Navajo nation, we have vast squaws of that huge nation that do not have running water. These circumstances created the perfect storm for American Indian, Alaskan Native peoples so that we would be so horribly affected by COVID-19 and have the greatest hospitalization rates and the highest death rates in the United States.

Stacy Bohlen (00:57:23):

Earlier, there was a comment made about, what can we do to... If we had a single-payer system, this would help the homeless. If we had a single-payer system, this would help so many people. I don't disagree with that. The National Indian Health Org started a program. It's an international indigenous health collaborative. Participating in it are the indigenous people of Mexico, Canada, Australia, and New Zealand at this juncture.

Stacy Bohlen (00:58:00):

We did some initial study about our commonalities of health, health disparities, and so forth. What we found is that regardless of the economic realities in which we find ourselves or the political constructs under which we live, our health disparities are the same. The Māori people... They are 12% of the population of New Zealand. We are 3% in the United States. Māori is an official language of New Zealand. New Zealand has a single-payer health system. Yes, their health disparities are exactly like ours.

Stacy Bohlen (00:58:39):

We believe that even if we had a single-payer system, it would not necessarily have the desired impact on our people. We believe that through policies of the past, like the boarding school policies, outlawing our religion, basically crushing culture and so forth, that we have been separated from that which really is required to be fully healthy, respect for indigenous ways of knowing, knowledge and use of traditional healing in the presence of cultural, religious, and spiritual practices that should very much be part of our social determinants of health.

Stacy Bohlen (00:59:22):

I do have hope for the future. I know that by giving you this historical perspective, it probably seems incredibly bleak and we have no hope. That is absolutely not true. It's hard to find a more resilient people than American Indians and Alaskan Natives. We are just determined to go on.

Stacy Bohlen (00:59:41):

I think that people of color who face challenges as all do in this nation are resilient, creative, determined people who will together fight for a better future. I don't think it is unique to American Indians and Alaskan Natives that the embrace, and respect for culture, and our own ways of knowing are fundamental to help. I don't think that is unique. As the person speaking to you who is representing tribal perspective, it is so critical to us.

Stacy Bohlen (01:00:18):

I'm going to close with this. There's a Canadian researcher named Michael Chandler who did a study out of the University of the Pacific... It's not the pacific. British Columbia. I almost said the District of Columbia. Now that would have been a trip. He stood a research project out of the University of British Columbia, looking at suicide rates among the indigenous people in Canada, first nation. You may not know this, but suicide is the number two cause of death of American Indian children, so we're very, very interested in this.

Stacy Bohlen (01:01:01):

He said the first things you throw out when you look at this are poverty and depression because they are as common as the sand. You begin to look for communities where suicide rates are very, very low and see what is different about what they are doing. What he found is that the stronger, more vibrant, more present, culture-wise, as a regular part of everyday life in indigenous people, the lower the suicide rate.

Stacy Bohlen (01:01:34):

I believe we could duplicate that research and apply those lessons learned across the healthcare spectrum. It would be incredibly powerful in lifting and elevating American Indian, Alaskan Native health. Tim Glitch, thank you for allowing me to share these thoughts with you today.

Sheree Crute (01:01:55):

Thank you, Ms. Bohlen, for sharing that comprehensive look at both history and how it contributes to Native American health challenges. Our last, and next, and final speaker today is Dr. Creshelle Nash. Dr. Nash is the Medical Director for Health Equity and Public Programs at Arkansas Blue Cross and Blue Shield. Dr. Nash provides leadership for developing, implementing, and evaluating health equity initiatives to help create a more inclusive and nondiscriminatory health care system throughout Arkansas.

Sheree Crute (01:02:33):

A significant part of this work is her leadership role in the Vaccinate the Natural State initiative. Under the leadership of Curtis Barnett, President and CEO of Arkansas Blue Cross and Blue Shield, the company chose to lead the Vaccinate the State campaign, a combined effort from a diverse set of organizations, to work to increase the adoption of COVID-19 vaccines across Arkansas, working across business-to-business environments and hyper local community engagement. Dr. Nash and in her own voice expresses that she is passionate about addressing health disparities in Arkansas's most vulnerable communities and taking action. Dr. Nash?

Creshelle Nash (01:03:16):

Thank you. Thank you. First, let me begin by saying, thank you for allowing me to be here to be a part of this important discussion. The previous panelist has been absolutely amazing. I just want to thank Stacy for sharing that important history. What I hope that you will see as I talk about my perspective, it will really very quickly illustrate the themes that I think I hope I can bring home in a timely manner as we wrap up this webinar.

Creshelle Nash (01:03:50):

Very quickly, I'm going to give you a quick Arkansas context and talk about some of the pandemic activities that will really lead us that form the background of the lessons learned, and ultimately, as everyone on this call is interested in, implications for health equity. I would like to echo with my previous speakers that while COVID has been a crisis, it has also been an opportunity for us. People of color are resilient. The mere fact of me being here with you today is evidence of that. The implications for addressing health equity is really forming the basis of my discussion today.

Creshelle Nash (01:04:37):

When I talk about Arkansas in general, I just want to give you just a quick little bit of context. In 2020, United Health Foundation ranked us as 47th out of 50 in overall health outcomes. We've made some progress as others have talked about on the phone in terms of access to health care through our Medicaid expansion in the state of Arkansas. When we look within the state of Arkansas, our data really does show persistent racial and ethnic health disparities in premature deaths overall, and chronic disease, and morbidity, and mortality. As we talked about here, it's a complex interaction of not only history but social, environmental, socioeconomic, and healthcare systems factors.

Creshelle Nash (01:05:32):

Prior to COVID, Arkansas Blue Cross, Blue Shield was already working on how we as a health plan address social determinants of health. Some of those ways we were doing that is having a model of community-based case management, meaning that nurses were living and working in communities and engaging, boots on the ground, with members. We have incorporated social workers in our medical management teams, and we are incorporating using social determinants of health measures into population health stratification. The final thing I'll mention in the pandemic, pre-pandemic, and post is the Blue & You Foundation, where we are trying to address those social determinants of health, like food insecurity, like physical activity and youth programs across the state of Arkansas.

Creshelle Nash (01:06:29):

As the rest of the nation and as the previous discussions that my colleagues have had, the pandemic has shown us real time, really, illuminated specific examples of how COVID-19 has impacted disproportionately communities of color. We've already talked about this, so I won't belabor this, but increased exposure, essential workers, increased prevalence of chronic disease, lack of access to resources, particularly including technology resources. I'll just give you one example.

Creshelle Nash (01:07:03):

When we started with the vaccine, you had to go online to make an appointment to get the vaccine. Well, what if you don't have internet access? What if you don't have broadband? What if you don't know how to use the technology and even access to personal protective equipment?

Creshelle Nash (01:07:23):

The final comment I'll make is this is also in the context of job loss, homelessness or near homelessness, as Mr. Watts was making reference to, and evictions. In spite of the CDC's moratorium, we still had people being evicted from home, and of course, the population that is incarcerated. This is an example of illustrating the complexity of the factors that we are facing.

Creshelle Nash (01:07:53):

Just a moment about the current vaccine administration... Although we are making headway nationally, here in the state of Arkansas, 36% of our population, 16 and up, is fully vaccinated. That varies greatly by geography and by race. I just took a snapshot from this week to show you it varies by county, from a low of 19% up to 37%. If you look on the right, you can see that for each subgroup of color, that the vaccination administration is less than their percentage in the population. This is the increased-risk population as we have defined in previous discussions, with the exception of the Asian population in the state of Arkansas.

Creshelle Nash (01:08:44):

You've heard a little bit about Vaccinate the Natural State. What I do want to do is focus in on the community engagement component, which is the part where we are engaging with community-based organizations and trusted partners in working with communities. What gives me such great excitement about this is because there's an explicit focus on reaching rural, underserved communities, and communities that experience these long-term racial and ethnic health disparities that are deep-seated, that we've already made reference to.

Creshelle Nash (01:09:19):

We have many activities, really, in Vaccinate the Natural State. I want to go down to responding to local community needs. We are increasing vaccine awareness by messaging and making sure that we have culturally appropriate language and media outreach. We are coordinating with community-based organizations, with government, CBOs, funding mobile units, and really, also, giving a data support. Really, one of the themes of Vaccinate the Natural State is working side by side with trusted partners who have already been doing this work around health equity in the state and augmenting those relationships.

Creshelle Nash (01:10:07):

One of those specific relationships is with the Arkansas faith network. I want to focus in on some key issues around the delta, which has unique challenges and persistent challenges with a very long history, also. Since 2016, my colleagues have been working specifically with a faith-based community that has historically played an important part in not only spiritual health but physical health in the communities. This is the same in COVID-19.

Creshelle Nash (01:10:43):

This month or in March, actually, they completed a survey with these faith-based leaders to define the barriers that we are seeing that are specific to, we think, minority and rural communities. Some of those barriers you see here: a lack of transportation, lack of technology, capacity to use that technology, a history... Again, history is important. A history of mistreatment of African Americans in government-funding research, but not just past, in the current healthcare systems.

Creshelle Nash (01:11:16):

We also have to deal with, and we heard about the myth, the concerns about the vaccines that include too quick, short and long-term complications, uncertainty, and the role of systemic racism. The other thing that came out of this work, also, was that we found that congregations or faith leaders were leaning on the experience of their members in the medical field.

Creshelle Nash (01:11:47):

From all of this work, we developed a delta initiative. It's a partnership, again, the theme of fostering a organization partnership between the Arkansas faith network, the Arkansas Department of Health, and the Arkansas medical, dental, and pharmaceutical association, which is an interprofessional group of African American providers, of dentists, pharmacists, doctors, PAs, physical therapists, and students.

Creshelle Nash (01:12:20):

In this partnership, the activities are really reaching faith-based leaders in rural and communities of color. They're calling it a concierge service. It is outreach. It is information. It is education. It is about access to resources including the vaccine in local communities, utilizing health educators and community health workers, but also supported by the expertise of minority healthcare providers, which are a trusted resource in their communities.

Creshelle Nash (01:12:58):

When I think about how all of these activities are telling us what to do in the future, I think about a couple of high-level things. You've heard this in the other presentations. Data and data analysis is very important to identify health inequities by all of these different factors. I would also add, by social determinants of health. You've heard that from Mr. Watts, also. In the healthcare space, we are starting to be able to do that with V codes at the individual level but also, at the population level by using the CDC social vulnerability index.

Creshelle Nash (01:13:39):

As a healthcare provider, I would also add that the healthcare system needs to address health equity as a component of quality. I believe Mr. Watts made reference to do that, also. How can you say you have a quality healthcare system if your quality varies by personal characteristics such as gender, ethnicity, race, geographic locations?

Creshelle Nash (01:14:04):

What is the future of health equity? I think it's about partnerships. As you've heard, public, private partnerships. We are also engaging the business community, but it's also about cross-sector partnerships to address social determinants of health. Whether you're talking about housing, whether you're talking about transportation, technology, environmental issues, we have to link to community social services and resources in the transformation of the healthcare system. We've heard about community health workers. NIHCM has done an excellent webinar in the recent past about community health workers who are experts in their local communities and trusted members.

Creshelle Nash (01:14:54):

I think the last point here about hesitancy and mistrust must be addressed. I think hesitancy really is too passive a word. It's stronger than that. It's mistrust and community concerns about systemic and structural racism. We've talked about that a little bit here, but I want to make a distinct point here.

Creshelle Nash (01:15:18):

This is different from interpersonal racism that we have all seen firsthand with cell phones at this point, right? This is about the systems of discrimination in policies and practices across sectors, whether you're talking about housing, education, employment, criminal justice, environmental policies, or health care. The key point here is that this can happen with or without intention, personal intention, that is. We need collective actions to improve health opportunities in communities of color. History does matter. There is a history of all people of color in this country that we have to have discussions about in local communities.

Creshelle Nash (01:16:12):

As I conclude, I think I want to say that Arkansas, specifically, with all of its challenges that's been highlighted by COVID, is also an opportunity. It has been an opportunity to increase awareness and knowledge about health equity, what it means, what structural racism means, and point to the future, and what we need to do about systemic change. I hope that the things you have heard are data-driven, evidence-based approaches, public/private partnerships and engaging communities, addressing social determinants of health and the historical systems of disadvantage, but also, more importantly, building community and organizational capacity for future public health or population health improvement. I hope that I was able to bring it all home to you and take away some key lessons. I will stop there and say thank you.

Sheree Crute (01:17:17):

Dr. Nash, thank you so much for packing such a powerful and insightful presentation into just a few moments. I am so sorry. We have gone over time today, so we will be unable to engage in a Q & A session. Many of our speakers sometimes entertain questions that we can email to them. If there's something pressing that you would like to share with us separately, we will forward those along after time.

Sheree Crute (01:17:47):

I do want to thank our entire panel of speakers for sharing their valuable knowledge with us this afternoon and sharing their time. Please take a moment, everyone listening, to share your feedback about the event, completing a brief survey that can be found on the bottom of your screen. Also, this webinar is part of a NIHCM series on the impact of race and inequity on health. You can access previous webinars on our website.

Sheree Crute (01:18:16):

Most important, I hope you will all join us again on May 24th at 3:30 for our upcoming webinar addressing the growing overdose and addiction epidemic. We will have speakers from the White House Office of Drug Policy and the CDC's Office of Addiction Prevention. Please don't forget to share your opinions. Again, to our speakers, thank you all very much. Thank you to our audience. Have a wonderful weekend.