Contagious Conversations / Episode 14: This Is an All-Hands-on-Deck Moment
"The pandemic has opened the eyes and minds of many folks."
Daniel E. Dawes is the director of the Satcher Health Leadership Institute at the Morehouse School of Medicine, an institute laser-focused on advancement of health equity. Now Dawes sits down to discuss the impact of the COVID-19 pandemic on communities of color and marginalized populations, and the importance of understanding political determinants of health in the context of American history.
Below: Daniel Dawes speaks at the Colorado Health Symposium
Transcript
Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent non-profit that builds partnerships to help CDC save and improve more lives. Joining me today is Daniel Dawes, a widely respected leader and scholar in the health equity movement who has led numerous efforts to address health policy issues impacting vulnerable, under resourced and marginalized populations.
Dawes has been instrumental in shaping major federal health policies, including the Mental Health Parity Act, the Americans with Disabilities Act, Amendments Act and the Affordable Care Act where he led the largest network of leaders committed to prioritizing health equity and federal and state public policies.
Dawes is the director of the Satcher Health Leadership Institute at Morehouse School of Medicine, professor of Health Law, Policy & Management, and the author of two books published by Johns Hopkins University Press, 150 years of Obamacare and the Political Determinants of Health. In this episode, Dawes discusses the importance of health equity and the social and political determinants of health. He also shares information about new partnerships to address the many unanswered questions about health inequities and COVID-19. Welcome, Daniel.
Daniel Dawes: Well, thank you so much, Claire. It's good to be with you today.
Claire Stinson: We're so glad you're part of this important conversation today. So Daniel, you've had a long career working on issues around health equity and health reform, you've been a lawyer and educator and author and more. Can you tell me about your background and early career?
Daniel Dawes: Thank you so much for that. So yes, I am a proud cornhusker, I know that surprises many people. I was born in Lincoln, Nebraska in a multiracial and multicultural family, my journey to improve the health of all communities, eliminate health disparities, advance health equity and reform our health system began after a series of personal experiences that I had with our health system. Witnessing my father struggle to attain healthcare owing to his preexisting conditions, observing disparities and the length of life and in the health status between my black and white family members, as well as a number of other things.
And my interest in health reform was peaked when I discovered the hardships, many people in my own community were facing. Nowhere is that hardship more evident and shocking, I soon learned than in healthcare where lack of resources or insurance and disparities and care can deprive desperately ill people of the quality care, treatment and medicines they need to survive and thrive. I wanted to do something about it.
So during high school, I volunteered at a hospital where I got an up close look at the massive problems faced by underserved communities. On my first day, I was assigned to the emergency department and witnessed an episode that convinced me I wanted to spend the rest of my life increasing awareness of and meaningfully addressing health disparities. It involved a woman who had immigrated from Haiti, she was in a great deal of pain, but each time she tried to tell the staff about her problem they responded with nothing more than blank stares.
Unfortunately, this patient could speak only Haitian Creole. As I watched her trying to make herself understood I couldn't help but think, "Oh my gosh, what if her condition is life threatening?" Every minute, every second would be critical. That afternoon was a real revelation for me about how vulnerable many patients really are and how complicated health delivery could be in the United States.
To tackle these disparities, I wasn't sure which degree to pursue. Of course, today I'm well aware that health inequities are multidimensional, they're complex problems, and so it's going to take a multidisciplinary and comprehensive approach to tackle these entrenched and systemic inequities. I decided to pursue law after finishing another internship during my junior year of college with a major in health systems.
During the internship, I had convinced the hospital administrators to allow me to develop and implement a program tackling racial and ethnic healthcare disparities after I read a groundbreaking report published in 2002 by the Institute of Medicine titled On Equal Treatment. That report highlighted rampant disparities in our healthcare system against communities of color. I was shocked by this report and wanted to do something about it.
So during my internship, I came up against several obstacles, every time I tried to develop tools or resources to aid clinicians in addressing health disparities and elevate culturally competent health care, the lawyers would push back and tell me, I could not do it for one legal reason or another.
And you can imagine as an undergraduate intern with no legal training, I had no way of pushing back and checking whether this was the case. I could not understand why the law, as they had interpreted it, would not allow for addressing racial disparities in health care. Why would the law allow people of color to be discriminated in the provision of health services? That made no sense to me and so after much deliberation and prayer, I decided it was better for me to study law and understand all the policies governing public health, health care, and discrimination.
Law school though only frustrated me more because every time I read these laws and analyzed their impact on communities of color, people with disabilities, women, LGBTQ+ people, and people with mental illnesses and substance use disorders, I couldn't understand why they did not employ an equity lens. Was no one at the table during the development of these policies who could attest to the issues of vulnerable populations were experiencing? Or did no one really care about these largely invisible populations?
So, during my last year of law school, I decided I wanted to pursue a career in health policy and was very fortunate to receive a postgraduate Health Policy Fellowship, the Louis Stokes Health Policy Fellowship, which brought me to Washington, D.C. I worked with Congresswoman Donna Christensen, who was the first female physician member of Congress and the CBC Health Braintrust, and then I went on to work on the Senate Health Committee or the Health, Education, Labor and Pensions Committee under the leadership of Senator Edward M. Kennedy.
Those experiences opened my eyes and while they answered many questions I had as a student, they also raised more questions for me. I knew which legislation were enacted into law and how the courts had interpreted them but I didn't know which policy ideas had been developed and failed to be enacted, or which policy levers had been pushed or pulled in the past, what worked and what didn't and why and how. This pushed me to start conducting research, qualitative and quantitative to understand policy attempts relative to minority health and health equity.
This allowed us of course to successfully reauthorize and authorize health policies that had long stalled in Congress for one reason or another. And after that experience, it was clear to me that I now wanted to share those experiences and inform the next generation of leaders about how to advance more equitable policies in America.
Claire Stinson: Well, thank you for sharing that. That's such an important story, and I'm so glad you had that internship because you're such an important voice in the health equity movement.
Daniel Dawes: Thank you, Claire.
Claire Stinson: So we're talking about health equity, it's certainly a term we're hearing more and more, especially during this COVID-19 pandemic. Daniel, how do you define health equity?
Daniel Dawes: Well, to me, health equity boils down to giving people what they need when they need it, and in the amount that they need to reach their optimal level of health. To that end, I think it's important to note that we're talking about health equity not equality, because some people incorrectly use these terms interchangeably. Equality, as you know, relates to the notion of affording everyone the same treatment whereas equity is focused on a more tailored approach.
What this means in regard to health is that equity is concerned with taking into consideration the needs and circumstances of a community, that impact their health status and access. Equality however is simply a one size fits all approach that does not provide the necessary flexibility to account for past harms and wrongs that lead to present and future health issues.
Claire Stinson: That's an important distinction. Thank you for making that distinction with us. So Daniel, when you first entered this space and started working on issues around health equity, what was the landscape?
Daniel Dawes: Well, this was during the 1990s and early 2000s and there was increased attention in research and policy to this issue. During this time there were approximately 600 peer reviewed studies published on the issue of health disparities.
Our global life expectancy rankings were declining, obesity was rising, healthcare costs were rising. The disparities between higher socioeconomic status individuals and lower socioeconomic status individuals were widening along with racial and ethnic disparities.
Claire Stinson: So would you say there was a national dialogue taking place on this issue?
Daniel Dawes: Absolutely. For the first time ever in our nation's history in 1990, our policymakers led by Dr. Lewis Sullivan under the George H. W. Bush Administration included "The reduction of health disparities", as a key priority in healthy people of 2000 and that was a really big deal at the time. We had never before had the federal government includes such a priority and in such a major public health agenda. Dr. Sullivan then created an office of research and minority health at the National Institutes of Health. Again, the first time ever that they had really done what they could to address the issues of minority health relative to research.
And during that time, Congress passed and President Bush signed into law, the Disadvantaged Minority Health Improvement Act of 1990, making it the first minority health bill to pass since reconstruction. In 1998, Dr. David Satcher, who was appointed the 16th Surgeon General of the United States and the Assistant Secretary for Health launched a new initiative to eliminate health disparities. The Racial and Ethnic Health Disparities initiative, which was a part of President Clinton's initiative on race at the time.
The goal was to eliminate racial and ethnic disparities by 2010 in six areas: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS infection rates, and child and adult immunizations, which meant that for the first time in its history, the federal government would set universal national health goals ending the practice of setting separate lower goals for minority populations.
You see, before this time, when the federal government set certain health goals, it had one set of goals for minority communities in the United States and another set of goals for the rest of the country. This effort eventually led to policymakers moving more boldly from prioritizing the reduction of health disparities to the elimination of health disparities with the development of Healthy People 2010, our nation's public health agenda.
And then in addition to that, we saw Congress passing its most comprehensive minority health and health disparities bill yet, the Minority Health and Health Disparities Research and Education Act. So, to answer your question, yes, there was a major dialogue going on but also major action following it.
Claire Stinson: That's interesting. So it sounds like we've come a long way but we still have quite a ways to go, would you agree with that?
Daniel Dawes: So during the early 2000s, we saw the publication of major reports from the Institute of Medicine, now the National Academy of Medicine, including the unequal treatment report that I mentioned earlier. The Surgeon General, including the first report on mental health disparities, and the agency for Healthcare Research and Quality, including its first National Healthcare Disparities Report. So all of those continue until to this day and then we have continuously used those inform policy.
Claire Stinson: Okay, interesting to note that. This is such a fascinating conversation. Let's talk a little bit about the COVID-19 pandemic, it's certainly on everyone's minds right now. As the pandemic has continued, public health has become part of the national conversation in ways that it has not been before. Daniel, do you see a shift in people's awareness about the role public health plays in their daily lives?
Daniel Dawes: So I've noticed a shift in the collective awareness of the role of public health and I'm glad, I think it's unfortunate that it's taken a pandemic of global magnitude to make public health relatable enough for more people to appreciate the role it plays. But when you've been fighting for health equity, as long as and as hard as I have, you learn to take the opportunities where they arise.
I credit the media, to a certain exten,t for continuing to place public health concerns at the center of many stories, which in turn keeps public health in the public dialogue. That said, news cycles are swift and fleeting and so it's incumbent on myself, on you, and all of our listeners to continue to advocate for what we believe in and continue to push for public health awareness.
Claire Stinson: Such an important point, we would absolutely agree with that and people are thinking about it in ways that they never have before, such an important point. So thank you for that. So research from CDC has noted the disproportionate health impacts of coronavirus on people of color, especially Black people. A recent CDC report found an overrepresentation of Blacks among hospitalized COVID-19 patients. From your perspective, where do you see the biggest challenges?
Daniel Dawes: So, early reporting in states like South Carolina, Virginia, Michigan, and Louisiana showed a grim snapshot of how COVID-19 hits communities of color hardest. In addition to the CDC's remarkable report, a report this month by the nonpartisan APM Research Lab found that the mortality rate for Black Americans across the country is at least twice that of all other racial and ethnic groups.
The disparities in some states are even more striking, we've seen Black mortality rates in Washington, D.C., for example, that are six times as high as white mortality rates. Five times as high in Wisconsin, and four times as high in Missouri and New York. The data, the APM researchers noted was evidence of, "A durable pattern of disproportionality."
For most people, I think they were asked your question regarding the biggest challenge, they would point to one of any number of the social determinants of health and to a certain extent, I would argue that they would not be technically wrong. However, from my point of view, I think the biggest challenge has to be the political determinants of health.
More specifically, how the political determinants of health manifest themselves in our data capture processes. Desegregated data is a powerful tool necessary to create equitable changes. Data have demonstrated that racial and ethnic minority groups are disproportionately impacted by the disease. A fact that further solidifies the disparate nature of race and ethnicity relative to one's health and the inequities in healthcare that these individuals experience.
For more than 400 years differences in health outcomes between Whites and Blacks, as well as Native Americans have been part of the American landscape. So entrenched in our society that many people fail to recognize that our nation's health, including its health inequities is not an organic outcome. The phenomenal research from the CDC does indeed detail that people of color are being disproportionately harmed by the coronavirus. But to truly determine why that is, and more importantly how to stop it, we need granular standardize local data that will help paint a fuller picture of the communities being impacted.
Obtaining that type of data has proven to be very difficult because the system does not have incentives to make obtaining that data easy. Addressing the challenges of America's institutional racism will take years, but there are steps that policymakers, academics and the private sector can take now to help reduce the COVID-19 crisis' impact on Black America.
First, we need clearer and more accessible methods for sharing public health information to assist policymakers in recognizing the current burden and identify hotspots as they emerge, and to ensure transparency about which communities are being impacted by COVID-19, why they're being hit so hard and how these disparities can potentially be addressed.
Second, we should all be working toward the delineation of the gold standard in data collection, especially with attention to categories of race, ethnicity, and primary language. And Congress should set that standard for the states to follow, COVID-19 does not care which state you live in.
Third, state and community public health infrastructure have been drastically underfunded for years. This disinvestment by government, by the federal government and in states serves to compound the barriers to uncovering the full impacts of COVID-19 on communities of color. That funding needs to be restored and increased, we cannot afford an unfunded mandate on data collection.
And finally, state and local health officials must redouble efforts to overcome deep mistrust many people of color have about the nation's healthcare system. Investing in the wider skill development and use of culturally tailored information, training resources and linguistically appropriate intervention, including for people with hearing, visual, and cognitive impairments is critical.
Moreover, we must invest in the pipeline of future healthcare and public health employees, including the frontline clinicians and contact tracers who must represent the increasingly diverse America of the 21st century.
Claire Stinson: We'll be right back with Daniel Dawes.
Since this season of Contagious Conversations is about the COVID-19 pandemic, please visit the CDC website for information and resources for how to protect yourself, what to do if you are sick, and the most up-to-date guidance and information. Visit cdc.gov/coronavirus.
And now back to our conversation with Daniel.
This is such an important conversation, and this is clearly such a complex topic. We really appreciate your perspective in outlining your recommendations for moving forward on this. So Daniel, you talked about the political determinants of health, you also talked about the social determinants of health, and earlier this year you released a book called The Political Determinants of Health. Can you tell me more about that book?
Daniel Dawes: Oh, absolutely. Thank you, Claire. So yes, The Political Determinants of Health is my newest book and it's my way of introducing a novel framework that seeks to help people understand that for far too long we've simply been nibbling around the problem of health equity. And that if we seek to effectuate lasting change, we have to look further upstream.
So more specifically, we have to understand and address the political determinants of health. If you were to envision all of society sitting on the banks of a mighty river, fishing and finding nourishment to the resources that the river provides, the health inequities that we face are represented by the differences and the caliber and quantity of fish we encounter.
Some people have a bounty of healthy fish and vegetation to feed off of, while others may only have small fish, no vegetation or malnourished fish. Different people having access to different types of resources, and different parts of the river represents the social determinants of health.
Some people are located in a slower moving part of the river by no fault of their own. Others are located in a more lush part of the river, and benefit because of such by specific decisions made on their behalf. These are the political determinants of health, somewhere upstream decisions were made to divert the river to benefit certain people and harm others, and decisions were made to place certain types of people on specific banks of the river while placing others elsewhere.
These upstream decisions have downstream impacts, and we must be involved in the decision making process. We know that the underlying factors such as cancer, asthma, heart disease, diabetes, lung disease, and other chronic diseases that put racial and ethnic minorities at greater risk from dying from COVID-19 have been striking disproportionately within communities of color for centuries in America.
The inequities that predate COVID-19 did not suddenly become inapplicable. African Americans, Native Americans, Latinx Americans, Asian and Pacific Islander Americans still contend with neighborhoods that are largely devoid of health sustaining and health protective resources. And they still contend with the political determinants or drivers that created or perpetuated and exacerbated these health inequities.
You see, COVID-19 is not striking all equally, why? Because our economic and social policies have not been benefiting all equally. Interestingly, a national crisis tends to magnify inequities in our society, like past epidemics or pandemics, the COVID-19 pandemic negatively impacts and further disadvantages lower socioeconomic communities, racial and ethnic minorities and immigrant communities the worst.
What these past crisis have shown us is how one political determinant after another resulted in a continual tightening of a chokehold on these disparate communities, and the eventual disaster that brought to light the inequities plaguing them. High obesity rates, diabetes, maternal mortality, depression, and many other public health issues can be firmly linked back to political action, or inaction. By understanding the political determinants of health, their origins, their impact, and interconnection with the social determinants of health, I think we'll be better equipped to develop and implement actionable solutions to close the health gap.
I know it's true that air pollution, climate change, toxic waste sites, unclean water, lack of fresh fruits and vegetables, unsafe, unsecure and unstable housing, poor quality education, inaccessible transportation, a lack of parks and other recreational areas among others play an outsize role on our overall health and well-being.
They increase our stress, they expose us to harmful elements and they limit our opportunities to thrive. These social determinants of health play an outsize role in these human made preexisting inequities. But underlying each one is a political determinant that we can no longer ignore. You know, too often, we stop at the social drivers of inequities, failing to dig even further to see the depths of the problem and understand their root causes and distribution.
As a result, we missed the link between social determinants of health and their policy roots. Consider for example, the studies linking higher rates of asthma in communities of color to greater air pollution, which other studies have shown is linked to bus depots, highways, parking, lots factories, and other social determinants of health that exists within these communities.To get to the root causes of these inequities, we must venture further upstream to understand how these social determinants of health were allowed to occur or not occur in the first place.
This pandemic demonstrates the inconvenient and harsh truth about the impact of social determinants of health and how collectively these factors significantly contribute to our society’s health inequities.
It shows the compounding effect of political determinants over personal responsibility, because no matter how much many African Americans, Native Americans and others try to act responsibly, there are always structural, institutional, and interpersonal obstacles hindering them. Beneath these communities notice, political determinants have pulled and continue to pull strings that prevent them from achieving their optimal health and full potential leading to what Dr. Arline Geronimus at the University of Michigan has coined “weathering” or “accelerated aging”, which increases these communities rates of chronic diseases and premature deaths.
Claire Stinson: Wow. This sounds like a fascinating book. And you released this book earlier this year and the river analogy is fascinating. That's such a great analogy to explain what's going on. You released this book before the pandemic occurred, do you feel like the book is even more important now that we have a global pandemic?
Daniel Dawes: Oh my goodness, I think that's the key to all of this, right? Is that during this pandemic where folks are now getting to see the magnification of these inequities. Before it was a little more difficult, right? You just couldn't understand or appreciate it for some, but now for the first time I have heard from folks who I've worked with for years in this country saying, "Oh my goodness, I now see what you're talking about."
So yes, the pandemic has truly opened the eyes and minds of many folks, I think they're truly understanding how entrenched these inequities were and are to this day. And I think the book has given them a tool, a resource for them to understand how we can go about deliberately, strategically with the evidence to move the needle towards health equity.
Claire Stinson: Fascinating. Thank you for sharing that. So let's talk a little bit more about political determinants of health. I know that they are a focus of your work leading the Satcher Health Leadership Institute (SHLI) at the Morehouse School of Medicine. It's named after its founder Dr. David Satcher, who we know well at the CDC Foundation. His long career in public health includes serving as director of CDC and the 16th Surgeon General of the United States and he's also served on our board of directors here at the CDC Foundation. The institute also has a focus on mental and behavioral health and health system transformation. Can you talk a little bit more about these priorities?
Daniel Dawes: Oh, I would love to. Thank you. So at the core of everything we do at the Satcher Health Leadership Institute is the advancement of health equity, it is the driving force behind all of the decisions we make and the reason we get out of our respective beds each morning. While health equity is the unwavering focal point of SHLI, there are three main priorities, as you mentioned, that also serve as our guiding posts.
These are the political determinants of health, health system transformation and mental and behavioral health. There is no health without mental health. Since SHLI's founding, mental and behavioral health issues have been prioritized through research and programmatic efforts aimed at reducing and ultimately eliminating mental health disparities within vulnerable populations.
Our institute will continue its pursuit in advancing mental and behavioral health equity, improving efficiency and integration within local state and national healthcare systems and supporting the agency of underserved communities in order to achieve optimal health and wellness.
Similarly, reduced life expectancy, worsening health outcomes, health inequity, and declining health care options are all realities for most Americans because of the health system currently in play. SHLI has always been a strong supporter of and breeding ground for health leaders and learners that are focused on transforming the health system in measurable and equitable ways.
Understanding the need to continue to advance research and thought leadership in areas that can be operationalized to lead the lasting change that is necessary in the United States. And this will continue to remain a priority for the Satcher Health Leadership Institute for many years to come.
Claire Stinson: Such important work that you all are doing on a daily basis and we're so glad you're the director.
Daniel Dawes: Oh thank you.
Claire Stinson: To further address issues related to health equity, the Satcher Institute and the Morehouse School of Medicine have announced a new partnership with the CDC Foundation. We're really excited about this. We're establishing a health equity task force to address the many unanswered questions about health inequities and COVID-19. Can you tell us a little bit more about this?
Daniel Dawes: Oh, I'm so excited about this partnership myself, so I want to thank the CDC Foundation for recognizing the importance of this work, because as we all know here in our country now over 120,000 deaths have been attributed to COVID-19 and morbidity and mortality rates continue to rise. As you mentioned in the CDC report and looking at preliminary data, it's demonstrated that racial and ethnic minority groups have been disproportionately impacted by the disease.
However, to date, it has also been challenging in the midst of this emergency to consistently collect demographic data on COVID-19 cases. As such, efforts to advance health equity are being hindered by under-reporting of data on racial and ethnic minorities, on socioeconomic status, on disability or mental health status, and other disparity markers of at-risk populations.
So to combat this issue as you mentioned, the Satcher Health Leadership Institute and the CDC Foundation will be establishing a Health Equity Taskforce devoted to monitoring and assessing the disparate impacts on vulnerable populations including, but not limited to racial and ethnic minorities, people living with disabilities and those of lower socioeconomic status.
A COVID-19 data consortium will be created to also ensure the standardization of COVID-19 data at all levels, the national, the state and the local levels and there are four components to this program. So, we will collectively be working with Google.org and we will work with them to establish a multi-sector data consortium devoted to COVID-19 impact on vulnerable groups, right? Looking at summary data to understand select geographic, racial and socioeconomic disparities, as well as looking at social determinants of health at the individual, the county, the state and national levels.
Then we want to also leverage this partnership to develop standardized evidence-based best practices for developing socio-culturally responsive resources and provide technical assistance to local and state health organizations to improve their COVID-19 responses, their data collection reporting, planning, and mitigation strategies, as well as screening and contact tracing initiatives.
And then we want to look at jurisdictional policies, we're going to be analyzing jurisdictional policies to see whether they have been exacerbating or alleviating COVID-19 outcomes, related to testing, contact tracing, resource allocation and management and the jurisdictions response and mitigation strategies overall.
And then lastly, because we have also firmly pushed the idea that mental health is truly a key component of systemic health, and no one has really crafted a data platform to look at the health equity impacts on mental behavioral health, we want to understand this better and develop a tool to track this and to address the issues that arise as a result of this pandemic.
Claire Stinson: Such important goals for this partnership and on behalf of the CDC Foundation I want to thank you for your partnership.
Daniel Dawes: My pleasure. Thank you.
Claire Stinson: So it sounds like the COVID-19 pandemic has become a catalyst to really help move a lot of these issues forward. Do you agree with that?
Daniel Dawes: Absolutely.
Claire Stinson: So Daniel, the institute also received a $1 million grant earlier this year from Google. This grant is to study the disproportionate impact COVID-19 is having on communities of color. Part of this work will include an interactive COVID-19 health equity map for the US created, in part, by a team of Google engineers and data scientists. Part of this data will be incorporated into the work of the Health Equity Taskforce. Once completed, how do you hope this data could be used?
Daniel Dawes: So it is our hope that as we engage in this ongoing research to build a comprehensive beta platform with a detailed breakdown of the viruses impact by race, ethnicity, gender, socioeconomic status, and other critical factors that the data will in turn help policymakers better understand how to ensure those communities receive the targeted help that they need, not only to close the racial gaps but also to ensure that communities receive the resources and support that they need to battle the virus.
Claire Stinson: That sounds like an interesting partnership. Who do you see as the ideal audience for this data?
Daniel Dawes: In terms of the ideal audience for this data, it's actually anyone and everyone. This pandemic affects everyone and it's going to take a concerted global effort to triumph against it. So truly with this public facing, comprehensive, interactive health equity map, it's our sincere hope that any and every individual with an eye towards equity will utilize the data for the greater good.
Claire Stinson: Data is such an important part of public health, and it sounds like this partnership is going to provide data that will have multi-faceted impacts, such a fascinating discussion.
Daniel, in a recent piece you authored for Essence Magazine, you wrote, "Our history has shown some success in times of crisis and bringing about a sea change when it comes to crafting more effective, more equitable and inclusive health policies." What are some of those successes that you believe could serve as a blueprint for more inclusive health policies during a pandemic like COVID-19?
Daniel Dawes: Thank you so much for that. So the interesting albeit disappointing fact is that when you look at our history as a country, never before have we been successful in advancing equitable health policies in the wake of an epidemic or pandemic. It's because of this reality that the partnership between SHLI and the CDC Foundation is so groundbreaking, it has the potential to provide us with precisely the type of information and momentum necessary to advance in equitable policy.
So that said for the history buffs out there listening in, I will point to a few often overlooked examples of the US government seeking a political solution to a health problem. So one involves our early sailors, as many of us know there was a Marine Hospital Service which eventually became the U.S. Public Health Service, and this entity mandated that privately employed sailors purchase health insurance because Merchant Marines were often injured or sick from infectious diseases, which had a negative impact on the nation's economy.
The early government took this opportunity to intercede and exercise its power to promote the general welfare and the provision of health services for sailors. This was the perfect confluence and alignment of two of the main political motivations necessary to see actual change to implement: the economy and national security. When an argument can be effectively made that presuppose that a given action will improve national security and is vital to the economy swift political action is typically soon to follow.
This is just an early example that we must continue to look to replicate in present times with an eye towards health equity concerns. Another one occurred almost seven decades later during the middle of the Civil War. So the first time we had infectious diseases ravaging our trade routes, the second time now involved the abolition of slavery and the opportunities to provide these newly freed people the necessities of life and to address their social determinants of health.
And this was negotiated in Congress called the Freedmen's Bureau Act, it took two years of intense negotiation in our Congress. There were of course opponents of this effort who fought month after month, day after day, to ensure that this bill would never see the light of day. And essentially what was being negotiated was not only the abolishment of slavery, but also to ensure that these newly freed people would have access to adequate clothing, access to nutritious foods, access to education, employment opportunities, security and health care among others.
And during that debate, like I said, it really unleashed one of the greatest debates in our Congress over the advancement of health equity. During that time after two years, the opponents succeeded in stripping out provisions that would have provided medical care to the newly freed people and to poor whites who were displaced as a result of the Civil War, primarily in the South.
So the medical care provision was stripped out. President Abraham Lincoln supporters determined that well, in light of all that we have retained in the bill, we will go ahead and compromise and get it passed and have the President sign it into law. And so they did just that President Lincoln signed into law, and a month later, unfortunately, the president was assassinated.
At that point, the supporters of the president, and champions for health equity, determined that the language of the law, the Freedmen's Bureau Act was written in such a way that it did authorize them to go ahead and provide medical care to these newly freed people and poor whites. And so they did just that, setting up a huge medical division. And so throughout the country, many of the Freedmen's hospitals and many of the hospitals even until today are the result of this law. The same thing with many historically black colleges and universities: Howard University, Morehouse College, Spelman College, and others, they are the result of the Freedmen’s Bureau Act to provide education.
And again, this law became the first time in US history that we had a comprehensive health reform law intended to address the social determinants of health.
Moving forward, let me just present one additional experience or episode in which we were able to successfully advance an equity focused federal policy. And this was right after World War II. So usually in terms of crisis, when it comes to wars, recessions natural disasters, we have been successful in realizing an equitable policy response. But again, not during a COVID, or not during an epidemic or pandemic. So in 1946, after trying for about 150 years in this country to pass comprehensive mental health reform, the mental health advocates actually went about working with the generals and the admirals and the surgeon general at the time, to highlight the fact that 20% of young people were found unfit for military service, and 40% of those who were found fit. Those are between the ages of 17 and 24 ended up leaving the military early because of a host of issues, post-traumatic stress disorder, anxiety, and depression, and so forth.
And 60% of the hospital beds were being occupied by individuals who also were experiencing these mental health challenges. So what the mental health champions did at that time was to look back in history, had these few instances of success in moving that needle towards health equity. And they held hearings and they created reports and they did their analysis and shared it with policymakers. And what happened was folks deemed this to be a national security crisis, 20% of young people being unfit for military service.
And so they went ahead and passed the National Mental Health Act, the first ever mental health reform piecemeal though it was at the time, it was still a huge win for these groups and really helped to create the National Institute of Mental Health that helped us to do research and examining the root causes of mental illnesses in this country.
And so after that, what we have seen now is an effort to learn from those past attempts and to use that as a blueprint for more inclusive health policies during the pandemic that we are facing today.
Claire Stinson: This is fascinating. I'm learning so much from what you're explaining, you provide such important historical perspective into these issues. I bet you're a great professor.
Daniel Dawes: I hope so. I think my evaluations have been overwhelmingly positive, so I hope my students would agree with that.
Claire Stinson: Oh good, I bet they do. So Daniel, as the pandemic continues, the nation still must contend with the existing health equity challenges that may have now become further strained since COVID-19. As part of solving these challenges, how do you see different sectors of public health coming together?
Daniel Dawes: So I think this is an all hands on deck moment if we've ever seen one. So the short answer to your question is that everyone should join this work. The long answer to your question is that everyone should join this work. In all seriousness, I do believe that the answers to some of the toughest questions we're facing are going to require innovative and collaborative efforts from actors, both inside and outside of public health that have not traditionally worked together, thinking outside of the box starts with conversations just like this one. So I thank you for allowing me to be here to have it with you.
Claire Stinson: Well, we certainly appreciate your perspective. This has been fascinating. I have one more question for you that we like to ask our guests: do you have any advice for the future public health leaders of America?
Daniel Dawes: My advice would be one, let me actually close by quoting my mentor and hero Dr. David Satcher, as we've spoken about him today. And I think what he has said back then is as relevant as today. What we need our public health leaders who know enough, who will persevere enough, who will persist and who care enough to get the job done. Until we have those folks with all of those qualities, I'm afraid we'll never truly be as effective as we can.
So I want folks to think about making sure that they engage, they educate themselves on these issues, they look and get to the source of these health inequities, that they persist with the truth ,that they share that knowledge, and they continue to advocate for these communities that are oftentimes invisible, that do not have a seat at the table.
Claire Stinson: Important advice. Thank you for sharing your passion with us and thank you so much for sharing your story with us today, we have learned a lot about the importance of health equity. I really enjoyed talking with you today and on behalf of the entire CDC Foundation, we want to thank you for your partnership.
Daniel Dawes: Thank you so much again, I appreciate it.
Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes and bonus content. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review and tell others. It helps us get the word out.
Thanks again for tuning in and join us next time for another episode of Contagious Conversations.
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