Hospitals In Focus

Advancing Health Equity: Understanding Social Determinants of Health with Dr. Georges Benjamin


America is reckoning with its public health on two fronts: COVID-19 and social determinants of health. Dr. Georges Benjamin is the Executive Director of the American Public Health Association and has spent his career working to achieve health equity for Americans. He joined Chip on our inaugural episode of our series Hospitals In Focus: Achieving Health Equity to discuss how COVID-19 has exposed and amplified issues in our health care system. Dr. Benjamin discusses the obstacles that many in communities of color and other vulnerable populations face when it comes to getting treatment – and what health care providers can do to mitigate some of their challenges.

Speaker 1 (00:05):
Welcome to Hospitals in Focus from the Federation of American Hospitals. Here’s your host Chip Kahn.

Chip Kahn (00:14):
The COVID-19 pandemic exposes and amplifies what public healthcare officials, healthcare givers, and Americans and communities of color have always known; your health and your prognosis as a patient is impacted by more than just the health services you may receive, is affected by socioeconomics and all too often, systemic racism. Subpar living arrangements, language barriers, and transportation impediments just to name a few of all those things that affect health and health care are unfortunately all too present. We see this every day in the COVID crisis, and it is further laid bare in the surging social justice movement sparked by the latest episodes of police brutality.

Health disparities are now a topic of broad discussion and it is important for healthcare providers to take a stand for their patients. That is why we at the Federation will recast hospitals and focus for our next few interviews as a new series aimed at disparities. We call it Advancing Health Equity. Over the next episodes, we will be speaking with experts in their fields about how people and policy can be shaped to overturn health disparities and achieve greater health equity across race and ethnic lines.

To start this quest, we begin with one of our leading lights in public health, the leader of the American Public Health Association, Dr. Georges Benjamin, APHA’s Executive Director. So glad to have you here today, Georges.

Georges Benjamin (01:51):
I’m very much glad to be here. Thank you Chip.

Chip Kahn (01:54):
Great. Well Georges, will you tell us a bit about the work you do at the American Public Health Association and your background for our audience?

Georges Benjamin (02:05):
Well, I’m happy to do so. I’m an internist who got involved in emergency medicine in the early days of the development of the specialty, so I really self-identify in many ways as an emergency physician. I was minding my own business one day and got offered to be the health commissioner in Washington, DC. I had been in and out of emergency medicine, probably for a while, and then I ultimately stayed in public health. So I’ve been in public health now since easily the early 1990s. And I’ve been at the American Public Health Association for about the last 18 years.

Now APHA has been around since 1872. We’re the nation’s oldest and largest public health association certainly in America, probably in the world, and we are the professional society for people who practice public health. We’re a 501c3, so in many ways we are a cross between a trade association and a consumer group, because we really don’t have a lot of pocketbook issues. We’re really always about advocating for your health.

Chip Kahn (03:04):
Let’s get right to it in terms of the kinds of issues I raised in my introduction. Will you define for our audience from your view Georges, what are social determinants of health?

Georges Benjamin (03:17):
The social determinants are those societal things that empower you to get good health or can hinder your ability to have good health. Let’s think about that. About 80% of what makes you healthy actually occurs outside of the doctor’s office. That’s painful for me to admit, but it’s true. If you don’t get a good education, it’s difficult to have good health literacy, it’s difficult to have adequate employment, and so education plays an enormous role. In fact, high school graduation turns out to be one of those defining moments in many people’s lives. People who have graduated from high school do much, much better than people who don’t.

We know that women and the correlation between women’s education and their child’s wellbeing in the first year of life is a strong correlation. Now, whether or not that education is a surrogate for class or income or some other function is not real clear, but we know that it correlates.

Food insecurity is a big deal. When I was in Washington DC, there was not a grocery store in the poorest part of town. This was east of the Potomac River in what we call Ward 8. To get good groceries you had to get on a couple of buses and walk a bit to get that. But you could get high caloric, high fat, low nutritious foods, in many local stores on the corner, as well as lots of beer and wine. So food insecurity plays a big role in people’s ability to be healthy.

And then if you think about the fact where you live. Safe, affordable housing plays an important role. The health solution to homelessness is a house, because it stabilizes the health intervention. If someone has a place to live, then we in the health community can be more effective in engaging them each and every day. Mailing them or calling them, even if they have a cell phone becomes easier if they have a place to live. We know that they are going to be theoretically warm in the winter and cooler in the summer than they would have been if they’re living out on the street.

Again, theoretically, they can fix nutritious meals if they know how to do so, and if they have a fiscal means to do so.

Those things collectively dramatically influence your health. And increasingly we in the health community are understanding how we can partner with organizations that are not … with health is their first mission, to try to make it more functional for people and easier people to improve their own health.

Chip Kahn (06:00):
How do we begin to focus on some other issues that seem parallel here? Do racism and discrimination intersect with health and these disparities that you see?

Race and racism, not race, but racism is a social determinant of health. Let’s talk about the whole issue between race and racism.

Georges Benjamin (06:25):
First of all, race is a social construct. It is artificial. It doesn’t have much of a biological basis. 99.9% of all of us, our genetic structure is the same. Now granted that 0.1% can make an enormous difference around therapeutics and people’s response to certain kinds of medications and diseases in some cases. Obviously there are genetic diseases like Tay-Sachs disease and sickle cell anemia, which tend to track in certain groups. But race is in many ways, a surrogate for a range of things. But genetically we’re all the same.

Racism is this false belief that one group of people is superior to another group of people. It is a real problem in our society because racism, falsely and inappropriately disadvantages some groups, it in appropriately advantages other groups. This is kind of the white supremacy argument. It really disadvantages the whole society. So when you have someone who’s been disadvantaged, we don’t get the value of that individual’s thoughts, engagements, and contributions to society.

If you think about it, Charles Drew, who was obviously very famous for his work on blood transfusions, we would not have had his brilliance had we continued to discriminate against people of color during the war when he helped us by saving millions and millions of lives because of his work on blood. The number of women we saw on this very fairly famous movie, Hidden Figures that we’re all seeing today, we will not have been benefited from those women’s brilliancies had we totally excluded them. Now there was discrimination in those days, but fortunately we were able to grab them and utilize their expertise and try to improve the health and wellbeing, we would have not got to space without them.

Chip Kahn (08:28):
Truthfully navigating our healthcare system can be complicated for any one of us, but what are the ways navigating healthcare can be particularly challenging for minority communities? You began to touch on that. What are providers doing to mitigate these challenges?

Georges Benjamin (08:48):
Well, I think the first problem we have of course is that obviously the social determinants for many communities of color are problems. The lack of health insurance coverage for everyone in this country is a big problem. The fact that we obviously have a very, very, very complicated patchwork system in our country, not only just on the financing, but on the service delivery system, so that understanding how to navigate that system is a problem for everyone, regardless of race or income level. I mean anyone who’s had to help their parents navigate the Medicare system, knows what we’re talking about.

I do think that we all bring a bias to everything that we do based on our own cultural experiences, how we grew up, what we experienced, what we know. And we often make the assumption that everyone has had the same experience and sees things through the same lens that we do.

For example, we don’t all remember the fact that prior to the passage of Medicare, we had segregated hospitals. There were African American physicians in the mid-60s could not be active members of the American Medical Association. We had constructed a system which was segregated, which discriminated against people, and to which people didn’t all get the same care.

So as we think about the fact that we have these historical differences in our healthcare system, we have to first recognize that the biases that we all bring to the table and then look at whether or not we’ve constructed systems in our healthcare system, which by their various construction, both purposely and non- purposely discriminate against people.

An example: Quite frequently people get very disturbed when patients, particularly low income patients, miss appointments, and don’t recognize the challenge for many of them to actually keep those appointments. We don’t construct systems to A, remind them or aid them to get to the doctor’s office. By the way, if we put those systems in place for everybody, it would help everybody make sure they keep their appointments. In fact, increasingly now with the new technologies, personal reminders to get to their appointment, helping people get to their appointment, having office hours on weekends, in the evening, recognizing that people who do shift work, it’s not easy for them to get to the doctor’s office.

Those kinds of things help mitigate some of these structural problems that we have in the system, which in fact, go through the lens that everybody has a Monday through Friday day job, everybody has the economics to get to work … Again, through the lens in which I grew up, because I grew up in a middle class family, that’s how I thought. But when I started working, I was the Chief of Ambulatory Care at the DC General Hospital in Washington, DC, which was the city’s public hospital, boy, did I get a lesson as a middle class, African American male in terms of the challenges that many people had of simply getting to their appointments each and every day.

I guess we just have to look through a different lens if we want to take care of folks in our healthcare system, recognizing how complicated it is.

Chip Kahn (12:23):
Seeing the problems is often the simple part. I mean, they’re just so clear as you described them. The hard part is tackling this long history and system of racial and socioeconomic disparity, and there have been attempts made in the past. What is different, hopefully this time, as we try to tackle these disparities that people have been talking about for years?

Georges Benjamin (12:46):
I think what we’re now beginning to acknowledge that using the word racism, people don’t duck for cover. Well, people are getting much more comfortable talking about it, but the first step is acknowledging that it exists. There really are three types of components of racism. There are structural racism, which a lot of people don’t quite get. This is, “Oh my God, slavery is gone. So racism … and I don’t hate people, so it must not still be there.” Well, we still have red lining. We still have differential access to resources. Again, we still have structured many of our health systems so they disadvantage some patients and unfairly advantage others.

There are structural things that we can use to address that. Even though they may have originally been designed to disadvantage people, we can fix those today. Obviously everybody understands this whole idea of personally mediated racism, where obviously I think I’m better than you and therefore I treat you differently. For me, it’s when somebody follows me around in the store based on race. What’s happening with COVID by the way right now, there are a lot of African American men that really don’t want to wear that mask because they’re afraid of being personally profiled, thought of being dangerous, so they don’t want to wear the mask. They have to be very careful doing that.

And then obviously this whole issue of internalized racism where people don’t feel that they’re valued. I think as a health system and health providers, we’ve got to recognize all three of those aspects and begin to create a society where everybody feels valued, where every person who comes up to you, who may not look like you or may speak a different language, recognize their personal value, and think first before you profile them.

And then deconstruct all the systems we put in place that don’t make it easy for people to get into the office. The easiest one to think about is what we do with people with disabilities, right? There was a time when we forced everybody to walk up steps and now we have ramps. We weren’t trying to disadvantage; we simply didn’t think about it. They had to tell us, “Look, we need help getting up these steps,” and so we created ramps to help them get by each and every day.

Chip Kahn (15:04):
Georges, COVID-19 is devastating for millions around the world obviously, but it’s been particularly disproportionate and its impact on racial and ethnic minority groups. It’s hard to find a silver lining, but if there is one in all of this, it does in a sense, give us incentive to zero in from a public health community and public policy maker standpoint on effecting change. What should policy makers be focusing on right now regarding these communities of color and others who are really disproportionately impacted by COVID?

Georges Benjamin (15:45):
We always knew those disparities existed. And I got to tell you, even I didn’t think that these disparities would express themselves in such an obvious, devastating manner. I think the first thing we have to do is recognize that these communities are more at risk and that if someone gets these diseases it’s because of exposure because they are public facing jobs; meat packing plants, working in chicken farms, bus drivers, people that are working as grocery clerks. Those folks we call them essential workers, in addition to us healthcare workers, they’re essential, and we really didn’t treat them that way when it came to testing and putting in systems to protect them early on.

I’m hoping that we will do that. We will think more thoughtfully about messaging the risk to them, making sure that we provide them the personal protective equipment that they need and making sure that they get it as well as healthcare workers, that the testing is done in communities in which they live so they have easier access to that. Many of these folks are on public transportation because they don’t have a car. Saying that we’ve got to have a car to drive to testing just doesn’t work. That’s going to be helpful.

And then making sure that the contact tracing that we do for these communities is such that it’s done in a culturally competent way, so people using the language in which they speak … so many of these individuals obviously don’t have English as their first language, particularly if they’re Latinx, making sure that we think through that.

Also thinking through cultural issues. Our nation is going through a time period, which I think is terrible, where we’re stigmatizing immigrants and scaring them basically from coming into the healthcare system. We have to address that because I got to tell you, if you call me up and said that I was some place and I was exposed to someone who had COVID and I didn’t know you, obviously I’m going to be a little reluctant to give them my information. And if I’m an immigrant and I’m worried about someone coming and taking me away or taking my family member away, even if I’m here legally and “my papers are in place” I’m still going to be concerned about that. We’re going to have to make sure that we build that trust on contact tracing.

And then the big issue now is this whole issue of who’s going to get the vaccine once it’s available. How are we going to equally distribute that? How are we going to do that based on risk? How are we going to do that in a way to contain the disease? That’s going to require a very, very broad community conversation so that everybody feels that the vaccine is A, safe and effective. That’s the most important part.

And then the fact that we’re treating everybody in an appropriate way that they have access to not only the vaccine by the way, the current therapeutics that we have today. Making sure that people will have access to that in an equal way is going to be very, very important if we’re really going to get our hands around this outbreak, because if you don’t do that, infected people will hide and not be seen. They will of course infect other people, and we’ll never get our hands around this outbreak. As well as the people that will get sicker and die will do so in a [inaudible 00:19:12] manner, which is not what we in the health care community want to happen.

Chip Kahn (19:14):
Well, hopefully we’ll have that problem in the sense of dealing with the vaccine, because right now we’re so stressed in all the communities by this virus. Let’s turn a bit though to your work. Could you tell us a bit about your generation for public health program? What is it and what is APHA hoping to achieve through this program?

Georges Benjamin (19:40):
We recognized several years ago that the United States was not the healthiest nation. Now, obviously if you can say, I would admit, this is where I want to be. We have extraordinary health care providers. Our hospitals are the best in the world, but it requires several things. It requires a get into the system card, i.e. an insurance card, it requires nothing to go wrong in the healthcare encounter. We just haven’t figured out how to do that on a very predictable basis.

In addition, as I pointed out, 80% of what makes you healthy occurs outside the doctor’s office. So while like most associations we have paid members, we want to expand our reach so that we actually influence everyone in our country to help us become the healthiest nation. We created this concept called generation public health to give everybody a place to go, to be part of our collective. Whether it’s people in every community, whether or not you’re a member of the American Public Health Association, meaning you’re a paid member, whether or not you are part of the American Hospital Association or the American Medical Association or the National Medical Association or your Federation members, they’re all welcome to be part of this because we think of it as a movement. A movement that is designed for us to all work collectively, to make sure that the United States can become the healthiest nation.

Now, we’re not saying that in an arrogant way that the US has to be the best, but we are saying that we’re not the best and we ought to be considering the fact that we spent over $3 trillion and we’re not getting the best health outcomes. So we look at that as a way to be competitive, we dare you to be the best nation. We’re trying to get everyone to be part of that movement and help us do that in a collective way, by talking about health, by working across sectors, trying to get some business community, the faith community, the education community, all be part of this movement so we can all move forward in the same direction with a singular goal of improving the nation’s health.

Chip Kahn (21:56):
Well, I wish you success with that program and we’d be glad to be part of it. Let me close with one further question though about disparities. What are the ways the hospital community can become more involved in solving some of these frankly racial disparity issues that confront us today?

Georges Benjamin (22:18):
Well hospitals quite often are … you’re always in a leadership role in your communities, but quite commonly, you are the biggest employer in town. And so you often have the opportunity to be what I call the chief health strategist in your community. You have the opportunity to do that for the nonprofit hospitals. They have a community benefit obligation. For the for [inaudible 00:22:42] they don’t necessarily have that obligation, but quite commonly you assume that obligation anyway, because you always do things to help the community.

I think first of all, looking at the health outcomes in your community, working with your local health agency or your state health agency, to understand what the data shows around what the needs are on those communities, and then engage in those communities as part of a collective providing leadership. If nobody else is doing it, you can step up. And doing this in a geographic way so that you’re actually saying, “Look, we’re going to improve that community.” Making sure that everyone in your institutions are culturally competent. That you have the resources there to make sure that you communicate effectively with your patients. That you look at programs so that patients don’t fall through the cracks. That we try to get rid of some of this complexity that we have in our health system. That you create systems with no wrong door to go in.

If someone shows up for a dermatology appointment within your health system or your hospital system, that someone’s saying, “You’re one of our patients. You’ve been with us for awhile, but we noticed that you haven’t had your flu shot this year. Would you like to be referred to someone who makes sure that that happens?” Those kinds of things.

If you go to an appointment and your blood pressure is too high, often that’s just a movement down to the emergency department, but sometimes it’s a call to their primary care provider so that you’re providing more holistic care for that patient. Assuming their blood pressure isn’t too high, they need to go to the ER. Just not just say, “Look, your blood pressure is high. You need to go out and make sure your doctor takes care of that.”

But enabling patients in many ways to get that care so that their trust in the healthcare system becomes at a higher level than we have it today, because quite frankly, all of us got into this business to improve people’s health. And while we might think of ourselves as a business at the end of the day, yeah, that’s what we do because that’s how the economy in a country like ours works. But at the end of the day, we’re really all about improving the health of the community. And if we think of that as our number one goal, then both the economics will follow as well as the trust and the success of our enterprise overall will follow that.

Chip Kahn (25:07):
Georges, you’ve given us so much to think about today. I’d like to express our appreciation for your perspective and just thank you so much for your leadership. So glad you joined us.

Georges Benjamin (25:20):
Chip, thank you very much. I want to thank your members because you folks just do amazing work. For those who know, Chip and I have worked together over the years and he’s just an amazing guy, so let me just give him a shout out as well.

Chip Kahn (25:34):
Thank you so much.

Speaker 1 (25:40):
Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media @FAHhospitals, and follow Chip, @ChipKahn. Please rate, review and subscribe to Hospitals and Focus. Join us next time for more in depth conversations with healthcare leaders.

Dr. Georges Benjamin, Executive Director, American Public Health Association

Georges Benjamin is known as one of the nation’s most influential physician leaders because he speaks passionately and eloquently about the health issues having the most impact on our nation today. From his firsthand experience as a physician, he knows what happens when preventive care is not available and when the healthy choice is not the easy choice. As executive director of APHA since 2002, he is leading the Association’s push to make America the healthiest nation in one generation.

He came to APHA from his position as secretary of the Maryland Department of Health and Mental Hygiene. Benjamin became secretary of health in Maryland in April 1999, following four years as its deputy secretary for public health services. As secretary, Benjamin oversaw the expansion and improvement of the state’s Medicaid program.

Benjamin, of Gaithersburg, Maryland, is a graduate of the Illinois Institute of Technology and the University of Illinois College of Medicine. He is board-certified in internal medicine and a fellow of the American College of Physicians, a fellow of the National Academy of Public Administration, a fellow emeritus of the American College of Emergency Physicians and an honorary fellow of the Royal Society of Public Health.

An established administrator, author and orator, Benjamin started his medical career in 1981 in Tacoma, Wash., where he managed a 72,000-patient visit ambulatory care service as chief of the Acute Illness Clinic at the Madigan Army Medical Center and was an attending physician within the Department of Emergency Medicine. A few years later, he moved to Washington, D.C., where he served as chief of emergency medicine at the Walter Reed Army Medical Center. After leaving the Army, he chaired the Department of Community Health and Ambulatory Care at the District of Columbia General Hospital. He was promoted to acting commissioner for public health for the District of Columbia and later directed one of the busiest ambulance services in the nation as interim director of the Emergency Ambulance Bureau of the District of Columbia Fire Department.

At APHA, Benjamin also serves as publisher of the nonprofit’s monthly publication, The Nation’s Health, the association’s official newspaper, and the American Journal of Public Health, the profession’s premier scientific publication. He is the author of more than 100 scientific articles and book chapters. His recent book The Quest for Health Reform: A Satirical History is an exposé of the nearly 100-year quest to ensure quality affordable health coverage for all through the use of political cartoons.

Benjamin is a member of the National Academy of Medicine (Formally the Institute of Medicine) of the National Academies of Science, Engineering and Medicine and also serves on the boards for many organizations including Research!America and the Reagan-Udall Foundation. In 2008, 2014 and 2016 he was named one of the top 25 minority executives in health care by Modern Healthcare Magazine, in addition to being voted among the 100 most influential people in health care from 2007-2017.

In April 2016, President Obama appointed Benjamin to the National Infrastructure Advisory Council, a council that advises the president on how best to assure the security of the nation’s critical infrastructure.