Explore the relationship between political determinants of health and health equity in this August 20, 2020, installment of the AMA’s Prioritizing Equity YouTube series. Join us as leaders in health care and politics discuss both the immediate and long-term impact political determinants of health have on the nation as it grapples with the COVID-19 pandemic.
- Daniel E. Dawes, JD—Professor of health policy, director of the Satcher Health Leadership Institute at Morehouse School of Medicine and author of the book “The Political Determinants of Health.”
- Jesus “Chuy” Garcia—Congressman Garcia represents the 4th Congressional District of Illinois. He currently serves as a member of the influential Financial Services Committee, Natural Resources Committee and the Transportation and Infrastructure Committee. He is a member of the Congressional Hispanic Caucus (CHC).
- Aletha Maybank, MD, MPH—Chief health equity officer, group vice president, Center for Health Equity, American Medical Association.
Aug. 20, 2020
Dr. Maybank: Good afternoon, everyone. Welcome back for the next edition of Prioritizing Equity from the American Medical Association. I am Dr. Aletha Maybank, chief health equity officer at the American Medical Association. It's such an honor to be here with you. I definitely want to make sure we recognize the Indigenous folks in the land that we rest on and their history and they're thriving and surviving until this day. And the legacy of our ancestors who were forced here for free labor from the continent of Africa and for all of their sacrifice and the shoulders that we stand on in order to be able to do our work in health equity.
So today we have an exciting day, I think a very timely conversation. Lots going on in our country, probably really across the world, as it relates to politics and policy. Just a quick reminder in terms of all the resources that we've been trying to provide as a Center for Health Equity. Just remember to visit our health equity resource center for COVID-19 on our AMA website. And we will be continuing these every other week for 30 minutes.
So we're now really in political season, as I mentioned, in the United States. We're actually always in political season. We're in election season, national election season in the United States, and it's in high gear. We're in the middle of the week of the Democratic National Convention, and next week with the Republican National Convention. And just lots of, from my perspective, lots of excitement and energy, but I think equally lots of maybe concerned fear and worry to some level of kind of where we're going, especially as it relates in the context of health equity. And so we'd really like to center today's conversation on addressing some of the ways specifically talking about COVID-19 and how these political determinants of health have impacted that. And we'll get an explanation of what that means, but also just even overall, like what's the overall scope in terms of the impact of the political determinants of health on immediate and long-term health equity considerations.
So with me, I am joined today by Congressman Jesus Garcia, who represents the 4th Congressional District of Illinois. He currently serves as a member of the influential Financial Services Committee, the Natural Resources Committee and the Transportation and Infrastructure Committee, and is a member of the Congressional Hispanic Caucus. So thanks for joining us today, Congressman Garcia.
Rep. Garcia: Glad to be here.
Dr. Maybank: And we also have professor and JD, Daniel Dawes, who is a good friend of mine and colleague, and has been just an excellent health equity partner for many years, who is director of the Satcher Health Leadership Institute at the Morehouse School of Medicine, and is author of the book, The Political Determinants of Health. So thank you both for joining me. So the way I usually start off the conversation is just, one, asking where you are, I guess both of you, maybe, but where you are in this country and how are you doing at this point in time and just really for yourself, how are you doing? How's it been with your family coping during this time and where we are right now in August 20th of 2020? So either of you can just jump in and start.
Rep. Garcia: All right. So thank you so much, Dr. Maybank for the invitation. I am at home in Chicago, in the barrio known as Little Village or La Villita. It is predominantly Mexican and very immigrant community on Chicago's Southwest side. It's the southern part of my congressional district. Today, I'm also in between workshops and events at the Democratic National Convention, virtually of course, and feeling quite strange, having been a veteran of quite a few conventions in the past. So I'm here. I just came from a press conference announcing a new initiative, a Spanish language initiative regarding COVID spread in Chicago. The zip code that I live in has one of the highest levels of COVID infections, so we are undertaking and just continuing to figure out ways to drive those numbers down. So that's what I'm doing on this lovely day in Chicago.
Dr. Maybank: Wonderful. Thank you for that. Daniel?
Dawes: Sure. Thank you. Well, it's a pleasure to join you Dr. Maybank and Congressmen Garcia likewise. I am actually in South Florida at my parents' house and helping with their issues. They are older, so I've been down here helping them try to maneuver this and go shopping for them, get their foods and that sort of stuff. So I am in a hotspot myself down in South Florida, working with many racial and ethnic minority communities here in this part of the country, trying to figure it out, trying to make sure that we tackle these political determinants of health. And I'm exhausted. Racism doesn't sleep. Inequities are entrenched, and it takes a lot of work for us to rectify them. So that's what I've been working on lately.
Dr. Maybank: All right. Just little stuff, small stuff for both of you. No, very big and important things. So Daniel, we'll start with you since you mentioned the political determinants of health. Your book has received a lot of attention. I have it sitting right here beside me. I don't know if you can see it. And can you just frame for the audience what is meant by political determinants of health? We heard lots about social determinants of health to the point where it's kind of jargon, honestly. But even beyond that, conceptually, I think people are getting it that there's just more to impacting health beyond what's happening in the health care system and the hospital and the doctor's office, but all these other opportunities and conditions that are in communities that impact health.
And then we hear more language also now about the structural determinants of health, right? What are those structures and laws and policies that impact those social determinants of health? But now you're elevating the political determinants of health, and I think it's, obviously, a really important conversation at this time, especially for the field of medicine. So can you describe to us, what do you mean by this?
Dawes: Sure. I would be delighted. Thank you for that opportunity. So, in my newest book, in The Political Determinants of Health, it's my way of introducing a novel framework that seeks to help people understand why. The why, right? Why, for far too long, we've simply been nibbling around the edges of the problem of health inequities. And it's really urging us to think more strategically, if we seek to effectuate lasting changes, then we have to look further upstream than we've been, right? So more specifically, we have to address what I'm calling the political determinants of health and connecting the social determinants of health to their political roots.
So if you were to envision, think about this for a moment, envision all of society sitting on the banks of a mighty river. So we're going to go fishing. We're finding nourishment in the resources that the river provides. The health inequities that we face are represented by the differences and the caliber and quantity of the fish that we encounter. Some people, as you know, have a bounty of healthy fish and vegetation to feed off of while others may have only small fish, no vegetation or malnourished fish, right? Or even no 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 that were made on their behalf. So these are the political determinants of health essentially. 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 that decision making. So just to put it all in context, when you think about all of the underlying conditions that have put Black, Indigenous and other people of color at greater risk of COVID or dying from COVID, the inequities that predated COVID didn't just suddenly appear nor are they inapplicable. We know that many of these population groups live in neighborhoods, they still contend with neighborhoods that are largely devoid of health-protective resources or help-sustaining resources. And in fact, many of these determinants or drivers have created, perpetuated and exacerbated these inequities. So when we think about COVID today, it's not striking all equally because our economic and social policies haven't been benefiting all equally.
And Dr. Maybank and congressmen Garcia, if we think about it in this context, when you look at the neighborhoods now, if you go in many neighborhoods today that are Black or Brown, predominantly Black or Brown, what do you often find? You often find highways cutting right through these neighborhoods. You'll see bus depots that were placed right next to these communities or in these communities or parking lots. And you can take the issue of asthma, for instance, that puts us at higher risk of COVID. Many of these neighborhoods we know have higher polluted air levels, but why is that happening? We know public health shows us it's because of these infrastructure that were located there. But I'm now pushing this notion of thinking about how they came to exist in the first place.
How did these highways get there? We know it's because of the Highway Act. How did you know these bus depots get placed there? We know, again, it was another policy. Or how did these houses get displaced, right? How did hundreds of thousands of racial and ethnic minorities get displaced? It's because their homes, their apartments were razed owing to another public policy at all levels, whether local, state or federal.
Dr. Maybank: Absolutely. And so thank you for that, and very comprehensive. And so congressmen, I would love, one, do you have any further thoughts as it relates to that? Because you are a politician, right? And so you are the policy makers and part of that body that makes these choices. And it's interesting, from my perspective, to kind of speak to somebody who's making these choices, and what do they think about this broader narrative kind of getting out there, right? These political determinants have always been there, right? I think what's happening is an individual like Daniel and others are just making something visible that really oftentimes has been intentionally made invisible so that people couldn't do something about it. And so now you have an audience that is going to be much more in tune to looking deeper and challenging deeper. What does that mean to you as a congressman?
Rep. Garcia: Well, I got pretty excited listening to Daniel's definition of political determinants of health. We've heard a lot more about social determinants of health and, coincidentally, this evening, I am participating at a panel to discuss movements for political empowerment of minorities in Chicago, fighting the machine against many of the things that Dr. Dawes has pointed out in his definition of political determinants of health. In my worldview, everything is political, and reason why people need to be engaged politically and civically, especially at this point in time in our country's history. So it's very exciting because politics affects everything you do from where you live in segregated cities like Chicago and many others across the country, to the type of transportation systems that you have, or do not have, but should have, to the air that you breathe, to your access to health care in your community, on and on.
And when you look at a map of Chicago, you can tell where minorities are located and thus their history of political disenfranchisement and disempowerment. Sometimes at the hands of political machines as has been the case in Chicago. And our response to that in Chicago has been to organize independent and progressive coalitions rooted in minority communities in particular, but always looking to form coalitions around causes of fairness and equity. And that continues to be the case of my political organization, which has been around for 37 years, but it holds me accountable. It ensures that there is transparency, and they watch how I vote, and they usually counsel me on how they expect me to vote. So again, the empowerment in the political realm, because it has an implication on who drives the agenda in Washington and state legislatures and in local city halls. So very, very important. And he got my juices flowing, starting our conversation this morning on equity.
Dr. Maybank: Well, that's great. Glad to hear that. So just to continue on accountability, as a leader of Congressional Hispanic Caucus, you introduced the Health Equity and Accountability Act with the Tri-Caucus. So folks may not be familiar with that legislation, so it would be awesome if you could just share that and just talk about kind of the importance of it and how it really centers equity.
Rep. Garcia: Gladly. So the Tri-Caucus in Congress is comprised of the Congressional Black Caucus, the Asian Pacific Caucus and the Hispanic or Latino Caucus. The bill that I am very proud to be leading in this Congress includes things like ensuring that there's better health data collection by race and ethnicity, expanding access to safety net programs for immigrants, equitable federal resources for Puerto Rico and the territories, culturally and linguistically-appropriate services and outreach and education strategies in minority communities on issues of behavioral health. Generally, the thrust is to help dismantle health disparities as it relates to communities of color in the U.S. and in the territories. For many years, the Tri-Caucus have laid out a complete roadmap to address persistent health inequities in our country. The Health Equity and Accountability Act comes at a time when COVID painfully exposes existing and persistent health inequalities among communities of color.
Dr. Maybank: Thank you. Yeah, go ahead Daniel.
Dawes: And if I could add to the congressman.
Dr. Maybank: Yes, please do.
Dawes: Okay, thank you. So I am so glad that you raised this important bill, the Tri-Caucus bill to advance health equity. It is certainly the roadmap, as the congressman mentioned, and has been so for many, many years. I just wanted to also add to that from the advocacy side that the Tri-Caucus has always been inclusive, has always allowed folks who are health equity researchers, clinicians, advocates, consumer representatives, to be at the table and help inform that. And so every Congress, I know they update the bill with the latest evidence, the latest research, and I would urge individuals who are interested in this space, interested in informing policy to join that movement.
Dr. Maybank: So I'm going to ask a slightly more controversial question, and either of you could answer this. But so what are the politics actually that prevents more legislation like this from moving forward?
Dawes: Well, congressman, did you want to go first? I'm sorry.
Rep. Garcia: Well, from my vantage point, are key factors, the role of big money in politics where special interests prevail, where they affect how members of districts that have minority groups living in them vote in Congress, whether they champion certain policies or not, whether they vote for bills in certain ways or not, a very important factor. So money drives a lot of it. And sometimes minority leaders and representatives at different levels of government become influenced by having to rely on those interests to get elected and then to stay elected. There's also the temptation of taking shortcuts and not having your own independent base of small contributors that are in your community or who support good public policy.
The other factor that we see a play, especially in the last few years in the country with the emergence and prevalence of conservative politics that are seeking to turn the clock around on civil rights and civil liberties, et cetera, is you see voter suppression taking place and coming in some of the traditional forms that we've seen all over the South. By preventing people from voting, by making it more difficult to vote, by barring people with criminal records from voting, by preventing you from voting if you owe locality money or the state or the federal government, et cetera.
And then we also see extreme measures that President Trump has put into place like attempting to not allow immigrants, certain immigrants to be counted in the census. Outrageous. The constitution says everyone should be counted. And they tried unsuccessfully, thanks to the Supreme Court, to include a citizenship question on the census questionnaire. So I would say two examples of the type of suppression methods that keep minorities from having a stronger voice in politics and in government at all levels.
Dawes: And if I could add to that with a historical lens, we know that in policy and policy making that it's always been easier to exclude groups rather than actually try to create more inclusive health policies. And so when you go back 401 years, what we saw was the intentional development of policies that would prohibit Black and Indigenous populations from being able to grow their own foods, from raising their own gardens, learning how to read and write. They were prohibited from congregating in large numbers. I mean, a host of policies that we know were intentionally designed to prevent folks from exercising their right to address their social determinants of health. But throughout history now, we know what has been done to exclude people, but what we haven't heard much about are the periods in which there was an attempt by health equity leaders throughout our nation's history to push this agenda.
And it was 70 years after our federal government was established back in 1863, there was an opportunity to now push and create a health policy. Well, that unleashed one of the greatest debates in Congress around the abolition of slavery, but even beyond that, to create a federal legislation that would address in a comprehensive manner, the social needs of newly-freed people and poor whites who were displaced as a result of the civil war. But again, there were opponents of health equity that fought tooth and nail for two years to prevent that bill from becoming law. Thankfully, they did not succeed, but where they did succeed was providing medical care, right? So President Lincoln and his supporters agreed that, you know what, we're going to go ahead and allow people to access clothing, get clothing and food, education, employment, but health care was that sticking point.
And so they decided in the spirit of compromise back then to let it go. Well, seven years after opponents finally struck that law, dismantled it, right? And it would take us 150 years in this country before we realized this similar law with the passage of the Affordable Care Act, in many respects, which mirrors that law. So the way I've looked at it is every single time health equity leaders have tried to push the agenda, they have really come up against some of the strongest currents of opposition. People just don't like, whether it is because of their racism or whatever is them, they just don't like to stretch that umbrella of inclusivity a little bit wider in policy. We've seen that time and again, and that's why we've only in this country realized piecemeal approaches to addressing health inequities.
Dr. Maybank: I think that's right. And I think, you're right, to bring up the prism of which that's through, and I think that is white supremacy in our history of racism in this country, and we have to be explicit about that. And the desire to preserve the self-interests of that power, the myth of hierarchy based on skin color, I think that's an important part of the political determinants of health conversation. So it brings me kind of to the last part of our conversation and kind of the role of organized medicine, and then more generally just the role of physicians and health care providers in this space of politics and focusing on the political determinants of health. So organized medicine has been very involved in politics. It's very interesting, as a person who was a student at one time and a resident, and I hear from other students from a few years back, how it was so discouraging to talk about politics, to bring up politics within the context and the walls of the hospital, and that medicine is apolitical.
And it really is just kind of bizarre to me because that's not what the action shows, right? AMA are here, very powerful organization, historically, in terms of, in DC and as it relates to health care legislation. So clearly, politics is actually really important to the health care conversation. And so, I think about the role of organized medicine, AMA issued an apology. You mentioned exclusion, our exclusion of Black physicians. AAP, American Academy of Pediatrics just issued an apology as well within the last month in terms of their treatment of Black physicians. But we as organized medicine also have to take stock in our contribution to the exacerbation of health inequities, as it relates to our role in engagement in politics.
One example being, in the 60s, and trying to really block the passage of the Civil Rights Act or being silent, let's put it that way, on the passage of the Civil Rights Act of 1964 and not really wanting to support amending the Hill-Burton Act, separate but equal provision, which allowed the construction of segregated hospital facilities using federal funds. So there are times clearly when organized medicine has not always been on the right side of advancing equity. And so what would be your message to, it could be organized medicine, it could be message for physicians and health care providers on just the importance and the need of their voice within the space of advocacy and health equity. And I'd love to hear both of your perspectives because you come from different parts of this conversation. So congressman, do you want to start?
Rep. Garcia: Yeah. I'm pleased and encouraged that the apology from the medical field has come forth, but since then, however, the country is living a tumultuous period of re-examination. It is sparked by the terrible and public murder of George Floyd, and it's begging America to look prior to George Floyd's murder at how African Americans and other people of color have come to experience the most extreme forms of violence, which is police violence against them and the use of state force in a disproportional and disproportionate manner against our communities. And this seems to have shaken the conscience of the country and mobilized people in historic unprecedented numbers that hopefully is ushering in a real period of reflection about the role of structural racism, white supremacy in so many institutions, local and national symbols, whether it's the Confederacy or other symbols of white supremacy are being questioned and removed.
And I think that this could be a precursor that will translate into a positive change at all levels. In the halls of the U.S. Congress, for example, we've passed over 500 bills, many of them landmark bills, including the John Lewis Voting Rights Act, which is being amended to reflect that. And let me just say that I came to this country as an immigrant from Mexico in 1965, just months before the Voting Rights Act was passed. Having served with John Lewis in the U.S. Congress is one of the highest honors that could be bestowed on someone like me. So all of that to say that I think we live at a time when basic fundamental change is possible in our country.
That is my hope that this election cycle, from the presidency to decisions made about the future of the U.S. Senate and the House of Representatives will also trickle down to local government as we reflect on the urgency of equity. The role of white supremacy in affecting how institutions function, both public and private, from how lending institutions in this country have created segregation and the exclusion of certain people from having the ability to flourish and to prosper in our country. And a better understanding of the disparities that the COVID-19 pandemic has exposed, because these are all clear reminders of the challenges to us as a country and for the rest of the world and how we move forward in our times and with issues that are also confronting us, including climate change. So it's about the local, but it's also about the national and the international. These are momentous times, and the question is whether we're ready to rise to the challenge and bring about transformative change.
Dr. Maybank: Thank you. And so Daniel, so how should physicians and health care providers rise to this challenge? And you can answer what else you were going to say too, before I cut into the question?
Dawes: No, that's okay. That's great. No, this is wonderful. I just ditto what Congressman Garcia said and just want to piggyback of what you were saying, Dr. Maybank, when you talked about the power and privilege that physicians have. And I hope that after today, that they understand that health equity begins and ends with the political determinants of health. We can no longer continue to pretend that these aren't connected, these social determinants are not connected to a political decision. We have to continue to engage in these very tough conversations around race, place and class if we are going to move that needle. And I do think it's important that folks understand that when they are working in certain communities, that they don't make the judgments that we've been making all along, that others have made about the people who live in these communities.
It's so easy to judge a community because we're such a transient community and we forget the history of these communities. We forget which past policies and programs at all levels have created and perpetuated and exacerbated these inequities. So I think it's so important that people realize when they're looking at these communities and they are judging them, that they realize that these political determinants have a compounding effect over personal responsibility. When you look at these groups that we've been talking about Black, Indigenous and other people of color, they often try to act responsibly. They want to act responsibly, right? Oftentimes, you hear that debate going on, "Oh, if they were only more responsible," but what they don't realize is that there are structural and institutional and even interpersonal obstacles hindering them. Because beneath these communities' notice, these political determinants have been pulling and they continue to pull strings that prevent them from achieving their optimal level of health. So I'm hoping that that will resonate and that will stick, and that they will use their power and privilege to effect those changes, to push back and address those political determinants of health.
Dr. Maybank: Awesome. Fantastic.
Rep. Garcia: And Dr. Maybank—
Dr. Maybank: Yes, please.
Rep. Garcia: I just want to mark one other very recent development because I just read about it a couple of hours ago, and that is that Steve Bannon, former senior advisor to President Donald Trump was arrested this morning for alleged fraud stemming from a fund that was created to raise money to build the border wall. And he is charged with fraud and stealing money from that front. The reason I single him out is because he is one of the most prominent white supremacists in the country who masquerades as a conservative operative. And just wanted to spread that around for folks because it's important that those types of news get out.
Dr. Maybank: Thank you. I appreciate that congressmen. And I appreciate you taking the time to speak with me today. I appreciate you Daniel Dawes as well for taking the time to speak with me, as well as for all of those are listening. I know this is going to be a very attractive and popular episode. It really was a great conversation. I wish I could have had longer time with you both, but I understand we all have very busy schedules. But really, thank you for your leadership and your insights in today's conversations and look forward to connecting again in the future. And thanks everyone for tuning in today, and please stay tuned and please reach out for any questions or any suggestions in the future. So thank you.
Dawes: Thank you.
Rep. Garcia: Thank you.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.