Health Equity Summit Celebrates Achievements, Plans Future Solutions

Early in the COVID-19 pandemic, racial outcome disparities emerged. In the first year, for example, Black and Hispanic patients were far likelier to die than white patients were.

Yet a bright spot occurred at Yale. Not only was the mortality rate throughout Yale New Haven Health in the pandemic’s first two years lower than the national average, but also no race-based survival differences occurred among discharged patients.

That was unusual, since health inequities in the United States have been documented across a vast range of diseases and outcomes. In fact, disparities in both health and health care “have existed for as long as we have had any system of health care delivery,” said Benjamin Mba, MBBS, professor of medicine (general medicine) and vice chair of diversity, equity, and inclusion for Yale School of Medicine’s Department of Internal Medicine, during the department’s September 2024 summit, "Advancing Health Equity: Lessons from the COVID-19 Pandemic and Beyond."

Hosted by Gary Désir, MD, department chair and Yale University’s vice provost for faculty development and diversity, the summit convened professionals from health systems around the East and Midwest. During panels, Q&A sessions, and a working lunch, they shared concrete lessons on what academic medical centers and health systems, including safety-net systems, can do to advance health equity.

Some takeaways: Health systems must broaden and reframe their responsibilities and pursue health equity, not just high-quality health care, as a strategic goal. Leaders must gather representative data and then set and pursue measurable community health goals. This can involve a range of tactics, including educating employees, building trust via community partnerships and direct investment, improving access by meeting people where they are, and engaging with law and policy. The pandemic demonstrated that with intentional strategies, health and health care disparities can be mitigated and health equity fostered.

Encouragingly, the participants concluded that such efforts are underway nationwide, and they can work.

Charged with achieving vaccination parity, for example, the Presidential COVID-19 Health Equity Task Force did so by prioritizing access, addressing structural barriers, and building trust, said Marcella Nunez-Smith, MD, MHS, associate dean for Health Equity Research and C.N.H Long Professor of Medicine, Public Health, and Management.

“In September of 2021, I briefed the president and the vice president on that historic achievement,” said Nunez-Smith, who is also founding director of the Equity Research and Innovation Center (ERIC) in the Office for Health Equity Research at Yale School of Medicine. “The early racial [and] ethnic gaps in COVID-19 vaccination rates closed, and we observed subsequent narrowing and even some reversals in COVID-19 mortality disparities.

As Yale New Haven Health began to plan for the pandemic, leaders aimed to ensure equal treatment for inpatients. After calculating a need for 150 intensive-care beds at the system’s flagship location, Yale New Haven Hospital (YNHH), they set out to standardize structures and processes across the health system, said Jonathan M. Siner, MD, associate professor at Yale School of Medicine, who chairs YNHH’s Intensive Care Unit Committee.

To create capacity, they canceled elective surgeries, repurposed negative-pressure rooms on cancer wards, instituted tele-ICU, and expanded ICU staffing.

Then, to reduce cognitive load and risks of bias, they assembled a team that created a COVID care pathway—a standardized treatment protocol that was evidence-based, frequently updated, and integrated into the electronic health record, so it was available to all hospitals and clinics.

The health system had already partly laid the foundation of pro-equity structural change. After Yale New Haven Hospital acquired the Hospital of Saint Raphael, a nearby community hospital, in 2012, Siner decided both campuses’ ICUs would come under the same banner. That meant making the same equipment and advanced techniques such as ECMO available at both units, as well as the same doctors and nurses.

“Everybody is treated the same,” Siner said.

The practice was well established by the time the hospitals began to fill with COVID patients. Had Yale New Haven Hospital Saint Raphael Campus become overloaded, or if patients at that ICU had lacked access to advanced treatments and done poorly, the YNHH York Street Campus would have had to absorb them.

“The equalization of care really made a substantial impact,” Siner said.

But achieving equity for critically ill COVID-19 inpatients, however laudable, is just the beginning.

“If you eliminate health care disparities, …you won't eliminate health disparities—which is either unequal outcomes or unequal burden of disease, or disproportionate burden of disease—because of a myriad of factors outside our health system walls,” said Jaya Aysola, MD, MPH, founder and executive director of Penn Medicine’s Center for Health Equity Advancement.

Similarly, it is not enough to treat an inpatient with congestive heart failure, only to discharge them to the very milieu that made them sick in the first place, said Harlan Krumholz, MD, SM, Harold H. Hines, Jr. Professor of Medicine at Yale School of Medicine, and the founder and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation (CORE).

“We send [patients] out into an environment where right away, they can't get food, they can barely afford the medication, they don't necessarily understand the plan,” Krumholz said. “Then they come back [for readmission], and we go, ‘…We did everything we were supposed to do.’ No, we didn’t. No, we didn’t, because we didn't address their risk factors for failing."

“Our job is to help people live healthy lives. Our job is to help people have successful recoveries,” Krumholz concluded. (Putting it another way, Kaiser Permanente’s Israel Rocha, Jr., MPA, said: “Our sole job is to give you back time.”)

In Chicago, where life expectancy plummets in neighborhoods that are farthest west from Lake Michigan, Rush University System of Health (RUSH) has explicitly pursued community health equity for over a decade. The challenge: to eliminate life expectancy gaps in the West Side neighborhoods it serves.

“We had an accountability, if not a responsibility, for what's going on in the neighborhoods,” said David Ansell, MD, MPH, RUSH’s first leader of health equity. “If we're going to do something as a health system, we have to take on life expectancy. And to take on life expectancy, we have to address racism and other forms of exclusion and oppression.”

Tactics have included embedding anti-racist principles in all the hospital’s actions, formal collaboration with other West Side hospitals, innovating care delivery and payment, and investing in local businesses like a laundry that serves the hospital while providing well-paid jobs with benefits for residents.

Health systems must also proactively build trust and help residents overcome barriers to care.

When the pandemic hit, Manisha Juthani, MD, professor of medicine (infectious diseases), began helping YNHH expand physicians’ access to infectious disease expertise. In September 2021, she became commissioner of the Connecticut Department of Public Health, where she partnered with community organizations to help the state improve vaccination equity. For example, guided by trusted leaders, a vaccination van drove to gathering spots such as churches and barbershops.

Another way to build trust is via community health workers, who come from the communities they serve and can give culturally competent care. For Ngozie Ezike, MD, president and CEO of Sinai Chicago, building relationships with these workers has been a powerful tool.

“There are very few win-wins in society, but this is a win-win,” Ezike said. “These people are now gainfully employed and now have insurance for themselves and their family, and they get to be a partner in the health system, in uplifting the health of the community.

“The health care systems of today can't stay in their beautiful buildings and say, ‘Okay, come to us, and we'll do great when you get here,’” she added. “It's all about getting into the community, meeting people where [they are].”

What about people behind bars and the formerly incarcerated? The United States’ 6,000 correctional facilities employ a half-million people and incarcerate some two million. This population faced much higher COVID-19 infection and mortality risks, said Emily Wang, MD, MAS, a Yale School of Medicine professor who directs the SEICHE Center for Health and Justice.

Yet these individuals were and continue to be largely overlooked by public health surveillance systems, Wang noted, and the CDC’s early guidance around mitigating COVID-19 in correctional facilities did not take the realities of lockup into account. For example, a policy of sending sick inmates to solitary confinement for isolation discouraged many from reporting symptoms.

Far more effective at reducing infections and hospitalizations among inmates was decarceration, Wang found. The Transitions Clinic Network aims to meet their needs. During the pandemic, working with formerly incarcerated health workers and partner organizations, the network aided homegoers with essentials such as phones, a place to quarantine, and immediate access to primary care and substance use treatment.

“The transition of care is such a high-risk time period,” Wang said.

Whether they relate to lifespan, heart failure readmissions, or prison, all equity interventions depend on equitable data.

“Without data equity, in a data-driven world, it would be very hard to even diagnose and prioritize on health equity issues,” said Bhramar Mukherjee, PhD, Anna M.R. Lauder Professor of Biostatistics and professor of chronic disease epidemiology at Yale School of Public Health, and the school’s inaugural senior associate dean of public health data science and data equity. She asked participants to think about who gets to contribute data to scientific studies and what the social determinants of data are.

Everyone, Mukherjee said, must have the same chance to benefit from data products. And as artificial intelligence (AI) trains on large datasets and offers results that may influence policy, the stakes rise higher.

“Even the best methods cannot rescue you if you're building your models in exclusionary cohorts,” she said. “What goes into the input of these AI models really matters.”

To achieve health equity, health systems and their employees must internalize that they are responsible for it in all that they do, panelists emphasized.

When Suja Mathew, MD, joined Atlantic Health System in 2022, she set about building a health equity initiative from scratch, starting with better data collection, stronger community collaborations, and systemic and shared accountability. During an educational campaign for employees aimed at conveying that equity is everyone’s responsibility, she found that many had trouble believing inequities even existed within the health care system.

Celeste Philip, MD, MPH, invited the audience to think about political determinants of health.

“When we're thinking about what are the real root causes for the built-in racism into infrastructure, a lot of that is law and policy,” said Philip, a professor of public health practice at Meharry School of Global Health. “What are the roles that health care facilities can help to make people understand that and to help change some of some of those policies and laws?”

A key step, Philip said, is “building in belonging and civic muscle, which means that people feel like they are included, that they feel like their vote matters, and their rights are not being infringed upon.”

Academic health centers, Ansell said, must strategically pursue the elimination of life expectancy gaps just as they pursue quality, safety, and research. That strategy, he added, includes public policy work.

“There's a countercurrent here between capitalism and the way we've organized our health systems, how we do margin work and equity,” Ansell said. “We’ve got to somehow get them working in parallel.”

The Department of Internal Medicine at Yale School of Medicine is among the nation's premier departments, bringing together an elite cadre of clinicians, investigators, educators, and staff in one of the world's top medical schools. To learn more, visit Internal Medicine.