Dr. Reuben Varghese (00:45):

Health is often or too often seen to be in the hands of healthcare providers. It's actually about culture change first. There's no one specific program that's going to solve this. The prescription pad for both treatment opportunities as well as prevention opportunities are really in the hands of policy makers at the government level, business level, and the nonprofits throughout society.

Robert McCartney (01:16):

That's Arlington County Health Director, Dr. Reuben Varghese, and this is Think Regionally, a monthly podcast of the Metropolitan Washington Council of Governments, or COG. I'm your host, Robert McCartney. This month and next we're doing a two episode series on equity in action. It looks at ways that local governments and other institutions are promoting strategies to narrow the gaps between lower income and better off populations. Next month, we'll look at advancing inclusion and equity in economic development. In this episode, we focus on how to eliminate the well-documented discrepancies in the health sector, and we'll see that health outcomes vary according to location, class, and race.

We'll hear about some promising programs addressing this issue both in our Washington metropolitan region and elsewhere in the United States. And we'll talk about some obstacles to reforms. I talked jointly to both Varghese from Arlington, a longtime member of the COG Health Officials Committee, and Dr. Steven Woolf, a professor at Virginia Commonwealth University. Woolf has authored reports on the impact of racial discrimination on health, including a major regional analysis that was commissioned by COG's Health Officials. I want to start by asking first, Dr. Woolf, what are the highlights or lowlights, if you will, of evidence of discrimination and lack of equity in health outcomes in our region?

Dr. Steven Woolf (02:50):

Well, there's extensive evidence. We've been aware of it for many years. We have data to show that life expectancy across the region varies greatly by as much as 20 or 25 years, depending on what census tract you're talking about. Mortality rates, that is the likelihood of dying from different conditions varies starkly, birth outcomes vary. A variety of health problems are occurring at different rates across our region, so there's a geographic diversity. And when we look at how it differs across population groups, we see that low income individuals and people of color face much higher risks of developing these diseases, developing complications that require hospitalization, and dying from that.

Robert McCartney (03:42):

Varghese referred to a study showing a 10-year difference in life expectancy between neighborhoods in Arlington. The gap was greatest between affluent communities such as Rosslyn and low income ones such as Buckingham.

Dr. Reuben Varghese (03:58):

For those who don't remember, Arlington's only 26 square miles. In a 26 square mile jurisdiction to have a decade of difference from one end to the other in a mild distance, that should say something to people. At least, it's a question to look at, are there known reasons that could be disadvantaging some and favoring others?

Robert McCartney (04:20):

Multiple factors contribute to these inequities, but economic conditions and related issues are at the core of many.

Dr. Steven Woolf (04:27):

It's not by accident that these disparities exist. There's a history that produce these neighborhoods, and we've studied that as well. But in each example that we have documented where you have the stark differences in life expectancy and other health outcomes across the street from each other, if you make a table listing out educational attainment, poverty rates, access to health insurance, apartments with inadequate plumbing and so forth, you see equally stark disparities across the board. It's, frankly, those disparities that are the reason that life expectancy is so different.

Robert McCartney (05:07):

Dr. Woolf described how external conditions may encourage poor eating habits and obesity.

Dr. Steven Woolf (05:14):

It's important in our conversation to understand the root causes for this, especially, when we're talking about behaviors. Because there is an unfortunate tendency in our society when we hear about things like that to blame those behaviors on individuals and to say, "Nobody's forcing you to put that food in your mouth or smoke that cigarette." Those are personal choices and people who make those choices are responsible for the health outcomes. That's problematic because those behaviors are shaped by conditions in our environment and in our society that either precipitate those behaviors or stand in the way of changing those behaviors.

Robert McCartney (05:57):

Dr. Varghese described how it was important to see a distinction between equality versus equity of opportunity.

Dr. Reuben Varghese (06:05):

There's a tendency for us to believe that there's equality of opportunity, and what we really need to be thinking about is their equity of opportunity. What I mean by that is do people functionally have the ability to do the best behaviors? If you're working three or four jobs versus one, time and energy is going to be much easier for the person with one job potentially versus one with three or four jobs. And how do you manage a family of two or four in those same conditions?

Dr. Steven Woolf (06:35):

Put yourself in the position of a low income family where people are living from paycheck to paycheck, and as Dr. Varghese said, potentially doing multiple jobs. The healthy choice is to go to Whole Foods and buy some fresh produce and make the nutritious menus that the American Heart Association recommends. But number one, that's expensive. Number two, the Whole Foods may not be in your neighborhood, and frankly, you don't have time to go to that store or to do all that food preparation when you're working multiple jobs and stretch to the limits. Right down the street on your way home is a McDonald's, and for $3 or $4, you can get some food that will feed the kids and not break your budget. It happens to be that, that fast food is calorie dense and precipitates obesity. Our food industry and our socioeconomic environment are driving people to the over consumption of calorie dense, inexpensive foods that produce obesity.

Robert McCartney (07:42):

Although the health inequities have been well known for some time, they have been highlighted recently by the COVID Pandemic and the new national attention to racial issues in the wake of the George Floyd murder. So let me ask each of you somewhat briefly to just talk about how these inequities manifested themselves during the whole COVID experience?

Dr. Reuben Varghese (08:07):

What I've been telling public is essentially what we discovered before COVID continued during COVID, and in fact, it just magnified the problem. COVID was a horrible experience for the whole nation, but it's still disproportionately affected those who already came in with those risks going into COVID.

Dr. Steven Woolf (08:28):

The phrase that people often use during the pandemic was that it had laid bare these problems that we were well aware of, at least in our field, long before then. So it was a tragic example, a tragic new example of an old problem. We documented decreases in life expectancy nationally during the pandemic and saw historic decreases in life expectancy for the United States of about 1.7 years, which was the largest since World War II. But in the Hispanic and Black populations, the decreases in life expectancy were three to four years and even higher in the Native American population.

Robert McCartney (09:10):

Has there been an increase in focus on the racial dimension to this, which is such a big part of it, since the George Floyd protest? Because there was sort of a national, I would say, awakening regarding structural racism following that incident and all the publicity around it. I'm just wondering if that's contributed to the increased focus in the discrimination in the health sector?

Dr. Steven Woolf (09:34):

My sense is like yours, Robert, actually, that it did have an impact. There was one segment of our society that reacted to that by thinking about how to be more inclusive? I think a lot of initiatives were launched to focus on racial equity, both in government where federal, state, and local government officials committed themselves to equity initiatives. Arlington County is a good example of that. But also in the private sector, businesses felt the need to put out statements and to develop DEI policies in their organizations.

Robert McCartney (10:10):

DEI refers to diversity, equity, and inclusion. In our area, many of the initiatives call on all departments in the local government to take equity into account in formulating policy. The goal is for an equity lens to be employed for viewing all issues. Some West Coast cities, including San Diego and Seattle, have adopted such programs, and they've been seen in the DC region as well.

Dr. Steven Woolf (10:35):

There have been several jurisdictions in our area that have taken this on in ways that I don't think you always see across the country. So next door in Fairfax County, for example, there is an initiative called One Fairfax, which is also taking a systematic approach to thinking about this.

Dr. Reuben Varghese (10:54):

What Arlington has done, they're starting with educating the various departments and the staff and the leadership in those departments to start embedding the thinking in all of their policy proposals and re-proposals. So that if you start incorporating the concept that there could be disparities, if you reduce those upfront, you will have an impact on health. The more that we start shifting towards centering equity, you're going to have the impact on centering health as the byproduct.

Robert McCartney (11:28):

In an example of an equity oriented project, jurisdictions across the region made extra efforts during the pandemic to reach out to marginalized communities, including those who are English is not the native language. To inform them about vaccines and related COVID matters. COG has also formally committed to promote additional investment of all kinds in census tracts with disproportionate shares of low income people and communities of color. These tracts, called equity emphasis areas, have about 30% of the Washington metropolitan regions population. But there are hurdles to achieving a broad based rollback of all the forms of inequity. One, of course, is cost. Supporters of such initiatives, like Dr. Woolf, say such spending would pay off in the long run.

Dr. Steven Woolf (12:17):

It's important for people who are also reacting to this by saying it's too costly to recognize, first of all, the cost of inaction and the fact that economists have studied this issue and demonstrated time and time again, including in our region, that investments to reduce inequities actually improve our economy. So it's better for local businesses and for the local economy to address these problems.

Robert McCartney (12:46):

Then there's the daunting challenge of needing to pursue a holistic approach, which means trying to improve equity in multiple sectors at once. That's like you're trying to talk about a whole transformation of so many parts of the society that it's all of these issues. I mean, housing, poverty, transportation, implicit racial bias, all these things have to be addressed in order to get to where we want to be in terms of health outcomes. But it seems to be there's also a risk that when it's presented that way, that people are going to say, "Oh, well, that's too much. It's just overwhelming." What do you say to that?

Dr. Steven Woolf (13:28):

Well, I understand that it can come across as overwhelming, and certainly, there's no harm done in doing pieces of it. But I often find that what we're really calling for are initiatives that are already in play right now. It's more a matter of connecting the dots and understanding that those initiatives that we don't normally think of as health initiatives like helping the middle class, improving wages, creating better job opportunities, dealing with college affordability are all parts of a holistic health solution.

Robert McCartney (14:06):

In closing, I offer some personal thoughts. Achieving equity in health is a goal that surely merits applause. As we've heard, it would mean narrowing gaps in economic conditions, which are at the root of so many of our domestic social ills. In addressing equity, COG and local governments in our area and elsewhere have adopted an ambitious mission. They aim to recast the thinking about nearly every budget choice and policy decision with a purpose to improve the lot of lower income and traditionally disadvantaged communities. Poor health and other social ailments in these populations have deep roots and long histories, and have defied past reform campaigns.

Moreover, the country's acute political polarization leaves little hope for progress at the national level. But on the bright side, in less polarized metro regions such as ours, we see an opening for county and municipal elected officials to push equity measures. Here the goal enjoys widespread support and the lessons of COVID combined with the surge of attention to the problems of systematic racism, may mean now is a favorable time for progress. I hope you've enjoyed this podcast. We welcome your feedback. Please email comments to Think Regionally, one word, at mwcog.org. This podcast is produced by Janele Partman and Lindsey Martin. Next month look for our second episode in this two part series on equity in action. This is your host, Robert McCartney, urging everyone to think regionally.