Transcript: Health Equity – The Washington Post

We’re going to be joined on stage by several individuals who are studying health inequity and trying to eliminate barriers to health care. First, my colleague, Jonathan Capehart, will sit down with Admiral Rachel Levine, the Assistant Secretary for Health at the Department of Health and Human Services, to talk about the Biden administration’s National Strategy to Advance Health Equity. Next, Akilah Johnson will be joined by Thomas LaVeist, the dean of Tulane University’s School of Public Health and Tropical Medicine, to discuss the economic toll of failing to achieve health equity. Then Akilah will be joined by Natalie Hernandez, the executive director at Morehouse School of Medicine’s Center for Maternal Health Equity, and Kortney James, a pediatric nurse practitioner at UCLA, to discuss how health inequity impacts maternal care.

Before we get started, I would like to thank today’s sponsor for this event, Bayer. We want to thank you again for coming, and after this short video, my colleague, Jonathan Capehart, will take the stage. Thank you.

MR. CAPEHART: Good morning. I’m Jonathan Capehart, associate editor at The Washington Post.

We start today’s conversation with the 17th Assistant Secretary for Health at the Department of Health and Human Services, Dr. Rachel Levine. Admiral Levine, welcome back to The Washington Post.

ADMIRAL LEVINE: Well, thank you very much. It’s really a pleasure to be here.

MR. CAPEHART: And this is your–I say welcome back because you have been here to Washington Post Live before but virtually. This is your first time live live.

ADMIRAL LEVINE: That is correct.

MR. CAPEHART: So let’s begin with the recent study of death certificates from the last two decades, which found that the higher mortality rate among African Americans resulted in more than 1.6 million premature deaths compared to the White population. How do you explain this?

ADMIRAL LEVINE: Well, this is a very important study published in JAMA, the Journal of the American Medical Association, which highlights the significant health disparities that exist in our nation, which impact life expectancy, particularly with African Americans versus other groups. This further confirms the information that we know at the Department of Health and Human Services about how significant these health disparities are, and it shows how far we have to go to achieve health equity.

MR. CAPEHART: Well, I mean, I’m glad you bring that up, because 40 years ago, Margaret Heckler, who was President Reagan’s Health Secretary, wrote a report that outlined the disparate health outcomes on Black and minority health, and as you bring up, the problem has only gotten worse. Is that–is it due to health disparities or the quality of care or a combination of the two or even more factors?

ADMIRAL LEVINE: I think that there–it is those two factors, and there are even more factors. One of the most significant issues is lack of access to care for many in the African American community, and that can be in urban areas and in rural areas. It has to do with lack of–potential lack of health insurance, but also I think the social determinants of health, those social factors that influence health that we don’t usually consider health related, economic opportunity, educational opportunity, nutrition, the environment, transportation, housing, and more, all of those factors together, I think, influence these statistics.

MR. CAPEHART: How about stigma?

ADMIRAL LEVINE: Absolutely. I mean, so structural and systemic racism and stigma have a big influence on this, and these are all issues that we are working to address at the Department of Health and Human Services under Secretary Becerra’s leadership and, of course, throughout the Biden-Harris administration.

MR. CAPEHART: This was an audience question I was going to bring up later, but it’s perfect to bring up now. It’s an audience question from Lyne Filiatrault. I hope–I know I butchered Lyne’s last name. I’m so sorry. From Washington. You can see it on the screen behind me. Do you agree that health inequity is a systemic issue? If so, what systemic changes do you believe are necessary to remove the health disparity across racial groups, age groups, and social classes?

ADMIRAL LEVINE: So I do think it is a systemic issue. Certainly, the covid-19 pandemic has shown us the depth and breadth of the health disparities in our nation and the lack of health equity. That is why the president started the COVID-19 Health Equity Task Force, which was run through my office and I was honored to have a seat on, which looked at many of these issues that were bringing–brought forth by the covid-19 pandemic and all of the different aspects of it. And so really, health equity is fundamental to everything that we’re doing now at HHS under Secretary Xavier Becerra’s leadership. It is foundational.

And so when we look at every grant, we look at every notice of funding, we look at every regulation, we look at every topic that we’re researching and that we’re trying to work on, health equity is central to it. We have a health disparities task force, which I’m very pleased to co-chair, and many different activities, both at my office of the Assistant Secretary for Health, CMS, HRSA, CDC, NIH, and more.

MR. CAPEHART: And I brought up the–I used the word “stigma” because sitting in that seat a few months ago was Dr. Demetre Daskalakis, who is the deputy White House coordinator for the for the mpox response, and he talked about many of the things you’re mentioning, but also stigma and how that is playing into a lot of the health disparities we see in the country, but also people’s access to HIV treatment, to the mpox vaccine. I’m sure a lot of people in this room understand and know what you’re talking about intuitively, but maybe for folks who are watching virtually, talk about why all of these things are in–why transportation and quality of health care, how all those things are intertwined.

ADMIRAL LEVINE: Sure. Well, stigma is critical, and we see that stigma in terms of the LGBTQI+ community. And in some ways, in many states in this country, that has gotten worse.

But in terms of transportation–so I was in East St. Louis last week. I was in St. Louis and then went just across the river to East St. Louis in Illinois and saw significant environmental justice challenges, saw significant issues in terms of availability of nutrition, availability of fruits and vegetables in that area, saw challenges in terms of access to health care. One of it is there’s very little public transportation, and many people don’t have cars. So if they’re going to go see their doctor or their nurse practitioner, how are they going to do that?

If you open a store in one part of East St. Louis with fresh fruits and vegetables, how do people on the other side get there? And so transportation is absolutely critical for access to health care and access to nutrition, to health, education, all of those factors.

MR. CAPEHART: So then which community–you talked about going into East St. Louis.

ADMIRAL LEVINE: That’s correct.

MR. CAPEHART: Which communities are most at risk of not receiving quality health care? Is it specifically communities of color, or does it cut across–cut across racial lines?

ADMIRAL LEVINE: Both. So absolutely, communities of color face enormous challenges in terms of health equity, and that includes the Black, African American community we’ve been discussing but also the Latino community and the American Indian/Native Alaskan community, which also significantly has these challenges.

But we see cross-cutting issues in specific urban areas. We have food deserts in urban areas where you cannot get–you can get food, but it’s going to be fast food and unhealthy fast food, but you can’t get fresh produce in many urban areas. We see that in even suburban areas and then certainly in rural areas, lack of housing, lack of transportation, problems in terms of education. So it is specifically for communities of color, but it is also cross-cutting in terms of other parameters.

MR. CAPEHART: So then what are some of the interventions or programs that the government has put in place or wants to put in place that would reduce racial disparities, and those programs that are in place, which are the successful ones? What are they doing?

ADMIRAL LEVINE: Sure. Well, one of the most successful programs is through HRSA the Health Resources and Services Administration. Those are our community health centers. We have many, many, thousand or more community health centers across the country. They are located in urban areas. They’re located in rural areas, and they’re located so people can access them. And they often have transportation to them to provide access to that care.

In terms of the Affordable Care Act and expansion of Medicaid, that and through the Centers for Medicare and Medicaid Services, that is a critical component to accessing health care and having health insurance, except there are still a number of states that haven’t expanded in Medicaid, even all after all this time. CMS is concentrating on many, many different factors in terms of health equity.

Within our Office of Minority Health and Women’s Health in the office of the Assistant Secretary for Health, we have many different programs focusing on this, including the issue of maternal mortality. Maternal mortality, women who are sick or with morbidity or mortality might die during pregnancy or during delivery or within a year afterwards.

The United States is the only developed country that has an increasing rate of maternal mortality, and it is almost exclusively in the Black, African American community. These are issues that all of our different divisions within HHS are looking at, being studied by CDC and NIH, and then being addressed by HRSA, CMS, and more.

MR. CAPEHART: Just–what was it?–last week or maybe two weeks ago, front page of The Washington Post, story about Black maternal health and just the increasing numbers of Black women dying–

ADMIRAL LEVINE: That’s correct.

MR. CAPEHART: –in childbirth or after childbirth. I had a conversation with a member of Congress where I brought this up, and she said every three months or so or every quarter, there seems to be three stories in The Washington Post, in The New York Times, all talking about this issue.

MR. CAPEHART: Each time there’s a story, it only highlights how much worse it’s gotten since the last story but no conversations about what can be done to make things better. So what can be done to make things better so that the next front-page story in The Washington Post about Black maternal health will not be it’s gotten worse, but we’re starting to see a decline in the rate of death?

ADMIRAL LEVINE: Absolutely. Well, first, we need to study it intently, and the CDC has been doing that. So they have been sponsoring maternal health morbidity review committees, with which when I was in Pennsylvania we started one, as well as perinatal collaborators to look at different factors within each state that can address those state-specific issues.

But we also need–a lot of it is access to prenatal care also with the different social factors that we’ve been discussing. It’s making sure that pregnant women have insurance, and it’s making sure that they have proper nutrition, all of those different factors. But we have programs, again, through my office, through HRSA, and really CMS and more looking to address that. And I think with this attention in the Biden-Harris administration and this dedication under Secretary Becerra’s leadership, we’re going to make progress, but it’s going to take some time.

MR. CAPEHART: Let’s talk a little bit more about covid-19 because that really highlighted–I’m sure you knew about this, but it really highlighted for the country, the health disparities that persist in the United States. What lessons did you learn from that experience?

ADMIRAL LEVINE: I think we learned a number of different lessons. One of the lessons is the critical importance of public health. Public health right now is the center of the universe, and it is so important that we invest in public health, that we invest in the workforce, we invest in the information technology and the data for public health. And I think sustainable funding for public health now and in the future is critically important as we continue to work through the covid-19 and long covid as well as prepare for the next pandemic.

The second is how critically important it is for local, state, federal, and international public health authorities to work together, and I think that we have made a lot of progress with that in the Biden-Harris administration working with state health officials–I was a state health official during the first year of covid–with our local health officials. And we have had many, many, many, many discussions, first online and now in person, with our colleagues in the states and the local governments to make sure that we’re in sync.

And the other is those social determinants of health, is that you can’t just look at medical care in isolation. Really, we have to look at these other social factors that influence health.

So to me, the work done at Department of Commerce is a health issue. The work done by Secretary Pete and the Department of Transportation, that’s a health issue. Housing at HUD, those are all health issues. And so we have to work with those to deal with the current challenges such as maternal mortality, such as the continued opioid overdose crisis, and so many of the other challenges that we face today.

MR. CAPEHART: As you mentioned, you were a former state official, but you’re formerly a pediatrician focused on child and adolescent behavioral health.

MR. CAPEHART: What impact do you think covid has had when it comes to the mental health of America’s children?

ADMIRAL LEVINE: Well, you know, we see many different studies–the newest one is the Youth Risk Behavior Survey out of the CDC–that indicate the challenges to mental health among our youth. A lot of that started before the pandemic, but it’s clearly been exacerbated by the covid-19 pandemic.

That’s why our Surgeon General Vice Admiral Viva Murthy issued a report and highlighting this in December of 2021, and we have many different programs and all the different–same departments and divisions we’ve been discussing, including, of course, SAMHSA, the Substance Abuse and Mental Health Services Administration, looking at youth mental health and trying to address that.

MR. CAPEHART: You’re the highest-ranking, out transgender government official in U.S. history. You and I were both at Vice President Harris’s Pride Month reception at the Vice President’s residence last night, and in her remarks, she decried the 500-plus bills that have been introduced in legislatures across the country. More than 70 of them have become law.

There have been challenges, to be sure. Just yesterday, federal judges in Kentucky–

MR. CAPEHART: –and Tennessee, they blocked bans on gender-affirming care for minors in those states. I would love your thoughts on the impact of these bills and laws popping up across the country.

ADMIRAL LEVINE: Well, it is very challenging for health equity for the LGBTQI+ community, and these politically and ideologically motivated laws and actions are harming youth, particularly transgender youth, their families, and even their providers who are under siege in many parts of this country. And they’re really interfering with the relationship between expert physicians, for instance, at children’s hospitals, these young people and their families. And it’s not where government belongs.

MR. CAPEHART: Personally, as an out transgender person–I’m not going to say as government official because I don’t want to get you in trouble, but personally, what do you make of the tenor and tone of the conversation that we’re having in this country when it comes to LGBTQIA+ issues?

ADMIRAL LEVINE: Well, you know, again, the challenge has been these regressive laws and actions that have been promulgated throughout the country, again, being done specifically for political and ideological purposes, but I see a change. I think things are changing. I think that since Transgender Day of Visibility and now the momentum we’ve developed at Pride, I think that the conversation is changing. I think the narrative is changing, focusing on these vulnerable youth and their families and their doctors. And I think with Pride Month just finishing up this week that we are going to continue that, to change that narrative, and continue to make progress.

That’s why I’ve said this should be a summer of Pride. We should have Pride all summer, which means that we need to continue these discussions. We need to continue to change the narrative about health equity and about families and about these young people so that we can get past this very challenging stage and continue the progress that we had been making before.

MR. CAPEHART: And in your travels around the country, are you–is that what’s driving what seems this optimism from you about a summer of Pride, that there is pushback around the country to the overall rhetoric and tone and tenor–

ADMIRAL LEVINE: That’s exactly right.

MR. CAPEHART: –of the conversation?

ADMIRAL LEVINE: That’s exactly right. So at the same time, I see these young people and their families, and I meet their doctors, who are having such struggles. But I sense a change. I sense a positive change that will–that I think is going to continue, despite the challenges that we face. And I think that that’s going to lead for the tide to turn, and I think that these laws and actions will not stand, and I think that we will continue to make progress.

Now, I’m a positive and optimistic person, because I choose to be positive and optimistic, but under the Biden-Harris administration and the leadership shown at the highest levels of government and across the administration for the LGBTQI+ community and the actions in states and in communities changing hearts and minds, I remain positive.

MR. CAPEHART: So I noticed you wouldn’t get personal in that, in that answer. So I’m going to ask you something else. Maybe you’ll go personal on this. The last–and this is a total diversion, but the last show you binged?

ADMIRAL LEVINE: So I don’t get to watch a lot of TV–

ADMIRAL LEVINE: –as you might imagine with a schedule that I keep. But between the time that I was nominated and then confirmed and started my position, I actually binge-watched “Madam Secretary” to get a feel of what Washington was like.

ADMIRAL LEVINE: Absolutely.

MR. CAPEHART: “Madam Secretary.” And so then what lessons did you learn?

ADMIRAL LEVINE: I learned that Washington can be an interesting place–

ADMIRAL LEVINE: –and with many opportunities and many challenges. I learned a little bit about how–about how different departments–of course, that was Department of State–and I’m Department of HHS–interactions with the White House, interactions with the press. And of course, it’s a TV show–

ADMIRAL LEVINE: –and it’s made in Hollywood, and it has a certain perspective. Amazing challenges were solved in one or two episodes. It takes a little longer to solve these problems.

ADMIRAL LEVINE: But if you look at many of the issues that were discussed in that show, they are ripped from the headlines.

ADMIRAL LEVINE: Environmental challenges. We haven’t talked about climate change and health and health equity. Look outside today–

ADMIRAL LEVINE: –in terms of the air quality that we have in the East coast and much of the Midwest. They discussed that. They discussed a potential war between Ukraine and Russia in that show. They discussed issues of health, issues in terms of economic opportunity, so many different issues that–the opioid crisis and more, that we see right now were shown in that show. So even though it’s a TV show, it was valuable.

MR. CAPEHART: What did you pick up from “Madam Secretary” that got completely obliterated by the reality of the job?

ADMIRAL LEVINE: Well, that she had like four or five staff that basically helped run her entire life at the Department of State. I have more staff than the Secretary had.

ADMIRAL LEVINE: But, you know, some important nuggets, some lessons, lessons learned from the show.

MR. CAPEHART: I find it curious, “Madam”–you binge watch “Madam Secretary,” which is great, but not “House of”–I mean “House of Cards”? Have you tried?

ADMIRAL LEVINE: No, I deferred on that.

ADMIRAL LEVINE: Because, well, I never watched it, so I can’t tell you exactly. But what I heard, it had had a much darker tone.

ADMIRAL LEVINE: Subtle, but that’s what I’ve been told.

ADMIRAL LEVINE: “Madam Secretary” had a very positive and optimistic tone. I’ve told you I’m a positive and optimistic person, and I think that in this administration, with the leadership that we have, that we’re making changes to benefit health equity and many other challenges that we have in the United States and across the world. And so I wanted a positive show, not a show that would be–show me what I was getting into in Washington.

MR. CAPEHART: [Laughs] Admiral Rachel Levine, Assistant Secretary for Health at the Department of Health and Human Services, thank you very much for being here today.

ADMIRAL LEVINE: My pleasure. Thank you very much.

MR. CAPEHART: All right. Don’t go anywhere. My colleague, Akilah Johnson, will be out here in just a few minutes with our next guests. Stay with us.

MS. JOHNSON: Good morning, and welcome back. I’m Akilah Johnson, a national health reporter here at The Washington Post, and I am joined by Thomas LaVeist, dean of the School of Public Health and Tropical Medicine at Tulane University.

Dr. LaVeist, welcome, and thanks for joining us.

DR. LAVEIST: Well, thank you for having me. It’s a pleasure, pleasure to be here.

MS. JOHNSON: It’s great to have this conversation in person.

MS. JOHNSON: So I want to start by talking about your study, which looked at the price society pays–or found the price society pays for failing to achieve health equity. And in 2018 alone, that was one $1.03 trillion. How did you get this number?

DR. LAVEIST: Well, we calculate that by looking at three areas. We look at the cost of health care that otherwise would not be used if people weren’t as sick as they are. We look at lost productivity at work. So people take time off work because of care for sick loved ones or for themselves. And then also we look at the cost of premature mortality. So as a society, we invest in public schools and other ways. We invest in human capital. But then people die prematurely before the society is able to recoup their investment in that, in that person. And when you calculate all three of those areas, it exceeds $1 trillion a year.

MS. JOHNSON: Now, what made you decide to look at the cost in dollars and cents of not achieving health equity?

DR. LAVEIST: Well, let me first say that health equity is a social justice issue. Without question, I don’t want to live in a society where people are living sicker and dying younger than they otherwise would live and die.

DR. LAVEIST: But there are many of us, including me, who are under the tent. We sort of got behind a health equity issue on the basis of the social justice argument, but there’s a bigger issue than just social justice, and there are some people who may respond more to a utilitarian argument, a fact that there’s an impact on the society in general. And so this is not just a problem for Black and brown people, but it’s a problem for the entire country because we all are losing the investment that we’re making in people and not recouping that investment.

MS. JOHNSON: So has that message–do you think it resonates, or how has it resonated with the general public?

DR. LAVEIST: I think it has. We’ve been doing these types of studies for some time now, and the first time we did it was right around when the Affordable Care Act was being debated in Congress. And we were told that there was some change of heart and there was an additional–some additional provisions added to that bill to address the health equity issue, in part, because people were responding to the fact that this is very expensive to society. However, most of those provisions were not funded, right? So we didn’t take the action that was needed to really move the needle, which is why now that we’ve redone this work, you know, almost 20 years later, we’re finding that the cost actually has increased.

MS. JOHNSON: And so you also calculated the economic toll when people don’t–when people can’t work, because like you said, when a relative is sick, like the cost of care, caretaking and caregiving.

MS. JOHNSON: How did you calculate that?

DR. LAVEIST: Well, what you do there is you look at–you look at use of health services and the cost that’s associated with that use of health services, and you compare people who in surveys indicate that they took time off from work, from presenteeism or absenteeism, and you’re able to calculate the difference between people who are taking time, people that are not taking time. And that’s where we can come up with that cost.

MS. JOHNSON: Okay. Because, you know, I think sometimes when we talk about health equity and then we talk about the economic toll, I guess I just wonder if people think there’s a disconnect there, right? Like, why are we talking about dollars and cents, and is that somehow commodifying the issue?

DR. LAVEIST: Maybe it is.

DR. LAVEIST: You know, maybe it is, but–and, you know, I think–I sometimes get people asking about this because people, a lot of us, including myself, responded to this issue from a social justice perspective. And for me, that was enough.

But the argument that this is bigger than just social justice, I think, is an important argument to make, and I also think it’s important to point out that the cost doesn’t accrue only back to the people in those communities but rather the entire society. And that’s best accomplished by showing how it impacts the economy. That’s why I think it’s important that we make the social justice argument as well as the economic argument for why we should address health equity.

MS. JOHNSON: And we’ve talked about this before, but when you talk about kind of the cost that society writ large bears as a result of this, you know, you’d mentioned, at one point, Social Security–

MS. JOHNSON: –and that being kind of a system that folks are paying into and not reaping the benefit.

MS. JOHNSON: Unpack that a little bit. Unpack this idea of–

MS. JOHNSON: –like what is lost by all of society for not achieving–

DR. LAVEIST: Yeah. I think Social Security–that’s a good–I think it’s a good example of–and it’s kind of a way that people can kind of just see the issue.

DR. LAVEIST: So we have a policy. We have Social Security program established in 1935. This program was established to help address poverty that many people after retirement were not able to basically live. The program was developed, but if you look at the differences in life expectancy, if you say you have a Black worker, White worker, they begin working the same day at the same job for the same company, they make the same salary, which may not always be the case, but in this example, they make the same salary, they pay the exact same amount of money into the health care–into the Social Security system, and they both retire the same day. Because the White person on average is going to live longer than the Black person, there’s going to be a difference in how much they’re going to get out of that system that they paid into.

It’s just a good way of–I’m not saying the Social Security is inherently racist, but I’m saying that it has an inequitable outcome because of the health inequities, and this is just a good way to demonstrate how that operates.

MS. JOHNSON: Social Security, you say Medicare too, right, things that folks aren’t achieving–

DR. LAVEIST: You could–you could say any number of programs.

DR. LAVEIST: But I think it’s just a good way of being able to just illustrate how the inequities kind of play out.

And again, it’s important here to point out when we talk about structural inequities, this is a structural inequity. It doesn’t require any individual to have racist beliefs or attitudes or values. It just simply is the way the system operates, and if we don’t intervene, it will continue to function this way.

MS. JOHNSON: You know, someone once said to me, when we talk about structural racism, structural inequities, that it is too blunt of an instrument to just kind of make it writ large structural racism, and that we need to kind of get into the nuances and how that manifests–

MS. JOHNSON: –thinking specifically around gender. What would you say to someone who said it is too blunt of an instrument if you just say structural inequity?

DR. LAVEIST: Well, I–that actually resonates with me quite a bit.

DR. LAVEIST: I think there’s just something to that. My strategy is to talk about structural inequities but also to talk about examples like the Social Security example or the fact that the country is racially segregated. So we live in different communities, right? And so we know that there–that health care resources are not distributed evenly across all community. Neither are–neither are high-quality supermarkets or restaurants, or we know that environmental hazards are not distributed equally, right? So just the fact that we have segregation facilitates the exposure to health risks and lack of availability of healthful resources, and so those structures are what is driving the health inequities. And I do think we need to talk about the structures, but just talking specifically saying structural inequity is kind of vague, and we need to give examples like the Social Security example or the racial segregation example.

MS. JOHNSON: Now you’ve looked at one year. I’m just going to–I’m curious as to why you looked at 2018 and didn’t do–I don’t know–since the ACA or since the Heckler report. Why did you just choose one year, Dr. LaVeist?

MS. JOHNSON: Well, we’ve been looking at–we’ve been doing this over time.

DR. LAVEIST: So we’ve done this many times, and we chose ’18 because we didn’t want to go into the pandemic. That was one of the issues. We’ll, of course, do another one to look at what was the impact of the pandemic. So that was why we do it.

But usually, what we do is we actually combine multiple years. So we may call it 2018, but it’s like three years combined to kind of create a rolling average over that period of time. So it’s really a little longer time period than just the one year.

MS. JOHNSON: Got it. And what the study found is that more than two-thirds of the economic burden experienced by communities of color–

MS. JOHNSON: –was attributed to premature deaths. Can you explain the economic loss you’re referring to? Like, talk about premature deaths. I know you mentioned a little bit with Social Security, but how does that translate to larger economic loss, and for whom?

DR. LAVEIST: Well, the loss is for the entire society–

DR. LAVEIST: –which is why we tie it back to the gross domestic product, right? It’s the entire society that it’s losing, because everyone who’s paying taxes is paying into a system that’s investing in the human capital, right? And so the society invests in human capital with the expectation that as when people become productive citizens, they’ll pay taxes back. And that will help to–that will help to elevate the society.

But when people die prematurely, if we don’t get to recoup that investment–and that’s–so it’s really–it is a counterfactual. It’s lost economic potential that we’re not able to capture because people die prematurely.

MS. JOHNSON: And when you say invest, how are we investing? How are we investing in those people and are we’re not recouping it?

DR. LAVEIST: Well, maybe we should say “invest” with air quotes, but, you know, we’re investing. We pay. We have public school, public education, for example, as a society. We do have other things that we consider part of the public good that we pay with our tax dollars, and those are the investments that we make in people.

MS. JOHNSON: Okay. So public schools, are you thinking health care? Are you thinking air quality? Are you thinking roads and streets, all of the kind of–

DR. LAVEIST: I would say–

MS. JOHNSON: –public goods that we’re consuming?

DR. LAVEIST: –everything that we pay for tax dollars that benefit the society in general, quality of the roads, things like that. All of those are investments.

MS. JOHNSON: Got it. And even though most of the economic burden was from the loss of premature life in the African American community, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native populations had the highest economic burden per person. Unpack that a little bit.

DR. LAVEIST: Yeah. Well, you have to look at the population sizes.

DR. LAVEIST: When you look at different population sizes, then that’s where that it happens. But something about those, the Indigenous populations, that is, I think, an important nuance that needs to be realized there, that many of those populations live in the U.S. territories and those–the U.S. territories are typically not included in a national data assistance. So we are missing a lot of people that were not even in this study, and I’ve projected if we were able to capture those individuals, that it would be even higher.

Also, we don’t have prison populations in this. We don’t have people in the military. So if we were able to capture all of those populations, all of those people, because we know that these are disproportionately Black and brown people in these states, this–the cost would likely be even higher.

MS. JOHNSON: What do you hope is the–what’s your ultimate hope and outcome for this study? What do you hope people take away from it?

DR. LAVEIST: Well, one thing is I’d like people who don’t necessarily resonate with the issue of health equity or an inequity as it relates to people of color to see that this is not just an issue of people of color, that everyone is harmed by this, because everyone is paying into a system and not getting the return on that investment. It’s a drag on the economy. It’s a significant drag on the economy, and in fact, the first time we did this, we calculated that the cost, the drag on the economy, was equal to the total economy of the 11th largest economy in the world, which was India. So we’re talking about a lot of money, and that it–

MS. JOHNSON: Wait. Unpack that. So when you say the drag on the economy, what did you mean by that?

DR. LAVEIST: This was the first–

DR. LAVEIST: Well, this is the way that we think about this, that this is–

DR. LAVEIST: It’s not that we’re paying money because of the inequities. It’s that we’re–it’s the lost opportunity.

DR. LAVEIST: So we consider that a drag on the economy. It’s holding the economy back a bit, right? And that hold is pretty substantial. We’re talking about a lot of money, and I think the most important point here is that I can’t tell you what it will cost to fix the health inequities, and it will cost something. But it also will cost something to not fix the inequities, and so to the argument that we shouldn’t do things because it’s expensive, I don’t think is an argument that’s sustained logically, because it also costs–there’s a significant cost of inaction. And that’s a cost that I think we should not continue to bear.

MS. JOHNSON: Got it. And what do you believe is ultimately driving–I know we talked about structural kind of inequality, but what–if you had to kind of pin it down to maybe the top three, what do you think is actually driving these excess deaths and premature deaths in communities of color, particularly the African American community?

DR. LAVEIST: Lack of will to act. It’s political. So when you look at the Affordable Care Act, one of the things that it did was it expanded Medicare–Medicaid eligibility, right? But it left open the option for states to decide whether to expand or not, and when you look at the states that did not expand, they are the states with the largest Black population, right? And so African Americans did not benefit from it.

Now–and I’ve had this conversation with legislators in some of those states. I lived in Louisiana. Louisiana did actually expand Medicaid. So I say we’re surrounded by states that did not, but we did in Louisiana. But when you–the expansion was paid for by federal tax dollars. Who pays federal taxes? We pay federal taxes, including the people that live in Alabama and Georgia and Arkansas and Texas. They pay federal income taxes too. So they actually paid for the expansion in states like Louisiana and California and New York. So I thank all of you who live in Georgia for paying to expand Medicaid in Louisiana and not benefiting from the–so it’s a political decision, and I think that we have to incorporate the politics, because politics are vital. And I think this is a big part of what’s driving it.

MS. JOHNSON: Absolutely. And so we are just about out of time, and I think–

DR. LAVEIST: Really? It’s so fast.

MS. JOHNSON: So fast. This is what happens when you’re having fun on a Thursday morning, Dr. LaVeist– [Laughter]

MS. JOHNSON: –and when you were actually engaging in the conversation and giving good answers. This is why we like talking to you. So thank you so much for joining us here today.

And all of you stay with us because we have more coming up in a few minutes. Thank you.

MS. LABOTT: Good morning. We’re going to continue on the issue of health inequality and talk about the impact of socioeconomic factors on overall health. Low income, poor education, and environmental factors can all affect health conditions and vulnerability to disease, and self-care can be an important tool. Thirty million Americans have no health insurance and can’t easily access a doctor or a hospital, and for many people, self-care offers the first and often only form of health care, and it shouldn’t be a luxury.

To talk about the socioeconomic impacts on health conditions and how self-care can help meet unmet medical needs, I’m joined by Abbie Lennox. She’s the member of an executive committee on Bayer Consumer Health.

Abbie, great to have you.

MS. LENNOX: Thank you. Thank you for having me, everybody.

MS. LABOTT: So at Bayer, you launched the research initiative for self-care equity to study these socioeconomic benefits of health and impacts of health.

MS. LABOTT: What have you found about the correlation between low-income populations and their health?

MS. LENNOX: Well, this is the first-of-its-kind comprehensive study, and what it’s done is it’s looked back across the last 30 years at more than 400 pieces of research and papers that have been published in links between socioeconomic and health outcomes. And what we found is that there are many different factors.

You know, we totally know that when you look at low-income consumers and patients, they normally have blue collar jobs.

MS. LENNOX: They obviously suffer more from pain issues. Taking a day off work to rest the body is not necessarily something that’s possible for them. So what we are finding is a huge link between the ability to need to be able to take care of yourself whilst also being able to look after your health and driving that through different products and different ability in managing your life rather than having to deal with the doctor all of the time.

MS. LABOTT: Right. But it isn’t just about income, right? I mean, many of these socioeconomic factors are systemic and self-reinforcing. So if you’re in a low-income population, you probably have poor education, less access to healthy food, possibly environmental factors that affect your disease. I mean, disease is more of a human condition, right?

MS. LENNOX: Absolutely. Medicine is always about treating the disease, and what self-care is about is about treating the human. So if you think about it through this lens, that what Rise, which is the initiative that we’ve done, has shown is there’s three key determinants. There’s the individual, so weight, lifestyle, nutrition, all huge factors. Socioeconomic is obviously part of that but also environment. And unfortunately, none of them are individual. You can’t take any of them and say, “Well, I’ll fix that one, and it will solve everything else,” because it’s cyclic and it’s cynical.

If you grow up in a low-income household, you probably don’t have access to green spaces, the ability to go out and enjoy the outdoors. You don’t have access to fresh fruit and vegetables. You don’t necessarily have access to the education that enables you to understand your own body, understand what your body needs to stay well, not just be well.

MS. LABOTT: And that affects your weight, and that affects heart disease.

MS. LABOTT: It’s all self-reinforcing.

MS. LENNOX: Absolutely. One of the things that the study showed is that African American women, for example, are more likely to suffer from bacterial vaginosis and leave it untreated, and if you leave it untreated, your increased risk of miscarriage later in life is tenfold. So by teaching people earlier on that going and getting a product that can treat it–it’s relatively noninvasive, and it solves the problem at the moment–later in life, you’re certainly going to have a much better chance.

MS. LABOTT: You and I have spoken about when we think health, we think let’s–I’m going to go to a doctor. I have to go to the hospital. We don’t necessarily think about how we can manage our own health before we get anywhere to the point where we need to go to the doctor and spend hundreds or maybe thousands of dollars. So talk about how self-care can play a role in improving health, and particularly for these underserved communities where they don’t have–may not have the access or the money to go to a doctor.

MS. LENNOX: So in 2018, there was a paper published in the Journal of Medical Economics, and what it showed was that 10 percent of U.S. visits to doctors could easily be avoided by using self-care.

MS. LABOTT: Oh, 10 percent.

MS. LENNOX: That’s $5.2 billion a year that could be saved, and that’s just with half of that 10 percent not happening. So think about that then being invested into things like health literacy, to be invested into helping people to understand how to take care of themselves. And if you don’t have to go to the doctor, you don’t need the day off work. You don’t need the day off school. This cycle that we are seeing about people not having the right education, not being able to feed their family, put a roof over their head, you start to break the cycle by enabling people to do what they need to do with their life.

MS. LABOTT: Well, I mean, self-care sounds like this simple concept. How many of us have said to our friends or family self-care? But let’s talk about the barriers to increasing self-care. I think–I would think for similar challenges for these underserved populations, not just access, but when people are struggling, they’re not thinking about self-care when they want to put food on the table or work to feed their families. It might seem like a luxury that you can’t afford.

MS. LENNOX: So let’s think about self-care in a slightly different lens. Let’s think about self-care rather than the bubble baths and the massages. Let’s think about what real self-care is. Self-care is about you being empowered to look after yourself, you being empowered to make the decisions and have access to the products that let you look after your family, your loved ones, keep them well, not just treat the issue.

And there’s lots of factors that make this difficult. You know, I think the three big ones–economy is obviously one of the guiding factors. Fifteen percent of people across the U.S. admit that they don’t take health medication or deal with a health problem, because from a priority perspective, the money needs to be spent on–

MS. LENNOX: Exactly. And this is a huge issue, and I think that by enabling people to understand that a small investment early on will actually mean saving an investment later is one of the big things.

And this links to education, which is one of the second areas of problems. Across the U.S., a recent study showed that a third of U.S. adults actually have what we call basic or less-than-basic health literacy. Now, this isn’t about being able to read and write. This is actually being able to understand the complex language. I mean, how many of you have opened a pill packet, and you’ve got a five-page leaflet to read? And how many of us actually read it, and what does it–does it make sense? So investing more in actually making that understandable for people is a huge thing, not just for the patients but also the health care professionals on how they can avoid those expensive trips to the doctors and actually advise their patients and advise people to take different products.

And then the third one is actually about the regulatory system. There’s been great leaps and bounds over the years in making OTC products come to the shelf, but there’s more work needed here. There’s more work about making it fit for purpose rather than applying the same rules to everything.

Safety, quality, and efficacy is the foundational role of everything in the health care industry. So it’s not about cutting corners, but it is about making it work for everybody.

MS. LABOTT: How do you argue for those changes in regulation? Is it simply just making an economic case? I mean, you said earlier about the billions of dollars that are spent that could be spent towards preventative or wellness care. Do you just make the case if you empower individuals to manage their own health and well-being, you can start to tackle these out-of-control health care costs?

MS. LENNOX: I think that’s definitely part of it, but I also think that sometimes you have to spend money to save money, and that also never quite goes so well when it comes to making decisions about changes in policy. So there’s a lot here around actually education and explaining the benefit of that as well.

There was a recent study that showed that $238 billion a year is the cost to the U.S. health system for poor literacy in health, 238–

MS. LABOTT: Just for lack of education, 230-some billion.

MS. LENNOX: Absolutely. Just because people don’t understand products and their health and the biology of the body and how to treat and look after. 238 billion. Let’s imagine that also going in with that 5.2 into the system.

MS. LABOTT: Talk about the role of science and innovation in addressing some of those issues.

MS. LENNOX: So at Bayer, obviously, as you’ve seen from the video, “Science for a Better Life” is our mantra. It’s the thing that all of us, I think, get up in the morning, and that’s the thing that drives what we do. So I’m never going to say that science isn’t going to be important.

MS. LENNOX: I’m also a scientist. You know, it’s important to me that what we do is grounded in that.

But I think we have to go back slightly further, because at Bayer, what we did recently was we published our opinion on what science-led self-care means, and in science-led self-care, we actually looked at a number of different factors that come together to drive real innovation in this world of health and self-care. And one of them is the science of the human, and like I said earlier, in health care, we often treat the disease.

MS. LENNOX: In self-care, we need to treat the human. We need to understand the fact that if you–if for example, you need to take a dietary supplement because that’s what your body needs to keep you well, to make sure that you’re at your best, you’re not going to take that if it tastes disgusting. You are not going to take that if it smells disgusting.

MS. LABOTT: Or if it’s a big, huge pill.

MS. LENNOX: Exactly. These are hugely important things that you have to build into everything you do as you innovate.

And then the other side of this is when we talk about the literacy. We are doing a huge amount of work at the moment on actually trying to use e-labeling, so QR codes, where people can go to the shelf. They can scan a QR code, or on the box, they can scan a QR code. It’s easier to talk in language that everyone understands through those sorts of things, through the digital medium that it brings.

So when we talk science and innovation, let’s always talk about it beyond the lab. Let’s look at it from that sense of the real human that we’re trying to look after.

MS. LABOTT: You spoke earlier about regulation. What about policy? Are there any policy changes that could help improve opportunities for access to self-care?

MS. LENNOX: Oh, yeah, absolutely. So the most obvious one is Rx to OTC switch, so taking those pharmaceutical drugs once they’ve had many years on the market to prove that they’re safe, and the ones that can go into the hands of the consumer, you don’t need a doctor.

MS. LABOTT: You just go to a drug store, and you purchase.

MS. LENNOX: Absolutely. We’ve recently switched to Astepro in the U.S. So that’s an allergy medication, and we’ve got many more to come. But you need a regulatory process that is open to that conversation. It listens to what consumers and patients are actually asking for rather than pure rules on a piece of paper.

We’re actually, at the moment, across the industry in the dietary supplement world, talking about trying to expand access to dietary supplements by adding them to the HSA and FSA rules in the U.S. So all of this is fundamentally about expanding access. That’s the goal of anything when it comes to self-care. How do we get the right products to the right people at the right time?

MS. LABOTT: I want to close on something you said earlier and expand on it a little bit about this concept of self-care. When we think of self-care, it is a luxury. It is–when we say to ourselves, “Oh, I need self-care,” “Oh, I need a mental health day,” or “Oh, I need a massage,” or “I need to go to the spa,” how do we, not just for ourselves, but as a society, stop thinking of self-care as this luxury that we’re spending time, we’re spending money, that we could be spending somewhere else, and see it as something that we need to do in terms of preventative health and staying healthy?

MS. LENNOX: So I’ve worked in this industry for many years, and one of the–one of the things that–you know, hindsight is a great thing–is–the bad thing for me is seeing “self-care” become this Instagram influencer word rather than what I personally feel self-care is. Self-care is about you as the individual being empowered to take control. That’s what it’s about. It’s giving the power to you.

And fundamentally, self-care is about you being able to have what your body needs, when your body needs it, at the right price point, and being able to access it, regardless of race, gender, equity, and where you live around the world. It’s about you having the opportunity to truly take control of your health.

Now, is that bubble baths? No. Sometimes bubble baths are fun, but that’s not self-care.

MS. LABOTT: And so is a mental health day.

MS. LENNOX: Yeah, absolutely. But that’s not necessarily self-care.

MS. LENNOX: Self-care is about how do I look after my body? How do I make sure that I not just get well when I’m ill?

MS. LABOTT: How do I know my body?

MS. LENNOX: Exactly. And then how do I keep it well? So I’m going to take the cough and cold medicine. It’s really obvious when I’ve got a cough and cold. I know what I need to do. Yeah?

MS. LABOTT: How many of us have–your spouse or your mother or something says, “Oh, have you taken something?” and you’re like, “No, not yet”?

MS. LENNOX: Exactly, exactly. And at the end of the day, these products are there not just to get you through the next day, but they’re also there–if we do it well and we do it correctly, they’re there to keep you well for the days to come.

MS. LABOTT: Well, I think the more we understand this concept, the more we understand income and other socioeconomic determinants that impact health, the better we can innovate these self-care solutions that will meet our needs, patients’ needs, regardless of income or access to health care.

Abbie Lennox, member of the executive committee of Bayer Consumer Health, thank you so much for this important conversation.

MS. LENNOX: Thank you. Thank you, everybody.

MS. LABOTT: The Washington Post will be right back in a minute. Thank you.

MS. JOHNSON: Good morning, and welcome back. I’m Akilah Johnson, a health reporter here at The Washington Post, and today I am joined by Dr. Natalie Hernandez. She is the executive director of the School of Maternal–of the Center for Maternal Health Equity at Morehouse School of Medicine, and next to her is Dr. Kortney James, a pediatric nurse practitioner with the National Clinician Scholars Program at UCLA.

DR. HERNANDEZ: Thank you.

MS. JOHNSON: So, Dr. James, it’s estimated that among pregnancy-related deaths, about 53 percent occur 7 to 65 days postpartum, and so more than 80–more than 80 percent of these deaths are preventable, right, meaning these are people who didn’t have to die as a result of their pregnancy. What’s going on? Why is this happening?

MS. JOHNSON: Easy question to start with, I know.

DR. JAMES: Right. Easy question to start with.

DR. JAMES: So oftentimes after you, you know, give birth is one of the most vulnerable times throughout the reproductive lifespan, right? And so as my background as a nurse, nurse practitioner, I’ve cared for pregnant people after they’ve given birth. And what happens is you can have blood pressure issues. There could be, you know, “leftover,” quote/unquote, issues from birth that will affect you, that sometimes people go for care after childbirth at six weeks. And as you said, things can happen before six weeks, if you are even able to be seen. We know maternity leave or options can, you know, cause problems with people actually receiving care. So being connected to care and being able to identify those issues early enough so that people aren’t dying is, you know, one of the issues.

DR. HERNANDEZ: And I can add to that.

DR. HERNANDEZ: Yeah. Because, you know, people love us when we’re pregnant, and then we’re discharged. And then we’re often left on our own, and we know that this is the most critical component, you know, where maternal–where most maternal deaths are happening, and you’re not receiving the support. You know, oftentimes with discharge, you’re just given a packet information and then sent home, and no one is really educating us about this fourth trimester of what’s really occurring during that postpartum period.

And then you’re oftentimes by yourself, right, because everyone goes, and people are focused more on the baby but were never really focused on us as women, our health, and our responsibility to take care of ourselves and others to also support us to take care of us.

MS. JOHNSON: You know, you touched on something that I’ve quite often heard when I speak to maternal advocates and reproductive health equity researchers, and that is kind of the lifespan issue when we talk about maternal health and how we’re so focused on this, like, single moment of time, right?

MS. JOHNSON: Like pregnancy. So talk a little bit about the lifespan, right, and why it is so important, and how a woman shows up to pregnancy ultimately can affect maternal health outcomes.

DR. HERNANDEZ: Yeah. We were just talking about this in the green room.

DR. HERNANDEZ: So, you know, a lot of women of reproductive age don’t have access to health care. So I am in Georgia. Twenty of women of reproductive age do not have access to care, and so people are going into pregnancy unhealthy, right? They’re not being seen. We know that the United States has an increase of chronic conditions, cardiovascular disease, hypertension, obesity, and when you don’t have access to care, you know, you’re not taking care of yourself. And with maternal mortality, we’re so focused on that pregnancy period, that we’re not thinking about that.

And so I think, you know, we need to be at a point where we can provide access, where we can educate, and it doesn’t have to be physicians, right? Like, at Morehouse School of Medicine, we have a project called “Project Impact,” where we’re providing preconception care but in community-based settings and meeting people where they’re at, because it’s really difficult to navigate a health care system and particularly as a young person. And so I think it’s critical that we’re addressing maternal health prior to people becoming pregnant, and if they choose to become pregnant, I think that’s a big thing.

MS. JOHNSON: You know, and, Dr. James, one of the things that we quite often hear about now are maternity care deserts, right? Like, if we’re going to stay on this issue of access for a little bit–

MS. JOHNSON: And so the March of Dimes, which as you know is a nonprofit that is focused on infant and maternal health outcomes, has said that 36 percent of the counties across the U.S. are designated as a maternity care desert. What is that, and what’s the impact of being in a maternity care desert?

DR. JAMES: Yeah. So I actually use the–March of Dimes has like this interactive tool where you can put in your zip code and see if you live in a maternity care desert, and so I did that, you know, my hometown in South Carolina versus where I live now in Los Angeles. And so what it is, it’s basically that there is no provider who is specialized in reproductive or obstetric care. So whether that’s a midwife, whether that’s a women’s health nurse practitioner, or a physician, an obstetric, obstetrician/gynecologist, there’s a lack of those types of providers within a certain mile radius where you live. And so oftentimes pregnant people are receiving care from primary care physicians or whomever that they may be able to see if they are able to see anyone. And so sometimes people have to travel long distances to receive care, and we know, as your pregnancy continues, you need more frequent visits. So some people may not be able to travel as far to get those frequent visits. So there’s a lack of access to care.

And then the quality of care that people may receive is also reflected in that term of maternity care deserts.

MS. JOHNSON: You know, and I think a lot of times when we–the collective “we,” right? When we think about issues of access and maternity care, certain kind of image or narrative pops up in terms of who we are talking about. But when it comes to the maternal care crisis, particularly when it pertains to Black women, it is irrespective of income or education, right? So talk a little bit about what’s going on and why income and education aren’t protective factors for Black women the same way they are for other folks who are giving birth.

DR. HERNANDEZ: Yeah. I think Black women just face a lot of different barriers, but a lot of it is those interpersonal, discrimination, structural racism, the way the systems were built with not–was built with not our communities in mind, that bias or unconscious bias or even conscious bias sometimes in that relationship with provider. And you’re right. You know, we see with the structural determinants of health, you know, where we work, live, and play should be protective factors, and they’re–for Black women, they’re not.

You know, there’s an example where Black women who say–sorry–Black women who enter prenatal care early still have worse outcomes than White women who enter prenatal care late. People talk about chronic conditions, right? Black women who are of normal weight still have worse health outcomes than women of all races and ethnicities who are obese. And so there’s something there, and what we come to terms with is that it is related to racism and structural racism, interpersonal racism between a provider and a patient. And, you know, we need solutions. We need policies to mitigate a lot of these barriers or a lot of this discrimination that our communities are facing when they’re accessing care.

And it’s not just when they’re accessing care. It’s just the racism that you receive your whole life. You know, that weathering, that chronic stress that it creates within your bodies is something that, you know, is what’s contributing a lot to what we see with the maternal health crisis.

MS. JOHNSON: Dr. James, what is weathering? Talk to us a little bit about this, right? So folks are not just kind of like–

DR. JAMES: We love weathering.

MS. JOHNSON: –oh, is this biologic–biological determinism, right?

MS. JOHNSON: And that’s not what we are talking about. So break down stress and weathering.

DR. JAMES: Right. Yeah. So we’re not saying that inherently people who are born Black obviously have like poorer health. That’s not what we’re saying. It’s nothing innately in Black people.

So what weathering is is that Black people, as Dr. Hernandez said, Black women specifically in this conversation or even gender-expansive people experience racism sometimes every day that they’re on this earth, especially living in what we call a “racialized society,” when you’re treated differently based on how you show up and how you appear in this world.

And so what that does over time, it’s just chronic stress. It results in high blood pressure. So I don’t know if you all are familiar with the flight or fight response, right? But if there was like a bear that came into this room right now, people would respond. Your body would react so that you’re escaping a threat.

Well, experiencing racism, you have that same bodily reaction with all these chemicals and hormones, and you’re taught to escape and flee. But this is your everyday life. So where are you going to go besides the comfort of your own home? So if you experience that bear coming into the room several times a day, possibly throughout every day of your life, that wears on your body. And that’s that chronic stress that, you know, increases your risk for high blood pressure, heart issues, all of these things. Even your mental health is affected. And so that just weathers on Black people’s health over time.

DR. JAMES: And so that is what weathering is.

DR. HERNANDEZ: They say it’s like gunning an engine, right, when you’re pressing on the gas, and there have been studies that found when Black women have a hard day and they go home, their blood pressure or stress levels actually increase compared to other racial and ethnic groups, where their blood pressure and stress will decrease. And so it’s always going up and never really coming quite down, and that really puts a lot of detrimental effects on your body and your physiology.

MS. JOHNSON: You know, and I’ve spoken to women who talk about, right, even that revving effect when they go to the doctor.

MS. JOHNSON: You know, having to kind of mitigate how they show up to the doctor, how they present to the doctor–

MS. JOHNSON: –which transitions to my next question. See what I did there?

MS. JOHNSON: Talking about the need for racially concordant care, and what does that mean, and how does that improve health outcomes? So like, you know, having a doctor who looks like you and is from the same background, how does that improve outcomes?

DR. HERNANDEZ: Yeah, absolutely. I mean, there’s a lot of data to show that. That have, you know, a recent study that demonstrated when a Black woman has a Black doctor, we’ve seen infant mortality rates decrease. You see patient satisfaction. You’re less stressed, and it’s critical, right? We have–we don’t have the most diverse health care workforce, and so I think, you know, it’s incumbent upon us to make sure that we’re training and diversifying the perinatal workforce. And it’s not just diversifying it, right, but teaching other types of providers how to provide culturally congruent humble care, because, you know, we are a diverse society. But everyone needs to be treated with respect the same way.

I think Dr. LaVeist mentioned, you know, the health of one person is connected to the health of all. If Black women see better outcomes, then everyone will see better outcomes because we’re creating a just system.

So I think there are different solutions, and, you know, we’re trying to do that where I’m at. You know, we’re at a historically black college. You know, our mission is to increase the diversity of the medical workforce or health care workforce in general, and you see the outcomes. You see patients being treated better. You’re seeing them being respected, and Black physicians, we have those same lived experiences as our communities.

We came into this. A lot of this work is really personal for us and how we want to demonstrate that to our patients or our communities.

MS. JOHNSON: You know, we talk a lot about maternal mortality, and I feel like we don’t quite often talk about maternal morbidity.

MS. JOHNSON: And so I was once talking to a clinician and also a health–a reproductive health equity researcher, and she said, you know, she was in conversation with a woman who said they put me back together, but I still didn’t feel whole–

MS. JOHNSON: –after the experience. I guess I’m wondering if we can unpack a little bit, number one, what is maternal morbidity and why it is so important to focus on it, but also what are some of the contributing causes to these life-threatening complications that women are seeing?

DR. JAMES: Mm-hmm. So like you said, maternal mortality is, of course, someone loses their life during pregnancy or shortly thereafter. Maternal morbidity is conditions that may affect your equality of life–

DR. JAMES: –that you have, you know, acquired during pregnancy or after childbirth.

And so my research focus is perinatal mental health, and so oftentimes I think, you know–and in discussing maternal mortality, we don’t think about how that can affect one’s mental health and always hearing about, you know, Black women die this many more times at higher rates or Black women this, Black women that, and as someone who is Black who may want to become pregnant, being aware of that narrative, even before you are pregnant, can affect your mental health and your experience in that pregnancy.

But also just, you know, naturally developing mental health conditions like postpartum depression, postpartum psychosis, anxiety, obsessive compulsive disorder, all these mental health conditions also aren’t discussed.

DR. JAMES: Or even if you develop high blood pressure during your pregnancy and it doesn’t go away once you give birth, then that’s another issue that you have to deal with, possibly long term, that you also need support for to be able to get treatment and get it under control so that you can thrive and live a productive life and still be here to care for your child.

DR. HERNANDEZ: Yeah. And for every maternal death, we know there are between 50,000 to 100,000 women that experience some type of severe maternal morbid event, and then there are also women who almost nearly died, which we call “maternal near misses,” where women almost died from pregnancy-related complications. And these are important to understand, because this is actually a better indicator of really understanding the crisis at hand, because we’re able to understand and talk to people who almost died about what went right and then what went wrong and then develop interventions to explore that.

We’ve been doing a maternal near-miss study where we’ve collected narratives from women of color across the country to really examine what happened, and we use a framework of the Three Delays model, which is the delay to receiving care, delay in recognizing symptoms, and the delay to have quality of care. And these are things that come up all the time and I don’t think gets enough–you know, doesn’t get addressed enough, right? 1,000 deaths but 50- to a 100,000 severe maternal morbidity cases.

MS. JOHNSON: You know, and we would be remiss if we didn’t bring up an instance of maternal mortality that has been really in the spotlight right now, and that is the death of Tori Bowie, right, the Olympian who recently passed away.

MS. JOHNSON: And so we actually have an audience question from–about this issue, Mignon Clyburn, and if I have mispronounced your name, I am sorry. I believe in putting respect on people’s names, so I apologize up front.

DR. HERNANDEZ: Yes. [Laughs]

MS. JOHNSON: “The death of Tori Bowie is yet another illustration of the gross disparities in African American maternal health. Please share how the profession plans to heal itself when it comes to these tragic outcomes. This should be unacceptable in 2023.” Do you agree, and what does the death of Tori Bowie highlight with this crisis for you?

DR. JAMES: Yeah. So of course, I agree that something–it’s past time to do something, right? We–Dr. Hernandez and I were talking earlier that there have been decades of just constant research about the current state of maternal health care and that Black women suffer from these inequities, right? And so now it’s time to do something.

And so what I often think about as a mother of a 13-year-old–hi, Kennedy.

DR. JAMES: I had to do it.

DR. JAMES: But also as a clinician, right, because I care for pregnant and postpartum people and then their children afterwards–is that people do not want to go in the hospital. They do not. They feel like, “If I go there, something bad is going to happen. People aren’t going to hear me. They aren’t going to see me. They aren’t going to care for me.” So how do we restructure those systems to better serve and care for the people that they’re supposed to?

DR. JAMES: But–and I say this every time in every space that I occupy is that Black women, especially Black midwives, not necessarily nurse midwives–they are also amazing, but Black certified midwives do the work and have great outcomes. And we–the health care system, the medical system should learn from midwives and see what that care looks like and why people are choosing to give birth at home instead of in the hospital, because they’re deathly afraid of something, you know, going wrong and being mistreated and not leaving the hospital to live to raise their child.

DR. HERNANDEZ: Mm-hmm. Yeah. And I think, you know, people saw this, you know, Black woman who just was the epitome of looking fit, right? Like, you often hear the narrative, a lot of these mother-blaming narratives. Oh, well, she’s obese, and she had this, and she had that. But just because you look a certain way doesn’t mean that there are other things going on, right? There’s so many myths about preeclampsia, when a lot of it is about nutrition, and it can be nutritional deficiencies that contribute to some of these conditions.

But I agree with you. We need more integrated models of care. It’s not just about a physician or just about a midwife. It’s about everyone working together, even our communities working together. It really takes a village to raise a child, but it takes a village to ensure that our birthing populations are going to survive and thrive through this crisis.

I mean, we are the United States of America. We’re one of the greatest countries. We shouldn’t have the death rates that we have right now, but it’s incumbent about us to make sure that we’re doing actions to prevent this from happening.

We keep talking about this issue ad nauseum, when we need to be creating solutions. We need to hold policymakers accountable to the–you know, addressing the structural inequities. We need to really reimagine a health care system that cares and values women’s lives, and I think all of that can really be fruitful in moving the needle forward towards addressing not just maternal health equity but maternal health justice.

DR. JAMES: Mm-hmm. Absolutely.

MS. JOHNSON: And I feel like that is such a–we can–that is the period at the end of this conversation, and we can go ahead and leave it there.

MS. JOHNSON: So I want to say thank you so much.

DR. HERNANDEZ: Thank you.

MS. JOHNSON: Thank you both for joining us today.

Wait. Let me see. I’m checking my card. And we are out of time. Thank you. I’m Akilah Johnson with The Washington Post, and that concludes our conversation.

DR. HERNANDEZ: Thank you so much.