The Dose - Fighting NYC’s Ongoing Public Health Crisis — Racism

Episode Date: April 28, 2023

This week on The Dose podcast, host Joel Bervell talks to Michelle Morse, New York City’s first-ever chief medical officer. Starting in her role at the height of the COVID pandemic, Dr. Morse quickly understood the importance of establishing strong connections between the health department and the city’s health care providers to help close gaps in equity, choose where to focus resources, and coordinate testing and vaccination efforts. In a wide-ranging conversation, Dr. Morse talks about Black New Yorkers’ disproportionately high rates of premature death, having racism declared a public health crisis in New York City, using community health workers to reach people where they live, and tracking the connection between wealth gaps and health outcomes. She also discusses the use of race in clinical algorithms that have “solidified racial inequities instead of trying to fix them and end them.” Listen, and subscribe wherever you get your podcasts.

The Dose is a production of the Commonwealth Fund, a foundation dedicated to health care for everyone. My guest today on The Dose is Dr. Michelle Morse. She's the first person ever to serve as chief medical officer for the City of New York's Health and Mental Hygiene Department. There, her primary role is addressing gaps between public health and the healthcare sector. In addition to being Chief Medical Officer, Dr. Morse is also the Deputy Commissioner of the City's Center for Health Equity and Community Wellness. She focuses on everything from community engagement to Medicaid policy to strengthening networks of federally qualified health centers. Dr. Morse oversees the department's work to

understand health inequities and end disparities relating to premature mortality, racial inequity, chronic disease, and so much more. Before I say any more about her work and accomplishments, let me just say first, Dr. Morse is one of the leading thinkers and doers in the health equity space. Her wide-ranging accomplishments span on-the-ground clinical work in Haiti, time-spent policymaking on Capitol Hill, and as a physician, advocate, and activist. She's an internist trained at the University of Pennsylvania Medical School and holds a master's in public health from Harvard. And she's an assistant professor at Harvard Medical School, Brigham and Women's Hospital. For me, Dr. Morse is a role model, and I'm lucky enough to call her a friend

and a fellow AfroBeats lover. So thank you so much for joining me on this conversation, Dr. Morse. Thank you so much for having me, Joel. It's really an honor to get to be in conversation with you today. So I just want to jump straight into the questions and ask, you're New York City's first ever chief medical officer. It was a newly created post in 2021 during the COVID pandemic. And I know that the city also has a health commissioner. So I'm hoping you can explain for our listeners the difference in your roles and how you came into the role as well. Thank you so much for that question.

Yes, I mean, I will say it's so fascinating to me that there hadn't been a chief medical officer role in New York City in the past. And at the same time, what I would say is, you know, the health department in New York City has dealt with so many health crises over the years. So there have been ways, of course, to make sure the work gets done. But I do believe that part of the reason and vision for this role and the creation of it was the depths of challenges that New York City faced during the pandemic. Certainly being the first kind of one of the first epicenters for the pandemic in the United States was part of it. But then what also was

very, very clear was that we needed stronger connections between the health department and the health care providers across the city, both in terms of understanding health equity, where to focus resources, coordination, both for testing as well as for vaccination and other prevention efforts. And so the case, I think, was clearer than ever that there was a need to have even more capacity for the connection between health care and public health. And I will say one of the most exciting initiatives that I got to be involved in was one that really brought together the healthcare organizations, specifically the safety net organizations across New York City, to really help them understand what

we were seeing coming down the pipeline from the public health perspective and help them to prepare and get ready for the waves of challenges that were to come. It's really extra capacity to connect with, coordinate with, and frankly, also to push healthcare organizations to focus on health equity, to focus on place-based initiatives, and to focus on the ways in which our healthcare systems fragmentation can be overcome with convening and coordination. And so while the position you're in is new, to focus on the ways in which our healthcare systems fragmentation can be overcome with convening and coordination. And so while the position you're in is new, some of the challenges, like you mentioned,

that were highlighted during the COVID pandemic are pretty old. Anyone stepping into this job is inheriting a lot, especially in New York, where it's not a blank slate. There's a lot of history, there's built systems in place, and there's structural race and class issues throughout the city. What was your top priority for when you began? I mean, you were instrumental in having racism declared a public health crisis by the New York City Board of Public Health in 2021. And I assume it just wasn't about COVID, but what were your top priorities? It's a great question. And there's no time like a time of crisis to really build alignment and to build analysis. I would also say

in addition to the COVID crisis, of course, we were also dealing with a racial justice crisis and the murder of George Floyd truly transformed the conversation. And the activists and organizers that helped to lead the movement that followed were incredibly important in, I think, creating a new kind of conversation about racial justice and how every single sector in society, including government, including public health, needed to reevaluate its role. So that was a huge priority coming in. I was also involved in doing an analysis looking at declarations of racism as a public health crisis across the country. And of course, there was an exponential increase in those declarations of racism as a public health crisis across the country. And of course, there was an exponential increase in those declarations in the months and year following the murder of George Floyd. So I was very honored to get to be involved in developing

that to, I would say, memorialize in some ways the outpouring of both outrage and action to try to change the patterns of racial health inequities specifically. And as you described, you know, premature mortality, so this is death under the age of 65 years, is one of those things that has some of the most dramatic racial health inequities, no matter where you look, but particularly in New York City. And so Black New Yorkers had the highest rates of premature mortality before COVID, and that continued after COVID, unfortunately. Another area of priority was really looking at policy. So how do we use policy to advance racial justice and public health practices to end racial inequities? And so there's been a lot

of work happening in New York State around Medicaid and advancing the flexibilities for Medicaid to take care of social issues in addition to health issues. And so that work has also been a priority that my team and the health department have been working very heavily on. And then we also were working on areas of institutional accountability. How can we advance institutional accountability when it comes to health equity and anti-racism in public health? And one of the things that we prioritized in that realm was the Coalition to End Racism and Clinical Algorithms.

That's a coalition that we launched in the fall of 2021. Again, as another way to kind of bring healthcare organizations to the table who were facing the same challenge of, you know, algorithms that use race in a way that is inequitable, and in a way that unfortunately, solidified racial inequities, instead of trying to fix them and end them. And so that's a shared problem, right? Even though our healthcare system is fragmented, that's the problem that all the institutions in New York City were facing and needed health systems and operational fixes to address. And so we thought, well, there's a great way to both advance and accelerate those institutional changes, as well as ensure that there is learning and collaboration across institutions to make the change even more efficient and impactful than if each institution did it by themselves. Absolutely. And I'm so happy that you started off that kind of answer the question by focusing on George Floyd. I think so many people, that was their first introduction, especially people that were not Black, that was their first introduction to understanding how much these kind of disparities impact people, not just in police brutality, but in healthcare and all these other spaces.

And it really opened up the conversation. I remember I was in my going to my second year of medical school when all those conversations are happening. It's really what motivated me to start using my platform to start talking more about it. I think it really opened up conversations for people to feel willing to be able to take this next step. And what you're talking about a lot of this reimagining of healthcare, I feel like has accelerated so much in the past couple of years. And of course, this work takes more than just imagination. It takes actual on the ground work. I'm curious, what would you say are some of the near term changes that you see being sent into motion? And you've mentioned a lot of kind of larger issues that your office is going after. What are some of the granular step by step

incremental changes that are happening? There's a lot happening right now for a number of reasons. I think one of the areas that we have been looking at very closely and working on is the end of the public health emergency, of course, and what that means for Medicaid redeterminations. And so instead of folks who were enrolled in Medicaid just kind of continuing to have access to those benefits, we're going back now to the phase in which each year the eligibility for Medicaid has to be reassessed. And some people, you know, no longer meet the eligibility criteria and will be taken off of Medicaid benefits and disenrolled from the program. I would say, you know, what is challenging is number one, that it's going to be very difficult to make sure that we have up-to-date information about where current beneficiaries are living and what their phone numbers are, because this has been a time of a lot of transition for many people and families. But it's also happening at a time when vaccines

and treatment for COVID are being commercialized. That means that for those who are uninsured or underinsured, they could face some pretty significant costs to pay for getting their COVID vaccine or to pay for getting treatment for COVID. And I would say that the incremental work that's happening is a lot of planning and conversation with various communities. One of the gifts of COVID was that we were able to launch a program called the Public Health Corps, which funds community-based organizations all across New York City to essentially be able to do the outreach and engagement and street-level conversations, including literally walking hand-in-hand with someone to take them to the

place where they can get their COVID vaccine. But the beauty of Public Health Corps is that it uses a community health worker program that is really based in the community. So whether you are connected to a primary care doctor or not, didn't matter. This is, you know, massive, you know, community engagement effort. And it was done with over 100 community-based organizations, many of which were doing this outreach in over 30 different languages. And so that infrastructure and connection is one of the things that we'll build on when we're continuing to do the outreach work and the connection work that we have been doing. I'm so happy you talked about these disparities and getting access to things, but also the financial disparities that affect people too.

And I think a lot about a study that you were a part of that looked at what would have happened to COVID transmission if the racial wealth gap had been eliminated prior to the COVID pandemic. Could you talk a little bit about that for listeners? Because I think it's so powerful what you guys found. It's interesting because in some ways what we were doing with Public Health Corps, focusing the investments in community-based organizations that were in the neighborhoods that had the most and unfair impact from COVID, in some ways is kind of what we found in this modeling study. What we attempted to do was we actually compared two locales. So one extremely inequitable, and that was the state of Louisiana, actually based on the Gini Index, which looks at inequity, economic inequity specifically. Louisiana has a very, very high level of economic inequity. And we compared it to South Korea, which interestingly has a very equitable rating on the

Gini index. So we compared the two and what COVID transmission looked like in those two different areas. And we modeled what would have happened if there was no racial wealth gap. And for those who are not aware, the racial wealth gap is, so wealth is very different than income. Wealth is assets minus debt, whereas income is, you know, the annual salary that a person or a family might bring in. Wealth, of course, reflects more of the generational dynamics of equity and marginalization or the lack or presence thereof. And so that's why wealth is a very interesting indicator for us to look at when we're looking at health outcomes. And when you look at wealth by race in the United States, there are profound inequities. So one study looked at Boston and found that the average

white household had about $247,000 in wealth, whereas the average black household had about $8 in wealth. That was a study by the Federal Reserve Bank in Boston in partnership with Professor Sandy Darity, Derek Hamilton, and many others. And that massive gap, of course, tracks with health outcomes. And so what if that gap didn't exist? What if there was not this massive racial gap in wealth? And when we looked at that in Louisiana, what we found was that transmission of COVID would have been somewhere between 30% and 68% lower for the whole community. So it wouldn't have only benefited Black people who had the lowest wealth. It would have benefited everybody.

And in some ways, that's on the level of the intervention impact of a vaccine, right? 30 to 68%. And the reason for that is because with wealth, you can, of course, live in less crowded housing. You can have a job that doesn't expose you as much as an essential worker to COVID. You can buy PPE and, you know, hand sanitizer. So there are a number of ways that wealth is protective in general, but specifically in COVID, it is clearly very protective. And so now I'm very excited that we are actually in the New York City Health Department. We recently published a white paper looking at the racial wealth gap and health inequities and how the two connect. And we're partnering with several partners, including CUNY, to do a survey in New York City assessing wealth by race across the city

as a way for us to, again, map and track how that wealth equity or inequity tracks with health outcomes. I love that. And you predicted some of the questions I was going to ask about the policies that you're working on. So I'm still glad you were able to talk about that white paper that just recently came out last month, or two months ago, I guess now in February, at the end of February. I read through it. It was incredible work. So I mean, obviously, thank you so much for everything that you're doing. I want to kind of ask about some of the policy issues and issues that you have going on in your office as well. You've mentioned some already, which I love.

For example, the Coalition to End Racism and Clinical Algorithms, something that I've also been very committed to understanding how we even got here. And so for some of the listeners who maybe don't understand what some of those algorithms mean, and I know you had a recent study that shows most people don't understand what that looks like. Could you help kind of guide us through what it looks like on the ground, in the hospitals? What work are you doing through that aspect? This is another one where I have to just shout out and appreciate all of the trainees, medical students, residents, etc. And that's how I first started learning more about this issue actually back in 2016. At the time, I was involved in co-chairing the Health Equity Committee for the Department of Medicine at Brigham and Women's. And the Racial Justice Coalition at Harvard Medical School was working on this issue. They were, of course, being taught about estimated glomerular filtration rate.

This is how we calculate kidney function. And they were being taught that they're supposed to multiply by a certain number if the patient is Black. So they were being asked, you know, and again, this is a routine and previously standard part of clinical practice, that clinicians were supposed to dichotomize the world of their patients into Black and non-Black, which is absolutely absurd and impossible. Race, as we know, and as we often state, is a social construct. It's not a biological construct. And so there isn't really a biological issue, but there are, of course, physiological impacts of the experience of racism over generations and on one's health. Now, that's an area that I think we can get into

into this conversation as well. But what was also clear was that when you look back at how that original equation was established in 1999, it actually only had just under 200 Black patients in the study, and Black race was assigned by the study staff. It wasn't self-identified race. And interestingly, over time, that equation, of course, is one of the many contributors that has led to Black people having a delayed rate of referral to kidney doctors and kidney specialists when they have the development of kidney disease. It's also been a factor that has delayed referral for kidney transplant, but there are lots of things that are actually the true causes of racial differences in health

outcomes that we can fix and have massive impact on. So the coalition is really meant to help providers and health systems understand that and change their practices, measure and evaluate how racial inequities and health outcomes change as they change their practices around use of race and misuse of race in the algorithms, and then actually do a patient engagement plan to make sure that patients, Black patients, for example, with kidney disease, understand that actually they need to have a new calculation done to make sure that they actually get the access to the specialty care and to transplantation evaluation and transplant in a way that they deserve.

And we have to be able to talk to patients about these algorithms as well. That's so powerful. And this topic has actually come up multiple times in this podcast miniseries. I had on Naomi and Kinsey, who was instrumental in changing EGFR at the University of Washington. Do you think there has been a change in practice or thinking that's significant in regards to physicians and also, as you mentioned, patients having to know about these changes? You know, it's a really good question. If you look at surveys of physicians about, you know, asking them, do they think that, you know, racism amongst physicians or, you know, consciousness about health equity amongst physicians is good or real? And it's really not. You know, a lot of the

surveys out there have shown that physicians like systematically underestimate and underappreciate how much racism is shaping health outcomes. So that's a huge challenge. Now, has there been a shift? I will tell you, I have been encouraged to see some of the professional societies come out with either task forces or new guidelines, really setting a new standard, a new gold standard for how race and ethnicity could or could not be used or should or should not be used in clinical algorithms. So the American Society of Nephrology, for example, in partnership with the National Kidney Foundation, they have done some really important work in this

realm and have supported a new algorithm that doesn't use race, Black race specifically, and is just as accurate. So have there been some changes? I would say yes, but we have far more to go. And again, I think the more that these kinds of changes can happen at a systems level, rather than clinic by clinic, hospital by hospital, health system by health system, the more powerful and impactful they will be. Absolutely. I'd like to shift gears a little bit to talk about the new report that you mentioned about analyzing the racial wealth gap implications of health equity. And I guess I'm curious, when it comes to structural programs like Medicaid and Medicare, how do we begin to embed equity

into these historic safety net programs? Such a good question. And it's interesting also, because I think the standard has often been that, well, if you have work that you're doing or planning work around Medicaid, then it's automatically health equity, right? Because it's an entitlement program that is specifically for people with low income, people who are living in poverty, people who are from marginalized groups. And there's a little bit of truth to that, but it's not the full story, right? There are ways in which programs like Medicaid can continue to even increase and deepen accountability

for health equity and outcomes in health equity. And I think that that's the kind of work that's already starting to happen. I know that CMS has been thinking a lot about that. I also know HHS, for example, has issued a set of rules specifically around civil rights within the Affordable Care Act and the ACA that actually, I think, strengthens the guidance and the floor for what kinds of health equity changes need to happen at a policy and systems level, including around clinical algorithms, which is very exciting. But I would say that, yeah, there's tremendous opportunity in using

benefits like Medicaid to advance health equity. In fact, I think some of the other things that we're starting to see from Medicaid policy and many other policies is we're starting to see the ability, again, to cover the cost of things like transportation, housing, healthy food, et cetera, because we know, of course, that these are some of the social needs and social conditions that allow for improved health outcomes, right? We know that healthcare alone is not going to get us to health equity. And we also can't have health equity with, you know, social injustice prevailing, right? And, you know, we've been doing some work within the New York City Health Department on using and learning about public health critical race praxis, which is the methodology and an

approach to really make sure that you're centering the margins, as we know is so critical, and building interventions that are race conscious, right? If we know that the highest rate of premature mortality is amongst Black New Yorkers for all the cumulative historic and current marginalization and wealth and other inequity reasons we know, well, then we need to focus resources in that community in ways that address the needs specifically for Black New Yorkers. Absolutely. And I feel like one of the communities that often gets overlooked, especially in the city of New York, is those that are undocumented.

And I'm curious if you can tell us a little about what state city of New York, is those that are undocumented. And I'm curious if you can tell us a little about what state lawmakers in New York are doing right now to make sure that health insurance coverage is accessible for undocumented New Yorkers of all ages who are often, like you're saying, found at these margins and not centered in conversations. Absolutely. I think it's a central health equity issue for our time and in fact is at crisis levels. The New York City as a city has received over 55,000 folks seeking asylum over the past year or so. And as was described, there are a number of serious and important health needs that we consider to be human rights for asylum seekers. And one of the ways that that work is rolling out and is happening, our partners at Health

and Hospitals, which is the public hospital system, has a program called NYC CARES, which is a program for folks who are undocumented to make sure that they have consistent primary care and all other health healthcare needs as well. And then the state right now is considering and trying to think about its approach to following suit to California, which recently passed a waiver. And this is a waiver that essentially allows for undocumented folks to get access to Medicaid and to ensure that they actually have access to health insurance, no matter what their documentation status is. We see that as something that, of course, is a huge priority. And we know that that's still only part of the battle, right? That's kind of

just one piece of the puzzle, because there's also, of course, the right to food, to housing, to all of these other social needs in addition to health insurance and access to health care. And as we wrap up, I want to look beyond New York City to kind of your approach. You've had so much grassroots experience. You co-founded a global NGO. You've worked in Haiti as a physician. You worked at ACT UP Philadelphia. You have policy experience at the Ways and Means Committee, and now you're truly on the inside. And given your broad range of experiences and insights, I'm curious, what have you found moves the needle the most? And what are your strategies for getting things done?

Yeah, what works? What works? That is the question, isn't it? I mean, I will say I'm continuing to learn more and more about the inside-outside game, for sure, and strategies working both inside and outside institutions to make progress, to transform systems, to transform society. I will say that one of my most powerful experiences was as a medical student involved in ACT UP Philadelphia to actually go to and attend the presidential nomination and campaign and being involved in ensuring that folks with HIV AIDS had access to all the full entire slate of health and social needs, including free access to HIV treatment and in fact, cash transfers, essentially, to ensure that their

social and health needs were being met. And it's very, very powerful to see how that kind of organizing and direct action work can translate into policy change. And, you know, my experience, of course, being involved in supporting the passing of the resolution declaring racism a public health crisis here in New York City with other colleagues, you know, that is the that's what's possible from the inside work and outside work. And I would say no one is going to get us to a new, transformed, socially equitable, racially just society. It's going to be more than anything else, I would say, Joelle. It's the coordination and relationship building across sectors, you know, social movements. It's taking that intersectional approach that I think allows us to build power in ways that could really change the game. I would say more than anything else is deepening those relationships across sectors and working in coordination for shared

goals that works. Well, like I said at the beginning, and I think listeners will now know as well, you truly are one of the leading thinkers and doers in the health equity space. I'm so fortunate to have you as my role model. You inspire me every single day. So thank you so much for your time. Thank you for speaking with us and sharing all your insights. Thank you so much, Joelle. That is beyond generous. You give me hope and the whole entire next generation of health workers gives me a lot of hope that things can change. So it's a real, real honor to be in conversation. And yeah, really looking forward to the next one. Thank you.

Take care. This episode of The Dose was produced by Jodi Becker, Mickey Kapper, and Naomi Leibovitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is Arizona Moon by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you'll be able to learn more about today's episode and explore other resources. Thanks so much for joining me on this special season of The Dose, exploring healthcare equity. I really appreciated these conversations, and I hope you enjoyed the episodes. We're taking a break, but The Dose will be back this summer with a series focused on women's

health. I hope you'll tune in.