A Blueprint for Establishing a Health Equity or Minority Health Office

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode, what it takes to open and sustain a health equity office at the state or territorial level.

ROHAN RADHAKRISHNA:
We like to say that if you're not intentionally equitable, you may be unintentionally inequitable.

JUSTA ENCARNACION:
If we focus on decreasing the disparities, identifying the disparities and decreasing the disparities, then of course we can link it to improving our health equity.

VERONICA HALLOWAY:
We need to adjust and adopt but stay focused on what the priority is, which is making sure that there's parity in health and equity for everyone.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the work required to build support for an office of health equity. How one agency launched an office only recently, while another has been at it for a long time. The political considerations and the best way to ensure your office continues regardless of changes in leadership. Three guests are here to talk about health equity offices.

ASTHO member Justa Encarnacion is commissioner of health in the U.S. Virgin Islands. Until recently, Dr. Rohan Radhakrishna was chief equity officer at the California Department of Public Health. They're along later to tell us how each agency has managed the process. But first we hear from Veronica Holloway, executive director of the National Association of State Offices of Minority Health.

HALLOWAY:
So every state and six territories do have some form of state office of minority health. And those are usually formed either through state health departments, as independent commissions, as advisory committees, as programs within public health departments, or they may have been established through state legislation, which is usually the most common way these state offices are formed is through legislation and is actually the best way to do it, and the most sustainable way.

JOHNSON:
COVID put so much attention on health equity. Were these offices created as a result of COVID?

HALLOWAY:
No, so most of them were already well established prior to COVID. COVID actually gave them prominence and more funding so that these offices could be established. All states, or most of the states, have some form of office of minority health or health equity, or multicultural health.

They're kind of, you know, variances or nuances in the names, but pretty much those have all been well established. And what COVID did was give more prominence to those offices and actually an opportunity for those offices to be better staffed because usually, in talking with my counterparts, most of these offices had either maybe one main person and maybe two administrative folks working with it.

California, I know, was a big one that had a large workforce within that office, but for the most part, they're like smaller components of the entity. For those that were created under statute, the benefit of that is that usually those are embedded within the office of the director of that health department in their state.

And so often those positions play leadership roles. And then for others, they're either embedded in programs or in other divisions within the agencies.

JOHNSON:
It sounds like there are a lot of ways to go about this, so what works best from your standpoint?

HALLOWAY:
The most effective process is for those entities that were developed through state legislation, because that kind of secures that prominence.

It's hard—versus those that were designed through executive order—if a new administration comes into town, those offices can be easily abolished or moved under, you know, certain divisions where they're really not that prominent or not that focused. So, for example, in Illinois, when the Center for Minority Health Services, which it was called, was created. It was put under the office of the director of the State Office of Minority Health. And the responsibility was for that office to provide technical assistance, inform the director on minority health issues, work within the agencies (which a lot of these state offices of minority health do anyway), work within the agency to promote health equity work among the various programs to make sure that there's equitable funding, to be the connector to communities, to understand the community's needs, and then to inform the agency so that information can be turned into best practices, policy initiatives within the agencies.

JOHNSON:
What are some of their day to day challenges? They're up and running, but what are they dealing with on a daily basis as a group?

HALLOWAY:
So, the first thing I would say is definitely the challenge of establishing yourself within your state agency, getting buy-in, because it seems like every time you talk about health equity, it’s just for some people it kinda rubs the wrong way. And so how do we promote that internally through workforce development for the entire agency? And having that buy-in. For some offices it is a challenge. But for others that are better established, you know, it just kinda helps build that dynamic within and working with those programs and offices to make sure that we have a diversified workforce and continue to provide training and resources to support what those agencies do.

One of our biggest challenges is always funding, right? So we are always competing internally to do funding. There are some programs and projects that, especially the way grants are written now, you have to focus on health and health equity. The other thing is in terms of establishing equitable funding, right? That is something that we try to work—whether the Office of Minority Health has the funding dollars themselves or other programs within the agencies have those funding dollars—just kind of working, making sure that those fundings are equitable, that we are connecting with our communities. We are understanding what the needs are in that community and not necessarily subscribing to them, how this funding should be used, which has been the longtime practice really of a lot of these public health related funding.

JOHNSON:
How are they helping to advance the idea of health equity inside their organizations and also in their communities?

HALLOWAY:
So it builds that trust, right? So, for example, during COVID, a lot of public health messaging was going into the communities, but public health, and we heard this a lot, did not necessarily have relationships with those communities, with certain populations, but we're trying to build their trust, to relate to the information that we've provided, off of those resources that we've translated in house that the community has no say in. Maybe we're not using their jargon. We haven't, you know, related it to their community's needs and their struggles. And so that was a barrier.

JOHNSON:
Seeing all of these offices, how was the health of the health equity office infrastructure around the country, around the territories right now? How are they doing?

HALLOWAY:
So some are faring well. Like I said, COVID really gave a boost. A lot of them were able to establish more positions. For example, Indiana went from two staff to about eight or 10 staff during COVID. A lot of them, especially those that were created by statute. It's a good thing, right?

Because the funding is kind of coming. They're not dependent on federal funds or outside funding to maintain those positions. A lot of times they're already embedded in their state annual budget process, you know, as a headcount for that agency anyway. So prior to covid, a lot of them were struggling and that's why the network, the Association for State Offices of Minority Health office always kind of, you know, we share, exchange best practices, serve as resources for one another, and just kind of help provide technical assistance, provide advice, just kind of help support each other in that way to kind of help maintain or build that infrastructure we have.

I know there were a few agencies or offices that kind of died or diminished prior to COVID and were moved under other programs, other offices, but even then, you know, the work of health equity, whether you're a one man show, or, you know, you have a team behind you, we kind of help identify ways that they can help inform the process and help move the agenda. So it's a challenge for some, but there is the support network that through the association that is provided.

JOHNSON:
What do you think is the future of these health equity offices?

HALLOWAY:
So I always try to remain optimistic, and I think that as long as there is health disparities and we're a long way from addressing it in some form or fashion, we're always going to be relevant.

We have to, you know, as the needs change or as administrations come and change and as terminology changes, we need to adjust and adopt, but stay focused on what the priority is, which is making sure that there's parity and health and equity for everyone. So it might look like us reframing how we do health equity work or how we speak about health equity.

We are right now working on, it's all about buy-in, right? How do we build that trust? How do we build that buy-in? How do we, you know have other partners within our agency see the value of working with, whether it's an office of health equity and minority health or whether it's a division or whether it's one person, to see the value of working to advance health equity.

So really, we just kind of you know, assess and just the work is still the same. It's ongoing. We're a long ways from getting there, but we need to adapt as things change and so that's what a lot of us are doing.

JOHNSON:
Justa Encarnacion is ASTHO's member and health commissioner in the U.S. Virgin Islands. Our first question, does your agency have an office of health equity?

ENCARNACION:
I am so pleased to answer that question by saying yes, we do. So we have opened up our Office of Health Equity. We've hired a director of health equity.

Outside of that, we've been practicing the tenants of health equity. Through our Office of Health Disparities, linked to, of course, our Office of Primary Care, focusing on increasing access to care, increasing the number of providers we have throughout the territory, we are looked at or determined as underserved population through our HRSA federal representatives, so we know what we need to do.

So just putting them all together and understanding that we have to link health equity throughout all the visions is actually helping us as well.

JOHNSON:
That really is exciting news because now you'll be able to have people working on this every day in the islands, correct?

ENCARNACION:
Correct. It shows that there's going to be continuity. And I think that that's one of the things that longevity is important for that thought process.

JOHNSON:
What were some of the considerations or challenges that you had to address or deal with as you got to this point of creating this new office?

ENCARNACION:
Technically, I would say finance. Because you had to determine exactly who you wanted in that position.

I chose to have a local funding source for that position, because that shows, one, that we are committed to it, and that it can actually give us that longevity that I just spoke about. So that's one of the things. Of course, a full understanding, territory wide, about what health equity is and supporting that position was something that was challenging at first, but I think that by ensuring that a lot of the leaders understood what health equity was all about, actually assisted us in garnering that support for that position.

JOHNSON:
And you've also hired someone who is local as well.

ENCARNACION:
Of course, yes. A young lady who is local, like you said, and has done her education here within a territory. She is a health educator. She also just got her master's in social work and so the two together and her commitment to the territory, I think will prove very beneficial for us.

JOHNSON:
So you're talking to partners across the Virgin Islands. What's been their reaction?

ENCARNACION:
We've had a very positive reaction. Most of them, a lot of them actually, I should say, came to a lot of the convenings that we've had. We had one convening that was awesome also, and that was in St. Thomas, and that was our community health workers.

So, it was introducing our community health workers to other areas within the government and the Federally Qualified Health Centers. After we had that convening, we got a grant, and that grant actually was a certification grant for community health workers. We've certified 25 community health workers thus far.

In this month, we are now going to be certifying 25 more community health workers. Several of them come from the Federally Qualified Health Centers, one in St. Thomas and one in St. Croix. Some from nonprofits as well. And now we have to say, what are we going to do? We're certifying these community health workers. One, what is the goal of the community health workers? How are we going to ensure that their level of care is consistent? So that's another challenge that we're taking on, and that is the certification process on an ongoing basis. So just because you're certified today and you're a community health worker today, have you maintained your training, your educational status? Are you ready to continue as a community health worker within the next two years by recertifying?

JOHNSON:
Is that a task that will be handled by the Health Equity Office?

ENCARNACION:
That's a task that will be handled through the Health Equity Office, yes.

JOHNSON:
What have you learned from putting all of this together and how did the pandemic impact the process?

ENCARNACION:
Well, the pandemic, I think, took each and every one of us to a completely different space and time. It was sort of like starting from scratch after the pandemic, but determination is really important. And we're not just doing it ourselves. We're also linking with Office of Minority Health in the different regions so that's definitely going to be a positive for us. So I'm not looking at it as a struggle. I'm looking at it as maybe a challenge that I know that we will be able to overcome. And I'm very positive about what we're doing in terms of health equity now. What we're doing right now, having chronic disease focus on looking at a Caribbean basin and how we actually decrease diabetes.

It's one of the most chronic disease, the numbers of chronic diseases you have within a territory is diabetes, hypertension, cardiac illnesses, and one that I, a lot of people don't see as chronic disease, and that's behavioral health. And how can we actually focus? So right now the focus is diabetes, a high priority for the governor as well as for myself.

So you take a bite, it's like each one is a bite, but then of course the pie will be eaten over time.

JOHNSON:
I really do like pie, so that's a very good analogy. You've learned a lot, it sounds like. I mean, you knew a lot coming in, but you've also learned a lot. What kind of advice would you give to your colleagues who maybe haven't done this yet or are thinking about it?

ENCARNACION:
Ask questions. Reach out. Acknowledge that you cannot do it by yourself. So, we have some connections and I ask you to do the same thing. Make those connections. Have network. And one of the things that I've done is I've made sure that I go to convenings with my staff, and a lot of times, several times, I've been the only commissioner in that convening, and I've done it because one, it engages you with your staff, and you develop a level of trust as well, but you hear things that you don't normally hear if you're in a meeting with our commissioners or secretaries of health, and so it gives you a completely different conversation you may not be thinking about, but people on the ground, first responders, they think so differently sometimes.

So we need to realize, okay, we were not always secretaries of health, the commission of health. Let's listen to the individuals who are not at this point in time, who are really engaged in the work and figure out, let's learn from them as they learn from us.

JOHNSON:
Thinking about the work that it has taken to get you to this point of being able to announce this office, what's been the most satisfying or gratifying thing about all of it for you?

ENCARNACION:
Besides actually saying we have a director of health equity, it's being able to share our milestones as we got to this era at this point in time to see the lightbulb in the governor's eye when he learned a little bit more about health equity, being able to go to the Senate president and saying we need to add these to the law because of the disparities that we're seeing right now with the territory, by winning engagement from others by being part of the process.

JOHNSON:
Dr. Rohan Radhakrishna is a family physician who worked his way up from local public health to a position as chief equity officer for the state of California. He was excited about the state's equity work long before he was leading it.

RADHAKRISHNA:
So, the office is really aimed to address those upstream structural drivers of health.

Going back to our foundation 10 years ago, it was written into the health and safety code, the same health and safety code that keeps our restaurant food safe, and our air and water safe, actually requires that this office exists by statute, that it has a public advisory committee to offer transparent accountability, and that it addresses more than a dozen of those structural determinants of health, and I'll name a few: housing, the built environment, planning, transportation, education, economic opportunity, workforce development, healthcare access, discrimination.

These are all the things that create a healthy society and community and can't be worked on necessarily within healthcare or always at the local level. So having a state office to play a leadership role, dot-connecting, convening role across various departments and agencies has really been essential to address those structural drivers of health. I love being the only health person in the room where we're taking that health and embedding it into all government policies to create healthy communities with healthy policy systems and environment change.

So that's kind of been the theory of change all along, and it's a very broad portfolio. You know, we don't have a staff dedicated to each one of those structural determinants of health, but we do pick our priorities based on the moment that we're in. For example, housing is a major challenge across the nation, but especially here in California as well, and has big impacts on the quality and quantity of a person's health and life. And so, we view our role as that of a convener, of a dot connector, of a champion, and a contributor to many government policies and plans that go on to affect a person's health.

JOHNSON:
You have liaisons who go out into the community and work directly with groups as well?

RADHAKRISHNA:
Yeah, Robert, we do have staff that work at a regional level and support the diverse locales of our very large state. But the liaisons I'd love to share with you and our audience is that of those embedded across the department. We like to say that to achieve sustainable statewide transformation, equity cannot be siloed in a single office or with a single equity officer. That's why we've built capacity to support deeper penetration by having nine liaisons that are spread across the broad portfolio of the Department of Public Health. So our goal is ultimately to put ourselves out of business, you know, a decade from now, I hope we don't need an office of health equity because equity is embedded into every programmatic area and has champions that are trained, so it deploys deeper into our programs and ultimately, down to the locals. And I'd love to share a little bit more about the topics that these liaisons cover because I think it's really important for sustainability.

JOHNSON:
And these liaisons then are working within the department, working in different parts of it?

RADHAKRISHNA:
Yeah. So let me give a few examples. We have a liaison within human resources. Workforce diversity is so important that our staff look like and sound like the people that we serve. This helps rebuild trust in government and it's actually a mandate from our governor's equity executive order. So having somebody to focus on the internal is really important.

Another liaison is in the Office of Policy and Planning. It's more external. It's embedding equity into our reports, our dashboards, our strategic plans. You know, every state has to create a state health improvement plan or a SHIP. And we've rebranded that as a SHEP, a state health equity plan, so we can model having actual equity outcome metrics that we're trying to move the needle on as a state, and so that we can support our counties in creating those county health assessments, those CHAs, and those county health improvement plans, those CHIPs, at the local level. So that's another one.

A few more I'd love to share are our legislative and governmental affairs team has an equity liaison for bill analysis. Every bill has an equity section to be analyzed and it's a real powerful way to have policy impact that's lasting. Another is for preparedness and response. We've talked about the lessons learned from COVID and how important embedded equity staff was for that. Well, now as we face the greatest public health threat of the century, which is climate change, and I know this is top of mind for our island territories, climate hazards like extreme weather, heat, and floods impact already marginalized groups more.

And here in California, one example are farm workers. Some of whom are indigenous and linguistically isolated, not speaking English or Spanish. So having an embedded liaison and preparedness and response is so important. A few other domains include infectious disease. We took a lot of lessons learned from COVID and applied those to mpox.

You know, we saw disproportionate impacts on Pacific Islanders, Black, Latino, tribal populations, and with mpox in LGBTQ community. So having messaging and communications and metrics and co-designing with those communities is so important. We also have liaisons for chronic disease, for family health, noting infant and maternal mortality inequities, environmental health to address environmental justice issues, and healthcare quality for our work with our facilities.

So, that's part of our lasting theory of change is to go deeper into a state health department.

JOHNSON:
Considering your colleagues who might not have an office of health equity just yet, what's on your list of items they ought to consider if they're thinking about doing it?

RADHAKRISHNA:
Yeah, Robert, we've thought a lot about it looking at our decade experience here in California, and I love learning from my counterparts in other states. Each state is so unique and has important lessons learned. We've put together playbooks, onboarding guides, sample duty statements that we'd share with national organizations like ASTHO, but there's a few key components I want to emphasize. Number one is strategically positioning an office of equity for generational success that will last across administrations.

What I mean by that is giving it statutory authority so it won't come and go. We don't want equity to be a buzzword for this decade. We want it to really be baked in and built in so it's untouchable as it goes deeper into policies and procedures. So it's not vulnerable to the pendulum swings of administrations or boom and bust funding cycles.

And that also means having this office of equity report to the highest health authority within your state or territory whether that's a secretary or a public health director. So I’m grateful to have access to our state health officer and director by reporting directly to them and I attribute that to the wisdom of the legislature and advocates that really pushed for that more than a decade ago. That helps us hardwire in the success.

A second key learning I'll share is making sure that there's transparency and accountability. So by statute, we have to have a public advisory board. Those are public meetings where people can ask us for accountability, if we're moving the needle, to explain deeper our priorities and to really try and get community power into decision making so those most affected are actually able to have a say in the impact of government decisions and resources on their lives and that o.ften means ensuring that this office of health equity can influence other non-health agencies and departments to address those upstream drivers like housing, transportation, planning, education, economic opportunity, workforce development, and the environment.

JOHNSON:
Finally, can you imagine doing public health in California without this office?

RADHAKRISHNA:
I can't. And I know it's a reality, and a lot of places don't have an office, an officer, or a team dedicated to it and people are still doing the work. I briefly want to talk about the challenges in rural and tribal areas and not all those jurisdictions may have an equity team or an equity officer, yet they're doing the work.

We recently had a webinar with a rural health lead and they're not allowed to use the words racial equity or equity, and yet, they're still doing amazing work and calling it different things. Access. Inclusion. Opportunity for all. Community engagement and empowerment. So no matter the starting point, starting to support staff with more full-time equivalent positions, with resources, with teams to support the work, no matter what you call it. I can't imagine having this work continue to grow and move the needle and close gaps without dedicated staff and teams to do it. You know, we like to say that if you're not intentionally equitable, you may be unintentionally inequitable. And if you don't have leads at the table, making sure that decisions are equity-centered and equity first, you can do unintentional harm unconsciously, like we've done for decades and centuries.

So, building that infrastructure and making sure that it's lasting, no matter what you call it, no matter what you're starting point is, is something essential for public health in this century.

JOHNSON:
A quick note, our interview with Dr. Radhakrishna was recorded in May. He has since left his position with state government.

Thank you for listening to Public Health Review. If you like the podcast, please share this episode with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr at ASTHO dot org. That email address again, pr at A S T H O dot org. You can also follow us using the follow button on your favorite podcast player.

And remember, you can stay up to date on everything happening at ASTHO by tuning in every morning for Public Health Review Morning Edition. We cover news like this every day. Look for the link in the show notes and let us know what you think. This podcast is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.