Q&A: 2021 will test dedication to ending health inequities – American Medical Association

In her 1995 autobiography, A Simple Path, Mother Teresa wrote, The greatest disease in the West today is not TB or leprosy; it is being unwanted, unloved and uncared for.

The late Saint Teresa of Calcutta couldnt have known what would befall the world in 2020the COVID-19 global pandemic, and heartbreaking and all-too-frequent instances of social injustice and racism. But she almost certainly anticipated something more enduring: how poor people, especially people of color, are not able to get the health care they need.

There are dozens of medical groups in the U.S. that have made it their missions to care for poor and underserved populations. One of these is Ascension Medical Group. Along with its parent company, Ascensiona leading nonprofit, St. Louis-based Catholic health system with hundreds of locations across the U.S.the medical group has been caring for underserved populations for decades.

Ascension Medical Group is an AMA Health System Program partner and its work to improve professional satisfaction was honored with its inclusion in the AMA Joy in Medicine Recognition Program.

AMA member Baligh Yehia, MD, MPP, is senior vice president at Ascension and president of Ascension Medical Group. Among many other roles during his career, as a medical student he served on the AMA Council on Medical Education. Board-certified in internal medicine and infectious diseases, Dr. Yehia is a nationally recognized expert on health disparities and HIV medicine, publishing more than 150 articles, abstracts and chapters in leading journals.

He also served as the first deputy undersecretary for health for community care at the U.S. Department of Veterans Affairs (VA) and oversaw the VA's Community Care Network. Dr. Yehia spoke with the AMA about how organizations can tackle systemic racism. The first step, he says: Prioritize this work. The second: Have a plan. The third: Make a long-term commitment.

AMA: Social justice deservedly became an especially hot topic in health care in 2020 and will doubtless continue to dominate strategic thinking in 2021, but its been a core emphasis at Ascension for years. Howso?

Dr. Yehia: Well, it starts with the mission, which specifies being an advocate for a compassionate and just society through actions and words. Some health systems only recently started to tackle health disparities, structural racism and diversity and inclusion. Ascension has been focused on health equity for a long time. In fact, weve had quality targets for many years that include disparity components.

For example, we know there's a disproportionate impact of diabetes in African American communities. So while we have a goal to improve hemoglobin A1c for all, we also have a specific focus to reduce it even more for the African American community. And we've done that for many other conditions, such as COPD and asthma and colonoscopies.

AMA: The concept of systemic racism entered the mainstream during the racial reckoning of 2020, and the AMA recently declared racism a public health threat. How does that play into your work at Ascension?

Dr. Yehia: Shortly after George Floyd was killed, our CEO, Joe Impicciche, spoke out publicly in support of justice and peace while condemning racism and intolerance. He then tasked our leadership team to develop a plan for Ascension to help address racism and systemic injustice by creating a more diverse and inclusive culture. We developed a framework called ABIDE, which stands for appreciation, belongingness, inclusivity, diversity and equity. This framework is intended to help us review and rebuild our policies, practices and ways of working so that we can eliminate the forces within the health system that contribute to or perpetuate inequities, including systemic racism.

The ABIDE framework also involves a four-part process of listening, praying, learning and acting. We just wrapped up our first listening phase, in which we asked all 160,000 of our employeeseveryone from environmental service workers to physiciansto participate in a series of anonymous sessions to share their viewpoints and help us identify themes for future action.

We have a large system that includes hospitals, clinics, nursing homes, home health agencies, insurance programs, all focused on delivering excellent patient care. Our goal is to intentionally digest it and then come up with a path to action that specifies what we are going to do, both within our system and in collaboration with others.

There are many steps we are taking todayfor example, we're raising our minimum wage. The organization is committed to helping every one of the people we serve to achieve their full potential, and it all comes down to our core belief that each person has value, whether they're rich or poor, Black or white, of any ethnic background.

AMA: Earlier in your career, you served in a significant leadership role in the VA and at prominent academic medical centers. How did that work prepare you for what youre trying to accomplish now with Ascension?

Dr. Yehia: When I had the chance to join Ascension, I jumped at the opportunity because it has such a deep commitment to serving all people, with a focus on the poor and vulnerable. So its a situation where my personal mission and the organization's mission are perfectly aligned.

But it also gave me the opportunity to work with many great individuals who were transforming care at a large scale. Its much like the VA, in that you have the opportunity to improve the lives for large groups of people across the country.

AMA: Your research at Ascension on COVID-19 outcomes by race, published in August 2020 in JAMA Network Open, yielded results that might be surprising to some. What are the main takeaways?

Dr. Yehia: We looked at the first part of the pandemic, between February and May, and what happened when patients were admitted to our hospitals. And we asked the question: did outcomes differ between Black and White individuals?

We described our population, in terms of their clinical conditions, sociodemographic factors and comorbidities. We also were able to include items like the neighborhood deprivation index, which uses ZIP code-level data to assess neighborhoods socioeconomic disadvantage.

Then we followed those patients throughout their hospitalization and we noticed something: There was no difference in mortality by race. The take-home point is that once you're able to get into careinto hospital careyour outcomes are the same, which is really important.

In the study, we emphasized the point that this does not contradict what we know from population health datathat minority groups have higher rates of COVID-19 cases, hospitalizations, and deaths. This is important because it shows the work left to do in this area.

AMA: Well, then, what do you think is missing from the public debate around health equity, structural racism and diversity and inclusion?

Dr. Yehia: In 2019, I would have said the first thing that was missing at the national level was the discussion itself. The pandemic and the protests over social injustice made this really evident in 2020 and encouraged many organizations to take a stand on the issues, which is important. But we need more dialogue and focus because that's where innovation happensin that researchers and scientists and community activists and patients and health professionals work together to come up with new ways to approach this important issue that has been under addressed for decades.

Another thing thats important is to acknowledge that we have to continue to strive to make progress in this area. Sometimes we make progress and then we plateau. Its a journey that requires dedication to change the structures and factors contributing to inequity.

Lastly, I think as a profession and health community we have to develop a common language. Many people don't have a complete picture of what we mean by health disparities, structural racism, structural inequities, and diversity and inclusion. While they are related, they are very different constructs. A diversity-and-inclusion initiative is not the same as a health equity initiative or a commitment to address structural racism.

AMA: So, where do we go in 2021?

Dr. Yehia: There are two things that should remain top of mind for physicians and care team members.

First, some are skeptical that the attention on systemic racism will last. When I talk to groups, that's what I hear. And this concern about sustainability is valid, because, after all, these are not new issues. Structural racism goes back many decades, so people worry, Is this really the time when things will change for the better? I tend to be more of a glass-half-full person, and I think it's great thatas a health system, as a community, as a countrywere addressing these important topics.

Second, especially with all the demands of the pandemic, everyone is wondering what action really means and how to stay focused. Its not an easy question to answer: How do we make sure something else doesn't come along and distract us from this important work? Thats where I think you look to your personal and organizational missions.

In other words, whats important to you? And to me and many others, this is very important.

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Q&A: 2021 will test dedication to ending health inequities - American Medical Association