On Oct. 1, 2020, the AMA’s Prioritizing Equity series joined Chicago's public health leaders as they share lessons learned, discuss the importance of equity and illuminate the challenges health departments have faced in response to the pandemic.
Panel
- Allison Arwady, MD, MPH—Commissioner of the Chicago Department of Public Health
- Eve Shapiro, MPH—Senior director of data & evaluation at West Side United
- Candace Moore, JD—Chief equity officer for the City of Chicago
Moderator
- Aletha Maybank, MD, MPH—Chief health equity officer, group vice president, Center for Health Equity, American Medical Association
Transcript
Oct. 1, 2020
Dr. Maybank: Good afternoon, everyone. Welcome to Prioritizing Equity. Dr. Aletha Maybank here to share with you our next conversation. We've been having wonderful conversations. I really think it's been such a privilege to speak with many leaders across the country who have been working very hard to center equity in their work, not only during the COVID response, but oftentimes before COVID, and definitely thinking through what they have to do after COVID. I just want to remind people that we have a health equity resource center for COVID-19 on the AMA website, and we're adding more and more information as time goes on. So as we know, public health officials announced on Tuesday that 1,362 people have been tested for COVID-19 in Illinois, and it's the lowest number of new cases confirmed in a single day statewide—I will be corrected if that is not right in a second—in almost three weeks.
The latest coronavirus cases detected among those, we have noticed that there's a lower positivity rate, which is fantastic, and that the case load is also going down. I am, and as many people are aware, AMA headquarters is located right in Chicago, and I've had the privilege and opportunity of living in Chicago this past year. And I've really loved my time there, but also have valued the partnerships and the relationships and building with the Chicago Department of Health and the mayor's office and West Side United. And we're going to speak to all those folks next, because I come from the New York City Department of Health, so I love public health people, very much near and dear to my heart. And I know how hard you all are working, and how critical partnerships especially are during this time. But also what I've recognized about Chicago is this direct intention to center and elevate explicitly equity and the importance of doing it, but even more so, racial equity.
And so we want and need more cities and entities or localities to take that kind of lead, so I really thank Chicago for that type of leadership. So today, we have Dr. Allison Arwady, who is commissioner of the Chicago Department of Health. We have Eve Shapiro, who has a master's in public health, and is a senior director of data and evaluation at the West Side United. And then we have Candace Moore, who's a JD, and is chief equity officer at the City of Chicago. And she's the city's first chief equity officer and trying to get more cities to do that, I am sure, in your work. So as I start off with every single panel, I usually just ask really, how are you all doing? I know where you all are for the most part. Well, that's an assumption. Maybe you all aren't in Chicago, but my assumption is as government type officials and local officials, that you are in Chicago. But how are you doing? And any of you could start. Commissioner?
Dr. Arwady: Yeah, I'll start. So my mood really does vary a lot depending on what our daily COVID numbers look like, and they've been looking pretty good for the last month or so here in Chicago, heading the way we want them to. So at baseline, I'm doing pretty well. I'm also excited, because today is the day that we were able to loosen some restrictions lightly. Those go into effect, so that's a real careful step forward, and we're having some fun with some Halloween announcements this afternoon. So, looking forward to that. I'm having a good day.
Dr. Maybank: Okay, that's good to know that today's a good day. Candace?
Moore: Yeah. I mean, I think I'll second what Allison said in that it's been a roller coaster ride, sometimes daily, sometimes hourly. In this moment, I'm good, relatively speaking. This has been, I guess as the saying goes, the best of times and the worst of times, sometimes all in one day. So there's just a lot going on. There are big decisions. There are just important things happening in our communities and in our cities, and there have been moments where it has been pure joy, because I feel like we have done something really important or made a difference and actually gotten a chance to see some of the impact. And then there are days where it feels like a huge setback, and so all of that kind of creates a slight sense of being maybe on edge a little bit, a little drained. And that's just the real of it, but I'm really grateful for being a part of a team that I think is just working so hard and so smart. And so for that, I'm just eternally grateful.
Dr. Maybank: Eve?
Shapiro: That's a challenging question these days, I think. I'm doing well. I'm healthy. I'm grateful. I'm in our West Side United offices, which I haven't had the chance to visit for quite a while. So it's fun to be back in the office, but it's been a particularly challenging week and a half, I think. On the 22nd, we had our 200,000th person who died from COVID, and then the next day we had the announcement that the grand jury indicted the officer, not for the murder of Breonna Taylor, but for wanton endangerment. So I just feel like we're really in an era where we're grappling with how our society values life and whose life they value, and racial equity sits right in the center of that. So I'm always happy to talk about that, and I'm glad for the health and all the good things that are happening in my life. But I do think that there's a heaviness to the last couple of weeks that we've been in.
Dr. Maybank: Absolutely, and thanks for that. Commissioner, go ahead. I saw you turn on your mic. Go ahead.
Dr. Arwady: Yeah. No, I was just going to say this has been a year like no other, and we were talking with staff a little bit this morning that today is October 1, which means we are three quarters of the way through 2020. We say hindsight is 2020, and everybody wants 2020 to be in hindsight, I think in a lot of ways. And it's in some ways felt like the longest year, and in some ways it's felt like it's been moving just so fast. But I think to both Candace and Eve's point, not just me, but our whole team, I think, every day, every minute, every month has felt in some ways like a different response, and continuing to try to keep everybody safe and healthy and productive and mentally able to handle what's just been such a difficult time for all of Chicago and for people who are working right on the outbreak. So I'm always, relative calm means a very good day at this point around here.
Dr. Maybank: Very well understood. And building off of what Eve said—and then I do want to actually—you mentioned the mental health of people, and I would love to hear more about how you all are supporting that, because it is brought up. It is elevated. I was on a panel yesterday, but it's still just not concrete for folks, I think, in terms of like what the actions can be potentially. So we will come back to that, but I would love for you first to talk, Commissioner, and then I want everybody else to chime in as well. What are the ways that you've been working to kind of center equity in the COVID response? I distinctly remember definitely kind of the call to action as it related to the missing data, and kind of the activation that happened that kind of seems like several levels of government in Chicago. But could you first speak to what the Health Department did? And then Candace, would love to speak to you. What was the conversation at the mayor's office as well?
Dr. Arwady: Yeah, absolutely. So as you mentioned right at the outset, the Chicago Department of Public Health has centered equity in our work for many years at this point. Between 2015 and 2020, our whole plan was around what we were calling health equity, and we started measuring success--not was the whole city doing better on something, but were priority populations coming closer to the rest of the city. And we had decided in 2020 for our next five-year plan to more explicitly focus on racial health equity, and specifically the racial life expectancy gap in Chicago, which is 8.8 years here.
Black Chicagoans live on average 8.8 years less long than white Chicagoans. And in fact, all other race and ethnic group Chicagoans. And we've seen a decline in life expectancy, sort of over the 2010s as a whole city. During that time, a slight rise for White Chicagoans and all other groups falling. And so we'd already decided we're going to focus on that 8.8 year gap, the five major drivers of it. And the first one, half of that gap was related to chronic diseases. And that's your diabetes, related diseases, your heart diseases, your lung diseases, all these things that we know put people at risk for severe outcomes, hospitalization, even death from COVID.
And so very early on, we were sort of primed to be looking at this from an equity and a racial equity lens. And we're quite early to be talking about the data in this way, to really be raising it up. And then Mayor Lightfoot has also been very explicit in her agenda for the whole city around, not just what are these outcomes, but what are the long standing root causes for these in terms of living conditions, social, institutional racism, frankly, and decades of disinvestment in some parts of our city that have led to those differences in chronic disease, et cetera. And so with COVID, very early, we said, first we're going to talk about this, but also we want to really develop a response that puts race equity at the center in many ways.
And that has been the plan from really, from very early on. Our very first dashboards already, you could slice and dice by race, ethnicity. Our press conferences from very early on talking about what initially was a very, very disproportionate impact on Black Chicagoans and still we've seen about 43% of our deaths here from COVID in Chicago among Black Chicagoans, even though Black Chicagoans are about 30% of the population. And then secondly, we saw a really significant increase in cases among Latinx Chicagoans, and here in Chicago, about 48, 49% of our cases have been in Latinx Chicagoans, where again, it's only about a third of the population.
And so we'll talk in some more detail I'm sure, about some of the very specific strategies that we use and how we use the data. But Candice has been part of this racial equity rapid response team, which we announced the very day that we announced these inequities because we wanted that to not just say here's a problem, but what are we going to do? And how are we going to do something different this time around knowing the underlying risk factors in this area?
Dr. Maybank: Yes, thanks. Candace, do you want to talk, because that's what I remember distinctly too, what you just said is the launch of the racial equity risk rapid response team. I was like, Oh my goodness, this is amazing. So go ahead, tell us.
Moore: Yeah, no, no. And I think I'm just pinging back off of what Alison said and that, I think one of the things that was key to that is that our public health department had done the groundwork, had been paying attention to race, had raised the issue to us here at the mayor's office that allowed us to sort of come together and talk about what could be done because the mayor made very clear, she said, yes, we have a fundamental responsibility to get this information out to the public, but we also have a fundamental responsibility to do something.
And the big sort of, I think, heavy question is if we understand what might be driving this, we're talking about systemic issues. We're talking about chronic underlying conditions, all of these different things. What do you do right now? And what does that look like? And so our Racial Equity Rapid Response Team was the brain child of a lot of different ideas that were being lifted up about what more we could be doing, the partnerships that we already had on the ground, such as West Side United, the assets that we had in our communities, like our community leaders. Like what does it mean to actually get in proximity and to bring all of these stakeholders at the table, not with a solution that we had dreamed up, but with the problem that we were facing and saying that it is our collective responsibility to act, to try to solve and to try to mitigate this.
And that is the spirit and the lifeblood of the Racial Equity Rapid Response Team. It Is a team that is comprised of government, city officials, our partners at West Side United, which we are also able to help leverage both community leaders and health care leaders from the health care providers across the city. And to bring that group together to say, we are going to hold ourselves accountable to a rapid response. We are going to look at the data. We are going to walk alongside the data and have that plugged in and serve as the sort of compass for how we think about the questions. But then we are going to bring our leaders to the table and ask, what more could we be doing? Where are we missing? What are you seeing on the ground? How are you processing some of these things? What could we be doing together?
And then we're going to execute together. And we're going to leverage the resources that the city has. We're going to leverage the resources that the private sector has. And we're going to leverage the resources that our communities have and understand that there is value in assets in each one of those. Because for me fundamentally, when I think about equity, yes, we're trying to solve and get to an outcome where we don't have some of the, I mean, when we first started off the numbers for the African American community were sort of sky high, and we saw this kind of move through the trajectory of COVID, but so we want to solve for those outcomes. We want to solve for those gaps that we see, but we also actually want to create a process that values the capacities of those most impacted by this.
So the leaders were from areas where the data showed us were most impacted. We're seeing that some of the highest negative outcomes from COVID, death and infection rates. We're going to find leaders in those communities, and we're going to have them help us lead in our response. And that was sort of the hypothesis in a lot of ways. And I think what I've experienced, and I'm sure Alison and Eve probably sharing this, is the power that has created, the ways in which we've been able to work together. And then the transformational relationships that we have built, things that we didn't think were possible for government and community to really to own and to have has been one of the products that I think I'm really proud, of is yes, we've been able to execute on these major outcomes, but we are also fundamentally changing the kind of relationships that government and communities and the private sector have and thinking about what our responsibilities are to service our community.
Dr. Maybank: Yeah. So thanks for that. And then just to elevate for folks who are watching this now and in the future, what the commissioner and Candice already raised are some of the core strategies of advancing equity actually, are one naming equity, right? And specifically naming racial equity, following the data and making sure we're collecting data and understanding the communities that potentially are most marginalized and then following that data in terms of action. Having the partnerships, but beyond that, what I hear is valuing community as kind of equal expertise to that quantitative data, but that value of voice and experience equally is absolutely critical. And then the sharing of power in terms of decision-making also really critical to advancing equity. So I just wanted to point pull that out for folks who are watching, who sometimes aren't able to translate and connect those dots to why this is really, why your process, as you said, Candace, it's not just about outcome, but why your process works towards advancing equity.
And so Eve, we've had the wonderful privilege as American medical association to sign on as a formal partner with West Side United last year for folks. Well, I want to let you describe what West Side United is, but we're very, and then I'll say what we do, what our role is, and then we'll talk more about West Side United and how it's all connected, as well.
Shapiro: Thanks. So West Side United is a health collaborative of six anchor hospitals and other institutions, like the AMA, who came together a couple of years ago with a vision for health equity. So that's really our root and kind of where our vision emerges from.
So currently there's a 14 year life gap expectancy between some West Side neighborhoods and neighborhoods in the Downtown or Loop area. And the vision of West Side United is to reduce that gap by 50% by 2030, which is very ambitious. And we have a social determinants of health framework, which means that we believe that environmental or contextual factors, like unemployment, or educational attainment, or access to health care really directly affect an individual's health. So accordingly, we have a variety of initiatives that address those different social determinants of health.
So I think we really leaned on our role as a convener with this kind of holistic framework about all the different ways that an individual's health can be impacted, when we came to the table with a Racial Equity Rapid Response Team. And I think that we've seen clearly the benefits that Candace alluded to, from having a collective of individuals with different skills, backgrounds and expertise, and that our response has been really strong.
So for example, Candace's team was able to secure thousands of masks that our community partners then distributed in neighborhoods to folks who need them and didn't have access to one early on. We identified areas where additional testing sites were needed. Our data working group provided feedback on the data dashboard that was put up pretty early on, so that the public had access to testing case and mortality data and could see it spliced out by age or race or ethnicity. So again, I just want to echo the strength that truly comes from having a diverse collaborative and really putting the community organizations and leaders as experts.
Dr. Maybank: Yes. And I think that's the value of West Side United. So it's the six health care anchor institutions, but from my experience, it's really, it's very community driven or neighborhood driven, and the voices are centered in decision-making in the governance of West Side United, as well, with business partners and many other folks, the government, the public health. So it's this kind of really complete collaborative that other places have across the country. But I always thought that the uniqueness was also having this health care part of it very explicitly, and in just more than one organization, because oftentimes public health and health care are segregated. Folks hear me say this all the time. It's one of our biggest challenges, I think very much elevated during this time of COVID that we have to move towards.
So to see all of these interested, and beyond interested, but really vested stakeholders, at the table together and having some levels of meaningful outcomes I think was really inspiring for me. And this was already mentioned a little bit, I have said that I always thought that this is like a form of emergency preparedness, the frame of it. What do you all think about that? Because you both mentioned, two of you, the importance that this was in place beforehand, the work and the centering of equity, but then now this time comes. So can you speak to the emergency preparedness aspect of having this type of relationship in the way you do your work?
Dr. Arwady: Yeah. Maybe I can kick it off. I could not be more proud of the emergency preparedness group at the Chicago Department of Public Health. They are a group that toils long and hard, preparing for things that we hope will never happen. And certainly here in Chicago, first, I mean, even just on the logistics side, we had built up an enormous stockpile of PPE. We had done exercises just last year. We had built up our, we had looked at our entire pandemic influenza plan and brought together groups and thought about what if school was disrupted? How might we think about feeding kids? What if this happened, what if that happened?
And there are 20 different sort of matrices there that we plan for and think for, and had actually worked with partners before COVID ever broke out, imagining what are some of the extra things that we're going to have to have thought about and paid attention to? And we have in there things like vulnerable populations, depending what, and that gets broken out into thinking about accessibility or health care or whatever, and we have in there very explicitly race equity, and then making sure that this piece and how might any impact actually show up differently in different neighborhoods or in different race ethnic groups. And how do we think about what we've learned from in the past?
And I think when something like a pandemic breaks, when you start, you're like, "Okay, we're on page one, we're on page two." You don't really think that you're going to ever get into the month nine planning, but it's been remarkable to me that although it didn't all happen in the order that we thought it would, right, like we were thinking school closing might be a little later, and this might be a little earlier, we've actually seen every single disruption from the agriculture and manufacturing to the hospital. Every one of them we've seen. The only one we haven't hit yet is the vaccination campaign, and of course we're doing a ton planning around that.
And again, taking this equity lens to that, recognizing that African Americans in particular have lower rates of vaccine uptake normally in our flu campaigns and our other campaigns, have higher rates of ICU admission for flu in Chicago, that there is a long history of medical and public health disrespect and, frankly, some experimentation on people of color. And we want to be honest about that, and then honest about the ways in which we have put processes in place to try to limit that, and be explicit about how do we know a vaccine is safe? How do we know a vaccine is effective? Why should I trust a vaccine?
I'm not always going to be the best messenger for that. I have the science piece, but how again do we bring many voices in Chicago with expertise at looking at clinical trials and helping understand this, match that up with community voices, answer people's questions honestly, not pretend like we have all the answers, which we definitely do not have when it comes to COVID, and which we do not have yet for a vaccine, but be honest about what we know, try to translate that into community language.
And so the job of the preparedness team is always to try to keep us at least three months ahead in all of our planning and all of our thinking. But because even the preparedness team that doesn't, you know, you might not think would have a particular equity lens, we've required every single program at the health department, even if they do mosquito control, to think about what might equity mean in the context of my program. When they report out every year, it has to be a piece. And we've worked pretty hard to try to just build that into the DNA of our programming. And I think it's just left us in a more prepared place. It doesn't mean we get all the answers right. It doesn't mean we don't make mistakes. But I think we put it on the table and then really look to the experts who often—
Dr. Maybank: You all just hired a chief racial equity officer. So when I say chief racial, am I saying that right? Because I get confused with mine sometimes. So a chief, which I think is tremendous leadership.
So moving towards what you mentioned in terms of having to bring multiple people in different disciplines together within the health department, Candace, can you speak to the work that you've had to do from the mayor's office level to really get everybody on board with the health equity and the racial equity lens of this? I would imagine it's not easy. And can you just speak to some of the challenges and how you've gotten over that?
Moore: Yeah. And I think what's been kind of striking for me, and I think this is in some uniqueness to this administration and to Chicago, is what hasn't been easy. It may be a little bit different than what I think people might think, at least in my experience.
So I had mentioned earlier that I'm incredibly grateful for the team that we have, but part of that is because the mayor is on board and is the champion of pushing for racial equity. And so as an administration, it has been clear from the outset. That is why I was hired into this job, and not only is she saying, "We're going to do racial equity work." She is saying, "And it's all of our business. It is not just the chief equity officer's job, it is all of our work to do." And then additionally, I think this moment around COVID, and a lot of kudos to the health department, the way in which we've been able to show the data and show the disparities and talk about that has really created this atmosphere where, by and large, a lot of folks get it.
The challenge I find more than anything is the, what do I do about it? How do I change? What does this mean? I get that I'm supposed to do something with a equity lens, but one, I might not be willing to say I actually don't really know what that means. Two, I don't know what that means that I'm supposed to do differently. And so what does that mean in this moment? And that's where I find a lot of the work. And so when I think about the role of our department and what I've tried to do across the multiple sectors that we work is really support people in building that capacity for what we can do.
And what's interesting is that I'm not an expert on everybody's everything. That's not my job. My job is to help push certain questions, to ask people, did you talk to those who are most impacted and what did they say to you and how did that impact the choice that you're about to make? How are you thinking about the constraints of what you can do and potentially expanding them based off of taking in more information? So if the community says, "I hear you want to do this strategy, but that's not going to work for us." What are we going to do differently about that? How do you then rethink what is possible? How do you look at your resources? A good example for me is actually something that I think came up in the Racial Equity Rapid Response Team around testing.
The city was adding some testing capacity by standing up some sites, but there were places that our community members were saying, "I actually really wish testing would go here." And for many different reasons the city had constraints in executing on that. But one of I think my proudest moment and the thing that really made the work that we were doing really special is that then the hospitals were saying, "Well actually, if we could pair this particular strategy with what the city is doing, we have capacity over here, and we could actually create a bigger solution where any one of us trying to work on our own would not be able to do." And I think a lot of people don't think about that being part of equity work, but it is pushing our imagination, pushing our constraints, pushing our systems to really think more broadly about what is possible.
There are assets in communities that they can offer to a solution. And sometimes we don't even think about that. We think we have to solve it, we think we have to come with all of the answers. There are assets that other stakeholders can bring. And so a lot of my work, I feel like I'm constantly trying to put a puzzle together, trying to get the people in the right room, trying to help open up conversations, ask questions so that we can apply much more creative, strategic, innovative and ultimately timely and needed solutions to solve for gaps and challenges that we're all trying to go fast and they're going to come up.
Dr. Maybank: Absolutely. And so as we close out, because we're at time, but we'll be able to talk a little bit more. For the after show, for those who haven't ever seen the after show, we will answer more questions. But I want Eve to say a few words here. And I guess being in the context of the community or the neighborhood perspective, what have you heard or what has been your experience that you think has been really positive and optimal and rewarding during this time of COVID coming from the West Side United context?
Shapiro: I've been really pleased to see that our mission as an organization around health equity and reducing life expectancy gap has been adopted by this administration and is really being embedded into and is the focus of Healthy Chicago 2025. So I'm just so glad to see that more and more folks are taking on the mission of health equity, particularly in relation to COVID. Again, I've said this before but I think it's so important to have the community voice front and center and I think that there are specific opportunities where that's happened, particularly in the Racial Equity Rapid Response team, and I think that that's unfortunately unusual occurrence. But hopefully seeing the effectiveness of having community input will help expand the opportunity for community members to really lead the charge in improving health in their neighborhoods.
Dr. Maybank: Awesome. Well, I want to thank you all for joining me. The time always goes by way too quickly, but I think what you shared today is going to be extremely valuable to many that watch. I also learned a few things as well. And to all those who are tuning in, this will be available pretty much for later in the day, so we encourage you to share it and we encourage you to also tune into our next installment. That's going to be on October 15, really speaking about Latinx community but also some of our progress and movement as we also honor and celebrate Hispanic Heritage month for the month of October. So thanks again for all that you all are doing and for your leadership. I know at the city government level and at the city level and the work that you're doing is non-stop, it's pretty constant. But really, thank you for your energy, your passion and commitment to always centering equity. So thanks a lot.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
