Paving the Way for Health Equity in Los Angeles County June 6, 2018 Public Health 987 Just over one year ago, Barbara Ferrer, Ph.D., MPH, MEd, was appointed as the director of the Los Angeles County Department of Public Health by the Los Angeles County Board of Supervisors. Dr. Ferrer brought not only over 30 years of professional experience as a philanthropic strategist, public health director, educational leader, researcher, and community advocate to the position, but also a collective vision for LA County: that everyone has the opportunities and optimal resources for health and well-being. So was established the Los Angeles County Health Agency Center for Health Equity. In a recent interview with Gustavo Friederichsen, CEO, Los Angeles County Medical Association, Dr. Ferrer shed some light on the research that led to the formation of the Center and its main focus areas for achieving optimal and equitable health for all in LA County. "If you look at population data and the LA County population as a whole, in many regards we are a very healthy community. When you start looking at the data for specific groups of folks or by residential neighborhoods, you see a different picture of LA. In fact, some people call it a picture of two LAs or three LAs. In particular, African American members of the LA County community are doing far worse on a whole host of measures than all of our other residents. Native Americans also fare significantly worse than others, and Hawaiian Natives fall into a similar category. So by race and ethnicity we see some dramatic differences that, in fact, aren't easily explained by income or educational levels," Dr. Ferrer told Friederichsen. With an unjust distribution of resources and opportunities in our local communities, health disparities are mostly afflicting underserved and ethnic communities. Tackling these inequities, however, is not just a matter of focusing on changes in clinical care, but looking at the larger picture of the resources individuals have to lead healthy lives, including access to economic resources, educational resources, environmental, and cultural competency resources. Dr. Ferrer understands that it is complicated and complex, but is optimistic that Los Angeles County's leaders and residents can work together to achieve system, policy and practice changes that lead to health equity. "LA County is a progressive and committed set of people. The Board of Supervisors stands above all other leaders in really acknowledging what it means to be of service to our community, and they do that by insisting that every day we put front and center the needs and voices of residents. When you put the needs and the voices front and center, you are going to make a difference…There is an opportunity for us in LA County to lead the way on how we can ensure that residents have what they need in order to fully contribute and be healthy." THE FIVE KEY INITIAL INITIATIVES The Center for Health Equity has outlined five priority areas to eliminate differences in health outcomes based on where a person lives, their sexual orientation, and/or their race or ethnicity: Infant Mortality Sexually Transmitted Infections Cultural and Linguistic Competency Healthy Neighborhoods Environmental Justice The gaps in health outcomes seen within the Center's focus areas are not necessarily caused by personal health behaviors or characteristics. They are mostly the result of past and present policies and practices influenced by racism, sexism, transphobia, homophobia, and other prejudices. These policies and practices lead to inequitable conditions that limit an individual's ability to grow healthy and thrive. Dr. Ferrer emphasized the need for medical communities across the county to not only mobilize to improve service quality, provision, and coordination but also to collaborate to better address the conditions and policies that drive and maintain health inequities. GOING BEYOND THE PRACTICE: THE PHYSICIAN'S ROLE IN HEALTH EQUITY Dr. Ferrer believes that LA County is at a strong advantage in advancing health equity because of its "very strong provider network" and "a network that understands the critical role that prevention plays in promoting healthy outcomes." All of the five key focus areas require action on behalf of the medical community. Achieving optimal health, especially for those communities impacted by social injustices, will require physicians to make changes inside and outside of a clinical setting. First, providers can ensure a welcoming and culturally respectful environment for patients and employees. As one of the most diverse communities in the country and with 60-70 languages spoken throughout the county, Dr. Ferrer believes that recognizing how implicit bias affects trust in relationships with employees, with each other and with the community is an important first step providers can take in developing cultural and linguistic humility to address the needs of local communities in building equitable care. Next, with a disproportionate burden of illnesses and an inequitable distribution of health resources among populations unjustly singled out by race, ethnicity, sexual orientation, gender identity and/or religious affiliation, it is important that practices adjust to understand the unique needs of individuals who experience high levels of stigma. These stigmas oftentimes can cause increased levels of chronic stress. Physicians should acknowledge and understand those stressors and assist with treatments that help the patient manage that stress in a positive manner. Regarding sexually transmitted diseases, a disproportionate number of STI cases occur among men who have sex with men (MSM), African American women, transgender persons and young people, with youth of color disproportionately affected. Dr. Ferrer believes that novel, coordinated action is needed to address the complex factors affecting STI rates countywide and placing some communities at higher risk. In addition, Dr. Ferrer stressed the importance of better screening and treatment among those populations seeing increasing rates of STDs. In LA County, the infant mortality rate of black babies is three times higher than the rate of white babies. Closing this gap will require developing innovative strategies with physicians to improve preconceptual, prenatal, and interconceptual care. Lastly, Dr. Ferrer urges all clinicians to pay attention to policies that influence access to healthcare and resources for healthy communities. In particular, there is a need to focus on policies that mitigate against climate change because of the dramatic impact it will play in disease burden. She said that we should all learn from past examples of policies around tobacco control, seatbelt regulations, and clean water that have been game changers in improving healthy environments. Additionally, whether physicians are in large provider groups or in solo practice, it is important to consider environmentally conscious purchasing options that would support issues addressing climate change and protecting the Earth. LACMA'S ROLE When it comes to policy, LACMA and its partnership with the California Medical Association is arguably the most influential healthcare advocacy organization at the county and state levels. Our members carry immense credibility when sharing their voice and representing the voices of their patients. That is perhaps one of the main ingredients in helping to achieve health equity in LA County. Dr. Ferrer mentioned the importance of getting clinicians involved in shaping the strategies around the five initiatives. "We don't have the answers; we know where we would like to go, but we need clinicians to help us figure out the action plans and what is going to take us there. So I think that is one task. Get involved. Join our planning groups and really help make sure that the voice of providers is being elevated in terms of the solutions and strategies that are being promoted," Dr. Ferrer said. Most importantly, leveraging the health policy-making platform of LACMA and CMA will be key in creating policies that will keep our communities protected and healthy. That can mean advocating beyond clinical issues to address the social determinants of health, like fighting for a living wage, paid sick leave, fair housing policies, among others. THE JOURNEY AHEAD In describing the incredible and promising journey ahead, Dr. Ferrer said, "I'd like to start from a place of deep gratitude for physicians. I think the job is really tough, and I think there are a lot of constraints on clinicians who want to practice the best medicine possible…I think of care as a continuum from prevention all the way through recovery and healing. We each have our specific roles to play, but the most important thing is that we understand each other's roles and places of contributions, so we are connecting these dots on behalf of our patients and our residents…We both have the science and the political will to actually come together and make this happen. I am excited about it." TO LEARN MORE AND GET INVOLVED, PLEASE VISIT: HEALTHEQUITY.LACOUNTY.GOV Dr. Barbara Ferrer works to further the Los Angeles County Health Agency's mission to integrate services and activities that enable the Health Agency to build health equity across the county. The Department of Public Health is one of three agencies that make up the Health Agency. Prior to her appointment, Dr. Ferrer was the chief strategy officer for the W.K. Kellogg Foundation, where she oversaw key program areas, including food, health, and well-being. She was also the executive director of Boston's public health department and headmaster at a district high school in Boston.