MaryAnn Black Symposium Centers Health Equity in 2nd Annual Community Event

Ms. Black passed away from cancer on March 25, 2020, at the age of 76. Strengthening the delivery of healthcare to underserved populations was an emphasis throughout her career and she will always be remembered for her commitment to serving others.

It was in that spirit that civic, community, and academic leaders and stakeholders plus a distinguished guest speaker — everyone committed to the pursuit of health equity — came together to honor Ms. Black's legacy. There were bold speeches, provocative discussions, and a diverse array of poster presentations naming county, state, and national public health challenges and envisioning a path forward, and reflections from Ms. Black's family.

Welcome Remarks by Michael Kastan, MD, PhD, Executive Director of DCI

"I'm Michael Kastan and I have the distinct privilege of serving as the executive director of the Duke Cancer Institute. The DCI is really thrilled to welcome you to the 2024 MaryAnn Black Distinguished Health Equity Symposium. You will hear much more about Mary and her extraordinary contributions to Duke and the local community.

I wanted to start by acknowledging her leadership and her service as a role model to all of us in helping us to understand the importance of connecting to the community as a critical component of providing optimal care to our patient population, both in health and disease through education, prevention, treatment, and holistic support of our patient population and their families. 

For those of us in the cancer world, connection to community is absolutely essential. It starts with the fact that there's nothing more scary than hearing the words ‘You have cancer.’ Those words change your life on the spot, and importantly, they also change the lives of your family and friends. If we're going to help cancer patients and their families navigate the tough road that’s ahead of them, there needs to be a bond of trust and that bond does not form on the spot. We can be so much more effective if that bond already exists. So, we need to be out in the community in real time, educating about cancer risk to reduce cancer incidence, educating about cancer symptoms to facilitate early diagnosis, and educating about our approaches to supportive care to help quell the fears that come along with a cancer diagnosis.

I'm so proud that the DCI has long recognized the importance of these connections. In fact, we created the DCI Office of Health Equity back in 2012. It started under the leadership of Dr. Nadine Barrett, who many of you know, and it focused on making connections to faith-based and other community groups on regular basis. Many of you in this room have been our partners in making those connections and we are so grateful to you. Thank you.Community outreach efforts have continued to grow over the past decade. I'm so grateful for the continued leadership of Dr. Angelo Moore, the director of our DCI Office of Health Equity, and the extraordinary Dr. Tomi Akinyemiju, who leads the overall DCI Community Outreach, Engagement, and Equity program. 

We could not do this without the active engagement of our community leaders and I want to do a special shout out again to all of you here tonight, this afternoon, for all that you do to support our community and help the DCI provide better care and support. And of course MaryAnn was our staunch partner in all of these efforts. This symposium is an acknowledgement of her impact and passion. So thank you, MaryAnn, for leading the way. Please enjoy the program and continue to help us in our calls to serve our community. Thank you."

Opening Remarks by Dean Mary Klotman, MD, Executive Vice President for Health Affairs, Duke University; Dean, Duke University School of Medicine; Chief Academic Officer, Duke Health

SOME EXCERPTS:

"I returned to Duke in 2010 as Chair of the Department of Medicine, and in that role, I got to sit in at a lot of leadership meetings. MaryAnn was a force, but she wasn't a force that had to be the loudest person in the room. She was a force because she understood how everything connected how are work within Duke connected to the community and how she could tap into that magic that really made things happen. And she knew how to make things happen. And I learned from her. As I said, it's not always being the loudest in the room, but it's really having a deep understanding of what the challenges are, what the resources are, who controls those resources, and how to bring it all together. So, I felt very fortunate to have worked with her until 2017, when she went on to the North Carolina House of Representatives. She did understand deeply the role of the institution like Duke in the community and really worked very hard to nurture that partnership. And I want to talk a little bit more about that partnership today.

Her ability to find common ground and build deep connections with people through empathy, humility, made her an incredibly effective leader. Her legacy lives on in the thousands of lives she touched and the lasting impact of so many of the bold ideas she put into action. These include the City of Medicine Academy, the Healthy Durham Coalition and so many more. This event offers a wonderful opportunity to honor MaryAnn’s work and to take note of how so many people at Duke and beyond are following her legacy.

It's especially exciting to see how this event has grown in just one year since the Community Outreach Engagement and Equity program launched the distinguished lecture last year. It’s gone to a full symposium with a poster session, keynote address, panel discussions, and more. Clearly Duke and the community were ready and eager for this. It's my sincere hope that each of us make the most of today's rich learning experience and rededicate ourselves to finding new and effective ways to address persistent barriers to health access and health equity.

And just a little bit about the role of an academic health system in that regard...Our core missions are research, education, patient care, and community partnership. And I'm very proud that that is a core mission of the School of Medicine. So those missions don't work in isolation. Each one builds off of the other. We observe in patient care, areas that we need more research. We make discovery and research that impacts patient care. Our learners are in that environment. They learn not only how to deliver care, but how to do research.

And the other mission — community partnership — is underneath all of that. Because that's really what not only informs us in our work, but that's where we see the greatest impact — on our community. So, it is a virtuous cycle. But what I think is really important about today is that embedded in all those missions, as part of that virtuous cycle, is the focus on health equity. And I'm very proud of the fact that we have intentionally built that focus in all of our missions; whether it's looking at how we teach and what we teach our learners, to teaching our research workforce how to understand concepts of equity when we're working in the community, and frankly, a primary focus of our research mission.

It's no accident that the office that we stood up in 2020 is called the Office of Equity, Diversity and Inclusion, starting with the concept of equity. It's because equity is at the core of everything that we do. As Kevin Thomas, my first vice dean in the EDI office puts it, 'Equity is a necessary condition that makes possible all our other values — diversity, inclusion, belonging, and respect.'

In healthcare, the pandemic highlighted some of the really glaring inequities within our own community. As many of you know, mortality, morbidity — especially early on in Covid — was much higher in our non-white communities. At one point in the pandemic in Durham, where the Latino population is almost 14%, almost 80% of the Covid cases and a disproportionate percentage of Covid mortality was also in the Latino community. We learned a lot during that crisis, but we don't want to wait for another crisis before we have another learning opportunity.

I think coming out of the Covid we have really focused very intentionally on effective partnerships, on true partnerships, around all of our missions. And I won’t catalogue them, they're quite overwhelming … but they're in every aspect of what we do. And for me, it is the right way forward that MaryAnn knew we needed to go many, many, years ago. So, our commitment to reduce disparities and enhance health equity through research, education, patient care and community partnerships is steadfast and ongoing. Our goal is to ensure that every individual, regardless of background or circumstances, has the opportunity to lead a healthy and fulfilling life. I'd like to think that MaryAnn Black would be proud of the direction, not the end of what we're doing. I encourage you to join us in building a healthier, more equitable community and world.”

(Watch her full address)

Keynote by Mary Bassett, MD, MPH, director of the François- Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Harvard University

Tomi Akinyemiju, PhD, associate director of DCI's COEE program and professor of Population Health Sciences, introduced the keynote speaker Mary Bassett, MD, MPH, noting that in Bassett's previous role as Health Commissioner, New York City Department of Health and Mental Hygiene, "she made racial equity a top priority and worked to address the structural racism at the root of the city's persistent gaps in health outcomes between white New Yorkers and communities of color."

"I have cited Dr. Bassett's scholarship, including a quote that was in The Washington Post, where she said, and this was during the Covid pandemic, 'there has never been a time, not a single year, where the U.S. population of African descent hasn't been sicker or died younger than the White (population).' That sentence always stuck with me and this just is a powerful reminder that health equity is also a human rights issue. There's still a lot of work that we need to do," continued Akinyemiju. "We have a legend and we have a formidable mentor in MaryAnn that kind of set the stage and the direction for guiding our work going forward, but it really takes all of us continuously paying attention to to the issues of health equity across all of our work and continuing to have an impact in the communities that we serve."

Akinyemiju went on to cite Bassett's work in medicine, academia, government, and nonprofits as "profoundly impactful" and exemplary of "the extraordinary legacy of MaryAnn Black."

Bassett's keynote — "An Unbroken Thread: The Pursuit of Health Equity" — reviewed the impact of racism and the civil rights movement on public health and envisioned a path forward. Bassett, a professor of the practice of Health and Human Rights, drew on her academic career as well as her tenure as New York State Health Commissioner (2021-22).

SOME EXCERPTS

President Lyndon Baines Johnson’s 1965 Howard University commencement address ‘To Fulfill These Rights’

“I thought I would take some time with you to share LBJ’s words from the vantage point of our present day. He talked about how the winds have changed from the Civil Rights Movement. He talked about the way in which the courts, the legislature, he as president, and the people of the United States had come through on the side of justice and progress. And he went on to talk about how fairness demanded an acknowledgment of the burden of centuries of oppression. He couldn't read the future but he mentioned how the ability to realize an opportunity — not just to have it but to realize it — would be the most profound stage of the battle for civil rights. And today it's very clear that his words were prescient. He was right that realizing rights remains the most profound battle that still confronts us. And he ended with these words that when we look at them now seem so radical and so relevant today and so in keeping with public health.

Well, he had a little gender bias, I have to acknowledge that so let me read these (words) to you. He said, ‘To this end equal opportunity is essential but not enough, not enough. Men and women of all races are born with the same range of abilities. But ability is not just the product of birth. Ability is stretched or stunted by the family that you live with, and the neighborhood you live in — by the school you go to and the poverty or the richness of your surroundings. It is the product of a hundred unseen forces playing upon the little infant, the child, and finally the man.’

I don't know how many of you have seen those words before, but this was 1965 so we're talking about 60 years ago. Now, what I did next was take a look at how some of these words show up in the public health literature.”

Equality vs. Equity

“Equality has long been an interest in the biomedical literature. Using this keyword (equality) in a public access database, there aare literally millions of articles related to the health sciences, and more recently we talk not about equality but about health equity…

In 2020, you just see an absolute surge in the number of citations that use the word health equity. 11,000 is not that many but you'll agree that it has a marked upward turn. Next, we can look at health disparity which has about the same number of citations and we can move on to health inequities which we're all committed to reducing, and you can see, similarly, that beginning around 2020 there was a huge increase.”

Covid 19

“Covid uncovered so many enduring inequities but the data also shows that it doesn't have to be this way … Commemorating MaryAnn Black is committing ourselves to turning things around…It was only two months into the pandemic when it was already clear that there was going to be an enormously disparate impact on hospitalizations and mortality by race, ethnicity. Almost immediately we saw first Blacks, and then Latin X, and then indigenous peoples, much more likely to be in the hospital then die, and these disparities were especially marked among young people. Most people who died of Covid were 34 years old. Gaps in terms of the relative risk were so much higher for young people — reaching a five to sevenfold higher risk of death for people in their 30s and 40s if you were Black or Latino and particularly if you were indigenous …

You can see the very dramatic effect of Covid on life expectancy. The gains in narrowing the Black/White gap in life expectancy were lost. It went from four years back up to six years. And for American Indian and Alaskan natives life expectancy fell to 65 years — matched only in our part of the world by the impoverished nation of Haiti.”

Disparities, Health Outcomes, and Politics

“A second thing that happened in 2020 was the very public murder of George Floyd in May 2020. People of all races all over the world reacted with horror to the video documentation of his life being casually snuffed out. Literally millions of people took to the streets in the midst of a pandemic under the slogan Black Lives Matter. The New York Times reported that somewhere between 15 and 26 million people in the United States participated in these demonstrations and these occurred around the world on every continent… There were demonstrations and they took place in at least 40 countries.

…This is just one data point…but I'm worried…They all suggest that the door opened by George Floyd's murder may now be closing, which is what a colleague of mine remarked to me…

It began with the attacks on critical race theory, with book banning, and as you all know in June of 2023 the Supreme Court decided against Harvard University and UNC and effectively overturned affirmative action. And since then, there have been various pushbacks against race related initiatives, including actually some involving this state. There has been a decision I believe, in either eight or nine states to close publicly funded university DEI offices…That's the political context in which public health occurs…

MaryAnn Black knew politics played a part, but the other thing to know here is that cancer disparities or any number of disparities and health outcomes don't disappear at the same rate at which political commitment to attacking them can vanish.

These are data on prostate cancer overall. I expect that an audience gathered by the Cancer Center would know this, but overall Black people have the highest cancer incidence and mortality compared to other groups… This was true when I was a medical student and I think that you can look at it and say despite all of our efforts it's still true…

White women are much more likely to have a diagnosis of breast cancer, but Black women are much more likely to die of breast cancer. This racial gap is consistent and is often interpreted as meaning that there must be something different about the cancers Black women get or the way Black women's bodies respond to these cancers, but I was looking at some data from England and Wales… There, white women are more likely to die than their non-white sisters and their mortality rate is higher — including higher than people classified as black Caribbean or Black African. The mortality rate for white women from breast cancer in the UK is higher than it is for white women in the United States.

I know that Dr. Tomi (Akinyemiju) does a lot of work on looking at the variations in the genomics of breast cancers. This is very important work. I'm not trying to denigrate that work, but when we talk about such variations, we have to look at context — how do we explain this — and that includes access to diagnosis and treatment.”

Bias

“So, there was a very iconic report released now 20 years ago by The Institute of Medicine and it showed that at every step of care seeking, there were disparities in the response for Black patients as compared to White patients, from beginning with the seriousness with which a presenting complaint may be taken by the healthcare worker, to the types of diagnostic tests that are offered, to the types of treatment interventions that are offered. And they showed also that there were these big differences in clinical outcomes that, arguably, logic would say, these are probably related. This bias, we know, continues to this day. It was just in the past couple weeks that we saw new reports that even complaints of pain by children are under acknowledged and undertreated when that child is Black.

Many of you may be aware of a new book by Uché Blackstock (an American emergency physician and former associate professor of Emergency Medicine at the New York University School of Medicine) … who spent a lot of time talking about her encounters with the healthcare delivery system and being dismissed. Now a lot of this is attributed to bias in doctors — doctors who don't listen, don't see, don't hear, don't act, and make decisions about their patients that are been tainted by stereotypes about the patients in front of them. All of this is true and some of it may be addressed by some of the interventions that I've heard mentioned already this evening— cultural humility, thinking about structural competence trainings… There are many programs that have embedded this type of training in their clinical training programs and in their medical schools.”

Unequal Facilities

"I want to talk about another problem and that's unequal facilities… I trained at Harlem Hospital, a hospital which at the time didn't have a CT scanner and so we had to negotiate to get our patients — often very sick patients — transferred to another hospital in order to get them the diagnostic evaluation that we felt they needed. So, it didn't matter how good a doctor I was because that test was one that was going to be really difficult for me to arrange. And we lost patients. In fact, we kept track of it and one of our attendings wrote it up and published it in the New England Journal of Medicine. The hospital has a CT scanner now but at the time I trained we didn't...

On the lefthand side of the slide is Mass General, a nationally even internationally respected hospital, which has a $400 million building and about 5% of its inpatients are Black. And there is the Carney Hospital located just nine miles away and just under half of their inpatients are Black. Now, you can just look at the pictures and think maybe there's some difference in these facilities and you would be right. We still have a very racially partitioned healthcare system. I want to make clear I'm talking about national data here. And I'm looking at a table of people who have worked to make Duke a very equitable and community facing place. Much of that work was done alongside MaryAnn Black, but nationally we still have de facto segregation of our hospital system — about 5% of U.S. hospitals care for 44% of Black patients and about three-quarters of Black infants are born in one-quarter of U.S. hospitals…

There are just over 5,000 hospitals in the United States… but of them 574 are Black serving and they're much more likely to look after Black patients…They also struggle with funding. They have reimbursement levels that are lower for Black serving hospitals… than they are for hospitals that serve other groups. And the researchers who published this finding worked hard to try and unravel what the source is. Most people would say they're looking after all poor people, that Medicaid reimbursement rates are too low, and that they have too many uninsured patients for whom they don't get paid. But in their analysis, they concluded that only about a third of the revenue difference between Black serving hospitals and others could be accounted for by the payer mix. And they concluded that by equalizing the reimbursement levels, which are negotiated by hospitals with private insurers, they would have boosted the reimbursement to Black serving hospitals by about $14 billion in 2018 — amounting to about $26 million per Black serving hospital.

So, my point here is to walk you into an idea that we have more than a problem of personal prejudice that may exist within individual providers. We have unequal hospitals that are an unequal in part because they're unequally resourced…

(showing charts) A Black and Latin X serving hospital has a 30% lower chance of having an MRI. They have a 42% lower chance of having cardiac catheterization available. So that means these hospitals have to be embedded in a system that allows them to transfer patients in order to get these services or they are not able to offer these services to their patients.

So many complex things drive unequal care. I think many of us who are involved in direct clinical care…think that we should just focus ourselves only on the patient-provider encounter; work to fix ourselves. But often we have to also consider the context in which we're working, our ability to recruit and retain doctors, specialists, nurses, because those also have a bearing on the quality of care.”

Pathways Between Racism and Health

"Researchers actually based here at Duke — Sandy Darity and Kirsten Mullen— published this book in 2020 in which they make a call for reparations. What they're really talking about is tackling the longstanding barrier to wealth accumulation that has affected the Black population and arguably the longer we wait the worse it gets… So let's look at these pathways between racism and health. These are pathways that affect everyone; it doesn't matter what your race classification is. Being poor is hard regardless of how you're classified; having adverse environmental exposures, experiencing psychosocial trauma of violence, abuse; all of these are things that affect everyone who's exposed to adversity. And I'm wondering whether we might be doing better if we start talking about…who's being left out, and think about the ways in which we tackle exclusion, then maybe we could get some more unity around fighting for a better world that makes us all healthier…

LBJ made the case, again in this speech, that the experience of people of African descent in this country has been unmatched, I would say except for the experience of the indigenous (people). There’s a poster out looking at cancer prevention among indigenous people and I learned that the state of North Carolina has a large number of indigenous groups — something that I hadn't known before — although of course my family claims Cherokee ancestry…

I would instead end with what people say to me a lot of the time, that ‘You know you're pulling the race card all the time.’ And what I hope I've convinced you of this evening is that the race card is in the deck… and it's affecting our whole hand now. So we have an obligation to pursue equity as a better pathway to health for everyone.”

Audience Q & A with Dr. Bassett 

Q: The statistics you presented about the life expectancy in the UK is very interesting. We know the NHS is not necessarily the most equitable or easily accessible healthcare system. What do you think is driving their gains as opposed to ours here ?

A: (excerpt) “The one thing that students always ask me when I talk about how we're doing compared to other wealthy countries is point out that most other wealthy countries have a more robust social safety net, and the U.S. notably does not guarantee universal health coverage. We have made a lot of progress uh since the Affordable Care Act, but there's still some 30 million people who are uninsured. That went down during Covid when people didn't have to recertify for Medicaid, but the number of people who are losing Medicaid coverage has been rapidly increasing. We still see racial inequities in countries like the United Kingdom where they have a National Health Service…Doctors are employees of the National Health Service and charged with looking after a geographic area, but they're underfunded. There are long waiting times...

As somebody who's (spent) most of my working life in public health I would just say to you that we need health care. There's no question about that, but it's not all that we need. People need healthy lives. They need access to decent housing; decent jobs where their dignity is maintained with safe neighborhoods. All of us can imagine what it means to have a decent life, but it means many different things. It means having access to affordable decent food. There's a poster presentation out there about making fresh produce available to people. People don't necessarily need to be educated about good food choices; they need to be able to afford them. All of those things have a bearing on whether or not you have good health. And the UK, like the United States, has had really galloping income inequality in the last 40 years.”

"Education is very important. And I will highlight the work of Dr. Moore (director of the DCI Office of Health Equity) and myself. We celebrate 10 years this year of bringing health education resources and services to the community (at the annual Women's Health Awareness Conference in Durham) so that women can learn how to be advocates for their own health...

I think, at the patient level, that physicians should play a major role in helping women and men to understand their health issues and how to build healthier lives.

I think that not enough time is given for people to actually talk and ask questions of their physicians during their appointments. I think we should put a concerted effort (toward) the physicians listening to our issues, our concerns, and helping us to mitigate those issues and concerns, and especially as it relates to cancer care. Because even though we’re getting the treatment, there may be things going on in the home that may cause us to have an adverse outcome to (our) cancer care that physicians may not know because they didn't listen to us. They know about the treatment, but they don't know what's going on with stress and the impact of what's going on in their homes. So I think that it lands on the care team as well. To be able to do that education." — Joan Packenham, PhD, Director, NIEHS Office of Human Research and Community Engagement

Black Maternal Health

"So many folks at Duke University have been so supportive (of my work) around Black maternal health. When I have elected officials (saying), 'Yes we know it's an issue, but can we just focus on maternal health, why do we have to say black?  Eventhough we know that even though we know that Black women are three to four times more likely to die from child birth than white women. The North Carolina Institute of Medicine showed even if you are a Black woman with a PhD, and I know I'm in a room with a lot of educated people, your birthing outcomes are worse than a white woman with a high school diploma. If that doesn't show you that race is playing a huge huge factor in our inability to do better with our healthcare outcomes, I don't know what is." — State Senator Natalie Murdock (NC District 20)

Toxic Waste Sites and Minority Communities 

"From an environmental standpoint it's important that we get out in the community and we help people to understand that where they live,work, and play has a great impact on their lives — their natural environment, the built environment, the social environment, and then occupational...Covid taught us about occupation and occupation as it relates to our health. So, it's important for us to get out there and talk about it so that communities, especially communities of color, where the environmental justice issues sit. Minority communities are more likely to live near toxic waste sites and industrial sites ... and it's due to what Dr. Bassette said today, red lining, socioeconomic status, all of that causes that issue. So it's important for us to help the communities to understand that they need to have an advocacy role and to make this happen. And we as the Federal Government have a role..." — Joan Packenham, PhD, Director, NIEHS Office of Human Research and Community Engagement

"I talked about a a community group in Alamance County that took that advocacy role. There's a Tar Heel Army Missile Plant in Alamance County. The surface was the Western Electric Plant, but beneath the surface two to three stories below, was the Army Missile Plant. They made missiles for the Army during World War I and World War II. And the Army left contamination there that is now leeching into the soil and getting into the aquifer. So that community came to us and IEHS and said 'What can you all do for us to try to help us?' The building and site has been abandoned for 30 some years. And that's the thing with minority communities as well... I don't know what the word or the term is but we go by these sites every day and because we think we have no power we say nothing instead of trying to figure out 'I wonder why that building has been abandoned for 30 years.' So, they came to us to said, 'What can you do?' So, what we did was we just had this big meeting where we had an all- government approach from the Federal Government to the State Government to the City and County government to sit down at the table and say, 'How do we mitigate this problem?' Because there is an 11-year lifespan difference between the minority community that lives on the side of town with that plant than the other side of town and it has been ignored since 1988. That's when the plant closed, in 1988. It's been sitting there abandoned and nothing had been done. So that's what we have to do. We have to empower the community to be advocates so that then they can empower us to do what we need to do — to be the voices so that we do what we're supposed to do. Their taxpayer dollars are going towards it. — Joan Packenham, PhD, Director, NIEHS Office of Human Research and Community Engagement

Audience Q & A with the Panelists