Q: February 6 marked your one-year anniversary as the Director of the Los Angeles County Department of Public Health. This also means one year living in Los Angeles.  What is your impression of LA?

A:  I love it! I was born and raised in Puerto Rico, but I’ve been in the States since college. I lived in Boston  for over 20 years and then I lived in Michigan for a few years. I didn’t realize until I came to Los Angeles how much I missed being somewhere where so many people speak Spanish. The diversity of Los Angeles is amazing and striking. And of course, I love the weather!

One of your first major moves as the Public Health Director was to create a Center for Health Equity.  Why the focus on health equity?

I think that health equity is the most important issue for public health.  It is intolerable to think that here in LA, right now, black babies are dying at more than three times the rate of white babies and that the rate of death for black babies now is higher than what it was 20 years ago for white babies. We need to make sure that at the very beginning of life, every baby has an equal chance of survival and that their survival is not correlated with the color of their skin. I just don’t know how you don’t say, “We have to fix this!”

In Boston, where you were a public health leader for many years, the black infant mortality rate decreased by 44%. What do you think was key to that success?

There is no silver bullet. There is no one thing that can fix such a complex set of issues. In Boston, it took us many years to see those decreases, and unfortunately a significant gap remains in black infant death rates compared with all other infants. Therefore, Boston, like so many communities across the country, continues to have important work to do.

One thing I believe was important to our work in Boston was acknowledging the impact of racism both in terms of distribution of resources and opportunities, as well as the impact of chronic stress on black mothers. There is now 20 years of research and evidence that shows the pathway of chronic stress associated with racism and particularly its impact on infant mortality.

What I learned from so many others was the importance of not only talking about the role of racism on infant mortality, but trying to figure out steps to dismantle racism that could help reduce both the chronic stress on mothers and the unequitable distribution of resources.

Being data driven is also important. Across the country it is clear that this gap between black babies and white babies is not really about levels of education or income. The data shows that the infants of black women who are well educated or have a modest/high income do far worse than the infants of white women who haven’t graduated from high school or who are very poor. The data allow us to understand, that although education, income, and behavior contribute to our health status, they do not explain the gaps that we see in infant mortality rates. We need to capture the stories and lived experiences of black mothers to understand the impact of racism and then use this information to stop the false narratives that blame black people for their poor health outcomes.

In Boston, it took a lot for us to understand how important it was to change our strategies from fixing people to fixing systems, and to try, and try and fail, and try and succeed. In LA, we can’t be afraid of taking risks, because what we are doing now is clearly not working to narrow the gap in infant deaths. If we were to eliminate our gap between death rates of black and white babies, somewhere around 60 to 70 more black babies would live every year. We have to do things differently.

How is health equity different from health equality?

Image: Interaction Institute for Social Change Artist: Angus Maguire.

The health equality approach is to “do for all and all will be lifted” but in health equity it is, “do the most for those that are in need and all will be lifted.” It’s like that analogy of three people of different heights trying to watch a ball game over a tall fence. If you give them all the same size stool, only the tallest person can see over the fence. The equal sized stool is not enough to help the other two people see the game.

We need to start by recognizing that an equitable, as opposed to equal, distribution of resources is needed to achieve good health for all. We should acknowledge that communities of color and marginalized communities need more resources to make up for chronic under-investment and then shift our resources appropriately. 

What are your plans for the Center for Health Equity?

I feel very blessed to have an amazing team leading this work at the department and we are all clear that we need to embrace a set of principles to guide our health equity work.

We need transparency around the data. Let’s make sure the information that we are collecting, presenting, and using represents the complexity of the lives that people live and tells their authentic stories. It is a two-way street. We have some data, others have different information, so let’s put it together to explain what we are noticing.

We need to elevate the voices and experiences of the people we serve. We need to figure out how to defer to and embrace community leadership. People have the inherent capacity to understand themselves, their circumstances, and the solutions to address their challenges.

Finally, our Health Agency staff need to have the skills to do this health equity work.

With these underlying values in place, we have identified an initial set of five compelling issues to address.

Infant Mortality is one of the five issues prioritized by the Center for Health Equity. Would you briefly discuss the other initial four health equity focus areas?

Yes. They are reducing inequities in STIs [sexually transmitted infections], reducing disproportionate exposures to hazardous materials in low-income communities and communities of color, building neighborhood coalitions to guarantee the well-being of residents with complex health needs, and ensuring cultural humility and linguistic competency across all Health Agency staff.

STI rates in LA County have increased dramatically in recent years with a disproportionate number of cases among men of color, LGBTQ [lesbian, gay, bisexual, transgender, queer/questioning] persons, and African-American women. We need to narrow these gaps with novel coordinated action.

Regarding environmental justice, we need to address the disproportionate burden of environmental health hazards that are located and experienced in low-income communities, which are also predominately communities of color.

We intend to support and expand Health Neighborhoods to improve the care of residents with complex health issues. The Health Neighborhoods initiative, led by the Department of Mental Health, links population-based approaches with comprehensive service delivery models. There are already 13 Health Neighborhood coalitions that all work on different parts of the puzzle of complex health needs. We would like to see coalitions expanded and supported across the county.

Finally, to do this work, we all need to build our skills around respecting and honoring diversity. Our fifth focus area is an internal initiative to train all 35,000 Health Agency staff around cultural humility and linguistic competency. 

What do you see as the role of primary care to further advance health equity?

I think that one of the most important strategies available for primary care providers right now, if they are not already doing this, is to figure out ways to allow their patients to have more of a voice.  I am talking about creating a platform for patients to provide their feedback about the quality and effectiveness of the services that they are offered. Individual providers can advocate for this as well, such as by asking at team meetings, “what’s our way of really involving patients?”

Secondly, I think that primary care needs to make appropriate referrals to a host of non-clinical services. This may not specifically be the job of the clinician, but it needs to be the job of the practice to make sure that somebody is connecting patients with resources that are going to dramatically influence their patients’ well-being.

For instance, let’s say the clinician prescribes a medication that requires refrigeration, but the patient lives in a house where the electricity has been turned off. There should be someone in the practice that checks in with patients to make sure that the clinician’s expectations are realistic for the patient.

Drilling down, what do you recommend individual providers do to advance health equity?

I think cultural humility is critically important. This may mean embarking on a new learning journey, since many practitioners may not have been offered training in this area. Perhaps clinicians can work together to deepen their understanding of the cultural background that represents the diversity of the patients they are treating.  This information can then be used to align practices to ensure that both employees and patients feel honored, respected, and heard.

Finally, I encourage providers to get involved in and support system, policy, and practice change that acknowledges the importance of addressing issues of implicit bias and discrimination, promotes healthy communities, and advocates for aligning resources with those in most need.

What are Public Health’s next steps?

We have been doing listening sessions across the County for the last few months and have been collecting unbelievably powerful information and wise counsel from the community residents and community-based organizations. We will use this information to support the community efforts to build equity, as well as to think about what our work is internally.

Public Health is also forming internal and broader external working groups around narrowing the health gap related to infant mortality and around STI inequities. We want health care providers, along with residents, to have an opportunity to influence the work and provide guidance on what makes sense. We appreciate the importance of working closely with the clinical community to make sure that our collective efforts resonate and can be supported by clinicians practicing across the county.

Dr. Ferrer, thank you for this interview.