- It's now my distinct honor to introduce
a public health leader who is having
an incredible impact in
Los Angeles and beyond,
the 2019 Lester Breslow
Distinguished Lecturer,
Dr. Barbara Ferrer.
(applause)
- Thank you so much, Dean.
Good evening, and thank you so much, Dean,
for the wonderful opportunity to be here.
I'm so honored and also
wanna thank Deborah
for allowing me to be
part of this legacy work.
It's always wonderful when you get to meet
a family member of somebody who
you've held in such high
esteem for most of my career.
And you know, that's really
where Dr. Breslow sits
for so many of us who are
in the older generation
of public health practitioners.
You know, he was a champion for the notion
that what we're really about is health.
It's not about healthcare.
And healthcare is an important component,
but I really think he paved the way
for understanding our work is
to ensure that everyone has access
to optimal health and
well-being so I wanna thank you
for the honor of being here.
And I also wanna acknowledge
and thank Dr. Carlisle.
He was the honoree last year,
and I think the world of
him and all of the folks
at CDU as well for joining
in this amazing place
of LA county that's really
putting front and center,
I think, some of the new practices
for public health as we
move into the next decade.
So, really honored to be
here with all of you as well.
James, Lamar, and Yelba, it's so exciting
to see sort of our next generation
of public health leaders
who are championing
issues around health justice.
Because that is the work
I think that paves the way
for us to create the kind
of world we wanna see,
the kind of world we wanna also
contribute to and be in service of.
I obviously owe a debt
of gratitude to Jonathan.
I actually wouldn't even be
here today without his support,
not just as sort of a
mentor for many, many years,
but also in making it
possible for me to consider
being part of the great county family,
and I wanna acknowledge
that I'm joined here
by Dr. Davis, our wonderful
county health officer,
and Lauren Dunning, our board liaison,
part of the wonderful county family
that supports the work we're doing.
I am gonna take a little bit of time today
to talk about really three sort of themes
that I wanna weave together.
And I wanna start with really
what does LA county look like?
And then what do we know
about health equities,
and I wanna really talk a little bit
about two examples, issues
related to infant mortality
and issues related to
differential exposures
to environmental hazards,
and then I'm hoping
I close with an introduction
of a possible framework
for us to move work forward.
So LA County, we're big.
You know, those of you who live here know
and have lived here for a long time
know we're about 4,000 square miles.
We have about 10 million residents.
We're made up of 88 cities.
These are what we call incorporated,
and another 104 unincorporated areas.
And one out of ever four
people from California
actually lives in our county.
We're also predominantly a
county of people of color.
Almost 50% of the folks
who live here are Latinos,
and then our white residents make up
only about a quarter of the folks here
so this sort of the land
where diversity becomes our strength,
where our cultural and
linguistic intersections
actually are woven into the fabric
of everything we do and
how we see ourselves.
And it has, though,
however, its implications
for health status.
So when I first came here and
I was looking at the data,
you'll notice, LA County,
our life expectancy here
is actually higher than
the national average
by about three years.
The problem is that it is hiding
some stark disparities or inequities,
where we literally have some folks
living ten years more than black
or African-American
residents in this county.
And you can also see life
expectancy not only varies
by race and ethnicity, but
also by where you're living.
And, again, a pretty
implicit connection there
between where you live
and your race and ethnicity.
Those folks that are living
in our poorer communities
and our communities of
color live on average
as much as 10 years less than those folks
that are living in what I call
some of our beach communities
and some communities
right around this campus.
And it starts at birth, where
black babies in LA County
are somewhere between three
and four times more likely
to die in the first year of life.
And you'll also see
this at the end of life
when our black residents are
significantly more likely
to die at a earlier age than others
and at a higher rate of mortality.
This is pretty much the
picture for African-Americans,
black residents in LA County
for just about every measure of health
that we routinely collect in terms
of both mortality and morbidity
with the exception of COPD.
I've put some measures up here,
and you can see that the picture is one
of stark, inequitable outcomes in terms
of people's health status.
So I'm gonna give you all a couple minutes
to just either turn to
the person next to you
or if you're not a person
who wants to socialize,
just sit and think yourself
but I'd like everyone to spend a minute
and say I see this, I've
either learned about it
or I understand it from
my lived experience.
What do I think explains it?
So I want everyone, feel
free, love for you to share.
If you're not in the mood
to share think on your own,
but we're just gonna do
this for about a minute
so that people can sort
of think what accounts
for this level of inequity?
(chatter)
I know there's a lot
of wisdom in this room
and I'm sure as I go
through my presentation
there are definitely parts of it
that are gonna resonate
with your conversations
and if you had had more
time you might've actually
talked about just about
everything I'm gonna mention
but I'm gonna try to organize it
in a way that allows us
to be very deliberate
about developing our understanding
of what are the factors
that we think contribute
to the inequity so that
we can be very deliberate
about the practices and
policies we put in place
to address the inequitable
distribution of poor health.
One thing I wanted to just start with
is this notion that although healthcare
is a really important
component of our well-being,
50% of our well-being is not tied
to the healthcare system at all.
It's actually tied to
environmental, social conditions,
the context and the constructs
that hold together our communities,
and to what I call the built environment.
And just about everybody here I think
has a really deep understanding
of what we now call
the social determinants of health
and the important role
that these factors play
in helping us understand what people need
in order to be healthy and in order
to live their lives to
their fullest ability.
And many of the things
that are on this list
I know are not new to folks.
We've talked a lot about
economic stability,
about the importance of education,
health and healthcare still very important
to all of us, what we
have in our neighborhood.
This isn't just our exposures to what
we traditionally call
environmental hazards,
but what's our exposure
to tobacco advertising?
What's our exposure to the sell of alcohol
and now cannabis in our neighborhoods?
And then the social sort of constructs.
Social cohesion is a term you often
hear people talk about, civic engagement.
How much are we encouraged/allowed
to work together,
join together to really
create those communities
where we and our families will thrive.
You'll see I've put in
issues around incarceration
because there are forces that both
promote social cohesion
and then there are forces
that actually work
against social cohesion.
And I wanted to tie this together,
oh, let me just go back for a second.
And I wanted to note that, for us at the
Public Health Department,
we're very focused
on the work and the world of understanding
social determinants of
health, but we've also
done this understanding the context
of racism and discrimination.
And really calling those
out, not as one of,
a variable that we need
to pay attention to
under one of our columns
here, but rather as
an overarching theme and
force that really helps
determine our ability to access
the resources that we need
for optimal health and well-being.
Racism has an independent impact on
our health and well-being,
which we'll talk about in a minute,
but it also has an impact on our ability
to really live with economic stability.
There's rampant discrimination
in the workplace.
There's discrimination
in how and what resources
are available to promote
good educational systems.
The way we fund education
is in and of itself a system
that actually penalizes those folks
with the least amount of resources
from having good schools
in their neighborhoods.
And we could go on and on
and talk for a long time
about why we claim that for pretty much
every social determinant
that you see in the column,
you can talk about an independent impact
that racism will actually have
on your ability to actually
have the kinds of resources
that we know are so important
for health and well-being.
And I wanted to say the
reason it's so important
for us to think about this is that
study after study after study
now shows the real connection
between the access to those resources
and health and well-being.
So, for example, the
Department of Public Health
did a study in 2016 around parks.
And what it noted in the study
was two very important
factors for LA County.
One is that the distribution of parks
and green space was very different.
And then, in fact, black
and Latino residents
had much less access to
parks and green space
than other residents in LA County.
And then it also went on and noted
that the higher rates of
obesity and chronic illness
that are experienced by black and brown
residents in LA County can, in fact,
be tied directly to a disinvestment
in parks and green space
in their communities.
And it's this kind of sort
of tying together the dots
that becomes, I think, critically
important for our work.
And then also allows
us to really understand
why we talk about health
equity and not equality.
I think this is a great illustration.
It's not mine, but we like to use it.
Equality is when you
give everybody the same
because you know it will be helpful
so we had a problem,
people needed to be able
to get around and we
went and bought 100 bikes
and they're all exactly the same bike
and then we distributed them.
And lo and behold, it's not,
in fact, helpful to everybody.
Some people couldn't use that bike at all
and other people were really struggling
with that resource.
When equity really means
that you really figure out
what it is that people
need in order for them
to have those kinds of
opportunities and resources
that lead to optimal health and well-being
and it acknowledges that it's
not a level playing field.
And that, in fact, if you're gonna do work
around equity you're
gonna understand deeply
that we have disinvested in so
many ways in our communities,
disproportionately in those communities
that are black, Latino, Asian, and uh,
continued to sort of look at patterns
of othering folks when we think about
what that distribution of
resources should look like.
Which means that, for
our work, we'd have to
actually acknowledge the disinvestment
and the discrimination and then figure out
what were the resources and opportunities
that everyone would need for
optimal health and well-being.
And I wanna use a couple of examples
to illustrate not only what
I think may help account for
and explain some of the inequities,
but also try to identify
a pathway forward.
Because again, this work
is gonna be difficult
and complicated and it's
not necessarily easy
to think about how to work on issues
that are complicated and complex.
I wanna start with infant mortality
because we talked a minute ago about
sort of the stark differences
in infant mortality rates
here in LA County.
And I wanna note that
this has been historic
so you can go back 25, 30 years
and you'll continue to
see this very wide gap.
As a matter of fact, the
rate of black infant deaths
in LA County today is higher than it was
for white babies 25 years ago.
And that it's primarily due
to the inequities that we see
in pre-term and low birth weight babies.
So black babies are much more likely
to be born early and at a low birth weight
than all other babies.
And being born very early and
at a very low birth weight
puts you at much greater risk
for both poor health outcomes but also
for dying in your first year of life.
And one thing that folks do
is when we think about this,
there are some folks who might say
well, maybe this is just genetics.
And some folks have even actually
talked about a black gene.
We know that's not factually possible,
but we also can just look at the fact
that here in LA County if
you're actually US born,
you have a much greater chance of having
a poor birth outcome than
if you're born in Africa
or in the Caribbean, the two countries
where most other black Africans come from
who are in LA County and give birth.
Foreign born Africans actually have better
birth outcomes in LA County
than African-Americans.
And it's not really necessarily
associated with education.
Education is important.
You can see here that obviously having
more education offers some protection,
but what it doesn't do is explain the gap.
So black women who are highly educated
actually have worse birth outcomes
than white women who haven't
even graduated from high school
and this isn't data just for LA County.
This is actually data across the country.
And we don't have a good
measure here in LA County
for income, but if we
used insurance as a proxy,
by looking at folks who
were insured publicly
versus folks who are insured privately,
we would still see that black women
who had private insurance,
which really stands usually
for being in the workforce
and having an income,
did worse than white women who were
receiving public insurance,
which usually means
they're at much lower
income levels than those
who are getting private insurance.
It's an imperfect measure,
but if you look at data
across the country, where
we actually use markers
for income, you will
see the same gradient.
And it's also not necessarily about
how black women are behaving.
Black women who enter
into prenatal care early
and stay in prenatal care
consistently still are
one and half times more
likely than white women
who don't get into prenatal care at all
or get in very late in
their third trimester
to have birth outcomes.
And smoking, smoking highly correlated
with poor birth outcomes, but black women
who don't smoke at all have worse outcomes
than white women who smoke everyday
during their pregnancy.
It's also interesting to note that
if you are a black woman and you do smoke,
your risk is much higher than
if you're a white woman who smokes.
And again, there is something going on
that we need to understand that's beyond
what our usual ideas are about
what are the factors that contribute.
It's not like these aren't important.
It's not like it's not important
to get into prenatal
care early or not smoke,
take care of yourself,
stay connected to services,
be able to get a good education,
but it doesn't explain the gap.
And research starting,
actually, with Dr. Michael Lu,
who is from UCLA, did
his first research here
about 20 years ago.
Folks have been actually looking at
what is the explanation?
And it turns out that
there's a lot of evidence
that indicates that chronic,
what we call toxic stress,
can, in fact, contribute to
very poor health outcomes,
particularly around birth outcomes,
and that you could think about
racism as a chronic stressor.
And if you thought about
racism as a chronic stressor,
it may help you understand
sort of the toxic impact
it has on childbirth.
So, you know, you think about our bodies
are really well-primed to handle stress.
If we saw a lion run across the room
our bodies would immediately
have a biological response
that would allow us to run much
faster than we normally run.
Certain functions would actually shut down
and other functions would really increase.
One thing that would happen is cortisol
would really increase, and that's good
because we ran fast and
we got away from the lion.
The problem is when the lion
is chasing you everyday.
When you have stress every single day
it actually turns out
you don't ever return
to a normal level of, in this
case, of hormonal response.
And, in fact, what happens
is, you're now not stressed.
You're stressed out.
And being stressed out just, you know,
simply so that, because we're
not gonna have a lot of time,
being stressed out actually
wears down body parts.
And it's that wearing down of body parts
that now there's ample evidence,
contributes to inequities that we see
in our health outcomes.
And that, in fact, for people of color,
particularly for black
people in this country,
this is intergenerational
at this point as well.
And so it's not just the
onslaught you're facing.
It's actually the historical legacy
of the onslaughts that
generations of folks
have faced as well.
So we do have a community action plan
for trying to address the
complexities that we think
contribute to this inequity
and birth outcomes.
We've pledged in five years
to actually reduce this gap
by 30% and we're focused
in a whole host of areas
that I think traditionally
public health departments
have not organized
their work to attend to.
And we've done this by
really understanding
that this inequity in birth outcomes
is not an individual failing.
It's actually a social problem.
And for people of color, for women,
particularly black women,
they have spent a lifetime
thinking that they have
done something wrong
that's resulted in their
baby being born early
or their baby dying in
that first year of life
because we have actually
reinforced that message
by focusing on individual actions
that people oughta be taking
to promote a healthy birth,
when in fact, in this case,
those individual actions
in and of themselves
would not be sufficient.
And you may need to
actually focus your work
in some other areas, and
here we sort of spell it out
about reducing this exposure to stress.
So our strategy, which was
developed thank in large part
to many black women who have spent hours
sort of guiding this work
over many, many decades
at this point, but also
sort of working and teaching
our staff about how would we think about
making a difference.
And you can see here, reduce
the sources of stress,
block the pathways that turn social stress
to physiological stress
and intervene early.
And so there's a entirely
different approach
for us at the health department
to organizing our work
and working with others to organize work
at the community level that would actually
help mitigate the factors that we think
contribute to a poor birth outcome.
And I don't wanna say,
we still think women
need to be connected to care.
We think women have to have good care.
We think we need support.
Women need to be healthy.
But our ways of approaching
this are to really
also understand that there
is a lot of policy work
that needs to happen as well,
and that we would be falling
short if we didn't figure out,
as public health practitioners,
how we engage with others
to promote the kinds of
policies that actually support
health and well-being for women.
Oh, sorry.
I'm gonna switch and give another example
around exposures to harmful
hazards, environmental hazards.
Because I want to try to
connect sort of the dots
between thinking about how do we mitigate
around toxic stress for individuals
to thinking about how do we mitigate
around toxic stress in communities.
So many of you here have
probably looked at what we call
the CalEnviroScan, which
really is a composite look
at where communities have both
the highest rates of pollution
and the highest rates
of poor health outcomes.
And for those of you who know LA,
you can see that this is certainly,
this poor sort of poor
health outcomes associated
with a high burden of pollution
is really concentrated
in a handful of communities
for those of you
who know LA, you know we're
looking at a lot of south LA
and some of east LA, and a
little bit up in Antelope Valley.
And when we think about
environmental issues
in LA County, one thing
we have to acknowledge
is we have a lot of heavy industry
located very close to what we call
sensitive use areas.
Sensitive use areas is where people live,
where people go to school,
where people go for recreation.
And, you know, there's lots of issues
with having heavy industry located close
to where people are living
and going to school.
Air pollution, noise and vibration,
and that's noise from like the port,
where you have all those
heavy diesel trucks
coming in and out, unloading
goods and bringing in goods,
to noise and vibration from oil wells.
There are 4,000 active oil
wells in the county of LA.
Some of those are literally located
in the backyards of
where people are living.
And the noise and vibration from that well
obviously is a source
of what we would call
an environmental hazard.
We have soil contamination and
we have contaminated run-off,
which is often times
from all the pollutants,
both in the air and on the streets
that then get into our water supply
and actually contaminate our ability
to sort of reclaim that water
and use it for other needs
that we have in our communities.
The health impacts are well-known,
particularly from pollution.
Pulmonary functions are reduced.
Cardiovascular disease is
associated with pollution.
Cancer risk and brain
growth and development.
As a matter of fact, in LA
County, again disproportionality,
you can see this in a
whole bunch of rates.
I'm gonna pull up the rate for asthma.
Black children are much more
likely than all other children
to have very high rates of asthma,
and if you look at sort of
what's going on in south LA
and in Antelope Valley you can actually,
once you start going down
to the neighborhood level,
you can see that there's
really excessive exposures
in those neighborhoods to pollutants.
I wanna talk about one
example about lead poisoning.
This was the Exide
battery recycling plant.
This is in east LA.
It was running without the
right permits for decades.
The state failed to
issue the right permits.
It was actually spewing all
kinds of environmental hazards,
particularly arsenic and lead for 38 years
into a community, predominantly
low-income Latino community.
Lots of renters and lots
of in and out migration
into the neighborhoods.
There's actually 10,000
parcels, 20,000 houses
in the neighborhood that was affected,
and the impact of this was that in fact
every single parcel in a 1.7 mile radius
had elevated levels of lead in the soil.
Now this impact was measured
years ago, three years ago.
Folks knew how polluted the area was.
And I wanna say that today,
out of the 20,000 homes,
10,000 parcels that need to be cleaned up,
less than 300 have been
cleaned even though
the legislature two years ago allocated
$196 million for the clean up.
These are the same communities
that score very low
on all of the composite
indicators that we have
around exposure to environmental hazards.
So it's not just that
these are communities
have high exposure to lead, they also
have high exposure to a
whole bunch of other stuff.
They're in the third and sixth percentile
when you rank them compared
to other communities across the county.
And so what I wanna point out here is
this is what I call an example
of what I call community stress.
We could think about individual stress
in our jobs as public health practitioners
to acknowledge individual stress,
but we also need to think
about community stress.
And I really think that the manifestations
of community stress are
important for us to recognize.
And I wanna talk about two in particular,
because I'm running out of time.
(laughs)
I wanna talk about systemic fraudulence.
So when the state is allocated money,
almost three years ago to
clean up in a community,
that has high levels of
lead at everybody's property
and those, there are
children who live there,
there are pregnant women who live there,
that lead is tracked in and
out of houses every day.
When you have $196 million
and you don't expedite
a clean up, that's what I would
call systemic fraudulence.
When you have weak social networks
because you actually tell false narratives
that shut down the voices
of folks in the community
around the exposures,
you have a big problem.
And we actually have
come up with strategies
for acknowledging the
importance of really focusing
on the fact that there
are all kinds of factors
that contribute to the disproportionality
of environmental hazards and if all we did
is stay in our usual box,
which is emissions reduction,
we would actually not be successful
in remediating exposures
that happen in communities
like the community surrounded
by the Exide battery plant.
That we, in fact, are gonna have to work
in three other boxes in
order for our actions
to be effective.
And primarily we need to pay attention
to the community empowerment box.
Because as a regulatory agency,
my powers are very limited.
The state actually has a lot more control
than locals do around
environmental hazards,
and without the empowerment,
the strategic ability
to allow people who have these experiences
to not only lift up their voices
but come up with the solutions,
we're gonna actually face many more
Exide like experiences in LA County.
We did a survey, we door knocked on
all 20,000 homes, we had lots
of people doing this with us.
In one day we reached 17,000 homes.
We collected as part of that
information from the residents,
gave that information back
to the community groups
working in those communities
and they produced a report
and they made recommendations
on how we actually
needed to address the
problems they were facing.
This is way more helpful than
having a health department
decide what needs to
get done in a community
like Exide, where in
fact, we almost become
part of the problem instead
of part of the solution.
And so, you know again,
I'm gonna flip to the end.
Okay, I see you're gonna hold up.
I just wanna talk about sort of,
how does this tie together then
for what we oughta be doing.
And what we really need to think about,
and this is Dr. Frieden's pyramid from CDC
when he was the director there.
We really need to do our work
at the bottom of the pyramid.
We're really good at working
at the top of the pyramid
but the most impact we're gonna have
is if we can actually do a
lot of work at the bottom.
And here at the health
department, one of the ways
we're organizing our
work to do it differently
is to really focus on
work around inequities.
And one of our sort of
signature effort here
is to actually publicly
state some measurable metrics
that people can judge our work by.
In five years about how we're actually
eliminating or narrowing gaps.
But you can go to our website and look up
more information about
the center and our plan.
What I think is important is that we have
some different constructs for ourselves
at the health department.
And accountability and
integrity are at the heart of it
and that means a lot of transparency.
People oughta know how we
spend every dollar we get.
We have a $1.3 billion budget.
We oughta be able to make a difference.
And people oughta know how
that money gets distributed.
I also wanna say that we have to do work
with the resources we have now
and do that work differently
in two very important areas
I wanna sort of shout out.
One is how we use data.
We can't continue to produce reports
that tell everyone that black residents
do worse than white residents because what
has happened with our reports is that
that has really just
perpetuated the false narrative
that for some reasons black
people are behaving in ways
that are actually accounting
for those health differences.
So data reports that
don't connect the dots,
that don't actually show
what are the conditions
that lead to the inequities
are actually more harmful
than they are helpful so for those of us
that are working in public health,
we need to sort of switch how
we're using our information.
We also need to understand
how important it is
for us to help lift up the voices
of people who have lived experiences
and have those voices, not
only be able to help us
with the actual, authentic narrative,
but also lead the way to the solutions
that are actually gonna make a difference.
We need to put our resources
back into communities
as communities are getting organized
to build the kinds of structures
and practices and policies
that they know make sense
for health in their communities.
And so I'm gonna just
close with a reframing.
I think we always ask
some really good questions
in public health, but some of those
are conventional questions.
And they're still worth asking.
We're still a
service-oriented organization
and we'll continue to do so,
but I think we need to couple that
with asking what I call the
health equity questions,
which are really questions
about how is power distributed,
how are resources distributed,
what's an organizing
strategy for redistributing
those opportunities and resources
that we know contribute to
optimal health and well-being.
I'm done.
(applause)
Right on time.
So thank you very much,
and I think there's time for questions.
- Thank you very much
for a wonderful talk.
We have time for a few questions.
- And I'll step down.
I'm gonna step down so I'm
out of the light a little bit.
So please ask some questions or comments.
Comments are welcome as well.
- [Male Audience Member]
Well done, very well.
- Thank you.
- Yes?
- [Rebecca] Hi, my name's
Rebecca Israel Cross.
I'm a doctoral student here
at the Fielding school.
And I actually study structural racism
and neighborhood health and so
I really appreciate your presentation.
So my question for you
is around how does the health department
partner with other regulatory
agencies in the county
because from my
understanding of LA County,
a lot of the processes are very siloed
and so the health department
can have all these
great kind of frameworks and
things but if, for example,
the Department of Planning is not on board
then land uses are not going to change.
So how do you all
partner with other folks?
- Yeah, I mean, it's
an excellent question.
And I really think is
sort of right on the mark
on sort of how narrow the purview is
of a public health department in sort of
determining how resources
are gonna be allocated.
But I do think there's hope.
One of the slides that I brushed over
was a slide that showed a
report we issued on oil and gas.
And those recommendations
are now being used
by both LA City Council to
do set asides and set backs
so this was really an important issue
about how far back from sensitive use
should an oil well be able to be active.
We are recommending at least 500 feet.
So that kind of information, you're right,
we really depend on
other folks championing
the issue and then moving
other elected officials
or other regulatory bodies
to actually adopt that.
But unless somebody stands up and says
this is the right thing and this is why
and this is the impact it has on health
and allows that information
to be in the hands
of folks in the community
in ways that they
can understand and use it, then I think
we have less of an opportunity
for the regulatory agencies
and/or the elected officials
to be able to actually move
in the right direction.
I would totally say that
the organizing part of this
is most important and that information
has to be made available
to folks who can advocate
for themselves and for their communities
because that's actually
gonna have more of an impact
on getting things changed than expecting
that bureaucratic
departments even like ours
are gonna be able to move everybody else.
But I do wanna say here in LA County,
both the Office of Regional Planning,
which is our planning department, and the
Community Development
Corporation have agreed with us
that we should not be building
sensitive use facilities
any closer than 500 feet from the highway.
Now sensitive use here is housing.
You can imagine the big debate,
given the housing crisis,
on where you should go to build housing.
You know people, wonderful
people are advocating
build housing wherever you can.
Our three departments are sort of saying
we understand those pressures.
There may be extenuating circumstances
and elected officials may
decide to do differently
but our three departments don't think
there's any justification for moving folks
who are already probably experiencing
some compromised health situations next
to a freeway that will
just exacerbate poor health
and that we somehow have to
figure out ways of building
the housing we need without
further compromising
the health and well-being of folks,
often who are vulnerable,
especially if they are homeless people.
But it's a big issue, and
I appreciate your question.
- Please.
- [Audience Member] I was surprised you
didn't mention homelessness.
Is homelessness a major
effort of your organization?
- Yeah, homelessness is
the number one priority
for all the county departments.
I didn't mention it, not
because we don't care
and we don't work really
hard with all the other
county departments, but just because
I didn't have enough
time to really talk about
all the issues we worked on
and I really just wanted to highlight that
for me, the issues around inequities
force us as a public
health department to focus
on both individual stress
and community stress.
And I think homelessness
is a manifestation
in many ways of sort of the disintegration
and disinvestment in some areas.
I don't know, you know, the other day
there was a report
issued that talked about
the fact that 40% of the homeless people
in LA County are black,
when blacks make up
only 8% of LA County's population
so disproportionality,
again, rears its ugly head
whenever you start looking deep enough
into issues that we face.
And this report actually called out
issues on structural racism.
I mean, sort of the set of recommendations
was address issues
around structural racism.
If you wanna really address
homelessness in LA County,
you have to address issues
around structural racism.
And this a report that
had many, many people
from different communities working on.
It wasn't a public
health report but it came
to a similar conclusion, be impossible
to address these inequities
if we don't really deal
with issues around structural racism.
- Yes, please.
- [Audience Member] Thank
you for the good lecture.
I'm Dr. Anaquinsi, chairman
of Global Care Medical Group.
I noticed in a lot of your presentation
about neonatal mortalities,
all the time the African-Americans
have higher mortality
compared to the other groups
and the way that I put it together is
it has to do with family stability.
That's what, when you compare
the African from Africa
and African-Americans here,
the Africans from Africa,
usually they have stable families.
And the African-Americans, unfortunately,
because of slavery, they
are still lagging behind
in family stability.
A lot of Caucasians or the Jewish groups
they have equity in
education, husband and wife,
and they can support each other.
You can see an
American-African woman with PhD
or law degree, she can't find husband.
She has nobody to support her.
So even with all the
education with insurance,
she's dealing with a lot of stress
because she can't find stable partner.
That's how I explain the oddities
that you're talking about.
- Yeah, thank you.
And I think the role of support
is critically important.
I also think we would
have to take a hard look
at some of our other
policies around sort of
family structures.
I think you're right to
note the legacy of slavery
has been really destructive
in this country.
But I also wanna say,
you know, the continued
sort of disproportionality
in arrests and convictions
has resulted in one of
three African-American
male adults in this county actually facing
either an arrest and/or
a conviction and/or time
incarcerated and that's really, again,
there's so much evidence
around the disproportionality
at every single step there.
But I have to say we have
a systems issue as well
about how we
react and address issues
around safety and laws
that unfortunately has
continued to fracture
disproportionately people of color,
particularly African-Americans.
I'll stop there because I
know there are more questions.
- [Ron] There's a lot of questions.
- But that was a great question.
And a great insight, thank you.
- I wanna thank you for clarifying
and shining a laser light
on blaming the victim,
as my way of saying it.
But I can't help thinking that
the rhetoric coming out of Washington
and out of other places
that have been encouraged
to come out and not be disguised
as they used to be, in
terms of the racism,
I applaud your efforts to try
to counteract those tendencies
that are happening today,
but I can't help thinking
how can we shut them up?
(laughs)
- That's a big question.
Does anyone have the answer?
(laughs)
No, I think obviously that's our struggle.
You know, it's been a long
struggle in this country.
And this president has really, I think,
unfortunately given license to folks
who, for a variety of
reasons, are very entrenched
in sort of the othering.
You're not like me.
You're bad.
And not only you're bad,
but I'm gonna blame you
for everything that's happening,
that's not going right in my life.
And I only wanna say from my perspective
that I think
the good news is so many people
have come together to fight against
the blatant racism and
the blatant discrimination
and the blatant, I call,
violence against people
that this president is
perpetuating that I'm hopeful.
I see people working together who haven't
historically worked together
and finding common ground
where they often haven't
been able to take the time
to find common ground.
Because I think there's so
much damage that is wrought
by this administration and this president
that it has forced us to understand
how much we need each other.
We've often said we don't
always find agreement
on everything, but I think this president
has made us understand
that for some of us,
there's a set of values that really guide
how we wanna interact with each other
and the people we work
with, live with, pray with
that are being violated right now.
And it's on those very
values that we can actually
find more common ground than
we may have in the past.
So I am hopeful.
I'm hopeful that we'll organize also.
I feel like as public health practitioners
we need to understand
the power of organizing,
and it doesn't always
mean a demonstration.
It just means coming together,
working across a variety of interests
to find that common
ground and really focus
on addressing root causes,
not going so quickly
to easy solutions for
very complex problems.
I'm old enough to have remembered
when we tried to sort of say,
30 years ago we were
gonna solve the problem
on black infant mortality
rates being so much higher
by lifting up all boats.
We're gonna just pour
money in for everyone,
and by doing that
everyone was gonna benefit
and everyone would enjoy
better infant mortality rates.
And there was some truth to that.
Infant mortality rates went down.
But the gap just got wider
because nobody really wanted
to focus on disproportionality.
Because why, if you focus
on disproportionality
you'd have to say we need more resources
going to help black women.
We need more resources going to systems
and organizations that are gonna support
black women and their families.
We need to understand
racism and its impact.
I mean the IOM produced
a report now I wanna say
15 years ago that
identified structural racism
across our healthcare.
Providers and hospitals, clinics, schools,
and that's still a shock
when you talk to people
and you say yeah, no people actually
don't get treated the same.
People actually think they do.
And they have a lot of explanations
about why that data can't
be possibly be right.
So we have a lot of work to do,
but I think we're the
right people to do it.
I particularly think LA
County is the right place
to try to do this work.
There's a lot of wonderful
leaders in the community
that really sort of can
help lead the way on this.
- [Ron] We have time for just
one or two more questions.
I think one over there.
Yep, please.
Yes.
- Thank you, Dr. Ferrer.
Michael Rodriguez, the
Department of Family Medicine
and Department of
Community Health Sciences.
And thank you for your
wonderful presentation.
I guess I wanna applaud you
for the work that you're doing.
I feel that part of what we need
is enlightened leaders like you.
And to meet with enlightened
leaders from other systems.
I think there is a systems issue.
You raised the issue of incarceration,
and I feel humbly that
we need to work at it
from the public health perspective,
but we also need to have some
cross-sector work with folks
in other areas, right?
In housing, in criminal justice,
so that we sort of align
the work that we're doing.
And I think work, as you
said, with the community.
I was involved with Project Export
that was funded through
the NIH Project Institute
and we worked for about 15 years
with many communities in LA
and particularly south LA
and I have to say in honor of
one of the community leaders,
her name was Loretta Jones.
And she is just a giant
and wonderful person
and very visionary because of
the issue of discrimination
that you talk about is not
just one that's institutional
but it's also within communities.
- Absolutely.
- And it's not really talked
about, but there is also
discrimination within communities.
And she was a wonderful
person who was able
to bring together the Latino community,
the African American
community, the Asian community,
to where we were working together
to address these issues
that they face in common.
And so that, I'm sure that
the work that you're doing
is building on some of that legacy
and continuing work that's going on
because it's so important
and I'm glad that you're here
so that we can have a
chance to work with you
and support your vision and
actualize and operationalize
that framework that you
have for infant mortality,
for environmental
justice, and for the many,
homelessness, and the many other issues
because it really is inspirational
so that we can go forward
and actually make LA
a place, a more healthy place and share
our experiences with other places.
- Yeah, thank you so much.
I mean, I wanna be clear this isn't,
first of all, I'm here
only because so many people
have taken the time and
had patience with me
and helped me on my own learning journey.
I have made so many mistakes
and so many missteps
and so many people were
patient and sort of said
let's keep talking to her.
Let's see if this lady will learn
what she needs to learn or understand
what she needs to understand and so
I'm only here because so many people
have really helped me grow
and helped me understand
and helped me learn
about how to be of service.
I'm privileged and honored that I'm here,
but I'm really a reflection of
hundreds of people who have
dedicated their entire lives
to this work and have been
willing partners and teachers
along the way to people like me.
So I wanna give a lot of credit
to a lot of other people for this.
I also wanna acknowledge that
I work with a wonderful team,
not just at the Department
of Public Health.
Dr. Davis is here, enormous
wealth of knowledge,
he comes and led this work up in Oakland,
in Alameda County, but also
even in our county family,
every single employee in the county
had to participate in
training on implicit bias.
So sort of like let's do some
personal growth work here
and let's have everybody understand
sort of one of the roots of disrespect.
And so again, I'm honored.
I am part of a larger county family,
and I'm obviously led by an amazing
Board of Supervisors who
also talks about issues
around racism and the impact
of racism and allows us
to focus our work in that
way because it wouldn't
be possible without that
kind of support as well.
- [Ron] So we have time
for one more question.
- Hello, I'm Ritu Sadana
and I'm a double Bruin
but I currently work at the
World Health Organization
in Geneva, and I was
part of the commission
on social determinants
of health and I must say
that what you've
described is the real work
in terms of really, not
just describing the problems
and particularly not
blaming the individuals,
but really understanding the root causes.
What are the social processes
that lead to stratification
and then what sorts of
systems and built environments
can make a difference.
My question is to what extent,
you mentioned that you
wanted to go beyond just
the metrics but really
understand what can be done,
and that's something that
we're really searching for
because we have a lot
of problem description.
But we're interested
in the what and the how
and ensuring that people
monitor the before and the after
so we're very keen to be
able to share experiences.
California is the fifth
largest economy in the world,
and as we've been discussing
over the past few days
with the UCLA Center for
Health Policy Research,
4% of the world is
Americans, but they spend 43%
of all the health expenditures
so there is a big masking
of disproportion in the
way that money is spent.
- Yeah, I thank you and
thank you for all the work
you are doing with WHO.
It's an amazing opportunity I think,
to really think about this work
as being global, which it is.
So I think there are two places where
as a sort of government
agency you can work quickly.
First, as I call it,
like an all in policy.
So you have to look at all the different
sort of books of business you have.
So one thing is we
contract out every year,
I wanna say like, God,
probably like $600 million
are going back out.
So if we looked at our
contracting policies
and we said, you know, what's
an equity lens on contracting?
Go local, increase the number
of minority owned businesses,
women owned businesses,
GLBTQ owned businesses.
You know sort of what could you do
if you just looked at your
contracting differently
and just actually put those dollars
back into the very communities
who we've disinvested in historically.
So that would have a huge impact.
And then I just sort
of walk down the line.
What are our HR policies like?
You know, how do they afford opportunities
for us to bring in the
talent that's there.
What is sort of a local hire look like?
And then back that up.
What are investments
in those organizations
that are training folks
who will then be able
to work with us and how do we support,
you know, I was formerly
a high school principal
of a district high school in Boston
so I feel passionately that you need to,
you need to offer young people
opportunities and support.
They're really across the
world they're pretty brilliant,
and the only reason they're
not in our work force
is they didn't have the
opportunities and resources
that others of us have
that made it possible
for them to come and do
what they dream of doing.
Because everybody has dreams.
So how do you start supporting programs?
I'm working right now
with Dr. Carlisle and CDU
to create a program that's CDU that's
for high school students that really
allows high school students to get support
through a summer academic
enrichment program
and then internships during the year
with community organizations
that are fighting for justice,
that they build their leadership
skills around fighting
for justice and they get support.
So what their dreams can become a reality
because there's a bunch of
folks that believe in them
and that are gonna help make sure they
have opportunities and resources needed.
So I think there's a whole
book of business there
that we forget that we can influence
because we're just a large county.
The county has 107,000 employees.
The budget for the
county's like $45 billion
so if you just think about
how could you use that money
sort of with an equity
lens you can understand
there's gonna be a big impact there.
And then I think the second part, though,
is how do we actually
engage in more policy work
and systems change work?
We're always gonna be
about doing services,
but even if you're doing services
you could do services in
a way that's empowering.
It doesn't have to always be
the we're in charge, you're not.
We're the people with all the information,
you're the people without
because you come and see us.
We're the doctors, the
nurses, how do you in fact
create sort of a different dynamic
even in your service delivery and then
offer people opportunities for
them to lift up their voices.
I mean, one of the things we're working on
at the health department
is we don't really have
like a consumer advisory board made up
of people who use our services.
We barely have satisfactions surveys
that are going out to everyone.
We have a lot way to go to sort of,
how do we actually lift up the voices
and have the people
who we're in service of
tell us what kinds of
services they need, they want,
and how we oughta be delivering those
so even as part of being
a service organization
we could do things differently.
So I think there's two tracks you can take
as a large organization.
I don't have an easy answer
like I'll do A, B, C, and D,
but I do think if you look at your work
in both those areas you
might have some insights
that would help figure
out what's a path forward
for your own organization?
- Thank you for a wonderful presentation.
(applause)
- Thank you all.
You've been a great audience.
Thanks a million.
- I'd like to present you with the 2019
Lester Breslow
Distinguished Lecturer Award
and thank you for your
visionary leadership.
- Thank you, thanks so much. (applause)
Thank you so much.
This is so nice.
Thanks a million for inviting me.
- It's been a terrific
and wonderful evening.
I want to thank Deborah for carrying on
the tradition and the
legacy and it's wonderful
to have you here.
It's wonderful to have all of you here.
And we hope to see you
at an upcoming event
and if you look at the
back of your program
you'll see a lot of events scheduled
so we hope to see you there.
Following this we have a
dessert reception outside
so if you haven't seen the
Lester Breslow Archive,
take another look and enjoy and socialize.
Thank you again for coming
and have a wonderful evening.
