Rae Woods:
From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Over the last year, there has been a real reckoning with the inequities that exist here in the United States. Inequities that result in dramatic differences in health outcomes for people of color. As white people continue to receive the majority of life saving coronavirus vaccines, there is real potential for the health equity divide to get a heck of a lot worse.

Rae Woods:
So, I wanted to bring an organization to this podcast to talk about their proactive efforts and share what they're doing to reduce inequities, to combat legitimate hesitancy and to build trust with communities of color. To do that, I've brought two leaders from Parkland Health and Hospital System. We've got the CEO, Fred Cerise, and the President and CEO of Parklands Center for Clinical innovation, Steve Miff. Hey, Fred, hey, Steve.

Fred Cerise:
Good morning.

Steve Miff:
Hello.

Rae Woods:
Have either of you been on a podcast before?

Fred Cerise:
I don't think I have.

Rae Woods:
Steve?

Steve Miff:
I've done a couple, and they're always... I think I find them very fun, and I find them very interesting to see what comes at the other end, because it's usually better than the input.

Rae Woods:
No pressure, no pressure. Well, thank you both so much for joining Radio Advisory to talk about this incredibly important topic. I want to start at the high level because there is so much that organizations can do to focus on reducing inequities. What led you and ultimately Parkland to focus on inequities in COVID-19 vaccinations specifically?

Fred Cerise:
Inequities is a big part of the work that we do with a public hospital, with the public health system in Dallas County. Looking at access to care and outcomes and those types of things, it's part of what we do. We know that at times of crisis, those disparities become exacerbated. We've seen that happen over and over again. We knew that that was coming. With the onset of COVID-19, whether it was testing or treatment, or now vaccinations, we knew it was something we're going to have to be intentional about focusing on.

Rae Woods:
Steve, why vaccines?

Steve Miff:
Even from a data perspective, it's part of everything that we do. Leveraging social determinants of health and leveraging data science to understand somebody's life challenges, is basically embedded into how we analyze and look at everything. With vaccines, it's been equally important to really understand those factors, understand the vulnerability, understand who's at highest risk, and be able to use that to prioritize or target things in a very equitable way.

Rae Woods:
We are going to go headfirst into all of that data, since we have an expert like you, Steve, on the line. But Fred, I want to come back to something that you just said, Parkland, takes on a public health role in the community. But I don't know that every other health system or hospital leader actually thinks that way. In fact, I've had folks specifically say to me, "That is not our job. Our job is not to do what the public health agencies do." What do you say to that pushback?

Fred Cerise:
First of all, Parkland is a little different, because we are the county hospital, and about a third of our budget comes from the county. We do have more of a role there than others. But I would push back to the other hospitals in general and say, health care consumes almost a fifth of the economy in the country, and hospitals are about 30% of that.

Fred Cerise:
There's a lot of investment in our systems, and there's a lot of resources that we have. If you look at the public health system, those things are generally narrowly funded, they're pretty lean, they don't have the capacity to surge the way hospitals, with the scale that we have, can turn things on at times of a crisis. I would push back and say it is the hospital. We can't ignore the fact that we exist in a bigger ecosystem, and the communities have invested quite a bit of money, trust in our systems. So, I do think we have a responsibility to reach beyond our traditional roles, particularly in a time of crisis.

Rae Woods:
When it comes to inequities in vaccination, there's a ton that leaders can do, but my understanding is that Parkland decided to start first on building community trust. Why was that so important?

Fred Cerise:
We know we're going to have enough vaccine at some point to vaccinate everybody that wants to be vaccinated. The limiting factor is going to be acceptance of vaccines. If we're going to read herd immunity, we need 70%, 80% of the people to accept vaccination. We also know that there's a history of mistrust among minority communities, some of that very well founded, understandable.

Fred Cerise:
The limiting factor is not going to be the availability of vaccine, but it's going to be acceptance of the population. We can't ignore that fact. On the one hand, if you didn't care about community mistrust in that piece, you still need to do that from a public health perspective to reach herd immunity. We do care about that other piece, and we think it's important that we address the historic mistrust that's well founded.

Rae Woods:
I appreciate the fact that you said that this mistrust is legitimate, right? There are well documented reasons throughout history, up until right now, for why black, Hispanic, Latino populations would be hesitant to use the health system, period, let alone receive a vaccine that's only gotten emergency use authorization. Let's talk about what Parkland did. You have described this as a little bit of a push, and a little bit of a poll. What do you mean by that?

Fred Cerise:
The push piece will come a bit later, actually, and that is people that are already coming to our system, that are accessing services, when they come, we will be able to push the vaccine out as they come in to access clinical services. Right now, the effort is to pull, and that is doing outreach to people who are not showing up at clinic for an appointment. But we're reaching out to them to say you're at risk, we know you're at risk for these reasons. So, trying to pull them in to our vaccination sites right now.

Rae Woods:
The pull, is I'm guessing where it matters a ton to look at data, which Steve is, I think, where you come in.

Steve Miff:
That's exactly right. What we've tried to do is really understand the individuals, the neighborhoods, the communities that are most vulnerable for COVID by combining a number of different data sets, not only the key elements from CDC, such as age comorbidities, but also incorporate into that, factors such as mobility, factors such as social determinants of health.

Steve Miff:
By doing that, understand who's most vulnerable, so then we can target more specifically, those neighborhoods, and also by doing that, understand the ethnic racial makeup of those communities. So any outreach can be done in a very cultural sensitive way, in a very targeted way.

Rae Woods:
Yeah, and Steve, your team put this together as a, I think it's called a vulnerability index, is that right?

Steve Miff:
That's correct.

Rae Woods:
It gets down to, I want to say it's block by block level data that you can use then for targeted outreach.

Steve Miff:
That's exactly right, we've been doing it at the block level to get really hyper localized and very specific. Then for some of the vaccination privatization work, we've actually taken that even to an individual level.

Rae Woods:
An individual patient or persons level.

Steve Miff:
Correct. Because if the data is available, we know the age, we know, the comorbidities based on their medical history. Then we can apply some of the other factors relative to the socio-economic status, and the level of mobility that occurs in their neighborhood, and combine those to be able to get a much more granular understanding of their environment, and also understand they live in an area that is a hotspot at that particular moment in time for COVID.

Rae Woods:
I've been curious, as you've built this vulnerability index, you've mentioned a ton of different inputs. Are there any that stick out as ones that maybe other organizations aren't prioritizing right now? The most obvious inputs are things like age, demographic, health status, do you have comorbidities? But because this is so robust, are there any inputs that you want to put on the radar for other clinical leaders to make sure they're incorporating?

Steve Miff:
The key learning for us was that incorporating the social determinants of health data made a significant difference in-

Rae Woods:
Like what? Like education, things like that?

Steve Miff:
Yeah, it's the combination of income level, it's the education, it's the housing situation, it's the transportation needs, the food needs, is really looking comprehensively at all those factors in aggregate, and using that in a way to understand also vulnerability. What we've noticed by doing the retrospective analysis is that when you combine all these different factors together, there's an 87% correlation to both infections and COVID-like illness presentation. So, they're very highly correlated, when you combine them.

Rae Woods:
High vulnerability index, high risk of disease and ultimately death from COVID-19. So, let's prioritize getting those people the vaccines first.

Steve Miff:
That's exactly right. Then one of the other things that we've learned is because as you mentioned earlier, COVID has impacted different racial ethnic groups, some a lot more than others. One of the other things that we wanted to make sure that we do is understand what's driving some of that? The key learning for us has been that by incorporating the social determinants of health, that has been, to some extent, the equalizer across different racial and ethnic groups.

Steve Miff:
For the point to the need to take that into account, not only particularly now for COVID, but a lot of the other clinically related things that we've done in the past and we'll continue to do in the future.

Rae Woods:
You used the word equalizer just now, which is, I think, incredibly important in this moment where a lot of people are anxious and eager to get this vaccine, particularly white people, white people who can take time off work, who can sit on their computer ready to refresh the page. I think there is a lot of concern and question about how do you balance appropriate prioritization with playing favorites, or maybe creating downstream effects that you didn't predict? Is that something that Parkland has had to deal with?

Steve Miff:
I would say almost daily, because you want to make sure that as you put this information out there, it's first of all, it's very data driven. It's guided and driven by science. Also, that's very transparent, this cannot be a black box, so you have to be very transparent of how inputs are, what outputs are, so folks at all different levels can understand how it's being done.

Rae Woods:
Fred, I wonder if you can give an example of how this kind of daily challenge of balancing appropriate prioritization and playing favorites has actually played out at Parkland.

Fred Cerise:
Probably about a month and a half or so ago, we knew that there would be a weekend, where we did not have people scheduled, to a large extent for infections. We're still in our ramp up phase, and we knew the county sites were seeing what you described earlier, and that is a disproportionate number of white individuals that had gotten onto the registration sites early and quick, and were getting vaccinated at the county site.

Fred Cerise:
We did some outreach to some of the communities that we know are heavily represented by minorities, that we know were not getting vaccinated at the county sites. Did some outreach to churches and did some outreach to community centers and whatnot, and said, "Listen, we're going to have some walk up availability on Saturday and Sunday from these hours."

Fred Cerise:
Well, I got blowback from people almost immediately about having a secret vaccination event [inaudible 00:12:40]

Rae Woods:
I know.

Fred Cerise:
There was nothing secret about it, it was all over social media. We had a line of people, probably four blocks long before five o'clock in the morning. So, it was definitely not a secret. But just by trying to do some targeted outreach to some areas that we knew were not getting in, generated that sort of backlash. The process Steve described of trying to... Now, we're trying to get people registered at a site, and then with that registration, apply the criteria that Steve's group has been able to develop, to prioritize once people get on the site.

Fred Cerise:
I'm maybe the 100,000th person to register on a site, but based on my risk, I'm going to get an invitation to get a vaccine in the next week, because by objective criteria, I'm a higher risk person.

Rae Woods:
This is really important. Every one that I know personally, and professionally has an online registration system for vaccines. That's where you hear the stories of more affluent people with more control over their schedule, blocking their calendar so they can just refresh the page over and over again. That doesn't even account for access to broadband issues, and do you have a computer and things like that. Have you stuck with this online registration system, or have you pivoted to other ways of registering more vulnerable populations for the vaccine?

Fred Cerise:
It's both. We have stuck with you online, but recognizing what you just said, we've had to do more outreach so that we can help people sign up, we can help people that don't have access to computers, partnering with community organizations that then can get people in and enroll people.

Fred Cerise:
Once they get on the registration list, then you can apply prioritization, based on objective criteria, but it is a challenge to get on that list. We've had to do a lot of individual outreach that doesn't involve being able to refresh, refresh, to get them top of the list.

Rae Woods:
There's of course the challenge of prioritizing the people that you want to engage. But now there are a heck of a lot more vaccines on the market. We've got J&J is one dose vaccine. We've got Pfizer, we've got Moderna. Have you made a decision as an organization about how you will prioritize specific vaccines for specific communities?

Fred Cerise:
We're in the midst of that right now, as you know, because the J&J vaccine just got released. So, we expect to get some of that this week. We're doing like a lot of organizations, you're looking at your populations that may be tougher to track to get back for a second dose, and that's who we're going to target with our J&J vaccines initially.

Fred Cerise:
We have a homeless health care program. That program will take the vaccines to homeless shelters into the sites that they visit around town. We have a jail health program, we'll take that vaccine to the jail to administer that way.

Fred Cerise:
One of the things that, I think everybody's looking at there, and you hear the conversation now is, okay, are you going to give a better vaccine to this group or that group?

Rae Woods:
Exactly.

Fred Cerise:
We just don't have the data to say we have a better vaccine. That's the honest truth.

Rae Woods:
Is that something people understand? Because there's a difference between reality and perception. We started off this conversation by talking about inequities more broadly, we haven't even talked about things like access and how difficult it can be to get somebody into health care, period, if they're working two jobs or don't have transportation, et cetera, which is a huge benefit of the J&J vaccine.

Fred Cerise:
Yeah.

Rae Woods:
The thing that keeps me up at night is, would those same vulnerable populations, those largely minority populations think, I'm getting the short end of the stick here. How do you combat that?

Fred Cerise:
It's a real issue. We've struggled with that too, as we're developing our strategy. But the truth of the matter is, we don't know that one is better than the other, they have not been tested head-to head at the same time. You've got the J&J that's been tested later, where you've got varying strains, you're not taking into account how many people will show up for the second dose or miss the second dose, and what the impact of that's going to be.

Fred Cerise:
With the best data we have, and listening to the experts that dedicate their lives to this, you got people like Dr. Fauci who are saying, take the vaccine that's in front of you, and then I really not the science to say one is better than the other right now.

Rae Woods:
I couldn't agree more. I'm thinking if I'm spending my time arguing with my friends over Zoom happy hours and telling them, "No, you've got to get any vaccine you can." I can only imagine how difficult it is when you extrapolate that out to the rest of the population. Steve, you spend a ton of time on building out this robust data set, this process, this ultra specialized way of prioritizing folks for the vaccine. I have to imagine that it hasn't always been a perfect process. What are some of the big hiccups or barriers that you've hit, and what did you learn from that, that you want to make sure our listeners know about?

Steve Miff:
You're absolutely right, it's a learning process, and the best we can do is adapt. I think there are two key things that come to mind. One is the amount of time and energy that we spend every day cleaning the data and making that actionable. What I mean by that is something that you actually alluded to earlier on folks registering again, and again and again, because if I do it 50 times, chances are maybe better than I'm going to get higher on the list. So, you have a lot of duplications of registrations.

Steve Miff:
Then the second one is to be able to actually proactively know if somebody on the list has already received the vaccine, because it's not always easy or convenient for somebody who is on the list to call back and say, "By the way, take me off the list because I received the vaccine."

Rae Woods:
Steve, I got to tell you, my parents literally went through that themselves, where my mom was able to get a vaccine appointment, my dad wasn't. They ended up going to the same appointment anyway, saying, "Please, please, can he get a dose?" He was able to get a dose, and then my mom spent two hours on the phone trying to cancel his appointment for the following week.

Steve Miff:
No, that's exactly right, and it's a very dynamic process. So, you'd have to do this daily. Because then once you provide the outreach teams with that list, their success rate for contact with somebody registering, you want it to be as high as possible. If too many folks have even multiple times on the list, and they're calling the same people if they've already received somewhere else, it's a little bit of a waste of their time.

Steve Miff:
One of them is really just that blocking and tackling to make sure that you use the information that's most curated and accurate. But the second one, you also alluded to, and there was a miss. When I think back, it's like, boy, it makes so much sense, why do we miss this? But we've described, we use this very data driven scientific way to rank folks that's based on their risk. Well, by doing that, what we've noticed is that you end up having families that you have a spouse who might be 65 with no comorbidity, somebody else who 74 with a comorbidity, and they might end up several hundred spots away from each other on the list, and hence, they're being scheduled at different times to different locations, which is not that convenient for them by any stretch.

Steve Miff:
Key lessons was, let's as we create these lists, let's make sure that we identify if you have folks that are together within the same criteria and categories, but bring them in a way that they can be scheduled at the same time.

Rae Woods:
We'll be right back with more Radio Advisory after this short break.

Rae Woods:
So far, we've been talking about the pull part of your strategy, the proactive data driven outreach that health systems can do to engage the communities who are in the most need of protection, not even the communities, the people, down to that very, very specific level. But the other side of the initiative that you described is more of a push. What does that entail?

Fred Cerise:
The push is more for the people that are coming to the doctor for other things, but you're taking advantage of that opportunity to get the vaccine to them. As we think about the mistrust that we talked about earlier, the one place that is consistently ranked highest among people in further source of medical information is their physician's office. They trust their doctor to give them a message.

Fred Cerise:
We want to take advantage of that. Also, from a convenience standpoint, a lot of the patients that we see, a day to the doctors a day off of work, it may involve childcare and transportation challenges. To the extent that we can push that vaccine at the time that we have people in the office, it's going to be a big advantage to us and to the people that we take care of.

Fred Cerise:
Right now, what we're doing is, we're routing down from the office, because it's not a disseminated vaccination site strategy at this point, you're still in hubs. We're capturing the office and then directing them to the vaccination site. But what we hope at some point, when we have a more disseminated strategy is to catch everybody when they're coming through the office and do their education there. While their visit for whatever, they're going to get the vaccine at the same time.

Rae Woods:
I love this comment, because it's such an easy thing to do. Even if you don't have the data and analytics to build this robust index, what you can easily do is make sure every time patients are showing up for their doctor's appointment anyways, that you're assessing their risk, addressing their concerns, and pushing them to an immunization. Ideally, that moment that they've already taken off work and et cetera, et cetera, if you can. I love that approach.

Fred Cerise:
So much of what we do is structured around the health system and the convenience of the health system. As we look for more opportunities to be more patient centric, how can we make things easier for the patients? That's just one small example of that, right?

Rae Woods:
We were just talking about using existing appointments as an opportunity to address concerns about the vaccine. This is another area where I will admit, I start to feel eeky very quickly, because I hear a lot of folks, a lot of well-intentioned folks focusing on education, and I'm afraid they might be missing the point. They're talking about we need to educate people of color, we need to educate black communities about the benefits of the vaccine, et cetera. But that assumes that these groups are uninformed and uneducated, when, in my experience, they're actually ultra-informed about the history of medical abuse and experimentation on their people. Again, gets back to legitimate mistrust.

Rae Woods:
When it comes to community outreach, when it comes to this kind of push, how do you see the difference between education and a campaign aimed at building trust?

Fred Cerise:
I think is a great distinction, because like you said, a lot of times the problem is not education, but sometimes it is. I think the approach has to be both. I'll give you an example, I talked to one of our housekeepers at the hospital a few months ago, and asked her if she had gotten vaccinated, she had not. I asked her what her concern was? She said she was afraid she would get COVID from the vaccine.

Fred Cerise:
In fact, when you look at the data, about half of blacks who are vaccine hesitant, list that as one of their concerns that you actually get COVID. There's a pretty straightforward educational opportunity there around how the vaccine works. I was able to have that conversation because I know the person and we already have a rapport, and she ultimately got vaccinated. But at a community level, that's probably a message that may be difficult for me to deliver, and it's going to be better received from somebody that has established trust in the community.

Fred Cerise:
One of the things that we're working with is, who are those community members that people know and trust, and how can they help us deliver, one, some of the FAQs, the educational pieces, but also, deliver a message from a trusted person perspective, that the vaccine is safe and effective?

Rae Woods:
Who are those people that you've maybe identified in the community?

Fred Cerise:
We've had a series of calls with community leaders, city council men, commissioners, church leaders, leaders of community based organizations, and one of the cool things our team has done is... When one of those individuals will come to the drive thru to get vaccinated, they'll do a video and capture the vaccination on video, that person can deliver a message, and then they will get a package, an educational package, a toolkit that's got their video in it, and it's got FAQs, and it's got information about the vaccine that they can then take to say their congregation and use that to educate people about it. They'll get their little education pack, and then they go on and they're ambassadors for the vaccine.

Rae Woods:
I love that term, ambassadors for the vaccine, and your role, the role of the health system is to provide the material to make it easier for them to be an ambassador in their community.

Fred Cerise:
Well put, it's exactly what we're trying to do. We try to establish trust, and it comes by showing up over and over and over again. But the reality is, there are people that are embedded in those communities that have been there forever, and people know them, they trust them, and they're going to be a better messenger than somebody from the hospital.

Rae Woods:
Yeah, exactly. You two have been at the forefront of creating this really robust campaign, right? We've talked about the proactive, data-driven outreach, making sure that you're connecting patients to vaccinations when they're already interacting with the health system, and then using community ambassadors to establish some trust in the community. What's the next step for this campaign?

Fred Cerise:
One of the things that we were working on before COVID, that really has applicability now, as well, and particularly as the vaccine becomes more widely available, is working through community groups that again, already have some established trust to help us get those health messages out. We have a group of high school students that have an interest in health care, that we've been working with as health ambassadors.

Fred Cerise:
During flu season, they helped us create a flu message that was done in English and in Spanish. Was promoted in their school areas, and were able to get, one day and a half over the weekend, between 1,500 and 2,000 people vaccinated for the flu, many of whom had never been vaccinated for the flu before, so to try to create some momentum there.

Fred Cerise:
Building on programs like that, where we're using the community assets to help provide some information, and then they can carry that message forward in their own community.

Rae Woods:
I love that example, because I think it's obvious to look towards ambassadors that are leaders in the community. The religious leaders, the City Council people, et cetera. But what you're talking about is the fact that you can establish some trust and you can create ambassadors with kids, with trusted kids in the community, in the high school.

Fred Cerise:
It was great too. Our high school student workers, they were able to deliver a message on Spanish speaking radio, so they became famous among their peers because they were on radio, and they-

Rae Woods:
Can confirm that, that helps.

Fred Cerise:
Right? They were giving a message of why the flu shot's important. People in the community were hearing from people they knew, and it pulls people in, again that may have an interest in public health and gets at an early age shows what an impact they can make.

Steve Miff:
Rachel, what I will add here, and it's by no stretch as interesting or sexy as Dr. Teresa's story, but from a more of a blocking and tackling perspective, it's important, we're tracking the administration of the vaccines at a very granular level, to really understand where and who's getting the vaccines. Are they coming back for that second dose?

Steve Miff:
Because while we look across the whole county, across the whole city, it's how this plays out within certain neighborhoods. So, make sure that as we track those elements, we're able to target better or better to understand where the uptick is lower, et cetera, because we're only going to get there by bringing the whole community up together.

Steve Miff:
Some communities, and some neighborhoods are falling behind, we then can understand why and double down there to make sure that we're able to elevate them concurrently.

Rae Woods:
You're also right, that some of the most important work that you can do is not the sexy stuff. It is the blocking and tackling and continuously going back to the data and figuring out what works and what didn't and fill the gaps, that really is going to make a difference here. Fred, I want to ask you sort of a personal question, before we close out. You are the CEO and the leader of Parkland, you are also a white man. What did you see as your specific role in this initiative, the thing that you didn't want to or knew that you couldn't delegate or pass on to anyone else?

Fred Cerise:
It's not a specific task, but it was the direction to say we're going to lean into this thing, and bring the full force of the resources we have in the health system to address not only things like testing and treatment and vaccinations, but to do it in a way that addresses, what I anticipated we would see, and that is the inequities that have played out across the country.

Fred Cerise:
To set the idea that, when the county was talking about doing testing for COVID-19, that we would bring our resources, and we would bring our resources to focus on the underserved areas of town, and make sure that those individuals are going to have access to testing.

Fred Cerise:
Then we have a team that just goes crazy. Once you point them in the right direction, and give them the resources to work, they're going to do it.

Rae Woods:
They're the whole vulnerability index.

Fred Cerise:
That's right. I didn't even have to talk to Steve about that, they knew that that was important, because that's sort of the work that we've done historically. But for our operations team, is basically setting the direction to say we're going to be active in this space, we're going to show up, and we're going to do it in a way that ensures people... It may take a little extra work, but the people that historically get in the back of the line in times like this are going to have access.

Rae Woods:
Yeah. Well, I want to thank you both so much for coming on Radio Advisory. At the end of every episode, I ask our guests to provide some actionable guidance to our listeners, to speak directly to the folks that are listening to this episode. I want to ask each of you, when it comes to promoting equity in vaccinations, what's the one thing you want our listeners to focus on right now? Steve, let's start with you.

Steve Miff:
Sure, and I would say this goes beyond the vaccination of COVID but certainly has a direct application now. That is creating digital connections to the broader community, because we're only going to get there with COVID, and with general healthcare needs as a community, where the hospital system plays a critical role, but it's not the only the single entity that is driving this.

Steve Miff:
Whether that's going to improve access, that's going to help both clinicians in the community identify and then connect individuals who beyond their clinical needs to be able to get assistance. By doing that, then we can help make it easier for individuals to do the right thing. But we need to meet them where they are, but we need to be able to engage the broader community, and that takes time. It doesn't happen overnight. Maybe during the pandemic is not the time to start. But you need to start sooner rather than later, because I believe that that's the future way we're going to be able to address health and health care equitably, and in a way that's scalable.

Rae Woods:
Yeah.

Fred Cerise:
I would say, health systems are living this tension of going fast, and ensuring equity. Oftentimes we think, you got to choose, but I would encourage people to think about the fact that you can do both, you can go fast, and you can address the inequities along the way. Health systems are very good at setting a vision, measuring and achieving. The equity thing is just one that you have to be intentional about. Because if you just go fast, we will perpetuate the inequities, we know that. But being intentional about addressing what the distribution of vaccine will look like along the way, and paying attention and measuring that, you can absolutely do both.

Rae Woods:
I love that. Thanks, Fred. Thanks, Steve.

Fred Cerise:
Thank you.

Steve Miff:
Absolutely. Thank you for having us.

Rae Woods:
Stay tuned for part two of this episode, where we'll continue our conversation on health equity, with Advisory Board expert, Solomon Banjo.

Rae Woods:
I sometimes get the feeling that everyone in healthcare is attuned to this equity challenge, but nobody really knows how to solve it. As much as we love the work that Parkland has been doing, we know that organizations can go further. So, I want to bring on my colleague, Solomon Banjo, to talk about what other institutions can learn from Parkland's efforts. Hey, Solomon, welcome to Radio Advisory.

Banjo Solomon:
Hey, Rae, so excited to finally be on.

Rae Woods:
I know, long time waiting for you to get on to the pod.

Banjo Solomon:
Yeah, although I don't like the sound of my voice, so this might be the one episode I don't listen to.

Rae Woods:
You get over that really fast when you're a podcast host. What did you think about our conversation with Fred and Steve from Parkland?

Banjo Solomon:
You've captured so many of the themes my team and I had been hearing when it comes to the challenges and also the solutions for it. One of the things that honestly struck me is how much they accounted for and addressed the inertia with so much of the vaccine hesitancy of historical mistrust. To explain what I mean there, when Fred talked about physicians being the most trusted source people have, the data shows only 23% of people are actually talking to a clinician.

Rae Woods:
Yeah, my first instinct when he said that was is that true for everyone, or is that true for white people?

Banjo Solomon:
I think it's a combination of, it's true for most people, but no one's actually talking to the clinician. The idea was a push of, oh, when we have you here, how about we bring that up, and then try and route you there. I thought that was a really good point. But you bring a great point where as you dig into the data, the aggregate data is almost useless, because it doesn't actually reveal what you need to do, especially for some of those communities that have been most impacted by COVID.

Rae Woods:
Yeah. But we should talk about the data, because that was probably the thing that stuck out to me in the conversation the most, and I will also say, has stuck out to me with every kind of A plus organization that I've spoken with that's addressing health equity, period. All of them have incredibly robust approaches to data.

Banjo Solomon:
Yes. I think the lesson there is we talk about the data, we talk about social determinants of health through the vaccine lens, that's what we're most focused on. But this is a long term play. But if you're talking about delivering better care, we don't have to get into the whole value-based care model. But when you think about the successful attributes of health systems going forward, much of what you have to do to address vaccine disparities, to address death and infection disparities are the same things you need to address, a host of other disparities, or a host of other issues, and I think that data point is one of the things that really struck with me too.

Rae Woods:
Is there anything else that you really liked or really struck you about their approach to reducing inequities in vaccinations?

Banjo Solomon:
Yeah, I don't think they called it this, but their ambassador starter kit, when they mentioned-

Rae Woods:
They should call it that.

Banjo Solomon:
They should. No royalties necessary. But just that concept of let's videotape the message you want to deliver, let's empower you with the FAQ so you can have those conversations. Because what we do know goes a long way to addressing hesitancy in any community, rural, doesn't matter. It's seeing and knowing people who receive the vaccine. So, actually empowering those people not just to say, oh, yeah, it happened to me, but hey, here's my story, and to amplify that, I love it.

Rae Woods:
Yeah, I loved that too, because it's a systemized approach and a scalable approach to community education.

Banjo Solomon:
Mm-hmm (affirmative).

Rae Woods:
Obviously, we like Parkland's approach, and it's certainly the most robust one that I've seen in the United States. But no organization has figured this problem out, and I don't think there are easy solutions to a problem as complex as health equity, and an issue as complex as legitimate vaccine hesitancy. Where do you think an organization like Parkland could be pushing further?

Banjo Solomon:
Personally, the place that comes to mind would be around the partnerships piece. When we have these conversations, and honestly, I've been guilty of this, we talk often about oh, religious leaders as a partnership. People trusted in the community. But I think to get to that herd immunity, the friends. Steve were talking about, that we know is the goal, we're going to need to make sure that our message is everywhere that these conversations are happening.

Banjo Solomon:
That may be unconventional places. In population health, we see in barber shops, other community settings, be really effective. I would say, again, this is where we need to be creative and scrappy, and not just following well trodden paths.

Rae Woods:
I think probably ready to repeat ourselves over and over and over and over again, because we do need to be everywhere that these people are. If I can reveal what makes me uncomfortable, there's two things that make me uncomfortable about the religious leader piece. One is I just get afraid that it's a stereotype. Like, let's go to black churches. But the second one that you and I are acutely aware of, because of some research that we're doing, is that the medical system has used religious leaders before for the wrong reasons, for experimentation, for exploitation, and those are things that are probably going to be front and center in folks' minds when they think about hesitancy.

Rae Woods:
It just comes back to your point of, it doesn't mean don't go to the religious leaders. But you also probably shouldn't just stop there.

Banjo Solomon:
Exactly. I think the real currency here is trust and figuring out, for the populations you're interested in, for those communities, who has trust, and how do you amplify their message, get them on board, and it's not just going to be religious leaders.

Rae Woods:
It might be places that you didn't expect. I love the idea that they haven't even quite turned on yet, but of high school students who are going to talk to their parents and their parents' friends. I would have never thought that, that would be an example of an ambassador that could establish trust. Anything else that, with all of your knowledge and experience that you think Parkland could be pushing further on?

Banjo Solomon:
Yeah, one piece of advice I've been giving, as I've been sharing some of this data and having these conversations is I show the aggregate national data of the breakdown of hesitancy, historical mistrust, et cetera. I'll just push Parkland there, for as rich as their data is in understanding at the block and individual level, the social determinants of health, do they have a sense for the different mixtures of, oh, in this community, how much of it is bing driven by mistrust, how much of it is being driven by hesitancy and tailoring their approaches, since we know those are two very distinct sets of solutions to those distinct origins of the hesitancy, if you will.

Rae Woods:
Maybe, even having different methods of capturing that data. So, if you're talking to folks about their questions with vaccines in the moment in the office visit, how are you actually also capturing that data to understand where their hesitancy is coming from and what people it's coming from.

Banjo Solomon:
Yeah. I think that it could be both. I might express hesitancy over some of the misinformation, are you also asking me, though, to get a sense of the historical mistrust. So, you're also addressing that, even though it might be the less comfortable conversation, especially for clinicians to be having.

Rae Woods:
Right. Parkland is obviously not starting from scratch, not with their health equity efforts, not with their social determinants efforts, not even with their vaccine programs. They mentioned a flu vaccine program that they had established pre-COVID. Most of the organizations that we work with, aren't that advanced. Do you have advice for folks that are at the beginning of their journey, they recognize that equity in vaccinations is a problem, they know that building trust is something that they should do, but they just don't know where to start?

Banjo Solomon:
The first thing I will say is, and conversations that often comes up is, oh, this is an additional thing we need to focus on, and I'm a believer in the power of defaults. Especially when you're early on in your journey, how do you start building in equity into how you think about success? I think of Fred's comment of, oh, you can be both fast and equitable, but I think that only happens if from the get go, you're thinking about, who are we missing? Who might our plan be missing, and asking those questions as you devise your strategy.

Rae Woods:
Well, Solomon, I'm going to ask you the same question that I asked of Fred and Steve, when it comes to reducing inequities in vaccinations, what's the one thing you want our listeners to focus on?

Banjo Solomon:
From a health system perspective, I echo what Fred said. I might focus then on drug makers and what my advice would be to those leaders, and I would say, this is the first thing we want them to do, which is increasing the supply of vaccines. But secondary to that, I would say, how can you enhance the range of support you're providing to healthcare providers to address vaccine hesitancy, to address historical mistrust, and really amplifying those messages, going above and beyond the technical support we know they're providing already?

Rae Woods:
Thanks, Solomon.

Banjo Solomon:
Thanks, Rae.

Rae Woods:
We were obviously very impressed with what Parkland has done, and I'm sure that you want to learn more. So, we've added some links in the show notes to some other articles that they've published about their robust process, and we're going to keep talking about the role of health equity in COVID-19, in vaccinations and in health care more broadly. This is an important and complex topic, and we want you to know that we're here to help.