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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. Friends, it's good to be here with you again. And this week, it's time for another one of those very special episodes where we get to break the rules a little bit and invite someone who, even if they haven't, like most of our guests, just published a new research article in the pages of Health Affairs, they do have some authentic and deep insight into the state of the health policy universe today. We're always so lucky to hear those perspectives and to learn from our guests' experiences.
Rob Lott:And today, we'll be learning from the one and only doctor Uche Blackstock. Doctor Blackstock is a physician and former associate professor in the Department of Emergency Medicine at, NYU School of Medicine, where she was also faculty director for recruitment, retention, and inclusion in the office of diversity affairs. She's the founder and CEO of an organization called Advancing Health Equity, which we'll hear about in just a moment. And she's an author. Her book titled A Black Physician Reckons with Racism in Medicine has been described as a generational memoir.
Rob Lott:It was published last year and was just recently released in paperback by Viking Books. Doctor. Blackstock, welcome to A Health Odyssey.
Uché Blackstock:Thank you so much for having me. I'm also gonna mention that it was an instant Legacy was an instant New York Times bestseller, which I think speaks to really the importance of the themes that the book covers.
Rob Lott:Oh, wonderful. Well, I can't wait to hear a little more about, your journey writing that book and what it's been like, talking to readers, over the last year. But first, maybe we can start with that you founded. I just mentioned, Advancing Health Equity, which describes its mission as, quote, partnering with organizations on their journey to eliminate bias and discrimination in health care. Can you tell us a little bit about what that looks like in practice?
Rob Lott:What's your day to day work? What kind of organizations are you partnering with?
Uché Blackstock:Yeah. So I I always call Advancing Health Equity my third baby. I have two kids, and I birthed this this organization about six years ago, really because I wanted to do work with health and health adjacent organizations in a way that was very authentic to me. And so through, several services like trainings, assessments, and strategic council, we help, as you mentioned, a variety of organizations on their health equity journey. So we work with nonprofits.
Uché Blackstock:We work with health hospitals and health systems, departments of health. We also work with pharmaceutical companies and even some non health related organizations that want to kind of learn more about what they can do in health equity space since we know that health care is not just about health is not just about health care. Right? So, we've really been able to do some wonderful, wonderful work. For example, we did a a department wide training with the New York State Department of Health over the last few years, and our recommendations to them after the training and assessment, influenced them to create health equity as their pillar, as one of the pillars for the Department of Health.
Rob Lott:Okay. Great. So, that's a that's a great example. And I'm wondering if you can sort of expand on that a little bit. To what extent is this kind of work focus internally with your partners sort of looking at things like organizational policy and practices, hiring, training, that kind of thing versus more external focus, like changing culture and societal structures.
Rob Lott:Is that even a useful distinction? How do you kind of look at those mentions?
Uché Blackstock:Absolutely. Because I feel like, a lot a lot of the work we do is both internal external facing. So we know that how organizations function, how and and what organizational culture is can influence, like, the work that that is being done even if the mission of the organization is one that, you know, is an alignment with our own. We know that there are lot of organizations that, you know, want to do the good work, but maybe don't know how to do it well in a in a culture way. But I think the other piece that is really important is thinking about how organizations engage with communities and patients.
Uché Blackstock:And so we also do those assessments, needs assessments with communities, focus groups with with patients. And we also look at policies. So we do what we call equity audits. So we look at organizations and institutional policies. We also look at policies involved with how these organizations interact with with community members as well.
Uché Blackstock:So in my opinion, the work is incredibly synergistic. You cannot do the internal facing work without doing the external facing work.
Rob Lott:So you founded the organization in 2019, I think. And we know there have been some pretty big external shocks since then, COVID nineteen, the George Floyd murder, these things have really shaped the health equity space in that time. But also I'm sure maybe you've encountered some surprises and unexpected realizations over the course of your work leading an organization like this. Can you tell us about some of those surprises you may have encountered?
Uché Blackstock:Yeah. You know, I think, you know, I think for a lot of organizations, you know, 2020 was that turning point for them and and thinking about health equity and and and and the factors that cause racial health inequities and what they can do about it. I think in the beginning, a lot of it was just sort of, like, level setting. Organizations just wanted to they want there were there's a lot of a lot of requests for trainings and, just spaces where people can have, like, courageous conversations about these really what so some people are uncomfortable about important issues. And then we noticed over the last few years that they've really been asking more for assessments, like organizational assessments, program assessments, and and we develop strategic reports and recommendations and strategies.
Uché Blackstock:And then now more so we're looking at more longer term engagements. So these engagements are engagements where we are counseling them on how do you integrate health equity into your strategic plan. So that it's something that is not necessarily in a silo, but it's something that everyone and every role within the organization is thinking about and that you have really clear goals for, you know, the next three to five years.
Rob Lott:Alright. Let's talk a little bit about your book, the title of which is Legacy, which I I understand is a reference to maybe at least two things. One is the legacy of racism and American health care stretching back centuries and really impossible to avoid today. But another is your mother's legacy. She went to Harvard Medical School, then so did you and your sister, making you all Harvard's first mother daughter legacy graduates.
Rob Lott:And in your book, write about how in the '80s and '90s, as you were growing up, she served as the attending physician in a public hospital in Brooklyn, the same neighborhood where she grew up. And you write about how she knew the community and the people she served intimately and practiced what we might today call whole person care. And so in her own day to day practice of medicine, she too was advancing the cause of health equity. Is that, a fair way to sort of describe, perhaps the sort of foundation of of her legacy?
Uché Blackstock:Yeah. No. Absolutely. And I think what what's even more profound is that, you know, my mother grew up in the same neighborhood in Central Brooklyn where she practiced. And unlike me, she had a very different set of of circumstances growing up.
Uché Blackstock:She grew up, in poverty, on public assistance, first person in her family to graduate from college, and then, through luck, fortune, and hard work ended up at Harvard Medical School, and really could have gone anywhere after Harvard Medical School. We know that most of the Harvard Medical School graduates go to some Ivy League affiliated institution for their residency and then stay there. But my mother, what was really important for her was to come back to her community. And so she came back to New York City, trained here, then worked for many years in the same neighborhood that she grew up in. And I think what is so important about that is that I think she had a really deep understanding of where her patients were coming from.
Uché Blackstock:And this understanding that we know health is not just about health care. It's about what's happening, you know, on a community level. And I think she and some other, you know, black woman physicians in our neighborhood, they had an organization where they would hold community health fairs, and they would make sure folks had access to, you know, housing housing advocacy groups and, groups that were doing work around food insecurity. So they were really thinking about, like, what health equity looks like, before that expression was even coined?
Rob Lott:Sadly, I know she died in 1997 when, you and your sister were 19. And, as someone myself who's also lost a parent in early adulthood, I can attest to my own experience at least that there's always something painful, but also maybe bittersweet too in a way when I think about everything they've missed since their passing, you know, achievements and disappointments, grandchildren's milestones and big world headlines, all the stuff, you know, we didn't get to share with them. And obviously, since you lost your mother, a lot has happened in your life, but also a lot has happened in health equity, as you said, and in our efforts as a society to confront racism in healthcare, an effort which she obviously was a part. What do you think your mother would make of the state of health equity in America today?
Uché Blackstock:It's it's interesting because in Legacy, I was able to include some of my mother's own writing from an essay that she wrote in the in the mid nineteen nineties. And and and in that essay, she talks about being a black woman in medicine, but she also talks about that the health disparities that she sees. And so thinking that so many years, decades later, you know, even though a lot of really wonderful work has been done and and we've seen some improvements, however, you know, we still see very profound, racial health inequities in this country. We actually see, like, all Americans not doing well. When we look at, you know, indicators of well-being, like life expectancy and maternal mortality.
Uché Blackstock:So that's for all racial demographic groups. But then when you look for people of color, indigenous, and black people, it's even more profound. So I think my mother would be, sadly disappointed, that despite advances in research, innovation, and technology, that we really haven't profoundly closed that gap.
Rob Lott:How would you describe the changes we've seen if we have seen changes in in the space over, the last five years since you founded this organization, but maybe to put a a finer point on it, over the last five months?
Uché Blackstock:Yeah. I mean, I think I would say five years ago, I felt so incredibly hopeful because, you know, I did you know, I founded Advancing Health Equity in 02/2019. It was before the pandemic, before George Floyd, I saw a need really to work with organizations on their health equity journey. Right? And so then when COVID happened, even though it was obviously horrible, horrible, George Floyd, horrible, but it kinda just validated, like, all of, like, the work that I thought was important to do.
Uché Blackstock:And it and it felt reassuring to see organizations dig, you know, dig dig deeper into that doing that work. And then and actually operationalizing what health equity looks like, like integrating it into their strategic plans. Right? Like, looking at what kind of data is collected. Right?
Uché Blackstock:And so and and then also thinking about health equity in terms of, like, quality improvement. Because when I think about health equity, I think about you want probably health outcomes for everybody. Right? Isn't that what everyone, not only in health care, but in this country wants? Right?
Uché Blackstock:That's what you should want. So, you know, I think that, you know, last few years, have to say that there were times when I could not even keep up with the client inquiries into the into the work that we were doing. However, that has totally shifted. Mhmm. Especially in the last five months, you know, I can personally say we had clients that have that are academic institutions that have canceled contracts with us because they are worried about being penalized by the federal government for doing health equity slash DEI work.
Uché Blackstock:I we've had delayed payments from from from from from organizations, federal agencies as they try to, you know, think about what's happening and as as as funds are frozen. And so it's I have to say it's, like, it's it's devastating to see to see this happening. I feel like there are similarities in some ways to 2020 to now and that in terms of a lot of uncertainty. But what I always thought then, I still think now is that we I still have to stay in alignment in in terms of the work that is important to do. And, you know, I think that there still are organizations out there that wanna do the work.
Uché Blackstock:And then also kind of maybe re framing how we how we speak about the work, the mission and the goals are still the same.
Rob Lott:Fair enough. I want to hear a little more about how you're, putting that mission into action. But first, let's take a quick break. And we're back. I'm here talking with Doctor.
Rob Lott:Uche Blackstock. We've talked about some of the recent changes we've seen in the health equity space over the last few years and the last few months. Going back a few years, Doctor. Blackstock, I know you held prominent roles in academia, associate professor, faculty director, big positions. But eventually you decided to step away from that.
Rob Lott:And in early twenty twenty, you published an article in Stats titled Why Black Doctors Like Me Are Leaving Faculty Positions in Academic Medical Centers. Can you tell us a little bit about how you made the decision to leave academia and some of the factors that, may have contributed to that decision?
Uché Blackstock:Yeah. Sure. You know, so I was, you know, I was in a department of emergency medicine, you know, at a, you know, well known academic, medical center. And, you know, even though it's one of the largest departments, of emergency medicine in New York City, and even though, like, it's in the middle of New York City, one of the most diverse cities in the country, it actually wasn't that diverse for a long time. For most of the time, was there as either the only black faculty or one of two black faculty.
Uché Blackstock:So it just didn't really seem to be, an awareness of, like, the importance of, you know, increasing diversity among faculty. But it really was you know, I did a lot of medical education work, which I really enjoyed. But about seven years in, I was appointed to a DI role in our school's office of diversity affairs. Super excited about it, tasked with focusing on recruitment and retention of women faculty and faculty of color, as well as students and trainees. And unfortunately, in that role, it was just a figurehead role.
Uché Blackstock:So it was very demoralizing when I found that out that I wasn't actually going to be empowered to do something in that role. And so I started thinking about, like, you know, is this kind of is this the environment that I really want to be in where I can't do work authentically and and show up as my full self? And so I made this decision. I know it sounds absolutely bold. And so I I decided to, you know, found my my my company advancing health equity so I could do the work the way that I wanted to do it.
Uché Blackstock:And then I thought maybe I'd stay part time in academia. But then it became really clear that I just kinda I wanted I wanted to leave. I just wanted to, like, kind of be free of these really, like, these institutions that I think, to be honest with you, I write about this in the stat piece. They were not they weren't even created with with black faculty in mind. They at the times they were created, they were created to exclude us.
Uché Blackstock:And so I feel like the remnants of that are still they're still there.
Rob Lott:Fair enough. I mean, perhaps with some distance now, you've you've been out for a a few years. How would you describe, what's what's working and what's broken? You've just sort of alluded to that here, about academic medicine more generally.
Uché Blackstock:Yeah. I mean, an interesting, like, to answer that question now because I feel like, you know, academic institutions, higher ed institutions are, you know, under more pressure. Right? Like, I just found out about this. Don't know if it's a proposal saying that, medical schools, can't use, like, there's a accrediting body called the l LCME, that requires that medical schools have diversity initiatives.
Uché Blackstock:They just kind of had to get rid of that. You know? So I feel like we are we're we're we're backwards. And I'm and I'm wondering how can we still do the work that's important, right, but under these very restrictive environments.
Rob Lott:So I guess in that context, I want to shift gears a little bit and sort of think about one of the starkest illustrations of how far we still have to go when it comes to health equity. One example is the really shockingly persistent disparities in black maternal mortality. And so, you know, here at Health Affairs, a policy publication, so often when assessing commentaries and perspectives, our editors look for pieces that describe a convincing mechanism or pathway that connects a given policy or lack of policy perhaps to various downstream health impacts. And so when we think about black maternal mortality, that crisis, I'm wondering if you can share some thoughts about what policies perhaps, what interventions or obstacles are translating to such devastating mortality rates among black women.
Uché Blackstock:And I always, like, use this statistic that even myself as a black woman with, you know, Harvard College and and and medical school degree, I still am, like, five times more likely than a white woman with an eighth grade education to die of mater maternal complications. Right? So, like, this is, you know, this is something that is not protective by your profession or socioeconomic status. And I think that, you know, when we think about the policies that would address this, it has to be policies that, you know, are, like, multifaceted policies. So, you know, obviously, about what the perinatal workforce looks like working on efforts to diversify that, looking at how the social determinants of health in in in black communities, how that impacts health, looking at, for example, even the climate crisis, and how we know that, black neighborhoods because of the legacy of redlining, they are essentially, like, these urban heat islands.
Uché Blackstock:And we know that that actually, is implicated in preterm deliveries. And so those are just obviously some some policies I think are important. The other one that I think is so important is thinking about, you know, a lot of the, the deaths that happen around, around birthing happen in the postpartum period. And a lot of it is because in this country, we have we don't have a mechanism or system in place to really care for people in that postpartum period. Most people will either just have one or two visits with their OB GYN, and that's it.
Uché Blackstock:And we know, like, the the Commonwealth Fund, you know, this is such wonderful, health policy work. You know, they talk a lot about and and and they've shown this in their data when you compare The US to other high income countries that, one, because we don't have midwifery centered model of care in this country, that that leads to more complications, and it doesn't treat the the pregnant person as a as a full, like, sort of along the spectrum as a as a whole person. The other issue is that we also need there to be systems in place so that people are followed after they give birth, followed very closely because, you know, people go home, they develop high blood pressure. There's no one taking their, you know, taking their their, readings, and then they develop preeclampsia or they're or they're hemorrhaging out. No one is going there to take care of them.
Uché Blackstock:And I think so I think paid family leave, paid sick leave, all of these really, I would say, policies that a lot of other high income countries have that we know improves, postpartum outcomes could make a real difference.
Rob Lott:So it's such a huge challenge, and I know this is one of your your focus areas. And I'm wondering if you could say a little bit just about how you keep from being overwhelmed when you've faced something so big as this. Or maybe a more realistic way to ask would be when you do feel overwhelmed, how do you cope?
Uché Blackstock:Yeah, I think recognizing that like this work is all about like sustainability and being able to do it in the long term and thinking about the long game. I also try to look for for hope and even in dark times. But I think also what I would recommend, I recommend for myself and other people, is really to look hyper local and locally at potential solutions. Right? So when everything seems so overwhelming, like I talk about in the book, there's a birthing center in Minneapolis called the Roots Birthing Center that was started by a black midwife.
Uché Blackstock:The mission was to provide dignified and respectful care to to to to black birthing people. And they've actually shown by this model that they have improving maternal complications and and and preterm delivery. So, like, there are a lot of really wonderful community based organizations very, very close to us doing a lot of this wonderful work. So we have to think about how we can amplify their work. How can we help fund their work?
Uché Blackstock:How can we, engage with them? So that gives that's kind of what gives me hope during these challenging times.
Rob Lott:That's that's a that's a nice way to to think about it. I I appreciate that. Before we wrap up, one question we often ask on this podcast is to ask folks to imagine if they could snap their fingers or make a member of Congress or governor or city councilor sort of take your advice no matter what you say or sort of however you imagine it, if you could change one public policy in order to make American health care more just and equitable, where would you start?
Uché Blackstock:Single payer universal health care.
Rob Lott:Okay.
Uché Blackstock:I'm I'm I'm a big supporter. I know that we we have the data that shows that this country, we spend so much on administrative costs. We're incredibly inefficient, and we have the worst health outcomes. And I don't well, I don't think single pane of universal health care will solve everything. I think it would make a significant dent in how, how people fare in life.
Rob Lott:And how do you sort of put that aspiration in the context of, you know, the next few weeks, the next few months, the next year of potential policy changes, if we can sort of acknowledge that we're unlikely to see that, you know, in the in the near term, what sort of more immediate changes do you think might move us from here to there?
Uché Blackstock:Yeah. I mean, I I also think well, one looking again, like looking local, I mean, there are looking local, state, I think there are a lot of really wonderful examples of localities and states sort of doing doing this work around making sure that, like Massachusetts, making sure that people have health insurance, you know, obviously supporting Medicaid expansions, even though we know that that's, you know, up for being cut as well. But I think advocacy piece is really, really important. So I am always contacting my legislators. You know, there are lot of really great apps.
Uché Blackstock:One is one is called five calls, where you can just, like, put in your your name, your ZIP code, and they'll they'll send a letter or a voicemail to to your legislators about these issues that mean a lot to you.
Rob Lott:Wonderful. Well, a great advice and a good spot to wrap up. Doctor. Uche Blackstock, thank you so much for taking the time to speak with us today.
Uché Blackstock:Thank you for having me. I forgot to mention I'm a huge fan of health affairs. Even though I'm no longer in academia, I love and look forward to the issues and and reading all the really wonderful articles that you published. So thank you for your work.
Rob Lott:Well, wonderful. Thank you. And of course, we're always eager to receive submissions and would love to perhaps see some pieces from you along the way, perhaps building on your book. Here's my segue, A Black Physician Reckons with Racism in Medicine, New York Times bestseller generational memoir available at bookstores now. And to our listeners, thank you all for tuning in.
Rob Lott:If you enjoyed this episode, recommend it to a friend, subscribe and tune in next week. Again, Doctor. Blackstock, thanks for your time.
Uché Blackstock:Thank you so much.
Rob Lott:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a healthy policy.