Twice as Likely to Die from COVID (with Dr. Joneigh Khaldun)

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Early on in the pandemic, people of color were nearly twice as likely to die from COVID-19. Those health inequities weren’t surprising to Dr. Joneigh Khaldun, who was among the first public health officials in the nation to demand her state of Michigan collect race and ethnicity data on COVID patients. In fact, solving them has been her life’s work. Now the chief health equity officer at CVS Health, Joneigh tells Andy where her passion for improving the health of underserved communities stems from, including her own personal experience being dismissed by doctors, and the tangible ways the health care system can do better.

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Andy Slavitt, Joneigh Khaldun

Andy Slavitt  00:18

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. It’s May 4. I know there’s a Star Wars joke in there somewhere for people. We have a really great show today. We also have a COVID wave we’re in the midst of. We also have a Supreme Court case that got leaked, how unusual. spend a minute on our guest. Before I talk about what’s going on with COVID Joneigh Khaldun is incredible. If you don’t know her, she’s named one of USA Today’s 100 Women of the Year, she was the head of the Department of Health in the state of Michigan. She’s currently the Vice President and Chief Health Equity officer at CVS Health. And she’s going to talk to us about what makes you twice as likely to die from COVID as others and related topics, including some of her own stories. She’s quite remarkable. So what is going on with COVID right now is we’re seeing a spike how bad a spike, it’s hard to really know. Because, you know, we don’t have as much of that PCR testing that gives us a sense of, of what’s happening every day. But we can put together a few things from what’s going on here and what’s going on in South Africa. But I thought it would be worth covering. We are experiencing a I think a few different things at once. In South Africa, which was the place where we originally saw Omicron, we are seeing new variations of Omicron that are turning up limits a little concerning that they’re turning up only five to six months after the last wave. And I think what we should be asking ourselves is does this mean that unlike the seasonal flu, which comes once a year, we’re going to see waves twice a year, variants twice a year, those are also coming to the US, although they’re not dominant, and around the world. So these little ripples of this infection seem to be spreading and mutating more quickly. Now they’re spreading along the Omicron line. So we are seeing drifting, not shifting, if you remember that phrase we learned on the show if you heard folks talk about it, or maybe it was me that talked about it, I don’t remember who talked about it. Maybe I didn’t even talk about it, but drifting is when you see different versions of Omicron continue shifting is when you see a whole another Greek letter. And drifting is better drifting means we’re getting, generally speaking, while slightly more contagious, slightly less severe forms and also ones that we are better protected against because they look a little bit more like what’s come before it.

Andy Slavitt  03:10

So that’s interesting. But what is also interesting to notice, there seem to be high levels of reinfection among people who had earlier versions of Omicron in South Africa, that tells us that that prior infection doesn’t protect us for long from infection that is, so a lot of infections going around a lot of infections going around in the US. I suspect we have levels of COVID that are seen at some of our highest peaks when we’re just not able to get visibility into them. And one of the ways I know this is because I checked with the sports leagues where they do test everybody every day, and they’re reporting in Major League Baseball, some of the highest levels of COVID that they’ve seen from a case standpoint. Now, what we don’t know is what this will ultimately mean, for more severe cases, for that particular question. I think the answer appears to be that we continue to see, relatively speaking, fewer very severe cases. And hopefully that means fewer deaths. So this layered immunity that we all have established, particularly if we’ve been vaccinated, it’s helping us a great deal. We haven’t been vaccinated; it’s helping us a lot less. So there’s a real benefit to being vaccinated and boosted particularly if you’re concerned that’s coming through. Still in all the data. Yet, I’d say that the current vaccines are not doing a great job protecting us against just pure infection. And you know what period infection is problematic. Sure, infection means missing work for seven to 10 days or school who can afford to miss work for 7 to 10 days, twice a year, twice a year. It doesn’t sound great. And of course the threat of having long COVID Even if you’re not going to die or go to the hospital. Many of us are worried about that there is a fantastic episode if you scroll back into everything we know about long COVID. And of course, COVID is still deadly for many people. We all know people who are sick, who have illnesses that make them more susceptible to COVID being serious for them, and just being old and frail, is one of them. So this is not a great picture that’s emerging, it is a picture that is more manageable, and it is a picture that is decidedly under the level at which you would see public health and political reaction. And we just have to know that whether or not you think that’s good? Do you think that’s bad? I’m telling you that, you know, we are in a place where a mild virus, even twice a year is a real problem, but not a problem. That is enough, that’s gonna see the bringing back of masks and mask mandates, court cases aside. So speaking of court cases, we have a very unusual event happening that you undoubtedly know about. On Monday, we saw the leak of a draft opinion, in the majority case that seems to overturn well does overturn Roe v. Wade, and Casey. And it’s quite shocking, even though it’s not unexpected in many regards. And, you know, we’re gonna get into that topic a little more on our Friday episode, our first Friday episode. In my conversation, Joneigh Khaldun, she talks about her experience in childbirth, I don’t want you to listen to it.

Andy Slavitt  06:40

What it reminds me is that, for all of the different opinions on abortion, the Supreme Court has essentially ruled that women will be forced to undergo what is a dangerous medical procedure. Giving birth is a dangerous medical procedure. I know it’s beautiful. I know that this is how we, our children are all born. I was in the room both times when my wife gave birth. And both times I had reasons to worry for her health. And the second time, she had an emergency operation. And I think as you listen to Joneigh Khaldun and relate her own experience. Among the many other things that go through my head, when I think about this court action, is the fact that we forget that this is a dangerous medical procedure that many women don’t survive. Many Black and Brown women survive at a much lower rate. And the court as essentially said, no, this is something that no matter the danger, no matter the impact on you, no matter the circumstances or the consequences, you must do. And as we talk more about all the meanings coming out of this case, this interview with Joneigh Khaldun really brought at least that part to the front, I think you’re gonna enjoy listening to her personal story, and her reflections on the healthcare system. And what essentially makes the healthcare system very, very, very dangerous for people and what makes COVID much more dangerous for some people than for others. So enjoy this, here she is.

Andy Slavitt  08:32

Dr. Khaldun Welcome to IN THE BUBBLE.

Joneigh Khaldun

Thanks for having me on.

Andy Slavitt 

What got you started in your career? What motivated you to enter medicine and enter healthcare?

Joneigh Khaldun  08:42

That’s a great question. I would say that I probably ended up becoming a doctor accidentally. My parents are both from the east side of Detroit. And they grew up literally a couple of blocks away from each other and ended up being high school sweethearts, getting married, etc. But I’ll tell you, the things I saw in my community in my family, and just the people of Detroit and underserved communities particularly really sparked something for me early on. My grandmother smoked like a chimney and unfortunately, she passed away too young because of her smoking and related diseases that came from it. But I think I just early on, felt a spark and a passion around improving the health particularly of underserved communities, and decided there was no better way to go about that then becoming a physician. So that’s kind of how I embarked in health and healthcare.

Andy Slavitt 

You know, the prevailing theory 10, 15, 20 years ago, about what goodness look like in health care was captured in the phrase the triple aim. We want to have good quality care for more people at a lower cost and satisfying way, and everybody could nod their head Add to that. But the thing that that mister seemed to me to miss when I was at CMS is you can have good average care for people. But the problem is there, nobody’s the average, that average could sometimes belie the fact that there are some people who get really, really good care. And some people with the exact same medical conditions, the exact same problems who live in a very similar area could give very bad care. And the outcomes could be quite bad. And so people started talking about health disparities, which then became an issue people talk more broadly that they refer to as health equity, for those people who haven’t heard that term before or have heard it but aren’t quite sure what it means. You tell us what that what good looks like when you think about health equity.

Joneigh Khaldun  10:48

Yeah, you know, I think and talk a lot about this. So you know, you can’t have quality without equity. There’s no equity without quality. And so what’s this buzzword to your point health equity, and quite simply, it’s just making sure that everyone has a fair and just opportunity to be as healthy as possible. That’s our definition of health equity at CVS health. But what does that really mean? It means regardless of this is how I kind of describing who you are, where you live, who you love, how you worship, right? So everybody, and that’s regardless of race, ethnicity, right? LGBTQ status, income, whether you live in an urban or rural area, disability, etc. And so it also recognizes that, quite frankly, we don’t have that in this country, I would argue we don’t have that across the globe. And the reason for that is not in most cases, it is not about a particular gene. There’s no gene that says that if you’re born in a particular skin color, you should have a lower quality of life or a shorter life expectancy has everything to do with how you experience the world. Not just within healthcare, I would argue primarily outside of a doctor’s office or a hospital, but access to education, housing, quality, jobs, resources, social drivers of health, what we call social determinants of health often, but I’d also argue you can’t really address health equity and think that a poverty, anti-poverty strategy is going to get you to eliminate health disparities, you have to address the isms, right? So racism, classism, sexism, ableism, etc. And the way that unfortunately, we divide ourselves and society and determine who’s more important than the other person. And then if you do that generation, after generation, after generation, you will find perpetual health disparities. And that is what we have in this country. That’s why we have a health equity crisis in our country.

Andy Slavitt  13:08

Just recently, Vice President Harris hosted an event in the East Wing, actually was in the White House that day, talking about maternal health in the Black community, and drawing attention to an issue that’s getting some increasing focus. And I’m wondering if we can use this as an example of what we mean. When we talk about a White woman and a Black woman, all things else being the same, are expecting a child, talk about what is going to happen differently. What is a Black woman’s going to experience differently than a white woman that most people don’t know about?

Joneigh Khaldun 

Yeah, I mean, that’s a perfect example of health inequities, and in a state that I like to talk about is relates to social determinants of health as well. So a Black woman with a bachelor’s degree or higher is 1.6 times as likely to have a poor pregnancy related outcome or die from a pregnancy related, poor outcome than a white woman that does not have a high school diploma. So it gets back to my point around it’s not just about poverty and giving people a house a job at a car.

Andy Slavitt  14:15

It’s not about education. It’s not about poverty.

Joneigh Khaldun 

It’s right. It’s about the experience. And so what’s the experience going to be so oftentimes, a Black woman will have less access, let’s talk about it more likely to be uninsured or underinsured in the first case, right? More likely to have difficulty accessing a provider with timely prenatal care, more likely to have less social supports when it comes to just kind of community and people who can support them and make their pregnancy and birth be a positive experience. More likely to have are less likely I should say to have a medical provider who looks like them or understands their cultural background experiences, more likely to experience care such that they feel their providers not listening to them or that they’re judged or being dismissed. I’d like to bring in my own personal experience. When I was having my first child, this was a while ago, because he’s almost 16. But when I was delivering my first child, the pregnancy was fine. I was healthy, I’d actually run track in college, I was pretty healthy, no medical conditions. And essentially, after the birth didn’t go, as I had anticipated, I ended up having a C section. I was having headaches afterwards. And I remember even the same day I delivered going to the nurse’s station and saying something’s not right, my head is hurting. They didn’t even look up. I remember at the nurse’s station; they didn’t look up. And they sent me home, I continue to suffer. At one point I was crying crawling on the floor holding my head in my hands. I had talked to my doctors, of course, everyone had had dismissed me. I’ve even talked to my kids pediatrician, who said, Oh, you know, you should probably follow up with your OB about that. It wasn’t until I called my own. This is my intern year in residency, I called my own colleagues, my own co resident, and asked them, you know, I think I just think I need to see somebody and they say what’s wrong, I said, you know, you need to come into the ER, I went into my own er, where I was an intern. And my program director diagnosed me with basically a head full of blood. Three weeks after he probably had initially occurred and ended up having emergency surgery now tell you, I wasn’t listened to. I was dismissed. And I think I know, if I was not a doctor, myself with doctor friends, I would like likely not be alive today. And so it’s the experience of just when you add so many things, and I had resources, right? But still my experience with health and health care, it can be very challenging to access to get people to I mean, when I go to the doctor, I try to dress a little nicer, I might sometimes put on a suit coat when I’m out and about if I want people to respect me, that’s what it means to live as a Black woman in America.

Andy Slavitt 

And to see this as overt biases. Do you see these as hidden biases micro aggressions? I mean, do you think people know that they’re in the medical establishment that they are demonstrating bias? Do they do they need to be trained and taught on that? Or are they know what they’re doing, and this is something that really needs to be just called out more publicly.

Joneigh Khaldun 

I do not believe as a practicing ER doctor, I still work a couple shifts a month, I do not believe that any clinician, Nurse Doctor otherwise comes to work every day wanting to advance perpetuate health disparities, and give disparate care I do not believe that exist. However, I do think that as human beings, we all have unconscious bias. I do believe that racism and the structures that are put in place in our healthcare system are such that they perpetuate disparities, you can even look at the workforce. And the fact that our workforce does not reflect our healthcare workforce, particularly at the physician level does not reflect the communities that we serve. If you look at who has insurance, who doesn’t have insurance, poverty, all those things contribute to your question about bias. I do think that we all bring our own biases, to our jobs, and particularly when you don’t come from or your personal experiences don’t necessarily resonate with the people that you’re serving, that can even be something about hair and skin and the health of someone’s hair and skin. And as a clinician just understanding that I as a practicing physician have often said no, you know, a black person’s skin should not look like that black people’s hair should not be falling out. I’ve literally had people tell me; I think that’s normal because they’re black. No, it’s actually not. So I think there’s subconscious bias and just structural racism that exists in the system.

Andy Slavitt  19:08

So I’ll tell you a quick story. I was a small part of starting an organization called it’s called Quilted Health. And the entire focus of quilted health is to provide maternal health care to Medicaid moms. And their approach is that they will get better outcomes, and that’s how they want to be paid. They will prove providing better prenatal care. There’ll be fewer babies that end up in the NICU. Fewer moms that deliver preterm, etc. And the CEO told me this story that when she went out into communities and told people she was going to do this, including talking to CEOs of hospitals and other prominent people. What you heard was Medicaid moms don’t care about maternal health and they don’t care about the health of their babies. And I will tell you that I didn’t even believe her so much that she was hearing that. So I asked the question, including of people in communities where I would not have expected to have that answer. And they said, oh, it’s a fool’s errand. And so what I then learned after that was that was obviously biased. But what I learned after that was that in so many communities in America, there’s not even access to an OBGYN, or access to other resources. So that women who are pregnant, oftentimes can’t even have one prenatal visit, get any prenatal advice, counseling, let alone images, and all the other things that so many other women just seeing as a natural part of the birth process.

Joneigh Khaldun  20:48

That’s right. That’s absolutely right. It’s lack of access, and you’re touching on the importance of poverty, right and place, which is so critical. And I’d also argue, when it comes to maternal health, we have to stop thinking of maternal health and infant mortality from the perspective of a woman being a baby making. That’s right, it’s got to be to the things you’re talking about, they probably have difficulty also accessing if you’re in a rural area for food, right. So good places to exercise, a contraception. So birth spacing, like those are the things that also contribute to having a healthy pregnancy, if you’re healthy beforehand, or have a baby, when you have decided that she wouldn’t you want to have a baby. So all those things play into it, obesity, have your blood pressure under control, health access to healthy food, transportation, like all those things, access to health care services. And so to advance health equity, you have to think comprehensively about all those things. And, and once you do get to the hospital, and are going to have the baby making sure your providers are listening, making sure I mean, we know that that you know, black women are at higher risk of having preeclampsia and preterm birth. So know that and make sure you’re listening, when they say they’re complaining of a headache, or when they say something’s wrong, listen, do the additional test. It’s really important.

Andy Slavitt  22:07

So then we have, I want to just kill keep moving through people’s lives here, because I think it’s so instructive. The effect of you know, you’ve talked about this, it’s not all about poverty. But I do want to talk about the effects of a certain type of poverty, the generational poverty, that has kept families, to a part of the structures of our society where they just don’t feel like the things that are there for most people are there for them. They’ve been trained that over generations, and where there is trauma, and the trauma is inherited, the trauma exists with people who are younger. And there’s an expression which you can help educate us about, there’s a bit of work on what people have called adverse childhood events, which you can explain to folks, which really, I think, indicate how important it is that the investments that we make in a young person’s life are so conditioned, what happens next. And we don’t recognize the fact that someone is born into generations of trauma and poverty, that you’ve got to do things different, or you’ve got higher amounts of risk.

Joneigh Khaldun 

Absolutely, I mean, you’re touching on something I could go on and on about this, but it’s something I worry about, particularly even with the COVID pandemic and knowing how many children particularly because that’s unfortunately how the pandemic has unfolded, black and brown children have been more, I’d say, deeply impacted by having a caretaker die, whether it’s a parent or grandparent. And so that’s an adverse childhood experience that you talk about. And so absolutely intergenerational trauma, adverse childhood experiences, and knowing how those adverse childhood experiences so the loss of a parent or caretaker trauma in the home, with substance use disorders in the home, all the things that we know, are crisis right now in America, what does that mean for our children, and also recognizing there’s clear data on the connection between those adverse childhood experiences, and those children in the future having high blood pressure, heart disease, shorter life expectancies totally doing now.

Andy Slavitt  24:16

Trouble in school, homeownership, just profound ties to the number of times a child has a traumatic event as a kid, and how that impacts almost every element of the life that they that they get a chance to lead? We forget that and so there’s a policy solution that went into place, called the Child Tax Credit, went in places, an outgrowth of the pandemic. And the statistics are pretty overwhelming. They would reduce childhood poverty by 50%. Sadly, we’re going to put this one probably more squarely on Joe Manchin shoulders, just to put a fine point on it. It was really the funding of the future child tax credits which were only Got it for two years, was one of the things that caused the biz build back better legislation not to pass it was something that that mentioned, wasn’t supportive of, or thought it needs to be adjusted pretty dramatically in terms of in terms of who qualified. And so I guess, you know, when people ask me, Dr. Calhoun, and I only have my only one person’s opinion, what’s the number one policy that would help health care? I said, well, the childhood tax credits is pretty good, pretty good as anything, yet it doesn’t look like that’s going to be a reality.

Joneigh Khaldun

Right, I mean, you’re absolutely right. You know, if parents can’t take care of, feed, clothe the children, I mean, the adverse childhood experiences, everything we just talked about just perpetuates. So you’re absolutely right. I mean, I worked on this when I was Detroit’s health commissioner. And I said to the mayor, we’ve got to go upstream, let’s focus on infant mortality, let’s focused on the health of our of our babies, that’s how you’re gonna get good health outcomes, 2030 years from now in the city. And we had some success and some of the work we did there. But I would agree with you focus on the children’s is that what we what do we value as a society, you know, and it’s got to be the kids.

Andy Slavitt  26:12

It feels like we spend the rest of our health care dollars and lives cleaning up after things we don’t do right at the beginning. And I’d remind everyone in this audience, the US spends about half per person in social services that the rest of the wealthy nations in the world do. So we under invest, it’s not as if we were wasting money, we’re not spending the money to begin with, you know, I’m sure there are isolated places where people are doing better and worse in this country. But as a whole, if you’re born poor, there is less to support you and more to indicate that you’re going to end up with more trouble than it’s true in most nations.

Joneigh Khaldun 

That’s right. And it’s unfortunate, again, you know, as from a public health and healthcare background, we also spend more on health care, but we have some of the worse outcomes of a kind of, quote unquote, developed country. So it’s we’re definitely not focused on the right things. We’re not focused on prevention. We’re not focused on our children, the mental and physical health and well-being of our children and our families. And that’s certainly unfortunate. And I wish it were different.

Andy Slavitt 

There’s a carryover to mental health and access to mental health and the air there equity issues there. I mean, first of all, we’re terrible at mental health in this country, period. Like everything else, I’m sure we’re worse for bipoc populations and rural populations and other more marginalized or ignored populations. Is it also true that, that mental health stigma is a challenge in underserved communities as well?

Joneigh Khaldun 

Absolutely. It’s all the same. So access to mental health services, access to diverse mental health providers, who actually would resonate with and who someone would actually want to see someone who they think would understand their background. We have issues with under and uninsured individuals, right. It’s really all, all the same thing. I’d also say that during the pandemic, foreign 10 Americans exhibited signs of anxiety and depression, that’s compared to one in 10, prior to the pandemic. So we have a crisis right now. And I’ll tell you, people are also for their mental health challenges, they’re more alert, not necessarily going to psychiatrists, they’re not going to therapists. If they’re presenting at all to any provider, they’re presented to primary care. And so when people don’t have access to primary care providers, that that’s a real miss as well. So absolutely. There’s a mental health crisis in our country and stigma, as well as it is another piece of that.

Andy Slavitt  28:56

Yep. And of course, there’s stories. I’m not sure what the data suggests that people in underserved communities and people of color are under prescribed medications, oftentimes, because of misconceptions, or beliefs that are, again, they may be unconscious bias, that exists within healthcare system, around providing medications into underserved communities, whether it’s around pain, whether it’s around mental health or anything else. And so then we ask ourselves, okay, if you’re Black, why don’t you trust the healthcare system? Right after all of this? We have, we wonder why people who have been served by a system don’t want to trust it.

Joneigh Khaldun 

That’s right. And that’s one of the thing that sometimes bothers me about the conversation around mistrust or hesitancy for vaccines or whatever it may be. When a group of people is for centuries marginalized, abused, Uh, the Tuskegee experiment, example, denied medication. And I think too, it’s also important. It’s not just historically, right. It’s two day, I described my experience as a physician in the health care system and thing, and I don’t think anyone comes to work in healthcare and wants to do bad things. But there certainly is bias. And it determines what tests we order, if or how we refer people to specialty services, and how we kind of think about providing services. So I absolutely think that it’s a crisis in this country.

Andy Slavitt  30:40

So let’s talk about what’s happened during the pandemic. I mean, we take all the things that we talked about, about how the system is already challenging, how there’s mistrust. And then how, you know, to such extent, I have described COVID, in many respects, is an occupational disease. It’s an age disease, but it’s also an occupational disease, if you work with the public every day, if you’re a frontline worker, if you get paid by the hour, if you’re a waitress, if you’re if you’re working out, you have more exposure, than if you’re sitting behind a desk in your house, on Zoom. That’s an occupation where you’re safer. What did the statistics show about how much less safe it was? For people of color than for white people during the pandemic?

Joneigh Khaldun  31:30

Yeah, and I’m certainly proud to have had the honor to be the Chief Medical executive for Michigan, helping to lead the COVID 19 pandemic response. And, and we were one of the first states actually, because I asked my team, I believe me algae team, we’re not releasing data that’s gonna look at race and ethnicity. So we were one of the first states to actually publish race and ethnicity data when it came to COVID-19 cases in that. So the data, essentially blacks and Hispanics, and this is kind of national data. Blacks and Hispanics are three times as likely to be hospitalized twice as likely almost twice as likely to die from COVID-19 has nothing to do with a gene, right? It’s all the things you talked about exposure, more likely to live in poverty, more likely to live in crowded or unstable housing, and more likely to have a lower income job where you can’t just say, oh, that’s fine, I’ll just work for my computer at home. So all the things that the CDC was recommending to do to protect yourself. Black and Brown people, by design of the system, over generations, were less likely to be able to do and so that’s what we saw play out with COVID-19. And why we saw the disparities.

Andy Slavitt  32:40

How much more likely were you to die from COVID. If you’re Black or Hispanic, than if you’re White?

Joneigh Khaldun 

Almost twice as likely to die. And again, let me also say, so it’s a little bit about exposure, but it’s also about things from well before the pandemic started. So you’re more likely to die from COVID. If you have an underlying chronic disease, high blood pressure, diabetes, you know, obesity, so those are the things that make you more likely to die from COVID-19. Because of the things we’ve talked about, already in this conversation, less likely to have access to care, more likely to live in poverty, not have access to high quality, nutritious food, all those things that contribute to people having underlying chronic conditions, though, which Black and Hispanics do have in this country. It’s not about genes. That’s why they’re more likely to die, increased risk of exposure, but then increased risk of having severe disease because of your underlying chronic conditions. And dare I say it’s particularly early on in the pandemic, that’s access to testing and treatments.

Andy Slavitt 

Yeah, I think I read somewhere, that being Black at 10 years to your life in terms of your risk factor, which also happens to be consistent with a lot of life expectancy, where the color of your skin, your zip code, can mean 10 years difference in your life expectancy. So it’s a really scary and sad way to think about it, that all of a sudden, you’re just 10 years older than the years you got to live.

Joneigh Khaldun  34:16

That’s right. That’s right. And again, it’s about place and space and not about genes. I think it’s important that people kind of recognize that. Because the reason why I bring that up is because people, when people hear about health disparities, I think there’s this sentiment of inevitability like oh, yeah, health disparities just exist, but no, they’re actually preventable. And if you focus and you’re intentional, you can decrease or dare I say eliminate the disparities that exist.

Andy Slavitt 

So when I was in the White House, we had a health equity Task Force, as you know, you were part of it on the transition, I believe. And so the first place that we opened up a federal site to distribute vaccines was Oakland, California. And the second place we opened up one was East Los Angeles. So historically Black neighborhood and historically Latinx neighborhood, the first day those sites were open. Would it surprise you to know that almost 100% of the people that showed up to the Oakland Coliseum were from San Francisco. And likewise, the people who showed up the zip codes where they showed up in East Los Angeles were from Beverly Hills. First time people got off that freeway exit. But here’s the point of the story. Once we learned that, we said, okay, well, we need to reserve times in these locations for people who live in these zip codes. That’s right. And when that happened, all of a sudden, we started to see the disparities gap close and vaccination rates, was it impossible. It wasn’t that people didn’t want to get vaccinated it was that people were working. And they couldn’t wait in line when a bunch of people came in from out of their area, and got the vaccines. So the lesson for me was it took a little extra effort. It took a little extra effort. And the thing that I’ve learned throughout my life, is everything worth doing takes work. That’s right. Everything we’re doing takes care. So we can complain about health disparities, we can say they’re bad. But if we don’t do something about them, do something specific, do something actionable, it doesn’t change. And guess what, when you make those steps, the thing about the pandemic that was so interesting is you get a real time feedback loop. It’s not like it’s not like, you know, blood pressure monitoring where you can’t measure the difference for necessarily, for 10 years, you could see right away that we had more people getting vaccinated. And to me, that was evidence that if you understand the situation, if you take action, if you understand the circumstances people actually live in and design around that you can solve the problem.

Joneigh Khaldun 

That’s absolutely right. And that’s what it also starts with data. Again, these disparities are not a surprise, but it starts with data. I mean, in the state of Michigan, I was proud. We were one of the first states, as I said, to look at the racial and ethnic disparities. And then kudos to Governor Whitmer and Governor of Michigan, she stepped in and said, Okay, Dr. Khaldun and team what should we do. And so we were very intentional about our policies about our even our messaging about partnering with trusted community members about making sure testing and resources were located in communities of color, make sure we understood what they needed. And we actually saw in 2020, we had a large, black white gap in cases and deaths. And we essentially over the span of about four or five months saw that gap actually closed. So by the time the fall came, ran around beginning of October, don’t quote me on this, but the curve and Michigan, if you look at it started with a big racial gap in the summer or early spring. And by the time we got to the fall that the gap was gone. As expected, I told my team this, it’s going to open up again. And it did, because the reasons for those disparities go back centuries. But we were intentional, similar to vaccinations, making sure we remember those days, we didn’t have enough vaccines. And I as the Chief Medical executive would determine who got what were in the state, we put some aside, we put some aside to be in vulnerable or say historically marginalized communities that they actually got access to vaccines, and we kept some to the side for them and community trusted community partners.

Andy Slavitt  38:58

To me, the core inside of what you’re saying is, equity doesn’t mean equality. In other words, if you recognize the isms, as you say, and the other structural disadvantages that exist, you have to do something to overcome it. So it’s not about giving the same number of vaccines to Beverly Hills as he used to lay. That’s not equity. That’s right. That’s sameness. And we can’t treat everybody the same where we’re gonna play into those biases.

Joneigh Khaldun 

because everyone’s not doesn’t start on the same footing. Now, do we want people in Beverly Hills to be vaccinated? Absolutely. It’s not about necessarily taking away and wanting one group to have poor health outcomes.

Andy Slavitt  39:42

I know people in Beverly Hills, they were gonna get vaccinated. They had cars and time and kids and websites; they were gonna get vaccinated. I wasn’t worried in the White House. That people with means weren’t gonna find their way there. I know people I heard stories people driving 6070 Miles Yep, to go get vaccinated, I was worried about the people who needed the vaccine to be right near them when they got off work. By the way, had to get home and cook a quick meal. And baby had a second shift. I was worried about those people getting vaccinated.

Andy Slavitt 

That’s right. That’s exactly right. And that’s how you have to think about it and be very intentional. Because if you’re not intentional health equity won’t happen.

Andy Slavitt  40:21

The other good result of which I think is, to your point about this is not inevitable, is I looked at the result of Medicaid expansion. And five years after Medicaid expansion, we saw a dramatic decrease in cardiac outcomes between black and white communities, oncology outcomes, improvements in maternal health and improvements in children’s health. And so, you know, we sit here and say, we have a bunch of people without insurance without access to care without a regular physician. And you could look at it and say, well, these people don’t care about their health. And in a way is, the more I thought about it as the most offensive thing I’d ever seen, because it was not malicious, but it was ignorant. And seeing the results of those studies, where those gaps did close, when we said, what happens if everybody has access to insurance, what happens if everybody has access to a regular doctor? Or it gets even, if it gets better? Those gaps close?

Joneigh Khaldun 

That’s right. And Michigan was a Medicaid expansion state and the Institute for Healthcare Policy and Innovation has done some great research analysis of what happened in Michigan, you’re right. gaps close, health care outcomes improve. And it’s not rocket science, right? Like get people insurance. You know, like people want in general, people want to be healthy. Just help break down the barriers, so that they can be.

Andy Slavitt 

So I’m going to embarrass you now. Dr. Khaldun, did such a recognizable job in the state of Michigan, that you were named, I believe, one of the 100 Women of the Year, can you tell us about that?

Joneigh Khaldun  42:04

Oh, thank you. So I mean, it’s, it’s certainly just been an honor, I was recently named US today, one of USA today’s Woman of the Year, a couple of months ago. You know, it’s certainly an honor and humbling to just be recognized for service and public service. And but you know, when I think about the awards, and I’m again, just honored, I’ve received several kinds of recognitions, particularly in in Michigan, but um, you know, it’s really a team effort. I was the public face and the governor, and we’re talking, I think we did over 100 115, whatever, live press conferences together. And so I’m the public face of COVID for the state, but man, that my epidemiology team, that the Medicaid team, I mean, people in other parts of government, local health departments, I mean, there’s so many folks who have contributed to pandemic response, and also what people don’t think about pandemic response, and all the other stuff that still has to happen. I mean, we were still addressing the opioid epidemic. And so kudos to my team that was still doing that. And so it’s certainly just been an honor, the honor of my life, quite frankly, to serve at this important time in our country.

Andy Slavitt 

That’s great. Well, look, I mean, you know, as you say, leaders can’t exist without great teams. But it’s also true that sometimes people need a leader to point to direction. And I was in touch with most states. And I really do believe that, despite all the division, that most people who were in charge, during this very chaotic time, one of the best, they didn’t want people to die, they didn’t want the economy to stagnate, had just a couple of obvious exceptions, who I think really probably have done a horrible job. But most states I think, would have tried their level best. You know, you had a lieutenant governor who I think, lost 21 family members. You had a young girl in Michigan, die early in the pandemic. I wonder if you could reflect on in some of those moments. And I’m really hoping you could do is just give people listening a flavor of what it must have been like, because when history is written and people see the good job that was done at all seems like everything was knowable at the time. But what was it like going through all of this? And can you describe some of those, those challenging moments?

Joneigh Khaldun  44:41

You don’t for me, I’d say personally. And then I also was practicing in the ER throughout the pandemic, seeing the stress on my team, my nurses, residents, students, other staff, other staff getting sick. That was quite hard in the beginning, when you knew that your colleagues were sick and We’re almost dying. Right? So that was difficult. But I’ll also say, you know, we got pretty divisive in Michigan, and there were some pretty scary things that happened. And I will, I’ll tell you, I’ll never forget walking through downtown Lansing in disguise, through the protests that kind of went national, with people with guns and all of that. That’s never anything I thought when I was getting my public health degree that I would be needing to do. And so I’m feeling that my life was potentially in danger and having to look at my child who said, Mommy, I don’t want you to die. When he was looking at the TV and seeing the protests, and I said, mommy’s gotta go, try to give the people a good message so they can live. That was a moment, I’ll always remember.

Andy Slavitt 

Was it scary?

Joneigh Khaldun 

It was scary. You know, but I’ve always just trusted out, just keep doing the right thing. You know, I think I’ve been put here. I really truly believe just the way things happen in my life. I was put here for a reason in that particular time to try to do what I could do. And I’m proud of the work. I’m proud of the work can I do it again.

Andy Slavitt  46:22

So when you think about back to the little girl, you were thinking about going into health care, losing your grandmother young, and the things you hope to accomplish? And that was just stipulate you’re far from done? […] How do you reflect on all that?

Joneigh Khaldun  46:45

I feel so privileged to be honest, I’m doing exactly what I want to do. People sometimes ask me, your ER, doctor, then you’re in government. Now you’re at CVS health. But what are you doing? And for me, if back to that story about Yeah, I guess being a doctor, but really, I like to do big things at scale to help the health of communities and particularly those who are most marginalized. And I’m going to be doing that the rest of my life. And so, I’ve just had, I’ve been blessed that I’ve had the opportunity to do that. And to help save lives in ways quite frankly, I didn’t even know when I took those jobs, whether it was chief medical officer Baltimore, you know, Detroit Commissioner, etc. I didn’t even know what was up ahead of me prior to taking those roles. But it’s, it’s I just feel like it’s an honor to be able to do my life’s work in this way.

Andy Slavitt 

Is experience taking its toll on you? Being around all the loss? All the grief?

Joneigh Khaldun 

I mean, who hasn’t? I’d say, you know, myself, but I’d say who has not experienced any some type of kind of, I don’t know, just mental exhaustion, from the pandemic, whether it’s in your personal or professional life. So I certainly am no exception. I worry about our public health workforce, I worry about all the people who have left governmental public health service, I worry about the pipeline of future public health leaders. That is something that I certainly worry about. But you know, I think I also gave a lecture earlier this week. And I’ve also become very intentional about taking care of myself, scheduling time, what I say yes or no to. And I learned that throughout the pandemic, because it’s what I had to do simply had to do to show up for my team, show up for the state show up for my children, my family. And so that is a lesson I’ve learned from the pandemic.

Andy Slavitt  48:45

Finally, I’ll ask you, what gives you hope, for the future that we’ve experienced over this last period of time and over the course of your career, both setbacks, and amazing surprise, accomplishments of progress. It is very easy to feel pessimistic at times. But I’m curious, you wouldn’t have gotten where you’ve gotten if you didn’t have hope and belief and determination. So what gives you what gives you the most hope for the future?

Joneigh Khaldun

You know, I believe we as a people are resilient. I mean, here we are talking vaccines have rolled out and you know, boosts etc. We were resilient. I believe we do have the resources quite frankly in this country to address health equity. You talked a little bit about LA and kind of how you intentionally redirected resources. I have the privilege of working at CVS health now and just all of the within a health care plan pharmacy benefit manager retail footprint. We have the tools we have the tools to advance health and health Care for our country for everyone. It’s just a matter of how do we all come together and do it and do it with intentionality. So that again, everyone has a fair and just opportunity to be healthy, which is health equity.

Andy Slavitt 

Well, thank you so much, Dr. Khaldun for coming on and coming in the bubble. It was a real joy.

Joneigh Khaldun 

Yeah. Thank you so much for having me on.

Andy Slavitt 

All right. That was a great interview, or at least I thought so. Coming up, our first ever Friday conversation. That’s right. We are now bringing in the Bible to you three times a week. And our first show was taking an in depth look at the recent Supreme Court leaks draft opinion from Justice Alito, on overturning Roe v. Wade, we’re going to talk about what will change for Americans with some great guests. If this ruling does indeed go through what to do if you live in a so-called trigger state, we’ll explain what that means. Who the helpers are, where are the solutions? That’s what we’re going to focus on a Friday conversations. And we’ve got some really great people to do this with. So hope you listen and hope you enjoy and give us feedback on Monday. We have Deborah Burks, who was from the Trump administration on the COVID task force. She was on the first task force I was on the Biden team and so it’ll be very interesting for us to get together and talk. She is apparently going to tell all about the Trump administration. She’s got a new book out. We’ll talk about that as well. And then Wednesday, we’re going to have a COVID update on the latest COVID Wave. Thank you all for listening. We will chat on Friday.


Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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