3-23-23 Urban Academic Medical Centers and Their Neighbors
March 31, 2023Information
3/23/2023
Cohen Auditorium and Zoom
Urban Academic Medical Centers and Their Neighbors: Then, Now, Next -- A Roundtable Discussion
Merlin Chowkwanyun, PhD, MPH
Author, All Health Politics is Local: Battles for Community Health in the Mid-Century United States
Benjamin Howell, MD, MPH, MHS
Assistant Professor of Medicine (General Medicine), Yale School of Medicine
Panelists
Mark T. Silvestri, MD, MHS
Virginia Spell
Katherine Tucker, DNP, RN, APRN-BC
ID9789
To CiteDCA Citation Guide
- 00:00Okay, hey, everybody.
- 00:02Hello people on zoom.
- 00:04Hello people here live.
- 00:06My name is Anna Reisman.
- 00:08I am the director of the Program
- 00:10for Humanities and Medicine and
- 00:11very glad to be here with you today
- 00:13for this talk on urban academical
- 00:15medical centers and their neighbors,
- 00:18I we have Merlin Chowkunyan,
- 00:21who is our keynote speaker.
- 00:23We also have moderator Ben Howell,
- 00:25and we have three wonderful panelists,
- 00:27and I will introduce all of them.
- 00:30Which will take me a few minutes.
- 00:31So but before I do that,
- 00:33I just want to say that Ben Howell is
- 00:36really the person who is behind this,
- 00:39this whole event.
- 00:40He will tell you about his
- 00:43longstanding friendship with Merlin,
- 00:46although they're just seeing each other
- 00:47today for the first time in a long time.
- 00:50But he approached me a couple months
- 00:52or probably six months ago and
- 00:54said can we bring Merlin in and.
- 00:57And can we put together a panel so it all,
- 00:59it all came together?
- 01:00Thanks to Ben. So thank you, okay.
- 01:04So Merlin Chakonyan is the Donald
- 01:06Jemsen professor of socio Medical
- 01:08Sciences at Columbia University.
- 01:11He trained in Columbia for
- 01:13his bachelor's degree,
- 01:14received an MPH from University
- 01:16of Pennsylvania and APHD,
- 01:18also from University of Pennsylvania.
- 01:20He's the author of all health politics
- 01:22is local community battles for
- 01:24medical care and environmental health.
- 01:27And is currently working on a book called
- 01:29Who Dies to be published by Norton,
- 01:31which reassesses how to think about
- 01:33the social determinants of health.
- 01:35He's also the Pi on toxic docs.org,
- 01:39a NSF funded repository that uses
- 01:42novel data science methods to make
- 01:44available millions of once secret
- 01:46documents on industrial poisons,
- 01:48and is currently serving on an
- 01:50expert advisory committee for
- 01:52the CDC on structural racism.
- 01:54So welcome,
- 01:56Merlin.
- 01:56Moderator Ben Howell is an assistant
- 01:58professor of medicine and the Yale
- 02:00School of Medicine with faculty
- 02:02appointments in the Sesh Center
- 02:03for Health and Justice in the
- 02:05program and Addiction Medicine.
- 02:07He received his medical degree
- 02:09from the University of California,
- 02:10San Francisco and an MPH from UC Berkeley.
- 02:14He completed residency and chief
- 02:16residency in the Internal Medicine
- 02:18primary care residency here
- 02:19at Yale New Haven Hospital,
- 02:21and following residency,
- 02:22he completed a health services research
- 02:24postdoc in the Yale School of Medicines.
- 02:26National Clinician Scholars Program,
- 02:28which is well represented here today.
- 02:31Clinically,
- 02:31Dr.
- 02:31Howell practices as a general
- 02:33internist both in the hospital and in
- 02:35outpatient settings with a focus on
- 02:36the treatment of substance use disorders.
- 02:40His research focus focuses on improving
- 02:42the health outcomes of individuals,
- 02:44families and communities impacted by
- 02:47mass incarceration and our panelists.
- 02:49So first, I will introduce Catherine Tucker.
- 02:53Who is the clinical program
- 02:55director for Heart and Vascular
- 02:57Center outpatient programs at
- 02:58Yale New Haven Hospital and the
- 03:00immediate past president of Southern
- 03:02Connecticut Black Nurses Association.
- 03:04She serves as the Yale New Haven
- 03:06Hospital DEI chair and the
- 03:08liaison to the Yale New Haven.
- 03:10Hospital president Doctor Keith Churchwell.
- 03:12She is currently the chair of the
- 03:14Target Blood pressure program and
- 03:16Barbershop initiative in New Haven,
- 03:17a collaboration with a heart and Vascular
- 03:20Center and the American Heart Association.
- 03:22Kathy leads A-Team,
- 03:23who works to educate communities
- 03:25affected by various health
- 03:26conditions like high blood pressure,
- 03:28diabetes and obesity by providing steps
- 03:30to improve health and quality of life.
- 03:33And Kathy received her bachelor's
- 03:36and master Science of Nursing from
- 03:38Quinnipiac and her doctorate of Nursing
- 03:41practice from Sacred Heart University.
- 03:43She is also a native of West Haven and
- 03:46currently serving as the Councilwoman
- 03:47for West Haven's 7th district.
- 03:49Welcome, Kathy doctor.
- 03:52Mark Silvestri is chief medical
- 03:54officer at Cornell Scott Hill Center
- 03:56Hill Health Center and assistant
- 03:58clinical professor in the division
- 04:00of Gynical Logic Specialties.
- 04:02At the Yale School of Medicine
- 04:04Department of OBGYN,
- 04:05doctor Silvestri originally came to
- 04:07Yale for his residency training and
- 04:09has stayed in New Haven ever since.
- 04:11He was also a postdoctoral fellow in the
- 04:13RWJ Foundation Clinical Scholars Program.
- 04:16He served as an administrative fellow
- 04:18with leadership of Yale New Haven
- 04:20Hospital and then joined the medical
- 04:22leadership of Cornell Scott Hill,
- 04:24a large,
- 04:25multisate,
- 04:25multispecialty community health
- 04:27system serving low income individuals
- 04:29across greater New Haven.
- 04:31And our final panelist is Virginia spell,
- 04:35who is currently the acting
- 04:36President and CEO of the Urban
- 04:38League of Southern Connecticut.
- 04:40With more than 25 years
- 04:42of nonprofit management,
- 04:43misses spell is focused on economic
- 04:46empowerment activities for
- 04:47individuals and families living in
- 04:49Fairfield and New Haven counties.
- 04:51Virginia spill is a longtime resident
- 04:53of New Haven and has worked on the
- 04:55community level to address racial
- 04:56inequity and racial segregation and housing,
- 04:58employment, and healthcare.
- 04:59She currently serves as president
- 05:01of the West River Neighborhood
- 05:04Services Corporation,
- 05:05shares the West River Neighborhood
- 05:07Revitalization Zone Committee,
- 05:08and is the chair of the Board of
- 05:10Directors for Continuum of Care.
- 05:12She also serves as a stakeholder in the
- 05:14Route 34 Corridor redevelopment project.
- 05:16Sispel is also an active member of the
- 05:19West River Community Resilience team.
- 05:21She's also a Co Pi on a multilevel
- 05:24multicomponent intervention,
- 05:25true Haven trusted residents and
- 05:27housing assistance to decrease
- 05:30violence exposure in New Haven.
- 05:32Welcome,
- 05:32Virginia.
- 05:35And I didn't say welcome Mark after
- 05:37I read yours, so welcome Mark.
- 05:41So the way this is going to
- 05:43work is I'm going to turn things
- 05:44over to Ben who will moderate.
- 05:46He will introduce Merlin briefly
- 05:49and and then we will hear from
- 05:52Merlin for about 2025 minutes and
- 05:53then our panelists will come up and
- 05:55Ben will moderate the discussion.
- 05:57We have a SL available for those
- 05:59people who need interpretation
- 06:01and closed captioning as well.
- 06:03And we should have plenty of time
- 06:06for your questions and comments.
- 06:08After we are done,
- 06:09so welcome everybody.
- 06:10Thank you for being here
- 06:16and I will keep my comments brief and so we
- 06:18can get to the the content of the evening.
- 06:20But as and I said I'm Ben Howell,
- 06:21I'm very excited that we were able to
- 06:24invite Merlin here to give his talk.
- 06:27As Anna hinted, when Merlin and I went
- 06:29to to college together at at Columbia,
- 06:31I should include that in my bio to to
- 06:32make sure there's actually a couple
- 06:34Columbia lions here in the audience.
- 06:36So we are well represented.
- 06:39We were both DJ's at the college radio
- 06:41station so there's a relationship that is
- 06:44spanned over over 20 years, but no one.
- 06:47Merlin published his book All
- 06:49Health Politics is local.
- 06:50I picked it up and a lot of the stories.
- 06:53Really resonated with it.
- 06:55My experience here in New Haven and
- 06:58with the role Yale New Haven has
- 07:00in the community here in probably
- 07:02many of the the tensions that have
- 07:04between the Community and the academic
- 07:06medical senator over the years,
- 07:08it seemed like a fertile opportunity
- 07:11to prompt a discussion for us today.
- 07:14So I'm really glad that we were able to
- 07:15get great panelists who represent many,
- 07:17many years.
- 07:18Of of work and and living here
- 07:20in the community of New Haven to
- 07:23help foster this discussion.
- 07:24Without further ado,
- 07:26I will see the podium to Merlin.
- 07:38Hi everyone, it's great to be here.
- 07:40I actually did a lot of research
- 07:42at Yale at the Sterling Library.
- 07:45I don't know where it is in
- 07:46relation to where we are,
- 07:47but I did a lot of research there and.
- 07:51I haven't been back to
- 07:51campus in a while though,
- 07:52so it's great to be here.
- 07:55I first want to say I'm just very
- 07:57appreciative of a lot of the labor that
- 07:59it takes to put on stuff like this.
- 08:01So I want to thank you again,
- 08:03Anna for running the series,
- 08:05Karen Cole back there for doing
- 08:07a lot of love behind the scenes
- 08:09scheduling and logistics,
- 08:10and of course Ben,
- 08:11the moderator and as he mentioned,
- 08:13occasional collaborator and as you also
- 08:16mentioned a guy I've known for 15 plus years.
- 08:20You probably don't remember this.
- 08:21In fact,
- 08:22I'm 100% certain you don't remember this.
- 08:24But you remember this part.
- 08:25So after college you worked for
- 08:28this dear and departed video
- 08:31store called Kim's Mondo Video.
- 08:33Other than days when people still
- 08:37rented DVD's and videos and stuff.
- 08:38And I remember one time,
- 08:40so I was still a little younger than that.
- 08:42I was still in college.
- 08:42I remember one time I really
- 08:45wanted to rent Titanic.
- 08:46Because I like Titanic,
- 08:47I sucker for romance and the
- 08:49kinds of emotions it starts out
- 08:51I really want to rent Titanic.
- 08:53And Ben was at the desk and you know,
- 08:56I knew he was a man of avant-garde,
- 08:59musical and aesthetic taste.
- 09:01So I really worried that he would
- 09:03make fun of me for renting Titanic.
- 09:05And so I actually thought about
- 09:07returning the movie on the shelf
- 09:09and coming back later time.
- 09:11But I decided not to do it,
- 09:12just went rented it and Ben
- 09:14did not make fun of me.
- 09:16Because he's a stand up great guy,
- 09:19and he still is, I'm glad to know.
- 09:23I'm also very humbled to be
- 09:25present with my Co panelists.
- 09:27I actually don't know a lot
- 09:29about New Haven history.
- 09:30One of the arguments of my book
- 09:32is that it's very important to
- 09:35learn about us locally specific
- 09:37characteristics of very specific places.
- 09:39And so I only know about New
- 09:41Haven in the broadest sketches.
- 09:43And so figuring out how the academic
- 09:45Medical Center as an institution has fun,
- 09:48how it's functioned here
- 09:49for better and for worse,
- 09:51is something I'm very much looking
- 09:54forward to dialoguing with you 3 today.
- 09:57So I'm very honored to be speaking with you.
- 10:01But Ben and mentioned that I've written
- 10:03this book and so I'll sketch out in 20
- 10:05minutes or so some of the things in
- 10:06this book that pertain to this larger
- 10:08conversation we're going to have today.
- 10:11Now this sounds like very crass marketing
- 10:14on one level and it certainly is,
- 10:17but on another level it isn't.
- 10:19I always say whenever I talk about this
- 10:22book that all the proceeds of this book,
- 10:24whether they're from book purchases
- 10:26or from talks I give about it.
- 10:29They go to my friend and comrade
- 10:32Sarah Nelson's labor union.
- 10:34President Nelson leads the
- 10:37Association for Flight attendants.
- 10:39This is the flight attendants union,
- 10:42and specifically my proceeds go to
- 10:44a Union Relief Fund that it runs
- 10:47for flight attendants who have been
- 10:49displaced by extreme weather events,
- 10:51many of which occur near airline hubs
- 10:54where a lot of flight attendants live.
- 10:57President Nelson is somebody who has
- 11:00been fighting for a vision of Labor
- 11:02organizing that sticks up for workers
- 11:04and better wages and contracts,
- 11:07of course,
- 11:07but it also focuses also on the
- 11:10larger communities and societies
- 11:12those workers live in.
- 11:14And that also includes sticking
- 11:16up for people.
- 11:17That is most of us who are not
- 11:20in unions as well.
- 11:21And it's really a model of,
- 11:22I think, ambitious,
- 11:24crosscutting political organizing
- 11:26that we really need right now.
- 11:28So I like to just mention President
- 11:31Nelson at the start of every talk,
- 11:33all right?
- 11:34Now,
- 11:34some of you might sense this title
- 11:37is actually a shameless rip off of
- 11:40former House Speaker Tip O'Neill and
- 11:43his famous quip that all politics is local.
- 11:46So if you're around in the 1980s,
- 11:49you know that Tip O'Neill was kind
- 11:51of the Nancy Pelosi of his time.
- 11:54He was also a very astute analyst
- 11:57of American politics,
- 11:58and when I was struggling with
- 12:00how to mold some of my material,
- 12:02I thought about O'Neill and something
- 12:04just really clicked by his famous line,
- 12:07all politics is local.
- 12:10O'Neill meant that the big swings
- 12:13in American life,
- 12:14whether it's changes in views
- 12:16on civil rights.
- 12:18Voter and political party realignments,
- 12:20even stuff like opposition to abortion,
- 12:23all those things.
- 12:24They don't fundamentally start with
- 12:26the Federal Congress or the Federal
- 12:29Supreme Court or national elections.
- 12:31They happen rather at the
- 12:33block and neighborhood level,
- 12:35and then they tend to bubble up.
- 12:37So if you really want to
- 12:39understand what's going on
- 12:40politically, you shouldn't just
- 12:41be looking at the national level,
- 12:43however important it is.
- 12:45You need to also zoom in and get granular.
- 12:49And so I took O'neal's insight
- 12:51and I slapped one word on it and
- 12:53I had a book title and framework.
- 12:56Now, his insight struck me as making
- 12:58a lot of particular sense for health.
- 13:00So most public health research
- 13:02of the kind that I do,
- 13:04and my colleagues as well,
- 13:05we prize this thing called generalizability.
- 13:09What we want to do is generate principles
- 13:12and elucidate causal relationships that
- 13:14are as universally applicable as possible.
- 13:18And so in public health work,
- 13:19you'll often get findings that say,
- 13:21X or Y variable affects Z health outcome.
- 13:25That's.
- 13:26Extremely useful information,
- 13:28for sure.
- 13:29But that quest for generalizability
- 13:32can also sometimes bleed out the local
- 13:35and specific context in which the
- 13:38people being studied are embedded.
- 13:41The people of New York, of Los Angeles,
- 13:44of Rochester, of Cleveland, and of New Haven.
- 13:48And yet that contextual stuff, I think,
- 13:51and Tip O'Neill certainly thought.
- 13:54Was and is hugely important.
- 13:57They're just often isn't a strong
- 13:59sense of specific setting or a sense
- 14:01of specific place in a lot of health
- 14:04policy discussion and public health work.
- 14:07And so I really wanted to restore
- 14:09that element here.
- 14:10I wanted to reinject local social topography.
- 14:14I want you, in other words,
- 14:16to see health policy not just as
- 14:20this unmoored statistical aggregate.
- 14:22Or just a national story like this,
- 14:24but I also want you to look at it like that.
- 14:29Okay.
- 14:29So I'm going to proceed now to three
- 14:32anchoring themes that I think will
- 14:34help us understand this historical
- 14:36role of the academic Medical Center in
- 14:39urban areas. And these are the themes.
- 14:41The first is affiliation or how
- 14:45academic medical centers increasingly
- 14:47become bound up with hospitals.
- 14:49And they're almost kind of unavoidable
- 14:51if you're in a city like this one
- 14:53or New York or Los Angeles or,
- 14:55you know, name your city.
- 14:57How did this affiliation process between
- 15:00academic medical centers and medical
- 15:02institutions like hospitals occur?
- 15:05Affiliation the second is community
- 15:07or how in the face of an institution
- 15:11like the Academic Medical Center?
- 15:13Academic medical centers have
- 15:15sometimes sought to bolster and
- 15:18include nonprofessional non physician
- 15:20voices of those who live around them,
- 15:23the community voice community,
- 15:25and the third is borders.
- 15:28So this is about the spoken but also
- 15:32sometimes unspoken boundaries that
- 15:34divide academic medical centers
- 15:36and those who live by them.
- 15:39And how that very tense and taught
- 15:42relationship has been negotiated over time.
- 15:45Now,
- 15:46before I head into the cases,
- 15:47I do want to say that there is sometimes
- 15:50a danger of drawing too tidy and neat
- 15:53of a parallel to a historical event.
- 15:56So a lot of the stories I'm
- 15:57going to tell you may remind you
- 15:59of something in the present,
- 16:01and I think that's useful.
- 16:02But I also think it's part of our goal.
- 16:04And This is why I'm really
- 16:05looking forward to our
- 16:06discussion. It's part of our goal also to
- 16:09figure out what's different and dare I say,
- 16:11also what has perhaps improved in the 40
- 16:15years hence stories I'm going to tell
- 16:17are all kind of in the 1960s and 1970s.
- 16:21All right. So with that note,
- 16:22let me start first with
- 16:24affiliation in New York City,
- 16:26where I just came from last night.
- 16:28So I want to take you back to 1961.
- 16:31I want you to just imagine you're
- 16:33regularly reading like the metro
- 16:35section of some New York City paper.
- 16:37So New York at the time and still
- 16:39now actually has the largest network
- 16:42of public hospitals in the country.
- 16:44Then it was around 20 hospitals,
- 16:46now it's about a dozen or so.
- 16:48But they were pretty beleaguered
- 16:50by the 1960s.
- 16:51And so if you were reading your
- 16:53newspaper on kind of a daily basis,
- 16:55you would encounter these hospital
- 16:56horror stories, dilapidated buildings
- 16:58that were falling apart,
- 17:01trouble staffing hospitals,
- 17:03difficulty attracting residents,
- 17:05you name it.
- 17:06This was a kind of a regular story
- 17:08in the late 1950s, early 1960s,
- 17:10about hospitals in New York City.
- 17:13And so the city did.
- 17:14What cities normally do
- 17:15and a thing like this,
- 17:16they convened a crisis panel and they
- 17:18said what are we going to do about this?
- 17:20And their solution to this was
- 17:22a kind of shock therapy.
- 17:24What they were going to do was they were
- 17:26going to take all of these public hospitals,
- 17:28almost all of which were purely public,
- 17:31city run, government run,
- 17:33government funded institutions and
- 17:35they were going to affiliate them
- 17:38with an academic Medical Center.
- 17:40The Columbia's, the Cornell's,
- 17:42the Mount Sinai's,
- 17:44the Montefiore's,
- 17:45you know, you name it.
- 17:46So it's essentially a subcontracting
- 17:49relationship whereby the academic
- 17:51Medical Center would get paid by
- 17:54the city to oversee everything from
- 17:57residency programs to staffing decisions
- 17:59to even infrastructural upkeep of
- 18:02buildings and stuff like that.
- 18:04And you see from this list here,
- 18:05this is from 1965,
- 18:07pretty much all of the public
- 18:09hospitals within a few years and all
- 18:12the fancy institutions got affiliated
- 18:14and coupled with one another.
- 18:17There's no need to read all of
- 18:18these individually,
- 18:19but the list just kind of conveys
- 18:22just how rapid and comprehensive
- 18:24affiliation was in New York.
- 18:27Now, as you can imagine,
- 18:28this probably did not sit well.
- 18:30This did not sit well with the
- 18:33previously autonomous public hospitals
- 18:35who really saw this as an incursion,
- 18:38a disruption of their autonomy on
- 18:41their longstanding ties that they had
- 18:44developed with their communities.
- 18:46So just to take one example,
- 18:48at City Hospital in Elmhurst in Queens.
- 18:51A group of advocates warned quote
- 18:54your family doctor can no longer
- 18:56be connected with your hospital.
- 18:58Your doctor may not be able to continue
- 19:01to maintain high standards of excellence.
- 19:04The kind of implication here being
- 19:06that Mount Sinai was going to come
- 19:08in and disrupt a number of people's
- 19:10patient doctor relationships,
- 19:12affiliations in many people's eyes
- 19:15also were really about something
- 19:17else. So just to continue
- 19:19reading off of that pamphlet.
- 19:20The conversion of public hospitals to
- 19:23affiliated facilities would result in,
- 19:25quote, a vast laboratory stressing
- 19:28research and teaching with its ward
- 19:32patients or and without influence
- 19:34serving as potential Guinea pigs.
- 19:37These were real fears.
- 19:38And I'm just sticking with this hospital
- 19:41in Queens just a little bit more.
- 19:43The County Physicians Guild also weighed in,
- 19:46and they characterized affiliation as,
- 19:48quote, forced absolutism.
- 19:50So those were all the claims about
- 19:54the possible horrors of affiliation,
- 19:58and some of them became true.
- 20:01So throughout the mid 1960s,
- 20:02we kept reading that newspaper.
- 20:04You would see that the newspaper started
- 20:07moving from covering the bad state of
- 20:10hospitals just in general to scandals
- 20:12around this affiliation program.
- 20:15It turned out that many of these
- 20:17academic medical centers were
- 20:19pocketing the government money and
- 20:21actually using it for other purposes
- 20:24besides running the public hospital.
- 20:26And even more scandalous,
- 20:28they were moving their least
- 20:30renumerative revenue generating patients,
- 20:32the ones that weren't making
- 20:34them a lot of money from bills,
- 20:35they were kind of moving them
- 20:37into the public hospital.
- 20:38So this is basically what
- 20:40we now call patient dumping.
- 20:42So the critique of affiliation
- 20:45starts to mount by 1968.
- 20:47There's one radical health advocacy
- 20:50organization that characterizes the
- 20:53affiliation program as exploitative and
- 20:56metaphorically it labels it a health empire.
- 21:00So the public hospitals,
- 21:01which are often utilized by poor
- 21:03patients of color, they are the colonies,
- 21:06and the private academic medical
- 21:08centers are the leeches,
- 21:10the colonizers.
- 21:10And this analysis was actually later
- 21:13expanded into a book that was published by
- 21:16Random House called American Health Empire.
- 21:19This was coedited by a health activist
- 21:23and writer at the time of someone
- 21:26by the name of Barbara Ahrenright,
- 21:29who plunged later into obscurity.
- 21:32So by the 1960s,
- 21:34with all of this, you know,
- 21:35this kind of mounting fatigue,
- 21:37newspaper exposes, etcetera,
- 21:38it was actually not very clear at all if
- 21:43affiliation would actually even survive.
- 21:45But affiliation,
- 21:46as we know, did survive,
- 21:48very much so.
- 21:49And that was because of a very new
- 21:52fiscal context that emerged in the mid
- 21:541970s rather suddenly when the entire
- 21:58country found itself mired in recession.
- 22:01And when cities like New York
- 22:03City were hit especially hard.
- 22:05So New York City almost famously
- 22:08defaulted on its debt in 1975.
- 22:11You see this famous headline
- 22:12here where the federal government
- 22:14refused to bail out New York City.
- 22:17And that plunges New York City
- 22:19into a very new and very jarring.
- 22:22Fiscal climate,
- 22:23kind of an austerity climate
- 22:25where budgets get very, very,
- 22:26very tight,
- 22:27budgets get slashed,
- 22:29and it was really hard for
- 22:31public hospitals to get along by
- 22:33themselves in a selfsufficient,
- 22:35independent manner with a city
- 22:37that is functioning under this
- 22:40kind of austerity sort of climate.
- 22:43Public hospitals, in short,
- 22:44were no longer in a fiscal position
- 22:47to sustain themselves without the
- 22:50resources that an affiliation provided.
- 22:53And so the fiscal climate of the
- 22:551970s, I think, is the central explanation
- 22:58for the ubiquity of affiliation today,
- 23:01and also the structural dependence
- 23:04that most public hospitals have
- 23:06in some way or the other on
- 23:09academic medical centers in cities.
- 23:11Definitely in New York,
- 23:12but also other cities as well.
- 23:15So, you know, whereas it looked rather
- 23:18uncertain in 1968 or 1969 about
- 23:21whether affiliation would survive,
- 23:23by the late 1970s,
- 23:25it's actually very hard to see any
- 23:28other means of sustaining public
- 23:30hospitals besides affiliation.
- 23:32And I still think that's the case today.
- 23:36There are very few health services
- 23:38now that are purely public that don't
- 23:40have some kind of contact with either
- 23:43an academic Medical Center or some
- 23:45kind of large healthcare network.
- 23:46And whether that's a good thing
- 23:48or a bad thing,
- 23:49I think is something for us to discuss now.
- 23:53I actually happen to think,
- 23:54and I was a little surprised
- 23:55to kind of conclude this,
- 23:57that I actually think New York City
- 23:59affiliation today works pretty well.
- 24:01There are more accountability mechanisms,
- 24:04more audits.
- 24:05Etcetera.
- 24:05To ensure that the sort of abuses I talk
- 24:09about don't don't happen at least as much.
- 24:12But we can talk about whether or not I'm
- 24:14being a little too optimistic there.
- 24:16Okay, let me move on to that
- 24:19second theme of community.
- 24:21I'm just going to admit I made a mistake.
- 24:22This should be in big letters.
- 24:23It should say community, but it doesn't.
- 24:26But in the 1960,
- 24:28there was this new agency called OEO.
- 24:31You know,
- 24:32Oreo without an ROEO,
- 24:34it's called the Office of Economic
- 24:36Opportunity during the Lyndon
- 24:38Johnson administration doled out
- 24:39tons of money to these really
- 24:41interesting Community level projects.
- 24:43It was actually run by Sergeant Shriver,
- 24:46the newscaster Maria Shriver's dad,
- 24:50and it had this rule called
- 24:53maximum feasible participation.
- 24:55So this basically was a mandate that said
- 24:58any community project that gets money.
- 25:01From these new OEO programs,
- 25:03if you get money,
- 25:05you have to have nonprofessional
- 25:07lay participation in how it's run,
- 25:10and usually this would be in the
- 25:12form of kind of a lay Community
- 25:14Board of some sort.
- 25:16But the big question, of course,
- 25:17is how much power do these lay
- 25:21boards really have?
- 25:22Now,
- 25:23what does maximum feasible
- 25:25participation actually mean?
- 25:27This is actually the exact words
- 25:29that were these are the exact words
- 25:31that were in the actual legislation.
- 25:33So in this book to explore this,
- 25:36I follow the trajectory of this
- 25:38community Health Center in the Watts
- 25:40neighborhood of South Central Los Angeles.
- 25:43Where most of Los Angeles's black
- 25:45population lived in the 1960s because
- 25:48of pervasive residential segregation
- 25:50and racism in the housing market,
- 25:52so the red shades here indicate that 90%
- 25:56or more of those census tracts are black,
- 26:00demographically.
- 26:01So this new watts center opens
- 26:04up here in 1967.
- 26:06That's a couple years,
- 26:07two years after the Watts riot of 1965.
- 26:11And it's a direct response to
- 26:14the huge resource deprivation
- 26:16that that Riot had exposed.
- 26:19And what this new center did
- 26:21was actually pretty ambitious.
- 26:22It was like $2,000,000 in $2,000,000 worth of
- 26:27money at at that level of currency valuation.
- 26:31It offered inpatient and outpatient services,
- 26:35and it opened to a lot of fanfare.
- 26:39But soon conflicts over governance
- 26:41overshadowed this kind of celebratory
- 26:44initial mood. One reason was
- 26:47that an academic Medical Center,
- 26:50the University of Southern California,
- 26:52the University of Southern California,
- 26:54or USC, was actually the one that was going
- 26:57to receive the OEO federal funds at the top,
- 27:01at the top for overseeing the project.
- 27:03So another thing about OEO was
- 27:05you usually had to funnel the
- 27:07money through some kind of inter.
- 27:09Intermediary middleman before it
- 27:10got down to the actual project,
- 27:13the Watts Health Center.
- 27:15So the intermediary here was USC.
- 27:18That produces no small amount of
- 27:22tension because in the past couple of
- 27:25decades USC have been rapidly expanding
- 27:27several miles directly north of Watts
- 27:30and bulldozing all kinds of houses,
- 27:33actual housing that stood in its way.
- 27:37There was this community organizer
- 27:39that I studied who was hired
- 27:41for this Watts health project.
- 27:42His name was Jim Bates,
- 27:44and for Jim Bates,
- 27:47USC's involvement aroused very
- 27:49justifiable suspicion.
- 27:51Jim Bates was a really fascinating guy.
- 27:53He was a black alumnus of USC.
- 27:55He had played football there a little bit,
- 27:57and then he went into community
- 27:59organizing and got hired by this project.
- 28:02And he wrote this memo where he
- 28:04summarized the sentiments and attitudes
- 28:07of watts residents rather bluntly,
- 28:09as follows.
- 28:10Quote we just don't want the
- 28:12University of Southern California
- 28:15in Watts under any circumstances.
- 28:18close quote,
- 28:20USC felt that suspicion right away.
- 28:23All three of the university's hand
- 28:25chosen administrators for this
- 28:27Watts Health Center were white.
- 28:29With the latter 2 assuming daytoday
- 28:31supervisor roles and you see
- 28:33them up there on the board chart.
- 28:35The other issue, though,
- 28:37wasn't just white administrators
- 28:39versus the mostly black neighborhood.
- 28:42And as the center's paid organizer,
- 28:44this guy, Jim Bates,
- 28:45also had a really thankless task.
- 28:48He had to form a mandated community
- 28:50Health Council.
- 28:51And it's highlighted over there
- 28:52and it says at the very top,
- 28:54neighborhood representation and cooperation.
- 28:56And he had to kind of build
- 28:59something to maximize that.
- 29:01But he really struggled from
- 29:02the outset to put it together.
- 29:05Now, Watts was mostly black,
- 29:07but that racial composition actually
- 29:09masked a lot of difference within watts.
- 29:13And this is actually a thing
- 29:14that I think isn't talked enough
- 29:16about both then and today.
- 29:18When we say Community,
- 29:19what do we mean by that?
- 29:21You know,
- 29:22what are the community's boundaries?
- 29:23Who is in it? Who is not in it?
- 29:25When we say Latinx Community,
- 29:27Asian community, black community,
- 29:29the community, you know who is in it.
- 29:31And when it comes to representation
- 29:33on a body like a community.
- 29:35The Navy Board who actually
- 29:36gets to sit on that body.
- 29:38And so that's what Bates was struggling
- 29:40with when he had to inform this,
- 29:42this Community Health Council.
- 29:44And what he ends up doing
- 29:46is he creates this really blunt tool.
- 29:48He's really exasperated over how to do this,
- 29:50but he creates this thing called
- 29:53a membership determining funnel.
- 29:55And it's basically a formula.
- 29:56It scores perspective Council
- 29:58members responses and interviews,
- 30:01and then he whittles them down
- 30:02by where they lived in watts,
- 30:04their age, their gender,
- 30:06how much education they had, etcetera.
- 30:08And he thought this was basically a crude
- 30:11but kind of ultimately necessary step
- 30:14towards creating an actual board that
- 30:16was at least somewhat representative.
- 30:19And I always take a look at this
- 30:21membership determining funnel thing,
- 30:23because it reminds me,
- 30:24actually of how hard it is to
- 30:27define and operationalize and
- 30:29implement something like community
- 30:31participation in real world practice.
- 30:33Here he was kind of trying to
- 30:35create as much variation and
- 30:38representativeness as possible.
- 30:40And to Bates and the center's credit.
- 30:43After these growing pains,
- 30:44this watts Health Center actually saw
- 30:47many decades of considerable success,
- 30:49and it also started to function
- 30:53eventually autonomously after USC
- 30:55phased itself out from the project,
- 30:57and it still exists today the center.
- 31:00I think one of the reasons for
- 31:02this was that there was this other
- 31:05fellow black physician named Rodney
- 31:07Powell who replaced some of those
- 31:09white USC physicians on the project.
- 31:12And he was somebody who I think
- 31:15really understood very sensitively
- 31:17the fraught dynamics and basically
- 31:19work to clarify how much power this
- 31:22Community council had and he basically
- 31:25proposed that it operate as a board of
- 31:27directors rather than get involved in
- 31:29every kind of little micro level decision.
- 31:32And I've always thought that Rodney
- 31:34Powell and that other fellow I
- 31:36was talking to about Jim Bates,
- 31:38they really exemplify too,
- 31:40just how important good interpersonal
- 31:43skills are when actually enacting
- 31:45something like community health or
- 31:47better relations between academic medical
- 31:50centers and projects like this one,
- 31:52and then the community at large.
- 31:54All right, my last case is about borders.
- 31:59So just imagine a black background
- 32:01and then it says borders.
- 32:03But I'll talk, you know,
- 32:05borders brings me to one of the
- 32:08less uplifting stories in my book.
- 32:10So I studied this area on the east
- 32:13side of Cleveland, which, like Watts,
- 32:16was also profoundly segregated and
- 32:19under resourced in the 1950s and 1960s.
- 32:22And I focused in particular
- 32:24on the Cleveland Clinic.
- 32:26So this is a map here that shows,
- 32:29yeah,
- 32:29the map here shows where the Cleveland
- 32:32Clinic is situated smack dab in the
- 32:34middle of this East Cleveland section.
- 32:36Now,
- 32:37I don't think I need to tell anybody here
- 32:40at a medical school that the Cleveland
- 32:42Clinic is not some quaint clinic.
- 32:45From the 1920s to the 1960s,
- 32:47the Cleveland Clinic developed
- 32:49into one of the most prestigious
- 32:51elite medical centers in the world.
- 32:542/3 of its clientele came from outside
- 32:58the county where Cleveland was located.
- 33:01And yet it was a profound contradiction
- 33:04because it was located in this
- 33:07neighborhood whose residents had pretty
- 33:09much no access to any of its fruits
- 33:13and. To add insult to injury,
- 33:16not only did the Cleveland Clinic
- 33:18not do anything for its low income
- 33:21African American neighbors,
- 33:22it also constantly expanded.
- 33:24So these are two aerial shots that I
- 33:27wanted to show you of the expansion
- 33:29over just a couple of decades.
- 33:31So on the left is the 1930s
- 33:32and on the right is the 1950s.
- 33:35And you can see on the left in the 1930s.
- 33:38There are homes there and then
- 33:41those homes are gone on the right.
- 33:44Side note, little side note,
- 33:46the Cleveland Clinic would actually
- 33:48not let me publish these in my book.
- 33:51And so I encourage you to take pictures
- 33:53of these and post them on Twitter,
- 33:56Instagram, TikTok, Reddit, Pinterest,
- 33:58and whatever else kids are using these days.
- 34:02This here is a map that kind of,
- 34:05you know, here, a little longer pose.
- 34:07All right.
- 34:09This here is a picture of a plan
- 34:12for a 30 block expansion where the
- 34:15Cleveland Clinic would have been
- 34:17the driving force behind this kind
- 34:20of new science and Medical Center.
- 34:22But as in Los Angeles,
- 34:24there was actually a riot in
- 34:26Cleveland in 1966,
- 34:28and that dramatically changed everything.
- 34:31The Cleveland Clinic executives
- 34:32actually really started to panic.
- 34:34They worried that people would actually
- 34:36come and torch the clinic next.
- 34:39They actually thought about picking up
- 34:41and just leaving Cleveland entirely.
- 34:43They pondered over whether or
- 34:45not they should set up their own
- 34:48private paramilitary force in case
- 34:50the National Guard was not enough.
- 34:52And they wondered,
- 34:54in their words whether they should start
- 34:56training what they called squad leaders.
- 34:59Who would be composed of men with
- 35:02previous combat experience and whether
- 35:04or not these men should be issued
- 35:06what they called ultimate weapons,
- 35:08which would be include firearms,
- 35:11pistols and rifles.
- 35:12For anyone who managed to enter a
- 35:16clinic building this kind of fear,
- 35:19the depth of this fear,
- 35:20a very racialized, very racist fear.
- 35:24I think really reflected widespread
- 35:27acknowledgement about medical
- 35:28exclusion in this neighborhood,
- 35:30not just among those who were excluded,
- 35:33but also among the excluders.
- 35:37And it actually ended up forcing
- 35:39the clinic to make a concession.
- 35:41So what it did was it promised it
- 35:43was going to build a primary care
- 35:46clinic on this east side of Cleveland.
- 35:49But the facility actually didn't
- 35:51get finished until the mid 1970s,
- 35:53almost a decade later.
- 35:55And for me,
- 35:56that clinic was always kind of 1/2 victory.
- 36:00By the mid 1970s, a lot of the energy,
- 36:02the political energy that had
- 36:04been unleashed by the riot kind
- 36:07of had disappeared.
- 36:08And so the clinic was actually
- 36:10back to its old tricks by the
- 36:121980s and once again expanding.
- 36:15And when it came to actual resources,
- 36:18the Cleveland Clinic really kicked
- 36:19in a pretty modest sum of money.
- 36:21It was about $200,000 for two years,
- 36:25but it was actually the county,
- 36:27the government,
- 36:28that ended up putting in most of
- 36:30the work and the money for this.
- 36:33You know,
- 36:34often times when an academic
- 36:35Medical Center is
- 36:36put on the defensive in a heated moment,
- 36:38it'll make all these kinds of lofty promises.
- 36:42But then when the moment is over,
- 36:44the commitments are often much more muted
- 36:47and modest than what they initially were.
- 36:50And so when you look at the picture
- 36:52of the clinic today, you know,
- 36:54it may have some more modest
- 36:56things that it does to reach out
- 36:58to its neighborhoods, neighbors.
- 36:59But the question I think still
- 37:02remains is this still an island
- 37:05in a sea of deprivation with a
- 37:08just a few nodes of contact?
- 37:10I think when many people think of
- 37:13an elite academic Medical Center
- 37:16with strained community ties,
- 37:18they tend to think of stuff like this
- 37:21stuff similar to what I've recounted
- 37:24here with the Cleveland Clinic.
- 37:26Let me close by reflecting in
- 37:27just my final couple of minutes,
- 37:29and I'm really looking forward to
- 37:31talking with everybody on just kind
- 37:33of what do we take away from this?
- 37:35Well, first,
- 37:36the experiences that I've described today.
- 37:40These kind of three cases,
- 37:41I think at the very least they did
- 37:45inaugurate very substantial zeitgeist change.
- 37:48So today there exists, at least minimally,
- 37:52some rhetorical commitment on the
- 37:55part of academic medical centers.
- 37:57To the residents around them,
- 37:59though you know how much that
- 38:02rhetoric actually moves.
- 38:03Beyond public relations, genuflection,
- 38:05of course, varies a lot,
- 38:07and that's something I'm really interested
- 38:09in getting into in our discussion.
- 38:11Second, a lot of these programs,
- 38:14like the Community Health Center in Watts,
- 38:16which again still exists,
- 38:17and the ones here in New Haven,
- 38:20New Haven is a place with,
- 38:21you know,
- 38:22some really good community health centers.
- 38:24They were and are actually very serious
- 38:27sources of not just medical care,
- 38:30but also training and jobs for
- 38:32people who live around them by
- 38:34virtue of their very existence.
- 38:36And that's no small feat either.
- 38:38They are part of a nationwide
- 38:41investment in longterm infrastructural
- 38:43improvement to alleviate stark
- 38:45maldistribution in medical care.
- 38:48I think we have to acknowledge
- 38:50and celebrate that third.
- 38:52I think an unresolved question is how
- 38:55much academic medical centers ought to
- 38:58be involved in these Community projects.
- 39:01So there's a wide spectrum of involvement,
- 39:04community projects,
- 39:05health projects that have no academic
- 39:07medical centers involved with them
- 39:09and ones that are basically run
- 39:11by the Academic Medical Center.
- 39:13And you know, I think instinctively because.
- 39:17People have heard and maybe seen things
- 39:20like the Cleveland Clinic's expansion
- 39:22in the in the mid 20th century.
- 39:24I think a lot of academic Medical
- 39:27Center involvement tends to
- 39:29elicit skepticism initially,
- 39:31understandably, and often rightfully.
- 39:33But I wonder if there's a way we can
- 39:36think about that a bit more rather
- 39:37than just dismissing it outright.
- 39:39And then fourth,
- 39:40I think it's worth probing what community
- 39:43participation should actually look like.
- 39:46This is a demand,
- 39:47both then and now,
- 39:48that morally,
- 39:49again,
- 39:49is very intuitive and very easy to
- 39:52get behind.
- 39:53But actually enacting
- 39:55community participation,
- 39:56defining what a community is,
- 39:59and actually acknowledging how much power
- 40:01that community does or doesn't have,
- 40:04those are much often harder questions
- 40:07that are sometimes glossed over.
- 40:09And then finally,
- 40:10I think we have to take stock of
- 40:12a very new landscape that's very
- 40:14different from the 1960s and 1970s.
- 40:16So as most of you in the room know on
- 40:19a health being at a medical school,
- 40:21Health Sciences campus,
- 40:23we're seeing a lot of mergers,
- 40:25acquisitions and consolidations in
- 40:27the healthcare space.
- 40:29These guys a couple years ago they tried to
- 40:31do something together and they ultimately
- 40:34pulled the plug on their initiative,
- 40:36but two of them.
- 40:38Amazon and JPMorgan are actually going in
- 40:41alone with their own healthcare venture,
- 40:44and it all makes the the local
- 40:47community battles around academic
- 40:48medical centers that I wrote about.
- 40:51You know about one hospital here,
- 40:52one controversy there,
- 40:54one community Health Center there,
- 40:56even one city.
- 40:57It all kind of seems a little
- 41:00quaint relative to the changes that
- 41:02might be coming on the horizon.
- 41:05Whatever we think of the
- 41:07academic Medical Center,
- 41:08we also may be heading towards a
- 41:10world where the Academic Medical
- 41:12Center is actually less central than
- 41:15it has been in the past half century.
- 41:17There are a lot of new actors in this space,
- 41:20and it leaves a lot of questions.
- 41:22And with that, I'm looking for this panel.
- 41:24Ben,
- 41:24should I just sit there and everyone else?
- 41:26Yeah.
- 41:31Yeah, actually, I'll ask our three
- 41:33panelists to come up as well. Dr.
- 41:35Tucker, Dr. Silvestri and misspell
- 41:38come up as well.
- 41:42I'm gonna take down the Basil's picture
- 41:47to move on.
- 41:50So we only unfortunately have one microphone.
- 41:53I obviously have a microphone up here,
- 41:55so you guys will have to share
- 41:58the microphone in your comments.
- 41:59When we the plan will be to have each
- 42:03of our panelists have 5 to 8 minutes to
- 42:06discuss some I will prime with a question.
- 42:08And then you can also reflect on
- 42:11what you heard from Merlin already.
- 42:14And after each of the three of you
- 42:15will potentially have a discussion.
- 42:16And then really open it up to the
- 42:19group as well as to people on the chat
- 42:21if they send in questions as well.
- 42:25First, I really want to obviously,
- 42:26Marilyn, you mentioned that New Haven and
- 42:28the specifics of Yale New Haven are not
- 42:31something you are intimately aware of.
- 42:32But rest assured,
- 42:33many of the things that you discussed
- 42:36as sort of do sort of permeate the
- 42:39history of this of our community.
- 42:41We are a highly segregated community.
- 42:45We are a majority minority city in a
- 42:48larger county that is majority white.
- 42:50Yale Mchaven serves as the Health
- 42:52Center for for both those community,
- 42:54both New Haven specifically and
- 42:56all the the suburbs and and most
- 42:59of southern Connecticut.
- 43:00We are sort of a community also
- 43:02affected by urban renewal and the
- 43:04deindustrialization of the midcentury.
- 43:06And so we had many of the issues
- 43:07that were affected,
- 43:08Cleveland and Los Angeles as well.
- 43:12I don't know,
- 43:13I'm just really excited
- 43:14about this conversation.
- 43:15I do want to acknowledge that the
- 43:18only human does has an obligation to
- 43:20report their Community health benefit
- 43:22and they do have a a triaminal report
- 43:25that they generate every three years.
- 43:27And you can look it up online and sort
- 43:29of see how they they report themselves,
- 43:31what are they doing,
- 43:32what they are doing for the community.
- 43:35They also report to the IRS how much
- 43:37of a community benefit in in monetary.
- 43:41Sense how much they they give back to me.
- 43:43I think it's on the order of $500 million,
- 43:46although almost 400 million of that
- 43:48is related to under compensated
- 43:50or uncompensated care that the
- 43:52hospital provides.
- 43:52So you can have a question about
- 43:54does that actually reflect the
- 43:56community benefit of the hospital.
- 43:58They're also the second largest employer
- 44:00in the city after the university.
- 44:04So with all those things,
- 44:05I do want to pivot to our discussion,
- 44:07I want to start with misspell as our.
- 44:10What's
- 44:14that? Oh, sorry for the camera.
- 44:16We got to get okay. We can reflect.
- 44:18We got mark in the picture now,
- 44:20so we can start.
- 44:22So although I do want to say that
- 44:24obviously I invited the three of you
- 44:26here because of your respective roles
- 44:27of Virginia role in the Community,
- 44:29Kathy, role in the hospital and mark
- 44:31your role the Community Health Center.
- 44:33But I want to acknowledge that all the three
- 44:35of you have many roles that you fulfill.
- 44:37And also that no person as Merlin
- 44:38mentioned can sort of speak for
- 44:41you know all the entity that all,
- 44:42the whole entity that they are representing.
- 44:44So with that caveat we will dive in.
- 44:47So I do want to start with Virginia.
- 44:50I generally want to hear your thoughts
- 44:53reflecting on what Merlin said and really.
- 44:56One question that always comes up
- 44:57sort of you are a New Haven resident,
- 44:59you live here in West River.
- 45:00I'm sure you have gotten
- 45:01healthcare here at Yelm Haven.
- 45:02I'm sure your neighbors and your family
- 45:04members have gotten healthcare at Yelm Haven.
- 45:06What is the perception of you and your
- 45:09neighbors of the care that they get
- 45:11or how responsive the hospital is?
- 45:13It's the needs of your community.
- 45:16I mean, we can, we can expand on that.
- 45:19But Virginia,
- 45:19if you could,
- 45:20at least 5 to 8 minutes to discuss that.
- 45:24So of course no
- 45:25community is a monolith
- 45:28and I can't speak for all of the residents
- 45:32in New Haven or even in West River Dwight,
- 45:35which is one of 10 communities
- 45:37in the city of New Haven.
- 45:39I think we've, we've always had a very
- 45:43tenuous kind of relationship with with
- 45:47the hospital and I think at the greatest.
- 45:53From a high level,
- 45:54I would assume that most folks
- 45:56are happy with their healthcare.
- 45:59I don't think anybody is unhappy
- 46:02with the service provided by
- 46:04Yellow Haven Health systems.
- 46:06There's been some changes with St.
- 46:08Rachel's campus, which I know we'll
- 46:10we'll we'll talk a little bit about.
- 46:11But for the most part,
- 46:14good care is provided by the health
- 46:16system in New Haven and I think most.
- 46:19Residents in the city would agree that
- 46:21that that we we receive good healthcare.
- 46:24What about how responsive the the hospital
- 46:26is to other communities beyond the
- 46:28individual care that the people receive?
- 46:34Well, you've really started something. So
- 46:38how residents in the city think
- 46:41about healthcare very broadly may
- 46:44be very different because you have.
- 46:47Communities that are significantly impacted
- 46:50by the change that happened with St.
- 46:52Ray fields, the change that's
- 46:54happened with you know removing
- 46:56the primary care service from the
- 46:58hospital and and sending it to.
- 47:03So my husband said 150.
- 47:05I was thinking about the healthcare center,
- 47:06so Cliff Cornell,
- 47:08Scott and and Fairhaven Clinic.
- 47:11So there there is definitely a
- 47:15strong feeling about whether or not.
- 47:17Community is represented when
- 47:19decisions like that are made about
- 47:22our healthcare and the greater
- 47:24impact that traveling to long
- 47:26north or traveling to a healthcare
- 47:29system outside of the hospital
- 47:30may have impacted families.
- 47:33Well, we can fill in some of the
- 47:35details for folks who don't know what
- 47:37specifically you're talking about,
- 47:38but you're referring to two things.
- 47:40#1, the Yamla Haven is now the only
- 47:43hospital in in our community where
- 47:45prior there were two hospitals, St.
- 47:47Rayfield's, the hospital Saint Rayfield's
- 47:49and and in Yamla Haven and now they
- 47:52are due to financial problems frankly
- 47:53at the hospital Saint Rayfield's.
- 47:55Yamla Haven purchased St.
- 47:56Rayfield's and so now there's only
- 47:58one hospital and two campuses and
- 48:00there we're still living through
- 48:02that legacy of that change.
- 48:03The second one is that when
- 48:04you don't even bought St.
- 48:05Rafael's,
- 48:06they moved some of the primary care
- 48:08services they provided there to a
- 48:10different location that instead
- 48:11of being in the community was
- 48:13arguably outside of the community.
- 48:15And that is something again and
- 48:17actually a good pivot to our
- 48:19representative from Cornell, Scott.
- 48:20Some of those primary care service
- 48:22previously offered by the hospital are
- 48:24now offered by the Community health centers.
- 48:26So with that we'll pivot to
- 48:28doctor Silvestri to Mark so.
- 48:30Cornell Scott is living the
- 48:32legacy of the OEO and then those
- 48:35innovations in the 60s and 70s.
- 48:38Still the the Community Health
- 48:40Center movement that started then
- 48:42and was funded as part of the
- 48:43Great Society is is is persisting
- 48:45now as Marilyn mentioned.
- 48:48So how how is I mean there are and
- 48:50that you I would love you to expand on
- 48:52what that means for Cornell. Scott.
- 48:54As far as their maximum feasible
- 48:56participation of the community,
- 48:59how Cornell Scott responds to community
- 49:01needs and also how they potentially fill
- 49:03in some of the gaps where potentially
- 49:05other healthcare systems aren't
- 49:06providing the care that the community
- 49:08needs and and can expand on that,
- 49:11sure. Thanks Merlin for a very
- 49:15engaging and entertaining also talk.
- 49:21Sometimes I wish I had lectures
- 49:22as engaging as you back when I
- 49:24was in school, but I think so.
- 49:29It's it's part of the nature and the DNA
- 49:31of how federally qualified health centers,
- 49:33or community health centers as
- 49:34they're colloquially known,
- 49:36were originally set up and established
- 49:39and by law are governed that we are
- 49:44kind of inextricably bound to our.
- 49:47Community, our Board of directors is
- 49:50comprised of at least 50% patients
- 49:54and members of the Community
- 49:56and that's by by federal law.
- 49:58But you know,
- 50:00I think it's probably even more
- 50:02importantly been part of just
- 50:04the DNA of who the organizations
- 50:05are from the very beginning now.
- 50:07I mean Cornell Scott Hill Health Center,
- 50:09which was originally Hill Health
- 50:10Center and then subsequently named
- 50:12after our founder Cornell Scott,
- 50:13the Cornell Scott Hill Health Center.
- 50:16Was originally formed by a partnership
- 50:20between members of the Hill
- 50:22community and members of the school.
- 50:24But the you know that that
- 50:26it's we're independently,
- 50:29we're an independent nonprofit
- 50:31and apparently governed by that
- 50:32board of Directors that remains
- 50:34majority community members.
- 50:35And so I think there are a number
- 50:37of elements of what we do that
- 50:39allow us to to remain plugged
- 50:41in with the Community and to try
- 50:43to be responsive to those needs.
- 50:44And it it's tied into just the nature.
- 50:47I think even of well it starts with
- 50:49a I think that we have a community
- 50:52outreach and marketing team and you know,
- 50:54their job obviously is to let the
- 50:57Community know about what we're
- 50:58doing in the services available,
- 50:59but it's also to get feedback from
- 51:01the community and bring them to us.
- 51:02So I mean they're doing obviously
- 51:04marketing and outreach events,
- 51:06but they're also doing mobile
- 51:08vaccination or or health clinics.
- 51:09And so all the time they're bringing
- 51:10back feedback to us, you know.
- 51:12For those of you know Carla Estelle Bragg,
- 51:14our director mark,
- 51:15they say it's taking four months to
- 51:17get a new primary care appointment
- 51:19that's too long.
- 51:20What can we do about that,
- 51:21you know and so we kind of get this
- 51:24real time ongoing feedback that I
- 51:26mean we want to be responsive to and
- 51:27guys what we do then we have medical
- 51:29services that are in the Community,
- 51:31not just our mobile health events but
- 51:32our school based health centers where
- 51:34we're in you know over a dozen schools
- 51:35we're interacting with principals,
- 51:37with superintendents,
- 51:38with parents and others there.
- 51:40Our homeless healthcare team that's
- 51:42in the shelters on the streets,
- 51:45interacting with harm or dust
- 51:47reduction task forces,
- 51:49trying to be responsive to the
- 51:51needs of particular communities.
- 51:52So the I think there are a number
- 51:55of ways that we try to obtain
- 51:57information and make sure that
- 51:58we know how the Community is
- 52:00feeling so we can be responsive.
- 52:01That's that's why we exist.
- 52:03If we if we cease to do that,
- 52:05we sort of lost,
- 52:07lost our way.
- 52:09So that to to push us a little
- 52:11bit on this relationship with
- 52:12the the Community Health Center,
- 52:14Cornell Scott and Yell New Haven is kind
- 52:16of like a triangle the the community,
- 52:18the hill Cornell Scott and then yell New
- 52:20Haven Hospital which is down the street.
- 52:23I'm sure that relationship between
- 52:24Cornell Scott and the hospital
- 52:26has evolved over the years.
- 52:29Can you speak to that a little?
- 52:30What are some of the tensions that
- 52:32you guys have when trying to both
- 52:34obviously serve the the same,
- 52:35the same community?
- 52:36What are ways that I can potentially
- 52:39improve that relationship going forward?
- 52:42Sure. And I know there are many
- 52:43in this room that have been
- 52:44here a lot longer than I have.
- 52:46I've lived in New Haven for 14 years,
- 52:49but I do I personally feel
- 52:51like I've seen an evolution
- 52:53even over even over that time.
- 52:56I would, I mean,
- 52:57I would say that. My impression,
- 53:00at least if you go back 15 years or so,
- 53:02was that it'd be the relationship
- 53:05was a little bit like 2 neighbors who
- 53:07live next to each other peaceably.
- 53:09Not, not a lot of hostility necessarily,
- 53:10but they don't necessarily
- 53:11interact or talk that much.
- 53:13I mean, you know,
- 53:15peaceable coexistence maybe or I
- 53:17think in in more recent years we've
- 53:21developed, I think it was a much
- 53:24more functional partnership where
- 53:26both organizations are leveraging.
- 53:28The the strengths and the strength of
- 53:34one another and and appreciating you
- 53:37know what we need to bring to the table
- 53:38and can bring to the Community also.
- 53:39So I think in that regard I mean
- 53:42and there's there been a few changes
- 53:44that I think have led to that.
- 53:46There's been, there been a lot more kind of
- 53:51transfers of folks between the organizations.
- 53:54You know, people who've come from the
- 53:56hospital or medical school to Cornell
- 53:57Scott or vice versa are sharing
- 54:00of an electronic health record,
- 54:02which kind of runs everything of how we do.
- 54:04That leads to a lot more visibility and
- 54:07transparency between the organizations.
- 54:09And then this partnership,
- 54:11ultimately the Primary care consortium
- 54:13with us adopting the primary
- 54:16care clinics from the hospital,
- 54:18we're at a place now and we can go
- 54:20into more details where I really think
- 54:22that we are able to take advantage of.
- 54:24Some of the resources of the Academic
- 54:26Medical Center and they're able to
- 54:28recognize and appreciate and let
- 54:30us do kind of what we do best.
- 54:32So I think there's still opportunities
- 54:35for for for work and.
- 54:38And if you want me to go into
- 54:39those now, no, no I think we
- 54:41should give give a doctor Tucker
- 54:42Kathy some time to talk as well.
- 54:44But that thank you for those comments.
- 54:47So. So Kathy you have worked at
- 54:48Yale New Haven for a long time
- 54:50and actually lived in in the
- 54:51greater New Haven for even longer.
- 54:53So you said both as a role
- 54:54in the hospital and a role,
- 54:55an important role in the Community.
- 54:58From your perspective how has that
- 55:01relationship between Yale New Haven
- 55:03and the Greater New Haven area evolved?
- 55:05And also I'd love to sort of because I think.
- 55:08Sometimes we people have a closed
- 55:10minded view of sort of the pressures
- 55:11at the hospital feels and I'm sure
- 55:13that you can speak to some of the
- 55:14pressures that the hospital feels
- 55:15about like they maybe they would
- 55:17love to do all these great things,
- 55:18but they're both financial and other
- 55:20pressures that limit what what they can do.
- 55:22So I'd love to to expand on
- 55:24those type of things if you can.
- 55:25Yeah, yes, I am a 27 year
- 55:29employee of the hospital.
- 55:31So I've been here, I grew up,
- 55:32all my nursing career has
- 55:34been here at the hospital.
- 55:35And I've seen the tensions over the years.
- 55:37I've seen the fights and the battles
- 55:39over the years between the community
- 55:41and the hospital and have learned
- 55:43a little bit about, you know,
- 55:44what it feels like to be on both sides of,
- 55:47you know, of that experience.
- 55:50I do happen to know because we're the
- 55:52ones that are charged with fixing it.
- 55:53You know, when when things go go
- 55:56wrong or they're not going very well,
- 55:58you know, so that it lands in our laps.
- 56:01But it's a real important thing
- 56:03to know that I think that the.
- 56:05The message really from the
- 56:07hospitals that they hear us,
- 56:08but it's a hospital first and a lot
- 56:11of times their position seems to
- 56:14not necessarily connect with the
- 56:16messages that are going on outside,
- 56:18but there's real work going on on the inside.
- 56:20And I know that personally
- 56:21because we've all been, you know,
- 56:22the people that kind of are
- 56:24trying to do the work.
- 56:25And I can just kind of Fast forward
- 56:27to now to say this is what I can tell
- 56:30you is happening now in the hospital.
- 56:32There has been the establishment of
- 56:33what is now the office of HealthEquity,
- 56:36right?
- 56:36Just based on all of the things that
- 56:38we know about health disparities and
- 56:39what we're showing up like in the
- 56:41Community or not showing up like in
- 56:43the Community and what we should do about it.
- 56:45There's a real effort to try to
- 56:47shift the culture of the organization
- 56:49internally and really just focus on
- 56:52teaching the employees in the hospital
- 56:54what they can do about addressing
- 56:56the social needs of the Community,
- 56:58social determinants of health.
- 56:59And things of that nature.
- 57:00So there's a lot of work going on there.
- 57:02There's been the establishment
- 57:04of relationships with community
- 57:06based organizations.
- 57:06So now we're asking patients about their
- 57:08financial needs and their transportation
- 57:10needs and their housing needs and such.
- 57:12There's an actual a mechanism that we can
- 57:14now use to connect people into the care.
- 57:16So it was one thing to ask the question and
- 57:19then not be able to do anything about it,
- 57:21but there's been a lot of effort on the
- 57:23part of the organization to really,
- 57:24you know, build those bridges.
- 57:26And then,
- 57:27you know,
- 57:28give US resources to kind of connect
- 57:30people into those resources to really
- 57:32help some of the other work is around
- 57:34the Community health needs assessment.
- 57:36And it was really interesting for
- 57:37me to hear part of the discussion
- 57:39talking about what is community,
- 57:40because that's been the age-old question.
- 57:42What is community?
- 57:43What does that look like?
- 57:44Who is the community and
- 57:46what we decided to do.
- 57:48And I do a lot of work as the
- 57:49liaison to Doctor Church.
- 57:51Well,
- 57:51now this is a recent appointment.
- 57:53But the work with the office
- 57:55of HealthEquity was really to
- 57:56kind of like to find out what,
- 57:58what do we mean by community and to
- 58:00do some work trying to kind of unpack
- 58:02the results of the Community health
- 58:04needs assessment and then reimagine
- 58:05what it can look like going forward.
- 58:08So a lot of what, you know,
- 58:11we did this past cycle was to really
- 58:14kind of like lean into the employees
- 58:17of the hospital who are residents.
- 58:19Of the community and use those folks
- 58:22and their opinion and their feedback
- 58:24about what could be done as a hospital
- 58:27better for them in the community.
- 58:28So that's kind of where we started, you know,
- 58:31trying to make some shifts and we're,
- 58:33you know, again,
- 58:33doing a lot of work going forward
- 58:36about the next cycle of the
- 58:38community health needs assessment.
- 58:39So
- 58:39yeah, that's why I have a I
- 58:40could ask a lot of questions,
- 58:42but I do want to let.
- 58:44Merlin sort of respond or interject
- 58:45on what he's heard and then
- 58:47after that maybe we if anyone
- 58:48has something they'd like to
- 58:49respond or we could open it up
- 58:51to the group after after Merlin
- 58:54no I've basically been just digest Oh yeah
- 58:57sorry yeah yeah they gave me my own yeah
- 59:04no, I've basically been kind of just
- 59:06digesting and and thinking but.
- 59:10Some, some takeaways.
- 59:12One is I'm very interested in hearing about.
- 59:15I mean often times like for me as
- 59:17somebody who I don't call myself
- 59:19a community based research at all,
- 59:21I'm not I I I look at paper all
- 59:24day and usually paper written
- 59:26by people who are deceased.
- 59:28So I for me community always has
- 59:32kind of an abstraction to it.
- 59:34And so it's been fascinating to
- 59:36hear from all three of you how
- 59:38you have enacted it.
- 59:39On the ground in some
- 59:41ways, in what actual mechanisms
- 59:43you have used to actually turn
- 59:48a moral kind of demand for community
- 59:52participation and avoidance of.
- 59:56Insular administrative decisions that have
- 59:58huge consequences for people's lives.
- 01:00:01How you've actually sought to thought
- 01:00:03to do that, I think there is kind of
- 01:00:06a foot to the pedal aspect to it.
- 01:00:08At some point you have to stop debating
- 01:00:10what community is and who is really
- 01:00:12the community and just try things.
- 01:00:13And I'd be interested to know more
- 01:00:16about what those mechanisms of
- 01:00:18community are like for example, Mark,
- 01:00:22how do you choose the 50% of the people
- 01:00:25who are on the board and that sort of thing,
- 01:00:27what kind of what kinds of
- 01:00:28frictions is that that bring up?
- 01:00:30But I'm fascinating to hear about that.
- 01:00:33The second thing I'd like to
- 01:00:35ask all of you actually is,
- 01:00:37I'm sure everybody in this room
- 01:00:39and everyone at this panel.
- 01:00:40Has felt the impact that 2020
- 01:00:44has had on the healthcare space,
- 01:00:47not just around issues of racism
- 01:00:50but I think larger issues about
- 01:00:53the distribution of resources and
- 01:00:55fairness and how we do public health.
- 01:00:57One of the things that I felt
- 01:01:01often is in the healthcare space.
- 01:01:04You know if you're the diagram
- 01:01:06like kind of the.
- 01:01:08The responsiveness of of big
- 01:01:11institutions in particular to disruption
- 01:01:14to social dislocations like that,
- 01:01:17it's like a big spike for a few years and
- 01:01:19then you get back into the doldrum period.
- 01:01:22And so I wondered,
- 01:01:23as people have been in this game a long time,
- 01:01:26how do you keep up that?
- 01:01:28Those that pressure and that interest when
- 01:01:30the when the broader public interest has
- 01:01:33receded after you know the 2020 moment.
- 01:01:36But my guess is that the office of
- 01:01:39HealthEquity that you mentioned is a
- 01:01:41direct consequence of 2020 because
- 01:01:43we got a new one too.
- 01:01:45And the question is you know is this
- 01:01:47going to be a real office or one that
- 01:01:50ultimately only exists on paper.
- 01:01:51And I think it all comes down to if if.
- 01:01:54If.
- 01:01:55That kind of social foment and the
- 01:01:57pressure can be maintained and
- 01:01:59I wonder about that.
- 01:02:01So those are kind of two reactions
- 01:02:03actually, mark, if you want to take that.
- 01:02:04The first question about the
- 01:02:06responsiveness or how do you how
- 01:02:08or if you know how Cornell Scott
- 01:02:10identifies the individuals to be on
- 01:02:12on the board and does that create,
- 01:02:14has there been tension with what the
- 01:02:16how they want the institution to move?
- 01:02:20Yeah. I'm not sure the answer to that
- 01:02:23question is probably super interesting.
- 01:02:24I mean candidates are identified by by any,
- 01:02:29by anybody in the organization,
- 01:02:31some anybody who's a patient
- 01:02:34and just as any board member
- 01:02:36of any organization would do,
- 01:02:37they kind of go through an
- 01:02:39interview and a vetting process.
- 01:02:40Obviously then the qualifications
- 01:02:41are more than just being a patient.
- 01:02:43You need to be able to serve as
- 01:02:45a board member and commit to that
- 01:02:46and what it would take and then.
- 01:02:48An interview by the the Board and
- 01:02:49the Governance Committee obviously
- 01:02:51it which is over 50% patients also.
- 01:02:54So it's it's sort of like any board it's
- 01:02:57just a requirement of of being a patient.
- 01:03:01So I don't know
- 01:03:03well now we get to the
- 01:03:04more juicy question. I'm
- 01:03:05sure others may have other opinions
- 01:03:06but that's that's actually the
- 01:03:07extent that I know of it because
- 01:03:08I'm I don't sit on the board myself
- 01:03:10sure actually I'd love to hear
- 01:03:11from Kathy in Virginia about
- 01:03:13Merlin's larger question about.
- 01:03:14The change in the hospital potentially
- 01:03:16partly in response to sort of
- 01:03:19social foment and how the does,
- 01:03:21I mean, I imagine the hospital
- 01:03:22wants to keep a commitment going
- 01:03:24forward but the pressure lets off.
- 01:03:26Does that stay.
- 01:03:27So what's your sense from the
- 01:03:28inside how that that happened?
- 01:03:30Yeah no, I I acutely feel the commitment
- 01:03:34by the hospital to operate differently.
- 01:03:37I think that the pandemic exposed.
- 01:03:41You know so much about where there were
- 01:03:42gaps in the care and the relationship
- 01:03:44between the community and where things
- 01:03:46could and should be done differently.
- 01:03:48And we saw the commitment during
- 01:03:51the pandemic to, you know,
- 01:03:53standing up testing centers and communities
- 01:03:56of color and you know, you know,
- 01:03:58when the vaccines were available,
- 01:03:59vaccinating people in the in communities
- 01:04:01have called, they did the work.
- 01:04:02They were really there.
- 01:04:03And I always say that the time to show up.
- 01:04:07Is when there's nothing going on.
- 01:04:09Because when the pandemic hit,
- 01:04:11if you weren't already there,
- 01:04:12you missed the bus.
- 01:04:14All right, so the hospital was already that.
- 01:04:16We already had relationships which
- 01:04:17made it easier for us to do that.
- 01:04:19Could it be better?
- 01:04:20Of course, it could be nobody's.
- 01:04:22We're not perfect.
- 01:04:23And I'm not sitting here saying that we are,
- 01:04:24there are opportunities to do things better.
- 01:04:26But I will say that they stood
- 01:04:29up in that moment,
- 01:04:30and I do feel the the connection.
- 01:04:33To the Community now very differently
- 01:04:35as a result of the work that had been
- 01:04:39done during that that period of time.
- 01:04:41But the office of HealthEquity is a
- 01:04:43system wide office of HealthEquity and it
- 01:04:46is you know being developed as we speak.
- 01:04:49And I'm actually here now
- 01:04:50in place of Doctor Lou Park,
- 01:04:51who's the medical director for the
- 01:04:53office of HealthEquity and Darcy Cobbs.
- 01:04:55Lomax was the director.
- 01:04:58And there's a whole team that
- 01:04:59they're assembling right now.
- 01:05:00So this thing is expanding.
- 01:05:02It's not getting smaller,
- 01:05:03it's getting bigger and it's moving faster.
- 01:05:05And there is a focus really on,
- 01:05:07you know,
- 01:05:08taking a look at our the health disparities,
- 01:05:10you know,
- 01:05:10that we have the ability to influence
- 01:05:12and impact and really going forward with
- 01:05:14making changes in how we deliver the care.
- 01:05:16So I don't see it as a,
- 01:05:17you know, a flash in a pan.
- 01:05:20I don't see it that way.
- 01:05:22That's not been the experience that I felt.
- 01:05:24I've seen flashes in the pan
- 01:05:25and this isn't that so.
- 01:05:28Actually a good pivot to Virginia.
- 01:05:29So you have been living in the
- 01:05:30community for a long time.
- 01:05:31You've seen efforts maybe in the past
- 01:05:34that maybe have not not persisted.
- 01:05:37What leverage do you feel
- 01:05:39like you have to impact the,
- 01:05:41do you feel like actually you respond?
- 01:05:43But I want to hear about your sense
- 01:05:44of how the leverage of the Community
- 01:05:46to keep the pressure on or New Haven
- 01:05:48in general to keep the pressure on for
- 01:05:50the hospital to be more responsive.
- 01:05:51So I would contend that the pressure
- 01:05:54on the hospital started before COVID.
- 01:05:57And I think their response to COVID
- 01:05:59was a result of the decision they
- 01:06:02made about moving the primary care.
- 01:06:04So the community was up in arms about that.
- 01:06:07And I think the hospital learned
- 01:06:09the lesson that they had not
- 01:06:11properly engaged the community,
- 01:06:12that it was a decision that was
- 01:06:14made behind closed doors without any
- 01:06:16conversation with the community.
- 01:06:18And it did not roll out the way
- 01:06:19the hospital thought it would,
- 01:06:21as it probably has had has over decades
- 01:06:24as we've seen the hospital expand.
- 01:06:27Into the the greater New Haven community.
- 01:06:30So the lesson was learned there
- 01:06:32that the community wants to be
- 01:06:35informed and engaged around decisions
- 01:06:37not just around our healthcare,
- 01:06:39but how the hospital is going
- 01:06:41to move through the city,
- 01:06:42how they're going to move into the
- 01:06:44community and what are the resource
- 01:06:46and what are the Community needs that
- 01:06:48we need the hospital to be responsive.
- 01:06:50Too, and I think because of the
- 01:06:53primary care situation,
- 01:06:54the hospital was well prepared
- 01:06:56when COVID hit.
- 01:06:58So we saw testing centers and vaccinations.
- 01:07:02We saw that system fall into
- 01:07:06place effortlessly because they,
- 01:07:08I believe they learn their lesson.
- 01:07:10I believe they understood what the
- 01:07:12need was going to be and what the
- 01:07:14response from the Community was going to be.
- 01:07:18I'm actually, I mean again
- 01:07:19I have followup questions,
- 01:07:20but I do want to open it up to the group.
- 01:07:23And also I know there was a question
- 01:07:25already online make sure we'll
- 01:07:26start with a question in the room.
- 01:07:28I'll have to repeat the question,
- 01:07:29but so keep it brief. I guess
- 01:07:32my question is
- 01:07:38thank you for your your talk.
- 01:07:40It really did kind of add some
- 01:07:43perspective to what the experience.
- 01:07:47I am a New Haven resident who was
- 01:07:50also employed by the hospital.
- 01:07:52I wonder if in your in your research you
- 01:07:58have looked at the relationship between
- 01:08:01the Medical Center and the academic
- 01:08:05institution and how that plays because
- 01:08:08this is very much a green person dance
- 01:08:12and the hospital and the community.
- 01:08:17University is, you know,
- 01:08:19separate but equally something you know,
- 01:08:22it's a.
- 01:08:23It's an interesting dynamic,
- 01:08:25and I wonder how that plays into the
- 01:08:30the success of the relationship
- 01:08:33between unity and Health Center.
- 01:08:38So I I will repeat the IT
- 01:08:39looks like the the ASL
- 01:08:40interpreter was able to hear it.
- 01:08:41So maybe the the people on
- 01:08:42the webinar could hear it.
- 01:08:43But I will just repeat the question briefly.
- 01:08:46The question was really focusing on in
- 01:08:49your research in Merlin specifically.
- 01:08:50So we talked about the
- 01:08:52academic mental center,
- 01:08:53but it's the Medical Center and the
- 01:08:55academic institution which both have
- 01:08:57their own I mean to to to improvise.
- 01:08:59Have their own sort of needs and demands.
- 01:09:03Did you look at that access as
- 01:09:05well between the university
- 01:09:06and the and the Medical Center?
- 01:09:09Yeah, I mean that's a terrific question.
- 01:09:12Yes and no. I think it's more of an implicit
- 01:09:15kind of thread than an explicit one.
- 01:09:18I the one thing I at some point when I
- 01:09:21was looking at academic medical centers
- 01:09:23in particular that I asked myself is.
- 01:09:27Is the tension between academic medical
- 01:09:29centers and their neighborhoods,
- 01:09:30is there something special about it or
- 01:09:33is it actually just bound up with the
- 01:09:37larger antagonism between say Yale and New
- 01:09:40Haven or Columbia and Harlem or you know,
- 01:09:43we can go on University of Chicago
- 01:09:45and the South South side etcetera?
- 01:09:47I think sometimes it is the same BLOB
- 01:09:50and there and community members are
- 01:09:52responding to kind of larger institutions
- 01:09:55that particularly pull their weight with
- 01:09:58or throw their weight around rather with
- 01:10:01real estate and economic and political
- 01:10:04control of large parts of the city.
- 01:10:07I also think there is a particular though
- 01:10:11a particular character to the Medical
- 01:10:14Center in neighborhood relationship.
- 01:10:17I actually think it's a very symbolic.
- 01:10:19There's a symbolic aspect to it too,
- 01:10:21because there's just something jarring
- 01:10:23about healing institution and often
- 01:10:27a very rich healing institution
- 01:10:29that's very technologically intensive
- 01:10:31and well capitalized.
- 01:10:32And the juxtaposition between
- 01:10:35that and deprivation,
- 01:10:36I think there's something
- 01:10:38about that gulf that.
- 01:10:40Emotionally resonates with people
- 01:10:43as quite unjust, quite unfair.
- 01:10:46Especially when,
- 01:10:47as in the case of Cleveland,
- 01:10:49the the the entity is also expanding
- 01:10:52literally to where they live.
- 01:10:55So in
- 01:10:55some, in some cases it's the
- 01:10:57it's the kind of larger BLOB,
- 01:10:59and in some cases it is the meta.
- 01:11:01There's particularities
- 01:11:02of the Medical Center.
- 01:11:04I think another issue, I think Ben
- 01:11:05talked to me about this the other day.
- 01:11:07I certainly know it's an issue in one
- 01:11:10of my previous stops in Philadelphia
- 01:11:12and it's all these institutions,
- 01:11:16medical or or the larger university
- 01:11:19entity are tax free, right.
- 01:11:21And so there's a big but you know,
- 01:11:24I mean nonprofit in in legal and name,
- 01:11:27but certainly.
- 01:11:29Lots of flush revenue coming coming
- 01:11:32through these institutions and so the
- 01:11:34big question is if that is happening,
- 01:11:37what kinds of policies might be put
- 01:11:39into place for these institutions
- 01:11:41to contribute something back and
- 01:11:44you know pilots is is 1 possible
- 01:11:47route I actually am interested
- 01:11:49in public benefit and how?
- 01:11:53I think it's actually a potential tool
- 01:11:56for community members and activists to
- 01:12:00use to press institutions to follow
- 01:12:02not just the letter of the law,
- 01:12:05but the spirit of the public
- 01:12:08benefit provisions,
- 01:12:09which have been considerably
- 01:12:11strengthened by the ACA.
- 01:12:13And I'd be curious to know from
- 01:12:16my New Haven Co panelists how
- 01:12:20that has actually played out.
- 01:12:22I I know certainly that there is what
- 01:12:26you might call charitably creative
- 01:12:29accounting and some at some academic
- 01:12:32medical centers where you know
- 01:12:34things like Medicaid reimbursements
- 01:12:37or Medicaid funded care is is
- 01:12:39counted somehow as public benefit.
- 01:12:41I think I think as I interpreted
- 01:12:44the spirit of that requirement
- 01:12:46and that mandate and the kind of
- 01:12:50larger social social movement.
- 01:12:52Reason why that that public benefit
- 01:12:55benefit requirement was passed.
- 01:12:57It's it's they're supposed to be
- 01:13:00spending it on real public health
- 01:13:02programs not just counting things
- 01:13:05that they already do as you know
- 01:13:08fulfilling that but I do that is
- 01:13:10also something that I think is
- 01:13:12unique to medical centers and in in
- 01:13:15terms of in terms of responsiveness
- 01:13:17to neighborhood
- 01:13:18pressure. So Kathy,
- 01:13:19to put you on this spot,
- 01:13:21so you you brought up that
- 01:13:22can we help benefit sort of
- 01:13:24what's your perspective on it?
- 01:13:26And I will say there is actually
- 01:13:28still continuing pressure
- 01:13:29in Congress about how the,
- 01:13:30how hospitals navigate that,
- 01:13:32that process of being a nonprofit.
- 01:13:35So I think it's a story
- 01:13:36that's still being told,
- 01:13:38but I'd love to hear your thoughts.
- 01:13:39Yeah, exactly. I think that's exactly
- 01:13:41what I'm saying is that we know that
- 01:13:43there's probably an opportunity to
- 01:13:45do things differently than what.
- 01:13:47Has been done in the past and that
- 01:13:49is that cycle we're we're kind of in
- 01:13:50the middle of right now and kind of
- 01:13:52redefining what that looks like or
- 01:13:54what that could look like in the past.
- 01:13:57You know I think you know it wasn't
- 01:14:00as transparent as we would like
- 01:14:01for it to be going forward.
- 01:14:03So that's that's all I can really
- 01:14:05say about that at this point because
- 01:14:07I don't really have the you know
- 01:14:08the depth of knowledge to be able to
- 01:14:10speak to what's actually been done
- 01:14:12and say it with credibility so but.
- 01:14:15But I do think that there's an
- 01:14:16opportunity for us to be a little
- 01:14:17bit more transparent and be more
- 01:14:18involved in the process that I do know.
- 01:14:22So actually, Mark,
- 01:14:25I mean I would, when I actually would give my
- 01:14:27hospital colleagues a lot of credit on this,
- 01:14:30we take care of a lot of uninsured patients.
- 01:14:33And I mean, I think one place where there
- 01:14:36can be very little debate about whether
- 01:14:38it's community benefit is the free and
- 01:14:40discounted care that the hospital provides
- 01:14:42to uninsured patients. I mean, we.
- 01:14:43For patients who don't have health insurance,
- 01:14:46we can get them essentially any
- 01:14:48medically necessary service what
- 01:14:49they need at the hospital.
- 01:14:50And I I don't know if it is
- 01:14:52that that way in other cities,
- 01:14:53but it it's it's phenomenal
- 01:14:56from our perspective.
- 01:14:57We don't have to spend a lot of time
- 01:14:59stressing about how we're going to
- 01:15:01get our patients what they need.
- 01:15:02The question about Medicaid and
- 01:15:04whether to count in community benefit,
- 01:15:06the gap between what Medicaid
- 01:15:08pays and what it costs to provide
- 01:15:10a service is interesting
- 01:15:12and in some regards.
- 01:15:15I wouldn't mind if academic medical
- 01:15:17centers got credit for that so
- 01:15:19to speak as community benefit
- 01:15:21because it might provide a little
- 01:15:23bit of an additional incentive to
- 01:15:25provide care to Medicaid patients.
- 01:15:27So you know you if you don't get
- 01:15:29credit so to speak for for the
- 01:15:31losses that you are are taking there,
- 01:15:33then the the incentive is to shift
- 01:15:35services away from Medicaid patients.
- 01:15:37So I think there's kind of two
- 01:15:39sides to that coin.
- 01:15:41No, it might be contextual too. Yeah.
- 01:15:43Especially with an if there's an
- 01:15:45institution that historically has slighted
- 01:15:48or tried to avoid Medicaid patients.
- 01:15:52So I would play the devil's advocate
- 01:15:54with that because as a community member,
- 01:15:57we don't see that part of the
- 01:15:59investment in the city, right.
- 01:16:01We see that as an investment
- 01:16:02in a in a patient's outcomes,
- 01:16:04which is important.
- 01:16:05But when you have streets that have potholes.
- 01:16:09When you have a very small tax base
- 01:16:11because of the university and the hospital,
- 01:16:14it's harder from a Community perspective
- 01:16:16to see the added value of giving
- 01:16:19that resource to the Community.
- 01:16:21We we have a phrase that we use.
- 01:16:22So I run a civil rights organization.
- 01:16:24We call it colored money when
- 01:16:26cities are disinvested and there
- 01:16:29are not buses that go out to Long
- 01:16:32Wharf to provide transportation
- 01:16:34to folks who need medical care.
- 01:16:37There's there's a disconnect
- 01:16:39between what the the community
- 01:16:40sees as an investment and what the
- 01:16:43hospital may see as an added value
- 01:16:45or an investment in a community.
- 01:16:48I'm not saying that it's not a value,
- 01:16:49it's it's a huge value because
- 01:16:51we know there are folks that are.
- 01:16:53Underinsured and uninsured.
- 01:16:54So it's important that folks get healthcare.
- 01:16:57But we also want the hospital and
- 01:16:59the university because we can't
- 01:17:00let them off the hook.
- 01:17:01We want them both to be invested
- 01:17:03in what the Community looks like.
- 01:17:06You know,
- 01:17:07if our if there's trash overflowing
- 01:17:09in receptacles by the hospital,
- 01:17:11what does that mean about the hospital's
- 01:17:14commitment to the neighborhood?
- 01:17:16You know, I live.
- 01:17:17In West River,
- 01:17:18my office is directly across the
- 01:17:20street from the Saint Refills Camp
- 01:17:22campus and where the new neoscience
- 01:17:24center is going to be built.
- 01:17:25And we as a community,
- 01:17:28we're excited because medical advancement
- 01:17:30is important to the community.
- 01:17:32However,
- 01:17:33investment in our communities
- 01:17:35is equally important.
- 01:17:37And what does that look like to a
- 01:17:39community member versus a hospital?
- 01:17:42There's another question in the.
- 01:17:51You know, are there other options
- 01:17:53with medical experience that are
- 01:17:55really going into creative grounds,
- 01:17:59really appreciated.
- 01:17:59The point about the buses and infrastructure,
- 01:18:02I just wonder, you know,
- 01:18:03and I appreciated that between the hospital
- 01:18:05is trying to get people in touch with
- 01:18:07resources and having this conversation,
- 01:18:09it's not important that as institutions
- 01:18:11are there any institutions?
- 01:18:13I think the country are really
- 01:18:16taking on the bigger issue
- 01:18:20of,
- 01:18:24well, I'll give you an answer that's kind
- 01:18:26of more of a referral and it's so I think
- 01:18:30a lot of people here may actually be
- 01:18:32familiar with the late Fitzhugh Mullen,
- 01:18:34who was a physician activist who
- 01:18:37ran this thing called Project Hope,
- 01:18:39which publishes the journal Health
- 01:18:42Affairs and he passed away I think.
- 01:18:45A couple, couple of years ago.
- 01:18:46But every time I would correspond
- 01:18:49with him fits as, as he was called,
- 01:18:52delighted in pointing out to me that
- 01:18:55Columbia ranked very low on the list of on,
- 01:18:58on a list of kind of academic medical
- 01:19:01institutions that contributed
- 01:19:02to their community.
- 01:19:04Every year he would put out this ranking
- 01:19:06and it would have it would include
- 01:19:09everything from spending on on, on.
- 01:19:13Programs and infrastructure and initiatives,
- 01:19:17community outreach stuff to the
- 01:19:19demographic composition of the
- 01:19:21kinds of people it it hired.
- 01:19:23And so he always loved to rid me
- 01:19:25about how haha Columbia is like
- 01:19:27in 59th place out of 60 years.
- 01:19:29So my answer is,
- 01:19:30I think that index is actually
- 01:19:32pretty was pretty powerful for me in
- 01:19:35terms of having a systemized rubric.
- 01:19:38So I would refer you to it at
- 01:19:41projecthope.org. Yeah, but.
- 01:19:44As well as these New Haven projects
- 01:19:46which sound great.
- 01:19:50I do want there's one question from
- 01:19:53the the chat that I'll put in bring
- 01:19:55it I think Kathy that it will sure
- 01:19:57you could hopefully address it.
- 01:19:59Unfortunately you're on the hot seat again.
- 01:20:03So I had the question is how do I talk
- 01:20:04with the C-Suite about this or how do
- 01:20:06we talk to the C-Suite about this.
- 01:20:07How do I get the them presumably the
- 01:20:10executives in the hospital to see
- 01:20:11importance of social justice and how at the.
- 01:20:14Academic Medical Center interacts with
- 01:20:15me that people live right around the
- 01:20:17the corner in fancy building around
- 01:20:19the corner from the fancy buildings.
- 01:20:20How do I get them to see that responsibility
- 01:20:23and then ask we have to address the
- 01:20:25food desert and transportation issues
- 01:20:26and need for job training programs and
- 01:20:28mental health treatment and health
- 01:20:29and and we should be doing more for
- 01:20:31the people right here in New Haven.
- 01:20:38It's true you know.
- 01:20:40Again you know they're.
- 01:20:42Your voices are very important
- 01:20:43and I think that you know,
- 01:20:45really just showing up to, you know,
- 01:20:47opportunities where I don't know when,
- 01:20:50if this is an employee, it's anonymous,
- 01:20:53it's an anonymous person.
- 01:20:54So obviously I can speak for
- 01:20:56employees of the hospital.
- 01:20:57We have mechanisms that we can
- 01:20:59speak to our leadership, you know,
- 01:21:01I'm not really sure what to
- 01:21:03advise about community outreach,
- 01:21:05but you know.
- 01:21:06There are probably mechanisms
- 01:21:08to reach the leadership.
- 01:21:09I don't know what to OfferUp
- 01:21:11in that in that regard,
- 01:21:13but I would say make your voice heard.
- 01:21:14Do
- 01:21:17you have something?
- 01:21:25Sure. And go ahead. And did any,
- 01:21:27did you have a question?
- 01:21:32I just find the paving specifically
- 01:21:35also generally in your experience in
- 01:21:37the studies you've done, what's the
- 01:21:42so new here? Just to be clear,
- 01:21:43New Haven does a very some very
- 01:21:45powerful unions that is pushing the
- 01:21:47university and the hospital and the
- 01:21:49city to do a better job so that we do
- 01:21:51feel that pressure here in the city.
- 01:21:56Well, I guess I could tie this
- 01:21:58actually to the person I opened.
- 01:22:00My remarks with Sarah Nelson,
- 01:22:03so she is identified with a brand
- 01:22:05of unionism that has sometimes been
- 01:22:07referred to as social justice unionism.
- 01:22:10And the idea behind social justice unionism,
- 01:22:12which is very controversial
- 01:22:13within the labor movement,
- 01:22:15is how wide should the
- 01:22:17purview of Labor unions be?
- 01:22:19Should labor unions only focus on
- 01:22:23aggressively getting amazing contracts
- 01:22:25and benefits and wages for their own
- 01:22:28workers within the circumscribed union?
- 01:22:30Or do labor unions actually
- 01:22:32have to not only do that,
- 01:22:34but also works often in coalition
- 01:22:38with community members to to address
- 01:22:42other parts of of the society really
- 01:22:45beyond just the workplace and the
- 01:22:48the rank and file a particular union.
- 01:22:50And in addition to President Nelson,
- 01:22:53I would say another exemplar of
- 01:22:55social justice unionism is the
- 01:22:57Chicago Teachers Union in Chicago,
- 01:22:59which has gone on strike.
- 01:23:00Two times over the past decade,
- 01:23:02but attracted huge community support.
- 01:23:05And I think it's largely because
- 01:23:06they did a lot of base building
- 01:23:09in Chicago neighborhoods.
- 01:23:10So people understood that the
- 01:23:11strike wasn't just quote UN quote,
- 01:23:13selfish teachers going on strike,
- 01:23:15but that they were fighting for
- 01:23:18better schools for people in the
- 01:23:21community and and also for a number
- 01:23:24of community improvements that
- 01:23:26may not have had anything directly
- 01:23:28to do with wages and benefits.
- 01:23:31So to answer your question about this,
- 01:23:32I think the social justice Union
- 01:23:34debate has actually been also
- 01:23:36a friction in health union,
- 01:23:38health worker unions.
- 01:23:39In a lot of the activism that I
- 01:23:42looked at in the 1960s and 1970s,
- 01:23:44I was actually surprised to see
- 01:23:46that in a lot of these debates about
- 01:23:50town and gown relationships and the
- 01:23:52racism of academic medical centers
- 01:23:54like the Cleveland Clinic and,
- 01:23:56you know, name all your other,
- 01:23:58name, all your other causes that.
- 01:24:00Some of the most militant and
- 01:24:03successful and left wing health
- 01:24:04worker unions were actually not
- 01:24:06very active in those campaigns.
- 01:24:09They were very active in the
- 01:24:11wages and benefits struggles,
- 01:24:12but less so on larger kind of health
- 01:24:16issues beyond wages and benefits.
- 01:24:19I think that's changing a lot,
- 01:24:21but I think it depends a lot on the local.
- 01:24:24And the leadership in the local,
- 01:24:26there's a lot of variation.
- 01:24:27So, you know,
- 01:24:29the Chicago Teachers Union does their thing,
- 01:24:31but you know the a FTUFT and New York
- 01:24:34City probably with a less holistic what,
- 01:24:39how about you?
- 01:24:40You
- 01:24:41probably have said on both
- 01:24:44sides of those conversations.
- 01:24:46Okay, fair enough.
- 01:24:47Okay, fair enough. Financial wealth.
- 01:24:50I do want to acknowledge that thank you
- 01:24:52we're we're at time now but so I do
- 01:24:55want to thank everyone for attending that.
- 01:24:57Thank you for our panelists
- 01:24:59for excellent conversation.
- 01:24:59Thank you Merlin for for priming
- 01:25:02the conversation with the research
- 01:25:04you've done and thank you the
- 01:25:06program the humanities medicine
- 01:25:08for hosting us and Doctor Reisman
- 01:25:10and Karen but yeah thank you.