On a mission

As a child growing up on Saint Thomas, one of the U.S. Virgin Islands, Marcella Nunez-Smith used to sprawl on the floor of her maternal grandmother’s house and listen to the adult conversation around her. “My grandmother’s home was a gathering spot—a place where people came to discuss everything from politics to community service,” she says. “She’d cook lots of food. People would come by, have something to eat, and talk.”

Overhearing these conversations opened Nunez-Smith’s eyes to the realities of life in the Virgin Islands. She grew up witnessing the juxtaposition of unparalleled beauty among the people and the territory’s turquoise-blue waters alongside the challenges confronting a small island—including access to high-quality health care. “It was a dominant theme I heard early on,” says Nunez-Smith. “Young people with debilitating illness were unable to get the care they needed. Or their care was delayed, which essentially is care denied. Too many people were dying young.”

Then Nunez-Smith’s father had a stroke that left him partially paralyzed. “He had to navigate through life with a severe disability because his hypertension was never diagnosed or treated,” she says. “This wouldn’t have happened if he’d had proper care. I became obsessed with thinking about the role I could play as a physician to change this narrative.”

Now, she is doing just that. As inaugural associate dean for health equity research and C.N.H. Long Professor of Internal Medicine, Public Health, and Management at Yale School of Medicine (YSM), Marcella Nunez-Smith, MD, MHS, is laser-focused on eliminating inequities among marginalized people. “Disparities in health care are persistent and prevalent,” she states. “They’ve been at a crisis point for many years, but until now, no one talked about them.

When I was a medical student, the term health equity didn’t exist. We talked about differences in outcomes. But there’s been an evolution in thinking. We’ve gone from a place where disparities were not talked about, to where they were talked about, sometimes ridiculed, and usually dismissed, to now being a topic in newspapers and on news shows.”

Nunez-Smith’s mother, a retired professor of nursing, instilled in her a steadfast commitment to improving health equity. Maxine Nunez had earned a doctorate from the Johns Hopkins School of Public Health, “one of the first women of color to do so,” says her proud daughter. “She had a stellar career in clinical care and was also a department chair and dean at the University of the Virgin Islands. She and my grandmother are my inspiration.”

Her mother filled the family home with books. “She said we would read together any book that I could reach,” says Nunez-Smith. “The medical textbooks were on the top shelf, so I’d go up on a ladder to grab them. I was fascinated by human anatomy.” While in second grade, Nunez-Smith brought one of the books to school. “I held court at recess: ‘Look! This is our body! Isn’t it amazing?’ I got detention for that.”

Graduating from high school at 16, Nunez-Smith enrolled at Swarthmore College, near Philadelphia. After she earned her undergraduate degree in 1996, Nunez-Smith returned home to help her mother and grandmother, who was very ill at the time. “I taught biology and physiology at my old high school,” she says. “Unexpected experiences shape you, and I found that I loved teaching and mentoring. I was able to start a dissection lab and launched our first science fair. I realized teaching really is the family business.”

Returning to the mainland after a year, Nunez-Smith went to medical school at Thomas Jefferson University (which merged with Philadelphia University in 2017) and completed an internal medicine residency at Boston’s Brigham and Women’s Hospital. Following a fellowship in Yale’s Robert Wood Johnson Foundation Clinical Scholars Program, she joined the Yale faculty after completing her MHS in 2006.

At Yale, Nunez-Smith wears many hats—professor, scientist, clinician, administrator, teacher, mentor, and director of several research centers. Her research focuses on promoting good health and health care equity for marginalized people, with an emphasis on community engagement.

She is the principal investigator on many NIH- and foundation-funded research projects, including one to develop a tool to assess patient-reported experiences of discrimination in health care. Nunez-Smith also leads other studies in workforce diversity, development, and inclusion.

The year of ‘triplets’

Given Nunez-Smith’s keen interest in global health and health policy, she is the founder and director of the Eastern Caribbean Health Outcomes Research Network (ECHORN), a collaborative consortium that conducts research in chronic diseases, including identification of risk and protective factors, across four groups of islands in this region.

Nunez-Smith is also the director of Yale’s Equity Research and Innovation Center (ERIC), which she founded in 2013. “I always say that’s the year I had triplets,” she says with a laugh. “I had a set of twins and gave birth to ERIC, with strong support from the school of medicine. It is a home for my research and for the research programs of other junior and mid-career faculty.”

The twins, a boy and a girl, are 10 years old now. She and her spouse, a professional equestrian, also have a 14-year-old daughter. Their younger daughter has complex medical needs, requiring the assistance of care providers and other helpers. “When I talk about people who influenced me, I’m grateful to my mom, my grandmother, and all my other mentors. But right now, my best life coaches are my children.”

Like those of busy families everywhere, the Nunez-Smiths’ world changed with the arrival of COVID-19 in 2020. “Going to [the children’s] school in early March to clean out their lockers, I remember saying, ‘We won’t be back here for a while,’” says Nunez-Smith. She was at Yale New Haven Hospital when the first COVID patient arrived. “The ER team called saying that they had a patient with possible SARS-CoV-2 infection,” she recalls. “I remember sitting with the house staff, planning our next steps. Even then, we started thinking about issues of testing and testing access.”

As significantly higher rates of COVID-19 cases, hospitalizations, and deaths afflicted minority communities throughout the United States, the pandemic shone a spotlight on health disparities. Examining this issue further, Nunez-Smith, Cary Gross, MD, YSM professor of medicine and epidemiology, along with other colleagues published a pivotal research paper in the Journal of General Internal Medicine in August 2020 that outlined the alarming lack of COVID data stratified by race and ethnicity. “We were among the first to say that these disparities are real and underestimated,” she notes.

Because of Nunez-Smith’s involvement with COVID-19 response efforts and research, she was asked to be part of Connecticut Governor Ned Lamont’s Reopen Connecticut Advisory Group, chairing its community committee. This group’s mandate was to ensure public safety as businesses, stores, recreational facilities, and other entities resumed operations.

“As the government advised ‘stay home and stay safe’ measures, it took us some time to figure out how to maximize safety for people who didn’t have the luxury of staying home,” says Nunez-Smith. “[Such as] people with economic pressures, who have service jobs or work deemed essential, who take public transportation, who live in homes that are crowded and multigenerational. We got up to speed quickly. Investing incredible resources, the state of Connecticut developed plans for supported quarantine and isolation.” This support has included public programs providing financial incentives and other services that facilitate quarantine.

In recognition of Nunez-Smith’s expertise, she was tapped by the president-elect to co-chair the Biden-Harris Transition COVID-19 Advisory Board, and later to chair the Presidential COVID-19 Health Equity Task Force, which was created to address COVID-19-related health care and social inequities. “This appointment presented an opportunity to create policy on a national level,” she says. “I used many of the lessons learned from Reopen Connecticut. One of our biggest challenges was fighting misinformation, disinformation, and limited trust. Our strategy was to use trusted messengers and tailor our messages to demonstrate our commitment to helping all people.”

Nunez-Smith adds: “If there is one lesson learned from COVID-19, it’s that we rise and fall as a collective. When it comes to wellness, opportunity, and economic recovery, we will only achieve and thrive as much as the least among us. Equity must be part of every conversation.”

Health equity at Yale

To expand health equity research efforts across Yale, the Office of Health Equity Research was established with support from Nancy J. Brown, MD, the Jean and David W. Wallace Dean of YSM and C.N.H. Long Professor of Internal Medicine. “This effort will help us ensure that our work addresses health and health care disparities in everything we do,” says Nunez-Smith. “To be centering health equity research here is extraordinarily exciting.”

Part of Nunez-Smith’s mission is to ensure that the next generation of physicians and health providers are trained to understand and address the root causes of health inequity. “Training and mentoring are at the core of everything we do,” she says. “At any given time, ERIC is host to Yale undergraduates, medical students, and public health students who serve as student research interns.” The ERIC program places interns into established research teams at ECHORN as well as at Yale, providing opportunities for experiential learning.

Taking this training one step further, student interns are invited to join the Alderfer Scholars Program, established in honor of Clay Alderfer, a former Yale faculty member who died in 2015. The program is co-directed by Nunez-Smith and David Berg, PhD, an organizational psychologist presently serving as a clinical professor of psychiatry. “The focus of the program is power in organizations, organizational change, and intergroup relations,” explains Nunez-Smith. “If we’re tackling issues of equity and causes of disparities, how do you do that from within an organization?

“We are tackling health inequity on many fronts,” sums up Nunez-Smith. “What I do is extremely rewarding, in large part because of the extraordinary people I work with across different teams and different spaces here at Yale. So much of our work is problem-solving, and there are many smart people here to do that. There is also a lot of opportunity for vision-setting.” She adds a caveat: “We’ve raised awareness; we’ve got people talking and thinking about disparities. But we can’t rest on our laurels. There’s more to do.”