PROVIDENCE – Work has been underway during the last three years to establish 10 Health Equity Zones, or HEZ, in Rhode Island communities, under the direction of the R.I. Department of Health, supported by funding from the U.S. Centers for Disease Control and Prevention.

Each of the 10 communities – in Providence, Pawtucket and Central Falls, North Providence, Olneyville, West Providence, Washington County, West Warwick, Woonsocket, Bristol and Newport – have been organized around a collaborative framework of numerous agencies and groups, rather than just one community agency. [There were initially 11 communities, but one decided to drop out.]

“What we are saying with the Health Equity Zones is different,” explained Ana Novais, the executive director of Health at the R.I. Department of Health, in a 2015 interview with ConvergenceRI. “Unless you work in the community, addressing the conditions that are creating that burden of disease, you are always going to be rescuing people. And, there is no money, not enough money, to rescue people indefinitely. If you start to diminish the conditions that led to the poor outcomes, then you are going to be more successful.”

The overarching approach of HEZ is to look at population health in a different way, Novais continued. Rather than defining population health as the patients being served under a health care delivery system program, the HEZ takes that approach one step further: to think about population health and the population that you serve as the population that surrounds where you are – “the larger, broader community that you are interfacing with.”

[The HEZ were actually the second phase of work begun under the Centers for Health, Equity and Wellness program at the agency, which targeted at neighborhood interventions, and which had been awarded to single community agencies.]

The focus on health equity has been strengthened under the leadership of Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health. As she told ConvergenceRI in a 2015 interview: “We want to make sure that all Rhode Islanders have the opportunity to live in the healthiest communities and have the healthiest lives that they can,” she said. “I like to say, if I could change the department name, it would be to the Department of Health and Health Equity.”

What happens to dreams deferred?
The dramatic consequences of a health care delivery system that does not address health equity can be severe.

In her November 2015 talk, “Unpacking Racial Health Disparities,” Brown University President Christina Paxson presented an economic analysis of how racial disparities in health outcomes created stark differences. [See link to ConvergenceRI story below.]

As ConvergenceRI reported: Paxson examined the morbidity for specific conditions – arthritis, heart conditions, stroke, high blood pressure, diabetes and breathing disorders – and detailed the large gaps between blacks and whites, not just in incidence, but when the onset of these conditions occurred, and the way in which they limited opportunities for work and wealth.

Paxson presented the stark differences between the total wealth for an average black household and the average white household in 2013: $11,000 compared to $190,000.

Most striking were her conclusions: that we cannot “educate our way” out of the disparities, nor will improved access to health insurance under the Affordable Care Act solve the persistent, structural racial disparities.

The take-away when you look at the data and studies, Paxson continued, was that the racial health disparities were a result of a complex stew of lower wealth, higher stress, greater discrimination, and lower economic opportunities. “I don’t think we are really going to solve this problem until we dismantle structural barriers to social and economic opportunity,” Paxson said.

Reshaping health outcomes, community by community
Health Equity Zones are charged with developing place-based strategies to reduce and manage chronic diseases, promote healthy lifestyles, assure healthy child development, and create environments where healthy choices are easier to make.

How have the HEZ in different Rhode Island communities attempted to reshape outcomes?

• In Washington County, the approach of the HEZ has been to target interventions around childhood obesity and children’s mental health, based upon several evidence-based programs, under the coordination South County Healthy Bodies, Healthy Minds collaborative.

The efforts target healthy eating, healthier lifestyles, early childhood literacy, and adolescent mental health; partners in these efforts include South County Health, Thundermist community health center, and Wood River Health Services, along with local libraries. [See link to ConvergenceRI story below].

• In Woonsocket, at an event on March 31, 2016, the local HEZ celebrated the completion of its comprehensive community needs assessment and its efforts to address gaps in accessing healthy, affordable foods. The event featured a tour of the new culinary incubator space that was under construction at NeighborWorks Blackstone River Valley. [See link to ConvergenceRI story below.]

As ConvergenceRI reported: At the event, which featured First Gentleman Andy Moffitt, Alexander-Scott said, in praise of the efforts underway: “Health does not begin in the doctor’s office. Health starts in the places where we live, learn, work and play.”

The dream of a common language
Recently, ConvergenceRI sat down to talk with Ana Novais about the future directions of HEZ in Rhode Island and the challenges they face in creating a sustainable infrastructure and ensuring a continued stream of funding.

As Novais emphasized in her earlier 2015 interview with ConvergenceRI, the story is still being written. “It’s not a story that we can tell on our own; it’s a story that we are writing together with the communities that we are working with.”

Yet, one of the biggest problems, Novais explained, centers around how best to tell the story of what has occurred with the ongoing development of HEZ in Rhode Island, to make it part of the vernacular outside of the public health community.

“I think that as much as we are proud of the work that we have done, and that we have gained national recognition because of our work around the HEZ – it’s been published, it’s been talked about, it’s been presented at national conferences, I don’t think we’ve done such a good job of explaining it, in a way that people can connect to it, with legislators or other key decision-makers,” Novais said.

If you are not involved in public health, she continued, “You may hear the words, health equity, and there is a disconnect.”

The fault does not belong to others, Novais said. “I think I fault us,” she explained. “[We] need to learn a new language, we need to learn new tools. We need to learn how to speak in a way that is not just targeted to public health goals.”

The challenge, Novais said, “is in learning [to talk in] a language that is not public health language, to get other folks to pay attention to what we are doing.”

Her hope, she said, is that in the future, when you stop someone, a key decision-maker, and you ask: do you know about HEZ, they would know; or, even better, Novais continued, “You wouldn’t need to ask, because they brought it up to you, as part of the health care conversation.”

Here is the ConvergenceRI interview with Ana Novais, executive director of Health at the R.I. Department of Health, discussing the challenges of telling the unfolding story of health equity zones in Rhode Island and in making the efforts part of the political and economic development vernacular in the state.

ConvergenceRI: What is the status of Health Equity Zones in Rhode Island? There are 10 ongoing HEZ. What has been the process been like?
NOVAIS: It’s been challenging; it’s been rewarding. It has also been slower than I would like to see at times.

At other times, it’s been reactive to what happens at the federal level, connected to funding.

We have not had, and still don’t have, any specific funding to work on health equity – on those cross-cutting issues that everyone talks about but no one funds.

ConvergenceRI: When you say, “no one funds these issues,” is that both at the federal level and at the state level?
NOVAIS: Nothing from the federal level, or from the state level, that says: here is funding to address, from a public health perspective, issues around community involvement around health issues, around housing, because they continued to see it as a separate agenda, not the public health agenda.

By approaching it the way we’ve done it with HEZ, we have braided funds: we have used disease-specific funding and we have braided that [with our community work].

The challenge is that we need to create the internal infrastructure to keep accountability for the silos of the funding at the federal level.

They still want to know what diabetes funding is buying as it relates to diabetes outcomes, what the tobacco money is buying as it relates to tobacco outcomes.

[As a result], it has created a financial structure that has been very challenging to manage; those grants have different timelines, one starts in June, one starts in September, another starts in March. So, managing the financial piece has taken an enormous toll on us, because we wanted it to be much easier at the community level.

That is one of the biggest challenges – to move programmatically, to move toward this more community-driven approach, because, at times, within the health department, programs which have that funding and feel the pressure from the feds, try to put that [pressure] back onto the community, by saying, I need you to do A, B, C, and D.

But it is really the A, B and C that the feds are asking for, and not what we told [the HEZ] that we were going to do, so that tension continues to be in place.

ConvergenceRI: To make sure I understand what you’re saying, the feds have their goals, and they are pretty much in silos determined by programs funded around diseases. At the same time, you are trying to braid funding resources to achieve a community approach that brings together a harmony around the health outcomes, ones that you can measure, but it’s really hard to mix apples and oranges.
NOVAIS: It is hard. But I think it is possible. At times, it creates tension between the community and us.

The community HEZ gets their funding, $300,000 a year or $200,000 a year, depending on the size of each project, because they are all different, and depending on their work plans.

They just want to do what they want to do, which is great, and it is what we wanted to see happen: they have a community process; they have a prioritization process, and they want to stay true to that process.

So, they do resent it, in a sense, when we have to say, yes, we are sorry, [but the budget needs to be changed.]

One example, as part of the budget process, the Governor had put in [to the FY 2018] budget proposal, $500,000 that would be coming from the increase in tobacco taxes to fund activities on cross-cutting health issues across the HEZ.

Which was [an amount] included in their budget, knowing, and stated clearly as a matter of transparency, that it was not a guarantee. And, the budget that the House passed and the Senate passed [and the Governor signed into law] did not have funding for the HEZ.

Now, we have to modify those contracts.

At the national level, if public health funding is reduced, it’s going to put in jeopardy many of those investments that we have done.

ConvergenceRI: I’m struck, as much as you’ve done a good job in the community around HEZ, it seems that legislators may need more education about what’s being done – not just from the Governor or the First Gentleman, but also from the communities, letting legislators know how important this work is at the community level.
NOVAIS: Yes, I think that is an important aspect. I think that as much as we are proud of the work that we have done, and that we have gained national recognition because of our work around the HEZ – it’s been published, it’s been talked about, it’s been presented at national conferences, I don’t think we’ve done such a good job of explaining it, in a way that people can connect to it, with legislators or other key decision-makers.

There is a challenge in talking about the HEZ in the state. If you are not involved in public health, you may hear the words, health equity, and there is a disconnect.

So, we may need to learn to talk about the HEZ without saying HEZ, to talk about what we are actually doing. Because, if you talk about what we are doing, it should be an agenda that gets everybody interested in it.

It is about economic development, it is about community building and community development; it’s about jobs, it’s about housing, those are things that folks are working on; they are working on education for youth and job training for parents.

But, we have not translated that so far [in our work] with HEZ. We’ve had a challenge in learning a new language that is not a public health language, in order to get other folks to really pay attention to what we are doing.

ConvergenceRI: In my interview with Sen. Sheldon Whitehouse last week, I asked him about health equity zones, it seemed as if he really didn’t understand the work that was going on at the community level.

With legislators in the R.I. General Assembly, I wonder if there is a similar disconnect, that they don’t see the way that the work impacts their constituents; it becomes more about the money than the outcomes.
NOVAIS: I do think, that with public health in general, there is a challenge around the messaging that we do.

We’ve had that forever. We haven’t taken the time to step back, and say, how do we talk about public health in a way that Joe [or Josephine] Smith can understand it.

People think about public health when there is a crisis, but public health is a day-to-day activity. When you brush your teeth, that is public health; when you got to a restaurant [and expect that the food will be safe to eat], that is public health. When you walk on the sidewalks, that is public health. When you are able to take public transportation to your community health center, that is public health. But, if you were to ask transportation folks, they might not think about it that way.

I do not fault others; I think I fault us. [We] need to learn a new language, we need to learn new tools. We need to learn how to speak in a way that is not just targeted to public health goals.”

ConvergenceRI: How can you change the messaging, to one that promotes connectedness? How can you make that translation?
NOVAIS: I don’t know if it’s because we are disassociated, or it’s because we stay in our own world. So, that when you go into someone else’s world, you continue to speak your own lingo and [have] your own set of expectations.

I think the HEZ are trying to change that, and they have changed that, from a public health perspective.

We trusted the community process and the community engagement; that the “troops” that exist within each community would do a better job [advocating] for themselves. At that level, it is absolutely working.

It is changing how we talk about public health; now it needs to change how we fund public health.

Right now, we are trying to look at all the creative ways to sustain HEZ and expand HEZ beyond the four years’ time that we have [in funding]. And, to allow the HEZ to build and maintain their own community infrastructure.

As the HEZ develop a community prioritization process and identify priorities – heart disease, diabetes, or high school graduation rates, whatever is identified – it allows us to draw upon those specific disease funding [streams], and fund [those efforts].

It also leaves a gap, that if they want to address community policy, do I have funds for that? I don’t in public health; I don’t have any [sources] to clearly fund those efforts.

So, we are trying to see what opportunities exist in our portfolio, in our toolbox, to allow us to do so.

One example is looking at conditions of approval [certificates of need]. When big hospital systems come to us with a request for expansion [of facilities] and so forth, connecting the dots is important.

Asking those hospitals systems, you know what, you have an obligation to do a community benefit process, you have a obligation to do a community needs assessment –don’t spend money doing what’s already been done; instead, connect and support what already exists in your cachement area if there is a HEZ.

Another example is reaching out to our sister agencies, and saying, you know what, BHDDH [the R.I. Department of Healthcare, Developmental Disabilities and Hospitals], eight of the HEZ have identified drug overdoses as a priority.

How can you support the HEZ? What funding do you have that can support their work?

ConvergenceRI: How does the work of the HEZ fit into the ongoing work of the State Innovation Model [SIM} to transform the health care delivery system?
NOVAIS: We are working with the SIM leadership team to make sure that the HEZ are a core element in the design of health care system transformation, addressing health care system transformation form a health equity perspective.

That [premise] has been accepted as part of SIM implementation plan, to look at the health system, not just the health care delivery system, and the continuum of health as its source. It is part of re-designing or re-imagining the system.

How much we are going to be able to push forward remains to be seen. But we are at the table, and I think that is already a victory, in a sense.

ConvergenceRI: How can you expand the reach of your public health messaging? Who are your natural champions? Do you need, for instance, to create a business or a legislative caucus?
NOVAIS: That’s an interesting concept. I don’t know about creating a caucus. I am not really a political animal.

We have developed a one-pager about the HEZ. We have that on Facebook, on the webpage, and on a HEZ webpage. We are trying to refine all of the presentations that we do from the health department. We are trying to be very strategic and intentional and making sure that people hear that health equity zones are a key signature investment initiative, as we look at transforming the health system from an equity perspective, as we look at truly achieving population health goals – and improving and achieving what you have called the diseases of despair.

Those are always poor health outcomes that are driven by poverty, and everything else that poverty brings with along it, [disparities] in education, in housing and the lack of opportunity.

If you do not address that, you fail. That is unacceptable.

ConvergenceRI: Your next big conference on the work with health equity zones in Rhode Island will be in 2018. What do you hope to accomplish at that conference?
NOVAIS: I see the conference not only as a way of sharing the work that has been done, in making the HEZ central and very visible to our department.

It is also an opportunity for us to better explain our work, to have that conversation with key decision-makers.

And, also to learn from folks attending the conference about ways to continue, to expand and to institutionalize the work of HEZ.

Health equity zones started with an idea. And, we put a lot of thought into it. But it does need to become more institutionalized as more of the core of what we do [in public health].

So that it becomes how we do public health in Rhode Island. I think the conference can help accomplish that.