Health Disparities and Hope: How the Dalio Center for Health Justice Will Make ‘Real Progress’

The health disparities laid bare by the COVID-19 pandemic are as startling as they are stark. Black Americans are two times as likely to die from COVID-19 than White Americans. Hispanic or Latino Americans are four times more likely to be hospitalized from COVID-19 compared to White Americans, and American Indians or Alaska Natives are five times more likely, according to data from the Centers for Disease Control and Prevention.

Sadly, the racial disparities in health outcomes are not limited to COVID. In New York State, Black women are three times more likely to die during pregnancy or after childbirth compared to White women. And while Black and White women get breast cancer at about the same rate in the U.S., Black women are 40% more likely to die from the disease, according to a recent CDC study.

“We recognize our country must address long-standing health disparities due to race, socioeconomic differences, access to care, and other complex factors that impact the well-being of our communities disproportionately,” said Dr. Steven J. Corwin, president and CEO of NewYork-Presbyterian. “NewYork-Presbyterian hopes to be a leader in health justice and developing programs to help solve these issues and improve the lives of our patients and our communities.”

To that end, NewYork-Presbyterian opened the Dalio Center for Health Justice on October 13. Funded by a $50 million grant from Dalio Philanthropies, whose founder, Ray Dalio, is a NewYork-Presbyterian trustee and an important thought partner behind the project, the Dalio Center for Health Justice will be a convener, collaborator, and grantor, bringing together renowned experts in diverse fields to fuel change and support health justice among NewYork-Presbyterian team members, patients and communities, and ultimately local and national policy.

“The COVID-19 pandemic exposed enduring health inequities in a new and alarming way,” said Dr. Julia Iyasere, head of the Dalio Center for Health Justice, “and the importance of health justice has never been clearer.”

In a candid conversation, Mr. Dalio, Dr. Corwin, and Dr. Iyasere, discuss why they each felt a personal “pull” to fight for health justice now and their goals for improving health equity, and driving action that results in measurable improvements in health outcomes for all.

Ray Dalio: Steve, you’re a doctor, you’re head of the hospital. You, like Julia and I, have a pull to do this. I’m just curious where your pull came from?

Dr. Steven J. Corwin: We’ve been doing a lot of work internally on a campaign that we called Respect, which was basically, how does one behave in a large organization with a very diverse population? It’s not enough to be diverse and inclusive; you have to have everybody feel that they belong. Then as COVID occurred, it became obvious that we were dealing with a public health crisis, an economic crisis, and a social crisis. Not only with the disparity in mortalities between people of color and white people, but also some of the attendant issues with Black Lives Matter. I felt it was important for us to take the next step. I felt very strongly that a Center for Health Justice was exactly what we needed to do and I felt that now is the time to do it. Then when you and I had the discussion, I felt that we were speaking from the same page in the same book.

Mr. Dalio: What did you see that pained you and made you feel the hospital should make this move? Because not all people feel that way — and not all hospitals act that way.

Dr. Corwin:   I felt that as a country we were traveling down a road that was extremely problematic. I thought Charlottesville was extremely problematic. Then you see the issues with George Floyd, Breonna Taylor, and it starts to raise the issues of what’s happened to Black Americans through our history. I felt it was extremely important that a public institution like ours, that exists for the public benefit, speaks out on behalf of marginalized peoples. The hospital could make a positive statement as to what its value system is, and I felt that was really important. We have 47,000 employees; over 50% of them are people of color or underrepresented minorities. I had to be their voice as well. So that’s what led me to it.

Mr. Dalio: Julia, this is a coming together of different people who share the same desire to do this work — as well as the board and its desire — so I’m just curious where you got your pull from.

Dr. Julia Iyasere: I come from a family of immigrants. My father came to the United States [from Nigeria] in his 20s, and I have always really championed issues of diversity, inclusion, belonging, and understanding for the social fabric of our nation. I think COVID-19 really showed the systemic inequities that we have across the country in a new and quite startling way. Then the social unrest that followed the murder of George Floyd really left me in a position where I wasn’t sure what to do next. I had been having conversations with Dr. Corwin over the past few years around health disparities, around work that we could do within the hospital. But he actually called me about two weeks after George Floyd was murdered and asked me how I was doing. I think my answer was, “I don’t know” and “I’m not sure what to do next, but I know we have to do something.” It was that conversation that really led me to have hope again for what we could do as an organization because Dr. Corwin said, “Give me all your good ideas. I want you to think outside the box. Give me the biggest ideas you have, and we’ll try them.” Months later, the idea for the Center for Health Justice was born. I think it’s a culmination of both my personal passions and my professional passions.

Mr. Dalio: Yes, you were up close, seeing this on a daily basis, and then you had the deep-seated background. For me, I came from a very lower, middle-class family. I was raised in an era with parents who believed in the American Dream and this notion of equality as being the fundamental objective of our society. Then in various ways, I saw the great inequality and inopportunity [in our country]. My wife particularly does a lot in school systems which addresses the education gap. If you don’t provide equal education, you’re not going to provide equal opportunity. And I think health and education are fundamental to having a successful life, and equality should start there. That drew me in. Then when speaking with Dr. Corwin, particularly when we had the COVID situation, we saw that this work needed to be done. He painted the picture, which I gather you helped paint too, Julia. So, maybe you could describe the picture of where we’re going.

Dr. Iyasere: At the core of health justice is always health equity, or the ability for everyone to attain their optimal health. But the reason why we pushed a step further to say let’s adopt the terminology of “health justice” is because leveraging our reputation, our size, our expertise, and the phenomenal generosity of the Dalio gift, we have the ability to really dismantle the systemic factors that lead to health inequity and to be an advocate for national change. The center will be a central resource, or, as Dr. Corwin likes to say, the conscience of our organization. We are dedicated to understanding and improving health equity, improving community relationships and programming, and we’re focused on really looking at all of our clinical programming and understanding where there are areas of unequal care. We will be a place to foster innovations in healthcare delivery; we will develop a robust health equity database upon which to guide our programming and our initiatives; and then we’ll be a convener of national groups to really move the needle in health equity.

Dr. Corwin: People don’t really recognize some of the biases that exist within the healthcare system. People say, “We just have to make sure that people have access to care.” It’s not just about that. It’s also, are people of color or underrepresented minorities getting access to the most advanced treatments? If they’re not, why? Some of this is just embedded in algorithms and people have not thought about it. We recently had an algorithm in heart failure that if your systolic blood pressure was less than 90, you moved up on the transplant list. But there are a lot of African Americans and Black Americans who have hypertensive heart disease and bad heart failure who don’t meet that criteria. As a consequence of this, we’ve seen a 20% reduction in the number of African Americans getting transplanted. The other thing is we have to expand our swim lanes so that we’re dealing with intersectionalities. A perfect example: If you’re a working mom in a single-parent household and your child has asthma that’s poorly treated and that child misses school, not only are you in a situation where the child is not getting educated and not getting adequate healthcare. The mother has economic consequences for having to stay home with their child. So the ability to provide much better, more holistic care to our communities that are underserved is a key piece of reducing this gap. Now take a look at this current crisis: The number of Black Americans enrolled in clinical trials for vaccines is not where it needs to be. Why is that? Well, you have a systemic set of issues that goes back a long time, where people of color were enrolled in nontherapeutic clinical trials, whether it’s the Tuskegee Syphilis Study or trials on radiation dosing to determine what the lethal dose of radiation was. So you have people of color who are very leery about clinical trials of any sort. If you couple that with anti-vaxxers, you could have a situation where not only do we currently have a disparity in mortality between people of color and white people [during the COVID-19 pandemic]. That could be exacerbated if the only people taking the vaccine are white people. This has enormous societal ramifications.

Mr. Dalio: Where do you want to go with this? Where will the Center for Health Justice be in one year? Five years?

Dr. Corwin: Ultimately, we’ve got to produce results. So this is not about me feeling good about it, or you feeling good about it, quite frankly. This is about how do we put your generosity to the best advantage? And what results do we demand? In the absence of measurable improvement in a number of different parameters, this’ll just be in the wasteland of good intentions, which is not the best way to proceed.

Dr. Iyasere: So what are we going to do? I want to get to it because I’m quite excited about the work:

• One of the most important things that we can do is develop a validated rich database around health equity. That sounds relatively simple: just ask people things and they should tell them to you. Well, when we start to think about all the different inputs — race, ethnicity, language proficiency, sexual orientation, gender identity — a lot of personal information goes into building out who a person is. But we have a lot of work to do. Dr. Corwin talked a lot about trust, and the lack of trust in some marginalized communities. So we’re launching an initiative called We Ask Because We Care, which is targeting our patient population, explaining to them why we ask for this information, and how this helps not only to personalize their care but also identify and then eliminate health disparities.
• We will be conducting a comprehensive analysis of our internal operations: understanding what our clinical outcomes look like, finding those gaps in care, and developing initiatives to eliminate health disparities. We’re also collaborating with both of our medical school partners, Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons, to develop research and innovation around health equity.
• We’re inaugurating a Health Equity Symposium this year for the education of our staff at NewYork-Presbyterian, Columbia, and Weill Cornell. Next year, we aim to have a national conference to convene groups that talk about health equity, data collection, and innovations in healthcare delivery.
• We’ll have an institutional equity report, ensuring that we’re meeting the metrics that we want to achieve. It’s about being public about [our progress] and having our patients and our communities understand what we’re doing and why. Then we will be partnering with our communities and community-based organizations to understand the needs in specific areas and building out programming in areas we serve, including Brooklyn and Queens.
• Lastly, it’s taking the stage nationally. After we have all of this data, after we know where health inequities lie, after we’ve trialed new innovative techniques for healthcare delivery, how can we take a national stage and say, “This is what is possible when you put in the time, the effort, and the resources to really effect change.”

Mr. Dalio: So, you’re speaking a lot about research, collecting data, and then communicating that. How will this be converted into treatment?

Dr. Iyasere: The way we have conceptualized the center is really in three arms. One is in research and implementation science. We want to be a sponsor for grants so that we can sponsor work in the universities, in our hospital, and [other] projects, as well as host an equity fellowship so that people can learn about this work over time. … It’s also evaluating all of our clinical programming, understanding new innovations, and then publishing on that work. The second is in education and leadership. How do we educate our future physicians, our future clinicians around healthcare, on response to pandemics, on health equity? It’s developing new programming for the entire spectrum of faculty and staff at NewYork-Presbyterian. Additionally, one of the largest arms where a lot of the work will be done is in clinical and community strategy and program development. How do we evaluate our clinical operations? How do we develop new initiatives? As an example, we were quite fortunate that after discussions about the center there was a lot of heartfelt desire to get involved. Early on, three women, Monica Nelson-Kone, Veronica Roye, and Nicole Golden, raised their hands and over time helped develop what is now the Black Transplant Health Initiative. How can we partner with communities, educate our patients, and increase the number of Black patients that we not only reach out to or see in our practices, but then we also follow them through transplantation? It’s a pilot program with an idea that started only in liver, but now we’re spiraling out to encompass the entire transplant service line at NewYork-Presbyterian.

Dr. Corwin: There are a lot of people who can identify an inequity in a particular clinical program that we can easily rectify. There are going to be some that are more obdurate in terms of the ability to improve them. We have to have a coherent strategy in terms of what our direction’s going to be. Just as you look at investment philosophy, there’s got to be a health equity philosophy in terms of what are we trying to accomplish and then how you convey that. Otherwise, it’s going to be a series of ornaments without a Christmas tree to attach them to. And that’s what we have to avoid. We have the profound obligation to make this happen, and we have a profound obligation to the Dalio family, who has put their trust in us to make this happen. I can’t express the gratitude that I have for you putting that faith and confidence in us, and for sharing a vision with us. This is going to be a journey; it’s not going to be a destination. But we’re going to make real progress in this space — and we’re going to do it arm-in-arm with you and your family.

Mr. Dalio: And I want to express my gratitude. I have the easy part. You have the difficult part. [laughs] But we will do it in partnership, and I’m very excited about the prospects.