November 27, 2024 • 26 mins
Dr. Carlos Rodriguez-Diaz joins EPITalk host and co-author, Dr. Patrick Sullivan, for an enlightening conversation about ways that epidemiologists can make important contributions in measuring and describing inequitable health outcomes. Their editorial, "From equality to equity: Increasing the use and reporting of equity-based approaches in epidemiology” can be found in Annals of Epidemiology’s Special Issue on Health Equity: Novel Equity-Based Approaches in Epidemiology.
Read the full article here:
https://www.sciencedirect.com/science/article/abs/pii/S1047279724001091
Call for papers on Novel Equity-Based Approaches in Epidemiology:
https://www.sciencedirect.com/special-issue/300230/health-equity-novel-equity-based-approaches-in-epidemiology
Episode Credits:
- Executive Producer: Sabrina Debas
- Technical Producer: Paula Burrows
- Annals of Epidemiology is published by Elsevier.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Patrick Sullivan (00:12):
Hello, you're listening to EpTalk Behind the
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,editor-in-chief of the Journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we're here with Dr CarlosRodriguez-Diaz to discuss a
(00:36):
recent editorial in the journalAnnals of Epidemiology that we
worked on together, titled FromEquality to Equity Increasing
the se in Reporting ofEquity-Based Approaches in
Epidemiology.
You can read the full editorialonline in the journal's special
issue on health equity NovelEquity-Based Approaches in
Epidemiology atwwwanalystofepidemiologyorg.
(01:01):
So now let me welcome our guest.
Dr.
Carlos Rodriguez-Diaz is anacademic activist- and I love
that term.
His professional work focuseson engaging the social
determinants of health toaddress health inequities among
populations made vulnerable byfactors such as race, ethnicity,
incarceration status, genderidentity, sexual orientation and
(01:23):
HIV status.
He conducts community-basedparticipatory research in Puerto
Rico, the continental UnitedStates and the Caribbean region
and has several funded projectsto improve primary care HIV
prevention services andinterventions to improve HIV
prevention services with sexualminority men, to enhance the
continuity of care forjustice-involved people and to
(01:45):
promote primary care for Latinxand transgender populations.
Dr.
Rodriguez-Diaz, thank you somuch for joining us today.
Thanks for the invitation.
So I'm excited to get to talk toyou about this, because
sometimes you work on writingsomething and it raises a bunch
more questions.
You know, it's almost like werarely sit down and have
something we understand fullyand then put it on paper, but
(02:06):
rather the process of workingwith colleagues and writing
leads us to more questions andgreat discussions.
So I'm excited to get to talk alittle bit about this, and I
wonder if we could start outjust by asking you we hear a lot
about health equity in thefield today, and I wonder if you
can just think a little bitabout this concept of health
equity and how you think thatdiffers from health equality.
(02:29):
Are these really talking aboutthe same thing, or what
additional dimensions do youthink equity might hold for us?
Carlos Rodriguez-Diaz (02:38):
Sure, and thanks for the question.
I agree that it's lovely tohave the opportunity to think
about what we've been thinkingand writing about and share
further thoughts.
First, health equity and healthequality is not the same,
although both have a meaning andunfortunately, often we misuse
both terminologies.
And I would like to start bytalking about health disparities
(03:01):
, which I think is the mostcommon way of talking about the
differences in health outcomesamong different groups.
And in fact we have healthdisparities.
Some of those healthdisparities are expected because
we have differences in thepopulations that can help us
understand that we will see adifferent health outcome because
(03:23):
something that exists in thecommunity or in the population.
Health equity is the goal.
Health equity is what we wanteverybody to enjoy and it refers
to the ability of having whatis needed based on the
population or individualcharacteristics.
(03:44):
Based on the population orindividual characteristics From
a system perspective and fromthe research that we do, he's
addressing those structuralfactors that create unjust
differences in the populationsthat we work with.
And then health equality it maysound like an ultimate goal but
in fact might not be, becausehealth equality speak of
(04:09):
everybody having the same healthoutcome, which is, for the most
part, we want positive healthoutcomes, but the challenge with
speaking of health equalitywithout understanding equity is
that we may think that we shoulddo the same with every
population to achieve healthequality, and that's not the
(04:31):
case.
So we need to understand thedifferences within groups and in
the different populations thatwe work with in order to address
the disparities, achieve healthequity and, in fact, having
health equality in our groupsand the people that we work with
.
Patrick Sullivan (04:50):
Yeah, I think this is such a good point and,
as you were talking about it, itsort of made me think that
another way into this equitydiscussion is the idea of
setting up the circumstancesaround us and the opportunities
so that everyone can sort ofreach their optimal state of
health-a nd what it takes to dothat.
Like what we as public health,you know people and what
(05:14):
clinicians and what people whorun programs need to think about
is that, if the goal is foreveryone to be able to obtain
their highest state of health,that what is between me and my
highest state of health may notbe the same needs as what's
between another person and theirstate of optimal health, so
that some groups may startfurther ahead on that journey
(05:37):
because they have access tohealth insurance, because they
live in a place where healthcarefacilities are more proximate,
because they're served byproviders who speak the same
language or who have differenttools at their disposal, and
some folks may start furtheraway from that state of their
optimal health, again because ofsome of these structural and
(05:58):
social determinants of healththat can sit between where our
health is today and that optimalstate of health.
That can sit between where ourhealth is today and that optimal
state of health.
And so I think the way that youtalk about it really sets us on
a path of thinking in deeperways and asking different
questions.
That if we're just sort oflooking at the percent of people
who are vaccinated forhepatitis, you know, for example
(06:18):
, and is it the same in allthese groups?
But to me health equity asks usto think about what that gap is
between where someone sits inour society, in the city, in the
health insurance scheme, inhealth literacy, and where that
highest state of their personalhealth is for them.
Like, if we start taking thatframework, what are the
(06:43):
consequences of that?
Like, how does it lead us todifferent questions?
Or, you know, in your own work,how do you, what range of
things are you thinking aboutand assessing that come about?
Because we're talking about ahealth equity framework rather
than the proportion of peoplewho you know got a vaccine.
So where does that take, yourown work, when you think about
it in that way?
Carlos Rodriguez-Diaz (07:04):
Yeah, I want to follow your analogy and
take it a little bit further.
What is the baseline fordifferent people?
Right, I think of the rootcauses, right?
What are causing those baselinenot to be at the same level?
So those are the reasons or thefactors that we should be
considering as we are aiming forhealth equity.
(07:27):
If we don't understand what arethe drivers of the differences
for the baselines, then we wouldnot be able to answer questions
or come up with solutions toachieve health equity.
So that inspired my work.
We have multiple scientists,including epidemiologists, who
are helping us identifying howcertain factors affect specific
(07:50):
health outcomes and, fortunately, we have moved from only
looking into health factors.
We know that there are socialfactors and besides, of course,
the biological factors that aredrivers of health outcomes, and
those are existingsimultaneously, or interact or
are additive to a specifichealth outcomes.
(08:13):
And because we have thatknowledge, that is what we need
to use in order to achievehealth equity, either by
describing what are the problemsand what are the pathways from
the root to the difference, orto, if we already understand
what are the differences and weknow where do we need to
intervene, then to intervene inthose areas that we know are
(08:36):
going to help us close in thegap and the difference of those
who can achieve health equitywith certain intervention or
resources and those that needmore resources or a different
kind of intervention to achievethe same health goal.
Patrick Sullivan (08:51):
Yeah, and I think that's such the key point
that you end on, which is thatwe need to think about
individuals.
Maybe as clinicians, we wouldthink about individuals, but as
epidemiologists or public healthpeople, we think about groups
of people.
And what is that recipe, whichmay be, you know?
We talk about like providinginformation to people, providing
(09:11):
rides to service centers, tooffering low copay services or
free services, to what languageis their office?
Those are sort of theingredients and it's that deeper
understanding of why people aresituated where they are.
So the idea that for me, I putthings in epi terms, but like
the observational epidemiology,of just describing things like
(09:35):
where the service points are andwhere the communities in most
need of those services are Arethey close, are they far away?
You get there by car.
Do you get there by publictransportation?
How long does that take?
Is that different for differentparts of town?
It may be health insurancecoverage, it may be language
that services are provided in,or other elements of cultural
competence.
So I think I really like yourframework and I really like
(09:57):
thinking about what's in theroots you know what are the
roots and following that all theway through and that suggests
you know ways to make thingsbetter.
So you know, I think sometimesis the work that both of us do.
We talk to colleagues and weshortcut sometimes and use
terminology to talk aboutdisparities or this or that
group you know has twice theburden of this disease, and like
(10:19):
we have a lot of language thathelps us communicate as people
who are interested in improvinghealth.
But I just wonder, you know, ishow we talk about health
inequities?
How should we be talking abouthealth inequities as we
communicate this information, sothat we're not further
stigmatizing or using languagethat might suggest that
(10:40):
communities share some part ofthe blame?
And I'll just say up front mythought is that when you look at
a community within a city andthey have a worse health outcome
, that's almost certainlyrelated to some kinds of
historical racism, you know,marginalization of populations,
some parts of cities not beingserved as well, with good roads
and public transportation andgrocery stores proximate and
(11:03):
walking distance, like all thosethings.
But how do we think about usinglanguage that really helps us
focus on those underlying causesand not further stigmatize
groups of people by race or ageor neighborhood?
Carlos Rodriguez-Diaz (11:18):
Well, yeah, I agree with you that
often when we work withcommunities, populations, we
often already know that thereare some structural factors that
have influenced their livedexperience and therefore have
caused negative health outcomes,and the community also knows
that.
So sometimes we try to doresearch to explain things that
(11:40):
the community knows very welland that can hurt the
relationship of scientists withthe community and also science
overall.
And I would say that the bestapproach that we can have, or
based on my experience as acommunity-based scientist, is to
listen to the community and,instead of looking at what has
(12:04):
not been working, why don't wepay more attention to the things
that are actually working?
Let's have a more asset-basedapproach to the solutions.
I have heard more than oncerecently from community partners
the phrase 'Carlos, we knowwhat the problem is, but we need
to solve the problem.
(12:26):
Why do we continue to describethe problem and to describe the
things that are not working toaddress the problem?
'So to me, what I'm listening is
hey, we have assets, we havegood things that are happening.
Why don't we tap on those andsee how that can help us
achieving the goals?
(12:46):
And sometimes they might nothave enough of that goodness
that helps solving the problem,but part of the solution could
be enhancing, bringing resourcesor improving the way those
resources can be used, andpublic health, health sciences
and epidemiology our fields cancontribute with communities in
(13:09):
order to get there.
And another aspect of this thatI think can make it, you know,
useful to the goal of achievinghealth equity is that then we
will be basing our work on whatthe community knows.
Their language, and thelikelihood of having engagement
and ownership of the communityin the process will help
(13:31):
research and will help thesolution and the sustainability
of the work that we do.
So we have great opportunitieshere if we start listening to
what is working, to the peoplethat we're working with, and
engage from that asset-basedperspective.
Patrick Sullivan (13:48):
First, I love the way you started, which is
that the community knows, and Ithink sometimes as scientists we
spend a lot of time with dataand prove things mathematically
or a significant effect orwhatever.
But again it's the culturalhumility of starting with those
discussions and there are thingsthat the community already
knows.
They may sort of see what wecome up with and say, yeah, we
(14:11):
could have you know, could havetold you that.
So I think there's anefficiency in having those
conversations.
And then I think, you know,because the readership of the
journal and I think maybe folkswho listen to podcasts do sit
more in that epi skill set, andso I think this is just moves us
ahead, you know, further downthe road.
So do you want to take thoseissues that are identified?
(14:33):
And maybe, instead of describingthese associations which, again
, like the community might justbe able to tell us, one could
ask a different question whichis like can we model what the
impact would be of severaldifferent alternative solutions
to that problem that thecommunity identifies, working
with the community to ask whichones would be acceptable?
So we don't, you know, modelthings that like wouldn't be
(14:55):
feasible or acceptable andreally stair step on the
knowledge of the community and Ijust want to acknowledge your
own work because there's also areal scientific basis and a
professional skill set toaccessing that information and
to working with the community sothat we can make those sort of
faster, smarter steps, insteadof a traditional epi approach
(15:16):
which sometimes is, like youknow, let's start by describing
the problem.
But do we need the epi skillsor do we need the listening
skills to get through that phase, or some of both?
So I really appreciate likehearing your perspective and the
kind of work and knowledge thatyou have working with
communities and holding that upto how my epi brain might take a
first stab at this.
Carlos Rodriguez-Diaz (15:37):
But the beauty is that we work together
and I encourage our listeners toremember that if you are
training epi or you're trainingin public health, we are in a
transdisciplinary field and weneed to work with people that
have a different set of skills.
That makes our work so muchmore meaningful and, let me tell
(16:00):
you, it's also fun because weget to learn from each other, we
get to nurture the experienceand if we are in academia, then
that also helps our students, ithelps our scholarly work in
general, and the community alsobenefit from people that have
different skills and differentexperiences, and we are leaving
(16:22):
something good behind when wework with the community from
different disciplines and withdifferent skills.
Patrick Sullivan (16:28):
Yeah, well said.
And when I look at thecolleagues that we work with,
even on this editorial, we'vegot physicians, we've got
physician epidemiologists, we'vegot PhD epidemiologists, we've
got folks with behavioralresearch, community-based
research, and I do think andhope that the way this turned
out really called on all thedifferent backgrounds of even
(16:49):
just the authors.
But I agree with you, it's therichest part of even just the
authors.
So, but I agree with you, it'slike it's the richest part of
our work when we put our skillstogether with someone who has,
you know, complimentaryapproaches.
So I'm just going to move usahead to the call for papers,
and I will-w e'll post up in theshow notes the link to the call
for papers.
But Dr.
Rodriguez-Diaz and I are, youknow, working with a number of
(17:12):
other colleagues and reallyinviting papers to Annals of
Epidemiology that get at some ofthe issues we've been talking
about.
There'll be a link in the shownotes to a call for papers where
we're saying like we're reallyinterested in this stuff and so
if you have papers that arerelated, you know, we'd like the
chance to, you know, to workwith them.
So we lay out in the end of theeditorial seven ideas for how
(17:36):
you know things that would be ofinterest for this special issue
, and one of them, just fromeverything you've been talking
about, to me just sort of ringstrue.
So I'm going to share this withyou and let you maybe just talk
a little bit about how youthink about this.
So, actually, the first one ofthese bullets is to use
appropriate methods toillustrate and deconstruct the
role of social determinants ofhealth that are giving rise to
(17:57):
inequities.
So you've already talked someabout the humility of learning
from communities but, like inthe work that you do, what is
this process of trying to gofrom?
Like, well, here's a gap inhealth, access to health
services, and we know thatthat's not somehow inherent to
this community.
How do you get todeconstructing down to what
those root causes are, maybethose social determinants or
(18:20):
structural determinants that arereally the underlying causes?
Carlos Rodriguez-Diaz (18:24):
Well.
So we can talk for hours aboutjust this one item.
So I would share two examples.
So one would be themethodological approach to
understand the problem right,because we still have to
understand certain problems thathave not been described well
enough.
And something as simple asusing a cross-sectional design
(18:46):
or using a longitudinal designcan lead us to understand the
problem differently and perhapswill also provide information to
know how to intervene and howcertain factors could change
over time, and that improve ourability to integrate that
knowledge into how theintervention may look like.
(19:09):
And another example is the useof qualitative methods in
combination with quantitativemethods that are the core of
epidemiology.
Sometimes we can useextraordinarily good methods,
epidemiological methods anddescribe very well and achieve
the goals and test thehypothesis.
(19:30):
But what that means when wewere to intervene with a
community, and qualitativemethods help us understand what
that means and it could be.
The qualitative methods can beapplied with the community, with
the population that we areworking with, but also with
other stakeholders, includingthe scientists, how we can make
(19:51):
use of this knowledge.
And I'm mentioning qualitativemethods as a companion of
quantitative methods, but withthat I also want to acknowledge
that mixed methods are extremelyuseful and that is also linked
to a very popular approachnowadays with implementation
science, on how we can describea problem, how can we understand
(20:14):
the problem and then scale upthe intervention or the strategy
that we know can work to solvethe problem within a group.
Patrick Sullivan (20:23):
Thank you so much for that.
So one of the things that is agreat pleasure in my
professional work and I know inyour professional work is
getting to work with earliercareer people that might be
students or master's students ordoctoral students or earlier
career.
You know faculty and I wonderwhat advice you might have for
students you know master'sstudents, say who are really
(20:46):
excited about this kind of work,interested in doing this kind
of work.
What advice would you give forsomeone who really wants to move
their career in this direction,around using these tools to
improve health equity?
Carlos Rodriguez-Diaz (20:57):
I will encourage the person to first
read a little bit of the historyof public health and how we
have engaged with people tobetter their health.
And the history of public healthis important because we have
made mistakes in public healthand if you don't know about
those mistakes, we are at riskof repeating those mistakes.
So that would be my firstadvice.
Second, surround yourself bypeers and mentors who are
(21:23):
aligned with your values on howyou see the practice of public
health and the public healthprofessional or scientist that
you want to be.
Nowadays, it's extremelyimportant to know not only the
methods that help us achievinggoals in public health, like the
epidemiological methods, butalso to understand the social
sciences and behavioral sciencethat is the foundation of the
(21:46):
observations that we make.
That will help us being betterwhen we apply different methods.
And lastly, as we have talkedso much about community, always
remember that you might beworking with numbers, with data,
but that information comes fromhumans, and keep in mind how
relevant the information thatyou have in your hands can be
(22:10):
for either clinicalinterventions, social behavioral
interventions or to better thehealth of our communities.
Never forget that our work isto better public health.
Patrick Sullivan (22:24):
Wow, that seems like a great place to wrap
this up, because that is thebottom line, but I just want to
ask you any last thoughts thatyou want to share with listeners
of the podcast, about eitherthis editorial, a career in
public health, health equitywhat's sort of your closing
thought here?
Carlos Rodriguez-Diaz (22:41):
Well, thanks for the opportunity.
I would like to be thoughtprovoking here and invite people
who want to think out of thebox in terms of how can we use
epidemiological sciences toachieve health equity?
What is that idea that you thinkcould be a new way of thinking,
of applying certain methods, ofillustrating how is that we can
(23:07):
achieve health equity, and thatincludes from describing the
problems to solving the problemswith interventions.
I think it's time to challengeourselves as a field and push
forward.
We got to where we are becausein the past, other people have
pushed the field.
We were not talking abouthealth equity the way we're
(23:30):
talking about health equitynowadays, and that's because
some people push the field to doso.
So what's next?
And if you have an idea and youcan come up with a good article
that is aligned with thatnotion, this is the special
issue where you should besubmitting their article and, as
an editorial board, we'd bedelighted to review it and
(23:51):
provide feedback and, at theleast, we will learn from the
work that you're doing, and weneed to nourish that work, and
we are here to use this platform, such an important journal, to
keep the conversation and topush the field.
Patrick Sullivan (24:06):
And, Carlos you can see, but our listeners
can't see that I got a big smileon my face because I think you
just really brought it rightback around, saying that the
reason this special issue isopen is because there's lots of
different articles.
It's not just analyses thatpeople can submit.
You could write a commentary,you can put forward a new idea,
(24:27):
and I just love your enthusiasmand openness, which is, I think,
how all of us feel, aboutopening up this space for people
to bring their ideas and tolearn from each other.
And, on that note, I feel likewe talk from time to time, but I
always feel like I both learnsomething and I leave ready to
dig in and do this work.
So, thank you so much for yourtime today, for the work that
(24:49):
you do, for your leadership inthe special issue for Annals and
just for all that you've sharedtoday.
We're really grateful and thatwill bring us to the end of this
episode.
Thanks again, Dr.
Rodriguez-Diaz, for joining us.
It was such a pleasure to haveyou on the podcast.
Thank you.
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
(25:10):
EPITalk brought to you byAnnals of Epidemiology, the
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast or to read the article
(26:07):
featured on this episode andmore from the journal, you can
visit us online at www.
annalsofepidemiology.
org.
Hello, you're listening to EpTalk Behind the
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,editor-in-chief of the Journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we're here with Dr CarlosRodriguez-Diaz to discuss a
(00:36):
recent editorial in the journalAnnals of Epidemiology that we
worked on together, titled FromEquality to Equity Increasing
the se in Reporting ofEquity-Based Approaches in
Epidemiology.
You can read the full editorialonline in the journal's special
issue on health equity NovelEquity-Based Approaches in
Epidemiology atwwwanalystofepidemiologyorg.
(01:01):
So now let me welcome our guest.
Dr.
Carlos Rodriguez-Diaz is anacademic activist- and I love
that term.
His professional work focuseson engaging the social
determinants of health toaddress health inequities among
populations made vulnerable byfactors such as race, ethnicity,
incarceration status, genderidentity, sexual orientation and
(01:23):
HIV status.
He conducts community-basedparticipatory research in Puerto
Rico, the continental UnitedStates and the Caribbean region
and has several funded projectsto improve primary care HIV
prevention services andinterventions to improve HIV
prevention services with sexualminority men, to enhance the
continuity of care forjustice-involved people and to
(01:45):
promote primary care for Latinxand transgender populations.
Dr.
Rodriguez-Diaz, thank you somuch for joining us today.
Thanks for the invitation.
So I'm excited to get to talk toyou about this, because
sometimes you work on writingsomething and it raises a bunch
more questions.
You know, it's almost like werarely sit down and have
something we understand fullyand then put it on paper, but
(02:06):
rather the process of workingwith colleagues and writing
leads us to more questions andgreat discussions.
So I'm excited to get to talk alittle bit about this, and I
wonder if we could start outjust by asking you we hear a lot
about health equity in thefield today, and I wonder if you
can just think a little bitabout this concept of health
equity and how you think thatdiffers from health equality.
(02:29):
Are these really talking aboutthe same thing, or what
additional dimensions do youthink equity might hold for us?
Carlos Rodriguez-Diaz (02:38):
Sure, and thanks for the question.
I agree that it's lovely tohave the opportunity to think
about what we've been thinkingand writing about and share
further thoughts.
First, health equity and healthequality is not the same,
although both have a meaning andunfortunately, often we misuse
both terminologies.
And I would like to start bytalking about health disparities
(03:01):
, which I think is the mostcommon way of talking about the
differences in health outcomesamong different groups.
And in fact we have healthdisparities.
Some of those healthdisparities are expected because
we have differences in thepopulations that can help us
understand that we will see adifferent health outcome because
(03:23):
something that exists in thecommunity or in the population.
Health equity is the goal.
Health equity is what we wanteverybody to enjoy and it refers
to the ability of having whatis needed based on the
population or individualcharacteristics.
(03:44):
Based on the population orindividual characteristics From
a system perspective and fromthe research that we do, he's
addressing those structuralfactors that create unjust
differences in the populationsthat we work with.
And then health equality it maysound like an ultimate goal but
in fact might not be, becausehealth equality speak of
(04:09):
everybody having the same healthoutcome, which is, for the most
part, we want positive healthoutcomes, but the challenge with
speaking of health equalitywithout understanding equity is
that we may think that we shoulddo the same with every
population to achieve healthequality, and that's not the
(04:31):
case.
So we need to understand thedifferences within groups and in
the different populations thatwe work with in order to address
the disparities, achieve healthequity and, in fact, having
health equality in our groupsand the people that we work with
.
Patrick Sullivan (04:50):
Yeah, I think this is such a good point and,
as you were talking about it, itsort of made me think that
another way into this equitydiscussion is the idea of
setting up the circumstancesaround us and the opportunities
so that everyone can sort ofreach their optimal state of
health-a nd what it takes to dothat.
Like what we as public health,you know people and what
(05:14):
clinicians and what people whorun programs need to think about
is that, if the goal is foreveryone to be able to obtain
their highest state of health,that what is between me and my
highest state of health may notbe the same needs as what's
between another person and theirstate of optimal health, so
that some groups may startfurther ahead on that journey
(05:37):
because they have access tohealth insurance, because they
live in a place where healthcarefacilities are more proximate,
because they're served byproviders who speak the same
language or who have differenttools at their disposal, and
some folks may start furtheraway from that state of their
optimal health, again because ofsome of these structural and
(05:58):
social determinants of healththat can sit between where our
health is today and that optimalstate of health.
That can sit between where ourhealth is today and that optimal
state of health.
And so I think the way that youtalk about it really sets us on
a path of thinking in deeperways and asking different
questions.
That if we're just sort oflooking at the percent of people
who are vaccinated forhepatitis, you know, for example
(06:18):
, and is it the same in allthese groups?
But to me health equity asks usto think about what that gap is
between where someone sits inour society, in the city, in the
health insurance scheme, inhealth literacy, and where that
highest state of their personalhealth is for them.
Like, if we start taking thatframework, what are the
(06:43):
consequences of that?
Like, how does it lead us todifferent questions?
Or, you know, in your own work,how do you, what range of
things are you thinking aboutand assessing that come about?
Because we're talking about ahealth equity framework rather
than the proportion of peoplewho you know got a vaccine.
So where does that take, yourown work, when you think about
it in that way?
Carlos Rodriguez-Diaz (07:04):
Yeah, I want to follow your analogy and
take it a little bit further.
What is the baseline fordifferent people?
Right, I think of the rootcauses, right?
What are causing those baselinenot to be at the same level?
So those are the reasons or thefactors that we should be
considering as we are aiming forhealth equity.
(07:27):
If we don't understand what arethe drivers of the differences
for the baselines, then we wouldnot be able to answer questions
or come up with solutions toachieve health equity.
So that inspired my work.
We have multiple scientists,including epidemiologists, who
are helping us identifying howcertain factors affect specific
(07:50):
health outcomes and, fortunately, we have moved from only
looking into health factors.
We know that there are socialfactors and besides, of course,
the biological factors that aredrivers of health outcomes, and
those are existingsimultaneously, or interact or
are additive to a specifichealth outcomes.
(08:13):
And because we have thatknowledge, that is what we need
to use in order to achievehealth equity, either by
describing what are the problemsand what are the pathways from
the root to the difference, orto, if we already understand
what are the differences and weknow where do we need to
intervene, then to intervene inthose areas that we know are
(08:36):
going to help us close in thegap and the difference of those
who can achieve health equitywith certain intervention or
resources and those that needmore resources or a different
kind of intervention to achievethe same health goal.
Patrick Sullivan (08:51):
Yeah, and I think that's such the key point
that you end on, which is thatwe need to think about
individuals.
Maybe as clinicians, we wouldthink about individuals, but as
epidemiologists or public healthpeople, we think about groups
of people.
And what is that recipe, whichmay be, you know?
We talk about like providinginformation to people, providing
(09:11):
rides to service centers, tooffering low copay services or
free services, to what languageis their office?
Those are sort of theingredients and it's that deeper
understanding of why people aresituated where they are.
So the idea that for me, I putthings in epi terms, but like
the observational epidemiology,of just describing things like
(09:35):
where the service points are andwhere the communities in most
need of those services are Arethey close, are they far away?
You get there by car.
Do you get there by publictransportation?
How long does that take?
Is that different for differentparts of town?
It may be health insurancecoverage, it may be language
that services are provided in,or other elements of cultural
competence.
So I think I really like yourframework and I really like
(09:57):
thinking about what's in theroots you know what are the
roots and following that all theway through and that suggests
you know ways to make thingsbetter.
So you know, I think sometimesis the work that both of us do.
We talk to colleagues and weshortcut sometimes and use
terminology to talk aboutdisparities or this or that
group you know has twice theburden of this disease, and like
(10:19):
we have a lot of language thathelps us communicate as people
who are interested in improvinghealth.
But I just wonder, you know, ishow we talk about health
inequities?
How should we be talking abouthealth inequities as we
communicate this information, sothat we're not further
stigmatizing or using languagethat might suggest that
(10:40):
communities share some part ofthe blame?
And I'll just say up front mythought is that when you look at
a community within a city andthey have a worse health outcome
, that's almost certainlyrelated to some kinds of
historical racism, you know,marginalization of populations,
some parts of cities not beingserved as well, with good roads
and public transportation andgrocery stores proximate and
(11:03):
walking distance, like all thosethings.
But how do we think about usinglanguage that really helps us
focus on those underlying causesand not further stigmatize
groups of people by race or ageor neighborhood?
Carlos Rodriguez-Diaz (11:18):
Well, yeah, I agree with you that
often when we work withcommunities, populations, we
often already know that thereare some structural factors that
have influenced their livedexperience and therefore have
caused negative health outcomes,and the community also knows
that.
So sometimes we try to doresearch to explain things that
(11:40):
the community knows very welland that can hurt the
relationship of scientists withthe community and also science
overall.
And I would say that the bestapproach that we can have, or
based on my experience as acommunity-based scientist, is to
listen to the community and,instead of looking at what has
(12:04):
not been working, why don't wepay more attention to the things
that are actually working?
Let's have a more asset-basedapproach to the solutions.
I have heard more than oncerecently from community partners
the phrase 'Carlos, we knowwhat the problem is, but we need
to solve the problem.
(12:26):
Why do we continue to describethe problem and to describe the
things that are not working toaddress the problem?
'So to me, what I'm listening is
hey, we have assets, we havegood things that are happening.
Why don't we tap on those andsee how that can help us
achieving the goals?
(12:46):
And sometimes they might nothave enough of that goodness
that helps solving the problem,but part of the solution could
be enhancing, bringing resourcesor improving the way those
resources can be used, andpublic health, health sciences
and epidemiology our fields cancontribute with communities in
(13:09):
order to get there.
And another aspect of this thatI think can make it, you know,
useful to the goal of achievinghealth equity is that then we
will be basing our work on whatthe community knows.
Their language, and thelikelihood of having engagement
and ownership of the communityin the process will help
(13:31):
research and will help thesolution and the sustainability
of the work that we do.
So we have great opportunitieshere if we start listening to
what is working, to the peoplethat we're working with, and
engage from that asset-basedperspective.
Patrick Sullivan (13:48):
First, I love the way you started, which is
that the community knows, and Ithink sometimes as scientists we
spend a lot of time with dataand prove things mathematically
or a significant effect orwhatever.
But again it's the culturalhumility of starting with those
discussions and there are thingsthat the community already
knows.
They may sort of see what wecome up with and say, yeah, we
(14:11):
could have you know, could havetold you that.
So I think there's anefficiency in having those
conversations.
And then I think, you know,because the readership of the
journal and I think maybe folkswho listen to podcasts do sit
more in that epi skill set, andso I think this is just moves us
ahead, you know, further downthe road.
So do you want to take thoseissues that are identified?
(14:33):
And maybe, instead of describingthese associations which, again
, like the community might justbe able to tell us, one could
ask a different question whichis like can we model what the
impact would be of severaldifferent alternative solutions
to that problem that thecommunity identifies, working
with the community to ask whichones would be acceptable?
So we don't, you know, modelthings that like wouldn't be
(14:55):
feasible or acceptable andreally stair step on the
knowledge of the community and Ijust want to acknowledge your
own work because there's also areal scientific basis and a
professional skill set toaccessing that information and
to working with the community sothat we can make those sort of
faster, smarter steps, insteadof a traditional epi approach
(15:16):
which sometimes is, like youknow, let's start by describing
the problem.
But do we need the epi skillsor do we need the listening
skills to get through that phase, or some of both?
So I really appreciate likehearing your perspective and the
kind of work and knowledge thatyou have working with
communities and holding that upto how my epi brain might take a
first stab at this.
Carlos Rodriguez-Diaz (15:37):
But the beauty is that we work together
and I encourage our listeners toremember that if you are
training epi or you're trainingin public health, we are in a
transdisciplinary field and weneed to work with people that
have a different set of skills.
That makes our work so muchmore meaningful and, let me tell
(16:00):
you, it's also fun because weget to learn from each other, we
get to nurture the experienceand if we are in academia, then
that also helps our students, ithelps our scholarly work in
general, and the community alsobenefit from people that have
different skills and differentexperiences, and we are leaving
(16:22):
something good behind when wework with the community from
different disciplines and withdifferent skills.
Patrick Sullivan (16:28):
Yeah, well said.
And when I look at thecolleagues that we work with,
even on this editorial, we'vegot physicians, we've got
physician epidemiologists, we'vegot PhD epidemiologists, we've
got folks with behavioralresearch, community-based
research, and I do think andhope that the way this turned
out really called on all thedifferent backgrounds of even
(16:49):
just the authors.
But I agree with you, it's therichest part of even just the
authors.
So, but I agree with you, it'slike it's the richest part of
our work when we put our skillstogether with someone who has,
you know, complimentaryapproaches.
So I'm just going to move usahead to the call for papers,
and I will-w e'll post up in theshow notes the link to the call
for papers.
But Dr.
Rodriguez-Diaz and I are, youknow, working with a number of
(17:12):
other colleagues and reallyinviting papers to Annals of
Epidemiology that get at some ofthe issues we've been talking
about.
There'll be a link in the shownotes to a call for papers where
we're saying like we're reallyinterested in this stuff and so
if you have papers that arerelated, you know, we'd like the
chance to, you know, to workwith them.
So we lay out in the end of theeditorial seven ideas for how
(17:36):
you know things that would be ofinterest for this special issue
, and one of them, just fromeverything you've been talking
about, to me just sort of ringstrue.
So I'm going to share this withyou and let you maybe just talk
a little bit about how youthink about this.
So, actually, the first one ofthese bullets is to use
appropriate methods toillustrate and deconstruct the
role of social determinants ofhealth that are giving rise to
(17:57):
inequities.
So you've already talked someabout the humility of learning
from communities but, like inthe work that you do, what is
this process of trying to gofrom?
Like, well, here's a gap inhealth, access to health
services, and we know thatthat's not somehow inherent to
this community.
How do you get todeconstructing down to what
those root causes are, maybethose social determinants or
(18:20):
structural determinants that arereally the underlying causes?
Carlos Rodriguez-Diaz (18:24):
Well.
So we can talk for hours aboutjust this one item.
So I would share two examples.
So one would be themethodological approach to
understand the problem right,because we still have to
understand certain problems thathave not been described well
enough.
And something as simple asusing a cross-sectional design
(18:46):
or using a longitudinal designcan lead us to understand the
problem differently and perhapswill also provide information to
know how to intervene and howcertain factors could change
over time, and that improve ourability to integrate that
knowledge into how theintervention may look like.
(19:09):
And another example is the useof qualitative methods in
combination with quantitativemethods that are the core of
epidemiology.
Sometimes we can useextraordinarily good methods,
epidemiological methods anddescribe very well and achieve
the goals and test thehypothesis.
(19:30):
But what that means when wewere to intervene with a
community, and qualitativemethods help us understand what
that means and it could be.
The qualitative methods can beapplied with the community, with
the population that we areworking with, but also with
other stakeholders, includingthe scientists, how we can make
(19:51):
use of this knowledge.
And I'm mentioning qualitativemethods as a companion of
quantitative methods, but withthat I also want to acknowledge
that mixed methods are extremelyuseful and that is also linked
to a very popular approachnowadays with implementation
science, on how we can describea problem, how can we understand
(20:14):
the problem and then scale upthe intervention or the strategy
that we know can work to solvethe problem within a group.
Patrick Sullivan (20:23):
Thank you so much for that.
So one of the things that is agreat pleasure in my
professional work and I know inyour professional work is
getting to work with earliercareer people that might be
students or master's students ordoctoral students or earlier
career.
You know faculty and I wonderwhat advice you might have for
students you know master'sstudents, say who are really
(20:46):
excited about this kind of work,interested in doing this kind
of work.
What advice would you give forsomeone who really wants to move
their career in this direction,around using these tools to
improve health equity?
Carlos Rodriguez-Diaz (20:57):
I will encourage the person to first
read a little bit of the historyof public health and how we
have engaged with people tobetter their health.
And the history of public healthis important because we have
made mistakes in public healthand if you don't know about
those mistakes, we are at riskof repeating those mistakes.
So that would be my firstadvice.
Second, surround yourself bypeers and mentors who are
(21:23):
aligned with your values on howyou see the practice of public
health and the public healthprofessional or scientist that
you want to be.
Nowadays, it's extremelyimportant to know not only the
methods that help us achievinggoals in public health, like the
epidemiological methods, butalso to understand the social
sciences and behavioral sciencethat is the foundation of the
(21:46):
observations that we make.
That will help us being betterwhen we apply different methods.
And lastly, as we have talkedso much about community, always
remember that you might beworking with numbers, with data,
but that information comes fromhumans, and keep in mind how
relevant the information thatyou have in your hands can be
(22:10):
for either clinicalinterventions, social behavioral
interventions or to better thehealth of our communities.
Never forget that our work isto better public health.
Patrick Sullivan (22:24):
Wow, that seems like a great place to wrap
this up, because that is thebottom line, but I just want to
ask you any last thoughts thatyou want to share with listeners
of the podcast, about eitherthis editorial, a career in
public health, health equitywhat's sort of your closing
thought here?
Carlos Rodriguez-Diaz (22:41):
Well, thanks for the opportunity.
I would like to be thoughtprovoking here and invite people
who want to think out of thebox in terms of how can we use
epidemiological sciences toachieve health equity?
What is that idea that you thinkcould be a new way of thinking,
of applying certain methods, ofillustrating how is that we can
(23:07):
achieve health equity, and thatincludes from describing the
problems to solving the problemswith interventions.
I think it's time to challengeourselves as a field and push
forward.
We got to where we are becausein the past, other people have
pushed the field.
We were not talking abouthealth equity the way we're
(23:30):
talking about health equitynowadays, and that's because
some people push the field to doso.
So what's next?
And if you have an idea and youcan come up with a good article
that is aligned with thatnotion, this is the special
issue where you should besubmitting their article and, as
an editorial board, we'd bedelighted to review it and
(23:51):
provide feedback and, at theleast, we will learn from the
work that you're doing, and weneed to nourish that work, and
we are here to use this platform, such an important journal, to
keep the conversation and topush the field.
Patrick Sullivan (24:06):
And, Carlos you can see, but our listeners
can't see that I got a big smileon my face because I think you
just really brought it rightback around, saying that the
reason this special issue isopen is because there's lots of
different articles.
It's not just analyses thatpeople can submit.
You could write a commentary,you can put forward a new idea,
(24:27):
and I just love your enthusiasmand openness, which is, I think,
how all of us feel, aboutopening up this space for people
to bring their ideas and tolearn from each other.
And, on that note, I feel likewe talk from time to time, but I
always feel like I both learnsomething and I leave ready to
dig in and do this work.
So, thank you so much for yourtime today, for the work that
(24:49):
you do, for your leadership inthe special issue for Annals and
just for all that you've sharedtoday.
We're really grateful and thatwill bring us to the end of this
episode.
Thanks again, Dr.
Rodriguez-Diaz, for joining us.
It was such a pleasure to haveyou on the podcast.
Thank you.
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
(25:10):
EPITalk brought to you byAnnals of Epidemiology, the
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast or to read the article
(26:07):
featured on this episode andmore from the journal, you can
visit us online at www.
annalsofepidemiology.
org.
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