Cuyahoga County Health Board Swims Upstream To Address Health Inequities

Ideastream’s health team is connecting the dots on how racism contributes to poor health outcomes in the Cleveland area. As government and health agencies have declared racism is a public health crisis, Cuyahoga County Board of Health officials tell us what they have been doing to target structural barriers at the root of health inequities.

Some people think health issues are the result of individual choices, completely isolated from society or anyone else’s choices.

And while that can be partially true, there are systemic issues and even racial discrimination that also contributes to poor health outcomes, according to many researchers and Cuyahoga County Medical Director Dr. Heidi Gullett.

For her, addressing racism as a public health crisis is all about looking “upstream,” at some of the other factors that can influence a person's health before they get to a doctor or hospital with a problem.

“As a physician, I was trained to treat the downstream problems that come from the upstream issues,” she said. “And so, I do that every day in my office, I give people medication, I talk to them about health they can control.”

But often, she said, working with people on an individual basis doesn’t lead to systemic change, which could make an entire community healthier.

“You’re dealing with things after people are already sick,” she said. “If we’re focusing more upstream, as physicians and clinicians and health systems and public health, we’re actually getting prevention in place and we’re giving people an opportunity to thrive before they’re living out the downstream effects of poor health.”

Gullett said the Cuyahoga County Board of Health (CCBH) has been working on systemic issues to improve residents’ health, with many of the projects focused on working with community groups to provide fresh food to communities. 

One example is CCBH’s work in building a full-service grocery store in Euclid, which was an effort to fight food deserts and provide healthier food in that community.

CCBH Project Manager Roger Sikes said that store has provided food access for more than 2,000 people who were previously considered to be in a food desert, and created about 45 jobs.

Creating jobs that hire local is an important part of the project., Sikes said

"We want folks to have access to good jobs in their neighborhoods. We know that when people have full and fair employment when they have more stable lives, all of those things are important to health outcomes,"  he said. 

CCBH also worked with community groups to bring back Farmer Jones Indoor Market in Maple Heights, which had closed during the pandemic, creating a food desert in that neighborhood. 

Local organizations joined together to form the Health Improvement Partnership, or HIP-Cuyahoga, with CCBH as its “backbone.”  County health board leaders are responsible for the organization’s financial and planning structure.

Healthy Eating and Active Living (HEAL) is a key priority for HIP-Cuyahoga, as well as eliminating structural racism. Chronic disease management and linking clinical and public health are also priorities for the organization. 

Understanding White Privilege And White Supremacy Is Key To Real Change

To achieve these goals, however, they first need to change people's perspectives on racism to have an impact on communities and policies, Gullett said.

"We realized we didn't have a shared way to discuss this work," she said. "Perspective transformation is about understanding white privilege and white supremacy and understanding how you may be interacting with other people and how racism can affect all of us."

Gullett's experience as a white person is not the same as her colleagues of color, she said.  She stressed the importance of people being on the same page about racism and their own biases.

“We recognized that we needed a shared vocabulary and a shared understanding of history in order to tackle structural racism in this community,” she said.

CCBH’s efforts to address structural racism also had to come from within, Gullett said. 

“The issue of working internally on understanding equity, diversity, and inclusion was really important to the Board of Health so that there were internal changes that were happening around things like procurement… ensuring there was culturally and linguistically appropriate services at all times.”

Perspective transformation is just the first step in HIP-Cuyahoga's goal to eliminate structural racism. To do that, Gullett said HIP-Cuyahoga partners are doing readiness assessments, and they are also offering Racial Equity Institute (REI) training to community members.

After perspective transformation, fostering collaboration, community engagement, and policy change are future goals for HIP-Cuyahoga. 

CCBH's next step is to identify potential solutions to structural racism. Through a grant, they built a simulation model so people can test out the different solutions to see where resources should be targeted, depending on what the simulation shows. 

"The simulation has a public interface that will allow people to test various solutions to see expected outcomes," she said. 

The simulation will be up for public use later this year, and she said they will use the solutions in the real world over the next year. 

Other county efforts to improve health equity include addressing opioid overdoses, adverse childhood experiences (ACEs), infant mortality and lead exposure. The county is working with community partners to remediate lead exposure and also to improve indoor air quality.

A Pandemic Within The Pandemic

For the past year, CCBH has been fighting the COVID-19 pandemic, but health care officials there know that certain populations have been hit harder than others, due to racial health disparities.

Many call this a racism pandemic within the COVID-19 global pandemic. 

George Floyd’s murder in Minneapolis sparked protests around these racial inequities, and the county Board of Health used its platform to speak out against racism.

“I cannot brief you on the status of the COVID-19 pandemic’s impact on our community this morning without first discussing the impact of the larger epidemic in this country that has killed far more people than coronavirus, and that is racism,” Cuyahoga County Medical Director Dr. Heidi Gullett said during a press conference on June 5, 2020.

The CCBH prevention and wellness specialist Romona Brazile, a Black woman, also spoke about her own experiences coping with racism.

“To learn through reports that Mr. Floyd had survived COVID-19, but not the cruel hands of racism, is too much,” Brazile said.

“It’s a feeling of being powerless and unable to protect yourself and your loved ones. But many African Americans went to work anyway this week, trying to keep it together, myself included,” she said in June of 2020, shortly after George Floyd was murdered. “We are taught to be strong, just deal with it, to accept the quiet and loud indignities for fear of losing your job, your freedom, or your life.”

Romona Brazile addresses the public and the media during a live press conference on June 5, 2020. [Cuyahoga County / YouTube]

“The ways we’ve learned to cope with and survive the pain is to bury it, to suffer in quiet moments alone, and then figure out how to go back into the world with hidden pain,” she said during the press conference. “But this way of coping has its toll, on mental wellbeing, and it also contributes to the chronic stress and the development of chronic disease.”

According to the American Psychological Association and other researchers, this chronic stress can have a lasting impact on both physical and mental health for people of color.

The health impacts of racism led CCBH to address the issue in 2009, helping national researchers identify Cuyahoga County policies that have impacted racial discrimination.

Then, in 2015, the health board and other organizations met to determine the area’s most pressing health needs.

“It was in 2015 when we first declared eliminating structural racism as a first key priority for this community, that unless we’re working upstream in addressing systems and structures that make up those systems and policies within those systems, we’re not going to get to health outcomes that are equitable," Gullett said.

HIP-Cuyahoga declared eliminating structural racism as its priority in 2019, which seemed like a daunting task, but Gullett said at the time that it needs to be addressed sooner rather than later.

A year later, many other organizations were in agreement. In the wake of Black Lives Matter protests, many governments and nonprofits declared racism as a public health crisis.

In fact, Ohio has the second-highest number of entities in the country that have publicly made the declaration that racism is a public health crisis, according to the American Public Health Association, but Gullett acknowledges there needs to be action behind it.

“Declaring it is a big step, but what do you do behind that, so that it’s not just an empty declaration?” she said.

There is still more work to be done to put action behind the resolution, Gullett said. Partnerships are one way to tackle any of these issues, she said, because they are all too big for one agency to address alone.