The first conversation in the Voices series brings us Sandro Galea, M.D., M.P.H, Dr.P.H., a physician, epidemiologist, author, and professor and dean at the Boston University School of Public Health and Julia Raifman, Sc. D., S.M., a researcher and assistant professor of Health Law, Policy and Management at the Boston University School of Public Health. Dr. Galea is a member of the Paradigm Project Steering Council.
This conversation has been edited for clarity and brevity.
Dr. Sandro Galea:
Let’s start by talking about health services research in general. I'm curious about your thoughts on where HSR fits with a more modern, more expansive view of health policy and management?
Dr. Julia Raifman:
That's a great question and something we're always talking about in our department. What is clear is that social and economic policies do as much to shape patient experiences as hospitals, maybe even more. When we try to improve patient outcomes, we can look at what's happening in the clinical environment and in the health system—but we also can look beyond to social policies and economic policies and think about how they affect patients. I think HSR is starting to go down this path.
HSR is well suited to do this because our expertise is using methods to evaluate policies. We can apply that to say, ‘Okay, what are the tax policies that may have led to inequities that shape people's experiences—inequities in wealth, in opportunities for education, in jobs, in free fair housing?’
We in HSR can think about what we as individuals can do, but also how we are part of the systems that inform HSR. The field needs to bring in diverse people who have different lived experiences than many in the field. There is an opportunity to lean in on diversity, equity, inclusion, and justice. How can we structure things to promote diversity, equity, inclusion, and justice within our field to more effectively do that in the world?
Dr. Galea:
Let's talk about the bringing socio-economic context into HSR, because I think it fits nicely from with you said. Can you tell me where you think the field is with that? How do health services researchers engage with context and where are trends going?
Dr. Raifman:
Every year there is more room for discussion about how social and economic policies shape what we see within the health system. We can do more though.
Right now, I think we have a lot of opportunities. COVID-19 is a catalyzing moment for HSR to look beyond what's happening in hospitals, because so much of what happens with COVID-19 patients and their outcomes is shaped by what happened in their lifetimes before they arrived at the hospital. The hospital is just what happens at the very end and is the combination of social and economic forces and structural racism and stigma that people experience.
As a response, we created the COVID-19 US State Policy Database, where we track several policy changes since the start of the COVID-19 pandemic. We track those responses to COVID-19 and trying to prevent the disease. But we also track changes to economic policies like eviction moratoriums and utility shutoffs, unemployment insurance, things that will be equally important in appreciating health in the years to come.
I think that's a lot of where the HSR research can go in the future—linking these kinds of policies and datasets from the broader world with what happens to patients in the hospital.
Dr. Galea:
Let's talk more about COVID-19. Do you think that COVID-19 is an inflection point in HSR and broadly in health policy scholarship? How has COVID-19 shifted our intellectual architecture to inject different scholarship and research going forward?
Dr. Raifman:
I think COVID sped up and laid bare many of the forces that were already in play in our world and helped change the discourse.
There were already enormous disparities and deaths among young people. Black 18- to 24-year-olds were one and a half times more unlikely to die than white 18- to 24-year-olds before COVID-19 hit. As COVID-19 makes so many people suffer morbidity and mortality all at once, we've become much more aware of the racial disparities in how the disease is playing out and in society. This is a catalyzing moment for us to say, ‘What are the forces that shape disparities?’ Historic and modern-day policies have deprived Black and Hispanic people of wealth, deny equal opportunity for education and jobs, and shape unequal housing and crowding in housing that then exposes people to COVID-19.
These are the forces that we need to study and document and think about how to change. Now that we're in this COVID-19 moment, what are the policies that help people?
When New Jersey increased minimum wage during the COVID-19 pandemic, how did that shape health outcomes for people? When states prevented people from being evicted from their homes during the COVID-19 pandemic, how does that affect people from contracting COVID-19 and COVID-19 transmission rates? How does it affect their other health outcomes?
Dr. Galea:
If you were a ruler of all HSR universe and you said there are five questions that we should address in the next decade, what would those be?
Dr. Raifman:
I think that first we should turn to some people who have not been a part of HSR, who have not had the ability to ask questions. I had the opportunity to meet with some teenagers from Roxbury, Mass., after they attended one of our Boston University School of Public Health gun violence events. We discussed how gun violence researchers looked like me—they are white. And there's a need for gun violence researchers who are Black. Black people experience a disproportionate burden of gun violence. That's especially true for young people like these students and they had completely different ideas.
They wanted to know how investment in community businesses affected gun violence? And I thought that was such an important question. That's exactly the kind of question we need more of. We as universities and medical schools can think about how to restructure our institutions to include those voices. I also think there are opportunities for conferences to do that. Then I think we’ll learn what five questions should be asked over the next decade.
Dr. Galea:
You lay out a radical vision which I admire very much. What I really like is that you also lay out a series of incremental pragmatic steps to achieve that vision. I've been thinking more and more about this and actually have a piece written about how the path to true progress is through having the courage to articulate radical visions and the persistence, patience and empathy to pursue the incremental steps to get us there. And I'm just curious what your reaction to that is.
Dr. Raifman:
I agree. I think that this work is challenging. It is hard to face change. It is really hard to face this moment. We see that everybody is suffering and that some populations are suffering more than others because of systematic disadvantages. It’s a really great opportunity for learning and having concern for one another. We're thinking about what we can do to help each other, help the field move, help our students, and help populations that are disproportionately affected by structural racism, stigma, and marginalization.
Dr. Galea:
There is a conception of HSR within four walls, as there is for all disciplines. I don't mean that critically, but I think you're thinking about removing some of those walls and saying that we need to make sure that HSR learns from fields like social epidemiology and social medicine. And that broader policy analysis and an inward-looking HSR need to be brought together.
Dr. Raifman:
In general, I find it helpful to knock down walls to learn from other fields and other people. It's conceptualizing HSR as perhaps looking at patient outcomes, by looking further back and finding the data sets to do that and using our HSR skills and policy analysis, or in qualitative interviews to get a conception of the world beyond what happens once people reach the hospital.
Dr. Galea:
Looking ahead with hope and opportunity, what do you hope for in the next few years as it pertains to this conversation?
Dr. Raifman:
That is a big question. I really hope we make progress in shaping a world that is healthier, particularly for the people who are most affected by structural forces that have shaped poor health. I hope that we will have a tax system that is more progressive and that helps build wealth among populations that have been marginalized. I hope that we will prevent people from being kicked out of their homes as COVID-19 cases climb. What we do right now is so important for shaping health in the next few years and well beyond that. I hope that in this moment of unprecedented crisis that we can help people through this moment.
Dr Galea:
One more question. I think this is a revolutionary moment and that's a good thing. And I think for young people there comes a moment of decision as to how am I going to dedicate the next 10 years, 20 years of my life to maximally help realize an aspiration of a better world. Can you just talk through why for that person, an academic path may be a valid path?
Dr. Raifman:
I have always felt incredibly privileged to be in academia and that our work allows us to focus on what we think is most important in the world. I think that this moment really shows us how important that is. The questions we ask, the data we collect, really drive the conversation. We see that with the data that are and are not reported on things like racial disparities in COVID-19 and how important they are for informing the COVID-19 response and how those data are still under-reported and presented in a way that is challenging for people to interpret.
We play a really important role in bringing our perspectives to the national conversation and the way we ask questions. This is especially important for students. Students bring the best ideas. Students look at everything with a fresh perspective and they look at the things that we have done and say, "Why is it that way? Why would we do things that way?" It's a wonderful moment to join academia, to help us improve academia and help us improve HSR, as well as broader economic and social policy research.
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