Ep. 65: Exploring Health Equity with Dr. Tony Iton

Achieving health equity is a complex and ongoing endeavor that involves addressing various social, economic, and systemic factors that contribute to disparities in health outcomes among different populations. 

If it sounds like challenging work, it is. But that hasn't stopped The California Endowment's Dr. Tony Iton from making it his life's work. We sat down with Dr. Iton to discuss his insights on the root causes of health disparities, the status of health equity efforts today in the U.S., and the $1 billion effort he leads with health equity in mind. 

Carol Vassar, producer

Views expressed by guests do not necessarily reflect the views of the host or management. 

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Carol Vassar, podcast host/producer:

Welcome to Well Beyond Medicine, the Nemours Children's Health Podcast. Each week we'll explore anything and everything related to the 80% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar, and now that you are here, let's go.

MUSIC:

Well Beyond Medicine!

Carol Vassar, podcast host/producer:

Health equity: that's the state in which every single person has a fair chance at attaining their highest level of health. Achieving health equity, well that's another story entirely. It's a story that requires us to look retrospectively at the causes of health inequity and health disparities and address the obstacles to health equity, which are a mix of economic, legal, social, political, cultural, and systemic factors. It's work being done by public health officials, researchers, healthcare providers, nonprofits, communities, and individuals nationwide.

In California, a private nonprofit organization called The California Endowment is investing a billion dollars over 10 years in its health equity efforts and providing a model for this kind of work for the rest of the nation. The man leading that effort is Dr. Tony Iton, Senior Vice President for Healthy Communities for The California Endowment. He's a physician, lawyer, and public health leader whose passion throughout his career has been working toward health equity. Born and raised in Montreal, Canada, Dr. Iton moved to the US in the mid-1980s to attend the Johns Hopkins University School of Medicine in Baltimore. And it was a bit of a culture shock, but it drove him to the health equity work he continues to this day. Here's Dr. Tony Iton.

Dr. Tony Iton, The California Endowment:

I think that in order for your listeners to understand kind of the impact that it had on me, you kind of have to understand a little bit of the difference between Canada and the United States. I mean, Canada is obviously a developed country, it's a wealthy country. It's got just a handful of cities, most of them are within 30 minutes of the US border. So when you grow up in Canada, you kind of feel like you know the United States because we would shop across the border. We had American friends, I went to college with American friends. And so when I was contemplating medical school, the idea of Johns Hopkins was basically a world-renowned institution in a world-renowned city. My sense was Baltimore was down the street from Washington DC. It's an American city. It's like any Canadian city. It's got resources, it's got parks, it's got infrastructure, it's got transportation, blah, blah, blah.

When I got to Baltimore and immediately adjacent to the medical school, and I'm not even talking a stone's throw. I mean, it was right there were the most blighted conditions I'd ever seen in my life. I mean homes that were largely facades, they were just brick faces, and if you stepped behind them, you just saw a pile of rubble. And there were cars up on jacks and mange dogs roaming around, rats, and babies playing in it amongst all of this. And I couldn't understand what I was looking at. I was literally shocked, and I was being toured around by an upperclassman who saw the look of shock on my face, and he asked me what was wrong with me, and I managed to stammer around something to the effect of "When was there a war here?" It looked like Beirut. This was in the mid-1980s, and I imagined a war zone would look like this with piles of rubble around the place.

And I'll never forget what he said to me because it changed my life. He looked at me with this look of just sheer disdain, and he said, "What did you expect? It's the inner city". And I thought immediately that, oh my God, I was supposed to expect these conditions. And that really kind of threw me for a loop because I was not expecting those conditions at all. And so I knew that I was in a very different place with a different set of expectations and norms, and I had to start looking at this place with a different set of eyes to understand what was tolerated in the United States that was not tolerated in Canada.

Carol Vassar, podcast host/producer:

And what did you figure out was different here in the US?

Dr. Tony Iton, The California Endowment:

Well, I mean, it took me a while because I was kind of in shock. But the conditions in East Baltimore, I mean, it wasn't just like one system had gone awry. Every major system was on life support. The housing was in tatters, and there were more boarded-up houses than I'd ever seen in my life. People were living in them. The streets themselves had weeds growing up through the sidewalks, if there were sidewalks. The transportation system was non-existent. The stores were run down and graffiti. The schools looked battered and prison-like. There wasn't a single system in this community that wasn't struggling somehow. And you can't look at that and just sort of decide that this is normal. You have to conclude that the people that live in this place have been devalued. They're not considered worthy of just basic infrastructure and the kinds of investments that we all need to be healthy. And I realized that I couldn't solve these problems with a stethoscope and a bag of pills and that I needed to start understanding how structure was created in this country, and primarily how policy shaped people's living conditions and what I could do about changing that policy.

Carol Vassar, podcast host/producer:

You have been known to say, and I may be paraphrasing here, that when it comes to health, zip codes matter more than the genetic code. Tell us, based on everything you've now laid the groundwork for as we converse about this, how you came to that conclusion and how true that statement is.

Dr. Tony Iton, The California Endowment:

Well, it was something that I started to think about when I was in East Baltimore in the mid-1980s because you could drive not very far from East Baltimore, literally seven minutes, and you would be in Roland Park, which was just beautiful rolling lawns and mansions and parks and river ways. And just the sheer contrast between East Baltimore and what I saw in Roland Park and other parts of the Baltimore area kind of just shook me up. I just said, well, how could somebody who lived in East Baltimore be expected to have the same health outcomes as somebody who grows up in Roland Park? And I knew that because it wasn't just one thing in East Baltimore, that it was sort of like the constellation of various systems and resources that were all on life support in East Baltimore, I knew that those had to have health impacts.

I couldn't prove it at that time. But subsequently, later in my career, because I never forgot this, I became a health officer in California, and I started being able to apply techniques to look at life expectancy in different geographical areas. And we found in Oakland, California, a life expectancy difference between the flatlands of the city of Oakland and the hills of 22 years, which is dramatic. I mean, that's like Sweden to Afghanistan in the same city. And people thought initially when we did this, it was such an unusual thing, and people thought that the problem was in Oakland. And I said, no, this is not Oakland. And so we went back to Baltimore, and we worked with the Baltimore City Health Department, and we replicated the study that we had done in Oakland, and we found a 30-year life expectancy difference in Baltimore, including life expectancies of 58 years in some neighborhoods in Baltimore, some near Johns Hopkins medical school. And then other neighborhoods with life expectancies in the high 80s and low 90s.

And then we went to Cleveland, we went to New York, we went to Philadelphia, we went to Chicago, we went to Cincinnati, we went to St. Louis, Denver, Minneapolis, Seattle, L.A., San Antonio. Everywhere we looked, did the same analysis, found the same phenomenon, and concluded that this was the American pattern. That zip code not only better predicts life expectancy, it is the strongest predictor of life expectancy at the population level. It's better than looking at genetics, it's better than looking at access to healthcare, and it's better than looking at behaviors. And in fact, all of those frames of looking at health are irrelevant really at the population level. At the population level, we're talking about political phenomena, we're talking about policies that create conditions that shaped people's health. And those policies are manmade. There's nothing natural about them. They don't come out of the 10 commandments.

There's decisions that people have made, and they can be unmade, and they should be unmade because they have dramatic impacts on people's health. And so that's what I mean when I say health is political. One definition of politics is it's the struggle over the allocation of limited and precious social goods. And when we're talking about limited and precious social goods, we're talking about things like potable water coming out of your tap when you turn it on or a park in your neighborhood or grocery store, or maybe even broadband internet. We know that these things are resources that all humans need, and certainly, all Americans need, in order to navigate a healthy life in this country in 2024. Yet, we do not allocate those things in an equitable way. We make very conscious decisions to deny people access to these basic resources. And I'm not talking about Cadillacs and Lamborghinis or Teslas, I guess these days.

I'm talking about basic health protective resources like a park or a transportation system that works, that can get you to a job that pays a living wage. This is not rocket science, and this is not socialism. This is basic societal structuring. When we look at the countries that we consider ourselves peers to, they all have policies that protect people's access to these fundamental goods. They all do. And universal healthcare, universal childcare, universal paid sick leave, community-wide investments in parks and libraries and education. In the United States, we don't have those things, and that's what makes zip code such an excellent predictor of life expectancy.

Carol Vassar, podcast host/producer:

I'm curious, historically, what are some of the policies that have set us up for this inequity that could be just a mile down the road between East Baltimore and the towns that surround it. Historically, what has caused this?

Dr. Tony Iton, The California Endowment:

It's actually quite simple, despite the fact that we try to make it complicated. What happened in the United States is that we had racial residential segregation. When we talk about how the determinants of health are structural, what we're talking about primarily is the neighborhoods that we've created by policy. Racial residential segregation in the United States was kind of the law of the land for a couple hundred years. And it has taken many forms, I mean, there used to be... And there's a great book written about Baltimore about this called Not in My Neighborhood, by a former Baltimore Sun Reporter, and he looks at the history of racial residential segregation. And Baltimore itself had what was called racial zoning. In other words, the city, the mayor, and the city council would essentially designate sections of the city for different racial groups by law. And they would pass an ordinance.

This is where blacks live; this is where whites live. By the way, they separated whites and Jews. And Jews had their own section of Baltimore as well. I mean, this was very official policy. It became federal policy in the redlining efforts of the federal government in the 1930s and '40s. And it became essentially the policy of the federal government to designate communities by their racial makeups and to allocate resources accordingly. And that's essentially what redlining was. And then we had racially restrictive covenants, which were basically private practices by realtors and others to designate certain types of, or certain lots and houses as to be owned only in perpetuity, meaning for the future of mankind, by white people and specifically not others. Including Jews, by the way, in many cases in Baltimore. So there's a very colorful history of all of these practices, racial zoning, redlining, racially restrictive covenants.

That's been well documented. Richard Rothstein wrote a good book about it called The Color of Law. When we say structure, we're talking about place primarily because it shapes so many other things. It shapes access to parks, access to transportation, access to jobs, access to infrastructure like sidewalks and potable water. And as I mentioned earlier, broadband. So when we say that these determinants are structural, it means that they're built into the fabric of our society and our institutions. Schools is another great example, is how we fund schools is based on local property taxes. Which means that low-income communities are going to have low-funded schools, and we sort of shrug our shoulders and say, well, that's the way the cookie crumbles. Well, that has profound health consequences on people's lives, and it shapes the life trajectories of whole populations of people. And by the way, it brings down the overall health status of the entire country.

Carol Vassar, podcast host/producer:

We know that there's a history of this. We know that it is not isolated to any one portion of the country, seemingly across the nation, The United States. At The California Endowment, you've been working on ways to even the playing field. What have you done? What have you found? What research will give us hope here?

Dr. Tony Iton, The California Endowment:

Well, I'll tell you, Carol, it comes down to, and I'm a simple-minded person. I like solutions that make sense that you can communicate to people and they know what they're doing on any given day of the week. So what we talk about in our work is called ABC, and these are the fundamentals of health equity. And A stands for "agency." Agency is essentially power. It's the ability to have some control in your life over what's happening to you. And the challenge in many of these communities is that they've been stripped of power. This is why we say it's political. It's not purely political, but its manifestations are primarily political. It's also social, it's economic. People feel powerless. And when you feel powerless, you get stressed. And when you get stressed, your health gets bad. So the example I like to use for people is like, if I give you two tennis balls and I say juggle them, you laugh at me, and you go ahead and you juggle them. And then I toss you a third one, and well, now you're not laughing so much, and many people are going to struggle to juggle three tennis balls.

There are some that can, but most can't. But then I toss you four and five and six, and now balls are falling all over the place. Well, that's what's happening in the lives of people in low-income communities. They have limited access to necessary life resources. And so, they're constantly juggling, trying to find access to what they need for them and their families. And that creates an enormous amount of stress. And stress over time kills you early. It just weathers your whole physiology. So that's the A. If we can help people derive a sense of agency and a sense of control, we can actually reduce that stress in their lives. And we do that by organizing people, bringing similarly situated people into, essentially, communion so that they can prioritize and decide what they want to work on together. And then we support them. We fund their efforts to make the changes that they think are important.

And what they generally do is they look at local government, and they point to ways in which that local government is not equitably allocating resources, and then they hold that local government is accountable. That's the start. And ultimately, as they get more sophisticated, they start to point to regional and state and they organize in much more sophisticated political ways. So that's A. B is belonging. And belonging, again, I'm simple-minded. Belonging to me is the opposite of racism. Belonging is basically a sense of being seen and heard and perceived in your full humanity, seen as a fully capable human being in your society. And what racism does is it strips you of that humanity. It trips you up that sense of value and worth. And so when you go into low-income communities and try to help people organize, you are immediately confronted by the toxic consequences of racism.

Racism is damaging. It harms people. And so you actually have to slow down and you actually have to build a sense of belonging. You have to rebuild that kind of glue that holds people together in a community so that they can see themselves as being represented, which means that you have to tell their stories about how they got to where they are. And you have to tell honest stories, and you have to tell hopeful stories about the future that reflects on the strength of our diversity and the talents that people have brought from all over the world to the United States to make us a great country. And then the C of ABC is what I like to refer to as rebuilding our social contract. It's fundamentally what I alluded to earlier, this notion that it's not rocket science what leads to healthy societies.

We've studied this inside and out, we know. And I'm going to say something that's going to sound a little odd here. I'm going to say universal healthcare. The important word in that phrase is not healthcare; it's universal because it reflects social solidarity. The fact that we're connected to each other and that we invest in each other's well-being. That's a reflection of belonging. So, the fact that countries that have social solidarity can develop the political will to pass universal policies is not rocket science. What we lack in this country is social solidarity. We're deeply divided historically by race, and it's taken different kind of vectors over time. But the deep root of this is race, and it's structured into virtually every institution in our society. And we can undo it. We can fix it. And that's what we're doing in California; we're rebuilding our social contract.

We're pursuing universal healthcare. We have virtually everybody in the state insured. We have a small group of undocumented people who make too much money for our Medicaid system. And we're trying to figure out a way to get them covered. And once we have them covered, we'll have coverage for everybody. We're funding universal childcare and paid sick leave. We're all employed people. We're trying to brick by brick rebuild our social contract because we know in the end if we invest in the well-being of all of us, we all do well. We all do much better than when we're all on our own.

Carol Vassar, podcast host/producer:

In the past, you've talked about the narrative of exclusion, the narrative of inclusion. Tell us about that concept.

Dr. Tony Iton, The California Endowment:

Over time, we've analyzed political speech and we've tried to understand why don't we have universal healthcare in the United States. It's not like we don't have research and studies to show. We have literally over 150 studies that show universal healthcare saves lives, it's better for you, and it's cheaper. Why don't we do it? That's the question. So, obviously, it's not the lack of evidence. It's something about, and this is what I learned early in my career. It's the difference between policy and politics. The difference between policy and politics is power. You can have all the great ideas in the world, but if you don't have the power to bring them into fruition, they're just good ideas. They're not actually benefiting anybody's lives. And so this question of why do we get stymied every time we pursue universal healthcare? And that's just one example. You could use the example of universal childcare or paid sick leave or any number of different policies that other developed countries, wealthy countries, have passed 20, 30, 50 years ago.

And so we recognize that, well, the way policy is developed is through stories, through narratives about who deserves what, who belongs. And there are basically two narratives in this country. And then there are a whole bunch of derivative narratives of these two kind of Uber narratives. One is a narrative of exclusion, which does three things. It basically, first thing it does is it dehumanizes the target of that narrative, and it makes them somehow less human, less deserving. This notion that the people are somehow not quite human, not quite deserving. And then the second thing it does is it sort of exaggerates this notion of zero-sum, and it sort of posits that we're in this sort of war for resources against a competing tribe, and whatever they get means that they took it from us. So our goal is to essentially keep our stuff and keep them from getting stuff.

And so that plays into this notion of scarcity. There's not enough. We can't afford to do basic things like universal healthcare. And then the third thing it does is it nostalgia the past. It talks about how things were great in the past, ignores genocide, racism, and incarceration of whole groups of people because of the war. And it looks the future with fear. They're coming, they're coming, they're going to poison our blood. These kinds of ideas, these are fixed features of the narrative of exclusion. It's got to dehumanize, it's got to play up scarcity, and it's got to talk about the past nostalgically and the future fearfully. And then the computing narrative is the narrative of inclusion, which basically doesn't do the opposite, but it does different things. One of the things it does is that it changes the narrator. It lets people tell their own stories so that they can be seen in their full humanity.

It allows them to humanize themselves. The second thing it does is it shows how our faiths are inextricably intertwined and that my future and your future are connected. And I need to make investments that benefit you; you need to make investments that benefit me, and we'll all be better off. The third thing it does is it tells the truth about our history, and it looks to the future with hope because it recognizes that diversity is our strength and that this country has the potential to be the first country in the world to successfully demonstrate a multiracial democracy in an increasingly complex and balkanized world. So these two narratives do battle every day in the policy field, and the victor of that narrative battle gets to write the policy, and those policies shape the conditions that ultimately have profound health consequences.

Carol Vassar, podcast host/producer:

So, what's the message to policymakers? What's the narrative you want them to hear and how can we have them hear the narrative that is ultimately going to benefit the entirety of the public health?

Dr. Tony Iton, The California Endowment:

Well, two things. Policymakers don't operate in a vacuum. And this is why we say at The California Endowment that democracy is good for your health. Good, vibrant democracy that is representative and participatory forces policymakers to make better decisions. Policymakers operating on their own will do what's basically expedient. And this is part of the problem with our political system is it tends to be the short-term focus. It's looking for short-term reward. It's not looking long-term. And so, we need political pressure on policymakers to hold them accountable for long-term investments. I mean, we're not going to solve climate change with a short-term focus. And universal healthcare is exactly the same. We have to make a long-term investment in the health of our population. The second thing I would say, which is important for policymakers, is that this affects all of us. It's not like there's some small minority group of people that are just having a bad time of it, and we need to offer them some charity.

The United States has amongst the worst life expectancy in the developed world, if not the worst, and it's falling. It's actually not increasing. It's been falling dramatically compared to the EU and most of the developed countries in the world since 1980. And when you look at just white Americans, it's still falling, and it's falling fast. And most policymakers don't know that they still labor under this narrative that the problems in this country are related to low-income people of color. And that's the challenge. And unfortunately, they don't have a lot of political power, so we don't have to worry about them so much.

Well, no. I mean, there's so-called deaths of despair happening throughout the heartland of the United States through the middle part of the country, in white rural communities where life expectancy is in free fall driven primarily by self-inflicted causes, drug overdoses, alcohol-related organ disease, and suicide. And just those three causes alone have killed more white Americans than the entire US HIV/AIDS epidemic. The scale of this is enormous. We're in complete denial about it because it's white people, and it doesn't fit the narrative. So policymakers, if they seriously are concerned about health, which they should be because they represent us, then they have to have a solution to this. You can't shrug your shoulders and say, "Well, [inaudible 00:28:14] the brakes". I mean, US life expectancy is in free fall, and policymakers are elected to solve those kinds of problems.

Carol Vassar, podcast host/producer:

As we look at some of the issues that you've laid out in our conversation, falling life expectancies, deaths of despair, how do we address some of these things? Are there pathways to solutions here?

Dr. Tony Iton, The California Endowment:

Yeah, and I think we're actually showing these in California. I mean, people think about California as being super blue and la-di-da surfers and skiers or whatever. First of all, it is not. If you look at a map of California, it's mostly red. It's blue along the coast where the populations are, but most of the inland is red. And in 1994, 30 years ago, California passed Proposition 187, which was deny undocumented people access to every basic social and human resource, including education for children. 60% of Californians voted for it in 1994. And that caused a serious backlash and many of the people who were directly targeted by Prop 187, and ended up getting essentially dismantled in the courts. But the people who were targeted by it got involved in politics and they started to organize themselves, and they started to create a wave of progressive politics that recognized all of the things that I talked about before.

That we needed a narrative of inclusion. We needed policies that rebuilt our social contract, and we needed to create meaningful conditions for all of us to be able to leverage our talents and gifts to be able to participate in the 21st-century economy. So California has been doing that. We've changed our narrative. We're investing deeply in populations that have been stigmatized, including formerly incarcerated immigrants, LGBTQ, boys, and men of color. We've focused policy on these populations to try to understand how we can remove some of the barriers to people being able to take advantage of their opportunities. And we've talked about California as a place where we all belong. And I like to say to people outside of California that, hi, my name's Tony. I'm from California, that means I'm from the future. And what happens to us today in California will happen to you tomorrow. So keep your eyes on us because we are the change that's coming. And I believe that that is true. We're the vanguard. We're going through that moment now in the United States, and we're going to come out looking a lot more like California.

Carol Vassar, podcast host/producer:

Is that what you mean? You've talked about reinvigorating democracy. Is that what you mean? California kind of on the cutting edge of the reinvigoration of democracy. What do you mean by that phrase, I guess is the question at hand?

Dr. Tony Iton, The California Endowment:

Well, two things. One is that we live in a democracy, and we don't invest in that democracy. And this is a challenge. Our democracy is to some extent, nationally, it's broken. You just use the example. You poll people, and you ask them if they want universal healthcare, and the majority always say yes. And then you look at politicians, and you say, well, the populace wants universal healthcare. Why don't we have universal healthcare? And the politicians say because the health insurance companies don't want it, some of the employers don't want it, and the medical device manufacturers don't want it. And so they're beholden to these special interests. I mean, in this particular case, like industry sectors that derive a great deal of profit and benefit from the status quo system. And so just right there is the case made for our democracy broken. And so if we hope to create the kind of health outcomes that we want to see in our country, we're going to have to fix some fundamentals about our democracy.

Which is why I say, people ask me, well, what do we say to policymakers? And I say I don't really say anything to policymakers. I say things to people who can hold policymakers accountable because policymakers will do the most expedient thing. And we don't need the most expedient thing here. We need some long-term thinking. We need some deep investments in ourselves as a country. And we need particularly policymakers, we need them to understand what are the actual drivers of health and not the typical individual responsibility, flavored ideas about what causes good health and what doesn't.

Carol Vassar, podcast host/producer:

Give me some hope here. As you look at your present work, what are you most excited about?

Dr. Tony Iton, The California Endowment:

Well, by far, it's young people and the work that they're doing in California and across the country, too, not just in California. I mean, you look at some of the political responses to climate change. It's being driven by young people. We say this sometimes at our organization that Martin Luther King and Stokely Carmichael, and Cesar Chavez, and many of these great leaders, Rosa Parks, they were in their 20s and 30s when they did their greatest work. And so the next, Martin Luther King and Stokely Carmichael and et cetera, is now probably a teenager. And it's those people that we need to invest in to allow them to see the possibility of their power. And so we invest a lot in the power of young people in California to make that change. And it pays off. It pays off. It pays off.

Carol Vassar, podcast host/producer:

Dr. Tony Iton is the Senior Vice President for Healthy Communities for The California Endowment.

MUSIC:

Well Beyond Medicine!

Carol Vassar, podcast host/producer:

Achieving health equity requires a variety of approaches and evidence-based solutions. What's working in your community? Leave us a voicemail on our podcast website, nemourswellbeyond.org. There, you'll find all of our podcast episodes, plus an opportunity to subscribe to the podcast and leave a review. That's nemourswellbeyond.org. Thanks to Dr. Tony Iton for taking the time to talk with us for this podcast episode. And thanks to you for listening. Thanks also to our podcast production team for this episode: Che Parker, Cheryl Munn, Susan Masucci, and Lauren Teta.

Join us next time as we find out how the recently completed PLAYERS PGA tournament is creating an environment to improve health and support local nonprofits. Until then, I'm Carol Vassar. And remember, we can change children's health for good well beyond medicine.

MUSIC:

Well Beyond Medicine!