163: How cross-collaborative partnerships can improve lifelong health trajectories
It’s important for health care workers to provide quality health care. But when it comes to addressing health disparities, clinical care can only go so far, says Dr. Diana E. Ramos, an OB/GYN who now serves as California’s first Latina surgeon general.
“It would be wonderful if that 10-minute appointment that a patient just saw me for made the biggest difference in the patient's life. That's not the reality,” Ramos said. “We have to [take] into consideration the environment that the people live in.”
Ramos says cross-collaborative partnerships between health care providers and community partners are critical to addressing health disparities.
In the latest episode of the Health Disparities podcast, host Dr. Claudia Zamora speaks with Dr. Ramos about what these kinds of cross-collaborative partnerships can look like, and what it takes to improve the health and wellbeing of people in California – and the nation. The transcript from today’s episode has been lightly edited for clarity.
Diana Ramos: One of the things that I would often encourage patients to do is to dance. And you can't help but not move, at least I can't, when I hear Celia Cruz. This is another way for people to move, is dancing and being in your home, being safe. And my grandmother would oftentimes have a dance party. Like, 'Come on, mija, let's put some music on.' And we would just dance around in the living room, and that is healthy.
Claudia Zamora: You are listening to the Health Disparities Podcast, a program of Movement is Life, being recorded live and in person at Movement is Life’s annual health equity summit. Our theme this year is “Bridging the Health Equity Gap in Vulnerable Communities,” and as always we are convening with a wonderful community of participants, workshop leaders and speakers.
I’m Claudia Zamora, your host for today’s episode of the podcast. I’m a health education consultant and health equity advocate, and I serve on the Board of Directors for the National Hispanic Medical Association and the Board of Directors for Movement is Life.
Dr. Diana E. Ramos is California’s second Surgeon General and first Latina Surgeon General. As California’s Doctor, her mission is to advance the health and wellbeing of all Californians.
Raised in South Central California, Dr. Ramos received her medical degree from the University of Southern California and completed her residency training in obstetrics and gynecology at Los Angeles County-University of Southern California Medical Center. She also holds a Master of Public Health degree from UCLA and a Master of Business Administration degree from UC Irvine.
Within the academic sector, she has served as an adjunct Associate Professor at the Keck University of Southern California School of Medicine for many years.
Dr. Ramos is past chair for the American College of Obstetricians and Gynecologist, secretary for the executive board of the National Hispanic Medical Association, and co-chair for the Women’s Preventive Service Initiative implementation committee.
Welcome Dr. Diana Ramos, we are thrilled to have you with us today.
Ramos: Thank you so much, Claudia. Un placer, it's so wonderful to be here with you today.
Zamora: Dr. Ramos, can you start with your overview of your presentation today at the summit?
Ramos: Sure, so I am so happy to be part of the presentation focusing on the emphasis of disparities and how social determinants of health really play a role in our ability to help our fellow human beings, our patients, the people that we care for, our community members, our families, and really just highlighting the fact that by focusing on adverse childhood experiences -- which are experiences that we have as children, that could be from neglect to abuse, as well as the changes in the household environment, such as divorce, separation, incarceration -- how all of that plays a role into how our life health trajectory is progressing. And the other most important critical piece is to take into consideration the lived experience. So the environment that people are growing up in. So we know that adverse childhood experiences can really play a role in mental health, in chronic disease, in the most common causes of death in the United States. But the critically important thing to remember is: What can we do about it? And the first thing is we need to know what is happening so that we can then start to make changes.
And the important thing to remember is that unfortunately, it's people of color, who are the ones that are disproportionately impacted more, and also those who are of low socioeconomic status. So you can have a child that perhaps is going to school and in an inner city situation. And the teacher may see the child as being uncooperative, maybe having ADHD because they're not being able to sit still. But then were developed a curriculum in California, that's called Safe Spaces. And that curriculum helps guide the education, the people in the education system, on recognizing what really is perhaps
going on in this child's life. So it may not just be what's happening in the classroom, but perhaps understanding that the child lives in an environment where there's three different families in that two bedroom apartment, that the one of the parents are incarcerated, that the one of the maybe the mom had depression. Maybe there is verbal abuse. So all of these things compile to really reflect in the child's behavior. And so why not be able to recognize so that we can then provide the help. California has invested over $4.7 billion in reimagining what behavioral health is going to look like, what can it look like, because we have to do something different, especially because of the fact that half of us have been impacted by some type of mental health condition, or it has been aggravated as a result of COVID. And again, disproportionately impacting Latino communities. So affecting the adverse childhood experiences is one of the big areas really looking at the mental health, in transitional aged youth, and transitional age, meaning those who are from high school to 24 years old, and helping them identify mental health issues.
We know that by age 14, 50% of all mental health conditions will be diagnosed. By age 24, 75% of conditions will be diagnosed, but that is diagnosed. So we need to make sure that everyone gets that ability to get not only the diagnosis, but the help the support in order to get their needs met. And it really is so critically important. So we want to be able to help not only children, but help adults, because it's the adults that are the parents, and we just continue to perpetuate a lot of the stressors, the maybe not so healthy parenting styles that we have. So we can prevent mental health conditions by 44%, we can prevent smoking by 33%, those are just some of the statistics. And just really critically important to remember that again, not everyone has the access to the resources, there's disparities. And I look at it as opportunities to recognize and then more importantly, support those communities who are not oftentimes thought of first.
Zamora: Now, when you're talking about how California is trying to obviously tackle this issue, in the Hispanic community, we know that there's a stigma, with mental health, admitting that you have issues. How are you, because you understand that that's what the community feels, how are you as a Latina Surgeon General, helping to tackle that?
Ramos: So, in California, 40% of the population are Latino. And so it's easy to keep in mind and be very cognizant of the fact that the Latino population is a priority. The fact that I have been appointed Surgeon General as a Latina was no coincidence, because I represent that 40% of the population. And we have had the direct directive from Governor Newsom, that all of the programs that report to him are, my office being one of them, has to really include equity as forefront and center in all of the work that we do, which is fantastic, because doing the right thing is an easy thing to do. So that means collecting the data, that means focusing on the populations that we sometimes overlook. In California. It's not just the Latino, it's the Black, it's American Indian / Alaskan Native
population, the rural population. So yes, believe it or not, there are rural areas in California. And it's so critically important to keep all of the groups in mind.
We know that in California, the programs we develop, the rest of the country is looking at as a model. They may not have the investments that we have that we're fortunate enough to come up with the innovative models come up with the models for diverse populations. And so this is the ability to be able to provide that resource, not only for California, but really the model for the rest of the country. And you may or may not know, 1 in 8.5 people live in California from the United States. So the changes that we make in California really have a big impact nationally. So doing the right thing has been second nature in California, because we know we need to have not only the language diversity, we are also ensuring and going out of our way that the programs that are being developed are based upon focus groups specifically related not just to Latino, African American, American Indian, but also looking at LGBTQ+ populations, rural populations, and really having that lived voice into the program development that we are taking on.
Zamora: That is wonderful, that you're not just thinking of California, but overall, specifically because Latinos are going to be the highest minority population by, I think, 2030.
Ramos: And as Dr. Hayes-Bautista from the Chicano Institute at UCLA says, if you are not Latino, you're going to be related to a Latino. We're all related.
Zamora: So in your talk called, "Opportunities for cross-collaborative partnerships," you're talking about how 80% of health happens outside of the health care setting, and you focus on innovative programs implemented in California, that are working to improve lifelong health trajectories, and eliminate disparities and health inequities. Could you share with our listeners, your take-home messages from your talk, in addition to what you've already outlined in the summit?
Ramos: Yeah, so really, the take-home message is that health is cross-collaborative. It's cutting through not just the healthcare providers office. So as a physician, as an obstetrician gynecologist, seeing patients in clinic, in California, sometimes you have 10 minutes, on average, to see a patient, and there's nothing unfortunately but frustration for the patient when they really want to have a longer conversation and opportunity to speak with the provider. And we have to realize that there are many programs that are developed and as a practicing physician, as a public health leader, as a community leader as well, I see the opportunities for cross-collaboration. And we know from research studies, and we know from publications, that really the health that leaves the doctor's office, when I share with physicians, you think that your patient is going to fill the prescription for that medication, depending upon what their life situation is, they may
not have the money to pay for the prescription, they may not have the money to be able to come back for a follow up prescription. So what we need to do is really cross-collaborate with community partners, with community programs.
I can share that in California, one of the programs that we developed when I was in Orange County was a perinatal mental health program. So we created a program where we made sure that we had the opportunity for organizations in the community to provide support, and organizations could be simple as churches, many churches have ministries to support mental health. Many churches have ministries on movement, you know, having walking clubs, there's PTA programs in some schools that will have a gathering of the parents, okay, let's you know, this is going to be our Walking Day, and just to move and to do things together, and to support each other. So those are community programs. There are many public health investments, many public health programs that have also been developed to be there to provide the support for the patients once they leave the doctor's office. An example of that is not only the mental health, depression prevention programs, but also diabetes programs. There are different obesity programs, weight loss programs that are developed by public health that are supported by community organizations. So really, it is that cross collaborative opportunity that we really need to tap into.
It would be wonderful, if that 10 minute appointment that a patient just saw me for made the biggest difference in the patient's life. That's not the reality. We have to keep into consideration the environment that the people live in. So if we are giving the recommendation, well, you need to go out and you need to walk more, and you need to be able to move more. But then we forget, and you may not be aware that that patient maybe took a bus maybe came from farther than than where you're seeing patients. And it's not safe for them to be able to walk. The sidewalk may not be the best condition, there could be a lot of cracks, a lot of uneven spaces. You know, yesterday, I was walking here in DC, and I was with my family member, and she almost tripped because the sidewalk. And this is somebody that's relatively healthy, you know. And so now when we're giving advice, and we're giving recommendations, we have to take into consideration the environment, the resources. And I oftentimes would hear patients, when I would encourage them to maybe move a little bit more walk a little bit more to help with their, with their weight with their diabetes with their high blood pressure, they would say, Doctor, so do you, are you saying that the fact that I'm working as a housekeeper at a hotel, and I'm moving and I'm, you know, on the constant go, is not enough? And so we have to keep into consideration the situations that people are living in. And that's the key takeaway is that cross-collaborative opportunities with the healthcare system, public health community organizations, are critically important to support many of our efforts that we're trying to all promote. And really the power of cross-collaboration together, we're stronger.
Zamora: Dr. Ramos, can you give us an example of how you've gathered, you've gathered all these different, you know, communities, maybe health centers, to get to collaborate to be able to tackle again, this issue?
Ramos: Yes, so when I was in LA County as director for reproductive health, we developed a postpartum weight loss program for moms to lose the weight that they gained during pregnancy. And we know that on average, it takes about two years for a new mom to lose the weight that she gained. There's nothing more than frustration and disappointment when a mom that I was taking care of delivered the baby and realize, well, the weight that I gained didn't go on and go away automatically after delivering the baby. So we developed a program called LA Moms, and it was a text message program that helped moms to remind them to drink water to breastfeed, encourage them to breastfeed as well as to walk. And that program, we worked together, that was a public health developed program that was available to all of LA County and whoever else texted to enroll. And we promoted that program with our WIC offices, with our physicians, with the community partners. And we demonstrated that the program really could work. So 97% of the moms lost the weight in three months, compared to the two-year average. The other thing that we saw was the fact that it was not just the moms out that was improving. It was the whole family. The mom was saying, Yeah, I'm going out and I'm taking, I'm taking my husband, I'm taking my children in the stroller, and it's becoming now a habit. So it's the beauty of really example and modeling. But being able to pull on our partners that are interacting with the moms on a daily basis was wonderful to be able to extend the program and the opportunity to stay healthy.
Zamora: And did any private companies or corporations collaborate in that effort?
Ramos: Yes. So in LA County, we had a lot of cross collaboration, private, public, so with private health insurance companies, as well as we had some pharmaceutical companies that looked to see what we were doing, and they said, Hey, can we promote this program? Absolutely. It's available to everyone. So that's the opportunity that we need to remember. And you bring up a good point, oftentimes, we overlook the partners that we don't typically interact with. And that's one of the reasons why I like to bring in people who will remind me of the different voices that are missing at the table. And I think that's something that we have to consciously do is be deliberate about who we are inviting so that they can make us aware of who's missing.
Zamora: Absolutely. You know, previously you spoke about how some of your patients may not have, you know, the right access to care when we're talking about social determinants of health, access to care, transportation. And some, you know, especially in the Latino communities, some may have one, two, three jobs, making minimum wage. So a lot of times, they're not gonna want to come back to an appointment,
because that that means missing half of their work. So how, how do you encourage your patients to say this is important? I know that, you know, there might be an issue with, you know, money, monetary issues, how do you get them to say, to understand that, it's very important for them to get the care that they need, and that you want to provide that care.
Ramos: So part of the issue is education, and knowing the importance. So I would explain to patients, you know, this is the reason why I want you to come back and and we have to remember from the patient's perspective, and I am oftentimes humbled when I'm on the other side, and I am the patient, that you, you're looking forward to that doctor's appointment, and they maybe spent 10 minutes with me, and it's like, oh, I didn't get a chance to, to ask about XYZ, or I'm not sure why they're asking me to do this. But the education is so critically important to help them understand, this is the reason why I want you to come back, because this medication may cause these side effects. And I want to make sure that you're okay. But the other thing that we have to remember is that there are now alternative ways to communicate with the healthcare provider. So depending upon the healthcare setting, there could be some emailing that could be done, there could be some text messaging done through safe portals that is provided through the health plan. And those are the opportunities to to look at and understand, so why can't you come back? Is it that you don't have the transportation? Is it that you don't have a babysitter? Is it that you, like you said, you have two to three jobs? And then help come up with solutions for the most common reasons as to why they can't come back.
And I totally got it when I would see patients that would take an hour bus drive to come see me because they didn't have transportation, I can now say, okay, we can actually do a virtual appointment now. Do you have access to a smartphone? Do you have access to a telephone that we can do a phone call. So there are alternative ways to provide that help? Technology is advancing. And I think, again, if we educate our patients on alternative ways to receive care, there's going to be higher compliance because now we're accommodating their needs. And we can't forget that the patient is core and central to everything that we're doing, right? The whole reason why we are providing carriers because we want to help them be the healthiest they can be.
Zamora: So California is definitely ensuring that telehealth is a big part of the solution.
Ramos: Well, telehealth is, you know, is not always the one and all solution because even in California, there are areas where there is no Wi Fi, there is no access to Wi Fi. And not everyone has access to Wi Fi. But there are other ways to get help. And it could be as simple as a phone call, it could be as simple as going to a regional medical hub
where they, you know, patient can interact with a provider through the system that connects them with with their health care provider in that medical setting.
Zamora: As a follow up to this from the initiatives you mentioned, could you expand on how ACES can reduce social determinants of health and inequities?
Ramos: So, ACES can reduce social determinants of health because, I mentioned earlier, this is foundational and part of really health. So it's one component is: what you have experienced personally in the past as a child, and really the more I think about it, I'm one year into being Surgeon General, the more I realize that adverse childhood experiences are just the label for what we experience in life. We now have a label, we now have a 10-question survey that can give us an indication of how our childhood impacted our our health. And so that's the one piece to keep in mind. The other piece too is that we are not living in silo and that's where the environment comes into play. That's where, are you living in a community that is safe? Are you living in a community that has access to clean air to clean water? Water, things that we sometimes take for granted, not everyone has the ability to have access to that. And the other is to is what are the resources that are available? Are the education level, the ability social mobility, you know, what does that look like? So, ACES, it's, it's a big puzzle, the puzzle of life. And it's one of the major pieces that can really impact the whole trajectory of not only children's life, but then it's transgenerational. We know that toxic stress, you know, the adverse childhood experiences in a pregnant mom can actually cause what's called epigenetic changes in an infant in a fetus. Meaning that some of that high cortisol level that has been present in the mom can change endocrine system in the baby. So increased risk for a whole slew of chronic medical conditions in that infants life. So wouldn't it be great if we start to address some of those adverse childhood experiences so that we can prevent half of all of the chronic diseases that cause death in the United States.
And movement, movement is really critically important in terms of, we know, mental health, and all of the the positive endorphins and really helping with obesity, diabetes, high blood pressure. But if you, again, have that environment that is not conducive to that, it's not so easy. So, thinking of alternative ways too, to provide the ability to move is critically important. And I do have to put a plug in, one of the things that I would often encourage patients to do is to dance. And you can't help but not move. At least I can't, when I hear Celia Cruz, or, you know, other artists, and it's like, okay, I start to dance. And I think, Okay, this is another way for for people to move, is dancing and being in your home, being safe. And like my grandmother would oftentimes have a dance party. Like, 'Come on, mija, let's put the music on.' And we would just dance around in the living room, and that is healthy. You're moving.
Zamora: Actually, I've done that before where I'm cooking. I'm in the kitchen. And I just started dancing to Celia Cruz.
Ramos: Yeah, I love Celia Cruz.
Zamora: You know, so again, talking about our Latino / Hispanic communities. They experience some of the widest health disparities in the United States. Why do you think it's important to have diversity in medicine and in the healthcare workforce?
Ramos: So you bring up a very good point. Right now, on average, about five and a half percent of all of our nation's population physicians are Latino. We know -- and data has proven research has shown -- that when you have a healthcare provider that is taking care of you that looks like you that, maybe shares similar backgrounds speaks the same language, there's increased rapport, and understanding and ability to want to ask questions. And that's something some patients are reluctant to do. Depending on the community, you may not even not just ask a question, but you may just stay quiet, you may feel intimidated that you can't ask a question. So we know that increasing the pipeline and increasing the reflection of of Latino, not just physicians, but nurses, PAs, the whole health care workforce will increase, hopefully, increase rapport, increase improved health outcomes, and we have the same problem with the Black physicians as well. The numbers, I believe it's like 7%, so it's low.
There are efforts that are happening nationwide, in trying to improve these improve our numbers. But unfortunately, for physicians, specifically, what ends up happening is that many students get turned away by the fact that wow, it's going to be how many years to become a physician. And after being a physician for over 30 years, I've come to the realization in having friends now who are in C-suites who are partners in law firms, have come to the realization that there are very few careers where people actually map out the number of years it's going to take to become what you want to become. So when I asked some of my CEO friends, how long did it take you? Would you say that it took you to become a CEO? They'll say, oh, probably about 20 years. And so, you know, if you were to tell that to a student, they're gonna say 20 years? Oh, no, I'm not gonna go into that. The same thing for for law firm for partners, I would say, I ask them, How long did it take, would you say, to be a partner? And depending on the law firm, they say, 15 to 20 years. So it's the same same concept, you know, but we have to frame it differently, we have to encourage our students and let them know. Yes, you know, life is constant learning. That's the first thing to realize. Many times students think that's it, I'm not going to be going to school for forever. But life is constant learning. So we need to change the narrative, we need to change the mindset and remind people, life is constant learning, you have, really there are organizations from Mi Mentor, from the National Hispanic Medical Association, from the National Association of Hispanic
nurses, that are there to support students to help encourage them and mentor them to continue a career in health care.
And they're not alone, right, many first generation students, and no one in my family was a physician, know how to become a doctor. So now with the internet, there are many resources that are available. And for free, that's the other thing, it's a matter of having that desire to look for the information and get the information that you need and find the mentor. I've had students cold-call me and they said, You know what, I found you on the internet. And I would love to talk to you and maybe get to know a little bit more get some guidance. And for somebody that has been so determined and was able to contact me, I say, Sure, absolutely. So it's our opportunity to really make a difference in the health not only maybe of Latino patients, black patients, American Indian / Alaskan Native physicians, oh, my goodness, those numbers are, it's less than 1% of all physicians. And I probably know a good percentage of those Alaska Native / American Indian physicians. And, again, it's oftentimes it's the the lack of opportunity to know, how do you get to that, through that whole process, because you're oftentimes the first person in your family going to medical school.
But we know that if we increase the numbers of physicians of color, physicians of diversity, then we're going to have better outcomes with with our patients. So it's, I'd say help helped me recruit and helped me be the the model of recruitment for increasing the diversity of Latino physicians. And the reality is, I think there was some data that was done a couple of years ago, is that it would take 99 years if we filled up every single medical school class in the United States, with Latino physicians to meet the the reflective representation of Latino physicians with the general population. So the reality is, we're not going to be able to do it. But there is an opportunity for us to help educate those who are taking care of Latino physician, Latino patients, on what our culture is like, what are our preferences? What are some, some simple words perhaps, that you can learn in in Spanish that will make a difference in them will help build rapport? So lots of cross-collaborative opportunities to be able to improve health?
Zamora: Oh absolutely. And the fact that you mentioned the percentage of Latino physicians, in my work, I started helping plan and accredit new medical schools in 2007. In 2007, the stat was, I believe, close to 5% Latino doctors. Now we're 14 years later, and we're at, I believe, almost 6.5. It's scary. They were saying we will have more and then the other thing is, I grew up in Miami. So you know, a lot of the Latinos, you know, they work, they help with their household bills. So a lot of times in their mind it's like, How am I going to quit working? I need to help my family to afford to go to medical school. And the average debt is about a quarter of a million dollars when you come out of medical school. So it's, like you said, we need outreach. We need to let them know
that hey, there are ways that you can go to medical school, help get paid for it. So that is absolutely one of the key things to get to increase the diversity.
Ramos: Right, and I've had the opportunity to meet many college students, many medical students and high school students. And it's a sticker shock and a reality when the price of tuition is higher than their parents' income. And they say that my parents can't pay for it, and I remind them, your parents are not supposed to pay for this. There are grants, there are scholarships, there are opportunities for you to be able to get that education. So again, it just goes back to informing the mentoring to make them aware of what is available.
Zamora: Outreach is key. So health equity is a primary focus of Movement Is Life, and an important priority of the state of California. How are you embedding equity into work to improve mental health, ACES and maternal health?
Ramos: So equity, as I mentioned earlier, is ingrained in everything that California does. And that has been mandated by Governor Newsom. And that includes collecting data that is so critically important, because the data drives action. When I received my MBA in 2020, that was the model, they said, Data is the new currency, whoever holds the data holds the key to programs, holds the key to innovation. And so that being said, California is making sure that we're collecting the data not just on race, ethnicity, LGBTQ+, rural population, so that we can develop the programs that are going to be offered to those who are living in the various regions of California. The other thing too, that is happening is that we are being deliberate, and including the voices of those who we're trying to impact. So making sure that we have focus groups, making sure we have listening sessions. We get ideas to improve the programs that we're trying to develop. Because we're not living, I'm not living in in the remote areas of Northern California that may not have access to a physician. I don't understand where they're living, where they're coming from, I don't understand many times the information that how American Indian tribal nations how they want to hear the the messaging, so I listen. And so this is so critically important is having the data, having listening sessions, and then creating programs and going back to them and say, Hey, are we on target here, or are we completely off? And so having that, what's called design thinking, having their voices at the table, helping guide us in designing programs. So we're being very deliberate and happy with the results that we're coming out with, you're gonna be seeing in 2025, many of the programs from the Children's youth Behavioral Health Initiative are going to be going live. And not only will California see, but the rest of the nation will see the work that's coming out of those efforts.
Zamora: So in addition to equity, part of our focus on Movement is Life is thinking creatively about how we can use movement for our minds and our bodies. With your busy schedule, how do you make time for movements?
Ramos: Every day, I try to at least walk at least probably about 45 minutes to an hour or so I get up very early. And I make sure I try to do that. That's my me time. And I do it early on. It just helps me be centered. It just helps me think and feel like, okay, I accomplished something for myself. And I think that's one of the things that we need to do, is take care of yourself first, so that you have enough of you to take care of everybody else and everything else you have to do. So yesterday, arriving here in Washington DC went for a very long walk, I think it was like an hour and a half around the mall. And it just, it's so nice to be able to see things from that walking perspective. And I know that many times, there have been times when I've not been able to get out and walk. So I will put on Marc Anthony, Celia Cruz, and I just started moving and like, Okay, I need to move here and change my mind, change my endorphins. So whatever, helps people feel positive, I would say, you know, find that and make it happen.
Zamora: Well, that brings us to the end of another episode of the Health Disparities podcast. Thank you, Dr. Ramos. We really appreciate you being here.
Ramos: Muchas gracias. Un placer. It was a pleasure to be here.
Zamora: And thanks to all of our listeners for joining us on America's leading health equity podcast until next time be safe and be well.
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