Dr. Richard Besser on Covid-19 in Rural Communities and Getting to the “Last Mile”

“At a time of crisis, I think there’s nothing more devastating than to feel you are not seen, that you do not have value, that your government and your representatives and your public health system doesn’t care about you,” he said. “That can be debilitating in terms of mental and emotional health.” – Dr. Richard Besser

In this conversation from Rural Assembly Everywhere, Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC, is joined by Ligia Cravo, Senior Program Officer at Hearst Foundations and board member of Center for Rural Strategies, for a conversation about the effects of Covid-19 on rural America.Recorded in October before any vaccines were authorized, Besser reflected on the importance and challenges of getting coronavirus vaccine to all adults across all communities.


Ligia Cravo: So I would really like to start by thanking Bob for this inspiring kickoff of our 2020 Rural Assembly. Bob, you’re definitely the rockstar on our board and we couldn’t do it without you and the family, absolutely. Thank you all so, so much for these generous introductions it’s such an honor, indeed, for me to be here with Dr. Richard Besser and share a candid conversation with the more than 1000 rural visionaries, who have joined the Assembly. Which I guess tells us we’re quite a thirsty bunch for sharing and caring across the land. Thank you everyone for being here. So Rich, I really can’t think of anyone that’s more qualified to comment and reflect on the disparities that have so long affected our rural communities and which are now more exposed than ever, due to the pandemic. And I know that you share this Assembly’s, have always shared this Assembly’s commitment to working together, to build a more just and inclusive nation, where prosperity is driven not just by equality, but also equity. What can we learn from this moment in our history about building a nation that really values all of the people and all of the places throughout their entire lifespan. And would you also comment on why it’s important to understand the difference between equality and equity to achieve this objective?

Dr. Richard Besser: Yeah. Well, thanks Ligia. It is truly an honor to be here with this group that cares so much about rural health, about health justice, about the issues that are right now in the news every single day. You know, one of the things about this moment that I hope is not missed, is the potential for incredible transformation. You know, where we’re faced with this health crisis, this pandemic that’s unlike anything in our lifetimes. You know I’ve never seen a health crisis of this magnitude. At the same time, we’re having an economic crisis that is just shining a light on the disparities and the inequities across our country. And added to that, is an incredible movement across the country for racial justice.

And the occurrence of all three of those at the same time, gives us an opportunity to think about what kind of society we wanna have. You know, the question you raised about equity versus equality is an important one. And one that the Robert Wood Johnson Foundation, we spend a lot of time thinking about, talking about, figuring out, well, how do you, how do you shine a light on that and explain the difference? In a setting of equality, everyone is given the same thing and you can say, “Well, yeah, that makes sense. “Give, everyone the same thing.” And then, see how things play out. Unfortunately, if you take that approach, you ignore the fact that different people have different needs, and for many different reasons. There are so many in our society, who have faced historical barriers over generations and generations, hundreds of years of barriers based on racism and sexism, ableism. That if you don’t account for that, and you give everyone the same thing, then you will continue to see major disparities, major differences. And one of the things that this pandemic I think serves to do, is shine a bright light on how that plays out. And, you know, I spent a lot of time talking about how it plays out in terms of a disparate impact, disproportionate impact on Black Americans, Latino Americans, Native Americans, who are being infected and hospitalized and dying at rates that far surpass their proportion of the population. And so much has to do with exposure risk, you know, a higher proportion of people of color, work in essential occupations. They work in healthcare, frontline healthcare workers and home health care workers and working in food production, and manufacturing and transportation, and first responders. And those are not occupations that you can do, like I can do my job sitting here in my basement remotely. And so you’ve got an increased risk of exposure. And as a society, we haven’t provided everyone with the protections that they need, to ensure that the risk is reduced to as low as possible. We also haven’t reflected on the fact that, you know, many people are unable to follow the guidance that public health is putting forward. I was really blown away Ligia, by the CDC guidance around what to do, if you think you’re sick. And what they said was, well, “Don’t go to the hospital or healthcare center, “call your doctor.” Well at the start of this pandemic, 28 million people in America lacked health insurance.

Ligia: That’s right.

Dr. Besser: And, you know, a greater proportion of people in rural communities, lack health insurance. So who are you gonna call, if you don’t have health insurance, you know and what they recommended is if you think you had COVID or you’re diagnosed that you stay home in a room away from other people, use your own bathroom. Well, you know, if you live in a multigenerational household and again, a high proportion of people in rural communities, live in multigenerational households, then you’ve got COVID and you’re likely to infect somebody in your home. And if you live in a household with people who may have underlying medical conditions or disabilities that put them at greater risk, you’re again gonna be infecting people who are at greater risk. And, you know, as you know, people in rural communities you know, over 50% have chronic medical conditions. So if you’re not recognizing that different people, different communities have different needs and you’re saying everyone do the same thing. You are by nature, disadvantaging of large sectors of our population.

Ligia: Yeah. I couldn’t agree more and added to it, I guess the confluence of also often disparate information from federal, to state to state has definitely left us without as uniform a response as we likely would have all wanted. But you touched on an important issue, many important issues for rural communities. Where in fact since August the higher incidents has been in rural America of cases, with some of our counties, really having to be very highest incidents. And today, again, the numbers as reported are up. And I wonder if you might comment on how, as I know you’re a data lover and the evidence driven champion, with all the data we are now collecting on COVID, again why is it so important to have all the specificity of this data, to ensure that equity, and also how do you think that this philosophy, belief system of pulling yourself by your bootstraps that is baked into our DNA, really has impacted our ability to have a more universal public health system. As you’ve pointed out, I mean, many of us are just doomed to be born in zip codes that have chronic structural disparities and the idea that you could get straps, let alone boots, just seems absolutely out of sync. So how can data help us change this false narrative?

Dr. Besser: Yeah, you know, I smiled when said I’m a data lover because I am. I’m a pediatrician and I’m also an epidemiologist and trained at the CDC and know the power of good data to drive action. You know, data that’s just collected to say, “Wow, look at this.” I find really kind of stifling, but data that’s used for purpose, for action, can be really empowering. But one of the things that’s so important to recognize, is that, you know, data is not apolitical, data has perspective. And if you’re not collecting, what data you collect, says a lot about what you care about and who you value. And one of the things that we’ve done as a foundation, is layout principles for equitable response and recovery for local officials. And the first principle we call out, is the incredible importance of collecting data that will allow you to look across your communities by race, by gender, by sexual orientation, by zip code, by disability. You know, all of these factors we know from specific studies have a relation to how well you’re gonna do with this pandemic or how well you’ll do in other health situations. But if you’re not looking at things by zip code, and you can’t pull out your rural communities and compare those to other communities, you may miss something big. You may miss a community that is not being well served by testing sites. Now, I’m on the Restart and Recovery Commission here in New Jersey. And one of the things we’ve been able to see by looking at data by zip code, is specific neighborhoods that lack access to testing. And then you can target that and address that. And if you’re, you know if you’re a state that is like so many states, mixed rural and urban, and you’re just looking at your statewide numbers, they may look really good but if you’re not being able to break it down to say, “Well, let’s look at our rural counties “and what’s happening there.” You may miss counties that lack that broadband connection to be able to do telehealth or may be the missing the access to hospitals that have intensive care units, that will lead to better outcomes with disease. So, data is really, really important, and it’s important that at the federal state, and local level data it is collected so you’re able to look at things down to those levels because if you don’t do that, one, you’re gonna miss problems and opportunities to save lives. But it also it says a lot about who you value and who you see and who you see fully, and, you know, at a time of crisis, I think there’s probably nothing more devastating than to feel that you are not seen, that you don’t have value, that your government and your representatives and your public health system doesn’t care about you. That can be incredibly debilitating in terms of, you know, mental and emotional health. 

Ligia: Couldn’t agree more again. And another sort of thought in relation to all of this, is of course, the role of the media and journalism, and you spent almost seven years in that role as well. How do you think that the media and journalists, may in fact play a very positive role in informing our communities and influencing, you know, best practices in public health, government and so on. And I wanna give a big shout out here actually to our very own Daily Yonder publication because they’ve done an extraordinary, extraordinary job of covering the pandemic. And at a time when, as you well know there are fewer and fewer local newspapers. And the fact that, Frankly membership is like increased by two thirds, readership rather, since March is very heartwarming because it means to me that people are thirsty for truth telling information. So what are your thoughts about the roles that could be played?


Dr. Besser: Yeah. Yeah, you know, when I think about media, it’s another one of those things where you have to break it down to be able to really see the good and the bad. And, you know, I see so much written that paints media with a broad brush as a media that is a part of the problem, media is also really part of the solution. And, you know, the loss of of small town local newspapers is really challenging. For a lot of places it’s a fabric that can hold a community together and lets you see and understand your neighbors as people, as individuals, and we’re losing a lot of that. Daily Yonder is doing a great job at calling out the incredibly high rates that we’re seeing now in rural communities. And those are stories that are not making the national news to the extent they should. You see how well the pandemic is spreading to Midwest you know, States it’s like, let’s break it down a little more, yes it is. You know, one thing about the virus, is it doesn’t care where you live. It doesn’t affect every community at the same time, but it will affect every community. And if you’re not able to call that out, and local papers are one way that you can do that. And you’re seeing online, replacements for some of that. There’s been great investigative journalism that has called out issues, called out issues of politicization of public health. That’s really, really important. You see a lot of websites that are replacing some of the traditional roles that the government has done. And some of those are media websites where you know, different media outlets are tracking cases and tracking cases by race and ethnicity, and gender and things that you’re not seeing on our governmental websites. But you also see a downside from some of the broadcast media outlets where they’re contributing to the politicization of this. You know, when I was at CDC, I was at CDC for 13 years, and for all those years, I led emergency preparedness and response. And during public health crises, we tried as hard as we could to keep politics out. And, you know, we viewed it as a true success factor if we could get bipartisan support for the public health response. And there was a period here during this pandemic early on when you saw Congress come together and pass the CARES Act almost unanimously. And that provided incredible support to a lot of people that recognized that people needed money in their pockets to be able to put food on the table and to pay their rent. And it gave supplemental support for unemployment insurance and protection against eviction and mortgage foreclosure, you know, on all kinds of things that are in there that are now, you know, lapsed. But there was that period early on where I was thinking, wow, maybe Congress can hold it together.


Ligia: Wow.


Dr. Besser: But you know, clearly that hasn’t hasn’t happened. And media feeds into that. You know, I spend a lot of time now because of the role that I’d had at ABC, I’m very comfortable, talking about science and health to general public. And so, you know, I’m on media outlets across the political spectrum. And what I hear on them is really unfortunately, a lot of feeding the flames of, you know, the political divide rather than looking to say, “Hey, you know “how do we address concerns? “If some people are concerned about wearing masks “and about social distancing, “I’m trying to understand why that’s the case “and address those concerns.” But it’s so challenging when you see this, you see such a discordant messaging between public health and the leaders at the federal level.


Ligia: Yeah. Again, very much in agreement but also I’d say I’m a bit of a viral optimist. So I need to have great hope in what’s ahead, and in fact, one of my big hopes, and I’d love to hear what your thinking is in that regard, is a moment when we shall have a public health system that really supports community health workers and that you know, and that means federal and every level, I just read I don’t know if it was University of Pennsylvania, some, you know, a really critical piece of research, commenting on the fact that if even just a third of our Medicaid patients were benefiting from community health outreach programs, more than $80 billion could be saved, not to mention the quality of their health and their care would be so tremendously higher. So that’s one of the silver linings I’m hopeful for, but would love to hear from your angle as an expert in public health.


Dr. Besser: Well, you’re an expert as well, and I think what you lay out does give a path forward that we should be hopeful about. You know, these that are so challenging, you know, I am optimistic that it will allow new approaches, novel ideas, innovation to rise up that will gain traction, and that, that will save lives. You know, the Affordable Care Act, allowed for the expansion of Medicaid. And we know in the states that expanded Medicaid, that it greatly helped, you know, entire state but rural communities in particular. You know there have been 170 rural hospitals that have closed since 2005, and with each closure of a rural hospital, what research shows is that there’s a 6% increase in mortality in the surrounding communities. And that’s before a pandemic, you know, with this pandemic we’ve done a survey work with Harvard School of Public Health and NPR, I’m looking at the impact. And what we saw there is that, one in four rural households had someone with a serious medical condition who was unable to receive care during the pandemic.


Ligia: Yep.


Dr. Besser: And that those individuals, the majority of them suffered dire consequences because of that. And so, you know, this is a time to look at new approaches. One is, you know the Affordable Care Act allows States to expand Medicaid, 12 States haven’t done so, those States have large rural populations. Those, you know, people in those States, need to push their governors, push their legislatures to say, “Hey, we need to expand Medicaid.” That’s a plus. Your comment about community health workers, I think is spot on as well. You know, at the Robert Wood Johnson Foundation, we have a program called Global Solutions for US Problems. This is one of those situations where there’s so much we can learn, from the rest of the world.


Ligia: Absolutely.


Dr. Besser: Yeah, I mean the model of community health workers, isn’t new and it’s shown to be incredibly, incredibly effective. When I was in Liberia in 2014, during the Ebola pandemic, I got to know an incredible health leader, named Raj Punjabi, who runs a program called Last Mile Health. And he’s based out of Boston, he’s from Liberia, but it’s all about getting healthcare to the people who are in that last mile, farthest from your health center, from your hospital, and it’s all based on community health workers, and what they can provide. And, you know, early in my career, I spent a year working in Bangladesh and I was assigned there to work for a group called the Urban Volunteer Program. And it was a program of community health workers that were going into slums in Dhaka, Bangladesh to provide services. And they were all women, they had no formal education in health, but they were taught to provide basic health services, to identify problems. And what the model of that program showed was that it improved the health outcomes for people in those communities. So there’s a lot of innovation, you know, that hopefully will gain traction during this crisis


Ligia: Which is really exciting. And that’s really what does not keep me up at night because I try to go to sleep thinking on the positive side. And I was also curious as to how we might as a sector, you know, collaborate together a little better because I often feel like we’re all like in disparate and yet united goals in our work. And what are some of the initiatives that, for example, you are working on at Robert Wood Johnson and should aggregate more funders like ourselves. Possibly we do try to be very mindful of providing support for free clinics, mobile units, rural, a lot of emphasis also on supporting minorities to enter the field, undergraduate and graduate levels. But I feel that we are perhaps missing an opportunity to be more leveraged together.


Dr. Besser: Yeah, you know, I think that’s right. I think that funders coming together is really important and can definitely help with grantees not being pulled in many different directions based on the, you know, the prevailing winds of funders. One of the things that we’re really excited about, and interested in at the foundation, is the whole area of community power and recognizing that people in communities, those closest to the inequities, those whose lives are impacted the greatest, are in the best position to identify solutions and to work to those for those solutions. And rather than us in Princeton, New Jersey saying, “Here’s the answer to your problem.” It’s saying, “What can we do to help you be more effective “in implementing the solutions that you see?” And I’m really excited about this shift in thinking. And it goes with this moment in time, where we’re seeing so much grassroots activity around the country, addressing issues of racial justice. How do we capitalize on that moment and say, you know, how do we see power and say that it’s critically important that the ideas that are coming up, lead to real structural and systemic change in America. You know, you were talking before about people lifting themselves up by their bootstraps. The other analogy that’s used all the time, is that you know, a rising tide lifts all boats. Well, what if you don’t have a boat? What if you’re not in a boat? You know, are you getting raised up? And so there’s this myth in America, of this being the land of opportunity.


And that anyone by working hard enough can do it. And one of the downsides of storytelling, is that you can find examples of that, of people who have overcome incredible hurdles, to achieve exceptional outcomes in their lives. But that plays against the norm, of people who have incredible dreams and aspirations. And if as a society we could remove barriers, it could be incredible what blossoms from that.


Ligia: Absolutely. And I think it also intersects with our notion that people don’t know what’s best for themselves. And I think we’ve seen time and again, that when you provide the quality of life that we can all have, where there’s clean water safety, housing, et cetera, people make the very best choices for themselves time and again. So, moving this narrative outside of, you know, our historical roots would be transformative, I think for the country not just across health, but all of our issues of equity. So I wanted to also ask you because it’s so topical about the vaccine issue, and as I said before, I am a viral optimist. I know there will be a vaccine and it will be an effective one at some point, but I’m also I guess, a middle aged, pragmatic with concerns about the distribution of how this vaccine will be held, especially in rural communities which already have such an infrastructure issue. Are you aware of any mechanisms that are already being designed by health officials for vaccine distribution? And does that give you some confidence or there’s nothing really in place yet?


Dr. Besser: Yeah, you know, I think it’s a critically important issue in terms of vaccine. There are several issues in terms of vaccine. One is, you know, I’m an optimist as well. And with the amount of investment going into vaccines, I’m hopeful that there will be one. But I think the narrative around vaccines right now is that there definitely will be one. And that is really dangerous. When you think about some of the biggest infectious disease challenges we faced as a globe, HIV, Malaria, you know, TB, dengue fever, hepatitis C, scientists have been working for decades, to develop vaccines, and we don’t have one for any of those diseases, that’s safe and effective. And so while there are many vaccine candidates that are in trials, in phase three trials, there’s absolutely no guarantee that any of them, that any of them will be safe and effective. And if they are effective, how effective they’ll be. So, you know, it’s so important that people right now follow the guidance of public health, and wear masks and social distance and hand wash and do what they can to protect, not just themselves but those around them. If there’s a vaccine, and again I’m hopeful there will be, the vaccine distribution issues that you raised, are really, really important. Vaccine distribution is key. Trust in the vaccine is also key. And, you know, when you look at the polling data right now, a very high percentage of people in America, would not want to receive a vaccine if one was licensed right now.


And there’s several reasons. One is the politicization of science and concern that political fingerprints are all over the FDA and CDC. And we have to ensure that everything’s being done possible to allow those agencies to do their work unfettered. Because without that, I wouldn’t want a vaccine. You know, I wanna know that an independent body of scientists has worked and made their recommendation to FDA, and that FDA had the authority to decide whether to approve that, and CDC through its work with the ACIP, which is the committee on immunization practices, it’s the advisory committee on immunization practices, that sets the recommendations that they’re able to do that, in an unfettered way. So assuming all that happens, and I’m an optimist saying that America won’t stand for political interference in those bodies. Distribution is key, and I’ve been on many conversations around distribution, states are required to get their plans to CDC around distribution this week, and they will all be reviewed. And there are a lot of challenges, you know, it depends somewhat on what kind of vaccine becomes available. One of the candidate vaccines needs to be stored at minus 70 degrees Celsius. Well, big challenges on that for rural communities.


Ligia: Yeah.


Dr. Besser: What it requires is centralized vaccine administration, because you will not be able to take that out to small clinics and maintain that temperature. And so, you know, there has to be deep thinking about how do you reach rural populations for that vaccine? The first vaccines that come available, will be for adults, not for children. And a lot of our vaccine distribution systems in America, are built around the Vaccines for Children Program because most vaccinations are for children. So you have to make sure you’re adapting to say, okay, how do you reach adults? And how do you reach all the adults? You know, a higher proportion of people in rural communities, lack health insurance and you don’t want someone’s insurance status, to determine whether or not they have accessibility to a vaccine. And you don’t want someone’s immigration status, documentation status to be a factor. You wanna make sure that you know, migrant workers have access to vaccines. So there’s a lot of things that are being discussed. And that’s terrific because this is the time to nail that down. It’s the time as well though to ramp up the engagement with each community. You know, there’s been real challenges in getting African Americans, to participate in vaccine trials because of long-standing distrust with the public health community based on abuse of populations and communities. So you have to engage with trusted leaders, so that if there’s a vaccine you know, I’ve heard it said time and time again that vaccines don’t save lives, vaccination saves lives. And so you could have a vaccine, and if no one wants to receive it you’re not gonna have any impact on this pandemic.


Ligia: That’s right.


Dr. Besser: And you know, people in rural communities, know what they need to, they know what their concerns are, they know what’s necessary in terms of getting access to healthcare and it is engagement and listening, listening, listening, listening and then providing the resources to address the concerns and the needs of each community.


Ligia: Absolutely. And again, you know, I keep going back to the concept of community health workers because they could play such a critical role in this process, both in having the trust of the people in their community, being educators, and of course that’s also the impact on job creation would be so timely, you know, so very timely. But I appreciate, you’re always very, absolutely factual and sobering comments because I did so much work in the ’80s, around the HIV pandemic in New York City. And you’re so right. I mean, let’s think about all these incredible problems we still have not come up with vaccines for. So as aspirational as I wanna be, and think everyone should be, it’s good to have this, sort of in the back of your head, that for the moment the power is in our behavior, not some miracle drug that doesn’t exist. And, you know, I think we’re gonna be running out of time and I wanna be mindful of our framework but, you know, I believe in young people as the future of this world, naturally, they are. And I wonder if you might have any advice for young people going into the various fields of healthcare and how they, you know, why they should also think more intentionally about rural in our country. We at Hearst are doing some work around that, but I would love to hear from you as well as an expert.


Dr. Besser: Yeah. Well, you know, I also have have faith in young people and, you know, I have to say at the foundation, that some of our newer, younger employees, come in with fresh ideas and different perspectives, and the idea of not accepting what is, for what needs to be. And this idea that now let’s challenge what is, with a new way is really important. I think, you know, we at the foundation we’re big supporters of universal healthcare and there are many ways to get there. And I think that one of the solutions, to getting young people to think about practicing healthcare in rural communities, is to provide opportunity. And if we had universal healthcare, people from rural community to recognize the strength, the joy of rural life and rural lifestyle, that sense of community, that sense of resilience. When I’ve gotten out, each year, we give culture health prizes, which recognize communities that are coming together towards building a culture of health, recognizing that health is about what takes place in communities. As I’ve gotten out to visit some rural communities that have one of those prizes, I’m just blown away by the sense of community, the sense of joy and the values of rural life. I think if the opportunities are there, you know, when you have 170 hospitals closing, it gets much harder for someone who wants to practice in a rural setting to do so. But if everyone was to have health insurance, if everyone was to have access to high quality affordable healthcare and if we were paying the healthcare system for health, rather than for treating disease, then we would see you know, more support for community health centers, more support for community health workers. And that would provide opportunity for people who really wanna stay in rural settings to do so.


Ligia: Absolutely, thank you so much. And my last, it’s a very selfish curiosity question because I am so enjoying your book. And I know this is not a PR moment, but here it is. I’m just curious, and I love it because you cover in very factual plain language, questions that we all ask ourselves, like, what do I do if I think I’m having a stroke? Can I take medication that’s long expired? Do people really die of a broken heart? Indeed I love the disparate issues that are covered. And since the book was published pre-COVID, I wonder if there’s a revision, a revised edition in the plan that will take us through COVID.


Dr. Besser: Well, no, I mean, thank you. Thank you for that. There isn’t. I wrote that with my wife, Jeanne Besser, who’s a food writer.


Ligia: Yes, that’s great.


Dr. Besser: And it was really fun to to write that together. But no, my focus now at the foundation, is somewhat different. I wrote that book when I was at ABC news, and there, you know, my role was to provide you know, clear factual information to the public, so that people could make better health choices. It was much more focused around an individual model of health. And at the foundation, our focus is much more, yes, the choices you make really matter but the choices you make depend on the choices you have, and our focus at the foundation is to really lift that up and say, how do we ensure that in America, has the opportunity to make healthy choices That every community in America, is a community that allows health to thrive. And if we can help shift some of that, during COVID and post COVID, I think we will truly have a more equitable nation and more equitable world. It’s been a real pleasure.


Ligia: Likewise, what a pleasure and I look forward to collaborating on future work and thank you again so much for the time to be with this precious Assembly, that is just kicking off. And I hope that you’ll stay tuned.


Dr. Besser: Thank you, I wish all of those attending well, I’m sure it’s gonna be a great event.


Ligia: Thank you so much Rich. Thank you. Really appreciate it.

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