Title:Community health in the nation’s capital

If COVID-19 has taught us anything, it’s that health is local—and extremely personal.

As the pandemic soared across the country, so raged nationwide debates on mask requirements, vaccine mandates, and school closures. And yet the picture that has emerged over the past two years is highly localized, demonstrating the need to tailor health strategies to specific contexts and to listen to what people in the community say they want and need.

Community health scholars and practitioners have long understood that you cannot apply a uniform lens to solving health issues. Each community has its own unique context and needs that must be factored in when shaping public health policies and interventions. And within each community, each person has a unique story to tell that will impact their health outcomes.

Yet this is not how health systems currently operate, according to experts.

“There are many opportunities for improvement. We often have this mindset that we know what a community needs, so we build it and expect them to come,” says Christopher J. King, PhD, MHSc, FACHE, chair of the Department of Health Systems Administration at Georgetown’s School of Nursing & Health Studies, dean select of the new School of Health. “Instead, we have to partner with the community, humble ourselves, and recognize we don’t know all the answers. We can learn from the community.”

No magic bullet

While the concept of community health has many definitions and interpretations, at its core it can be understood as where community needs and priorities intersect with science and evidence. It is also where multiple disciplines come together around a set of shared goals to improve the health and quality of life of those who live and work in a given community.

The very nature of community health defies easy categorization and oversimplification, according to Derek Griffith, PhD, a founding co-director of Georgetown’s Racial Justice Institute, founding director of the Center for Men’s Health Equity, and a professor in the Department of Health Systems Administration in the School of Nursing & Health Studies.

“There’s not going to be a one-size-fits-all singular solution—a magic bullet, if you will—to solve every problem. We need to cobble together different pieces that operate together and allow us to take one bite at a time,” Griffith says.

Acknowledging how the ideas should flow is half the battle, he adds. When academics try to “export” their ideas to communities, they don’t know if they will work in that particular local context.

“If the ideas come from the community to academics, they usually have already resolved a lot of the local ecological, contextual issues, and we know that they at least fit culturally and resource-wise,” Griffith says. If sequenced properly, an institution like Georgetown can then add great value to the process by bringing additional and complementary scholarship and academic rigor to community-identified issues.

Race and place

When it comes to health outcomes, the District of Columbia is home to some of the largest racial and ethnic gaps in the country. While the overall health profile of the city is high, a different picture emerges when health indicators are broken down by race.

Disparities in life expectancy are deep and persistent, with Black men and women in D.C. living 12 to 17 years less than their white counterparts, respectively, according to a 2020 study published in the journal Nature. The percentage of Black residents living with diabetes is nearly six times higher than white residents, the percentages of those living with high blood pressure and dying from heart disease are more than two times higher, and the infant mortality rate is nearly five times higher in Black infants than white infants, according to DC Health Matters.

Far from having emerged in a vacuum, these disparities are part of a much broader story of inequity that has taken root in D.C. over generations.

In the recently published Health Affairs article “Race, Place, and Structural Racism: A Review of Health and History in Washington, DC,” King, Griffith, and other colleagues examine the history of local and federal policies that have disproportionately impacted the health and well-being of Black residents from the District’s founding in 1790 through today. (Bryan O. Buckley, DrPH, MPH, adjunct assistant professor at Georgetown and a research fellow at MedStar Health’s Institute for Quality and Safety, and undergraduate student Riya Maheshwari also contributed to the piece.)

The article outlines how racially significant historic events such as urban renewal and “white flight,” along with now-outlawed housing policies such as redlining, have all led to health disparities by what the authors term “race and place.” In addition, Washington’s lack of statehood and federal representation has uniquely spurred an imbalance in power and resources.

One example is the District’s Barry Farm, a thriving community of Black intellectuals and entrepreneurs in Anacostia, including Frederick Douglass, that emerged after the Civil War. By the early 1940s, the community was destroyed when the government used eminent domain to seize 34 acres and demolished homes and businesses to make way for Suitland Parkway.

Understanding the history of structural racism is an important precursor to understanding health disparities today.

“When you have an entire generation stripped of their homes and ability to accumulate wealth, they are not able to pass on assets or generational wealth to their family members,” King says. “Over time, there is a cumulative effect on Black residents’ health because of where they live, their job opportunities, even the air they breathe.”

Journey to cultural and linguistic competence

While history can offer important context for D.C.’s health disparities between Black and white residents, it is important to look at a range of demographic factors when seeking to engage in community-based research.

Researchers must gain a holistic understanding of the demographic makeup of the city in order to ascertain who is most at risk for certain conditions, according to Tawara Goode, MA, associate professor of pediatrics and director of Georgetown’s National Center for Cultural Competence.

“We must ask, ‘Are there disparities based on race, ethnicity, age, gender identity and expression, disability, or language spoken?’” Goode says. “Then you begin to get a good sense of who might be the population groups that are at risk, and who within those populations do we really need to focus on based on these multiple intersecting demographic factors.”

Goode is part of a federally funded collaboration known as the Georgetown-Howard Universities Center for Clinical and Translational Science (GHUCCTS) that has as one of its primary aims to strengthen and support community-engaged research in D.C.

She says researchers will sometimes balk at engaging underserved populations in research, claiming it will cost too much or be too time-consuming. But by not being more inclusive, these researchers are missing an important opportunity.

“So certain populations are written out of the opportunity to participate in research, and then we don’t get the broad pool of folks that we actually need to be involved for our research to mean something,” Goode says.

Goode notes that people who do not speak English as their primary language, for example, or people with disabilities are routinely left out of health research studies. Researchers lack the knowledge and capacity to include them and because of the time and resources it takes to establish relationships within these communities and build trust.

Bias is another issue that can cloud researchers’ and providers’ understanding of individuals’ health issues.

Lucile Adams-Campbell, PhD, is a cancer epidemiologist with the Georgetown Lombardi Comprehensive Cancer Center who has spent her entire career doing community-based research and addressing disparities—well before it became a popular area of exploration. She encounters many scientists and others who use the term “minority” as synonymous with poor and low-education level.

“There are people who have low levels of health literacy across all socioeconomic statuses. A Black person with a high income might have poor health outcomes because maybe they don’t have anyone talking to them about their disease and providing the care that is needed due to insurance issues.” Academic and health care institutions must avoid the pitfall of overgeneralization—assuming that just because they think they understand a culture that they can apply those generalizations to an individual.

Through the School of Nursing & Health Studies, Georgetown has played a key role in developing a new educational module on implicit bias that is being offered by the D.C. Department of Health. The module, “Implicit Bias: A Practical Guide for Healthcare Settings,” offers continuing education credit for any employee in the health care setting, including providers and staff, engaging participants in self-reflection about their personal biases and institutional biases.

King, who is a faculty expert for the virtual course, says that even well-intentioned health care professionals may be doing more harm than they realize.

“In the past, many mandatory cultural competency trainings were designed to put people in categories. This oversimplified approach can perpetuate bias and stereotypes,” King says. Instead, people in the academic and medical communities can be more impactful by doing more listening, and less assuming.

“I call it the journey from cultural competency to cultural humility,” King says.

Goode notes that work in cultural competency has evolved considerably since the early days. Rather than lumping groups together, scholars contributing to this space differentiate interventions based on granular characteristics and not broad categories. This reflects the nuance and complexity that comes from listening to communities of individuals.

Further, she says while cultural humility is centered on individuals, cultural competence goes beyond that to address systemic barriers, such as those within an organization’s policies, structures, practices, behaviors, and attitudes.

Give and take

Experts are quick to point out that community-based research must remain reciprocal, and not transactional. Information must flow from the community to the researcher, and then back again, in a continual dialogue.

“Academic medical centers can’t do this work alone, as communities know their own needs,” Goode says. “They also know their interests, they know themselves.”

The principle of reciprocity is equally important when it comes to resources, especially when academic centers receive research funding for their community work.

“If you get a large grant, who do you hire from the community? How do those financial resources make their way in a meaningful manner into those communities? Community engagement should really result in a reciprocal transfer of knowledge, skills, and resources among all collaborators and partners,” Goode adds.

To maintain this spirit of reciprocity, the GHUCCTS center that Goode is part of convenes a community advisory board consisting of diverse constituents largely representing community-based organizations, as well as a participant advisory board consisting of individuals who participate in clinical research trials.

Likewise, Georgetown Lombardi’s Office of Minority Health and Health Disparities Research, overseen by Adams- Campbell, relies on a community advisory council. Even though she grew up in the District, Adams-Campbell says she does not pretend to understand what people in her old neighborhood in Ward 7 might need now.

“Even if I were to go back to my old street where I grew up and say, ‘Let me lead this,’ that’s not right. People who are living there now should lead us,” says Adams-Campbell.

The Office of Minority Health oversees community grants to fund activities the advisory council identifies as important, including recent projects related to COVID-19. For example, when a local Vietnamese organization said they did not have any pandemic information materials written in Vietnamese, Adams-Campbell’s office issued them a grant to develop materials in Vietnamese about the importance of vaccines.

Other activities on the horizon for her office are a new Men’s Health Initiative to engage more Black men in the community in clinical trials, and a forthcoming initiative on spirituality and cancer proposed by a minister who serves on the community advisory council.

Griffith also has plans to promote Black men’s health through a project called Mighty Men, which seeks to reduce Black men’s cancer risk by working with churches to promote weight loss and healthy lifestyle changes.

Above all, respect for the whole person must govern every interaction with community members. People are more than what they can offer to researchers.

“When researchers need a sample of blood, urine, or DNA for a study, where does one think they come from? They come from the community, they come from people,” Adams-Campbell says. “For every sample that is stored in a freezer, I think about how many steps, how many people, how many hours did it take to gain that person’s trust so they would donate the blood or urine or cells from their mouth.”

Beyond the classroom

Georgetown students have ample opportunity to get out of the classroom and work directly with D.C. populations on health-related issues.

The HOYA (Health Outreach for Youth and Adults) Clinic, for example, is one of the most coveted real-world experiences for Georgetown medical students to take part in. For nearly 15 years, the clinic has provided free, non-emergent medical services to District residents experiencing homelessness. In recent years, the HOYA Clinic has expanded its operations to include a range of other activities, including providing health education, flu vaccinations, autism screenings, and even a sports camp for children of clients they serve.

The clinic also partners with the Latino Medical Student Association and CURA Medical Spanish Volunteer Corps, both housed at the School of Medicine, to provide Spanish and English translation support.

In these ways, the growth of the clinic’s operations and focus reflects how students are listening to community members’ interests and needs.

Another example is the Health Justice Alliance (HJA), a unique medical-legal partnership between Georgetown University Medical Center and the Law Center that is training the next generation of health, law, and policy leaders to work together in pursuit of health justice. The premise of the HJA is that one’s health outlook is deeply rooted in daily challenges such as poor housing conditions, food insecurity, lack of insurance, education, employment, and other issues that often require legal advocacy to overcome.

Medical students and MedStar providers who partner with the HJA add legal services to their patient care toolkit. That might mean working with new or expectant mothers in the D.C. area who are confronting legal issues related to their pregnancy and employment, or learning how to recognize when patients living with mold, mildew, or lead need a lawyer to enforce their rights against a landlord. Eileen Moore, MD, associate professor in the Department of Medicine and Family Medicine at Georgetown’s School of Medicine, serves as HJA’s medical director.

Access to the HJA means that once they have identified patients who are confronting legal issues that might be directly or more tangentially related to their health issues, they can rely on HJA lawyers or law students for help. Through specific cases, the medical and legal students learn how to view the delivery of health care through the legal lens.

HJA is currently using a planning grant to design a new fellowship at Georgetown that would be the first medical-legal fellowship in the country, according to Vicki Girard, JD, a professor at Georgetown Law and faculty director of the HJA.

The HJA also brings medical and law students together through the Health Justice Scholars program, which prepares second-year medical students to conduct advocacy on Capitol Hill for health justice issues. In this way, medical students learn how to take what they have learned from the community about its priorities and channel that information into advocacy.

Girard says the popular advocacy experience reveals to students how much they have to learn from members of the community who may not have the same platform.

“It’s not that people are voiceless—it’s that no one has been listening to them,” Girard says.
Girard and the HJA team always advise students to approach their work with humility and with the goal of co-creating with people in the community.

“It’s about understanding that we don’t have all the answers and that we are learning from the people that we want to stand beside,” Girard says. “We’re just another piece of the very complicated Washington, D.C., puzzle.”