Working Towards Health Equity in the Rural Space

00;00;01;02 - 00;00;24;27
Tom Haederle
Rural America has a seat at the health equity table. Until now, it seems rural America has been excluded from the inclusion discussion. Not only does that lead to resentment, it leads to apathy. Those words are from a rural health care provider who refused to accept the status quo about the relevance of health care equity in his community.

00;00;24;29 - 00;00;50;00
Tom Haederle
Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a series from the American Hospital Association. I'm Tom Haederle with AHA communications. We hope these episodes will shed new light on the challenges, triumphs and issues facing rural health care providers who are a health lifeline for approximately 20% of Americans. Health equity is a discussion that's often framed only around race.

00;00;50;02 - 00;01;06;18
Tom Haederle
But it means much more. In today's podcast, recorded at AHA's 2023, Rural Health Care Leadership Conference, two heads of rural health systems explain the stake that their organization is have in working towards equity and the steps they're taking to get there.

00;01;06;20 - 00;01;33;13
Leon Caldwell
Hello, everyone. I'm Dr. Leon Caldwell, senior director for Health Equity Strategy and Innovation at the American Hospital Association's Institute for Diversity in Health Equity. I'm joined here this podcast being taped, as we say, is old school word "tape," being streamed here at the AHA's Rural Conference. This is an exciting lineup. I have here two of my favorite rural leaders.

00;01;33;16 - 00;01;47;00
Leon Caldwell
Nothing against the other ones, I know. I have with me Terry Scroggins from Titus Regional Medical Center in Texas, and Ben Anderson from the Colorado Hospital Association. Welcome to both of you.

00;01;47;02 - 00;01;47;20
Ben Anderson
Thanks for having us.

00;01;48;04 - 00;01;49;25
Terry Scoggin
Thanks for the opportunity to tell our story.

00;01;49;26 - 00;02;19;25
Leon Caldwell
Yeah, this is really a fun thing for me. You know, I like both of you quite a bit. We've had great conversations around health equity, in particular health equity in rural areas. You both do exciting work and will continue to do exciting work in this space. So one thing that's always been kind of in the back of my mind is that, you know, we do health equity kind of an injustice to some extent in rural spaces because we don't really define it well enough.

00;02;19;27 - 00;02;50;04
Leon Caldwell
And we often times put this racial spin on health equity and it can miss the mark, because it allows some of our rural leaders to say, well, you know, we don't have the many of those people in our community or we're just 90% white or whatever it may be. Right. But reality is, equity, if we think about it, is not just about race and ethnicity, it's about human differences and providing the services as people need them, right, across whatever the spectrum is.

00;02;50;06 - 00;03;05;25
Leon Caldwell
And both you've done some really phenomenal work in that space, inclusive of kind of race and ethnicity, but much broader. What brought you to that work? Like how did you get there as leaders in rural America thinking about equity?

00;03;05;27 - 00;03;26;09
Ben Anderson
I was in a health care delivery science master's program at Dartmouth College, and I had a classmate from Boston, Massachusetts, challenged me. I really had shared some of the skepticism that you just described, Dr. Caldwell, around "am I really invited into this conversation? Is this really my work to do as a rural white man?"

00;03;26;16 - 00;03;44;00
Ben Anderson
And her challenge to me was, go home, take what you're already measuring and divide it by people group and see what happens. And she said, race is not the only denominator. It's an important, even defining denominator in our generation. But it's not the only one. So I went back and we engaged our community kind of to prove her wrong.

00;03;44;01 - 00;04;11;16
Ben Anderson
Engaged our community, got 85% of our households to respond to a community engagement survey that essentially asked people how do they define their health and wellness? Who do they believe is responsible? Is it the health system? Is it their own choices? Is it the environment as a whole? And then in the major sectors of society, health care, public health, early childhood development, research and extension, faith community, employers, community as a whole in each of those sectors, what services from a list would they be aware of that would help them improve their health?

00;04;11;16 - 00;04;33;19
Ben Anderson
And what would they like to see more of? And they answer those questions in 10 minutes. They got $10 in in local chamber bucks. You had to spend in a local business, which of course, was a win at home. And when we divided that data by between white folks and and Hispanic folks, the numbers were different. And the reality was for me is we couldn't unsee that.

00;04;33;22 - 00;04;39;03
Ben Anderson
And once we knew about it, of course, we have an ethical obligation to do something about it. So that drew me into the work.

00;04;39;10 - 00;04;41;00
Leon Caldwell
Right. Great. Terry, about you.

00;04;41;07 - 00;05;03;22
Terry Scoggin
So I'm an East Texas boy, doc, and, you know, my father drove me into it. So growing up, my dad took care of anybody. My dad was one of the purest people I ever met, ever knew. And he didn't see color. He didn't see income levels. He just saw people. So I grew up watching that. So as I'm raising my boys and as I continue my career, you look for opportunities to help   people, and health care is that.

00;05;03;27 - 00;05;30;14
Terry Scoggin
Titus is in Mount Pleasant, Texas. So we're in the northeast corner of Texas and we are rural. Everything you want to describe in rural: older, Medicare, poverty. Have a chicken processing plant, our largest employer. 44%. Hispanic. 43% white. 10% African-American. We've got all the challenges in rural. So we were a melting pot. So when you talk about equity and you talk about that piece, it's what we live in every day.

00;05;30;17 - 00;05;49;05
Terry Scoggin
So what we're doing is I want to repeat, it has nothing to do with race and ethnicity alone. There's so many pieces. And Benjamin talks about the opportunities he has to study. And he actually encouraged me to go back to college. And I'm going to a program, the University of Texas, right now for the health transformation course at the Value Institute.

00;05;49;08 - 00;06;12;17
Terry Scoggin
And it's opening my eyes on a daily basis just to see segments of people not race, not age, not gender, but break down those segments. And it might be race, it might be the ethnicity. But there's so many pieces when you start breaking it down to make things equal and reduce disparities, you can't treat everybody the same. I want to say that again, right?

00;06;12;19 - 00;06;31;18
Terry Scoggin
You and me have talked about that we can't treat everybody the same. That's wrong. We've got to learn the cultures. We've got to learn the history. You got to tell the story and hear the story. Most importantly, we have to hear the story as health care administrators, we need to shut up and listen. It's people say all the time, God gave us two ears,

00;06;31;18 - 00;06;33;19
Terry Scoggin
one mouth, take into consideration.

00;06;33;25 - 00;07;03;28
Leon Caldwell
Yes, it's really important this notion of equity making a distinction between equity and equality. Right. Like and you guys have we've had these conversations. You've been around our work as we launch the health equity roadmap. And we've we've talked about this notion of, you know, treating people, giving them what they need. Right. And actually them telling us what they need, not always us just giving them what we think they need.

00;07;03;28 - 00;07;18;18
Leon Caldwell
Right. Versus just giving everybody the same thing in your work, right? You've had to make some decisions and make probably some stance to change the minds of folks who may not have understood that. Tell me about that experience.

00;07;18;20 - 00;07;55;06
Ben Anderson
Yeah, one lesson a couple lessons that come to mind. One is this epiphany that rural America has a seat at the health equity table. And until now, it seems as though rural America has been excluded from the inclusion discussion. And not only does that lead to resentment, it leads to apathy. Maybe this isn't my conversation. Maybe I'll just check out of it when we when we exclude ourselves from that conversation or feel thaat we're excluded from the conversation, we lose the opportunity for a very important 20% of the United States to engage in what we believe is the most important work of our generation.

00;07;55;08 - 00;08;20;03
Ben Anderson
So that's the first lesson I think I'd take away from it. I think it is so crucial to know not only that we have a place in this conversation, but where that place is. And that we find we find our role in it. I don't believe this is optional. I think when we looked at that data that I mentioned earlier, Dr. Caldwell, the phrase we use in West Kansas where I was living at the time is, that ain't right. Nothing about that is right.

00;08;20;10 - 00;08;37;21
Ben Anderson
Looking at those numbers that were different and so, well, then what are we going to do about it? Because we can't leave it there. And so we just knew we have to do something about that. And so I think the next lesson that comes to mind is it's so crucial that we know or that we ask patients for their biography before we collect their biology.

00;08;37;23 - 00;08;59;10
Ben Anderson
First, we learn their story. To Terry's point earlier, and when we know their story and when we ask them questions about what they need, they will tell us if we're willing, if we have a humility to ask and not assume that we know. And one of the cardinal mistakes in this work is to assume we know without asking. Nothing about us, without us.

00;08;59;12 - 00;09;02;00
Ben Anderson
So if we start by asking how we get to good places.

00;09;02;04 - 00;09;02;24
Leon Caldwell
Yeah.

00;09;02;27 - 00;09;21;17
Terry Scoggin
So rural health care's late. Benjamin's right. We're late to the table. We've got a lot of ground to make up. But once you see that data, you can't unsee it. And the data is not just numbers or graphs or infographics. The data is people. It's people you talk to, people you listen to, and when you hear their stories, you can't unsee it.

00;09;21;20 - 00;09;42;26
Terry Scoggin
So as I've changed myself, I've been in health care now ten years. I've been in industry for 32 years. And what you're seeing and hearing today, and once you look at these numbers and you look at what's happening in maternal births and pre needs, all the prenatal work that's going on, talk about diabetes, you know, we have 9% African-American population in our county.

00;09;42;26 - 00;10;13;26
Terry Scoggin
That was our largest hindrance during COVID. As far as getting that number down. We had the highest Covid per hundred thousand in northeast Texas in our county, the lowest mortality rate. Unfortunately, African-American population suffered more deaths than our white population and Hispanic population. So working with those church officials and government leaders and going door to door to make changes. The community of color is part of rural and rural has to understand that.

00;10;14;03 - 00;10;35;08
Terry Scoggin
And if we want to make a difference in rural, we can't leave the door shut any longer. And I think when health care administrators start realizing that and getting into it and see it, they're not going back. This is an easy decision. It's not a hard decision. Once you start having these conversations. I'm a believer. And meeting Benjamin...

00;10;35;10 - 00;10;45;21
Terry Scoggin
meeting you, meeting your team, it just fires us up more. And I think as other rural, administrators learn that and it's it goes to the organization quickly. People want to hear it.

00;10;45;23 - 00;11;05;16
Leon Caldwell
You know, it's interesting to hear your take on this and that to some extent rural has been possibly a little late in, you know, Benjamin's point, we haven't really included you in the conversation. So to some extent we've allowed you to be excluded. The question I have is how do we become more inclusive of roles? 

00;11;05;21 - 00;11;12;27
Leon Caldwell
What is the role that, you know, whether it's HHS or other organizations, how do we support you differently?

00;11;13;03 - 00;11;36;00
Ben Anderson
I'd love to take a stab at that one. I think - And I visited with folks around the country, probably 30 or 40 states at this point - specifically on the subject of rural health equity. And I believe the answer to that question, Dr. Caldwell, is you start with their pain. We can talk about the pain of of the urban person of color, and they can't relate to that because it's so distant from them.

00;11;36;08 - 00;12;07;25
Ben Anderson
But when we talk about a rural American dying 50% more often due to unintended injury than an urban American, that registers. We talk about people dying sooner due to avoidable circumstances or chronic illnesses. And the challenge that I think we ask is does that make us, as rural Americans, dumber, less sophisticated, less responsible, caring less about our health or are there structures in place that are driving those disparities? And undoubtedly there are structures that are driving them.

00;12;07;25 - 00;12;38;11
Ben Anderson
Well, if there are structures that are driving rural health disparities, then could there also be structures that are driving, say, racial disparities in health outcomes? Well, absolutely there could be. But we start with the pain that they can feel. And when we go and talk about white privilege, for example, with a dairy hand, a dairy worker who's making $14 an hour without health insurance in Syracuse, Kansas, on the edge of nowhere, and we start talking about white privilege, that doesn't that doesn't register with them.

00;12;38;13 - 00;12;41;24
Ben Anderson
But when we start with their pain, they start feeling the pain of others.

00;12;41;26 - 00;12;42;26
Leon Caldwell
Understood.

00;12;42;28 - 00;13;00;23
Terry Scoggin
When they hear that and when they have the conversations, you start talking to your community. Rural people are good people. And when rural people hear that pain that you are talking about. Benjamin, rural people want to make a difference. So real people want to jump in. So you ask, how do we get that message out? We've got to go where they're at.

00;13;00;28 - 00;13;22;12
Terry Scoggin
We've got to continue this forum today. We've got to have these conversations. AHA conference here today and tomorrow has quite a bit equity discussions. This is not racial discussions, it's equity. And they've got to build that in. If we want to stay independent, we have to address this issue. We want to remain an independent health system. We have to address the equity situation in rural America.

00;13;22;19 - 00;13;37;23
Terry Scoggin
It's the only way we're going to get an outcomes based data. You can't argue outcomes based data. You can look at mortality that Benjamin talks about. You can talk to all the different things related to health outcomes. That's going to open people's eyes so that health outcome data is going to be key.

00;13;37;26 - 00;13;39;27
Leon Caldwell
How did you white guys get into this work?

00;13;40;00 - 00;14;03;23
Terry Scoggin
It's personal. In rural America, it's personal. One Saturday, we were having a health fair at the hospital, and I found that one of our African-American churches was having a Black History Month. Didn't know about it. They were having a presentation and talking about the midwives history in northeast Texas. So I left my health, went over to the health fair, went over to that with the head of my rural community group, and there's 25 people there.

00;14;03;25 - 00;14;21;22
Terry Scoggin
Majority of them were over 55-60. But we listened. We had the conversation and somebody was there talking about Medicare and confusing him. And I just stood up and said, you know what, half this room has my cell phone. If you have problems, text me. In rural America, it's personal. We see these people. Our kids grew up with these people.

00;14;21;25 - 00;14;36;16
Terry Scoggin
So I'm not looking at that skin color, Hispanic, African-American, poor, rich. It doesn't matter. We treat people the same. And that's what we got to continue to do. And as far as my mission and our vision is our health system, our community.

00;14;36;18 - 00;14;57;11
Ben Anderson
I got invited in by a gay black guy from Atlanta. He called me, cold called me on the phone and said, "Do you want to be part of the Leadership Advisory Council for the Institute for Diversity Health Equity?" And I thought, what in the world is this guy calling me for? I don't belong in this conversation. And he said to me is, as health equity has risen to the center of the national conversation, it has largely overlooked the disparities between rural and urban Americans.

00;14;57;18 - 00;15;13;24
Ben Anderson
And we tend to villainize white people, white guys especially. And neither of those are right. Both heard the long term work, he said. Rather than calling you out for being a white guy, I'm calling you into the most meaningful work of our generation. I'm asking you if you have the courage to be the only straight white guy on a board of 20 people.

00;15;13;27 - 00;15;29;02
Ben Anderson
And I had to process that because I was I was expecting to be judged. And he called me and invited me into something better. And I mean, it just was 100% consistent with my values, and I couldn't ignore that. And so I'll spend the rest of my life at some level in this space.

00;15;29;02 - 00;15;51;20
Terry Scoggin
And him requesting Benjamin to be on that drove me because when I met Benjamin and heard Benjamin speak, it drove me to even go further in looking at this. Because that one person calling Benjamin and asking Benjamin to serve thing, look what it's doing. Northeast Texas will never be the same because of what Benjamin went through and that small step.

00;15;51;22 - 00;16;10;26
Leon Caldwell
Yeah. Thank you, guys, both of you guys. But you point to so this could be like a two hour session with you both. And really data, I hear both you saying data and different types of data, not just quantitative, but telling the stories of folks so you can hear their pain and also meet them where they are is critical pieces of us being more inclusive in this work.

00;16;10;28 - 00;16;37;11
Leon Caldwell
So, you know, on behalf of the Institute for Diversity and Health Equity, I thank you both for your time. And in closing, all this work, it seems to start, was consistent with an invitation. An invitation to be humane and to respect humanity and to share our gifts with each other. So I thank both of you for sharing your gift with me, this time with AHA and look forward to continued partnership and working with the Institute for Diversity in Health Equity.

00;16;37;15 - 00;16;39;01
Leon Caldwell
And we'll talk later.

00;16;39;03 - 00;16;41;03
Ben Anderson
Thanks. Dr. Cole. Well, thanks for the opportunity.