IHI Open School Short

Video Transcript: What One Thing Would You Do to Create Health Equity?: A Conversation Between Donald Berwick, MD, and David R. Williams, PhD, MPH

Donald Berwick, MD, Senior Fellow and President Emeritus of IHI
David R. Williams, PhD, MPH, Professor of Public Health, Harvard T.H. Chan School of Public Health

BERWICK: I can’t help asking this. So I give you a lamp with a genie installed, and you get three wishes that would really close this health equity gap. And you know what? You choose. Answer it either from the viewpoint of health care delivery, you run a big hospital or a large system, what would you wish for that system? Or from a larger social perspective, what would be the biggest leverage we could get?

WILLIAMS: It’s a good question. I served on the commission that actually addressed this question, and reported that the single biggest thing we could do in the United States is to ensure healthy development of every child. And invest in early childhood, particularly birth through age three. We tend to, when we ever think about early childhood, we tend to think of ages four and five. And the processes that shape childhood development and affect health begin earlier. So I think that that is certainly one big area. But it’s not the only one.

I would also say that I think we need to put more health into health care. What do I mean by that? Many patients who come into a health care context are coming with a range of social challenges that we face. And if all we do is provide them health care, and not address the problems that made them sick in the first place, and sent them back to the same environments that made them sick in the first place, we have delivered good health care, but we haven’t had a long term positive impact. So there are models, and there are multiple conversations and multiple examples in the United States of programs that are, as part of the health encounter, linking a client, linking a patient not only to good medical care, but to social services that might help them address some of the challenges they face. And we know that if we do that, we might keep some of those people from coming back into the health care system, back into the emergency room within 30 days, if we can in fact link them with a social service. I think that’s one other strategy.

And the third thing I would say strengthening education, which would prepare individuals for successful employment and career advancement, is important. Maslow, many years ago, taught us about a hierarchy of needs. And if people’s basic needs are not met, they don’t worry about the higher order needs. And many of the things that we want individuals to do, to get regular exercise, to not smoke cigarettes. I mean, tobacco is the crutch that helps people make it through the day. And some of my own work, and the work of others, have shown that smokers have higher levels of stress and psychosocial stressors than nonsmokers. And that if you intervene on the stress or underlying depression that they face, you enable them to quit at higher rates.

BERWICK: Really?

WILLIAMS: Yes. So again, trying to take a big picture and trying to address some of the social challenges that individuals face will put them in a position when they can act to take steps to improve their health.