Travis Gayles

DR. REGGIE ALSTON: Our distinguished lecturer series in terms of the purpose of it and it exists to provide a forum for campus scholars, students, academic professionals, and practitioners in the community to discuss science, policy, culture, and politics at the intersection of health, aging, and disability. Renowned researchers and thought leaders, like Dr. Travis Gayles, are invited by the AHS Office of the Dean to share their perspectives on a topical subject related to health and to lead the university audience in an exchange of ideas.

The lectures are open to the university and occur at least once a year, usually during the spring semester. The ultimate aims of the lectures are to expose attendees to the most current international models and paradigms on health and wellness, to advance students' understanding of factors driving health care policy and delivery in America, and to generate research ideas and ignite interdisciplinary collaborations among campus scholars.

We're joined this morning also by the Dean of our College, Cheryl, Hanley-Maxwell to provide us a message from the College and a greeting. Dean Maxwell.

CHERYL HANLEY-MAXELL: Thank you, Reggie. Hello, everybody. I surely wish we were doing this in person rather than virtually, when I'm excited that we're still going to get to be able to do a virtual presentation this year. The focus of this afternoon's talk, disparities in health and health care, is not only timely. It's a critical issue.

The coronavirus has brought us-- really into sharp focus the problem that has plagued marginalized communities for far too long. It's well past time that we take charge of this issue and we stop wringing our hands and pretending that it's insurmountable and we can't do anything about it. I'm proud to lead a college that's dedicated to educating professionals who are and will be on the front lines in battling for optimum quality of life for all, not just for the privileged few. Since its inception, the College of Applied Health Sciences has focused on teaching, research, and outreach activities that improve the health and well-being across the lifespan and throughout our diverse societies.

AHS is committed to diversity in all that we do. We are fortunate enough to have one of the most diverse student bodies on campus. These students will contribute significantly to a future in which those who are most directly impacted by the-- I'm sorry, those who most directly impact on the welfare of individuals, families, and communities look and are as varied in race, ethnicity, religion, gender identity, and age as the communities that they serve. One of our former students whom we are extremely proud to call an alumnus is our distinguished speaker, Dr. Travis Gayles. Welcome, Dr. Gayles. I'll turn things back over to Reggie who will introduce you to Dr. Gayles. Thank you everyone for coming in. And I hope you thoroughly enjoy the talk.

DR. REGGIE ALSTON: Thank you. A few ground rules before I introduce Dr. Gayles. You will all notice that your mics have been muted, your videos deactivated. I ask that you log your questions in the Q&A box at the bottom of your screen. And at the end of his talk, I will ask as many questions as possible so that we can have a lively discussion. I also want to share that the presentation today is being recorded. And so if you would like to have a copy or access, please contact me or Ms. Sally Marshall at the College.

Dr. Travis Gayles received his BA degree in public policy and African-American studies from Duke University. He has a proud alum of the University of Illinois, where he attained an MD degree from the College of Medicine and a PhD degree in Community Health from our own College of Applied Health Sciences. Dr. Gayles completed a residency in pediatrics at Northwestern University and renowned Lurie Children's Hospital in Chicago.

Prior to his current position, he has held leadership roles in health care with organizations in Illinois, Washington DC, and Maryland. Dr. Gayles holds faculty appointments as a lecturer or associate at John Hopkins University, New York University, and the University of Maryland. Lastly, his opinions concerning health care issues have appeared in prominent print news outlets, such as The New York Times and the Washington Post, and on TV news programs such as "60 minutes," in which he was recently featured discussing the topic for today. It is with pleasure to present to you our distinguished lecturer, Dr. Travis Gayles.

DR. TRAVIS GAYLES: Good afternoon. And thank you, Dean Hanley-Maxwell. And thank you, Dr. Alston for the introduction and invitation to be here with you all today.

I confess I was scoping out the list of participants and saw some familiar names-- Dean [INAUDIBLE], Dr. Jokela, Dr. Rucker who was a classmate and close friend of mine during my time in Illinois, and two others who I may have missed. It's good to see you again. And to new folks, it's nice to meet you. I certainly would have preferred to be in person with you, but the situation is what it is. And hopefully we will get to the other side of this so we can be together and fellowship together in person very soon. And so again, thank you for the opportunity to be here with you all. I owe a lot to the AHS program, the Department of Community Health-- well, the Kinesiology Community of Health.

And also I just want to personally say a special thank you to Dr. Alston who happened to be my advisor during my time and definitely got me through and has continued to provide guidance as I move through my career. And so as a special note to those students watching, mentorship is important. Never stop learning. Never stop reaching out for those who have come before you to help get guidance. No matter how senior you may be in your career or how old you may be in your trajectory, there's always somebody there who can provide some great guidance for you to help you along the way.

So with that in mind, I would like to share with you a couple of sides about some of the things that we've been working on in terms of looking at disparities in COVID rates and vaccination. And before we get into the presentation, I also want to apologize to a lot of folks who fit into different demographic groups and different cohorts who are not included or who may not be included in this discussion because unfortunately, we still have a dearth of data across the board in a lot of different areas that chronicle the presence of disparities. And that in itself is an inequity and a disparity and something that we have to fix.

And I challenge and hope that, again, the students who are watching-- as you continue to move through your career and formulate research questions that you will ask, I hope that getting more data will be a part of those conversations. So just to give you some background we'll talk about today, we'll talk a little bit about a quick primer on health disparities, some of the realities of the COVID-19 situation, and then ultimately have a conversation about where do we go from here. And as always, for thoroughness, I don't have any relevant financial relationships to disclose.

Now, when we talk about disparities, or at least historically when we've talked about them, we naturally pivot to race. And in this country right now, it's trendy to talk about race. It's in to talk about race it's trendy, to make sure that every entity has the diversity officer, that they're diversity conversations and trainings happening. At the same time where we're having larger questions about how we discuss race and how we deal with that on a system and a national level, we continue to have those conversations on an institutional and local level as well.

Now, when we go through these conversations, naturally we think of some of the movements that have spurred up or have been in place for a number of years but now are getting more traction and attention based upon some of the political issues that are plaguing our society right now, from Black Lives Matter to a host of other movements that have, again, popped up and continue to move forward based upon social justice and racial justice concerns here in our country. And I mention these because it's important to get context and background within the environment that we are operating to talk about health disparities and to talk about how we move forward and what types of influences will push those conversations.

Now, we know that a large-- and this may be a sore subject for some on the call. It's a sore subject for me. The NCAA tournament just finished. And as Dr. Alston mentioned, my original Alma mater was Duke, that didn't even make the tournament this year. And Illinois, my other team, didn't quite make it out of the first weekend either. But it's been interesting seeing how sport has coalesced around this idea of racial equity and disparities and injustice. And this is a picture of Colin Kaepernick, who was chastised greatly for the stance he took in terms of taking a knee for years, and blacklisted by professional sports leagues. And it's interesting now that we as a country and those corporate entities are embracing that, or at least appearing to embrace those same protest measures that he stood up for a number of years.

Now, we not only have to think about context in terms of equity related to race particularly right now given, quite frankly, what I would call an assault on civil rights for our individuals within the transgender community in a number of states right now who are enacting laws to prevent trans youth from being able to participate in sports. And so the extension of rights and the extension of the conversation around equity goes far beyond this race. It goes to, as Dean Haley-Maxwell mentioned, sexual identity, gender identity, ability status, gender, geography, socioeconomic status, you name it. And it's important to remember that as we talk about disparities. But again, unfortunately, there is a significant dearth of data to be able to talk about some of these categories extensively based upon the lack of data available.

Now, this also moves forward as part of the national conversation as we see talks about civil rights and renewal of our voting rights. And some states have chosen to implement laws that remind us of times back in the '60s where we were significantly segregated as a society. And significant groups of folks at that time, based upon race and ethnicity, were not allowed the basic American right of voting. And that is a part of our national conversation right now. So as much as we celebrate movements as we've talked about earlier in advancing rights, we also have to make sure that we understand that we are in an environment right now that is-- there's a lot of folks who don't quite support those efforts.

Now, that gets us to this concept of health disparities. A rose by any other name is still a rose. And us in public health services, we have done a really great job of renaming health disparities. A couple of decades ago, it was health disparity. Then it was health equity, then health inequity, then health inequality. And in a meeting a couple of weeks ago, someone used the term health inefficiencies. And it got me thinking. We have done a great job of renaming the issue, but we haven't done as good of a job in actually tackling the issue and removing the disparities and equities, inequities and inequalities, or the inefficiencies that exist.

And I'm reminded back a couple of decades ago now, my first job out of college. I worked at the Institute of Medicine on, at that time, a report looking at pediatric end of life care. And I was in the same division with the team that put together the, at that time, groundbreaking report called "unequal treatment" that confronted racial and ethnic disparities in health care. And Dr. Brian [INAUDIBLE], who was one of the chief authors of that report, also gave, I believe, the first distinguished lecture series talking about the same topic.

And in that report, they chronicled disparities and reported the data as it was. But they also talked about, what are some of the root causes that continue to drive those disparities and outcomes? And when thinking back, this particular model is based upon race. But really, you could put any demographic factor in here, and these same variables are what impact and influence differences by those who would be considered non minority versus those in the minority category-- things such as appropriateness and need, patient preferences, the ecology of the health care system and environmental factors within the environments within which folks live, and then this third component-- discrimination, whether it's overt racism-- because overt racism is different and it contributes to systemic racism-- but then also the concept of bias and cultural uncertainty because the key is, none of us get to be off the hook on this. We can't always look at extreme examples. We all have to do our own internal homework and think about how we can contribute to these parameters and paradigms that continue to perpetuate these health disparities.

Now, health disparities are costly. This is why we talk about them. They cost over $93 billion in excess medical care and were $42 billion in lost productivity each year in terms of lost wages and lost employment due to not being able to perform duties. And that manifests in a host of different ways. One of the ones that we celebrate over the last decade is driving the uninsured rate down, which, as you can see, we have made tremendous strides in that. But over the last five years or so-- due to an administration change, largely-- we've seen those numbers plateau. And actually, for example, the Black community-- that number starting to increase from 9.9 in 2015 to 11.5% in 2018. And similar for the Hispanic community. And what that translates to is potential delays in care or folks not receiving the type of care that they need or deserve and their health condition worsening or reaching a point that could have been prevented by earlier addressment of their other care.

Now, to set the stage before we get into COVID, the more things change, unfortunately, in spite of all of these efforts, the more things stay the same. So we unfortunately, decades later-- so the "Unequal Treatment" report was released in 2002. Almost 20 years later, we're still talking about issues of barriers to access to care, higher uninsured rates in communities of color, persistent disparities in outcomes, whether we're talking about life expectancy, infant mortality, heart disease mortality, mental health services and access to that, and this thing called COVID-19.

If I were in person, I would ask everybody to do a show of hands of how many of you were surprised when we looked at the first set of COVID outcomes in terms of who was getting it and who was getting sicker and dying. How many folks were surprised that the demographics played out that way? And what was alarming is the fact that even though we know who these chronical histories of worse outcomes and preexisting conditions, that there were many people who were like, oh my gosh. I didn't know this. I didn't realize it. How did we get here? That's part of the issue is, how did we get here knowing what we knew all along?

And so I actually saw this from the Kaiser Family Foundation site that looks at health disparities as a pandemic in itself and pulls out some specific statistics by race. And again, I apologize for any of those other categories that aren't based upon race and ethnicity because there's no clear cut data that shows us in a way such as this. And it's incumbent upon us to do better and get those better statistics.

But when you look at these host of pre-existing conditions that have predisposed folks for having worse COVID outcomes, Black Americans-- 30% more likely to die of cardiovascular disease, three times more likely to have end stage renal disease, two times more likely to die of asthma. In the Latin American community, 40% more likely to die from a stroke. And you just look down the list of all of these different factors. These are the same things that predispose-- these pre-existing conditions that have set up the trajectory for worse COVID outcomes.

Now, to pivot a little bit to the COVID space and how this all factors in, I want to share with you-- I'm going to throw a couple of case studies in here and pit stops to share with you a little bit of information from the ground. So a cruise down the Nile. March 5, 2020. I had just finished getting my workout in. Literally finished a spin class and had just gotten home. And I received a call from the then Deputy Secretary of Health for Maryland, Fran Phillips.

And she said, Hi, Travis. Guess what? You've got the first three cases of COVID in Maryland, Virginia, and the whole DC area. And what we found was those cases were all associated with individuals who had gone on a cruise down the Nile and had come back home.

And a lot of our emphasis at that time was placed to find people who had travel histories. We were only testing folks who had a significant history. If you can think that far back, at that time, to get a COVID test, we had to sign off on it as a local health department, then call the state, who then had to call the CDC and get approval from them before we tested an individual. And at that time, only individuals who had a significant concern in travel history were tested. And at that time also, Egypt was not one of the places that was on the list to get tested.

So think about how that process has matured and how it has grown over time to where we did start to implement other standards such as testing individuals without travel histories, more on their symptom history. And think about how that window allowed for more cases to spread in the early stages where we didn't fully understand the parameters of community transmission. At that time we were also not recommending individuals who were asymptomatic from quarantining and isolating from others.

I think back to our first protocol said that if you test positive for COVID and you have symptoms, go back all the way to when you developed symptoms. And the 48-hour period before you developed symptoms, you were not contagious. Again, fortunately, we've learned more, and we've changed those types of policies to prevent as many cases spreading as much as possible. But you can think how those factors pulling out-- at the time we thought it was more of an illness of those who were wealthier and had access to be able to travel. And we didn't think about it in the context of what other factors might enhance and drive community transmission that would predispose certain groups to coming into contact with it and unfortunately having worse outcomes.

Now, in the early stages-- and this actually is through the end of the year for COVID cases in Illinois by race. This breaks things down. So Black Illinois residents make up 14% of the population, 16% of cases, yet 24% of deaths. Latino residents-- 17% of the population, 31% of cases, and 19% of deaths. And white residents-- 62% of the population, 45% of cases, and 52% of deaths.

And I thought this was an interesting map. This was from earlier in the pandemic when Chicago actually received a lot of national attention based upon how some of the early cases were spread. I think if you recall back, there were what they would consider their index cases were spread out to family gatherings and funerals. And when you think about how it breaks down by city, we know that, unfortunately, Chicago has a reputation of significant segregation from a housing perspective. But when you look at the higher percentage of Black residents by neighborhood, the darker orange reflects a higher percentage of Black residents.

Then you look to see where, again, the darker blue shades represent higher numbers of COVID cases. And then, unfortunately, that matches up very closely when we look at where the higher percentage of COVID-related deaths are. And unfortunately, what we see having played out in Chicago has played out in a host of other jurisdictions, including our own here in Maryland, DC, Virginia, New York, California. And unfortunately, the list goes on and on.

And as we move forward through the pandemic-- this was back in August. You could see where, again, our mortality rates by race and ethnicity-- and this is national level data, not specific to Illinois. But at that important inflection point, it's also important to recognize that this was where we started to see the first wave really drop down across the country.

We felt good about ourselves. We felt good that we absorbed that first surge. Some places had a little bit of a second wave. And we were going to ride this out until we got vaccines at the end of the year or at some point in the near future. This was an important opportunity to learn those lessons and to think about which groups were hit hardest, why they were hit hardest, and how we could put in policies to address those issues before things worsened again.

Well, we all know that didn't really happen because a second wave-- however you define it-- then a third wave hit us very hard in the winter months before we could get folks vaccinated. And in fact, here's what the mortality rates look like across the country. And then, even to this degree, this third wave-- or fourth wave. Again, depends upon how you determine that-- in the end of 2020 and the earlier part of this year, we saw rates go up for everybody, but in particular indigenous populations and the Black community. And we see also smaller increases in the Latino community, the white community, and the Asian community.

But again, we had an opportunity to learn the lesson. We were all surprised and upset about those pre-existing conditions and the disparities. But yet we unfortunately really didn't learn a lesson in terms of putting in and implementing strategies to prevent that from happening again.

So I just want to stop here and have everybody think through, what types of factors do you think influenced and enhanced or continue to influence and enhance the spread of COVID-19? And since we aren't in person, again-- Dr. Alston can tell you my teaching style is I call on people. If we were there, I would call on you, and we would have a discussion. So in the interest of time, we'll move forward and look at a host of these strategies.

One we've already talked about is the notion of pre-existing conditions predisposing folks for having COVID. So yes, those same disparities that have existed long before COVID came in terms of all of those disease status and conditions predisposed certain folks from developing worse disease trajectories and unfortunately having a higher fatality rates. Now, part of that also in the public health world that I think that we can improve on is, having pre-existing conditions is not that the blame totally lies on that individual. We have to have a conversation about, what types of care do folks have access to in a meaningful way to help manage those conditions, to keep those in check that may have prevented those worst cases from happening and those fatalities from happening?

We think about testing access. Again, going back to the early stages of the pandemic, you could only get a test-- even as we increased testing capacity, you can only get a test with a provider's prescription. Or at least that's how it was here in the state of Maryland.

So think about it. I may have been exposed to it, or I may have some symptoms. But what if I don't have a medical provider? Where am I going to get that prescription for? Or where am I going to get that order from?

We created a hotline for individuals here who didn't have a provider where they could call into our command center, do a basic intake interview, and then have an order created-- I believe it was standing order by 9:00 AM. But we could get them into our county testing sites so that they had access to a test.

Housing density. This gets to the whole notion of housing security, affordability, and density. For example, here in Montgomery County, we are a mix of suburban/urban and a little bit more rural outposts further in the Northwest part of the county. But in our areas, Bethesda, Silver Spring, Takoma Park-- these are areas where lots of apartment buildings are. And even in the smaller dwellings, because housing is so expensive, you have multiple families living in single family units and dwellings. And you can imagine if one individual is symptomatic how quickly it can spread throughout the rest of the household.

And then we get to employment status. For many of us, we've had the opportunity to be able to work remotely and to telework. We also have, of course-- if we've got really good jobs with good benefits, we have the ability to have paid sick leave and family medical leave. So think about those employees who we ask to continue to go to work, to stand up and support those businesses, to keep things running, from grocery stores to restaurants and retail places-- many of those places don't unfortunately offer that level of benefit, but yet those individuals continued to work because they had to meet the needs of their families and also continue to keep the economy moving forward. And they were at increased risk.

And in many jurisdictions not all of them were required to have protections such as face coverings and those kinds of things in the earlier stages of the pandemic that predisposed them from contacting it. And again, if you're in an economically depressed situation, you're likely to have some issues with housing security as well. And that may be an increased factor to increase transmission within certain communities.

Digital access. We've built a great vaccine system, I think. But most of them were actually-- before the call started, we were talking about the concept of registering online and getting your appointment link on your email so that you could go back and schedule an appointment. Does everybody have access to broadband, the internet? Do they have the literacy to be able to navigate the systems that we've set up, that we celebrate and pat ourselves on the back that works so great for many? They do work for a lot, but not for everybody.

One of the other factors-- and there's a whole host of others-- transportation access. We actually, in the early stages, had a lot of drive-through testing. It's like, great, yes. We're going to drive-- get everybody to drive through. Well, does everybody have a car? Oh. Well, this is a drive through. Is it accessible by public transit? Oh.

Well, the mass vac sites that we have available-- are they able to come in for folks who don't have a car? Are they, again, accessible in mass transit sites to make it easier for individuals to access and take advantage of? And then, again, going back to those we've asked to go to work-- if they've been on public transit, what types of things have they been exposed to put them at greater risk?

So just to take a pause, if you've Googled me and COVID response, you probably came across some articles related to the opening of schools. And before we get to vaccines-- because this kind of moves forward in the time trajectory-- we had some controversy here in Maryland about reopening schools and what's safe. And I can't go into great detail because I have been sued over this. And the decision that we made was, at the time of high levels of community transmission, based upon CDC guidelines, we did not think it was safe for schools to return.

And I include this as an example from an equity standpoint because when schools did make the decision to go to virtual platforms, that did remind us that there's a huge digital divide within communities that existed long before COVID. And also, we received a lot of feedback that non-public schools have more resources than public schools. And so they can buy a lot of the equipment and keep their kids safe in a way that public schools can't, again highlighting significant disparities in funding and access to different resources. And again, yet another opportunity where we can learn from that and have a conversation about it that's not solely tied to COVID.

Unfortunately, as a number of schools did choose to open at that time, we saw a significant number of outbreaks related to schools as well as extracurricular activities. Fortunately, as we move forward and learn best practices and schools have returned across the board-- non-public and public-- we haven't seen those numbers at those levels. And we continue to work to keep community transmission levels down so that we decrease the opportunity and likelihood for kids and teachers and staff to bring COVID into the school setting.

Now, the last feature I want to move to quickly is to talk about vaccine distribution because that's another component. And that's where most of us spend a lot of our time and energy these days. And when you look at the state of Illinois, this is the breakdown of the percentage of population-- the percentage of residents across the state who have been vaccinated.

And if you can think back to the earlier slide that broke down, at least for White, Black and Hispanic residents, we saw that White residents make up 65% of the population. 72% of those who've been vaccinated. Black residents were, I think, 14% of the population, 9% vaccinated. Hispanic residents-- 17% of the state population, and 11% vaccinated.

And here are some statistics of where we stand in Montgomery County. This breaks down the percentage of-- the blue bar is the percentage who received the first dose. The gray bar is the actual percent of population. And you can see we still have a ways to go here. When you look at the percent who received the first dose, for example, our Black residents make up 19% of the population, but only 12% have received the first dose. And for our Hispanic community, 11% have received the first dose, while making up 20% of the population.

Now, that has improved over time. At the very beginning, we saw significant gaps in terms of the percent vaccinated versus population. In fact, the gap between White residents and Black residents was 20% in the very beginning. We've shrunk that to-- now I believe it's 5% to 6%. This slide was from last week. But with our new numbers this week, we think that's somewhere in that area. So we're making significant strides to address that, as other jurisdictions are also looking at strategies to be able to close that gap, particularly given that we know that race is a risk factor in many jurisdictions for catching COVID and having a worse outcome and making sure that folks have adequate and appropriate access-- fair access to the vaccine. And again, this is just another number to show you how the percent vaccinated within different groups has improved over time, certainly as capacity and volume of does have been provided as well.

And so how do we get there? And this will be our last case study before we shift to talk about where do we go from here and have some time for questions. So we recognized early on that when we put up the vaccine sites, because of the online portal and folks' ability to sit and scavenge for appointments and who had access, that we needed to do something to make sure that folks who fit into those high risk categories were not left out of the system. There was a little bit of controversy in terms of how the state approached addressing equity. For example, he's now confirmed the secretary said, the way we address equity is when we put a vaccine site in a Black community in a predominantly Black county.

Well, they did that. But only 10% of the people getting the vaccine were from that county. 30% were from counties like mine and others who had access to scheduled appointments and drive over and get the doses. So the intention, while admirable to locate a site there, was not achieving the equity goal because it was ignoring all of those other factors that block and prevent people from having fair access to the system.

So what we decided to do-- and now the state has followed suit-- is look at those zip codes from a geographic perspective who had the highest volume and burden of COVID-19 in terms of COVID cases, transmission levels, test positivity, and COVID-related fatalities. And we gave extra weight to those individuals who had preregistered within the system when were sending out allocations of doses.

So we had to create a prioritization system. I think every state has done that based upon age and type of employment and so forth. And we've been promised now that doses are coming, so it will be open to everybody. But in the limited doses that we were receiving, we gave special preference to those who lived within these zip codes because they had disproportionately higher risk based upon the burden scores of all those different factors that I mentioned.

And so this is how it played out. These are the zip codes within our county. And just as a point of reference, if you can see my cursor, here is DC right here. Here is Bethesda. For any of you who have these NIH grants who've had to come to Bethesda for meetings, here's where you are right here. For those of you who watch Real Housewives of Potomac, this area down here by 495 is that area.

Silver Spring is here. Rockville is in the center of the county. And here are some of our more rural areas of the county out here. Montgomery County is approximately 1.1 million people. Majority of the population is enclosed in this area here towards DC, and very diverse, as you can see by the racial breakdown. But we've actually been able to close the gaps and see high percentages. Again, green the darker the green shade a higher percentage of your residents who've been vaccinated.

And when we look at those over 65 in some of these other zip codes that are higher percentage of residents of color, we've been able to see that gap shrink. Now, we still see-- this is for those under 65. You see a lot more zip codes of lighter shade. So you can see we have a lot of work to do in terms of closing those gaps and moving us forward.

So how do we get there? Where do we go from here? Now, within the context of COVID-19, I'm sure some of you have seen these different models of community health and wellness. The approach that we have been taking and implemented before COVID, and we will continue to use, is this notion of a health in all policies approach, where we recognize that a person's physical health and clinical health isn't the only thing that is going to shape their outcome. It's shaped by housing access, housing security, food security, education access, employment opportunities, zoning laws, safety of neighborhoods, access to transportation, the quality of air within the neighborhood, the quality of the environment, as well as access to health insurance and access to meaningful care, not just, you have access because you're in program X. But what's the level and depth of benefits you actually have to be able to drive and improve your health outcomes?

And this is also just a schematic I borrowed from Kaiser Family Foundation. But we all are aware of the social determinants of health, many of which I just mentioned. And we've got to do a better job of figuring out how all of these factors influence health and whether we're talking about COVID or these other conditions that have plagued us for many years. So we've got to figure out how will they influence it, quantify the impact of these, and put money amounts to say, when you have a housing insecure community, this is what this translates to in terms of health outcomes, whether we're talking about specific conditions or health overall, because quantifying it allows policymakers to see the financial impact, as we talked about health disparities costing $90-some billion a year, to understand the true value of an impact of the policies that they're implementing.

It also creates an opportunity to reach out to agencies who have traditionally not been a part of public health conversations to understand the impact of the decisions that they're making, whether it's transportation, housing, housing, education, et cetera. So we've got to do that work. But then the third thing that I want to mention because we've seen it play out time and time again is to go back to that category of discrimination, racism, homophobia, transphobia, not respecting different groups and cohorts and understand the impact of how those types of beliefs play out in the implementation of these policies, which ultimately impact the individual's health outcome. And so we've got to have meaningful conversations and be able to engage on that level to really root out the root causes of what's driving these systemic issues that continue to perpetuate these disparities that were here before COVID, have certainly played out in COVID, and I guarantee you will be sitting here waiting for us when we've achieved herd immunity and vaccination and ready to move on to talk about other public health issues.

So that concludes the presentation. I'd be happy to address any questions that you all may have. And again, thank you so much for the opportunity to be here with you. I could talk for hours about all the different things we've experienced in COVID. But hopefully this concise, comprehensive presentation addressed some of those concerns. Thank you.

DR. REGGIE ALSTON: Thank you, Travis, for a very good discussion on disparities in general and what it means for COVID specifically. And we have some questions for you, one being, how might vaccine passports factor into COVID-related disparities? Or are they not a concern related to this issue?

DR. TRAVIS GAYLES: Well, I think the big point-- before we get to the vaccine-- well, let me say this. To be eligible for a vaccine passport, you have to be completely vaccinated. And so that's the key. I think the issue from the disparity is, how do we get everybody to that point where they've achieved full vaccination status to be able to enjoy the merits or privileges of a vaccine passport once that's finalized?

And so yeah. I think for me, the discussion shifts a little bit more back to the, how do we get everybody up to speed and access to the vaccine so that folks can have good uptake? I think one of the unfortunate things is, early on in the process, a lot of folks-- a reality was that yes, there has been hesitance around it. But a lot of folks wrote disparities and uptake off as, well, Black and Brown people just aren't taking it. That's not true. And so we've got to do a better job of, again, making sure that we have programs that remove those barriers and promote folks being able to get opportunities to get the vaccine.

And so yes, I would love to have a problem of 80% of our population having vaccine passports and figuring out how to use it because that means we will have closed those gaps that we're seeing right now in folks not getting vaccinated.

DR. REGGIE ALSTON: OK, thank you. What are the disparities within races by gender for infection, death, and vaccination rates-- heart disease methods driving strategies for COVID-19 education, prevention, and outreach?

DR. TRAVIS GAYLES: That's a great question. I think it depends by location. I know for us here in Maryland, it's probably been a little bit closer to 50-50 in terms of the cases by gender. We have seen higher uptake of the vaccine, however, in women versus men so far. And that's been true across all of the different racial categories.

And so yes, I think it's important to, again, be able to tailor messages to get outreach to folks. I think it speaks to, again, the type of job opportunities and things that people have access to in terms of their level of exposure based upon the work that they do. And it underscores the fact that there can't just be one message to be, stay at home or wear a mask. You've got to figure out how to nuance that message to different communities so that you're presenting information in a way that resonates and addresses the specific concerns of the community to alleviate their fears, alleviate any hesitancy, and to promote health and wellness movement forward.

DR. REGGIE ALSTON: We've scheduled a meeting between you and students from the College, both undergraduate and graduate. We have a question here from a student. I think it's a good one. What can we do as pre-health students to address these disparities related to health care?

DR. TRAVIS GAYLES: That's a symposium in itself. Well first, representation matters. And representation can be defined in many different ways. Representation can be defined by the color of your skin, your gender, where you come from, who you love, how you identify.

And so when you do have opportunities to speak on panels or to be a part of meetings or to be a part of planning sessions, those kinds of things, use your voice and speak up. And I think one of the tendencies too as-- when you're at the student level, there's sometimes this fear of, I'm not senior enough to say something that's going to resonate or have impact. And that's just not true. You have a lived experience and a set of experiences that no one else has. And so it's important to remember that you can contribute even at this level of your training when you do have those opportunities to speak and give voice to all of the different communities and experiences that you may represent.

I think the second thing is, given that for many folks studying in the practice research is an important thing-- so going back to the data piece, asking a research questions to get data to help inform and drive conversations. I remember actually, one of the things that inspired me to get a PhD in a research training was that first job that I mentioned when I was at the Institute of Medicine. We were looking at disparities in access to end of life care for families who had children who were dying. And the committee wanting to talk about it. But my job as a research associate was to go look for it. There was no data there.

And so we have a blurb in-- chapter 2, I think, is the epidemiology chapter-- that basically says, we acknowledge that this is a reality and disparities exist. But unfortunately, there is a paucity of data at the time. We are hopeful that this report will encourage those questions to be asked and that data to be gained.

And so part of my motivation was to say, well, you know what? There's a lot of questions that I want to see asked. And there's a lot of policy that I want to be made. And if I can get that training, I can ask those questions and have the statistical background to be able to get that data so that policymakers can't say, well, we don't have the data to that subject. Well, here it is. What are you going to do now that the data and the background information's there? So continuing to ask a diverse set of research questions and utilize your training and skills to get that data to help drive those conversations.

DR. REGGIE ALSTON: OK. I think we have time for a couple of more questions. We have several. But one is, as vaccination efforts continue to progress in the country, is there a concern with HIPAA as it relates to proof of vaccination? Will health disparities prevent individuals from having access to certain sites and activities due to the lack of proof?

DR. TRAVIS GAYLES: I think that is an important question that the legal folks are trying to figure out and why I don't think we've seen a formal vaccine passport type program released yet. I think they're trying to figure out the parameters within which to do that. I know that, at least on a local level, we've been trying to figure out, well, how do you actually ask for proof of vaccination and making sure that's consistent with other forms of proof of vaccination for example, the flu shot each year where you document you received it or you document that you refused it?

So given that we're seeing the increase in vaccination rates improve-- hopefully more quicker than they are right now in the near future-- that those types of questions will be answered more clearly.

DR. REGGIE ALSTON: OK. Could you speak to the intersection of vaccine access disparities and vaccine hesitancy in marginalized communities? These seem to create an especially tricky problem.

DR. TRAVIS GAYLES: Well, you're right. So the hesitancy is one that we know it's real, but we know it's not just exclusive to communities of color. For example, there was a poll done here in Maryland that showed that the highest rates of hesitancy were in White men who self-identified as Republican, that that rate was much higher than any other community across the board.

And so I think hesitancy-- the way you address hesitancy regardless of the community, in particular as it relates to race, is to not make assumptions and to take time to have conversations with communities to say, well, tell me what your concerns are, as opposed to coming in and saying, well, it must be because of A, B, and C, and trying to implement strategies where that-- I know history matters, certainly. And we have lots of examples of public health concern to build mistrust in communities. But it's not always history for somebody. It's their current lived experience.

And so making sure that we take the time to do the due diligence to have those conversations whether it's through focus groups or surveys to find out what folks' real concerns are to help inform the types of outreach that we put out in terms of programming and addressing their particular needs. And so that's a piece of hesitancy.

Now, part of what also, I think, plays a role into hesitancy with that lived experience is when you see systems that are set up that don't really address your needs. It's hard to watch and say, hey, well, the state put a site here where Black people live. But we're not getting the vaccine because it's set up to support people who have means and access who can sit and look for sites and have access to the internet and all those things to be able to take advantage of those sites.

And so the other thing too is, you think-- and there's countless examples of that. Back to the "60 Minutes" interview, the correspondent who I met with talked about his experience in New York. There was a site set up, I think, in the Bronx in a heavily Black and Latino community. And 90% of the people who came to the first set of appointments were from upstate New York because they knew how to use the system and got the appointments. And saw all that to say that when people continue to see things like that happen, that confirms their potential lived experience and further drives that mistrust in the system that may make them hesitant to participate in the program.

DR. REGGIE ALSTON: OK. One more question. As you know, Travis, we have many undergraduate students who pursue medical education following their time in the College. And this is a question from a student-- says, how has being an M.D. helped you within your public health and health disparities research and work?

DR. TRAVIS GAYLES: One, in some ways, in some rooms, it has been an automatic qualifier, if you will, in terms of folks respecting having that clinical background and experience the level of training. I often sit at meetings and say, well, I'm not a doctor, so I'm just going to-- I've never practiced medicine, so I'm going to defer to Dr. Gayles in terms of having that experience of being able to speak in terms of having increased credibility because you have that training and background.

I think it also helps shape the perspective of being able to see how all of this plays out when you have seen the physical manifestations of these different things and the different outcomes in that way. I think there is a certain way that we are trained in clinical medicine that offers a different perspective to the public health conversation that you don't necessarily get from that training background that-- I'll say this-- is coming in very handy in working with politicians and elected officials in the last year. And so I think it's been a great opportunity to bring them together.

On the flip side, having a public health background has improved how I work with patients and how I don't necessarily-- while I'm not practicing now, I don't necessarily just look at a clinical explanation for everything. And I'm able to think through multiple lenses about how all of the different social factors can influence a clinical outcome.

For example, I use this a lot in our teams. We spend a lot of time around diabetes management as a chronic disease. And from the clinical standpoint, you just say, hey, OK. Your hemoglobin A1C is elevated. I need you to go on a diet. I need you to eat healthier. And I need you to exercise.

All right. Well, that's easy to say from the clinical perspective because I know that's going to improve your numbers. But what does that mean? Well, are my diet recommendations culturally appropriate for the types of food that that person eats? Is the message that I've sent to them able to resonate to know that, if I tell you to eat food x, that may not be a staple of their diet. So how can I work with them within their background to understand how to make those changes?

Or I need you to exercise and go walking. Well, does their neighborhood have sidewalks? Are their playgrounds there? And so thinking through strategies as opposed to just give a directive and thinking of it from how all of those other things influence their ability to be able to be successful and ultimately improve their health.

DR. REGGIE ALSTON: OK. So we have three minutes left. I want to squeeze one more question in here, Travis. It's no secret that the Governor of Maryland is not a fan of yours. What has been your experience navigating those waters, which can be quite turbulent at times? And you have had-- there have been threats against your person. Talk a little about that.

DR. TRAVIS GAYLES: Sure. Well, I think the thing that we've been committed to is making sure we stick to science and data. I am very quick to remind folks, I'm not an elected official. I'm not a politician. I'm a public health official who's been charged with providing the best guidance around science and clinical practice.

And that is what we have stayed committed by-- we stay committed to-- in terms of driving what we do. It has not always been popular. And I don't say this in a way to brag or beat my chest. But when you look at the numbers throughout the pandemic, our numbers have held in a better position than a lot of other jurisdictions who haven't taken some of those tougher stances informed by the data that we have.

And so I think this goes back to the other question actually about having a medical background. I don't ever practice medicine doing what I think is the popular thing to do. I make decisions for my patients and their families based upon what is the most medically sound decision after being very thoughtful and reaching out to others.

Going back to an earlier comment about mentorship, last year I realized I don't have all the answers. Our team may not have all the answers. So we actually created an advisory group of health care experts across the region to meet biweekly to say, hey, here's what we're thinking. Is this the right thing? Should we be considering some other things or moving in those directions? Because getting additional help and expertise and guidance is important too.

So I stay out of the fray with the governor. He has his job to do in terms of how he wants to proceed. But I'm charged by the state rules and the state laws in Maryland to provide medical guidance and public health guidance. And in those situations, I will always be guided by the principles of public health ethics and the principles of science and data.

DR. REGGIE ALSTON: OK. Well, fantastic. We've reached 1 o'clock, which is our end time. Travis, I want to thank you on behalf of the College and Dean Cheryl Hanley-Maxwell for presenting some very insightful, useful information as it relates to COVID, and providing that on the ground perspective, which is useful for students to hear, and also for our faculty and researchers to hear as well.

As I noted earlier, this presentation was reported. So if you need access, contact me or Ms. Sally Marshall, who I would like to thank publicly for all her work in helping me coordinate the virtual presentation today. Again, Travis, thank you a lot. Thanks a lot. And I'll applaud for everyone else.

And you'll be back shortly, so don't get lost. We have a meeting scheduled with students and with faculty later as well.

So thank you to everyone for attending. Take care. Bye.