036 Daniel E. Dawes, JD on how to overcome deep-rooted challenges in the American health care system

From his childhood on a rural Nebraskan farm to the negotiating tables in our nation’s capitol, Daniel Dawes has combined his lifelong passion for health equity, political acumen and confidence in a collaborative process to create real and powerful changes in the American healthcare system. With contagious hope and a non-partisan process, the widely respected health equity and policy expert leverages his understanding of the root causes of America’s healthcare problems to advance solutions.

 

Megan Hayes:

Daniel E. Dawes is a widely respected healthcare and public health leader, health equity and policy expert, educator and researcher who currently serves as Senior Vice President for Global Health and Executive Director of the Global Health Equity Institute at Meharry Medical College. He's also founding Dean of the School of Public Health at Meharry Medical College, the first school of public health at an historically black institution. He has also served as Executive Director of the Satcher Health Leadership Institute at Morehouse School of Medicine and is a professor of health law policy and management. Highly respected for his ability to achieve sound policy changes in a nonpartisan manner, Professor Dawes is an elected member of the National Academy of Medicine and an elected fellow of the New York Academy of Medicine.

He serves as an advisor to the White House COVID-19 Health Equity Task force, an appointed member of the Centers for Disease Control and Preventions Advisory Committee to the director and co-chair of the CDC'S Health Equity Working Group, as well as the National Institutes of Health's National Advisory Council for Nursing Research. He's the author of two groundbreaking books, 150 Years of Obamacare, published in 2018, and the Political Determinants of Health published in 2020, both by Johns Hopkins University Press. Among his many achievements, he was an instrumental figure in developing and negotiating the Affordable Care Act's health equity focused provisions among other landmark federal policies.

He's the principal investigator for the nation's first health equity tracker, and he's a recipient of the American College of Preventative Medicine, Dr. Daniel S. Blumenthal Award and the National Medical Association's Louis Stokes Health Advocacy Award among many others. Professor Dawes holds a bachelor's degree in business administration from Nova Southeastern University and a juris doctor in law with concentrations in health law and labor and employment law from University of Nebraska-Lincoln. Later tonight, he will address App State students, faculty, and staff, as well as members of the broader community as the keynote speaker at Appalachian State's 38th Annual Dr. Martin Luther King, Jr. Commemoration, where he will speak about his work as well as the legacy of Dr. King. Daniel Dawes, welcome to App State and welcome to Sound Effect.

Daniel Dawes:

Well, thank you so much for having me. It's wonderful to be here.

Megan Hayes:

I'd like to start, if you don't mind, if you wouldn't mind just beginning talking a little bit about your personal background and the path that led you to where you are now.

Daniel Dawes:

Yeah, absolutely. For me, it starts in Lincoln, Nebraska where I was born. You always wonder where should I start? I'm going to start from where I was born, because I think that played a significant role in who I am today. Born in Lincoln, Nebraska to farmers in a little town called Deshler, Nebraska, a town of 600 people in rural Nebraska, and really this product of a interracial marriage, black father, a white mother. What I found interesting as I was growing up was the dichotomy in terms of their health statuses on each side. On my mother's side, I noticed that a lot of my grandparents, uncles, aunts, other relatives were able to live past their 60s, 70s, 80s, 90s, had longer lifespans.

But then on the white side of my family, I mean on the black side of my family, I realized that they were lucky they made it out of their 60s. They had higher rates of diabetes, higher rates of cancer, high blood pressure, heart disease, stroke. I kept thinking to myself, why is that? What is the reason that they seem to have worse health outcomes and lower life expectancies? As I was investigating, my dad and his mom, quite frankly would say, "We just have bad genes." I thought, "Gosh, is it really true? Could it be genetic solely?" As I was investigating that, interestingly enough, I went to college thinking, "I'm going to do healthcare administration." I'm going to do it because there was a report that had come out in the early 2000s from the Institute of Medicine, now the National Academy of Medicine called Unequal Treatment.

Then, there was another report from the Agency for Healthcare Research and Quality that had come out with a national healthcare disparities report. I thought, "Wow, there's more to this." It seems like it's maybe our healthcare system that isn't providing equal care and equal treatment depending on your background. That really excited me that folks were looking into this and exploring what were the causes of these outcomes. I decided, "Yup, healthcare administration, that's exactly what I'm going to do." I decided I wanted to focus on cultural competency because of an experience that I had. Now, after my parents moved from Nebraska, from Lincoln, Nebraska, they actually moved to Miami, Florida. Imagine that. Quite the opposite, right?

Megan Hayes:

A little warmer, maybe.

Daniel Dawes:

A little warmer, exactly. It was interesting now growing up in that setting meeting folks from diverse backgrounds and cultures. One day I decided I wanted to intern in a public safety net hospital. I wanted to get a feel for why there's so much dysfunction and fragmentation in our health services. The CEO at the time of this hospital said, "Sure, feel free. You can go to the emergency department and observe as long as you have permission from leadership." I said, "Sure." They gave me permission. On my first day I witnessed this woman who was pulled in on a gurney and she spoke very limited English. She was writhing in pain trying to be understood, but the triage nurse just couldn't understand because they couldn't communicate in the same language.

I saw her then ask one of the other nurses on the team to go and speak with her. The nurse goes there, and it didn't even last a minute. You saw the nurse go back to the triage nurse and an argument erupted, where to make a long story short she says, "I have no idea what she's saying." The triage nurse said, "Well, I thought that you could speak her language. You have an accent." I thought, "How did she not know?" Because I picked up on the accent really fast. I said, "It sounds to me like she is from a Haitian Creole speaking nation, so a French Creole speaking nation, maybe Haitian Creole. It really caused me to start thinking, how many times does a situation like this happen in our hospitals, in our clinics, and in other healthcare entities across the United States?

From that point, that really was the impetus for my journey to advance health equity nationally. After that experience, I then applied for a leadership development program with a hospital system, one of the largest in the country, the largest Medicare provider in the country, and one really that served a diverse group of folks internationally. I said to the administration at the time, I said, "Listen, there are these major studies that just came out showing tremendous disparities in healthcare, and I'd like to work with you all to rectify it." They looked at me and they said, "Well, we don't discriminate against our patients." I said, "Well, I'm not saying you do, but the literature," and at the time there were 600 peer-reviewed journal articles, "are demonstrating that this is something that is systemic.

Perhaps we can try to create a cultural competency toolkit." Finally, after making the business case that this would be a competitive advantage over such and such hospital in your backyard, they finally let me do this. We created this toolkit that was, I think, pretty groundbreaking for the time, and one that really brought the community out and really engaged the community in developing, and it's something they appreciated. From there, they used it in all 50 of the hospitals at the time. During that process though, one of the things that struck me was how many barriers I had to go in order to do this project. I had every lawyer in that health system bother me and say, "You cannot do this because it would be a violation of X, Y, Z statute."

Now remember, I'm an undergrad, never gone to law school, couldn't even research the law, much less interpret it. I just thought, "You know what? Instead of going the hospital administration route maybe, or the public health route, maybe I should go the law route and immerse myself in the health laws and anti-discrimination laws in this country so that I can fight for people who really have been locked out of our health system." That is what really pushed me on the journey. I then, of course, immersed myself in the law and left and got this amazing fellowship in Congress where I got to work with Congresswoman Donna Christensen, who was the first female physician member of Congress. She took me under her wings, this lawyer, imagine the doctor, the lawyer.

Usually, were butting heads, but she took me under her wings and she helped me to understand how the sausage is made. She introduced me to her network, she mentored me. Because of her, the rest really is history, I then got to work with the late great Senator Ted Kennedy on the Senate Health Education, Labor and Pensions committee, and worked on behalf of special needs populations. These are people with disabilities, people who have been marginalized in our society. Really have been excluded from enjoying the benefits, the social and economic benefits of our policies. That again was eye-opening to get to work with one of the lions of the Senate at the time, and to see how you could effectively push policy that would positively benefit as many people as we possibly can. That really was my journey in a nutshell.

Megan Hayes:

That's an incredible story. One of the things that occurred to me when you were talking about this, I was going to ask a little bit about, I think our students might be interested in how your educational background, both your undergraduate and your graduate background, informed the work that you do today. I was just thinking, you're sitting there talking about how you had to make a business case, so you're using your business background and then you had to make the legal case, so you used your legal background. I think it's just interesting. Do you find yourself now drawing on the undergraduate experience too, as well as your legal experience?

Daniel Dawes:

Oh my goodness, every day. Every day. I think in the introduction you talked about my focus and it really was on business administration and psychology. I find myself as this advocate for mental health under the umbrella of health equity, employing a lot of what I had learned in psychology and realizing even from a relational standpoint, we talk about proximity theory, the closer you are to someone and the more rampant you engage with them, the more they like you. It just helped me to understand how to negotiate. Business, my business background as an undergrad, we were quite fortunate, I would say, to have professors who allowed us to not only learn the theory, but apply that in the classroom and outside of the classroom and with externships and internships.

For me, I see how my undergraduate degree has helped me to figure out how in the world I can negotiate a very complex statute or bill, a legislation, perhaps it's a regulation. I can also see how the law degree would help me, of course, to be able to do that. But in terms of building coalitions, building alliances, building a national network of really transdisciplinary group of folks, there are folks who have economics degrees. They may have sociology degrees, English degrees, humanities even, and whatnot. You really appreciate the contributions that we all can make in this movement to advance health equity. That's what I really love, because no one discipline has all the answers.

I think through our unique lens, no matter what we concentrate on, no matter what we major in or minor in, I think it will add value if you care deeply about health justice.

Megan Hayes:

Yeah, so your work now is heavily involved in advocacy to ensure health equity. Can you talk about what health equity means?

Daniel Dawes:

Oh, my gosh, absolutely. A lot of folks, they think health equity means health equality. There's this notion, I think all of us, especially for those of us who went to law school, there's always this emphasis on equal protection of the laws, on equality. Interestingly enough, when you think about equality, it's giving everybody the same thing, but equity now looks at where we all are starting off, not everybody's starting off at the same point. Some folks may need maybe extra health services or extra resources in order to reach their optimal level of health, to reach their full potential, their full health potential. It's really thinking about what it's going to take to overcome the barriers that groups that have been locked out of our health system for generations, what resources they're going to need.

What structures need to be dismantled in order for them to have a fair shot. It's really rooted in distributive justice, rooted in this idea of fairness.

Megan Hayes:

I think that the way that you were talking about health equity is a great segue to my next question, because what I'd like to do now is talk to you a little bit about some questions related to your latest book, the Political Determinants of Health. You began the book with this allegory of a farmer and an apple orchard to explain all of these challenges that our nation faces in providing quality healthcare. All the trees begin as seeds, but they're growing conditions affected their health and productivity. As I was getting into the book, I was like, "Okay, I'm getting this." Then, you start talking about, a little bit, as you layer on all of the different aspects, the condition of the soil.

Whether they get fertilizer and whether they get pesticides and whether they're used for research and all of these things. Well, let me ask you this. Why did you decide to use the allegory of an orchard and apples to tell this story?

Daniel Dawes:

Because when you're dealing with sensitive topics, you're talking about racial inequities, racial injustices, you're talking about ableism, sexism, classism. They're very sensitive topics. I thought perhaps I want folks to keep reading. I want them to feel like I'm not personally attacking one group versus another. That's not my intent. I wanted to create an allegory that could tell that story because I felt when you look at what has been done, you look at the parables in the Bible, they're not as threatening. You look at allegories that have been created by non-religious philosophers. It seems to do its job in really pulling folks in and helping them to imagine, "Okay, I can see how this could then lead to one thing versus another."

I wanted to really pull folks into this without hitting them in the eye. I wanted to create a story that I thought would be pretty compelling, and every part of that story having significant meaning. That was really the reason for that.

Megan Hayes:

Yeah. I think too, as I was listening to this, I thought the language is equalizing too, in terms of there are so many just topics and terms that have gained stigma, whether they were ever intended to or not. In this way, perhaps you can remove all of that and just simply talk about these seeds.

Daniel Dawes:

Absolutely.

Megan Hayes:

Yeah, it was interesting. I think a lot of us think about the many factors that affect our health and the health of our loved ones. I'm a Gen X-er, I'm in that sandwich generation. I have children that have aging parents. I was actually on the phone with my mom this morning and she was like, "We might be taking your dad into surgery next week." We hear a lot in the news about these social and environmental determinants, like water quality, all of these things. Is there a factory nearby that might be messing with the soil quality or the air quality? But you state that the political determinants of health are the underpin of all of the other determinants. Can you talk a little bit about that?

Daniel Dawes:

Oh, absolutely. I'm so glad you raised social determinants of health first. A lot of folks in public health and in healthcare have accepted what Michael, Sir Michael Marmot, Paula Braveman at University of California, San Francisco and David Williams at the Harvard School of Public Health have been focusing their careers on. It's really fleshing out and helping us to think beyond the downstream impacts that we see, those immediate outcomes that we see. What led to them? Can we really go to the root causes of these poor health outcomes among population groups? Folks have said, "Well, healthcare is one aspect. Genetics, as we talked about earlier, that does play a role." Probably a 10% to 20%, it has a 10% to 20% impact on your overall health.

Then, they look at behaviors, right? Behavioral health, which can include, of course, from exercise and diet to, of course, mental health. That has about a 30% impact. Then, they fleshed out and they said, "But there is one key driver among all of these determinants, and that is the social determinants of health." These structural conditions in which all of us are born into, we live in, we die in. No matter your race or ethnicity, no matter your background, we all are affected by the social determinants of health. Understanding that, understanding, as you mentioned, the housing issues, water issues, transportation or the lack thereof, education, employment, all of these are "social determinants" of health.

But then, as a scholar of history, and as someone who has studied policy, studied law, worked in this public policy arena for a number of years now, it just never sat right with me because I felt we hadn't completed the equation, that we're still nibbling at the edges of the problem of health inequities by addressing the social determinants of health. Yes, they play an outside role, but what instigated those social determinants of health? For every social determinant of health, I came down to this conclusion. There was a preceding policy action or an action that resulted in it, a ordinance at the local level, legislation at the state level, a regulation at the federal level, or a case law that came out of a federal court, state court, you name it, and they have health implications.

I've been on this quest going all the way back to, not 1619, although I do believe that is a fair starting point, but it's 1641. I wanted to know why is it that we see these disproportionalities in health between groups. It's going now and doing that equation, doing the examination to understand what preceded that social determinant of health from a political standpoint. What is that policy that created or has been instigating or exacerbating the results? Then, in addition to that, can we go back in history to identify when it started? We're going to learn about that tonight, obviously, so I don't want to give away too much. But it's just fascinating when you look at what was leveraged by the commercial determinants of health.

Let's add that into the equation, and understand how the commercial interests back in the 1600s, wanting to sustain their business model of slavery, created this body of liberties law to legalize slavery. The abolitionists at the time were fighting and saying, "This is absolutely immoral. How dare you all do this?" But the commercial interests worked with the political interests, and they created this template, the Body of Liberties in Massachusetts. Then, from Massachusetts, they started advocating, lobbying other governments in New York, in Connecticut, in Maryland and beyond. But as we have seen in the course of history in this country, every time proponents of health equity and justice have fought to elevate the status of a group that have been oppressed in our country, then there's this backlash, pushback.

As they received that backlash with that legislation, they again regrouped and said, "But it never included the offspring of these enslaved groups." Then, they went about, the commercial interests and the political determinants, went about amending the law to include the offspring, and as if that weren't enough, what else do they do? Then, they introduced other laws that today we know as these social determinants of health. They restricted their social determinants of health needs. They were unable to move about beyond a certain mile radius. They were unable to raise their own food. We know food, access to nutritious foods is a key social determinant of health. They were prohibited by law from learning to read and write, from being educated. Again, another social determinant.

You can see then how the political determinants of health really played a role further upstream. They are the fundamental causes going way back in history and still today in terms of what we see with the health inequities.

Megan Hayes:

I think frustration with the medical system is somewhat a universal experience. Everyone has had at one time or another.

Daniel Dawes:

Yeah, and that would be fair.

Megan Hayes:

We've all been in the emergency department urgent care. You talked about that experience that you had where there are other sick or injured people, and seeing them express frustration and maybe even leave without being treated.

Daniel Dawes:

That's right.

Megan Hayes:

It can feel like such a huge problem. I think it's one that many of us feel powerless within, especially when you're in the moment trying to figure out how to problem-solve. You sit there. I was in the ED recently with my husband who just had a minor injury, but we waited six hours and we saw all these people come and go, and people who needed to be treated leave. In my head I'm thinking, "Boy, they just need to do this and this." Then like, I know, right? I'm the expert on this from all of my six hours of sitting in the emergency department. But it does make me wonder, especially as we think about how complex the problems are and how deeply rooted they are in the history of our country, how do you energize people to get involved? What are those beginning steps that you suggest?

Daniel Dawes:

I love this question because just today, actually, on my flight here to App State, I was reading this article published by ProPublica, and it was detailing a student at another university in Pennsylvania who has struggled with a health problem. Fortunately for him, both his parents are professors at the university. They had the wherewithal to fight the insurance company that had been discriminating against their son and believed that his treatment was not medically necessary. What I found very compelling from the article too was a statement that said that only 0.1% of folks in our country have fought and appealed any decisions made by an insurance company. I thought that was pretty compelling. I mean, 0.1%, only 0.1, not even a percent, 0.1% of folks will appeal a decision that is averse to their health status.

Under the Affordable Care Act, it's called the Patient Protection and Affordable Care Act, there are provisions in that law that consumers really should be leveraging to protect themselves and their loved ones and to fight for what they are owing under the law. That was pretty troubling. But to get to your main point, because you reminded me of this story that really tugged at my heartstrings this afternoon, but how can we fight? I think we absolutely cannot lose hope. It seems like the system, as complex as it is, can force one to lose hope really quickly. We know that our systems, whether healthcare or otherwise, were intentionally designed to make it frustrating for many people.

The way I look at it is, and I've worked with groups that whether you're in Texas or in Florida or in the South, states that may be hostile to this agenda of health justice, what we have done is to say, "Let's take a look at what you can do, what's in your power to do." Perhaps you're in a state where you may have a legislature that quite frankly is setting forth policies, and they don't want to advance a more comprehensive agenda, but perhaps there may be a piecemeal agenda that you all can work on collectively. I like comprehensive because I'm like, "Let's just resolve this as much as we can." But perhaps the piecemeal approach might be one way.

There's another tool that I found very few health equity and health justice advocates have used, which is citizen initiated ballot initiatives, but they've been very successful, about 25% success rates in the past and been around since the 1800s, and yet we haven't really leveraged that, and so that's another one. Of course, it takes money. I understand that, but it's still another tool. Then, there's the piece, when I think about what you can do at the local level, a lot of what we have been able to do at the federal level, and that I would include in legislation that I was working on were incubated at the local level. I always remind folks, there are amazing ideas that you can employ in your city, in your county, that you never know another county or city might then adopt.

Maybe tweak, depending on how different they are with their population. Then, ultimately, through your successes we can make the case for greater investments, federal investments in those kinds of programs. That's one way. Then, there are those who say, "Oh my gosh." Like my wife, who wants nothing to do with policy or politics. I said, "Well, you know what, honey? You are a dentist. You are a public health dentist trying to provide oral health services to folks who are locked out of the system, working a federally qualified health center." I said, the number one thing that she complains about is the lack of Medicaid reimbursement, or the fact that Medicaid oftentimes is trying to prevent her from saving the tooth because it would be more costly.

You're only allowed to extract the tooth, get rid of the problem. I've said to her, "You know what, honey? I think if you don't want to get involved in policy development, you need to get involved in your association, your trade associations, your medical societies, and really urge them to harness the power of collaboration to push forth policies then that will help the very people that you struggle every single day to help." I think those are ways that we can. If you remember from the model in the book, I talk about the four different levels of discrimination, but really there are levels that I think each of us can operate in. The intrapersonal level, perhaps there are things that we need to correct within ourselves to get us ready for this advocacy work.

There are interpersonal things that we can do. There's also the institutional piece. If you work in a company or you work for an institution, there are things that you can do to change the processes. Change the private policies in an institution. Change the culture so it can be a more welcoming environment for diverse groups of folks. Then, of course, structurally for those who are ready. Those are the public policies, the economic policies, social policies that you can help to either advocate for or to ensure that they are informed by the evidence, that you are helping to inform them by virtue of you being an expert in whatever area the bill touches on. I think that's the beauty of how we can all contribute. It gets back to that multidisciplinary lens that is needed to inform policy.

Megan Hayes:

In your book you give a peek behind the curtain into the incredible process that brought the Affordable Care Act into being. Those of us who were old enough to remember and followed it in the news, I think we did get a sense of just the public side of the process, which I at the time felt very complex. One day you think you know one thing, and then the next day you're like, wait a minute, I thought we knew that. No, now we know this instead. But what you really do is take us behind the scenes into that incredibly complex process of bringing together all these groups representing very diverse segments of our country's population. Gaining consensus around meeting these challenges that really have faced our nation since before we were even a nation.

I've heard the word collaboration come out of your mouth several times since we've sat down here, but it's against adversity that takes a lot of forms. Sometimes the adversity is people, sometimes it's the system, the process. All these hoops that you got to jump through. I think for young college students in particular, but really for a lot of us, there's a sense of passion mixed with urgency. When they learn about problems, they just want to fix. How do we fix it? Give me a quick fix. Maybe if I jump up and down and yell out enough or call the right person, then they'll fix this situation.

Daniel Dawes:

I want a quick fix too.

Megan Hayes:

Sure, yeah. But how do you balance that sense of, let's get this done with the patience that it takes to compromise, find that right research, develop the right message, gain momentum, and then not lose the momentum that you've gained?

Daniel Dawes:

Oh, my gosh, that is a great question. Like I said, I am someone who wants the quick fix. I have had to learn to be a little more patient because change does take time. It takes time to educate folks on what the issues are and what are the potential, and develop the potential solutions with folks so they have buy-in. I think there's a professor, Johan Mackenbach, from Rotterdam University in the Netherlands, who I found his writings very interesting because he says, he basically comes to the conclusion that he doesn't believe that we can ever reduce health inequities. Because you're going to have to get the government, first of all, you're going to have to vote in a government that is supportive of health equity.

You're going to have to work with the masses, with the citizens of that country to educate them about why these are important so they can keep sustaining and pushing that agenda with the government. You're looking at it twofold, government and the people, and you're doing this, what I find interesting, educational process with people so that they can support what the government then is pushing in terms of the health equity agenda. We see that going on right now. I think for me, it's knowing that this is a journey. It is a arduous journey. I know that there have been so many people before us who have fought for people with mental illnesses in this country, to open up opportunities for them.

Who have fought to provide health services to poor whites in the South who were displaced by the Civil War and freed blacks as a result of the Civil War. Who have fought to keep those doors open and to really desegregate our institutions. It's taken a while because you do have to educate folks. We see what's going on right now where we're educating folks now on all these other issues, from LGBTQ health inequities, to the disabilities that confront people with disabilities. You're talking about ableism. It takes time. If folks don't walk in your shoes, you're going to have to take time. I've heard people say to me, it is not my job to educate people on these issues. I'm not wasting my time. You need to go and do your homework.

I say to folks, "Well, I do think it is our job to educate folks, because they haven't lived in your shoes. They don't have your same lived experiences." Sometimes folks don't even know where to begin to research a particular issue. You do need to sensitize, and then you have to win them over so that they will support the movement, support the cause. If we fail to do that, then you may be able to get a government institute that supports health equity, but then you will have folks, whenever the government is trying to do something, pushing back and saying, "Absolutely not. We don't support that." The government gets scared and backs off. I look at it in terms of, we need to get something done. I need to think about what are the opportunities that have been presented right now?

Where are the challenges in terms of building the alliance and the coalitions of folks that are needed to do this? How do we work together to make that happen? All of that takes time. Otherwise, you might as well just institute a dictator. Yeah, if you want that quite frankly to be a quick fix. It takes time to build the consensus with folks and to build it within government and outside of government. I think once you do build consensus, then it will sustain that much longer than if you basically try to cut corners and do things impatiently.

Megan Hayes:

Yeah. This is an in the weeds question, but I thought it was also really interesting the role that staffers play in this process and play in the legislative process in general. I think a lot of us have this impression that our elected officials are the key people we need to get in front of when we're advocating for ourselves or for other people. Not that that's not the case, but can you talk about the role that their staffers play in the process of developing legislation?

Daniel Dawes:

I love that one. I'm hoping some of your students may be interested in becoming congressional staffers or even agency staffers in the future, perhaps interning or seeking a career in public service. Well, I think a lot of folks have that same mindset that it is the elected official that really wields all the power and is the only one I should be talking to. I'm not wasting my time with these staffers. Oftentimes, the staffers are folks who that elected official highly trusts. You're in an environment where trust is key. They, of course, are surrounding themselves with people who they trust, with people who have, quite frankly, the expertise in particular subject areas. A lot of times you may have an elected official who is passionate about one or two issue areas, but there are a host of other public policy issues that they will confront as members of Congress.

They have to pull in these experts, and they are relying heavily on these folks to what? Craft a bill, or to amend legislation in the committee and to put their stamp of approval on it. They want their fingerprints over that legislation as well, because they want to demonstrate that I have done something on behalf of my constituents. These folks, a lot of times when you see folks going in, they're always surprised how young the staffers are, "Oh, my gosh, what is this?" Then, they dismiss them. That is the worst thing you can do. These staffers are, my God, they're brilliant, they're exceptional. They are working ridiculous hours day and night in order to create positive changes for our country.

I think it is such a rewarding experience to finally see your baby, if you will, this policy that you've been working on come to life eventually, and to negotiate that and to learn how to work with those across the aisle. You have issues working within, whether you're a Republican or Democrat, working within your respective groups, trying to get them to that point of agreement. Then, you will learn how to then work with folks who may oppose or maybe have different opinions on the mechanism or perhaps the approach that needs to be taken. I think it is such an incredible experience for folks, especially here at App State, who may be interested in working in that environment.

I just think it is second to none in terms of experiences, and truly complimentary to what they are being taught here at the university. I think they are a powerful force to be reckoned with, and oftentimes they are dismissed, but they should never, folks should never do that because they are the gatekeepers.

Megan Hayes:

You say in your book that political determinants of health inequities in the United States have rarely been addressed unless their reduction or elimination served other purposes. Can you talk about what this has looked like historically and also what you think it might look like in the future?

Daniel Dawes:

Yeah, absolutely. In the book, I talk about the four different arguments that have been tried and tested in order to advance this agenda. A lot of folks are quite surprised, and I'll tell you, my students are shocked. They come in, they're all gung-ho, and then we talk about the moral argument. There are so many thousands of people dying each year. You have 83,000 racial and ethnic minorities dying each year alone. You have countless people with disabilities dying, people in rural areas of our country without the ability to access health services, again, dying prematurely. You try to raise the moral argument with policymakers and say, "This should be sufficient for you to want to pass this legislation to help them."

That is absolutely not the case, especially at the federal level. In terms of advancing more egalitarian policies, that has never worked. The moral argument alone has been insufficient. You usually have to tie that to an economic or a national security argument. Let me give us an example since you raised that. I'll bring up mental health since that's my number one passion. We know that we are seeing disproportionate rates, higher rates of suicides than we've seen in quite a while. We have seen the toll that depression and anxiety is taking in this country. Yet, what we have found in mental health policy is that usually there has to be a major, a major crisis for our government to invest the resources to address mental illness.

I'm going to go back about 150 years ago, because that was the time when Dorothea Dix, who was a schoolteacher from Massachusetts tried ... She had actually gone to Europe. There was this movement to advance mental health reform on the continent. She comes back to the United States and she says, "We need to do right by people with mental illnesses. These folks, they were being pushed out of their homes." Because sometimes you have a loved one with schizophrenia or bipolar disorder. Family members, they didn't have the wherewithal, they didn't have the ability to take care of that loved one. Their only recourse they felt at the time in the 1800s was to push them out. They were then left to fend for themselves on the street. They were then pulled in, really locked up by the police, by law enforcement.

What was so sad, and what really angers me is the lack of consideration, of thoughtfulness that people paid to those who really are struggling with a mental illness or substance use disorder. At that point, what they would do is they would lock them in these jails. They would strip them naked. They would chain them to the walls. They would beat them, "We're going to beat the devil out of you. We're going to beat this illness." It was a horrible time. If you had a mental illness, it's always a horrible time. Even today, we know mental health is relegated to an inferior status on the hierarchy of chronic disease value, but especially back then, where folks really didn't understand the science behind our brain in terms of brain diseases.

At that point, she was making the moral argument, and she spent 40 years of her life going around the country, trying to make the case for why the government should create a mental health reform bill. She finally convinces Congress after she highlighted these abuses. But then, the President at the time, Franklin Pierce, President Pierce, who really should have been the most sensitive president when it comes to mental health issues having witnessed the tragic death of his son, his only child at the time, his wife and him, they had just had left a funeral for a loved one in New Hampshire. They were heading back home by train. Unfortunately, it was a new invention at the time. The train crashes in a ditch and their son was the only one to die. Poor Mrs. Pierce was, the former first lady, was never the same. She had succumbed to clinical depression and anxiety for the rest of her life. She was a devoutly religious woman and believed that God had inflicted this on them for some past sins. Her husband became an alcoholic, a substance misuser, and is actually deemed one of the least effective presidents in our country. But he didn't recognize how he was suffering and how his wife was suffering. He said, in vetoing that law that had taken decades to get passed, he said, "While it pains me not to be able to sign this into law and provide the resources that these people need, unfortunately, it is not the role of government to provide these necessities for them, and so based on our constitution we cannot do that. It's a violation of the Constitution." He argued.

He essentially made a confederalism argument. Well, that veto message then set the federal policy of inaction in mental health policy for the next almost 100 years. No matter how much the mental health advocates tried to push their mental health reform agenda, they just couldn't succeed. Until we went through a civil war, we went through World War I, and then World War II, when the country is finally on its knees in terms of mental illness. What they found at the time was the generals, the admirals, our surgeon general at the time as well, recognized, wait a second, my gosh, these young people, they're suffering. They're not able to serve in the military. 20% of young people they found were unfit to serve in the military, 40% that ended up in the military actually ended up leaving.

Then, what they also found was that at the time in 1946, 60% of our hospital beds were being occupied by people with mental illness. Now, we have this major national security crisis, because we don't have enough young people to serve in our military. In addition to that, then the business interests were starting to get nervous because now we don't have enough young people who are going into the job market. They recognize, wait a second, huh. There's an economic issue here, and there's a national security issue. It's not just a moral issue. We've got to address this. We've got to expend government resources to rectify this immediately. Finally, oh my goodness, after 150 years of being established as a constitutional republic, our federal government then passes this very peacemeal legislation to establish the National Institute on Mental Health.

To provide some resources to people so that they can have the services and supports that they need in order to get better and stay better. That's how they finally recognize the mental health advocates. That you can't just make the moral argument that, gosh, people with mental illnesses are dying prematurely. In fact, people with serious mental illness die 25 years earlier than the general population. Think about that. But if we give them the services and supports that they need, guess what? They live much longer and they too can contribute to our society and they deserve that.

Megan Hayes:

When you were talking about that, what occurred to me is while the compelling rationale was the national security rationale or the business rationale, it's the story that goes along with the moral argument that really probably helps sell the legislation or the changes.

Daniel Dawes:

That's right. For folks like me, the moral argument is always sufficient. But guess what? There are not a lot of Daniel Daweses in our US Congress, and I mean that on both sides of the aisle. You not only have to be policy savvy, but you have to have some political acumen, and you have to know what levers to push and pull in order to affect those changes. I think when folks realize that, you'll be a much more effective advocate for your community.

Megan Hayes:

Are you hopeful for healthcare equity in the future?

Daniel Dawes:

I absolutely am hopeful, and I'll tell you why. Because I believe that we are in the fourth period of an awakening, a great awakening for health equity in the United States. We've had three prior awakenings. The first, as you read about in the book, happened under President Abraham Lincoln's administration. But we saw how short-lived that was, right? That was the first time in trying to provide healthcare access, in addressing the social determinants of health needs for newly freed black people and poor whites. The second opportunity for us was addressing the overt forms of discrimination in our society, in healthcare in particular.

The third one actually opened up in the mid 1970s where folks said, "My goodness, we've addressed segregated healthcare, but yet we see these striking disparities." There was a movement in this country and an awakening, if you will, about these subtle forms of discrimination, and so there was an attempt to address that. Then, we have now come through a really interesting time where we have, for the first time ever, a federal government that has centered and prioritized health equity to a degree that I never dreamed possible, at least in this lifetime, and has actually prioritized addressing the upstream factors that drive these poor health outcomes for everyone. Whether you're white, black, Asian, Latino, Native American, et cetera. That's what makes me hopeful.

It makes me hopeful that when there have been backlashes after each of the previous three awakenings, the last one for the third awakening was much shorter. They've usually been pretty long. It's getting shorter. I'm hopeful because of what I see with young people, I'm telling you, these college students give me so much hope. They understand what it's going to take to create a healthy, equitable, and inclusive society. They are not apologetic about creating a society that values everyone, and that gives me hope.

Megan Hayes:

Boy, isn't that the truth? You'll be speaking to a lot of young people tonight, but you'll also have their mentors, their parents, family members in the audience as well. What do you want the leaders of tomorrow to take away from your talk tonight? What message do you have for those of us who are supporting young people as they learn to become leaders in their communities?

Daniel Dawes:

I want them to take away this notion that this movement to advance health equity really is not for the faint of heart. It takes courageous leadership. We need folks to understand what Dr. King was pushing when he talked about direct action. If you read his writings, letter from a Birmingham jail, you read his convocation speeches, a lot of them really emphasize the need for direct action. You'll hear me emphasize in my remarks tonight, the two myths that he believed we had to address. The myth of time that we should just let things play out, it'll actually fix itself, just wait, be patient. Then, the other myth is the myth of legislation. Again, the fact that folks say, wouldn't time be better spent on education and religion? Let's just really grasp and convict the hearts and minds of the population.

He kept saying, that's a half truth with that second myth, but we need folks who are focused, who are courageous, who are going to directly act. It is not enough to sit on your laurels and believe that it's going to work itself out, or that the legislation's just going to miraculously be created and push the agenda forward. We need to speak up. We need folks to really advocate. I'm hoping that after this talk people will be excited to participate in our democracy.

Megan Hayes:

Wow. Well, Daniel Dawes, public health expert, professor, dean, author, most recently, of The Political Determinants of Health, it has been my absolute pleasure to speak with you today. It was an incredible conversation. I appreciate your time.

Daniel Dawes:

Thanks.

Megan Hayes:

Thank you for sharing your insights and your perspective with us here, but also with our students tonight.

Daniel Dawes:

My pleasure. Thank you again for having me.