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Episode 55
Duration 33:11

Dr. Marcella Nunez-Smith: The Systemic Roots of Inequities in Health

Harlan reports on three negative—but striking—trials presented at the American Heart Association’s annual meeting; Howie reflects on the victories for health in Tuesday’s election. And they’re joined by Dr. Marcella Nunez-Smith, a Yale internist and nationally known expert on healthcare equity, to discuss her service in the Biden administration and the need for a broad approach to tackling racism in healthcare and systemic inequities in health.


“Another Fibrate Fails to Show Cardiovascular Benefit”

“DCP: HCTZ vs. Chlorthalidone in Improving CV Outcomes in Elderly Veterans With HTN”

“TRANSFORM-HF: Loop Diuretics Show No Difference in Mortality and Hospitalizations for Heart Failure”

“Nunez-Smith to lead Biden health equity task force”

Pozen-Commonwealth Fund Fellowship in Health Equity Leadership at Yale University

“Voters will have a say on abortion in 5 states with high-stakes ballot measures”

“South Dakota votes to expand Medicaid”

Employer-Reported Workplace Injuries and Illnesses—2021

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.


Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Marcella Nunez-Smith. But first, what’s got your recent attention, Harlan?

Harlan Krumholz: Yeah. Thanks, Howie. I just came back from the American Heart Association meetings in Chicago, and it was the first time that they had held the meetings in a couple years, and it was nice to be back in person with folks and get a chance to meet. It was striking how different the meeting feels than it did before. I mean, there was an energy about it because people hadn’t seen each other, but really, the size of the meeting was much smaller, maybe a third of what it was normally. And maybe that’s in part because there are fewer international visitors. But I also think that the people had gotten into this new normal where everyone’s not just seeing these as compulsory events to attend and people being more selective about the meetings that they’re going to. The exhibit hall, which is the place where companies show their wares and people walk around, in the early days of my career would be football fields of just yards and yards and yards of these booths, and now it’s really just a handful.

And so that’s a very different feel, it’s a more intimate meeting, which in some ways was good, but it did show me that there’s this pivot point. I wanted to mention that there were three clinical trials that were presented that might interest people. We’re often excited about trials that have positive results, and we tout them, and we’re excited about how they’re going to change practice. But there were three important trials that were presented that were negative. In one of them, they were testing one of a class of drugs called fibrates. And for a long time, people thought fibrates, starting back with clofibrate in the 1960s, would be a very effective way to treat elevated lipids. And we relied almost exclusively on the idea of, if your blood test looked better, if your cholesterol went down on your blood test, then certainly that must be good for you because we believe cholesterol was bad for the heart and the vascular system.

But these series of studies starting, way back, have consistently showed that this drug, even though it makes your lab test look good, actually failed to improve your health outcomes and has reinforced the importance of studies that actually go all the way to say, “What happens to people?” We can’t just accept what people call “surrogate endpoints,” these proxies, the idea that a lab test can tell you what’s going to happen to people’s health. There’ve been a string of studies that have failed to show that these are better than placebo. And this one in particular, I think they thought they had a newfangled approach with the same class. Interestingly, in the other drugs, they did actually lower the LDL [low-density lipoprotein] cholesterol a little bit, what they really did was raise HDL [high-density lipoprotein] and lower triglycerides. So anyway, they made your lab test look better. This one actually didn’t have that effect on the overall cholesterol, but the bottom line was the same. No evidence of benefit.

You need to know, billions of dollars have been spent on these medications over the years. They were touted widely. They used to be advertised in every medical journal. And it’s just wild to see the ride, and reinforces the importance of this idea of evidence. I’ll just quickly say two other studies that were very interesting. One was of two common antihypertensive drugs, blood pressure medications, diuretics. So there are many kinds of diuretics that are used for blood pressure in this country. Hydrochlorothiazide—that’s not hydroxychloroquine, by the way, so people hear that, for COVID—hydrochlorothiazide is a very commonly used drug that will lower blood pressure. And so it’s chlorthalidone, it’s a different kind of medication, but same class and lowers it. And for a long time, people have wondered, “Is there any difference?” I mean, if you use different medications within the same class, that means that there are largely similar molecules, similar compounds, but there are some differences that people tout, companies tend to tout these differences.

And finally, after decades and decades of use of these medications, we did a trial head-to-head to see whether or not one was better than the other. Da, da, da, no difference between the two. So that’s good news. I mean, people have often wondered whether they’re being disadvantaged to be in one versus the other. So these common, cheap medications for blood pressure in that class of diuretics were about the same. And then quickly, another diuretic study, but this time in patients with heart failure. There are two common types of more powerful diuretics that are used to help people to release some of the fluid in their system to get into better fluid balance when they’ve got a condition called heart failure, where the heart’s not able to pump properly. And so then, there’s often fluid accumulation. And there has been a question about whether or not it makes a difference, which one of these more powerful water pills is better than another.

And a series of studies suggesting one might be better than another, one might not. And this study done in the VA pretty quickly, including with the Yale investigators—Eric Velasquez was involved—showed no difference, no difference again in this. And I think these are very important studies because we’ve been wondering, can you assume when one drug is approved that others within that class, similar drugs might have slight differences, can be considered to have the same effect? We probably should continue to do head-to-head studies, but these, I think, were reassuring studies that for, in the case of the diuretic use for blood pressure and then these high-powered diuretics or water pills for heart failure, that the alternatives within the class were more or less the same. It means you don’t have to worry about pricing. It’s just like, in this case you could use one or the other. So this is always a set of three trials that didn’t find differences between the two groups, and I think it gave us really important information and is going to be used to help direct practice in the future.

Howard Forman: I just really appreciate that you’ve brought up the issue of surrogate endpoints because ironically, this keeps coming up in my class, my undergraduate class, to understand this concept, you just forced me to think more about it as well. And I hope that we can spend maybe a large chunk of a segment in the future talking more about it for our listeners, because there’s so much about medicine that is predicated on our seeming understanding of how disease occurs and what will naturally follow. And we don’t always test for that. We very often are just testing about whether blood pressure can go down or glucose control can be better or whether rhythm control can be better. And sometimes those are not the appropriate endpoints to look at, because length of life and quality of life are ultimately what we’re aiming for. So I appreciate you bringing that up.

Harlan Krumholz: All right. Let’s get on to Marcella.

Howard Forman: Dr. Marcella Nunez-Smith is the associate dean for health equity research and the C.N.H. Long Professor of Internal Medicine of Epidemiology and of Public Health at Yale as well as a professor in the School of Management. Dr. Nunez-Smith’s research focuses on healthcare equity for structurally marginalized populations, and with funding from the National Institutes of Health, she established the Eastern Caribbean Health Outcomes Research Network, or ECHORN, a research collaborative across four Eastern Caribbean islands. She founded the Equity Research and Innovation Center, ERIC at Yale, which investigates topics such as population migration, cardiovascular disease, and pediatric obesity through a health equity lens. Dr. Nunez-Smith was co-chair of the COVID-19 Advisory Board and chair of the COVID-19 Health Equity Task Force under the Biden-Harris administration. She earned her bachelor’s degree at Swarthmore and her medical degree at Jefferson Medical College. She completed her residency at the Brigham & Women’s Hospital at Harvard and her fellowship at Yale’s Robert Wood Johnson Clinical Scholars Program, where she also received a master’s in health sciences.

Harlan Krumholz: Hey, Howie, do you know one of my favorite people in the world is? Howie, do you know? Our guest today, Marcella Nunez-Smith. That’s one of my favorite. I didn’t notice that you meant—

Howard Forman: No. I was going to say it. So we all have known you for quite some time, but the activities the last couple of years have just been so incredible in terms of your involvement at the local, state, and federal level in policy setting and advancing the agenda for health equity and helping to highlight the gaping holes in our healthcare apparatus and our ability to deliver healthcare equitably to all. And so I just want to acknowledge that first, but I also want to just ask you, “What has this rollercoaster been like for you?” Because you basically got involved before Biden was elected, and you’ve seen this through to the crisis period of the pandemic. Tell us what it was like working within the administration and what you accomplished and what you hope that they can continue to accomplish after your term ended.

Marcella Nunez-Smith: Oh, my gosh. May I just start by saying how excited I am to be here and to be in conversation with both of you? This is a lovefest and it’ll come full circle, but...

Howard Forman: Which one do you like more?

Marcella Nunez-Smith: Stay tuned until the end to find out. And what wasn’t part of the intro is that I’m so grateful to both of you. When I came here as a fellow to Yale in the Robert Wood Johnson Foundation Clinical Scholars Program, it was a gift in so many ways and in this conversation, each of you a gift both in terms of the content and the knowledge, but even more important, just the support. Yeah. So, Howie, asked a big question. And so let me say, and I think that’s a really appropriate description, I mean in terms of a rollercoaster. It’s just been an incredibly busy time, I mean not just for me certainly, but for the entire team at all the levels working in the state with the governor on the Reopen Connecticut work. I certainly really want to lift up everybody with part of that and how notable it was that the governor said, “We’re going to have a committee that’s focused on those who are most vulnerable and at risk for COVID-19.”

And that was unusual. That was the beginning of the pandemic, and being able to recognize and observe what many of us expected but then saw come into fruition in the disparities and put that focus on it. I think it’s to the governor’s credit there. And then having the chance to work nationally on this hopefully what will be a once-in-a-lifetime public health crisis. It’s also welcome to have a chance now to sit and reflect on that, because really I think I come out of this with just a new respect, a deeper respect for public servants, to be honest. Because the folks who are working literally around the clock, I mean career and political members of the incoming administration and of the administration just tirelessly and often thanklessly. So I always try to make as a priority to recognize the many people who very much centered on equity.

So this isn’t, by any means, not me alone. And I think importantly, in many of those conversations, I wasn’t the first person to raise equity. And I think that was such a driving principle. It was a directive from the president-elect and the vice president-elect. And of course, once they were in the administration, they held us all accountable for making sure equity was at the center of the pandemic. So working in the task force and sharing that, an extraordinary group of members, a great federal staff supporting us, really tremendous the work I think we accomplished there, but also working as a senior advisor, that daily cadence in the White House. And I think the work we accomplished we’re very proud of there too. I mean, there’s much work to be done, but I think it’s really important to note that as a country, really for the first time ever, we closed the racial gaps in vaccination when it came to COVID-19 for adults. And that was a lot of heavy lifting from a lot of people, but really much credit goes to the leadership of the administration.

Harlan Krumholz: It made me feel so good and I became so confident when you got into that position because I knew that there was someone with deep knowledge and a deep commitment to the community who was in the inner circle in helping to guide that. I wanted to probe one thing with you. I’ve been thinking deeply about this issue about disparities in health equity, of course, for a long time, but I’ve been reflecting back on the fact that a recent series of articles we’ve done has shown, I won’t even say little progress, almost no progress nationally, locally, New Haven County, nationally. So at a time when trillions more at the margin are flowing into healthcare, I’m just saying, on top of the real dollar increase with inflation where at the margin, increasing the percentage of the GDP all the time, and yet we’re not really making any progress on overall health of the population. But the distance between Black Americans and White Americans, for example.

And we did make a little bit of progress on life expectancy in the beginning of the last 20 years, but then it flattened, and now we’re back to where we were in ’99 without progress. One of the things that people are raising, and I was part of a panel this weekend at the American Heart Association where I introduced some of these ways of thinking is as long as we’ve got the marked income inequality in this country, it’s going to be hard to make progress because wealth and income are such an important part of health.

Now, I want to say clearly that doesn’t explain all the disparity, but the income disparity is so marked, the concentration of wealth among White Americans compared to Black Americans, for example, is just so disparate and getting worse. Where is your thinking on this issue of economic equities, needs to be part of our discussions of vocabulary around this issue, and also about, let’s say, the issues of reparations in this country. How can this country begin to invest in big ways in communities to address some of the things that went on? I mean, what are your thoughts about this?

Marcella Nunez-Smith: Yeah. No, I’m really grateful for that framing, Harlan, because when I get asked the magic wand question, what do we need to do to solve for health disparities in this country? My answer is economics, and it’s not healthcare. And so if I had one thing, it would be that. And I think where the investments are, I always say it’s about creating economic opportunity, right? Often through educational pathways, not exclusively, but that if we are really committed to the idea of health equity. I mean the point you raise is exactly right. We’ve known this for a long time. If you think about what contributes to the variance as we talk about these differences that we see, I’m with you a hundred percent, we should not excuse the 10% to 20%. Maybe that is due to variations in healthcare and healthcare equality and access.

But if you’re thinking about this as a pie, the majority of that pie has to do with economic issues and economic challenges. So it is the right question to say if we are going to make an investment in health and health outcomes, what are we doing about that wealth differential? And I want to make sure that people notice that difference. Certainly income is important, and that’s one factor, but that concentration of wealth, and it often falls along the lines of zip code and neighborhood. And so it really has been intentional structural disinvestment in particular communities, communities of color in particular in our country that get us to where we are today. And so the interventions have to be intentional and have to address that root cause. So I would say even beyond incremental, some of the things I was very excited to see as an administration, we were investing in, for example, around workforce development.

So if you think about ways, community-based workforce in particular, I’ll lift up as one example. If you think about interventions that address all of the issues, I think we’re going to be more successful. And so if you invest in a community-based workforce, not only are we (a.) looking to the community’s most effective for the solutions, right? To know where the needs are, to identify them. And not only are we increasing access, hopefully from some trusted and trustworthy neighbors and community members, but we’re also, if we do it right, creating economic opportunity for people in neighborhoods and communities through these positions. So we have to do bigger and we have to do more and we have to be very deliberate. But I think if we focus on interventions that really are too narrow and don’t recognize that important fundamental fact that this is a matter of economics, then we’re not going to see the change that we need.

So I think that question around reparations and investment, and what do we need to do to get a healthier society. I mean, we are losing life expectancy. This is one of those top lines that really should just stop everyone in their tracks, and no one’s health is better for this. And this is fundamentally important. I think there are many, many reasons to push on a health equity agenda and to anchor that in a social justice frame. But I think it’s too often people miss that this is for the betterment of us all, not for one segment. We are all losing health, and we’re all losing life at this point.

Howard Forman: I want to pivot. First of all, I just want to acknowledge the fact that what you said is you connect the dots: the absolute block of endowment to a huge chunk of society for 150 years and then continued redlining and other things that limited them from having wealth has gotten us to this point. So I think people have to acknowledge that we actually can connect those dots for a long time. To see how we get to this, how we solve it, I think, is more challenging, and it’s great to hear that we have strategies to do that.

I wanted to pivot though to one of the things you’re working on that I think aligns with that mission and that is developing leaders in this field, the generativity part of the work that you do. You’ve been so effective in working with young faculty, with medical students, with undergraduates, and so on. And specifically on this podcast, I think it’s worth mentioning that you are the founding director of the Pozen Health Equity Fellowship. And I just want to hear your thoughts on how do we develop people and leaders in this field to carry on the work when Harlan and I are long gone and where you’re hopefully taking care of our grandchildren.

Marcella Nunez-Smith: What great imagery, right? Yeah.

Harlan Krumholz: Thanks, Howie.

Marcella Nunez-Smith: You each are a role model, this is a wealth just for me personally, but this is the most important work I find that I do. And I’m really excited, quite frankly, by all the norming of this content in so many spaces. I mean, there’s more and definitely like Pollyanna about this, but when we think about at least health professions training, this deep recognition to understand these policy societal drivers, how that affects the health of our individual patients, but of our communities and others, I mean this is now a curricular mandate, particularly from the learners themselves, to say, “We have this understanding, and we want to be taught through this lens and through this frame and thinking about equity at the center.” So I’m really excited about that. And then it’s just a privilege to work with advanced learners, with you, Howie, through the fellowship; Harlan, obviously through the Clinical Scholars program for years.

This is how you both trained me, and I’ve been very fortunate to be in training environments that begin with that health equity lens and go from there. And so it is the most important work I think we can do. I’m all about getting this down to the youngest of children to have these conversations, whether it’s through a data literacy understanding or window. But really I feel like everyone should have a working toolkit and knowledge about these issues. And then for those who are going to be deeper leaders and transformative change agents to have these opportunities through, for example, the Pozen Commonwealth Fund Fellowship, it’s tremendous and I’m excited to hopefully see others come into the space and create these professional development opportunities for people. But there are a lot of things that keep me up at night. But one of the things that helps me sleep better at night is knowing this next generation, I mean they really are standing prepared for the baton passing. And I find that inspirational.

Harlan Krumholz: But I wanted to just think locally for a second. All three of us are of this area, of the New Haven County. And as I’ve said, we’ve made such little progress. And I look at places like Kansas City, for example, where they seem to be making a really concerted effort to both acknowledge what’s going on in the past. Like New Haven, there was a highway that was built that separated the city and essentially segregated the city more. I mean, created a physical barrier, like that happened in New Haven with the [Route] 34 connector. And they’ve got a long history of issues within the city like we do. And yet they’re voicing them. They’re talking about the redlining, they’re talking about the way that certain communities were disadvantaged. They’re talking about the mortality differences that exist within their community and persist, and they’re trying to determine strategies to fix that.

I really wonder if it’s a moment in New Haven where we ought to be all holding hands. We ought to be taking some of the resources available in the university and others around the country and actually, out loud, making a commitment to say, “Within 10 years we want to close this mortality gap that exists within our community, that if anything has stayed static over time and disadvantages one population compared to another.” So given your work on the national level, your influence and contributions on a local level, how can we do that? What can we do to get that kind of attention? Get City Hall, the hospital health system, and Yale University to say out loud, “This is unacceptable. We will not allow it to continue and we’ve got a plan. We’re going to put together a plan that within a decade we will make substantial inroads.” Can we do that?

Marcella Nunez-Smith: Yes, we can. I’m going to end on that note of optimism because, yes, I know it is a moment, but we have to seize it, and I think we can. I think we can meet this moment. I think we can meet it here in New Haven. Really. And I give credit, you’re right, everything you say about, for example, redlining, Dr. Nancy Krieger, Dr. David Williams, many people have showed us you could overlay the maps for COVID-19 and the disproportionate burden right over redline. But you could do that for so many things. So we understand, for example, the power of housing and how housing segregation, but I also agree with you that we know what to do. Dr. Camara Jones years ago made that call to action for us to name racism as a public health issue on crisis. So many have done that. You know, us now included.

And when you do that, naming it is critical, but it is that next step. And so I know their conversations underway right here in New Haven to do this, but I really want people to hear what you’re saying, which is if we don’t have metrics—and this is something that came out clearly in our task force work too—that we don’t have accountability. And so we have to be able to say we are together working on the same North Star to be able to turn that conversation into meaningful action. But I do feel like we’re on the cusp. I do. I do feel very optimistic that we can in New Haven and that there is momentum. And let’s be really clear. I mean we name a lot of the large institutions here where power and resources are centered, but we should never underestimate the power of communities to really pull those levers and push for that change.

And that’s quite frankly where my hope and inspiration derives, because I get to be and bear witness and be in conversation and learning with graduate organizers and community organization leaders. And the status quo is not acceptable anymore. And I think that’s where we’re going to see that push and that pressure to really make these large institutions pivot in a way they haven’t before towards their shared goal. But without accountability, there’s nothing. So we need those metrics. We need those data. And that I think is a continuous push for us. But that’s the right vision is, we have to go big and others have done it and we can do it here too.

Harlan Krumholz: Well, what a treat to have you here today. Thank you so much for joining us, and yeah, let’s offline, let’s work together toward that vision and figure out what we need to do. I agree with you. Community is the ultimate one who can pull the lever, but we also have to bring—

Marcella Nunez-Smith: Absolutely.

Harlan Krumholz: ... to have vast resources within the community to the table and an interest in alignment. It’s in their interest too. But thank you. Thank you so much for joining us.

Marcella Nunez-Smith: Be well, everybody.

Harlan Krumholz: So that was great with Marcella, Howie. What’s on your mind this week?

Howard Forman: Yes. I’ve got a lot, but I’m not going to get through all of it today. So I’m just going to talk about two major topics. The first is the election. So we’re taping this on Wednesday, and hopefully our listeners will get this Thursday or a few days later. But the election was not just about democracy or the Republicans or the Democrats, it was also about healthcare. Healthcare was on the ballot, and California, Vermont, and Michigan codified constitutionally a right to abortion for those states. And Montana and Kentucky opposed measures that would’ve restricted abortion access constitutionally. So five states moved in the direction of greater abortion access or not limiting abortion access. There were no successful measures as far as I could tell to limit abortion access. So that’s a step in what I think is the right direction in terms of women’s agency and ability to decide for themselves to carry a pregnancy. So that was one big political election outcome.

And the other was South Dakota, which by a more than a 12% margin voted to expand Medicaid as Obamacare has allowed for the last more than a decade. So this is going to allow 45,000 poor South Dakotans to have access to Medicaid when they were previously uninsured. This is a major step in the right direction, and I will point out: South Dakota, their governor, their legislature has basically not wanted to expand Medicaid, but the popular vote, the people of South Dakota want a Medicaid expansion. And so South Dakota will now get a Medicaid expansion. So those are the election things I wanted to mention. I want to very briefly mention a survey that came out this morning from the Bureau of Labor Statistics that I think you’ll find interesting. And that’s this annual survey on injury and illness. And it demonstrates, not surprisingly, that respiratory illnesses are dramatically increased for 2020 and 2021 compared with 2019. So we don’t have data for 2022 yet, but for 2021 still up considerably from 2019. No big surprise.

But the magnitude of the effect is really notable to me. So the number of individuals, the number of days missing from work, effectively, among nursing home workers has more than doubled among nursing home and nearly doubled for hospital workers. And these are often the lowest-wage workers and oftentimes people of color. This is a meaningful drain on our workforce, and it’s also an under-discussed cause and burnout and strain on our labor force. And a lot of this probably ties back. We have less granular detail on this to the topic that you have spent considerable time investigating and studying, and that is long COVID. And what can we do about that, and how do we minimize that so that people are not prevented from doing their work?

Harlan Krumholz: Those are all really great topics. I’ll just say one other thing about the election. First of all, as you know, it defines certain expectations, and it just always shows that people, you have to see the election to really understand what’s going to happen. But also they’re very interesting in terms of increased diversity among people who are elected. The first Gen Z member of Congress, the first openly lesbian governor who’s in Massachusetts, the first female governor of Arkansas, first Black governor of Maryland, first Native American Center from Oklahoma in a century.

Anyway, these people may be on different sides of the aisle sometimes, of different pieces, but it’s nice to see that also we’re seeing greater diversity in people who are being elected. And I thought that was also a nice thing that’s nonpartisan, but of note as well. So lots more to unpack in today’s…and as you know, the election still is persisting. And one thing I could never figure out is really, we can’t count votes any faster than this? I mean, it just is in the 21st century, it’s insane that it may take a week or two in California to figure this out.

Howard Forman: Yeah. I, look, but as our listeners probably know, a lot of this is self-imposed. It’s not that we can’t. It’s that we legislatively tell us that we’re not allowed to start counting until after a certain time, even if we’ve had these ballots waiting. So it’s a little frustrating. I share your frustration with this.

Harlan Krumholz: No, it just feels so retro.

Howard Forman: Yep.

Harlan Krumholz: Yeah. You’ve been listening to Health & Veritas, with Harlan Krumholz and Howie Forman.

Howard Forman: So, how did we do? To give us your feedback or to keep the conversation going. You can find this on Twitter.

Harlan Krumholz: I’m @hmkyale. That’s hmkyale.

Howard Forman: And I’m @thehowie. That’s @T-H-E-H-O-W-I-E. You can also email us at Aside from Twitter and our podcast, I am fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs where you can check out our website at

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer, they are simply amazing. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan, talk to you soon.