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PW exclusive: A conversation with the first Chief Equity Officer at NC DHHS

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Photo: Screenshot by Lynn Bonner

Victor Armstrong will lead the Cooper administration’s efforts to address racial and ethnic health disparities laid newly bare by the pandemic

The disproportionate impact of the COVID-19 pandemic on people of color has further exposed racial disparities and inequities in health care, which residents with chronic illnesses have confronted for years.

While Black residents are 20% of North Carolina’s population, 26% of patients hospitalized with COVID-19 so far have been Black. Latinos are about 11% of the state population, but so far have represented about 18% of COVID-19 cases.

People of color were more likely to hold jobs that did not allow them to work from home, increasing their chances of being exposed to the coronavirus.

The pandemic has pushed the state Department of Health and Human Services to consider how to increase access to COVID-19 health information and medical care for underserved communities. The agency plans to use some of the strategies it developed responding to the pandemic to close longstanding health gaps that result in people of color dying more frequently from common diseases.

The COVID-19 pandemic repeated patterns seen for other heath conditions. Black residents are more likely to die from heart disease or colorectal cancer [2] than white residents, according to the Healthy North Carolina 2020 report. Black and Native American residents are more likely to have diabetes than white residents. And Black, Latino, and Native American adults younger than 65 are less likely to have health insurance than white adults.

Black babies in North Carolina are more than twice as likely to die before reaching their first birthdays than white infants. Life expectancy for Black men is shorter than it is for Black women, white men, and white women. Life expectancy for Black men is about 70 years, while for white men it’s more than 75 years.

Last month, the state Department of Health and Human Services announced Victor Armstrong’s appointment as its first Chief Equity Officer [3]. His job is to promote health equity, reduce disparities, and guide the agency’s diversity and inclusion efforts. He oversees offices of Health Equity, Rural Health, and Diversity and Inclusion.

Armstrong has been at DHHS for about 18 months as director of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services.

Policy Watch asked Armstrong about his new position and goals for the office. The interview was edited for length.

PW: Where did you work before you came to DHHS? 

Armstrong: The bulk of my career I spent in the behavioral health space. Prior to this I worked at Atrium Health for six years as vice president of behavioral health, where I ran Atrium’s largest behavioral health hospital. And prior to that, spent couple of years with Cone Health, and prior to that I’ve worked for both local managed care entities across the state, a couple of DSS organizations across the state. But the bulk of my career has really been focused on creating resources and connecting resources, and building a stronger system of care for individuals across the state who live with mental health challenges. So, I’ve always kind of worked in that behavioral health space, which really caused me to have a little bit of health equity lens.

PW: You’re a trained social worker, is that right? 

Armstrong: I got my MSW from East Carolina University.

PW: Did you ever work with clients? 

Armstrong: Yes. I started my mental health career working in Eastern North Carolina where I worked for an area mental health program. We covered five very rural counties, Beaufort, Martin, Tyrrell, Washington, and Hyde counties. I started out there as a mental health clinician. And there was a span of time when I was the only therapist in three of those rural counties.

PW: What did you learn from that experience that will influence what you do in your new job? 

Armstrong: It was really an eye-opening experience about what you have to do in some of the more rural communities when you don’t have the resources you’d like to have, and how resourceful people can be in some of the rural communities – but really not having an equitable playing field in terms of access to services, access to resources. It also gave me a really candid look at some of the challenges that people face, seeing it across the gamut of services from working with adults, working with kids.

PW: What are your goals for the position you have now?

Armstrong: This sounds broad because it is. It’s really to embed equity practices in everything that we do in terms of our strategy, in terms of our policies – to really create a framework where every individual across the state of North Carolina has the opportunity to live their healthiest life.

To get to that, there are a lot of things we have to do and have to focus on. Obviously, a lot of our focus right now is in response to the COVID pandemic. We’ve had to pivot pretty quickly to be able to address some of the health disparities in some of our Black and brown communities, in some of our rural communities. We’ve had to build a framework pretty quickly to be able to do that. So part of what we want to do is to be able to mitigate some of the equity challenges in responding to the COVID pandemic. We know that we have pediatric vaccines that are coming up. We have booster shots that are coming up. We have monoclonal antibodies. So some of our immediate work is making sure that we are continuing to weave in an equity framework [4] and we are continuing to have an equity lens where those things are concerned, making sure we are providing access in communities [5] where people live, work, and play.

Beyond that, it is looking at how we take some of the lessons that we’ve learned in responding to this current pandemic and really now start to pivot to a recovery. On this other side of this pandemic, whatever that may look like, how do we make sure that some of the things that we have had to do over the last year and half – some of the things we’ve done out of necessity and the partnerships and collaborative relationships we formed over the last year and a half – how do we make sure now that we really build upon those and create a framework going forward? Part of that involves looking at the data, how do we utilize data to really drive a lot of our strategy and goals around equity?

There’s also an internal focus. About a year or so ago, we started here at the department building Diversity, Equity, and Inclusion Councils to really look at how we are applying those equity practices internally. Some very good groundwork and foundational work was started with that, and part of our challenge in our division of health equity is going to be to look at how we are supporting and helping to lead and coordinate that work internally, because it would be disingenuous of us to only focus externally on how we are improving health equity across the state but not make sure that we are really applying that lens of diversity, equity, inclusion to our folks internally.

PW: What strategies that you used in the pandemic can you see being used to address health disparities in historically marginalized communities? I’ve heard people talk a lot about community health workers and their effectiveness.  

Armstrong: We have been able to utilize community health workers as those “boots on the ground” folks that have been instrumental in helping us address a lot of the issues around COVID and really helping to connect people with some of the things that impact social determinants of health. So we do see that community health worker initiative as being a big part of our work going forward. The other piece that I think really coincides with that is we have our Healthier Together [6] initiative where we partnered with an organization called NC Counts to work in the communities on the ground, with community-based organizations [7] to recruit and to hire people locally to help us go into those communities.

PW: How do you think about the limitations of your office? DHHS doesn’t train doctors or send them to rural areas, doesn’t build housing, or locate grocery stores. Health equity is about more than being able to see a doctor.  

Armstrong: I think that we have a few ways to influence change. I do think as a department we have a certain amount of muscle, and by muscle what I mean is that there are a lot of dollars that pass through the department. And what we have not traditionally done as good a job as we’d like to is to look at how we are equitably distributing those dollars and how do we tie outcomes to those dollars that lean into equity.

I think the second thing that we can do from our position and our perspective is we can convene. We have begun to reach out to different entities across the state. While we don’t directly hire those physicians and the psychiatrists and the psychologists, there are things that we can do to bring folks together to say, “how can we all work together on this to really work toward more equitable outcomes?”

We provide so many services across the department that influence how people get access to housing, how people get access to healthy foods, how people access healthcare. We can collaborate with folks at a community level. We can collaborate with change agents across the state – organizations, funders – we can work with charitable organizations to make sure that we’re all on the same page in terms of driving equitable outcomes.

PW: At the end of your tenure, what do you want to have accomplished? How will the health of communities be different?  

Armstrong: One of the things that we are going to lean into very heavily is infant mortality. When we look at the disparities in infant mortality among women of color and white women, I think it’s very telling. That tells us a lot about prenatal care and that tells us a lot about how we are bringing Black and brown children into the world.

There’s so much data that tells us that there are so many other things around social determinants of health that impact infant mortality. So if we can move the needle on infant mortality, that will be one thing on one end of the spectrum.

And again, I’m speaking very broadly here, we are looking at life expectancy. If you just take Black men for example, Black men have the lowest live expectancy in terms of race and ethnicity, gender – just across the board. So if we can influence the things that impact life expectancy, which include things like heart disease, diabetes, high blood pressure, drug and alcohol use. There’s data that shows that for folks who live with serious mental illness, that their life expectancy is 15, 20 years less than people who don’t have severe mental illness.

If we can begin to impact and influence those kinds of things, that’s where I would love to see the needle move.

The other thing I think that’s going to be really important for us is to change the conversation, to change the narrative. We do tend to talk about equity in terms of just race and ethnicity. And part of what I hope we’re able to do is really broaden that conversation because when we talk about health equity, it’s not just Black and brown communities that are being impacted. Our rural communities are being impacted. Our seniors are being impacted. Part of what I want us to be able to do is to change the narrative and to really help to educate our state that health equity impacts all of us. It’s about all of us regardless of race, gender, ethnicity, zip code, age.  It’s a hope that we can change that conversation to where we all embrace the need for health equity across the state and realize that, at the end of the day, it benefits us as a state.

And finally, I think what I would love to see at the end of my tenure is that when people talk about DHHS, that we don’t just talk about best places to work in terms of private entities and private industries and private organizations, but that we see DHHS as a best place to work, in part because of our efforts around diversity, equity, and inclusion in the value of all of our teammates. I think if I can have those three things accomplished in my tenure in this role, I’ll be satisfied.