Intro: Welcome to Pediatric Voices, Duke Children's podcast about kids' healthcare. Now, here's our host, Dr. Richard Chung.

Dr. Richard Chung (Host): Hello and welcome to Pediatric Voices, expert insights about timely topics in children's health, brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center. My name is Dr. Richard Chung, a physician at Duke Children's and a co-host of this show.

Host: Today, we'll be exploring the topic of health equity. Inequities in health related experiences, care and outcomes have long been an immense challenge. This is a particularly timely topic because the COVID-19 pandemic has only widened the gaps between the health and wellbeing of different children and youth in our communities. In addition, society generally and healthcare systems specifically have been increasingly focused on systemic issues that affect health.

To help us understand this topic better, I'll be speaking with Dr. Gabriela Maradiaga Panayotti, a physician and faculty member here at Duke Children's. Full disclosure, Gabby and I are colleagues and friends, so I'm particularly excited to share this conversation with you all. As you'll soon find out, she is an exceptional person and professional. And if there were a Dr. Maradiaga Panayotti Fan Club, I would probably be president or at in the executive committee.

A bit more about Gabby. So, Dr. Maradiaga Panayotti is an associate professor and clinician advocate in the division of general pediatrics and adolescent health here at Duke. She's originally from Honduras and grew up in Central America and the Caribbean. She received her undergraduate degree from Yale, worked as a public school teacher in Brooklyn, and then received her medical degree from Georgetown University. She trained in pediatrics at the University of California San Francisco. While at Duke, she has served in many different capacities, including as medical director for both the Duke and Duke Regional newborn nurseries, Medical Director of the Pediatric Healthy Lifestyles Clinic, and physician lead for the Breastfeeding Task Force.

Over the last few years, Dr. Maradiaga Panayotti has immersed herself in advocacy work for children and immigrant families. She has worked both locally and nationally with elected officials to influence critical policy. In March of 2020, she co-founded LATIN-19, the Latinx Advocacy Team and Interdisciplinary Network for COVID-19, which was one of the recipients of Duke's prestigious presidential awards. Among other successes, LATIN-19 has made tremendous strides in both decreasing rates of COVID-19 and increasing rates of vaccination in the local Latinx community.

Gabby, welcome and thank you for being here.

Dr. Gabriela Maradiaga Panayotti: Gracias, Ricardo. Thank you very much. It's a pleasure to be here.

Host: Awesome, awesome. Gabby, I mentioned a little bit about who you are and the work that you do, but share some more. Tell us about your current work. What do you do day-to-day?

Dr. Gabriela Maradiaga Panayotti: Well, my everyday pediatrician life is I think a little bit of what we imagine in the old magazines. Children come in for their routine checkups. We check on things like asthma, school, development and growth, and now increasingly mental health. And outside of the clinic walls, I also do advocacy work to improve the healthcare of Latino children and families. For example, right now, I'm collaborating with other doctors and community partners to improve access to culturally humble mental healthcare services, which I mentioned is of great need right now. And I'm also working with our health system to make it a more welcoming place for these families.

Host: Great. So, it sounds like day-to-day you're both in clinic, as you said, as people imagine a pediatrician would be, but you're also in the community, addressing factors that lead to different health outcomes as we'll get to. How did you get interested and involved in children's health in the first place?

Dr. Gabriela Maradiaga Panayotti: It's funny because I am the oldest grandchild of a very large Hispanic family with lots of cousins. So, being around kids always felt natural and fun. And during medical school, I enjoyed many things, but I always gravitated towards kids. They were always the most fun and most authentic. So in the end, this seemed like the best fit for me, and that has turned out to be correct.

Host: They are really fun, aren't they? And the authenticity is a great point. They kind of are who they are and they don't have any pretense about that. That's one of the privileges of pediatrics I would say.

Dr. Gabriela Maradiaga Panayotti: Yeah. And I think a lot of people shudder at the thought of taking care of children, but I always say, "You know where you stand." You know, if the kids don't like you, they'll let you know. And that's great. That's who they are. With adults, sometimes you have to figure out how much they're telling you the truth or what their ulterior motives are. But kids, they're refreshingly honest.

Host: Sometimes painfully so, right? That's right. I mentioned a little bit about your personal background, your family background, but say some more. I know you've shared this with me personally before, but I would love for the audience to hear this, just a very interesting background.

Dr. Gabriela Maradiaga Panayotti: Yeah. I always say I have this really fun family history because I grew up in Honduras, in Central America. And because of my father's work, we moved around Central America and the Caribbean, and my extended family has come from all over. During the great migrations of the early 1900s, I have great grandparents that came from Italy, from Palestine, from Spain and other countries. And so, in my world growing up, it felt very normal and I would be having things like tabule and couscous and tortillas and spaghetti. And I just thought everybody else grew up that way and didn't realize how fortunate I was to have this rich background. And it a wonderful story because from a very young age, I understood how wonderfully enriching differences can be and how additive they are, and I think that unconsciously has helped me in my work now.

Host: That's really interesting. It sounds like it was such a privilege really to have such different backgrounds and perspectives as a part of your sort of fabric of the family you were within. And I imagine some people might think of that as being difficult or complicated or whatever else, but for you it was really something that was a privilege or something you really enjoyed.

Dr. Gabriela Maradiaga Panayotti: Yeah. And even growing up throughout Latin America, which is an incredibly heterogeneous place, the work I do now, I take care of families from all over, from the Caribbean, from Central America and South America, and growing up in many of those different places helped me really understand some nuances, which don't necessarily change the actual medical advice, but help you connect with families. So, a different accent or perhaps there's a big rivalry of how tortillas are made differently in every country and who can identify the country by the thickness or width of the tortilla. And so, all those differences really helped me appreciate how diverse Latin American people are. Even within just a few miles of each other, a lot of richness there as well.

Host: Really interesting. Gabby, we're not going to be too controversial on this podcast, so not going to be talking about the tortillas today, but maybe offline we can discuss. Can you say a little bit more about your childhood and how that sort of framed up your understanding of child health equity?

Dr. Gabriela Maradiaga Panayotti: I didn't realize it at that time, but inevitably it did. Because growing up in Honduras and these several other countries, I was able to see tremendous levels of inequity and inequality and wealth primarily, but all the consequences that come from that education and employment and political rights. And so, I distinctly remember growing up seeing children in squalor on the streets, begging for money, mostly naked or impoverished. And at that time, I knew it didn't feel right and I knew there was some injustice there, but I really couldn't name it. And now as an adult and a pediatrician, I understand more about factors that are both small and large that perpetuate many of the conditions our families face that make it really hard to escape poverty. And so, I think the little grain of sand was planted in what I saw growing up and has now manifested in a lot of the work I do.

Host: Very interesting. Let's dive into that topic of health equity a bit more. Let's start actually with the terminology. I'm a big believer, as I know you are, that words matter, right? The words that we use to describe this or that, that's the foundation upon which we can communicate and understand and then actually maybe do something about it. And so, I've always gotten a little bit confused to be honest with terms like equality, equity and justice, and those may be others as well that you might add in, but can you walk us through some of the basic terminology of this domain?

Dr. Gabriela Maradiaga Panayotti: Yeah, and I agree with you. I think it really helps us do a better job if we understand some of the differences. And again, this is something I've begun to think about in the last 10 years really, trying to pull the thread on what they mean and why they matter. And I think a lot about a comparison my mother made on a totally different topic, but she was describing how her different children needed different kinds of support from her at different times. Some really needed the hands-on childcare support like me in those early baby days. Some people needed more moral support through a tough time. Some needed financial support. They all needed her in different ways. We all did. And sometimes we needed more than one type of support. And I see these definitions similarly.

So, equity is about supporting folks to succeed in the different ways that they might need help. It doesn't mean giving everybody the same thing, but it means giving different people what they need. And it doesn't necessarily mean you divide resources fairly. You don't give everybody the same number of apples, but you give people what they need in the moment. Equality means giving everybody the exact same thing. And then, the concept of justice is about removing barriers in the first place, so it creates long-term equity.

And I love the cartoon that often is shared, is different kids looking at a baseball game over a fence. And so, maybe you have a 15-year-old and four-year-old and they all need a different level step stool so they can all see over the fence. So if you give everybody equality, you give them the same height step stool, but then that doesn't help the little kid because they still can't see over the fence. But if you have equity, you give everybody a different step stool that's different in height, and then they can all see over the fence. And then, justice would be about removing the fence altogether, so everybody who wants to can just enjoy the baseball game from afar.

Host: Gotcha. That's very helpful, I think the differences. Each of these terms are really important to consider and are a part of the lexicon or the words that we should use to talk about these issues. But they are different and they help us understand things at different levels. So, thank you explaining that. And I can very clearly see how they applied to healthcare and health factors that are outside of the clinic setting, which we'll get to in just a second.

In this area of health equity, what is the most common misconception or misunderstanding that you hear from people who are involved in this conversation?

Dr. Gabriela Maradiaga Panayotti: The biggest challenge that I hear from people is a sense of discomfort, that by providing a resource to one group that is different than a resource you provide to a different group, it's somehow taking something away from that other group or from you. The idea this is a Zero-Sum game and you just have a finite number of resources so that if you give some to one, you're not giving to the other. And the way it manifests is as a sense of unfairness that can make people understandably feel upset and resentful and angry, rather than thinking that this is a rising tide that lifts all boats and how it could be a win-win for everyone, and that is the most common misconception or challenge that I find in this space.

Host: Very interesting. So, the idea that as we support a child or a family in a particular way, it's not taking away from somebody else, right? That we are all bound to each other at some level, as a part of the same community. And so, for an individual child to do well, we should all celebrate that, right? That is a win for all of us at some level and not sort of taking away. It's interesting because I talk with our kids all the time about the scarcity mindset. And I think even as adults, I think we often operate with that, right? The first instinct is, "Okay, how does that affect me? And why not me?"

Dr. Gabriela Maradiaga Panayotti: And that's natural. I think we are just such an interconnected specie. So, you can imagine your kid goes to the same school as many other kids and maybe the child of someone who doesn't have the same access to healthcare may be sick. And guess what? They're sitting next to your kid in class. So now, your kid is sick and now you're sick and you're missing work and all this. And so even in a selfish way, we have to remember we are interconnected. And the healthier we can make these children and families so that they can thrive, I see it only as a win for everyone. There's no loss there.

Host: Yeah. And even further, if my son's classmate is out because of an illness, my son is being robbed of a wonderful classmate, right? Somebody to play with or to learn from.

Dr. Gabriela Maradiaga Panayotti: Exactly.

Host: And so yeah, that's a great way to think about it, Gabby. Sort of related to that, you know, not all families, young people that I work with are or they don't at least seem equally affected by these structural factors or these inequities in the systems around us. And so, why is this conversation not just for healthcare providers caring for the family who's struggling, and it's certainly not just for that family who's struggling? Why is this conversation really for everybody? Like why should we all at least have some understanding and be at some level engaged in these conversations?

Dr. Gabriela Maradiaga Panayotti: Yeah. I think it's a really good question that I challenge everyone to ask themselves on a regular basis. Because, as you've said instinctively, we are driven by our immediate nucleus of life, our close family, where we live, where our children learn, where we do our daily routines, like go to worship and buy our groceries and play. We're not islands. We interact with our communities in many different ways. And the pandemic just really made that come to the surface.

In the early parts of the pandemic during the first shutdown, so many people were able to stay home and work from home, including myself at times. But a lot of frontline workers still had to come to work. And in those early days, we didn't know necessarily what the best way to protect yourself was. The inventory wasn't there. So, that included healthcare professionals like us, Richard, who sometimes needed to go. But the other hardworking people that harvest our crops and stock our grocery stores and provide our food, and so when those folks were sick because they maybe didn't have equitable access to healthcare or to food, that affected all of us. And it really helped people see how interconnected we are, even to those of us who are very different than us and people that maybe we think we don't have any connections to.

And so, it is something I think you have to actively think about, perhaps on your Sunday trip to somewhere, think, "Okay, we are going here, but how are other people making it possible for us to do the things we love and enjoy? And how can we remind ourselves that they're part of our life too, even if in a disconnected way?"

Host: Those are great, great insights. Thank you, Gabby. I want to shift gears a little bit actually and talk a bit about LATIN-19. This is something that I mentioned in the introduction, but I'd love for our audience to hear a little bit of the story of LATIN-19. And so, could you share what LATIN-19 is, how it came about and how you experienced that process of developing it and then sustaining it over time?

Dr. Gabriela Maradiaga Panayotti: I'd love to. The Hispanic Latino community in this area has been growing over many years. And in the last few years before the pandemic, a group of us who work with this community had come together on different occasions when different issues had come up in an informal way to see how we could communicate better and work together. And after a horrible shooting in El Paso, Texas in 2019, we came together to talk about the issue and there was a core group of us that were in touch via email. And so when the pandemic really hit us hard in March, I remember thinking that week that the basketball tournament was shut down and I thought, "Oh, my goodness. If Duke is canceling basketball, it's really bad." And then, Durham Public Schools said they were going to go remote. And the first thing I thought of was all my patients. And I thought, "How are our families going to deal with virtual school?" In general, all families because we didn't know what that would look like, but especially thinking of my immigrant families, where a lot of parents maybe didn't finish school, don't speak English, don't have the technology at their fingertips. And in my head, it all snowballed and I thought we have to do something and we have to act fast.

And so, I reached out to this group of leaders that had been already gathering informally. And many of them especially my co-founder colleague, Dr. Vivianna Martinez-Bianchi, has had a worldwide reach already. And so, we were already hearing how this was unfolding across the oceans and had a little bit of a window into what might be coming to us. And we quickly got together via Zoom, which was so new back then and tried brainstorm what were the crisis needs at the moment and how could we address them. And it was truly amazing to see how people from every sector of society joined in with us right away. We had folks coming obviously from the health systems here and UNC. The public schools,, government, public health, education, individuals just in the community really joined in quickly to problem-solve.

And so, the beauty of LATIN-19 when it started is that we were getting direct reports from the community right away. And they were saying, "We're having problems getting access to testing because the testing sites are all on the other side of town." And we would have folks on the call who were the changemakers and said, "Oh, we didn't know that. Okay. How can we address that?" And so, we were able to be very nimble and quick about addressing important urgent needs very quickly from a programmatic and systematic way. And so from that beginning, we were able to harness this sort of niche strategy that we had developed and grow it. You know, first, it was testing and then it became vaccination and food distribution. And now, that the pandemic has officially ended, but has exposed so many other needs and disparities, we've been able to continue to work the LATIN-19 model to improve the health and wellness of these families.

Host: Thank you for sharing that. It's just a remarkable example of a great leadership, I would say, of you and Viviana and others and just collaboration. And I would love to dig into some of the core ingredients that really went into that success. But before I sort of go there, it's really interesting, right? Because you mentioned that when the pandemic broke out, so to speak, you thought of your patients, right? And the inequities that we're talking about preexisted the pandemic, right? Before a pandemic, even on a good day, our systems are already tilted in different directions, right? And so our system, even on its best day, is already inequitable. And then when you throw in the chaos and uncertainty and the flux of a pandemic, that's when those gaps widen, right? And so, it's kind of like a young kid or a teenager can have certain health experiences and they're inequitable at baseline, but it's when they get sick, right? Or something doesn't go according to the script, right? Those inequities are just shown even more stark than they typically are. And so, yeah, thank you for sharing that process.

I guess my question and, you know, we can certainly talk about LATIN-19 for hours, but what I'm most interested in is, how did you do it? You kind of alluded to it, right? And so, I think I won't speak for the world, but for myself, and I know for many others, like we would love to do things that are meaningful, right? And I'm sure all of us have everyday ideas about certain things that we can do, but it's very rare for things to really come together and for impact truly to be had. And so, obviously, there was a pandemic, which is a once in a lifetime kind of need, right?

Dr. Gabriela Maradiaga Panayotti: Let's hope, Richard.

Host: Hopefully, right? And so, that was a unique terrible, but sort of an opportunity, right? There was a gap there that needed to be filled. But beyond that, beyond the weirdness of the pandemic, how else did you make this happen, you and the team?

Dr. Gabriela Maradiaga Panayotti: And it's a good question to ask repeatedly throughout any project or endeavor that we're going through. And obviously, we've thought about this a lot. I would say a few things. The first is to recognize when you can do something more than taking care of yourself and the people around you and honoring that that is enough also, that sometimes there is not the bandwidth in your life, and there are seasons where you can add more and seasons where you can't.

So if this is a season where you think you might do more, the first thing I would say is really think about what lights your fire. What is something that really burns you up, keeps your conversations going, what is that passion? And there are many things that drive us all, but often there are some things that really get under our skin or motivate us. And that's what you have to identify because that's what's really going to keep you going. And accept limitations. You can't do everything. So, focus on the one or two things that really drive you the most because there are going to be people who have different ones, and I think we have to trust our brotherhood and sisterhood of peers to work in this village. So, the first thing is think hard about what is the one or two things that really light your fire?

And then, think about what is your sphere of influence. I think at least for me in academics, we're often thinking really big and how can we change populations and millions and millions of people. And I think the challenge is to consider what is your sphere of influence. Local is great and that local could be your home, you know, that your sphere of influence could be your home and that may be enough. The example that you said among your family about how you speak about certain things. It could also be your neighborhood and your church and your school, your city council. So, don't discount how important an effect you could have in your local area.

The next really essential ingredient, which I think for LATIN-19 has been really the special sauce, is to find your buddies. Who else cares about this? I mentioned Vivana, but we have so many folks who, again, were doing this work like Dr. Leonor Corsino in the Department of Medicine Division of Endocrinology. She had already been doing a lot of work and Viviana had, and I had, and we have colleagues in the school of nursing like Dr. Rosa Gonzalez-Guarda. And so, we all kind of said, "Hey, you, I know we've worked together. What if we all literally work together, and then it becomes additive?" And so, breaking down those silos and partnering together to do this work really just exponentially increased the results of what we could do. And then, when you take those individual pieces and put them together with communities that are doing this work, then that's where the magic happens, right? You find all your friends, find your family and commit to the work together. I mean, LATIN-19 is the example of how you can truly make changes for your local community.

Host: That's great. Thank you, Gabby, for breaking that down, these really critical ingredients that came together not just for LATIN-19, but for other similar efforts, right? Where people do come together around a particular need and find that they have traction and they have impact, which is just really remarkable. You touched on this a little bit, but let's say for parents or families that are listening and let's say they want to take a step in this direction of doing something meaningful to help address inequities in our community. What sort of advice would you give to a parent or our family as to like where to begin? It just seems like such a big --

Dr. Gabriela Maradiaga Panayotti: right. It seems like a big, big jump. So, what I would say is the first step is to do an audit, do a self audit or a family audit. Whatever group you are trying to engage in, an idea or a project, what things do we really care about as a family? Could it be the environment or keeping children safe from violence? Perhaps it's related to food security and hunger, or maybe promoting your own culture and your heritage. So, think of yourself or your family. What things are meaningful, and identify that first of all. And once you have identified those issues that really excite you, then find what are some local organizations or groups that are active in that space. And thankfully now, with our access to the internet, it's often very easy to find who is involved, look up their webpage, sign up for their newsletter or maybe phone a friend who may be involved in that group and kind of get a sense of what they do. And once you find a group or other people who are involved, think of how you could become engaged, what would be something that you could add to that group. Maybe you have an expert gardener in your family and you can make a commitment to contribute that knowledge and expertise to the community garden.

And I would say really don't focus on a result. Like, don't hope to raise this much money or change this law. But especially for kids in their developmental stages, it really helps to focus on an action that you can do on a regular basis because it builds that muscle of commitment, of practice. And in the same way we address other health behaviors, we try not necessarily to get a result, but to make that habit stick. And so, work on that practice with your kids. For example, volunteer every month at that community garden. And then, this is a really key part because our engagement center in our brain really loves to see what we've done, chronicle it, right? Now, everybody has a phone. Take those pictures. Go to your local store and get a big cardboard thing and make an artwork out of it. Or make a digital photo book and then display it. Have them share it with their grandparents, so they can really own the effort they did. And that really cements it in to children's minds. And they'll remember, as a family, we really committed to this project and we did it. And now, it'll become a cute little time capsule memory at some point.

Host: I love that. That's great. And it seems like those sorts of activities as a family will also help children, whatever their age, to learn over time about these issues and how our communities work and the role that they can play. You mentioned earlier on your own childhood, kind of observing inequities, knowing that they weren't right, knowing that something was wrong. But maybe not having the language at that time, right? You didn't maybe know what equity, equality or justice were at that time, but you knew, right? Because kids know in their heart when they see things that aren't right or the way they should be. And so, it sounds like this would really set parents up to help their young people learn over time so that they're really equipped, especially as they grow older and go out into the world.

Dr. Gabriela Maradiaga Panayotti: Yeah. And I think it takes the burden off parents that they have to lead their child on this once in a lifetime creation of a nonprofit kind of activity. I think it makes it realistic because parents can decide what can they do. And then, let the children have some ownership and make some choices within the boundaries of what the adults know they can handle and then recognizing that the value is really in the doing and the practicing, and not necessarily on the result.

And I think you and I both have young kids, we know the burden of all these achievements, expectations that are out there. And I think it helps to guide the children in more of the process and the journey as opposed to the final destination.

Host: Great. Gabby, we're almost running out of time, but I do want to give you an opportunity. Are there any community partners or other entities that you would like to shout out that you feel like are just doing special work and are worth recognizing?

Dr. Gabriela Maradiaga Panayotti: I love how North Carolina has really welcomed so many Hispanic and Latino communities here. And I would encourage those listeners who have an interest in learning more to do a quick search. There are so many festivals, concerts, sporting events. This past weekend, I took my children to a local dance festival where dance troops that do traditional Aztec dances from all over the state gathered and showed off their traditions, and it was just lovely to see. So, there's always food and often dancing, and what can go wrong there? And so, a quick internet search can find these events for you. Local papers and websites will do these too. Support these locally-owned businesses if they offer something that you enjoy. And try something new with the kids or the family or you're special someone. There are a lot of options here.

Host: Wonderful. Thank you, Gabby, for this conversation today where I've learned a lot and hopefully our listeners as well about this issue of health equity. I think we've talked about a variety of different aspects of this topic, how it matters through the pandemic and now even beyond. Gabby shared a lot of real great insights as to how we, as individuals and also families, can really take this up as a part of how we try to make our communities better, stronger and healthier.

Before we let you go, Gabby, I mentioned that I am one of the officers in your fan club. So, I do want to make sure everybody understands just how wonderful are. But just a couple more words from you on a personal note. What inspires you most day-to-day in your work or your personal life? What keeps that fire going?

Dr. Gabriela Maradiaga Panayotti: For me, Richard, that would be the families of the children I work with. I am struck every single day by the parents, the moms, the dads, the uncles, the grandparents, and they work so hard to make life better for these kids. And it doesn't matter what job they do or how many jobs they have, what it does is it reminds me that there is dignity in every life path. And that at our core, we're all trying to do the same thing, right? Which is to give our kids the best chance to have a healthy, happy and fulfilling life. And every day in clinic, seeing those families there is a good reminder that we are all in this together, and they're very inspiring.

Host: Wonderful. That is beautiful. And it's a reminder to me, and I'm sure to you that it's such a privilege, right? For us to be able to try to remove barriers for people who are just trying to do the right thing for their kids. And so, thank you for articulating that. And then, my last question, if you weren't a pediatrician, who would you be? What would you do? What is the alternate sort of parallel universe Dr. Gabby?

Dr. Gabriela Maradiaga Panayotti: Yeah, on earth too, my lifelong dream has always been to be a professional salsa dancer. I would be touring with some of the best musicians in the world like Juan Luis Guerra and I would be up there on the stage dancing away. Somewhere, someday, maybe some of that will happen.

Host: Very good. Thank you, Gabby, for that. And we'll bring you back for another episode. We'll talk about the health benefits of salsa dancing. Maybe that'll be our topic.

Dr. Gabriela Maradiaga Panayotti: Okay. After our randomized control trial on that.

Host: That's right.

Dr. Gabriela Maradiaga Panayotti: Thank you, Richard. It's been a pleasure.

Host: Sure thing. On that note, Pediatric Voices is produced by the team at DoctorPodcasting. The show has been developed by Rebecca Casey, Dr. Angelo Milazzo, and me. Thanks to Dr. Ann Reed and the administrative team at Duke Children's for their support.

Find our show and hit the subscribe button wherever you find your favorite podcast. We want to hear from you as well. Please provide feedback at dukechildrens.org on Facebook or on Twitter. We'd love to hear your feedback about the show as well as your suggestion for future topics. Thanks for being here. We look forward to talking with you again.