Ngozi Ezike, MD: Hello everyone. I'm Dr. Ngozi Ezike, and welcome to another episode of More Than Medicine. Today, I am super excited to be joined by Dr. Helen Margellos-Anast, President of Sinai Urban Health Institute affectionately known as SUHI. SUHI is a leader in health equity research here in Chicago. Helen is a social epidemiologist and health interventionist.

She has dedicated her career to addressing health inequities in partnership with communities. Helen has led pivotal studies on racial and ethnic health disparities and is making a significant impact in the field.

She has just completed her doctorate of public health and leadership at the University of Illinois at Chicago. Helen, congratulations on that, and thank you for being here.

Helen Margellos-Anast: Thank you Dr. Ezike and thank you for having me.

Host: What a pleasure. [00:01:00] So I think post COVID, everybody has heard the term epidemiologist, but I think pre COVID, a lot of people just thought that must have been related to skin or dermatology. How did you become interested in epidemiology?

Helen Margellos-Anast: When I was out of college, I thought I was going to go to medical school and I'm a first generation college graduate. My mom immigrated from Greece. My dad was first generation, lost his dad young though, so did not go to college. So I don't know. I think a lot of times, I loved health. I was interested in it.

I just, it was assumed I was going to become a doctor. And then at some point I stopped and I said I don't know that that's what I want, but I actually went through the whole process of applying to medical school first. And I said, I don't know what, if that's what I want. I think I'm much more interested in keeping people healthy than I am in treating them once they're sick.

And then I also had had an opportunity to work in a nursing home as an intern, during my senior year of college and had gotten to investigate or help investigate an outbreak within that facility to crunch some numbers. And I thought, this is so fascinating. You get to [00:02:00] do something different every day. I get to be a detective. And, that just really drew me in along with this desire to really do something meaningful and good, for the world. So, that was how I got into epidemiology.

Host: That's awesome. What a great story. And I love how, you know, you start off thinking you're going to do one thing and then life experiences lead you down the path that you're actually supposed to go down. Thank you so much for sharing that. So, I want to understand how you came to SUHI, but first we probably need to tell people a little bit more about SUHI.

So for those who might not be familiar, and unfortunately there might be a lot of people, even though SUHI is this incredible organization, you know, there's this phrase that, you know, a prophet sometimes is not honored in their own town. So maybe even though this great organization is sitting right here in Chicago, a lot of people may not know about it.

Can you talk about the Sinai Urban Health Institute, what its mission and role is as, especially as part of Sinai Chicago?

Helen Margellos-Anast: Of course. So Sinai Urban Health [00:03:00] Institute, or SUHI, we're the community engaged research arm of Sinai Chicago. So we were founded in 2000, just celebrated our 25th anniversary, and we were founded by Sinai specifically to support the health system in better understanding the communities from which the patients were coming.

So when I think about this, it was so innovative at the time. I mean, now we're all required to do these community health needs assessments. And as health systems, if we're nonprofits to understand our community in some way, there's population health. All this is happening. But at that time, way before that, Sinai was really showing their commitment to health equity and understanding that our patients, if we're going to really treat our patients, we need to know where they come from.

We need to understand the context of their lives. And that led to the Sinai Urban Health Institute being formed. So our mission really revolves around health equity and advancing health equity among communities. We do that by understanding health inequities in a real intimate way, ensuring that we understand them at a hyper-local level.

So we're looking in community to community and, and understanding what's affecting that community. We're [00:04:00] diving deep, partnering with communities, contextualizing those health inequities, understanding what the true drivers are, and then taking actions. So that has, from our inception, been part of it.

It's never been about data for data sake. It's about data to action. So our role within Sinai remains similar. It, it really is to ensure that the decisions Sinai is making are grounded in community priorities, that they're data based and that they're advancing health equity.

Host: Thanks for that. You said it was born here at Sinai. Why was Sinai the place that it started? You know, like what were the inciting events that led to its creation?

Helen Margellos-Anast: SUHI was founded in 2000, as I already said, and it was really in large part due to the leadership of the CEO at that time, who was Ben Greenspan, along with Dr. David Ansel, who was at that time Sinai's Chief of Medicine.

As I said, they really recognized that many of the things that they were seeing within their patients, that we needed to better understand those issues. And we now know quite definitively that only 20% of a person's [00:05:00] health is really determined by what happens within the healthcare system, so via clinical care. That other 80% is driven by health behaviors and socioeconomic factors such as education, income, employment, the physical environment. And so they really wanted to do something towards understanding that better. And so David Ansel happened to be good friends with Dr. Steve Whitman who was at that time the director of Epidemiology at the Chicago Department of Public Health. And by the late nineties, Steve had created a reputation for himself in Chicago as a real advocate for social justice and understanding health inequities. In his role at CDPH, he was among the first to really dive deep and at CDPH, specifically look at health inequities by community areas.

So looking at that hyperlocal level data and focusing on black, white disparities in particular and socioeconomic disparities. And then the other place that Steve really made a mark was in the 1995 Chicago heat wave, where there were 514 confirmed heat related deaths in a one week period. This was a huge, tragic event in [00:06:00] Chicago's history.

Steve really sounded the alarm on the fact that, that was disproportionate. Those deaths were disproportionately affecting black people, one and a half times higher than white people. And he also used epidemiology to show that we were undercounting. So 514 is probably not the right number. It's more of 700 to 800 deaths.

So it happened that David knew Steve and thought this could be the right person to bring into Sinai to start the SUHI, Sinai Urban Health Institute. So together David, Ben and Steve developed the concept and got the board approval. Steve brought a couple more people from CDPH with him, Jade Dell and Abigail Silva, and that was the start. And I came on nine months after that.

Host: That is an incredible story and really when we think about what they were doing 25 years, I mean, this is commonplace now. Like everybody is steeped in this work and thinks in these ways. But 25 years ago, they were absolutely on the cutting edge. So, and just even the story about the heat wave and, you know, that was like a smaller version of COVID, right? In terms of having the [00:07:00] vulnerable communities being disproportionately impacted, as we know should be expected, and being able to signal that alarm and how we have to work specifically on those communities that are, that are most in need.

Really, ahead of their times. And for you to have been a part of this work from the very beginning, like you are part of this trailblazing, team. So thank you for all of that. So, as they started this work, what were some of the things that really helped to distinguish SUHI in this work early on? Did people appreciate what they were doing? Did they get it?

Helen Margellos-Anast: Not immediately. I mean, I think there were people who of course, were already buying into it and understood it and were passionate. And there others that were part of this movement. But not the majority of people. Right? So a lot of what was happening in those early days was raising awareness of the fact that there are health disparities and they impact certain communities to a larger extent, and [00:08:00] it's important to understand the drivers. And Steve was talking about racism as one of the drivers, the driver, I shouldn't say one of, the driver of health disparities, again, long before most people were even willing to say that word. I mean, I remember when I first started with SUHI, and I mean, I grew up in Minnesota, very homogeneous sort of environment.

I had not really done a lot of sociology or, you know, I hadn't really studied this either. I really had come more from the science background. And so for me too, like when the word racism would come up, I didn't understand it the way I understand it now, and I, people think about interpersonal racism.

They don't think about the structural factors and Steve got all that. He knew that we needed to, yes, there's an interpersonal part as well. We, there's a lot of that that we still have to work on, but we also need to think about like the systems and how the systems are being impacted and have been impacted by these policies that have favored one group and disfavored other populations over time.

So, it was a lot of using data, telling stories and partner with communities so we could tell the right story and take action in the right [00:09:00] ways.

Host: Again, thank you so much. And you know, unfortunately, fortunately, some of the things that he was leading the way on 25 years ago, we're still trying to get that message through. We're still trying to show and prove that racism really is at the foundation of some of these disparities and that there's a lot of work to be done.

So even though it's 25 years later, and I know a lot of great work has been done, a lot of work is still the same. We're still working at some of those same premises. So has the work evolved? How has the work evolved if it has?

Helen Margellos-Anast: The central mission has stayed the same, the vision has stayed the same. I think the way the work has evolved is that it's in some ways become more formalized. We've really formalized into what we need to do specifically, so focusing on understanding, and initially when we first started, with that understanding health inequities, it was a lot of looking at population level data that was either publicly available or that we could get existing data sources, vital statistics data, and [00:10:00] showing that there were these inequities or disparities in mortality rates or birth outcomes. And from there, the question becomes, well, what's driving those and how do you get to that?

And early on that meant that we, in 2002, 2003, did Sinai's first large community health survey, focusing on six community areas that were different in terms of racial and ethnic background and socioeconomic status so that we could get some comparisons and looking at even something as simple as disease prevalence.

We didn't have that data at a hyperlocal level at that time. We barely had it at a city level. So for the first time we were getting prevalence and for asthma and diabetes and also control levels of those conditions and thinking about the social determinants of health and looking at access to food and and smoking, right. And there was so much data that we got through the survey. And then from there it became about continuing and building on the intervention side. So we have done a lot of work continuously on that understand side, including going beyond Chicago now and doing more work on the national level and looking at Black, white, inequities in [00:11:00] particular, in the 30 largest cities for a number of disease states. But in terms of implementation and action, that's where we've also done a a lot of work, and that's evolved over time. We can talk about community health workers. I think that has been central to what we've done.

Actually, when I first joined SUHI, I joined as the evaluator for what we would now call our first CHW program. Let me just take a step back and define community health workers for anybody who, who has not heard that term. So community health workers are people who are from the community. They're frontline public health workers.

They're from the community, trusted people that live within the communities that are experiencing these health disparities. As we talk about how we've evolved, we started out with community health workers working more in disease management, so thinking about asthma and diabetes and managing those conditions. We then started to do more around prevention, and so we got into more breast health and navigating women to mammography and through treatment, preventing diabetes, the diabetes prevention program, we would expand to different populations.

Once we have a model and we show that it works. So [00:12:00] we've also always evaluated everything we do so we can show it works. We know how it works. Then how do we translate it to a new population and how do we ensure that it works in that new population? So with asthma, we started with children, we moved to adults, we moved to Chicago Housing Authority, and looked at it in that population.

We did some work in the ED. So these are all different populations with slight tweaks to the model to make it impactful. And then we've been interviewing CHWs into Sinai Chicago more formally for the past five years now. That's meant generalizing the model. So going from that more disease specific approach to thinking about community health workers who are more generalized in a healthcare setting, screening for social determinants of health, connecting with patients regardless of what's bringing them into the four walls of the hospital and connecting them to what they need post-discharge to ensure that they stay healthy and continue to improve in their health.

And then we've also, another main evolution that we've undertaken has been to think about how we can get our expertise out more broadly. Not only by disseminating through [00:13:00] the traditional means, but also through thinking more as a having more of a business mindset and thinking about how do we help others. So in 2017 we founded Crowd, which was the start of that. It's a CHW training and consulting center that we have.

We've trained over 3000 community health workers, across the country at this point. We with over 70 organizations to help them bring community health workers into their organizations. And then, we've also have similar work that we do in the evaluation space. So we do culturally centered evaluation.

We're very good at that. We work with organizations that want us to bring that to their organizations.

Host: I mean, it's incredible. An organization that started as a, a homegrown kind of cell here in Chicago has gone national and is spreading this important work throughout the country. And hopefully beyond and this is exactly where we need to go because as you mentioned at the outset, maybe only 20% of health is determined by what happens from [00:14:00] that clinical encounter. And so all these other pieces are so instrumental and so we have to be focusing on that 80%. So, we really are grateful for the lead that SUHI has taken and how we are spreading this important message.

You know, you talked about so many things that the community health workers are doing. I think when Dr. Whitman first started, there was a lot of work with asthma and breast cancer, but now it looks like there are many new frontiers that we are focused on. Where do you see us going? Where's the next frontier? Where are we going next with this work, do you think? 

Helen Margellos-Anast: Well with community health workers in particular, we continue to innovate and do research. So there's the part about actually researching new models and then getting to the point where we show that they're effective and we know how they're effective, and then we scale them or translate them somewhere. So we continue to do research with community health workers, and specifically we're really [00:15:00] focused currently on behavioral health.

We know that we have a behavioral health crisis. I know Dr. Ezike, you and I were both at an event where we actually saw the findings of a survey that SUHI's also been involved, well led in terms of understanding mental health and wellbeing in adolescent girls in Chicago in particular.

And while I think we recognized before that, that there was likely a crisis overall, we've seen behavioral health challenges exacerbated after the pandemic. We see the same sort of thing in adolescent girls. So there is this real need to partner with communities to expand access to behavioral health services because there's a shortage.

It's not easy to get people in. So one way that we thought about doing that is having community health workers who are trained not to take on the most complex cases, obviously, but to start to triage and to start supporting some of that initial work when somebody might, not be able to get into a therapist for a time or to support somebody and connecting to them, maybe have more a [00:16:00] virtual therapist and breaking down barriers to that.

So that might mean working with them to make sure they can do something like this and do it virtually, that they have the right equipment. So, CHWs in the behavioral health space is definitely one area. We actually have founded the first apprenticeship program for community health workers within a healthcare system in Illinois. And this is a real win because it allows health systems like Sinai, Chicago to actually have these positions paid for through the Department of Labor for a time while the community health worker, it helps them because they are trained at the same time that they are being paid to work.

So for communities that are challenged with health inequities, this is a real opportunity to build a workforce from within. And then this whole community centered model, you know, the other thing that we're doing a lot of is collaborating more. We've always collaborated, but thinking about how we have more cross sector collaborations that are bringing together partners with different areas of expertise.[00:17:00]

That's how we're really going to solve the biggest issues that we have. So one example of that is we have something called the One Lawndale Community Health Collective that SUHI was funded to facilitate. We have two anchor organizations, one in North Lawndale, one in South Lawndale, which are two of our community areas that we work in.

That collective now has over 50 organizations that either have CHWs or want to bring them on. And this includes healthcare systems, it includes community-based organizations, and it includes federally qualified health centers and then other organizations that are a part of it as well, like schools and others as well.

But the intent really is to think about how we most efficiently utilize our resources towards a larger impact. So collectively, if we're all networked and our community health workers are networked, there's a place where my CHW's roles might end, where another CHW might be better versed. That's a within another organization, and we can quickly connect.

We also can more efficiently train because we have the ability to share resources with one another and share our wins and our experiences. And that's had phenomenal success. [00:18:00]

Host: So actually that leads us down a very important path in terms of, you are describing these community health workers as just an, a very integral part of the broader healthcare team. And sometimes they're working directly in clinical spaces, sometimes they're in community. But obviously they don't have a way to actually get reimbursed by insurance. Tell us about what SUHI is doing to help see if we can move that needle.

Helen Margellos-Anast: Yeah, so there's a few things we are doing. So, first of all, there is legislation that's been passed in Illinois that opens the door for reimbursement by Medicaid for CHWs. That legislation, I think it passed in 2021 or 2022. I can't remember exactly the year. But essentially,

there's a certification process that needs to be in place before that can happen. So SUHI has been at the table supporting how we develop the right certification process, making sure that we are being sensitive to the needs of our [00:19:00] community health workers, like what they actually need and how they can actually become trained and best be assessed.

Because I think generally we, we think assessment we need to assess and make sure somebody is competent and we are going to give them a test. Well, that doesn't work for everybody and it certainly doesn't necessarily work for our community health workers. So having more ways to, for experiential learning, learning from one another, and then ensuring that, that we are assessing competency by really observing what they're doing in the field and thinking about field observation, other things like that. So that's one piece. The other piece is that we are involved in actually putting together the training that is going to be used by the state to train the CHWs in their core competencies.

So we're doing that work and we are also supporting bringing together of communities of practice that will allow for continued learning among those that are trained as community health workers. Beyond that, there's other ways to reimburse CHWs that we also have been really on the forefront of.

So one way would be, as we do have more population health [00:20:00] priorities, payers are more likely to actually engage community health workers as our health systems as part of that. So SUHI, actually, again, I think we were way ahead of the game on this in 2011 is when we first started working with some payers, Medicaid MCOs around asthma specifically and working with their members, having our CHWs implement our proven program with their members who have asthma. And that was a really successful program and it supported the payer in terms of having their members healthier and supported SUHI by allowing another opportunity for us to sustain our CHWs and, and make an impact.

Host: So a lot of ground has been covered and there's still ground that we're hoping to break ground on. So really excited for what the future holds. As we wrap up this wonderful time together, what is your vision for the future of SUHI?

Helen Margellos-Anast: So I moved into the President role in May of 2020, which clearly was a pretty interesting time to take on a leadership position. And SUHI was [00:21:00] already very much established at that time as a leader in the health equity space. So suddenly, with COVID, with all the things that were happening, people were now recognizing that health inequities were a thing, like something we've been talking about for years. So that was happening and people were seeking out the expertise that we have. Then we have all this expertise with community health workers and trusted messengers recognized as vital to supporting the communities that we were seeing seeing were more impacted by worse outcomes in, all the things that they needed to get better outcomes.

So our expertise with community health programs was very much a priority. So we grew really quickly. Between 2020 and 2022, we doubled in size, doubled in budget. So we took a step back and I was like, we've been growing, we've been reacting, but now we need to stop and we need to be strategic and think about where is it we want to go. What is it that SUHI can bring that no one bring.

So we went through a whole strategic planning process. We figured out that we were really around understanding, implementing, and evaluating. We also developed a business model [00:22:00] around that because part of this is making sure that we are sustainable for the long term and that we can continue to innovate.

What we bring that nobody, most people don't bring is really that long history with communities. We already have a close, trusted relationship. We've been working together. We've gone from being community informed in our beginning to community engaged to community driven now, because that's how close we're working with communities.

So that's something that we bring and we can do in Chicago, and then we can also support others in doing in other parts of the country. As I'm looking into SUHIs future, I think there is that expanding more to get our best practices out to beyond Chicago. The environment right now is very different than it was three months ago. Public health and healthcare and research, everything that all those systems have been, there's a lot of chaos. They've been, I'm upset about that, but that means that the need is even greater because as we sort of see these disruptions that are inevitable in some of the safety net systems, the disparities that are there are going to only be exacerbated further.

They were exacerbated through [00:23:00] COVID, and this is going to exacerbate them further. So part of what we're going to be doing in a slightly revised version of this is continuing to sound the alarm, going back to our roots and talking about these inequities, like looking at what's happening. Continuing to make sure that people are aware of what we're seeing in the communities.

And then in collaboration, in partnership with cross sector partners, really thinking about how we stay the course and not only get through this, but grow through this.

Host: Well, I just want to say thank you, Helen, for all the incredible work that you have done throughout your career at SUHI, um, for advancing health equity throughout the city of Chicago and, and actually beyond. As the work has gone, you know, national. Um, your dedication is an inspiration. I want to say congratulations to you and SUHI on 25 years of impactful work.

It's a remarkable achievement. So here's to many more years of progress and helping make that significantly needed, uh, [00:24:00] improvement in the, in the health disparities and health inequities that we are seeing. Thank you so much.

Helen Margellos-Anast: Thank you.