crisis from [only] the top down. You have to have the top down and the bottom up. You have to have an organized community that partners with government.” When he reached out to his network through a series of phone calls on Easter Sunday night to form the Black Coalition Against COVID, everyone accepted.¹ The group consisted of church leaders, returning incarcerated citizens advocates, artists, labor leaders, small business community, and many others “across the infrastructure that defines Black life.” Physicians needed to make sure they were credible and trustworthy to community leaders. Their initial job was to interpret the science, which, he reminded participants, was moving and changing rapidly. The community infrastructure could take the information and message it through their channels.

Community influencers did public service announcements. For example, the chair of the African American studies department at Howard University explained the need for contact tracing. Having vigorous defenders of Black rights transmit this message, he commented, was more important than hearing it from physicians. Poetry slams, a video contest, and other creative efforts interpreted the public health messages. Local health navigators at churches helped identify the challenges with quarantine and housing. “We were consistent. We went to the hardest-to-reach areas in DC. We were at every meeting, week after week, month after month,” he said.

Early on, the group recognized the need to enroll Blacks in vaccine clinical trials, along with the challenges in doing so based on the memory of past abuses. “We needed strong firepower from the entire leadership of Black health,” he said. The coalition reached out to the National Medical Association and Black Nurses Association, Black medical schools, and Black medical leaders. All agreed to participate from the start. All this began with no budget. A company produced, pro bono, a video featuring Black doctors and nurses called “A Love Letter to Black America.”² With BlackDoctor.org, 30 virtual town halls were held, each involving top leaders from the National Institutes of Health, Centers for Disease Control and Prevention, and other entities. One session had 800,000 attendees. It was important to both disseminate information and listen to the voice of the community, and Dr. Tuckson related that meaningful, often emotional, conversations took place, for example, about vaccine hesitancy. The NFL Alumni Association and Black media outlets were also great partners, although he said he wished active athletes were more involved. A media team called JOY Collective

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¹ For more information, see https://blackcoalitionagainstcovid.org.

² The video is available at https://www.youtube.com/watch?v=QoPSHB5gBow.

worked with family members of men involved in the Tuskegee experiments to create a video in which they expressed their anger and frustration that people were equating the pain and agony of their families’ experiences with a decision not to get COVID-19 vaccinations. The coalition also partnered with a community newspaper to publicly thank all those who worked with them with a full-page ad, “honoring and thanking people who are not normally thanked.”

Dr. Tuckson closed with seven lessons. First, it is the moral and ethical duty of health professionals to translate their expertise into service and discourse with society. Second, he said that “we must consistently demonstrate an undying love for Black people, and through that love, an undying love for all people.” Third is the need to listen with humility and treat people with respect even if they are not in agreement. Fourth, partners need to share power, with each building on its expertise and assets. Fifth, consistency is needed—this is not work for the faint of heart or for people who want to fly in and fly out. Sixth, he said that “we have to advocate for resources.” The funding for infrastructure should already be in place, and, he added, the funding should go directly to the Black community rather than having to wait for resources from the white community. Seventh, quoting Martin Luther King Jr., is the need to make a way out of no way.

A ROLE FOR SMALL AND LARGE NONPROFITS

Dr. Holder related that a COVID-19 collaboration in South Florida with physicians, nonprofits, churches, and others also had strong results, with improvements in reductions in mortality compared with communities that did not mobilize. She echoed the importance of Black media, churches, and community organizations, but also underscored the sweat equity and financial resources required.

Looking more broadly, Dr. Holder cited a McKinsey report (2021) that nonprofits disbursed $64 billion last year. Many times, the funds are filtered so that grassroots groups are “grabbing and begging and writing grants with an infrastructure you don’t have.” When the urgency of the pandemic arrived, those same underfunded organizations were the ones who stepped up, she said, adding that nonprofits have always been able to move the needle faster than public agencies. She noted that philanthropies fund climate change at about $320 million a year and environmental justice and change at $1.4 billion. In contrast, education is funded at $10 to 11 billion, and health at $24 billion. She suggested breaking down silos to balance

the funding given, for example, that climate justice relates to health and education. Similarly, the Inflation Reduction Act of 2022 (P.L. 117-169) includes $360 billion for climate, and she asked how it can support infrastructure being built through churches or community-based organizations. The model of collaborations of nonprofits on the ground has been shown to save more lives than government programs, she contended. “When we center the population, we find solutions that save all of us,” she added.

In finding ways to increase the number of Black doctors, she called for philanthropic organizations to consider their history. Citing a recent article in Academic Medicine (Morsy, 2022), Dr. Holder said systematic funding, primarily through the Rockefeller and Carnegie Foundations, contributed to continued underrepresentation of Black physicians. In the early 1900s, for every $123 in Rockefeller funding that went to white medical schools, Black medical schools received $1, thereby defunding and destabilizing Black medical schools and leading to the closure of five of them. At the same time, philanthropic dollars for Blacks went principally for industrial education, especially in the South.

“Philanthropy is powerful, but we must change the context and leverage the dollars,” she said. All are needed—grassroots nonprofits, large nonprofits, and the federal government. “Instead of trickling funds down, how can we continue to create the infrastructure that we’ve developed and make changes in Black health?” The COVID-19 model of collaboration will work for climate change, she posited. In Miami-Dade County, funding from the Kresge Foundation and other sources supported an evaluation of community needs with community members at the table. They identified heat as the primary concern. Because there was the political will, the position of chief heat officer was created, the Climate and Heat Health Task Force was established, and “heat season” is now designated to take appropriate measures. The Extreme Heat Action Plan includes many suggestions from the community. “We came out of silos from the beginning,” she said. “These models, especially in climate, have to be collaborative.” She added that Black health professionals should be looking at how hospitals can play a role in their communities, using a social determinants of health model.

BUILDING HEALTHCARE ADMINISTRATOR LEADERSHIP

Mr. Bluford noted he is providing comments on the role of nonprofits in the context of $4.3 trillion spent on health care, which is almost 20 percent of the gross domestic product. Of that amount, $800 billion is spent

through Medicare and more than $600 billion through Medicaid. What is key, he said, is that 40 percent of that amount is in hospital sector spending, with another 25 percent going to physicians and clinics. Physicians are critically important and bring expertise, leadership, and gravitas to the table, but most of the resources lie elsewhere in community hospitals, he contended. Most of them are nonprofit or governmental entities.

As a hospital administrator 10 years ago, he had oversight of a $1 billion enterprise. He learned that having the right people in the right places can direct resources to Black communities and make a difference. He started a program, mostly, but not exclusively, at Historically Black Colleges and Universities, for talented African American and Hispanic students to introduce them to healthcare administration as an alternative to medicine and nursing or to combine administration with those fields to be a physician leader, medical director, or chief nursing officer. The Bluford Healthcare Leadership Institute is a didactic, experiential program similar to Harvard University’s mid-career programs. Sixteen students are selected for the 2-week program in Kansas City. “They begin to understand they can have an impact in their communities without the years of medical school, and sometimes the debt that follows; earn salaries well into the six and seven figures over the course of their careers; and direct millions of dollars to communities with the ultimate goal to eliminate health disparities among minority and underserved populations over the next two generations,” he said.

People get their health where they live, work, learn, play, and pray, Mr. Bluford commented, and the program drills in on the social determinants of health and on keeping people healthy, not just fixing them when they are broken and ill. Of the 130 students so far, 86 are now in the healthcare field and starting to navigate their way to the C-suite. They are learning to be leaders though a range of internships and with mentors, coaches, and sponsors. He highlighted some of the students who have come through the program. “We need to expand the vision beyond clinicians, nurses, and physicians, and think about management that drives the dollars,” he concluded.

ACADEMIC MEDICINE AS PARTNERS

In response to a question from Dr. Nivet about how hospitals and academic medical centers can better partner with nonprofits and other community efforts, Dr. Tuckson began by stressing the need for more research on such topics as a clear, granular understanding on how Black people make

choices and decisions. Academic medical centers can also do a better job of using their credibility to advocate for the resources at the local, state, and national levels, and to show how well the resources are used. Data need to accumulate, articulate, and translate into advocacy for funding.

Regarding earning the trust of the Black community in the healthcare system, Dr. Holder said institutions may not have gained people’s trust, but people do trust the physicians and others when they are involved in the community. She called for physicians to act more as consultants and listeners, and not stigmatize personal decisions about, for example, vaccines. While she said her group’s work may not have improved the standing of the healthcare system as a whole, it demonstrated how to overcome fear and mistrust. She wished there had been funding for research to understand the paradigm shift brought about by the pandemic in how to deliver health and health education to a low-wealth community. The outcome is clear—fund the groups that do the work, including local National Medical Association societies. Every Black physician in the country was involved, she said, but with only 50,000 Black physicians (out of 1 million physicians nationwide), they cannot reach everyone who needs them.

Dr. Nivet commented that Mr. Bluford’s program is building a new cohort of leaders, but he asked how to change existing CEOs and board members. Mr. Bluford pointed out that all nonprofit hospitals have a community benefits responsibility, legal and otherwise, or they lose their nonprofit status. He said agencies, nonprofits, and coalitions need to understand what the community benefits should be and hold the institutions accountable to ensure Black communities are getting their share of the resources. “The money is there,” he said. “We just need to make sure that it is targeted where it should be.” He added that hospitals need to think “outside the bed” and be in communities.

Cedric Bright, M.D. (East Carolina University), asked how people who are not in the C-suite learn about a hospital’s community access dollars. Dr. Tuckson commented that regular communication about funding should take place. Dr. Holder said it is difficult to access these funds and many hospitals are sitting on large reserves. Hospitals also often use these funds to write off uncompensated care, which she said should be challenged. One strategy is to show hospitals ways how they can use the funds to lower emergency room use. She noted some hospitals have created housing, which gets people who are homeless out of hospital beds. Other ideas could include improving education and air quality in low-wealth communities, she suggested.

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