The Fight for Health Equity

Dr. Richard Besser, head of Princeton’s Robert Wood Johnson Foundation, is making a difference

By Wendy Greenberg | Photo courtesy of Robert Wood Johnson Foundation

Dr. Richard Besser, a pediatrician and head of the Robert Wood Johnson Foundation (RWJF), has volunteered in a clinic in every place he has lived.

Seeing children once a week at the Henry J. Austin Center in Trenton brings health inequity into focus. There, in Trenton, the life expectancy for children is 73 years. In Princeton, the life expectancy for the same-age child is 87 years.

The clinic grants a window, he said, “into the lives of children, many of whom have profound barriers to health, children growing up in very different circumstances than the children in my hometown of Princeton.”

At a New York City health center, Besser met a grandmother who knows her grandchildren needs daily physical exercise, but was concerned about the safety of playing outdoors. He met a youngster whose asthma attacks were triggered by environmental contaminants in the family’s apartment. At the Trenton clinic, he met a mother of a son with significant developmental disabilities who has been waiting two years for services that would help him.

This map shows the distribution of New Jersey’s health outcomes, based on an equal weighting of length and quality of life. The map is divided into four quartiles with less color intensity indicating better performance in the respective summary rankings. (Map courtesy of the University of Wisconsin’s Population Health Institute County Health Rankings and Roadmaps; and the Robert Wood Johnson Foundation)

This kind of work has helped Besser rethink health in terms of opportunities to lead healthy lives: the choices people make are dependent on the choices they have. “In too many communities, health choices just aren’t available,” he says via email. “These encounters fuel my passion for the work that we do (at RWJF). It is through these conversations that I come face-to-face with the incredible structural inequities in America and the importance of addressing these head on.”

Princeton-raised Besser trained as a pediatrician, served as the acting head for the Centers for Disease Control and Prevention, and has been a medical editor for ABC News. Each move provided him with a different perspective and approach to public health, and it all came together in leading the RWJF.

RWJF, headquartered in Princeton near Forrestal Village, is the nation’s largest philanthropy dedicated solely to health. Since 1972 it has supported research and programs targeting pressing health issues. Its approach is to help build a society in which everyone has “a fair and just opportunity for health and well-being,” says Besser. The RWJF calls it a “culture of health.”

It requires “shifting how people may think about the drivers of health — how the choices we make depend so fundamentally on the choices that we have,” continues Besser. “It requires helping people recognize who has opportunity and who does not. It takes working to remove the barriers to health caused by poverty, racism, sexism, and so many other social factors.”

Photo courtesy of Shutterstock.com

An Interest in Public Health

Besser came to the RWJF in April 2017, new to philanthropy but not new to public health. “I’ve been incredibly fortunate in my career to be able to pursue issues that I am passionate about,” he says. He grew up in a family committed to helping others, primarily through health care, says Besser, the son of an obstetrician/gynecologist and a social worker, and the grandson of a neighborhood family doctor in Philadelphia and the nurse who worked in his office.

“While I was attracted to improving health from a very young age, I knew my approach would be different. I was excited about the power of public health to create conditions that improved the health of entire populations,” he says.

Besser, who received a bachelor’s degree in economics from Williams College and medical degree from the University of Pennsylvania, completed a residency and chief residency in pediatrics at Johns Hopkins University Hospital in Baltimore. “What I love about pediatrics is the opportunity you have to affect the entire life course of a child,” he says. “However, from the beginning of my career I knew that public health was where I belonged.”

After his residency, he worked doing research for the Johns Hopkins School of Hygiene and Public Health in Bangladesh, and worked at the Centers for Disease Control and Prevention to learn how to be a disease detective in the Epidemic Intelligence Service. His first job after this fellowship was running the pediatric residency program at the University of California, San Diego, and at the same time he conducted research on the cross-border transmission of tuberculosis in children. In San Diego, he had the opportunity to provide medical commentary for one of the local television news programs, and learned the value of “clear information presented honestly.”

This map shows the distribution of New Jersey’s health factors based on weighted scores for health behaviors, clinical care, social and economic factors, and the physical environment. Detailed information on the underlying measures is available at countyhealthrankings.org. The map is divided into four quartiles with less color intensity indicating better performance in the respective summary rankings. (Map courtesy of the University of Wisconsin’s Population Health Institute County Health Rankings and Roadmaps; and the Robert Wood Johnson Foundation)

After five years in San Diego, and missing working in public health on a national level, he returned to the CDC. There, over 11 years, he worked on issues including antibiotic overuse, Legionnaires’ disease, meningitis, bioterrorism, and emergency preparedness and response.

Besser’s gift for communications again proved useful as he led the initial response to the 2009 H1N1 flu pandemic. “As part of our response we put a big focus on communications to the public,” he says. “We recognized that during a public health crisis, people were concerned about their health and needed information they could trust. We knew that trust required a level of communication often difficult in large bureaucracies. Each day we held press conferences and told the public what we knew, what we didn’t know, and what people could do to protect their health. We shared what we were doing to answer critical questions and we were gratified that polling showed a very high trust in governmental public health.”

His next stop was ABC News as health and medical editor. “At first I thought this was an odd fit for me, but the more I thought about it, I saw this as a chance to practice public health in front of a camera — a chance to give millions of people information to make more informed health decisions, a chance to explain health information that might be daunting or incomprehensible,” he says. “Through my time at ABC News, I saw the power of the media to shape public perception of health events and I honed my communication skills.”

Photo courtesy of Shutterstock.com

Health Equity Initiatives

Leading the Robert Wood Johnson Foundation, Besser finds he uses all of the skills he has acquired during his career up to this point.

In this year’s annual message, which includes a video, the RWJF shows how housing is a key part of the health equation, and linked to health equity. The stability and quality of housing and neighborhoods play a major role in health, especially when a large part of a paycheck goes toward rent or mortgage, and other needs are set aside as a result.

A major RWJF statewide initiative is The Policy Roadmap to Help all New Jerseyans Live their Healthiest Lives. The report was driven by growing gaps in health from county to county, and even within neighborhoods, particularly affecting the poor, and people of color. According to Besser, “barriers to being healthy are often the result of unjust policies and practices that have persisted for generations. Policy actions have sometimes created unfair gaps in health. We can also leverage policy to dismantle those barriers.”

The report, produced in partnership with the Center for State Health Policy and the John J. Heldrich Center for Workforce Development at Rutgers University, documents policy options to close inequitable gaps and broaden opportunities, such as improving maternal and infant health outcomes by enhancing care, supports, and prevention. The recommendations span education, housing, nutrition, income, and health care, with a focus on health equity, including paid family leave benefits, the minimum wage increase, and access to early education.

How does New Jersey compare to other states on the issue of health equity? New Jersey, says Besser, “has a lot to be proud of — higher life expectancy rates compared to the national average, higher high school graduation rates, relatively higher incomes.” However, in every part of the state there are “wide, persistent — and in some cases, growing — gaps in health.”

Take downtown Trenton, he says. There, the life expectancy in ZIP codes 08611 and 08618 is 73 and 75 years, respectively. The life expectancy in the more suburban 08619 and 08648 ZIP codes of Hamilton and Lawrence Townships jumps to 80 and 83 years, respectively. The average life expectancy in the affluent 08550 ZIP code — just outside of Princeton and only 13 miles from downtown Trenton — is 87 years. All of these ZIP codes sit within Mercer County, but across the county, life expectancy varies by as much as 14 years, he pointed out.

Moreover, each year, Bergen, Morris, Monmouth, and Somerset counties see three infant deaths per thousand compared to eight deaths per thousand in Atlantic, Camden, and Cumberland counties.

And, he noted, black infants in the state are more than twice as likely as white infants to die before their first birthdays, and black mothers are more than three times as likely as white mothers to die from pregnancy-related complications.

Across America, babies born just a few miles apart have dramatic differences in life expectancy. Developed by the RWJF Commission to Build a Healthier America, this city map displays life expectancy values alongside common geographic landmarks and highway exits, to show how opportunities to lead a long and healthy life can vary dramatically by neighborhood, and in communities across the United States. (Robert Wood Johnson Foundation)

Location, Location for Healthy Living

Not everyone has healthy choices, he emphasizes. “Health is about more than what takes place at the doctor’s office. Access to good quality health care is important, but the most important aspects of health take place where you live, learn, work, and play.

“Yes, personal responsibility plays a key role in health, but the choices we make depend on the choices we have available to us. Not everyone has healthy ones. There are people who live in communities where there is no access to healthy, affordable foods and people who have to choose between housing and prescription medicine. This is real. Too many people start behind and stay behind because of where they live, how much money they make, or discrimination they face.”

The Besser family, which includes two sons, does its part to live healthy. “We are incredibly fortunate to have the opportunity to make healthy choices,” Besser says. “We are all very active, love to eat healthy food, and are socially connected. My wife, Jeanne, is a food writer and an amazing chef who knows the importance of eating unprocessed food. Physical activity and exercise are things we truly enjoy. We don’t smoke or overly consume alcohol. We get our annual flu shots. We don’t take these opportunities for granted for we realize that not everyone is so fortunate.”

Princeton’s Influence

Besser says he loved growing up in Princeton. “Throughout my education, I had teachers who cared about me and got me excited about learning. I remember in fifth grade, our teacher wanted us to understand what a million looked like, so she had us work to collect one million bottle caps. It got me interested in math.

“My high school world history teacher got me excited about learning about people, cultures, and countries around the globe. He helped me understand the ways in which we are all interconnected and helped begin a lifelong journey to improve health for people here and around the world.

“It’s amazing the power teachers can have. They can inspire a student to see things in a new way. They can also limit that which a young person views as possible. I’ve been fortunate to have teachers who have opened my eyes in incredible ways. We must work together to make sure every child in America has that opportunity.”

His philosophy is that everyone benefits from policies that remove barriers to revitalizing neighborhoods, improve schools, health care institutions, and housing. “America cannot be healthy if we are leaving behind entire communities. Communities with highways running through them, toxic dumps next to playgrounds, neighborhoods with more liquor stores than grocery stores, lack of safe and affordable housing, or poor-quality schools.”

“Regardless of our differences, every person hopes and dreams for a better life for themselves and their kids,” he says. “And we all benefit when our neighbors have what they need, when communities give everyone a fair shot at being as healthy as they can be. That means access to good jobs with fair pay, good schools, affordable housing, safe neighborhoods, and quality medical care. This approach, an approach towards greater health equity, is crucial to a productive workforce, and a vibrant nation.

“We can’t solve this on an individual level, it will take all of us working together.”

As head of the Robert Wood Johnson Foundation, Besser is helping to lead that effort.