Social Justice Webinar: Healthcare Equity and Accessibility Around the World

William Hsiao, K.T. Li professor of economics emeritus in the department of health policy and management and department of global health and population at Harvard T.H. Chan School of Public Health, and  Ellen L. Idler, director of the Religion and Public Health Collaborative and Samuel Candler Dobbs professor of sociology at Emory University, discuss the equity and accessibility of the U.S. healthcare system and other healthcare systems around the world, and the intersection of religion and global health. Holly G. Atkinson, affiliate medical clinical professor at the CUNY School of Medicine, moderates.

Learn more about CFR's Religion and Foreign Policy Program.

FASKIANOS: Welcome to the Council on Foreign Relations Social Justice Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR.

Today’s webinar series explores social justice issues and how they shape policy at home and abroad through discourse with members of the faith community. This webinar is on the record, and the audio, video, and transcript will be available on CFR’s website, CFR.org, and on the iTunes podcast channel, Religion and Foreign Policy. As always, CFR takes no institutional positions on matters of policy.

We are delighted to have Holly Atkinson with us to moderate the discussion on “Healthcare Equity and Accessibility Around the World.” I will just give you highlights from Dr. Atkinson’s bio. She is an affiliate clinical professor at the CUNY School of Medicine. Previously, she was director of the human rights program at the Icahn School of Medicine at Mount Sinai. Dr. Atkinson is currently an associate editor of the Annals of Global Health, and a member of the Council on Foreign Relations. We’ve dropped a link to her bio and the speakers’ bios in the chat, so you can look there. But I’m going to turn it over now to Dr. Atkinson to introduce our distinguished panelists, and then start the conversation.

So, Holly, over to you.

ATKINSON: Thank you, Irina. And good afternoon, everyone. I’m really delighted to be moderating this very distinguished panel. Let me introduce you to them.

William Hsiao is K.T. Li professor of economics emeritus in the department of health policy and management and the department of global health and population at Harvard T.H. Chan School of Public Health. He received his PhD in economics from Harvard University. Dr. Hsiao is a leading global expert in universal health insurance, which he has studied for more than forty years. He has been actively engaged in designing health system reforms and universal health insurance programs for many countries around the world. Dr. Hsiao developed the “control knobs” framework for diagnosing the causes for the successes or failures of national health systems, and he has shaped how we conceptualize national health systems. He’s published several papers and books and served on editorial boards of professional journals. Dr. Hsiao served as an advisor to three U.S. presidents, the U.S. Congress, the World Bank, the International Monetary Fund, the World Health Organization, and International Labor Organization.

Ellen Idler is the director of the Religion and Public Health Collaborative and Samuel Candler Dobbs professor of sociology at Emory University. Previously, she taught at Rutgers University. Dr. Idler received her PhD and MPhil from Yale University, her B.A. from the College of Wooster, and attended Union Theological Seminary on a Rockefeller Brothers Fellowship. At Emory, she holds appointments at the Rollins School of Public Health, the Center for Ethics, and the Graduate Division of Religion. She is a fellow of the Gerontological Society of America. Dr. Idler studies the intersection of religion with public health at the individual, population, and organizational levels. She is the editor of the Oxford University Press book, Religion as a Social Determinant of Public Health, and author of numerous studies on religion’s role in health. She is also an associate editor for PLOS One. Welcome to you both.

Bill, let’s get started with you. We have a gathering of individuals today, many of whom are from the faith-based organizations and institutions. And I’d like for you to describe what the control knobs approach is to formulating health policy. And of course, particularly in the context of what we’re talking about today, which is equity and accessibility to health care.

HSIAO: Control knobs is a new analytical approach for health policymakers and analysts, as well as for the public, to understand health policy. Let me give a brief history. Traditionally when we look at health care, we look at the inputs—how many doctors, nurses we have, and how many hospital beds, and community centers we have. That’s the input. This new control knobs framework is saying, no, let’s look at the output, the outcomes, that’s what we care about. And such as equity in health outcomes, equity in reducing the poverty caused by health expenses.

And to look at how these outcomes are produced, we identified major so-called “control knobs” that determines the outcomes. That’s including financing how you organize health care—for example, do you rely on the market, or do you rely on the government—and the payment system, how do we incentivize the providers, and the regulation. And here, my last point, to determine the outcomes there you want to look at the equity of the health outcomes and the reduction of impoverishment due to health expenses.

ATKINSON: Well, let me stop you right there, Bill, for a moment. And can you give us a working definition of what you mean by equity? And how do measure that? It’s obviously an ideal that we have as an outcome, but how do you actually measure equity across a national health plan?

HSIAO: Well, not being a philosopher, like Ellen, because I work more on the practice side, that equity is a principle made very well known by John Rawls, the theory of justice. That under a veil of ignorance, we want to give more resources and health services to the most disadvantaged people. It can be the poor people, the handicapped, the ill people. But these people could be disadvantaged for genetic reasons, social reasons, and environmental reasons. So it’s very hard to classify them, to say really what is due to their circumstance versus their free will, let’s say, to control their weight.

Therefore, in the health policy world, we actually change that word “equity” in practice to “equality.” We want to give everyone equality regardless of income, gender, race, region, education, and so forth, to see whether they have equal outcome in health—like, their health status, as well as how many of them get impoverished because of health expenditures. So with that, we can actually measure it, because you can measure the health status of people regardless their circumstances. So in practice, we actually practice equity translated into equality. And Ellen may disagree with that.

ATKINSON: Well, you’ve really raised the issue of what we call the social determinants of health. And Ellen, of course, in the introduction, I mentioned this marvelous book that you’ve edited, which is Religion as a Social Determinant of Public Health. Before you talk about religion as an SDH, as we call them, tell us what a social determinant of health is.

IDLER: Sure. Thank you. I’d be happy to. (Laughs.) It is really the paradigm for public health and epidemiological research these days that you think about the most upstream factors that determine the health status of individuals. It’s not the close-in kind of health care or health behaviors that are the most important. It is those social determinants of health that have everything to do with income, and wealth, and education. And the World Health Organization had a commission on the social determinants of health in 2007. The concept was around for a while there, but it really got a very official designation with that WHO commission that was led by Michael Marmot.

And the definition from their report is social determinants of health are the circumstances in which people are born, grow up, live, work, and age. And I love that definition because it captures the life course aspect of health. But it does begin at birth. I think about these social determinants’ circumstances of birth and I always think about the parable of the sower in the Gospel of Matthew. The sower sows the seeds. And some of the seeds are scattered onto rocks. And some of them are scattered to very dry ground and they can’t grow. But other seeds fall on fertile ground, and they have sunshine, and they have enough rain to grow and thrive.

And the point about that parable and the point about the definition here is that people don’t choose the circumstances of their birth. We are born, some of us, into very advantaged situations, and others of us into very disadvantaged ones. And we didn’t choose those. We were given them. And for some of those people, religion is present in the social world that they’re born into, and for other people it isn’t. So our purpose in that book was to take a look at religion among the social circumstances of birth. I will mention that the World Health Organization did not include anything about religion in their report, which struck me as a notable absence, being how important it is as a circumstance.

ATKINSON: It is an interesting oversight, isn’t it? Well, tell us how you conceptualize this. In the introduction I also spoke about the fact that you published and thought about this on an individual, population, and organizational level. Tell us about how you conceptualize religion as a social determinant of health.

IDLER: Sure. I’ve been thinking about this for a long time. And I was really helped out by a group of researchers at Harvard, who published in July in the Journal of the AMA a big, systematic review and meta-analysis of studies on religion and health. There were two panels. One of them studied religion and spirituality in serious illness. So those were mostly patient studies. And the other study, the other panel, was for, they called it, health outcomes. So those were more epidemiological population-based studies with representative samples, so that the estimates could apply to a larger group.

And that second group found a really, really strong evidence of association between how often people attended religious services and their rates of survival. So the higher the frequency of attendance at—the attendance part is critical. It’s the social part—(laughs)—of joining with a group of people on a regular basis. And people who had that social tie were much more likely than people who did not have that social tie. And there’s what epidemiologists call a dose response relationship. So the higher the frequency, the greater the survival. And at various steps along the way, survival declined.

But that was one of the findings. There were many findings. But that was certainly one of them. And it was the one for which the researchers said there was the strongest evidence. So I would call that the evidence at the microlevel. It’s a way to think about the way religion plays out in the health arena. And in the lives of individuals, the presence of a religious community and attachment to it is definitely protective of health. That was really strong evidence with respect to mortality and many other health outcomes that they look at.

But there are other levels. We can think about it at the institutional and also at the state level. But I don’t know if you want me to stop there and—(laughs)—or talk a little bit about those two. You let me know.

ATKINSON: Yes, we’ll get to that. Bill, I want to get you in the conversation here about how do you see that religious faith fits into this control knob framework? You’ve worked in numerous countries, over twenty countries, working on revision of their healthcare systems. And what’s been your experience of how religious faith fits into the control knob framework?

HSIAO: It fits very closely and tightly because we have to—we asked the countries to define their goals for health care. And where equity is the principal, equity or equality of health outcomes and a reduce of impoverishment. So what determines the equity part? Well, in the books I’ve coauthored with three others, we emphasized the ethics, ethical values, of a nation. We show you how important this is. For a country, when my team and I go in, the first thing I ask them to do is, one, to form a steering committee to define their equity principles based on ethical principles, values.

But of course, ethical principles are influenced strongly by religious faith. And now also we ask them to allow us to have focus groups with the public, or even large public meetings. Again, common people’s values of equity is influenced by religion. So in my work under the control knob is that actually religion has a very close tie and strong influence on the goals a country sets for itself. But it’s different between countries, though, because their values and their religion can differ greatly.

ATKINSON: Well, I think this is an area here in the United States that we certainly could pay more attention to in terms of the ethics of equity in health care. And, Ellen, I want to return to—you and I had a conversation the other day, and I wanted to return to something we were talking about. We were talking about what faith-based organizations bring to partnerships. And I wonder if you can expand upon that for us, about what do you see as the real skillsets and advantages that FBOs bring to movements of social justice, particularly in the context of equity in health care?

IDLER: That’s a great way to put the question. Faith-based organizations in the United States and around the world play an incredibly important role in health. And I’ve just been reading for a chapter that I’ve been working on about the amount of aid that goes to more and more faith-based organizations around the world, and accounts for a good amount of global health spending, especially by philanthropic organizations like the Gates Foundation. And in the United States, there have been many examples of real, I think, sort of organized efforts in crises, especially, to respond to them. And in April 2019, we did a special section of the American Journal of Public Health featuring the work of faith-based organizations as partners with public health in meeting public health goals.

And one of the chapters, just to lift up one example, was by my colleague at Emory, Mimi Kiser, who was one of the principals in the interfaith health program that began at the Carter Center in the 1990s, and then moved to Emory around 2000. And the interfaith health program in 2009 worked together with federal government agencies to organize faith-based organizations’ vaccine drives for the H1N1 influenza response. And from that, they developed ten sites around the country where vaccinations were given to especially hard-to-read populations. That was the title of the article was, “Faith-Based Organizations Role in Accessing Hard-to-Reach Populations.”

One of the sites provided over four thousand vaccinations and more than 40 percent of the people who were getting them did not have health insurance. And this is after the Affordable Care Act. So they were getting flu vaccines, for free, into communities. And, for example, one story was about how well one particular group could go out to vaccinate migrant farm workers by being there at the crack of dawn before they went out into the fields to work, and then also being there in the evening when they returned. So reaching hard-to-reach populations is important, and is possible, from faith-based organizations because they play a trusted role in their community.

And this particular drive that they might want to be working on is only one piece of the overall mission of that faith-based organization. So it has the context of being a known quantity that has social capital in its community and can really play on the assets of that community.

ATKINSON: Bill, can you give some concrete examples of how religious faith has shaped health policy? And in particular, what population groups were affected?

HSIAO: Well, I can give a couple concrete examples around the world. Well, one—let’s say, in another country. And the obvious way is gender inequality. And some faiths actually do not treat women as co-equal. And when they invite us in to design their health policy, to formulate policy, they reveal that preference towards males, and for sons, and so forth. And we had to struggle with that and try to persuade them that’s not what WHO or UN Declaration of Human Rights, and so forth. That’s one example of it. But in United States, the obvious example is on abortion. And abortion is so closely tied with religious faith of different groups, and I don’t need to explain how that shapes the politics of it and even court rulings, and then—so.

But putting in a more positive light, faith, usually I find—regardless if it’s Christianity or Judaism or Islam or Hinduism or—(inaudible)—because I work in all of these countries—they really all embrace certain fundamental beliefs about human beings. And they expect a basic principle that every human being may have some part which is given by God. So there’s a divine part. Usually it’s defined as goodness part of ourselves. And so in using the control knob that we’re trying to say, OK, you want to create equity or equality in the health outcomes of your people? Then which group has been mostly neglected, OK?

And Ellen just pointed out, you have interfaith groups. Yes, I observe many interfaith groups doing very good work globally. However, I will just say they don’t cover that many people, I’m sorry to say. You really need government to take a major role to deliver basic health care and basic education to people. You cannot just rely on charity and the faith-based dedicated people. They can make a difference, but it doesn’t make it universal.

ATKINSON: Before we turn to you now, how do we move forward in terms of partnerships to improve equity to health care, Bill, I just want to check in with you. So how many nations that you’ve worked with have used this control knob framework to redesign their healthcare systems? And how successful have they been?

HSIAO: Actually, I personally got involved with nearly twenty countries around the world. But including the two largest ones, China and India. Together, they have 40 percent of the population of the world. I’m also working in Africa, the Middle East. So among the twenty, the program we actually designed for them, I’m sorry to say, did not take into account the social determinants. So there, let me explain. All the WHO, and the world now, is talking about social determinants of health, which is important. But government structure is not built that way.

The minister of health doesn’t control housing, food. There you have to talk to the prime minister or president. They usually pay attention to creating jobs for people. Even President Biden. It’s, how do I control inflation? How do I reduce war? The top person doesn’t get into these issues about social determinants, where he or she has to bring all the ministers together. (Inaudible)—in human rights. It’s a determinant of health. Education is definitely. Environment, income, general equality. And I don’t need to bore you with how many ministers, as far as consensus, you have to bring.

So I applaud people who really push for social determinants. And I know—(inaudible). However, the practical world, I discover you really have limitations because the governance structure of the government make it very difficult to make that a reality. And WHO, which I serve on the advisory council, knows that. So I call it a noble vision, but I will argue, let’s pay attention and make a real difference rather than just put out noble vision.

ATKINSON: So before we open it to the floor to receive questions, Ellen, how do you see us going forward from here in terms of partnerships that could be established to really help move forward equity and accessibility in health care?

IDLER: Well, my long-range plan on that—(laughs)—is to educate students to understand the structures and missions of other organizations so that they can work together. At Emory, we have a dual degree program between the Candler School of Theology and the Rollins School of Public Health. And we have a certificate program. And so we have a structure that allows students studying for a master’s in public health, for example, to sit in a classroom for a semester with students who are studying at the Candler’s School of Theology to work in some faith-based organizations or in local congregations. And because they can influence each other’s thinking about this and make the presence of that other structure real.

And I feel like while they’re students now, they will be leaders of their organizations. And ten years from now, fifteen years from now, they could be in a position to see a situation where the possibility of partnership is made much more real because of the fact that they had this educational experience that’s going to carry with them. So that’s my long-term plan. (Laughs.)

ATKINSON: And, Bill, from your vantage point as an economist working on healthcare reform for forty years, how do you see that the faith-based organizations could help move the agenda forward?

HSIAO: I really think the faith-based organizations actually have a tremendous amount of influence. But you have to go through the intermediate step, apply to your faith, your religious faith, translate that into a set of ethical standards, which I call values, which then can be used in policy. Because policy, including the United States believing we should provide health care through the market, OK? That’s a policy decision. And if you understand through the teaching of the faith that you want to have greater equality, markets cannot achieve that for you. You’ve got the exact opposite. The poor people cannot afford it. And insurance companies will not insure the elderly people and disabled people.

So I would urge faith organizations to really understand what criteria that are the control knobs. Which is used, by the way, now close to 36,000 policymakers around the world. The ministry of finance, ministry of planning, the ministry of health. This is through an executive program financed by World Bank that’s done by WHO. So you want to do that translation, that would be what I hope.

ATKINSON: Well, thank you, both. I just want to invite our participants now to ask a question. You can either put it in the chat or you can click on the raised hand icon. And we will call upon you.

FASKIANOS: Yes. That is correct, Holly.

(Gives queuing instructions.)

And I’m looking now for raised hands, to see if anybody—oh! We have our first raised hand from Galen.

GUENGERICH: Thank you, Irina. And thank you to the panel for a fascinating discussion.

I have one very quick question and then one that perhaps a little bit more discussion.

FASKIANOS: And, Galen, introduce yourself, please.

GUENGERICH: Oh, I’m sorry. I’m Galen Guengerich, senior minister of All Souls in New York, and a member of the Council.

A question for Ellen. Do you have a percentage of the decrease in all-causes mortality between the most active participants and the nonparticipants in religious communities? So that’s a simple question. The other question is probably for Bill. You’ve talked a lot about the importance of policy, and the importance of getting government at various levels to do what they need to do policy-wise, so that the inequities are reduced. When it comes to the role of individual religious communities, where is the greatest point of leverage? In other words, it's pretty simple for me to open our buildings and get volunteers to do something like have a vaccine clinic. Where do I point people to effect policy most effectively? Thank you.

ATKINSON: So, Ellen, percent decrease in all-cause mortality?

IDLER: I can take the first one. It’s easy. So there was a systematic analysis that, if I could just quote a study of my own that was in PLOS One in 2017, we analyzed data from the health and retirement study. And so people who attended weekly or more often were 40 percent less likely to have died by a twelve-year follow-up period—ten, sorry—ten years—compared with people who never attended. And then it was—so it was a 40 percent reduction and then, like, 30 and 20 percent reductions for people who had some ties to faith communities, but yeah. And that’s from fully adjusted models. That’s after taking account of the health status of people at the beginning of the study, and other kinds of health behaviors. And so it’s—and income, and education, and all of those things. So that’s the final most adjusted model, 40 percent difference.

HSIAO: My answer to you is that I believe there are two vehicles where the individual religious organization can make the most difference. One is actually, particularly here in the United States, is to get people to discuss the ethical value for health care. And then they can influence other social determinants, as well as the direct health care itself. The second part is to actually engage in some political organizations, like Boston has the Great Boston Interfaith Council, which then they promote political action. They’re very effective because religious organizations have a moral standing. And the people really listen to religious organizations and groups organized by religious groups. Those are my quick comments.

ATKINSON: Hmm. Ellen, that reminds me of an opinion piece that I believe you wrote in the American Journal of Public Health about best practices for faith-based organizations and religious institutions to engage in these kinds of partnerships. Can you review some of those for us, that you’ve really been able to identify as those top best practices for an institution to engage in?

IDLER: Uh-oh. This is a test. I don’t have that piece of paper on my desk right here, but I will call up some things from memory. I think that mutual respect is one of the most important lessons that come from partnerships. There is some history of distrust by religious groups of public health. And some of the Tuskegee studies and other things that I’m sure we could all mention of very, very bad public health processes that have resulted in even more injustice. So the role of public health as a social justice warrior in our culture—(laughs)—we might think of that as fairly recent. And in the past, it wasn’t always so. And so there are—there is mistrust.

And I think that in public health, a lot of times we talk about getting religious groups to do this for us. And there’s an instrumentality to the idea of using faith communities to accomplish some public health goals that doesn’t recognize the importance, fullness, and much broader mission of those public health—of those faith-based organizations or religious congregations. So I would say mutual respect and care in working out and finding where the common ground is is really a big message.

Because faith-based organizations or congregations and public health have—they both have missions. And their missions may overlap at times, but most of the time their missions don’t overlap very much. And so finding where there can be common ground is a lot like what we talk about as bipartisanship in politics. Find where you both want to work together on something to accomplish it, and leave the other parts aside. And so it really requires strategy, and being willing, I think, to find where that area of common ground is, even if it’s not obvious at first.

ATKINSON: Thank you.

FASKIANOS: Thank you. And the next question is, right, from Lawrence Whitney.

WHITNEY: Hi. Lawrence Whitney. I’m a research associate at the National Museum of American History and a fellow at the Center for Mind and Culture in Boston.

Question about the ways you see different religions interacting in public health situations around the world. And I’m thinking particularly when COVID started there were a number of folks claiming that Confucian societies were better able to handle the pandemic. And then a group of policy experts in Global Policy Journal noted that arguing that Confucianism explained East Asia’s success would be as implausible that Europe and the United States’ failures stem from their Christian roots. No serious study has yet offered evidence for such claims. Of course, two months later Andrew Whitehead and Sam Perry came out with a study pointing out that Christian nationalism actually has been a key factor in limiting our ability to handle the pandemic here in the U.S. So I’m wondering if you could comment on the ways different religions interact differently in these spaces and can be helpful, but also detrimental, to the goals of public health.

HSIAO: So you’re asking me or Ellen? (Laughs.)

WHITNEY: Yes.

ATKINSON: Either.

IDLER: Well—

HSIAO: Well—go ahead, please, Ellen.

IDLER: OK. I’ll jump in. I will say that I was very attuned to the headlines about religion during the COVID epidemic, especially at the start of it. And there were a lot of negatives here in the United States, but around the world too. And some of the outbreaks occurred in religious settings initially. People sing—(laughs)—very often when they are in worship services. And singing is a really bad way to project a lot of aerosols. So I did, with a couple of grad students, a text analysis of articles on religion and COVID in the New York Times, from January 2020 through July 2020. And we also looked at the text for the guidelines for faith communities from the World Health Organization and the CDC. And finally, went to the websites of every religious group around the world I could find that had a COVID statement on it, and analyzed all this text together.

It definitely was different from the headlines. The New York Times—we did two things. We did a sentiment analysis, which is based on emotion kind of words, and saw a very strong trend from the quite negative to the reasonably positive sentiment in the New York Times for articles on COVID and religion. And we also did a topic analysis, which showed a considerable overlap between the topics of—that were present in the CDC and World Health Organization documents and the COVID statements that were on the websites of religious groups. And that was fascinating. It wasn’t like they posted the text from the WHO guidelines at all. These were very much faith-based organization statements about their own group’s response. So the message from the actors themselves was a lot more positive than what might have appeared in the headlines.

However, I certainly would not want to ignore the fact that religious liberty arguments were being made about the freedom from wearing masks, and not wearing—not getting vaccines. And so, yeah, there was the Christian nationalism, and Perry and Whitehead are great. That was a really, really good contribution from them. So certainly, that was there. But on balance, there was a much more positive response of the organizations on their own websites, but also big webinars that the National Council of Churches ran repeatedly. And so it was a mixed, but on the whole positive, kind of analysis that we got from our analyzing all that text.

ATKINSON: Bill, do you want to add to that at all?

HSIAO: Yes, because the question is about Confucianism. And I came to the United States at age twelve, but I take a deep interest in Chinese philosophy. So I read some Confucianist writings. I think that Confucianism—Confucianists do not emphasize God or a supreme being. It’s really more a philosophy. And the one major point of philosophy influence this COVID or public health is for the—people who rule, they must actually preserve their position. That means they are looking after the welfare of the people. So in the COVID pandemic, you see the East Asian countries that embrace Confucianism—that’s including Taiwan, Japan, South Korea, and Singapore—these countries’ leaders took action very quickly, unlike the democracy, democratic form of government, like the United States.

And then, of course, there are tradeoffs. China has autocratic government. Originally, policy was very good, but then they make the wrong policy with the—as the COVID, the virus, mutated. And so there are tradeoffs under that Confucianist teaching. However, I just want to emphasize, if they were really practicing what Confucius taught, it’s to be a political leader you have to be observant. You show to people you actually can bring them benefit. And I would say you can say there is some compatibility with democracy here.

FASKIANOS: Thank you. We have several questions in the chat. So I’m going to take the first one, read the first one from Lai Sze Tso from Gustavus Adolphus College.

The translation process for FBOs sounds fascinating. Would there be feedback from local, national, non-FBO health and government administrators? Or are we targeting international charities/USAID?

I don’t know who wants to take that.

HSIAO: I think that’s for you, Ellen. (Laughs.)

IDLER: I’m not sure I understand the question’s point. So I’m—is it about the leverage points, or? I’m not sure I—

FASKIANOS: Lai, are you in a position to unmute and clarify for us? If not, we can go to the next question.

IDLER: I’m sorry. (Laughs.)

FASKIANOS: No, that’s OK. That’s OK. Sometimes with the written questions it’s a little bit more challenging.

SZE TSO: Hello?

FASKIANOS: Oh, hi, yes.

SZE TSO: Hi. So the translation process was referring to when Bill said that for faith-based organizations instead of directly doing work that is charitable with limited effect in a community, that it would be even more effective to translate ideals and goals and ethics into a set of standards. And I was hoping for additional clarification on if that was just at the local and national level, or are we also engaging more widely with international charities, as well as strong influences from organizations like USAID?

HSIAO: Oh, I’m sorry. I misunderstood the question. And sorry I throw that hot potato to you, Ellen. (Laughter.) Let me offer my quick comment. I think actually you want to influence health policy decided by the domestic government. And I would consider that the main avenue. So you want influence in a country, the local churches or even mosques can actually influence how people think and express their views about health, about equity, and access to health care. That’s domestic. Internationally, well, actually, the United States under President Bush did this, which I experienced. Any country to even mention, use the word “Planned Parenthood” cannot receive U.S. foreign aid. And during this administration, actually, the population, the birth control and so forth, really took a major hit.

So we can look through the government channels. But through the NGOs, with interfaith organizations, they continue to do very good work. However, let me just say this. Historically, the Christian missionaries went overseas offer free education or free health clinic and drugs. (Inaudible)—I’m trying to draw you into my faith. That history is still there. It makes the local people very suspicious when they hear it’s an interfaith organization doing something. They wonder what’s the other motive behind it. And so some interfaith organizations were able to overcome that very successfully, but others may not. Because there’s a variety of interfaith organizations working in the world. Literally tens of thousands of them. That’s all.

SZE TSO: Thank you.

FASKIANOS: Great. So we have several questions. The next question I’ll take is from Heather Laird.

I appreciate the discussion on ethics. I found in the work of mental health, ethical humility is needed. Oftentimes, collective values are missed completely in many charters and ethical codes. Do you find this to be the case across health care in general? This is a question for both of you. As you are looking at social determinants, how do you account for diverse views of equity? And how do you ensure voices are represented? And Dr. Heather Laird is at the Center for Muslim Mental Health and Islamic Psychology.

HSIAO: Do you want to go first, or do you want me to? (Laughs.)

IDLER: I think we can both try to answer this question. Great question. So the social determinants of health framework originated with researchers in the UK. And that’s somewhat ironic, isn’t it, because of the National Health Service and the provision of universal health care to people that is free at the point of service and has been since 1948. And so I think that was somewhat of a surprise to people, to find out that income and education and the other social determinants play such an important role in health status of the U.K. population, given that they already had a very robust system of health care in place that was equitable and accessible to everyone.

In the United States, we understand that people do not all have health care. And still, 10 percent of our population remains without insurance, and many people are underinsured. And we also know that medical bills are a big cause of bankruptcy. So it’s—health care is actually driving poverty, driving inequality in a really bad way. So I guess we sort of know that. And the social determinants of health framework makes sense all around us here in the U.S. But even in other countries, where there is equitable access to health care, quality health-care services, there is still inequality with health.

HSIAO: If I understand your question correctly, you want to know about mental health. Is that correct? Let me comment about what I observed around the world. Around the world, the awareness of mental health is not at such a high level as the United States or European countries. And usually, it’s out of ignorance. And because their education level is very low. As Ellen pointed out, that’s a social determinant of health too. And so therefore mental health is neglected. But meanwhile, physical illness is so visible—the pain, or the fever, or disability is so—mental health has lagged behind. Partly, though, I would say religion also has something to do with it, if I may just say.

The question is, in your religious faith do you believe psychology is an important part of the human makeup? Let’s say Russia’s system, Russia and the materialism doesn’t believe psychology has any role. That’s not part of our human makeup. And so I work in China trying to overcome that. And they are now trying psychiatry. And they do not—and the social stigma for the mental health is so severe that you have to overcome all these barriers to be able to bring in really medical health. And the educational part actually becomes the first—as far as really educating the public as well as the policymakers—to say how important mental health is. And that that would draw on the literature, really studies, evidence from the United States and from European countries.

ATKINSON: Well, thank you, both. Unfortunately, we are out of time. It has gone very quickly. And I am going to turn it now back to Irina.

FASKIANOS: Great. I’m sorry that we couldn’t get to the additional questions but, as Holly said, we are out of time. Thank you all for today’s hour discussion. It was very insightful.

We encourage you to follow Bill’s work at hsps.harvard.edu and Ellen’s work at sociology.emory,edu. And you can also follow CFR’s Religion and Foreign Policy program on Twitter at @CFR_religion. Please do email us with suggestions for future topics and speakers. You can send us an email to [email protected]. Wishing you all very happy holidays.

Our next Religion and Foreign Policy Webinar will be in the new year on protests in Iran, on Wednesday, January 11, at 2:00 p.m. Eastern Time. So we will reconvene in 2023. And again, wishing you all happy holidays. Stay safe and well.