Empowering Providers and Patients to Get Political - Dr. Alister Martin, Founder of VotER

JANNAH AMIEL: Hi, I'm Jannah Amiel and today on Raise the Line, I'm happy to be joined by Dr. Alister Martin. Dr. Martin is a practicing emergency physician and a faculty member in the Harvard Medical School Center for Social Justice and Health Equity. He had a particularly busy year as a founder of VotER, which is a non-partisan project that provides people with the opportunity to register to vote. His passion for health policy that empowers patients also informs another project he created called Get Waivered, which aims to expand access to treatment for those struggling with substance use disorder. Thank you so much for being with us today, Dr. Martin.

DR ALISTER MARTIN: Thank you, Jannah, and it's a pleasure to be here.

JANNAH AMIEL: Excellent. So first, if you can start just by telling us a little bit about yourself and what led to your interest in pursuing a career within medicine and specifically emergency medicine.

DR ALISTER MARTIN: My interest in emergency medicine really comes from my own personal story growing up in a low-income community in New Jersey. I grew up in a shore town in New Jersey, it was majority minority. Grew up with a single mom at home and like many other families and communities like the one that I grew up in, we struggled with access to health insurance. We struggled with access to healthcare. And when it came time for me to get checkups or to get evaluated for non-urgent things, often the decision was to go to the ER, not unlike many of the patients who I see now. And so, I learned from a young age that emergency rooms hold a special place in vulnerable communities. They not only help with emergent or acute issues, but they're effectively the central node that vulnerable communities go to when they need things that are healthcare or healthcare adjacent. Things like getting a work note or things like getting a prescription refill or addressing some of the other social determinants of health, things like housing access or issues with addiction.

So, I learned from a young age that ER docs and emergency rooms really hold this incredible social safety net together, and that it was going to be my responsibility to be everyone's doctor as an ER doc, irrespective of ability to pay, insurance status, or other functions of our contorted healthcare system. When I went to medical school, it was fairly clear to me that I was going to be an ER doc. It was also fairly clear to me as a medical school student how broken our healthcare system is for those who it really, really cannot afford to be broken for; the most vulnerable patients, people of color, young people, poor people.

What wasn't clear to me though, was how I was going to be part of the solution and not part of the problem. So I decided to take some time off, went to the Kennedy School of Government, learned how the levers of change work to a degree in this country when it comes to healthcare policy changes. Then I worked in state government for about a year up in Vermont, and then eventually came back to start my emergency medicine training here at Harvard and have since stayed on as faculty after graduating.

JANNAH AMIEL: That is incredible. So, one thing that you touched on -- and I have this conversation sometimes too as a registered nurse when I'm talking to students and other healthcare professionals -- it's interesting, because I feel like in the role that we play in healthcare, we're positioned in a different way than other professions are positioned to see some of these social determinants that you spoke about. And what you've done is stepped out, kind of outside of that clinical box, to say, "I recognize this and I think I need to help form a solution in this way and acquire these different skills and knowledge to do that." And so, I'm really curious about the VotER, this initiative, and when and where and what inspired you, and where that is now.

DR ALISTER MARTIN: So, my experience as an ER doctor informs “the why”, behind why this is important. My experience working in politics taught me “the how” -- how we might be able to address some of the problems that I saw. Just to sort of start at the beginning. We have 50 million people in this country who are not registered to vote; voting age, eligible people in this country. That's the entire population of Spain. And when you look demographically, the top three groups that are overrepresented in terms of not being registered are young people, poor people, people of color. Those are the same exact groups that are most often marginalized by the healthcare system. Young people, poor people, people of color. And so, it became clear to me that we have a very obvious demographic overlap. Those two Venn diagram circles nearly completely overlapped with regard to who is not registered and who is most often marginalized by our healthcare system.

Let me pause for a second. There's no accident we have this overlap between who is not registered and who suffers the most. You see, because in our system, if you are not at the table, you are on the menu, politically, so in order to make our healthcare system work better for vulnerable people, we have to organize them politically. We have to help them vote. VotER, really, was just a very simple and straightforward approach to helping people get their power back. As Toni Morrison said, "When you get these jobs that you're so brilliantly trained for, remember that your real job is, if you have power, to empower somebody else." Healthcare providers have forgotten that. So, VotER really is about how do we use healthcare settings, places where healthcare is delivered, to invite people to register to vote. I can tell you more about the functions of what that actually looks like, but that's the why.

JANNAH AMIEL: Yeah, I'd love to hear about that. And maybe in the context of this election season, do you feel like you accomplished what you wanted this to do?

DR ALISTER MARTIN: Look, two years ago, we started the initial planning for this work, and we knew that we had to have a system that met three criteria. Number one, non-partisan. Absolutely cannot be affiliated or associated with any candidate or any campaign. Number two, non-coercive. We absolutely cannot be having patients feel like, "Oh, if I don't register to vote, you're not going to give me my levofloxacin.” And number three, non-interruptive. I'm an ER physician. I do not have time to walk around an ER with voter registration paperwork helping people register to vote. You're a nurse, Jannah, you don't have time. If I don't have time, you definitely don't have time to be walking around doing more paperwork. So, it had to be non-interruptive because we have a job to do and the primary job is caring for patients, but while we're there, the question is, could we come up with a system that was seamless for patients to do most of the work, 99% of the work, to get themselves registered to vote?

So we started about a year and a half ago deploying kiosks to emergency room waiting rooms. These kiosks had big signs over them that said, "Use this kiosk to register to vote." We had gotten all the way up to February and March -- we had 25 hospitals using these kiosks -- and then the pandemic hit and it didn’t make sense to send another touchscreen surface, a fomite, to hospitals across the country, in the middle of the pandemic. So, we had to pivot and we had a decision to make. “Do we stop doing what we're doing? Because maybe the country just isn't in a good place for voter registration. Maybe it's not a good idea to be leveraging healthcare settings at this time. Or, is this the reason why we need to be doing this in the first place?”

We had so many doctors, individual doctors, med students, nurses reaching out to us saying, "I'm upset. I'm angry. I'm frustrated that I'm using the same N95 for four weeks in a row. When previous to this, they told me this was a single use item. I'm pissed off that I'm now being told, I’ve got to make decisions about who gets a ventilator and who doesn't." We heard this fury, this indignation from healthcare providers all across the country asking us, "What can I do other than post on Twitter and Instagram?" We said, "Great. Yes, post on Twitter and Instagram, and get three people registered to vote." We created a new system called the Healthy Democracy Kit, which is – and I know the listeners can't see this so I'll try to explain it in concrete fashion -- every healthcare provider when they go to work needs to wear a hospital ID. and most providers have a lanyard that holds that ID.

What we've done is we've created a huge badge backer that goes behind your ID that has really clear wording on it that says, "Register to Vote," and it stands out aside from your ID. It has a QR code and a text message code that patients can use to register to vote or check their voter registration or get a mail-in ballot. Then they have a lanyard that we use to connect their hospital ID and their badge backer. The lanyard says “Register to Vote” on it as well. So for example, when I go to work on Saturday, what will happen is likely what happens every shift. A patient will ask me, "Hey doc, why does your lanyard say ‘vote’ on it?" And I'll say, "Well, it says vote on it because if you're interested, while you're here, I can help you get registered to vote. All you have to do is use that QR code or that text message, and it'll take you 90 seconds. I think it's really important for you to register."

So, that's kind of how we do it. We've gotten 25,000 healthcare providers across the country who have those Healthy Democracy Kits, and we've gotten over 48,000 people, either registered to vote or who have started their mail-in ballot process. These are healthcare providers across the country who are helping their folks get ready to vote.

JANNAH AMIEL: That's amazing and brilliant.  A big takeaway is that because the pandemic hits and now it feels like the world is shaken and upside down, you could just forget everything that you had plans for, but instead you utilized that as the catalyst to say, "No, we're going to keep going. And this is how we make the change." And maybe this narrative changes. That's fantastic. What about Get Waivered? I'm curious about that. So, that's become a national model for expansion of treatment of opioid addiction. Can you tell us how that works and what that has achieved at this point?

DR ALISTER MARTIN: It's a good question. It's animated by the same forces that VotER is, which is “can we use the opportunity that we have with vulnerable patients who come to the ER to help them move forward in a more productive direction.” We have in this country -- COVID has obviously knocked it down a peg -- but we still are very much in the grips of a national opioid epidemic. When I started back in 2015 in emergency medicine, I had a patient who came to me asking for help with her opioid addiction. I was a young and excited and naïve new doctor who had worked maybe two or three shifts. And this woman came to me asking to get into recovery treatment. I remember being in that room with her and feeling the desperation that she had. She was even there with her suitcase.

We call it the “positive Samsonite sign”. If a patient has a piece of luggage or a suitcase in the ER, you know you got a problem. This woman had nowhere else to go. She literally came with everything she had to the ER for us to help change her life. She was done with her addiction. She had never signed up for this, never wanted this to happen to her and she was asking me for help. So, I leave the room and I'm thinking, "Of course, we're going to help her." Of course, as a two-week-old doctor, I had no idea what we were going to do so I went to my attending, who was my boss, and I said, "Look, I got this woman here who needs help" and I created a draft plan. I said, "Let's admit her to the hospital, and let's consult some specialists, and let's get her sorted out and get her on the road to recovery."

He said to me, "Alister, that's wonderful. That's also not what we do here. Discharge her." I remember that walk back from my attending's desk to her room was the longest walk I've ever taken. I remember seeing her roll her suitcase out of the ER with a stack of discharge paperwork in her hands to detox facilities that I, and she knew, were defunct; that would not actually help her get into recovery. Half those numbers didn't even work. They weren't even the right numbers. The other half, you needed some mega insurance to get, which she didn't have. So, I was discharging her with a bridge to nowhere and that is the current state, unfortunately, in the majority of ERs across the country. So Get Waivered was all about, “how do we transform emergency rooms into the front door for recovery?”

Well, you have to first start by having a Drug Enforcement Administration “X waiver” so that you can prescribe a medication called buprenorphine. The vast majority of people who get started on buprenorphine get their lives back, recover, get their jobs back, make amends with their families, go back to school. In 2015, this was definitely not the norm. Get Waivered is all about trying to get as many physicians across the country to get their “X waiver” so that they can prescribe buprenorphine in ED settings. At this point we’ve gotten about 3,000 doctors across the country to get their waivers and these are agents of change in their local ERs and communities, and they're helping to institute protocols in their ERs to help get patients into recovery.

JANNAH AMIEL: Fantastic. What's next for both of these things then? What can we look forward to for Get Waivered and for VotER?

DR ALISTER MARTIN: For VotER, the goal is to deepen the foundations of our networks all across the country. As I mentioned, we have about 25,000 individual healthcare providers who are using VotER kits to help their patients register to vote year-round because strengthening our democracy is more than just what happens on November 3rd. It's a year-round exercise. It's a muscle that must be strengthened. So, we are deepening our networks in that regard. We have about 300 hospitals so far that are partners of VotER. We'd like to 10X that over the course of the next year to two years. And really, it's all about how do you build power not only within the patients that we serve by helping them get registered to vote, but also how do you build power among healthcare providers? Healthcare providers for too long have been apolitical, have been bystanders, have been, as I mentioned, items on the menu.

So, how do we help providers learn some of the fundamental skills of community organizing, of making hard asks, of power mapping. These are things that we do here at VotER because that's just how you do this work nationally. We want to teach that to other providers so that they can be effective in their local communities. For Get Waivered, it's simple. We want 10,000 people who we have helped get waivered in the next 16 months. We currently are on pace to get there. The way we do it is we actually have national Zoom waiver training classes that are these mega classes. So, one of our classes in May had 1,200 participants who signed up. One that we had in December had about 600.

If folks are interested on that end and you want to get your waiver, go to getwaiver.com/remote. Classes are free. You can sit at home in your living room and do laundry and your dishes and get your waiver. So, that's the next step on that end. On VotER, if you want to get a kit, that's free also. We highly recommend you do it. It's vot-er.org/kit. Get your kit, start empowering your patients, start empowering your friends and family, and make sure that you are a part of this democratic process year-round.

JANNAH AMIEL: Excellent. And you can't beat free, guys. You just can't beat it. Awesome. So, I'm going to pivot a little bit to COVID because we cannot ever have a conversation, right, without COVID. It's just a very real thing and multilayered and happening to us in very different ways. I'm curious, from your perspective, especially being in the ER, what do you think that this COVID crisis has revealed about our healthcare system? And what are some of those key steps that you feel like need to be taken in order to strengthen it?

DR ALISTER MARTIN: I think that COVID unmasked for some people glaringly obvious healthcare disparities that we have in our country. Look at who died the most, disproportionally speaking: people of color. Look at where you saw disproportionate impact of morbidity, mortality, because of COVID: big urban cities, metropolitan areas. And primarily in those cities, the low-income districts. Look at who was able to work from home, or who was able to go to their summer house at the Cape, right? And who wasn't? And so, at the end of the day, I think what it demonstrated to us was, we have a deeply unfair and two-tiered system. Not only of our healthcare system, but of our labor system, and who is able to have flexibility in their work and who is not. Until we are able to start from the beginning when it comes to health policy, thinking about health equity, we are going to continually chase our tails and I have a good example of that.

When it came time for us to be thinking about instituting crisis standards of care in our hospital here -- not only in our hospital system but every single hospital in the state of Massachusetts -- we had to come up with rules about who was going to get a ventilator and who wasn't, basically. Well, guess what happened? The rules stated, if you have things like diabetes, or if you have things like end stage renal disease, or even CKD with a creatinine over three, or if you have obesity, or HIV -- all of these things that are found at higher rates in communities of color -- you get those points to count against you, making you less likely to get a ventilator.

Well, why do those folks have those diseases at higher rates in the first place? Because of the brokenness of our health care system. So now when they come to the ER with COVID, a disease that impacts them more frequently, now you're telling me that also they're less likely to get a ventilator, less likely to get critical care resources, less likely to get resuscitation? And so, just one example of many, where if you don't start with health equity, what you'll find is you'll end up creating systems and policies that just deepen the divide.

So, I would say that it's not enough to just identify that there are healthcare disparities. It's now, what do we do with it? That's the challenge for healthcare. That's the challenge for each of us as individuals, because there are a lot of policymakers and decision-makers that are listening to this. What will you do to ensure that the policies that you helped to implement start with health equity so you don't inadvertently deepen the divide, so you don't inadvertently cause more harm? So that would be the challenge for all of us.

JANNAH AMIEL: That's a fantastic point. I just want to stick with that for a minute, with health equity, and specifically thinking about healthcare professionals. Right? So, I'm the person who's always advocating for "Get out there and do something. You're more than the doctor, the nurse, the nursing assistant, this person." We meet people at various stages of their life. We see the community in ways that other people don't see community because of how they come to present themselves in the ER or on the unit. What do you think, as far as the healthcare professional -- whether we're talking about doctors or nurses -- what do you imagine needs to be a part of our role in order to better serve the community? And to be more astute, to pick out and to identify when we see this disparity, we know it's happening, right, and we have ideas, what do we need to do? What didn't we learn in school that we need to make sure that we're equipped and empowered with so that we can help to push these changes?

DR ALISTER MARTIN: Yeah, that's a good question. I think the first thing I'll say is, most people did not learn this in school and that's an unfortunate reality. I think that just like we didn't really learn civics in school, many of us, and we didn't really learn the legacy of historical injustices towards people of color in this country, in the correct way, or the legacies of institutional racism in the correct way in this country. So in fact, it's not even learning, it's almost unlearning that has to occur first. People have assumptions and misconceptions and biases about why certain groups, people of color, have worse health outcomes. There are dispersions that there is some sloth or this insensitivity towards their own health or lack of care towards things that might make them healthier. All of these things represent, unfortunately, the bias that's been drilled into us living in this country.

So, there's unlearning that must begin first, I think. And folks have to check their own biases and figure out how do you really think? What do you really think about why we have healthcare disparities in this country? You start digging into that a little bit and you start to go back to, "Well, actually, maybe the system is actually working exactly as it should, and patients are just suffering the consequences of that system." For example, you start reading about red-lining and the ways in which African-Americans after the great migration were effectively corralled into the poorest, least healthy, most congregated slums of big cities. You start reading about the way that certain groups were blocked from, for example, the GI bill, or ability to get home loan assistance, or mortgages to begin to accrue equity. And you start to begin to sort of make the connections that maybe this is not so much individual decision-making that's leading to dramatic healthcare disparities in this country.

Maybe this is just actually the result of policy-making over the course of decades, if not centuries. So, I think that, that would be the first place to begin, is to sort of do some internal reflection on what you really think about why there are healthcare disparities. And then go educate yourself, figure out if you're right or wrong; maybe you have it correct. But I think if you look at the history and you look at the arc of history with regard to policies and how they impact people of color in this country, you'll come to a conclusion that I think most folks have, which is that the system is deeply unfair and we have to exert a lot of effort, energy, and an intention to try and undo where we are now.

JANNAH AMIEL: That's excellent. Excellent and actionable. Thank you for that. So, we're a teaching company and we love to fill knowledge gaps. I'm curious, is there any topic that you'd like to educate us on that you think everyone ought to know?

DR ALISTER MARTIN: The connection between politics and public health is incredibly robust. In fact, to try and disarticulate public health from public policy is nonsense. Where there is higher voter turnout, more resources, i.e., money, is dispersed to those districts. What does that mean? What that means is when the mayor is thinking about who gets that next health center, who gets that next boon of assistance for folks who need whatever form of healthcare they need, where do they look? They look at who voted. They look at who contributed, and often, politicians have this great internal tension. Right? They sit with their aides in a room and they look at two different maps. On one map, it's who are all the people who voted for me at high rates? Who turned out to vote? And on the other map, it's who needs the most help? What are the areas that need most assistance?

Unfortunately, what ends up happening is the groups that turn out, the groups that contribute to political campaigns, are the ones that are from districts that don't actually need the help. Right? But because they did so, they did turn out at 60% turnout as opposed to 12% in the black community of that city, that 60% turn-out group, they're getting it all. Right? Because that politician feels a sense of what? Reciprocity. Maybe unspoken reciprocity, sometimes it's spoken. I've been in the room. So, in order to be able to correct some of the healthcare disparities that we have, and in order to really truly send assistance to the areas that really need it, we need to help our people vote. We need to help our people be part of the process. Why? Because politicians listen to and are attentive to the folks who are actually being part of the process.

Unfortunately, I mean, that's just the reality of the system that we've built. So, I would think a lot about how do we help our most vulnerable people be part of this political process, have their voice heard, because it benefits us all. That's the education, the homework I would give folks. Learn more about that connection between politics and what that actually ends up representing in terms of local health care policy and the distribution of resources.

JANNAH AMIEL: Noted. That is great advice. And for our students right now in our audience who are listening, for our healthcare professionals that are early on in their career, is there any other advice that you would give them in the way of how to meet the challenges of the moment? And that can be COVID and dealing with that, or that can be what we've been talking about, about these healthcare disparities? Is there any other advice that you would give to these early folks?

DR ALISTER MARTIN: I used to think that there is this room of smart people somewhere in state government and federal government who had 30 whiteboards all around them, and had some of the smartest minds in one room, figuring this all out, all of the challenges that we have. And then I learned, that room doesn't exist. You are in that room. It's on us now. All of these policies that I've talked about, the issues with our health care system, the ways in which we don't care for people in the ways that we should, none of these things are immutable. All of them are subject to change.

They just really need energy, effort and intentionality from you to fix them. And they won't change if you don't get involved. What I learned also is that those rooms often are not filled with folks, like those really smart people in a room, they're not thinking necessarily about what are the innovative new ways that we can make things better? Often, they are the agents of the status quo, and often they want to keep things the same. So, I'll end with this: we are who we've been waiting for. Get to work.

JANNAH AMIEL: Amazing. Thank you so much, Dr. Martin, for being with us today. This has been fantastic.

DR ALISTER MARTIN: Thank you, Jannah.

JANNAH AMIEL: I'm Jannah Amiel. Thanks for checking out today's show and remember to do your part to flatten the curve and Raise the Line. We're all in this together.