About the Series:
Change Matrix has launched a new Podcast Series for 2021, called Equity in Action. Since our inception in 2008, founders Elizabeth Waetzig, Rachele Espiritu, and Suganya Sockalingam have maintained a focus on cultural competence and eliminating disparities. We continue a focus on equity on all of our current projects, continuously look for ways to take action, and look forward to a world where all people get what they need, in ways that work for them, in their communities.
What we Discuss in this Episode:
Dr. Larke Huang learned as a child on the playground about discrimination when she was bullied because of her racial identity. When she grew up, she made a career out of advocating for marginalized minority populations as a senior advisor at Georgetown and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Listen as Dr. Rachele Espiritu, Change Matrix co-founder and a long-term colleague of Larke’s, delves more deeply into her approach to using her professional roles and opportunities to bring about a more equitable environment for all. Listeners will also learn how Larke believes we should all be moving to action in pursuit of equity.
Transcript of the Conversation:
Rachele Espiritu:
Hello, I’m Rachele Espiritu, a founding partner with Change Matrix. And this is the second podcast in our Equity in Action series. I am joined by Dr. Larke Huang, who I’m so excited to get to talk to you today. I first met Larke almost 20 years ago when I was interviewing for a faculty position at Georgetown University. And she’s been my supervisor, a powerful mentor for me, and an incredible role model throughout my career so far. So welcome, Larke.
Larke Huang:
Hello, Rachele. It’s great to hear your voice. And we have known each other such a long time.
Rachele Espiritu:
I know, it was so exciting to kind of reflect on that when I was thinking back to when we first met. It was very early in my career and at that point, it was probably mid-career for you at that point at Georgetown.
Larke Huang:
Yeah, I think it was mid-career, and Georgetown was kind of a middle piece of my, what feels like a very long career. So I know we did some really exciting things at Georgetown, too. So, this made me reflect a little back into the beginning and the middle and the current part of my career. I guess it is kind of, I don’t know if I’d say it’s the end of going on to different things.
Rachele Espiritu:
Yeah.
Larke Huang:
But it’s been a long time in this work.
Rachele Espiritu:
Yeah. Well, before we get into kind of the work part of your career focused on equity, I wanted to kind of start a little bit at the beginning. Now we’ve been asking our interviewees a little bit about when in your early life did you first learn about equity? I’d love to hear about what your journey has been.
Larke Huang:
Well, I’m an older person, so that journey could take a long time to convey to you, but I’ll try to be quick about it. And when I think about it, it wasn’t even considered equity at the time that I was experiencing different things. And I have to tell you that really, my first encounters with what would be considered injustice at the time was what we called it, was really as an elementary school. It was really when I think about it, it was playground fights and playground bullying. We weren’t calling it bullying at that time either, but it was just being teasing because you were different. And I was one of the few Asian students in the elementary school I went to, which was primarily white and, which, interestingly, now is primarily Hispanic. But some of my most vivid memories from that school are the people who were fighting with me on the playground calling me names, saying disparaging things.
And I don’t even remember the other people, but I remember the names of the taunters. And so that struck me as very interesting when I was thinking about it, that that really had both an emotional impact and a long-lasting memory. And it wasn’t something that I talked about with my family — didn’t talk about it with my parents. My cousins also went to the same school, so they were in the same fights. So, we at least had each other there. We were kind of living in an extended family situation. So it really started way back then. I also saw, as I grew older, how my parents dealt with racism and discrimination. We were unable to rent apartments in certain areas. My father was constantly frustrated being passed over for what he felt were deservedly promotions. So, it wasn’t an overwhelming theme in our life, but it was there in our lives growing up.
And, really, I think it was watching what my parents went through as well. And then when I had my own children, I thought, “Okay, this isn’t necessarily going to happen again.” But it did happen to my children in their school settings as well. And we handled it very differently. We really had open discussions about it. We believed in this pediatric concept of anticipatory guidance and wanted to prepare them for it, so they wouldn’t be blindsided, they’d know how to react.
And then my, probably, best friend and person who has been my husband for 40 something years, in high school and college, we were very active in civil rights issues. And really, we’re in a very active group of Asian American students who were learning from the African-American civil rights movement and really trying to have a voice for justice and equality at the time for Asian populations, which were small then, smaller than we are now. Not particularly vocal, not particularly organized. And this is in the mid-to-late ’60s. And both of our parents, his parents also being immigrants, were very fearful of the work and the activism we were involved in saying, “You’re never going to get a government job.” And at that time I thought, “I don’t want a government job.”
Rachele Espiritu:
Oh, the irony.
Larke Huang:
The irony being that eventually, you know, 30, 25 years later, I end up in a government job in a senior position where I had some say and capacity to make a difference for populations. So it’s interesting to me, you made me think about it actually, in terms of how far does this go back, this issue of feeling that equity is important and worth battling for? But we didn’t call it equity. And there have been so many different terminologies over the decades that have evolved to the point of equity.
Rachele Espiritu:
Yeah. It’s so interesting to hear you tell your story, Larke, because I think I had such a similar experience as well as I was growing up, where I was the only student of color in my elementary school. I’ve often shared the story that I never had a teacher who looked like me until I was in college and the message that sends to young students as we’re growing up and how you just see the world a different way.
Larke Huang:
Absolutely. I had one teacher who was Japanese in third grade and she has been my favorite teacher ever since. And we’ve even communicated up to, oh, I don’t know, that’s like 40, 50 some years later. Periodically, we stay in touch.
Rachele Espiritu:
That’s amazing. It’s amazing what an impact it makes.
Larke Huang:
It really does. And you know, you hear about that. You read about it, but you realize that it does make such a critical impact. And now the science supports that. I think I just read something about children who are African-American and have at least one African-American teacher in their public school training are more likely to graduate from high school.
Rachele Espiritu:
Yes, exactly.
Larke Huang:
So, it’s critical.
Rachele Espiritu:
Yeah, yeah, definitely. So Larke, you’ve had such a long career in equity and we talked a little bit about when we first met at Georgetown, but I’d love to hear a little bit more about what your professional journey has been like in this realm, recognizing that at the beginning, the term equity wasn’t what was used. But I remember seeing your book, “Children of Color,” when I first joined Georgetown and was so excited that I got to work with the author and the editor of this book. So, you have clearly been doing this work for a long time. So, tell me a little bit about what that’s been like for you.
Larke Huang:
Sure. So, it’s been a long journey and it’s had its ups and downs, but it’s actually been a very exciting, and even in more recent years, it’s continued to be a very exciting journey. And I wouldn’t shy away from it, and I would encourage people to really immerse themselves in what really does equity mean for our country. And when I started out, we were talking more about equality. We were talking about prejudice and discrimination. That evolved into cultural competence and anti-racism. And I was thinking about all the cultural competence work we did at Georgetown, Rachele, in terms of children’s systems of care and cultural competence in managed care. That really was a critical turning point in the equality discussions and gave us new concepts to think about and also to try to measure. And it’s interesting how cultural competence and anti-racism have evolved into new terminology.
Now, we hear so much about implicit bias. We hear now more about social justice, microaggressions, and equity, and it’s constantly refining the issue. And it’s just as even we, as people, how we refer to ourselves. The terminology has changed over the years from Orientals to APIs. But I think with that constant refining of the issue, it also brought it more into the health care arena. That when we were working on civil rights issues, they were really justice issues. They were legal issues. And now I think we’re seeing it more as public health issues. And I think that’s critical in terms of how we understand the health of individuals and the health of communities. And so, a person doesn’t necessarily have equity, but a community or a system may have equity. And that really broadens how we understand it. And to me, it also moves it more into a policy domain.
It’s just not a clinical or individual encounter issue, but it really becomes something that’s important to think about in terms of systems, in terms of public health issues. And it gives you kind of a different playbook for addressing equity. And I like your title of your podcast, Equity in Action, because I think as the terminology’s evolved, it’s given us more of a focus on taking action.
Rachele Espiritu:
Absolutely.
Larke Huang:
And you know, Rachele, you and I have often both been very action-oriented people. And so that’s, to me been a guiding principle in the work that I do.
Rachele Espiritu:
Yeah. I’ve always admired all the work that you’ve done and from the Georgetown work. And I remember our focus on Data Matters and one of our first publications on EBPs, on evidence-based practices, and thinking about what it meant for communities who are often unrepresented in those studies and in the work. And I just think about the shift that has happened, that you just so eloquently described.
That we’ve moved from individuals and programs to more recognizing the systemic racism that exists in our country and the impact it’s had. And so, I was just reflecting also on remembering the first time you talked to me about the NNED, the National Network to Eliminate Disparities in behavioral health. And I vaguely … not vaguely. I actually vividly remember taking a phone call from you when I was at a meeting in Florida and you sharing this idea of this network, this national network that would bring together community-based organizations that are pockets of excellence doing this work. And it kind of became your baby in some ways during your time at SAMHSA, and for me at the beginning of Change Matrix, it was one of our anchor projects, one of our first projects that came into Change Matrix. So, tell me a little bit about how that came to be.
Larke Huang:
Sure. So I was invited to join SAMHSA as a special expert, I think — or senior advisor special or expert — by the current administrator, Charlie Curry at the time. And he asked me to be a senior advisor on children and family issues. And I agreed to that, but I also said I wanted to really focus on cultural competence. And he gave a nod to that, not really thinking I was really going to invest a lot of time in that. And so I said, “And I also want some money to create a network.” So he agreed to that. And SAMHSA is, does terrific work in the field of mental health and substance use. And they invest a lot in different programs and they’re primarily a grant-making agency, so they’re supporting services. But it became apparent to me very quickly that there are whole populations, particularly ethnic, racially diverse populations, that weren’t really getting the benefits of these investments.
So I really wanted to create a network of community-based organizations again, whose focus was primarily serving the underserved populations and help them to build capacity, learn about each other, become a working network. And at that time, I was reading all about organizational management literature and network structures and how in aggregate they could seed and sustain major movements on what were considered intractable problems. So, looked at some other types of networks in the field and outside of the field and decided to put together a network, invite community-based organizations doing unheralded, but impactful work in their communities. And many of the organizations had developed because of lack of services, lack of mental health and substance use services for their culturally diverse communities. And, in some ways, this really started with my work at Georgetown and some of the work we did. Really looking at what happened to community-based organizations when managed care hit? And they couldn’t keep up with the managed care technologies.
They didn’t have the resources to do new MIS systems or utilization management or contracting, and many of them closed. And we actually at Georgetown, sort of did a study looking at how many were able to survive and how many closed. So it was really thinking about, again, these are under-resourced communities, under-resourced CPOs and now I was sitting in a place that had resources and I wanted to direct them to these communities. So that was the beginning of the National Network to Eliminate Disparities in Behavioral Health care, more easily referred to as the NNED. And that’s when I said, “I know somebody who could really manage this network well.” And called you, Rachele. And we started out with just 35 communities, and I believe we’re up to over 1100 communities that are part of the network now.
Rachele Espiritu:
I used to remember all the names of the organizations, and all the members, and now it’s grown so large.
Larke Huang:
Right. And so we’ve been very excited about the growth and the things that the network has been able to do. And even SAMHSA has come to recognize that this network, not heavily resourced at all, but at least bringing attention to some of these communities and helping them to be more competitive for SAMHSA grants and learn from them. I think the critical thing is we were also learning from them, what works in those communities. When we have evidence-based practices, they always don’t necessarily transfer to the diversity of communities in this country.
So we were learning how they were making adaptations to evidence-based practices. Figuring out effective engagement and outreach strategies that they were using in their communities that we could learn and take to our other grant programs as well. So the NNED’s increasingly a well-known structure now, and is referred to not only by people in our agency but other federal agencies as well. So, we haven’t totally leveled the playing field, but I think we have a viable network of community-based organizations doing remarkable service in their communities. And we wanted to really shine a light on those communities.
Rachele Espiritu:
It’s been amazing. So Larke, you’ve also talked about your leadership roles, the various leadership roles that you’ve had and your ability to impact policy in various places that you’ve been. And so I know while you were at SAMHSA, you implemented the Disparity Impact Statement as a requirement for many grantees to have to complete. Tell me a little bit about how that came about.
Larke Huang:
Sure. Thanks for asking Rachele. That was a mammoth undertaking.
Rachele Espiritu:
Oh, really?
Larke Huang:
Oh my gosh. Yes, it was. But it’s really had a significant policy impact. So the office that I created at SAMHSA was the Office of Behavioral Health Equity. And that was an office that actually was mandated to be stood up by the Affordable Care Act in 2010, and we stood it up by 2012. And Secretary Sebelius was the secretary of HHS at the time. And she put out the first-ever report on racial-ethnic disparities in health. And there are a couple of overarching recommendations in that report. One of them being that HHS grantees should expect Disparity Impact Statements from all their grantees. And it was a very simple recommendation, not a lot was written about it, and it really left it up to the various agencies within HHS, like CDC, CMS, FDA to figure out how they were going to implement that overarching number one recommendation in the report.
So, we were very excited about it in my office. Because we found it gave us an opportunity to have an impact on our grant-making process that was coming from the secretarial level. And this is what I call an inside-outside strategy, that we were getting an expectation from a senior outside executive and we were poised and ready to do it internally. And it was really that combination that allowed us to make major changes in the grant-making process at SAMHSA. So we formulated this Disparity Impact Strategy. We had to move it through our grants management piece, through our grants review piece, through our programmatic centers, through our senior executive leadership team, to get the approval to have a requirement that grantees must submit how they’re going to address needs of disparity-vulnerable populations in their catchment area and submit that to us as a condition of their getting funding. Tying it to funding made all the difference in the world.
Our funding announcements had routinely required something like, ‘You must show that you’re culturally competent.’ But it really didn’t spell out what it meant by that or how they had to show it, nor was it tied to them getting their funding. So before they could get their funding, they needed to identify a population that was underserved in their catchment area and how many in that community they would serve, what kind of services. And they needed to track numbers served, what they were provided in terms of services and what the outcomes were. And that was really no new data collection because they already had to submit that as part of their GPRA requirements — as part of their funding rounds, they have to submit data on service and outcomes. So, we’re not requesting new data, but we’re requesting that they look for underserved populations and it was very interesting. Some of the grantees would say, “Well, I don’t have any of those people in my community. I don’t have any minority people.”
And it was just astounding when they started looking, how they found those people. And all of a sudden they said, “I have a new immigrant population here outside of my suburban Atlanta organization.” Or, I remember a group in Utah saying, “Well, we don’t have many minorities out here.” And then they found a Somali refugee population living in their community. So, we wanted to push them, to do better outreach and engagement with diverse, marginalized, underserved populations. We wanted to expand the reach of SAMHSA resources to these populations. And then some grantees did terrific jobs. They hired people from those communities to help them do outreach engagement. They trained potential providers in those communities. Some engaged in the school-to-prison pipeline. Some of their school-based grants realized that there were more harsh disciplinary practices for students of color, and they implemented guidelines around that and training for school personnel.
So it made people adjust their thinking. It made people think out of their box and we’ve gotten a lot of recognition for that initiative and other agencies also trying to model or adapt our framework for the Disparity Impact Statement in their own grant programs. And that’s been in existence since 2013, so seven, eight years, it’s still an expectation in our grant programs. And we still want to increase how we help the grantee and the grant project officer use the data that they’re submitting to better identify strategies for improving engagement and outcomes. And we also tied it to the national Culturally Linguistically Appropriate Services Standards, the CLASS standards, which really has some very good guidance for how to improve outreach engagement and outcomes for ethnic minority populations in health care.
Rachele Espiritu:
It’s such a nice example of how, at a federal level, a requirement that can be mandated of grantees has such a trickle effect into the way grantees think about it and uncover those often unheard voices in their own communities. And while it was not new data, it forced people to look differently at their communities and engage them in different ways.
Larke Huang:
Right, right. Yeah. And we’re excited that it’s continued to remain a part, and it has really pushed people to think differently. And even our own staff, some staff embraced it really well. Other staff said, “I don’t know how I can monitor this. What am I supposed to do?” And we tried to give as much support as we could from our small office to the grant project officers as well. But the executive leadership team bought into it. They sustained it. And I think we’re going to continue to refine it and continue to grow our expectations around it, given that I think there’s greater recognition across the country on how disparities are so prominent in our health care system.
Rachele Espiritu:
I think it’s great to think about what it could look like moving forward too, because sometimes I think when there are these mandates, there tends to be a technical response, right? It’s a checklist. I did my statement and now I’ll move on to other work and maybe not pay as much attention to it. But as we continue to recognize in our society, the need to focus on equity issues or social justice, what are the challenges that communities face that they can overcome that do require changes in the organization or in the system?
And you and I have talked a lot about how when funding isn’t dedicated towards equity, you can’t really expect change to happen. And it shows the commitment of an organization, or even a federal agency, to look at your budgets and see how much money is being dedicated to the work of equity? What does it look like in your staff? How does it look like in your hiring practices? How do you take an equity lens in who you decide to partner with? All those different organizational and systems kind of changes are necessary to make continued movement in our field.
Larke Huang:
Yeah, no, absolutely. And it’s interesting. I think with the COVID pandemic, there was a greater and undeniable recognition that there are serious disparities in many of our service systems. Whether it’s education, whether it’s criminal justice, whether it’s labor; employment systems; housing, certainly; and health care. And people didn’t usually think about health care as being a disparity-ridden system, actually. And I think now people are recognizing that and recognizing that communities that are living with multiple kinds of challenges and struggles in every aspect of their life, it’s not necessarily because of their own doing. But I think during the COVID pandemic, I’ve heard the concept of institutional racism. Institutional social impediments, greater than I’ve heard in my lifetime. I haven’t seen it so much talked about in the press, in the media, in dinner discussions over Zoom — because you can’t get together with the people anymore — but it never just was so front and center in discussions [as] now.
So I think this is an incredibly important time to think about this window we have for really looking at systems work, at not just program work, but what’s really embedded in our institutions we take for granted. Whether it’s our health care system or our school system in terms of the disparities that they tend to perpetuate for different communities. I think it’s so starkly revealed now that we can’t deny it any further.
Rachele Espiritu:
We can’t ignore it.
Larke Huang:
So this is an opportunity for things like the disparity impact work or the NNED to rise up and really say, “We are addressing some of these issues and we can collaborate with you and learn with you and improve services for our communities.”
Rachele Espiritu:
Well, that so nicely ties into the title of our podcast, “Equity in Action.” And I think that I would love to hear from you around what would you like our listeners to take away in terms of an action that they can take as you think about the changes in our society and the fact that this is so much in the forefront?
Larke Huang:
Yeah. So, Rachele, that’s really a good question, and I’m not sure I have the answer for everyone. But I know that a guiding principle for me in all of my work, from the very first days of even being in graduate school, it was really get to action. And sometimes that got me in trouble, or I got push back from that. But I think in this area of really addressing equity, I think, and I would often say this around cultural competence, too, that we have to get beyond just the awareness. The awareness is the first part, but some people stop at the awareness and think, “Okay, that’s the action that I’ve taken. I’ve gotten to awareness.” But I think that we really need to look at well, what does action mean? And how do you get to product, or how do you get to action?
And that’s really engaging in behaviors or supporting policies that really will make a difference in people’s lives and recognizing what actions or policy levers you actually have control over. And people often don’t realize that. I know when we were doing — whether it was a Georgetown or whether it was at AIR or SAMHSA, as you mentioned, the budget is probably the biggest policy lever that organizations have. And what you influence, what you advocate for in your budget, what you don’t advocate for in your budget is making a policy statement. So I think people who are in those decision-making positions really need to look at the different kinds of policy levers they do control, and look at their policies and the intentional or unintentional impact on increasing or decreasing disparities. We have many policies that have good intentions but actually created more disparities. I was talking to a new school teacher who said she was told to keep track of children with difficult behaviors so that they could get services.
So she kept an accountability notebook on these students, and she also sent them to the principal’s offices. Well, many of them were students of color, and many of them eventually got expelled, and she thought she was doing something supportive so they would get extra services. But she realized that wasn’t the case at all. So she had really good intentions, but they worked out very negatively for the students until she realized she needed to change her behavior. So I think looking at the unintended consequences of decisions one makes is really critical, because they’re often made with best intentions. I think looking that at policy advocacy, I was just looking at the new American Rescue Bill that Congress just passed. And there are some striking provisions in there that are very health-focused and education-focused, and that will help children of color. The child subsidy of $300 per month for children under 17 — and I think even more for children under 6 — really is going to help children of color.
They feel it’s going to bump children out of poverty by about 50% and have a major impact, particularly on African-American children. So I don’t think people necessarily see that in that legislation, but those are things to look at to ensure that it gets not just enacted, which it should, but how does it get implemented? And in fact, will those children get the unconditional subsidies that are part of that plan?
So we often have subsidies or funding that goes to states or that goes to communities, but the right people aren’t always at the right table. So I think working with your community advocates to make sure they’re at these decision-making tables is critically important.
Rachele Espiritu:
Absolutely.
Larke Huang:
So I actually think that we’re positively trending right now and that there is an important window to really take action and it could be on a small level or a major policy level. But I think I to have this kind of front-and-center in your thinking in terms of the work that anyone listening is doing to recognize that you can work to reduce disparities. And there are specific steps to really improve equity for all populations. And I think when we do universal programs, like this American Rescue is going to do, it’s going to raise all boats for all children. We’re not just targeting one particular population, but we do have to make sure that the most vulnerable are included in those allocations.
Rachele Espiritu:
Right. Because I’ve heard you say in the past, when we focus on the most vulnerable everyone benefits.
Larke Huang:
Right, right.
Rachele Espiritu:
And that’s important to remember.
Larke Huang:
I believe strongly in the trickle-up theory that focus on those who are vulnerable, it will trickle up to all populations. When you just focus on those who are most advantaged, it does not trickle down to the least advantaged populations.
Rachele Espiritu:
It does not. Larke, I so enjoyed our conversation. I want to just leave with, well, one, thanking you. And I miss you tremendously now that you’ve retired from SAMHSA and I don’t get to talk to you on an every-other-week basis anymore. And what are some of your next steps? Where are you going from now? You didn’t talk about the end of your career. You talked about a different point in your career. So I’m curious to hear a little bit about what is in the future for you.
Larke Huang:
So some of that’s still to be determined. I’m taking a break and recovering from work and enjoying not having deadlines or meetings to attend every hour, on the hour. But I still am dedicated to improving communities and peoples and children and families lives. And particularly with a focus on those again, who tend to be more marginalized. So I’m sitting on a couple of boards that I think hopefully will make a difference. And I will continue to be a strong advocate in ways that I can for the whole equity agenda in ways that I couldn’t before. As a federal person, I couldn’t actively advocate on the Hill or get involved in political issues as much as I can now. So I hope to do some of that. And I’m up for thinking about how I want to spend my next couple of years.
Rachele Espiritu:
Yes. Well, thank you so much, Larke. I appreciate that you’re staying in the field because your voice has been so important for so many decades. So thank you.
Larke Huang:
Thank you, Rachele. It’s been great working with you on the NNED and other projects. And I know that our paths will continue to cross.
Elizabeth Waetzig:
You’ve been listening to Equity in Action. Join us next month as we hear from Julie Ramirez, a community leader in Southeast Colorado Springs about her work collaborating the Change Matrix and the Colorado Equity Compass. Julie will speak about how to authentically engage communities and how to use data and stories to advance healthcare equity.
