Biden’s appointment of a health disparities adviser is historic. But will the White House empower her?

WASHINGTON — President-elect Biden’s slate of high-level health care appointments includes an unprecedented selection: The first-ever presidential adviser with a sole focus on combating racism and racial disparities in health care.

Since December, Marcella Nunez-Smith has served as a top Biden adviser and the chair of the incoming administration’s new task force specifically focused on combating pandemic-related health disparities. Her work, Biden has said, will ensure “that fairness and equity are at the center of every part of our response.”

Amid a pandemic that has devastated Black, Latino, and Native American communities, health equity experts have uniformly applauded Nunez-Smith’s appointment. By including the Yale physician and health disparities researcher in Biden’s inner circle, they argued, the incoming administration has signaled an extraordinary commitment to combating health care injustice.

But all the same, her appointment left behind a key question: What will her job actually entail?

“One needs to have decision-making power and a seat at the table to really be shaping upstream policy decisions and resource-allocation decisions,” said Alondra Nelson, a former colleague of Nunez-Smith’s at Yale and the president of the Social Science Research Council. “The role itself is really important, but the role itself is insufficient.”

So far, the Biden campaign has provided little detail about Nunez-Smith’s specific role. In response to questions from STAT, a campaign spokesperson provided only a brief job description. Nunez-Smith, she said, will report directly to Jeffrey Zients, the former Obama administration economist who Biden has tapped to serve as his Covid-19 coordinator, overseeing the administration’s pandemic response.

She will also help to oversee the pandemic response efforts from health care agencies and the federal government more broadly, the spokesperson said, citing specifically the Departments of Health and Human Services, Veterans Affairs, Labor, Housing and Urban Development, Homeland Security, State, and Defense, among others.

The spokesperson declined to share more specifics about Nunez-Smith’s responsibilities, including whether she’d have a staff or to what degree she’d have decision-making power in Biden administration health policy debates.

Three health equity advocates who spoke with STAT were clear about one thing: just having a high-ranking official focused on the issue was a huge step up. Nunez-Smith has advised Biden for months already. Her experience as a co-chair of Biden’s coronavirus task force, alongside David Kessler and Biden’s surgeon general nominee, Vivek Murthy, will only expand the access she already enjoys to all aspects of the administration’s pandemic response.

“It matters to have a position that is approximately Cabinet-level, and have the ear of and regular contact with the executive,” said Nelson. “That’s just important, to the extent that you can help to amplify all the work that is taking place in these other bodies.”

Coordinating will also be critical, the experts said. They point out, for example, that it’s impractical to ask Americans exposed to Covid-19 to skip work and quarantine unless they receive housing support and paid sick leave, initiatives that would require cooperation from HUD and the Department of Labor.

Nunez-Smith will also serve as a liaison between the Biden administration and communities of color, according to the Biden transition. That role will likely be critical amid the push to encourage all Americans to seek Covid-19 vaccines, given broad vaccine hesitancy nationwide. Public health officials have specifically cited the need to gain Black communities’ buy-in for the vaccination effort, even amid widespread distrust of the medical establishment in light of past ethical abuses.

But Nunez-Smith has urged caution. In an interview with STAT following her appointment as a co-chair of Biden’s coronavirus task force, she argued that singling out communities of color — or even suggesting that historically marginalized groups should receive priority vaccine access — can be a double-edged sword.

“People of color all hold the memories of experimentation that are not all so distant,” she said. “It didn’t just start with Tuskegee or Henrietta Lacks. So you can really understand if there are communities that are wary to be called out in a way that …. [feels] like another way of continuing experimentation.”

The wide-ranging portfolio means the full scope and details of Nunez-Smith’s assignment likely won’t become known to the public until well after Inauguration Day in three weeks’ time.

But in general, advocates aren’t concerned about the lack of detail in her assignment. In interviews, they argued Nunez-Smith’s experience in patient advocacy and research, along with her time spent advising Connecticut’s governor on Covid-19, will all equip her for the new role.

Nunez-Smith’s highest-profile appointments include serving as the chair of the Southern Connecticut Sickle Cell Disease Association’s medical advisory board and, since this summer, as one of Biden’s top pandemic advisers.

She is also the Yale School of Medicine’s first-ever associate dean for health equity research and an accomplished researcher. She serves as the lead investigator on a number of federally funded studies — one of which includes a five-year project to study the factors linked with heart disease and diabetes in the Caribbean, including in the U.S. Virgin Islands, her birthplace.

Nunez-Smith’s work at the sickle cell advocacy group will also foreshadow her future responsibilities, argued Nelson. Sickle cell disease, she said, disproportionately plagues people of African descent and has long gone ignored — only in recent decades have federal research authorities and pharmaceutical companies begun to research new treatments and cures.

It’s unprecedented for the White House to appoint a high-level adviser whose expertise lies principally in the field of health equity. But that doesn’t mean the federal government doesn’t devote resources to the cause; to the contrary, there is a substantial federal infrastructure devoted to combating health disparities. The Department of Health and Human Services houses a sub-agency called the Office of Minority Health, and there’s a similar office embedded in the Centers for Disease Control and Prevention. Separately, the National Institute on Minority Health and Health Disparities funds over $300 million in research grants each year. Nunez-Smith herself has won several.

Nunez-Smith’s appointment has already earned plaudits from the woman who helmed the Obama administration’s health equity work: Nadine Gracia, who served as director of Office of Minority Health and currently works as COO of the public health group Trust for America’s Health.

“She will have great colleagues to work with throughout the federal agencies, embedded within the minority health and health equity leadership structure,” Gracia told STAT in an interview.

Under Trump and throughout the Covid-19 pandemic, however, the federal offices focused on health equity haven’t played a major or public role in responding to the crisis. That has led advocates to criticize the officials in charge — and the Trump administration more broadly — for remaining silent amid Covid-19’s devastation to communities of color.

Nunez-Smith herself has been outspoken regarding the country’s — and the government’s — failures not only to care for people of color during Covid-19, but to simply collect data about which communities were suffering most.

“We cannot address what we cannot see,” Nunez-Smith said last month during a Kaiser Family Foundation briefing. “We are making a choice every time we allow poor-quality data to hinder our ability to intervene on racial and ethnic inequities.”