Joan Quinlan, MPA: A Career Dedicated to Serving the Underserved and Driving Access to Health Care

Q:  Joan Quinlan has dedicated her entire career to advocating for the underserved. As the founding Director of the Center for Community Health Improvement, and the current Vice President for Community Health at Mass General, Joan has strived to improve the health status of disadvantaged communities and their access to healthcare, by addressing their unique public health needs and the structural barriers they encounter. 

In addition to work in CCHI, Joan has lent her expertise to a variety of other Mass General initiatives related to substance use disorders, gun violence prevention, and diversity and inclusion.  

Prior to coming to Mass General, Joan served as the Administrative Director for the Boston Healthcare for the Homeless Program, was the advisor of women’s issues to Governor Michael Dukakis, and the Executive Director of 9 to 5, the organization for women’s office workers. So welcome, Joan. It’s a pleasure to have you today. 

A:   Thank you for having me, Kelsey[?]. I'm happy to be here.  

Q:   So, to start off, I’d love to ask, how did you develop your career in community health? 

A:   So I never planned to have a career in community health. I came to Boston. I was an English literature major at Boston College. And my passion at the time was journalism. And when I graduated, I freelanced for a while. But the economy was such that jobs were hard to come by. 

And I remember this moment, riding in the car with my then-husband, and hearing a story on the radio about an activist organization that was fighting for women’s rights. And I said, “I want to work in a place like that, that actually is doing things, not just writing about them. Not that writing about them is not important.” And my husband said, “Well, why don’t you try?” And that was totally shocking to me.  

So I went ahead, and I applied. I was turned down because I didn’t have the experience. But I went out and did a few related things for less than a year, and they called me and recruited me. And the rest is history. So my career is not so much community health as it is social justice. 

Q:   And what was that experience like being turned down in the beginning for something new that you were pursuing?  

A:   It was tough. But on the other hand, I never thought I even belonged there, in the first place. And I tend to get a little stubborn. And if you turn me down for something, I'm liable to say, “Okay. What do I have to do, to figure out how to turn that no into a yes?”  

I frequently am told that I like the Sisyphus role note, which is the Greek mythology that he’s pushing the rock up the hill. And it’s an impossible task. But every once in a while, you get up there. So I enjoy that challenge. 

Q:  Earlier, when you said you didn’t feel like you belonged there, because I think that’s something probably a lot of women can relate to. Can you talk a little bit more about that? 

A:  I think that is something a lot of women relate to. For sure, I didn’t feel like I had the qualifications for that first job. And while maybe I didn’t, I wasn’t so far off if they recruited me within a year. Throughout my career, I have struggled with that feeling, certainly in the Governor’s office. There I was very young. I was on the Governor’s senior staff as his advisor on women’s issues. 

And to find a voice on these issues that others maybe didn’t think were so important, childcare, teen pregnancy, etcetera. Particularly in the earlier days at Mass General, here I am, in this tertiary, quaternary care hospital, talking about the community. And in the early days, people looked at me like I had three heads.  

So it’s always finding that voice inside that says, “Maybe you really don’t belong here. You're really out on the fringe a bit. It’s hard.” And you internalize some of that. But yet that little stubborn streak that says, “But there's something of value here to this organization and to the work,” and just keeping at it. But —I was always wondering. Should I be keeping at it?  

Q:   And how would you find that stubborn streak within you, especially so early in your career?  

A:   It’s funny. I hear the voice of my mother when you ask that question. Who has accused me of being stubborn. I don’t know where that came from. Some might have accused me of being foolish, because some things took a long time to build the case for. I just kind of wouldn’t give up. 

And a very reasonable person might have given up. And that wouldn’t have been the wrong decision either. Because maybe they needed to move faster. There may be some little piece of that’s about myself, my need to prove myself, to myself, first and foremost probably. And others might not have such a need. 

Q:  With so much of your earlier career dedicated to advocating for human rights, for women’s rights, how does that background intersect with your work at Mass General? 

A:   Well, I think it does really completely, because the thread is harmony, social justice. And when I was organizing for women’s rights, it was not necessarily professional highly paid women, it was low paid women office workers, who were struggling to raise their families, etcetera.  

And when I got to the Governor’s office, I made a very conscious effort to focus on a set of issues that might benefit everyone, but had particular relevance and importance to low income women and women of color.  

So I think everyone’s familiar with health disparities, at least today they are. If you didn’t know about them before COVID, you probably do after COVID. And people may automatically think, “Oh, we just need more and better and easier access to healthcare, to solve those disparities.” 

But the truth is, 80 percent of your health status is attributable to a set of social and economic issues, things like, do you have access to a family-sustaining wage? Do you have access to quality education, to affordable housing, to healthy foods? And those are the social justice issues that disproportionately affect people of color, that have this huge, 80 percent impact on your health status. 

Q:  When you thought about making that transition, what was most interesting to you about entering the field of healthcare? 

A:   Well, actually, when I entered the field of healthcare, I didn’t do it because of healthcare. This was way back, in 1990, when I went to the Boston Healthcare for the Homeless Program. And at the time, I had two very young children. And I thought, I'm not actually so interested in a service delivery organization like healthcare for the homeless. But I want to work less than fulltime. And this would be a good thing to do while I have two young children.  

And lo and behold, I became completely fascinated. Because first of all, there are the social justice issues around homelessness. And, I had this amazing opportunity to learn all about the healthcare system, and how complex it is, and how that creates barriers for people. So I kind of stumbled into. . 

Q: What sort of challenges did you face when you first started working in Boston Healthcare for the Homeless, and in Mass General, and in the field of healthcare?   

A:  First of all, the healthcare system—Things like reimbursements and regulations are so complex, it’s like reading a Dickens novel, you know. The bureaucracy is just so complex, you fall down the rabbit hole into it. But yet, if you can figure out some of it, you can really accomplish things.  

So we were able to do that on a number of things at Healthcare for the Homeless. And then bringing that lens to Mass General.

So, what happened in 1994, is that the Attorney General of Massachusetts issued community benefit guidelines. A few years prior to that, the Boston Globe had done a spotlight series on infant mortality in Boston.   

And the bottom-line message of that was, Boston had some of the highest infant mortality rates in the world, as did most American cities, particularly between disparity between white babies and black babies. And some of these were literally outside the door of some of our major academic medical institutions.  

It really begged the question of, what's the role of major academic medical institutions in taking responsibility for health of our neighbors?  

So Mass General, along with other hospitals, said, “Well, we want to show up well in this. So we’ll hire someone. And they’ll, keep us out of trouble, honestly.” And so it took a long time for both the community and the hospital to understand what the goal was. The community did not trust us at first.   

I remember being asked to a community meeting, “What’s your hidden agenda? You must have one. You're not here to just do the right thing for us. Do you want to roll us in your studies?” Literally, I was asked things like this, which is fair, because under-resourced communities do not have positive history, in general with large powerful institutions. 

So it took years of showing up, listening to the community, and actually then following through on what the community told us. 

Q:   That's really interesting. I'm just wondering what your experience was like building that trust with the communities. 

A:   I actually have seared in my memory that one community meeting. It was early on in my first months on the job. I now do understand where that came from. Don’t know if I fully understood at the time where that came from, in terms of communities’ mistrust of the healthcare system, in large powerful institutions, and how they had been abused over history.   

But that little stubborn streak came out again, and I realized, okay, we’re going to have to prove this to people. You can't just say it, you have to do it, and you have to sustain it, and mean it, and show up over time.  

Q:  You mentioned that Mass General as an institution was fairly eager to get involved. But what was it like in the very beginning of that conversation? 

A:   Well honestly, in the very beginning, I spent almost all my time in the community. And the hospital was a little puzzled about why we were doing this. And I remember being asked, on the hospital side, “You know, we’re a tertiary-quaternary care center. We don’t do public health. And why should we? 

So I think of my 25 years in these four, maybe five phases. And the first phase was building trust in the community, and actually developing programs. The second phase, was then engaging the hospital. And part of that was Peter Slavin became President of the hospital. And Peter Slavin has been just a stalwart champion of community health. 

And I remember going to him, and saying, “Would you be open to hearing feedback from three outside experts around the country on our community health portfolio?” and he said, “Sure. Let’s do it.” Which he has said to every single thing I've ever brought to him. And so we did. And it wiled down to a few key things.  

They said, “You’ve got some great programs. But this community health agenda is not integral for what we can see to this academic health center. And if it were. 

“We would see it in the mission statement. We’d see it in the governance structure. We’d see it in the strategic plan, in the development priorities. We’d see it interwoven through other departments.” So, it came down to six key bullet points. And I brought them to Peter. And I remember going into the meeting and thinking, “Well, if we could get one or two of these this year, and another year or two we’ll get one or two more. And we’ll make progress.”  

 And, by the end of that hour, Peter said, “Let’s do it. Let’s do them all. They all make sense. Let’s go for it.” I remember just being so elated. And so we went to work in mid-2007. 

And community health had never been a formal part of the strategic plan of the hospital.  

So we were now part of the mission. So we chaired one of the pillars. And we took what we call the community health needs assessment. So it’s essentially engaging the community, surveys, focus groups, public meetings.  

And presenting data, but also saying, what are the most important issues to you? And in that 2012 community health needs assessment, all three of the communities we focused on at the time—and we do more now—said the opioid epidemic. And it was before the opioid epidemic was in the media every day.  

And we took it forward. It took a little work. We got our colleagues in the population health to analyze impact of who was in our in-patient beds. And they were shocked to find out the number of people with a substance use disorder.

And long story short, a comprehensive initiative to transform the way we care for patients with substance use disorders became the number one clinical priority of the entire hospital’s 10-year strategic plan. So that was truly transformative.  

Q:   That’s amazing. And you talked about sort of the phases of your career. Can you talk a little bit more about the other phases of your career as you see them? 

A:   Two was getting to approval of all of those initiatives. Three was actually getting into the strategic plan, and then operationalizing. 

But next phase was really developing that executive committee on community health. We went on a learning journey our very first year. We brought in guests around the country who were doing interesting work in community health. And we learned about anchor institutions.  And we recommended, based on that, that we move forward with that. 

So an anchor institution, if you look at Mass General or MGB, we have billions of dollars in economic clout. We hire. We purchase. We build. We invest.  

What if we set aside, in a very intentional way, a percent of each of those set of dollars, and we made sure that that business and that investment occurred in low-resourced communities of color locally? What we would do, if you go back to those social determinants of health, is invest in those communities to bring up and affect and impact their economic and social status.  

So they have a positive impact. It’s sustainable. It’s more powerful. It needed to be a system initiative.  

Q:  And I’d love to talk again about sort of that trust-building with the communities. Seeing the changes throughout your time at Mass General, and the trust that has been built between Mass General and the communities, how has that sort of impacted your outlook on the work that you do? 

A:  The only way any humans will work together and move forward is if they trust each other. So with COVID, we had to act really quickly. And we would not have been able to do that without a longstanding and deep relationship, and the trust that those relationships were built on, in our local communities. 

So trust is everything. One of the ways you build trust, is really listening to communities. And one of the potential pitfalls of this work is to sit in the ivory tower and do the data analysis and say, “I know what the problem is. And let me look in the literature. And here is the best evidence-based solution,” and try to parachute it into a local community. 

It will not work. I can remember another early community meeting, where a very well intentioned young physician got up. And he had all the data on how heart disease was the most pressing health issue in that neighborhood. It was a packed room. And they were always very polite to their doctors. And they said, “Thank you, Doctor.” And then they got up and talked passionately about how substance use was destroying their community. 

It was fueling crime. We’re losing kids. And that was the most pressing issue to that community. You can try to work all you want on heart disease, but if that’s not where there's burning passion in the community, you will not make progress. That’s a fundamental tenet of doing this community work.  

Q:   And you talked about community health in the time of COVID. I’d love to hear more about the unique role of community health and during the pandemic. 

A:   I have to say personally, it was—and this is true for everyone in the hospital and in the community—certainly, the most intense, most stressful time of my long career. You know, 12 to 15 hour days, seven days a week, week after week. It was purely brutal. 

However, I have a lot of privilege. I can remember, when I first heard about COVID, I wondered, for a nanosecond, if this was a disease that might only affect wealthier people who could travel around, and then be the spreaders. But we know, and history tells us,that poverty, race, those are the people who always are disproportionately affected.  

So all those social determinants conspired together to create—in Chelsea, we think it’s the highest rate of COVID infection in the country.  

And so high rates of poverty. Housing overcrowding, two, three, or more families crowding together in apartments. One bathroom, whole families in a bedroom situation. Essential workers, people not really having the choice to work from home, having to get on public transportation, all of these factors conspired. And these are all social determinants, really. 

So we worked really closely with city government and community partners. And certainly, the City of Chelsea government did an astonishingly good job, and worked so hard. So the city manager, Tom Ambrosino, was on the phone early. “We need more testing in this community.”  

I became a part of the incident command, the hospital incident command structure, along with Joe Bettencourt. We co-chaired the Equity and Community Committee. 

We had this kind of formula. It was testing, isolation, which is the hotel, mitigation, [00:28:42] masks, communication, which is everything from calling high risk patients, to social media messaging around how to stay safe, and what to do if you think you're infected. And then finally, social determinants.   

The food crisis in Chelsea was really astonishing, and continues to this day. The city paid to feed 3,500 people stood in lines every day, for months. And they are trying to come up with alternatives means. And we’re part of thinking through and funding some solutions there. It was a team of people, everyone from Dean Xerras, who’s the Medical Director at MGH Chelsea, to Joy Rosen, who’s the VP, to Joe Bettencourt, to Leslie Aldridge, who heads up our Center for Community Health Improvement. It was an all-hands-on-deck effort. 

Q:   There's been talk of a second surge. Are there ways that this first experience is helping you and your team prepare moving forward? 

A:   Yes. And there is—We are doing surge planning. So nowhere in anybody’s emergency preparedness manuals is there a protocol for what to do in a community health emergency.  

So there were literally hundreds of people across the hospital who needed to be involved. But there was no clear communication and command structure on the community side of things. So a lot of time in the beginning—and everyone had this experience – was spent with so many really energetic and well-intentioned people, reaching out saying, “We've got to do this. We have to do that.” And the people were spinning. And the same 10 people were working on the same thing. 

So mapping out who’s in charge of what, and what the communication network needs to be, has been part of the learning there. I think the other part of the learning is, it is hard to get—convince people who are immigrants, perhaps undocumented immigrants, to come to an isolation hotel. It is hard.   

People are afraid that ICE will make a raid. They don’t trust. And it’s also hard to ask people who are sick to leave their family, or so many people had childcare responsibilities, or sick parent responsibilities, that supporting them with food, and as much mitigation resources as possible, is also something we need to do.  

Q:  Can you talk a little bit about what needs to happen in healthcare to better address social and economic conditions of these communities? 

A:  You know, we were having a conversation at a meeting last week about the food crisis. And somebody said, “But what can we do about the food crisis?” It is, in fact, a chronic issue. It was a problem before the pandemic. It was just exacerbated by the pandemic.  

And my answer to that is, “Healthcare can't own that problem. But we need to sit at the table with the other stakeholders, with government, with foundations, with community-based organizations, and we need to each play a role in a coordinated strategy to deal with food.”  

So one of the things we may be doing more of, in Chelsea for example, is the Shaw Family Foundation has done an incredible analysis of the food problem in Chelsea. And so there's a certain percentage of people who are eligible for SNAP, formerly known as food stamps, who are not enrolled. 

So we might take on, okay, we’re going to redouble our efforts to enroll in our own patients, as well as community members in SNAP. And that might be our role. We also have a food pantry, where our most vulnerable patients, who might have diagnoses affected by their lack of access to healthy food, can access food. So there are things we can do.  

And finally, we need to be screening all of our patients for social determinants of health, things like food security, housing security. And we do, at the Center for Community Health Improvement, have community health workers who then work with patients on connecting them to community-based resources, to this food pantry, to the SNAP benefits, to whatever they might be eligible for.  

Same with housing. They do the same thing. They can't obviously build a house, or even find a house themselves, but they can connect them to other community-based organizations. And that’s their job. So it’s really at a kind of broad systemic level and an individual level, and everything in between, that we need to play a role.  

Q: And we talked a little bit about what needs to happen within healthcare. I'm wondering if you can tell me, what do you think needs to happen outside of healthcare to better address sort of the conditions these disadvantaged communities are living in, especially in today’s age, when there is more attention on health disparities? 

A:   Yes. Actually, a lot. Because another strategy, I think we as a healthcare system should engage more in—and I think this is now happening—is in policy and advocacy, on those issues that affect the health of underserved communities and communities of color. And that is housing policy, because housing is a health issue. There's all kinds of studies on how it affects your health. 

It is food access and a host of other issues. Actually, the system just took a position on a bill that would guarantee legal counsel to everyone facing eviction, because—eviction or lack of housing has that impact on your health. We also recently took a position on the Safe Communities Act, which is all about immigrants not being unduly punished for their status.  

 Q:  And I have to believe that this type of work can be very emotionally heavy, or trying at times. So how do you and your team practice wellbeing?   

A:   Some are better at this than others. I have something I do every day. I will hop out of the office, back when we were all in the office—for something like 45 minutes. That's a lot of time, and do an aerobic walk. I will just strap on my shoes, and go. 

And it is the best thing I can do for my mental health, and it is the best thing I can do to keep my energy up. I can work longer, harder, if I've done that. I try to support staff in saying, you know, “Taking care of yourself is first.”  

If you're sick, if you have a kid issue, if your mother needs a support going to a doctor’s appointment, I hope I always encourage, just take care of what you need to take care of. Put those things first. Because that’s what's important in life. Not always the best role model, however.  

Q:   Do you have to do anything different during the pandemic to maintain your wellbeing, or anything, in addition to what you were already doing? 

A:   I didn’t have time. I did much less. And my wellbeing took a hit, I would say. It was a stressful time. Trouble sleeping. Whether you're dealing with it, or actually experiencing it, it was an incredibly stressful time. 

Q:   And when you think back about your career, are there any particular milestones that jump out as having propelled you in a certain way? 

A:   You know, I always have said that the best preparation for Mass General Hospital was four years in state government, in the Governor’s office, because Mass General Hospital is a large complex political organization, as is state government. 

At Mass General, there are decision-makers, and there are influencers. And you really have to be schooled at how to figure out who the influencers are, and figure out what's going to get them onboard. Go talk to them. Ask them what their interests are. And that’s how you make progress. 

So that was the best training I ever got. And I went on and got a Master’s Degree at the Kennedy School after that. But still, my time in the Governor’s office was more valuable.  

Q:  Can you talk a little bit about how community health, separate from the work, just impacts you as a person, and your outlook on everything?  

A:  That’s a hard question, actually, because I'm so identified at this point, that it’s a little hard to separate between me and community health. But it gives meaning to my day. It gives me purpose. I have to feel like, when I get up in the morning, that I'm chipping away at making some meaningful contribution that will help somebody down the road. 

I do not have the privilege of working directly one-on-one with people in need. So sometimes you don’t get that immediate gratification. But you do get the gratification of making those systemic changes. And that’s what gives me a purpose and feeling like I'm making a contribution to the world in however small a way. 

Q: And we talked a little bit about what needs to happen within healthcare. I'm wondering if you can tell me, what do you think needs to happen outside of healthcare to better address sort of the conditions these disadvantaged communities are living in, especially in today’s age, when there is more attention on health disparities? 

A:   Yes. Actually, a lot. Because another strategy, I think we as a healthcare system should engage more in—and I think this is now happening—is in policy and advocacy, on those issues that affect the health of underserved communities and communities of color. And that is housing policy, because housing is a health issue. There's all kinds of studies on how it affects your health. 

It is food access and a host of other issues. Actually, the system just took a position on a bill that would guarantee legal counsel to everyone facing eviction, because—eviction or lack of housing has that impact on your health. We also recently took a position on the Safe Communities Act, which is all about immigrants not being unduly punished for their status.  

Q:   Thank you so much. And before I let you go, I just have my final questions to ask you. What's the best advice you’ve ever gotten? 

A:   I can't remember who I got it from. But somewhere along the line, I picked up, you know, success or progress is 50 percent hard work, and 50 percent luck. So work hard and look for those opportunities that are going to make you lucky. And don’t take yourself too seriously.  

Q:   What rituals help you have a successful day?  

A:   I would say it’s the ritual that I described earlier, of if I don’t take that walk, I do not have a successful day. And I am committed to that. It’s—It’s like, this is my time, and I have to take it.   

Q:   What advice would you give your younger self? 

A:   Don’t be so stressed about everything. [laughter] It will work out. Don’t feel guilty. It will work out. Yeah. Just chill a little. 

Q:   What's the best decision you’ve ever made?  

A:  Maybe to take this job. I had no idea, when I took it, what it would become. And I never thought I would stay at a place for 25 years. I thought only people who got stuck in their ways did that. This has been a completely dynamic experience with no year being the same as the year before. So it was a great decision. 

Q:   Do you have any guilty pleasures? 

A:   Well, in COVID, one of my things is I watch a bit of junk TV. And right now, although it’s not that junky, I'm working my way through 30 Rock. And I'm a little addicted to it. I'm on season five of seven.   

My other guilty pleasure is chocolate, dark chocolate every day. That’s another ritual perhaps.  

Q:   I can appreciate that one. Amazing. Thank you so much, Joan. We’re really happy you could join us today. Thank you.  

A:   Thank you for having me. This was enjoyable.