Expert panel issues recommendations for addressing cancer inequities

Originally posted on Mirage News on March 29, 2021

  • Recommendations stem from conference of National Cancer Institute and Comprehensive Cancer Center representatives
  • Recommendations call for enhanced community partnerships and higher priority for community-outreach efforts

New recommendations co-developed by Dana-Farber Cancer Institute call for a significant expansion of the National Cancer Institute (NCI) and NCI-designated Comprehensive Cancer Centers to understand the causes of inequities in cancer care and a commitment to building sustained community partnerships to reduce them.

The recommendations, published in the March issue of the journal Health Equity, are based on a 2019 “listening session” in which representatives from the NCI, comprehensive cancer centers, and the broader cancer community discussed current efforts to address disparities in cancer care and how they can be strengthened. A separate paper on that meeting appears in the March Health Equity.

“Events of the past year have brought renewed attention to issues of health equity – how we think about the ways that structural racism, income disparities, and geographic location, affect the care that people receive,” said Christopher Lathan, MD, MS, MPH, faculty director for cancer care equity at Dana-Farber Cancer Institute, the senior author of the two papers. “In recent years the NCI has moved to strengthen the requirements for comprehensive cancer centers around community outreach and engagement. The 2019 meeting was organized as a conversation between the comprehensive cancer centers and the NCI about what measures have worked in the past and how they can be made more effective in the future.”

The nation’s 51 Comprehensive Cancer Centers are certified by the NCI for their expertise in laboratory, clinical, and population-based research. In addition to initiating clinical trials of novel therapies, they’re also required to conduct outreach and education programs and inform the public and healthcare professionals about research and treatment advances. Institutions designated as Comprehensive Cancer Centers receive grants from the NCI to support these efforts.

The 2019 meeting identified five major opportunities for the NCI and Comprehensive Cancer Centers to improve the impact of their community outreach programs:

  • Adopt an explicit focus on health equality, prioritizing efforts with the greatest potential impact
  • Understand and address the structural barriers to equitable cancer outcomes
  • Improve access to quality care by creating lasting collaborations with community partners
  • Advance legislation and government policies that support cancer control
  • Evaluate the effectiveness of community outreach programs and implement improvements as needed

Within each of these categories, the meeting’s participants developed specific recommendations for the NCI as well as individual Comprehensive Cancer Centers. Examples include:

  • Support research into the drivers of cancer disparities and encourage investment in community-scale outreach efforts
  • Increase funding for community outreach efforts in NCI “core” grants to cancer centers
  • Shift from a narrow focus on clinical trial recruitment to a longer-term focus on addressing the challenges that interfere with trial participation
  • Establish long-term partnerships with trusted community organizations to build understanding of local communities and connect patients with resources.
  • Educate policymakers on gaps in care that result from lack of coverage or enrollment in health plans that do not comply with the Affordable Care Act benefit requirements
  • Include community members in the development of community outreach studies to ensure accurate representation and analysis

One of the major concerns voiced at the 2019 meeting was that while comprehensive cancer center investigators “do excellent research into the social determinations of health, the traditional scope of research grants hasn’t supported the kind of long-term engagement in the community that makes a lasting difference,” Lathan remarked. “We need to find ways to better align our research with the community’s needs – to build relationships that have durable results for people in the community.”

The recommendations set forth in the new paper will provide an agenda for those efforts going forward, he continued. “Health equity research needs to be more than descriptive – more than identifying problems – but has to involve the people who will benefit from it and engage them in building programs that work.”

The co-authors of the two papers are: Patricia Doykos, PhD, of Bristol-Myers Squibb Foundation; Moon S. Chen, Jr., MPH, PhD, of the University of California Davis Comprehensive Cancer Center; Karriem Watson, DHSc, MS, MPH, and Vida Henderson, PhD, PharmD, MPH, MFA, of University of Illinois Cancer Center; Monica L. Baskin, PhD, of O’Neal Comprehensive Cancer Center at the University of Alabama; Sarah Downer of the Center for Health Law and Policy Innovation of Harvard Law School; and Lauren A. Smith, MD, MPH, Neeraja Bhavaraju, MBA, and Samantha Dina, MBA, of FSG, Boston.

Harvard Legal Experts Identify Pathways to Mainstream Produce Prescription Programs

A new policy strategy report from Harvard Law School’s Center for Health Law and Policy Innovation aims to scale up the provision of nutrition benefits in health care and food systems.

Diet is a key driver of both poor health outcomes and health care costs, however nutritious foods can be out of reach, especially for those struggling financially amid the COVID-19 pandemic. The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) released a report highlighting opportunities to improve access to nutritious foods through federal, state, and institutional policies. The report focuses on the use of Produce Prescription (Produce Rx) Programs: interventions that enable health care providers to distribute benefits to patients to purchase fruits and vegetables at little or no cost.

Diet-affected chronic health conditions, such as cardiovascular disease, obesity, diabetes, and some cancers, cost the United States over a trillion dollars in direct medical expenses each year. Yet, eating more fruits and vegetables can considerably lower the risk of such diseases. Produce Rx programs promote access to healthy foods while reducing the financial burden of maintaining a healthy diet. CHLPI’s new report, Mainstreaming Produce Prescriptions: A Policy Strategy Report, recommends feasible and cost-effective pathways to increase access to produce prescriptions using existing health care and food system programs, such as Medicaid, Medicare, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

“Growing evidence demonstrates the ability of Produce Rx programs to drastically improve the health and well-being of patients struggling with diet-related diseases,” said Robert Greenwald, a clinical professor of law at Harvard Law School and faculty director of CHLPI. “Despite the promise of Produce Rx, access to these interventions remains extremely limited. Our policy strategy report highlights a variety of opportunities to leverage existing government-funded programs in order to make Produce Rx programs—innovative, evidence-based interventions—widely available to those who need them most.”

The new report outlines 20 recommendations to overcome key barriers to mainstreaming Produce Rx programs, addressing issues such as funding, research, patient data and privacy, infrastructure, and the need for programmatic guidance to advance the field. Among the recommendations are calls to broaden coverage of Produce Rx in Medicare and Medicaid, expand support for the GusNIP Produce Prescription Pilot, and enhance programs that support the viability of healthy food retailers, especially in low-income or historically marginalized communities.

“Our analysis of opportunities and gaps yielded clear results: there is more we can do to better connect patients with the foods they need to thrive,” said Emily Broad Leib, a clinical professor of law at Harvard Law School, deputy director of CHLPI, and faculty director of CHLPI’s Food Law and Policy Clinic. “Our report offers a roadmap for health care providers, payors, agency officials, local organizations, researchers, food retailers, and other stakeholders to take the steps necessary to scale up access to Produce Rx programs.”

Our current food system puts healthy food out of reach for tens of millions of families, increasing the risk of chronic diseases that cut years off of their lives and straining our health care system,” said Devon Klatell, Managing Director of The Rockefeller Foundation’s Food Initiative. “We funded this report to better understand how we can create a healthier future by ensuring that everyone has access to affordable, healthy food and reducing the burden on our health care system.” 

Mainstreaming Produce Prescriptions: A Policy Strategy Report is available on CHLPI’s website, along with an Executive Summary and an analysis released last October titled, Produce Prescriptions: A U.S. Policy Scan.

Food Equity in the Age of COVID-19: A Conversation with Professor Emily Broad Leib

Interview by Kira Traylor, originally posted on Harvard Health Policy Review on March 19, 2021

HHPR Editor Kira Traylor interviewed Emily Broad Leib, J.D., a Clinical Professor of Law at Harvard Law School, Faculty Director of the Food Law and Policy Clinic of the Center for Health Law and Policy Innovation, and Deputy Director of the Harvard Law School Center for Health Law and Policy Innovation. As founder of the Harvard Law School Food Law and Policy Clinic, Broad Leib launched the first law school clinic in the nation devoted to providing clients with legal and policy solutions to address the health, economic, and environmental challenges facing our food system. Broad Leib focuses her scholarship, teaching, and practice on finding solutions to some of today’s biggest food law issues, aiming to increase access to healthy foods, eliminate food waste, and support sustainable food production and local and regional food systems.

Kira Traylor (KT): How did you first get interested in food equity? Was there a particular book, moment, or event that sparked your interest?

I went to Harvard Law School and while I was there I mostly did work in the global human rights field. After graduation, I thought that I was going to do humanitarian law and help rebuild legal systems post-conflict. For a multitude of reasons, I instead accepted a Fellowship doing community-based work in the Mississippi Delta with the goal to bridge the academic and community divide as well as improve economic development and health. I learned from the community I was working with that there were a lot of questions about food. From the consumer side, those questions were largely about access and ability to purchase food; 25% of households in the county didn’t have access to a vehicle and there was no public transportation. On the producer side, there were a lot of small farmers and food producers that wanted to sell within their community but had a lot of legal questions. While there, I started reading a lot about this area of law and found that there were many people working on food systems issues but not looking at it from a legal angle, as well as looking at how the law is helping and hindering these goals for the system. I really carved out this space and now teach and engage students in working in this field.

KT: Can you give an overview of the Harvard Law School Food Law and Policy Clinic? What are some of the clinic’s most notable achievements?

The clinic is an action learning program at Harvard Law School with three main goals. Firstly, we teach students in the classroom about laws that regulate the food system. Something very interesting about food is that it’s regulated from many different angles, including regulations from food safety, labeling, and first amendment protection in regards to labeling restrictions and requirements. Furthermore, environmental regulations play a role through subsidies, support for agriculture, and state and local regulations in food access and food security. Second, the goal is to teach students about all of these pieces and then help them apply them through a work component. We take on clients that are either nonprofits, startups, or government agencies, and students are required to produce deliverables for these clients because we truly believe that they are trying to improve outcomes for the food system. Students are able to learn about the scale of doing this work through policy and systemic change while having a real-time impact because we are putting research and resources into the hands of the groups that are pushing to make these changes. Our third field of work is building a field of food law and policy. In particular, my work has been in building coalitions and associations that help with the infrastructure of this field. For example, we have a coalition of seven law schools that work together on putting out up-to-date information about the U.S. Farm Bill and changes to it. We hold an annual event that brings together law students from all over the country that are interested in food law so that they can learn, network, and hear from experts in the field. In terms of the work that we focus on, it centers around four main topics that shape our work. These include food access and nutrition, sustainable and equitable food production (such as the environmental and climate impacts of food), community-led systems change (bringing out resources to local community coalitions that have an idea for change), and food waste and food recovery. We focus on each of these four areas and have active projects going on about them at any different time.

KT: What does the future of food security look like in the United States? Are we progressing towards a more equitable future?

It is hard to say because of the influence of COVID-19. There is a really big problem in the food system because the benefits and the burdens aren’t equitably shared. The people who benefit from the current system are big farms owned by white, male land-owners, and not women, black and farmers of color, small community-level food producers, and entrepreneurs. Also, the burdens aren’t equitably distributed. We have high rates of food insecurity and have seen a little bit of a roller coaster. During the 2008 recession food insecurity rates went up to 15%, which is extremely high. Rates then went down to about 10% right before the COVID-19 pandemic and then they skyrocketed because of the economic fallout. If you dig into the data, people of color, the elderly, and food workers are disproportionately impacted. Workers throughout the food system are twice as likely to be food insecure than the average American, so in times of crisis, we see a spotlight shed on food insecurity. However, on a whole, we have a very, very inequitable system. Since 2008, we have seen the SNAP program, the largest food assistance program in this country, expand because so many people were out of work. Yet, because the program’s costs increased as more people enrolled, it had a large target on its back within the last few sessions of Congress and the outgoing administration. So, what we have seen over the last 2 years was a series of rules passed by USDA and other agencies to make it increasingly difficult for more people to stay in the program. My concern is that while we have seen rises in program access because of covid, which will later cause a backlash against it once the price is in the rearview mirror. It is really hard to predict right now what the future will look like; we have made some tweaks in the programs to make sure people have access to food during covid, but as a whole inequality has been rising in this country in the food system as it is for economic security more generally. I am normally an optimist and am certainly optimistic about the things we can do, but we are undoubtedly seeing rising inequality in the food system.

KT: What do you see as the biggest problem in achieving food equity today? How should it be addressed?

First is that there is a big challenge because of a political and ideological divide, and it means that there is a lot of work that needs to be done in terms of building a narrative about what the responsibility of the government is to ensure people’s access to food and improving the food system. Recently, we have had trade wars with China and the COVID-19 pandemic which have led to big payments programs for farmers and the data has shown that these payments have been extremely inequitable. I think that another big concern to think about is the question of how we increase equity within these payment programs on the production side. A big project of mine within the past few years has been pushing for the creation of a National Food Strategy. This is not the single solution, but one of the challenges with the food system is that the way that we regulate is very disjointed; there are currently fifteen federal agencies that play some role in regulating food with their individualized lenses. Additionally, there is not a coordinated effort to say what the goals for the food system are and how we are going to achieve them. I think every day that we make policies, there are inherent tensions that do not take into consideration the tradeoffs. For example, there is a priority to keep food prices down because of food security concerns, but conversely, we know over time that the cost of food is not the real cost because there are many external costs such as environmental effects, what food businesses obtain supporting, and the aggregation of wealth. A National Food Strategy could help get input from different stakeholders and have the way that we regulate drive towards those optimal goals as opposed to being disjointed. We published a report in 2017 that was looking at other countries similar to the United States that created a National Food Strategy. This past fall we updated it and concluded that three years ago this would have been a nice thing, but now COVID-19 has made it necessary. The work I do is toggling between the small policy changes and taking a bigger picture lens that looks at where we want to be five to ten years from now as well as coming up with a path to get there.

KT: How has the COVID-19 pandemic affected access to healthy foods? What populations have been impacted the most?

There is no official data yet, but at the end of 2019 the food insecurity rate in the U.S., the number of people in the U.S. who do not have access to enough food to live a healthy lifestyle, was 10% and had been decreasing since 2008. Preliminary estimates from the past few months have now placed it at 20-25%. What’s even more concerning is very low food security, the number of people who at this moment do not have enough food in their household, went from 4% at the end of 2019 to 11% in August. Anecdotally, we have heard the same. I have been doing work with a woman in the city of Boston who, because she realized how much hunger there was in her community, set up a food pantry in her backyard. By the end of December, she was serving 300 individuals. The data and anecdotal stories are showing that there is a massive problem. Additionally, a lot of people have seen photos of the long lines of cars outside of food banks and distribution sites. Similarly again, it is disproportionately Black and Latinx households that are facing high rates of food insecurity, with the numbers rising since the start of the COVID-19 pandemic. For Black households, food security went from 9% to 20%, and for Latinx households from 5% to 19%. Furthermore, food workers themselves do not make a livable wage, another external cost of the food system. Restaurants closing or lessening business has caused food workers to struggle. This is going to be one of the biggest challenges. Another impact of COVID-19 is causing lots of food waste because of the uncertainty of governments limiting businesses. One effort to combat this is the Farmers to Families Food Box Program, which is where the USDA creates contracts with distributors who normally serve the hospitality and food service sector so they can purchase food from farmers and get it delivered. However, we do not know what this will look like with the change in administration but recent stimulus legislation shows that there will be some continuation of a program like this. Also, another group I am concerned about is unauthorized immigrants. This population does not have access to a lot of these programs, such as SNAP, and the outgoing administration put in place the Public Charge Rule which makes the SNAP program a disincentive for immigrants because it could impact their ability to have a more permanent immigration status. This population cannot benefit from SNAP, Medicaid, and other programs. Additionally, they are the people who have a lot of essential roles in food.

KT: How have food system workers been disproportionately impacted by COVID-19?

Across the food system, we’ve seen workers in meat, poultry, agriculture, and grocery stores face disproportionate impacts of COVID-19. From the first day of the pandemic, these workers have continued working to keep the food system flowing, placing a big toll on their health as a whole. According to the work of Leah Douglas at the Food and Environmental Reporting Network (FERN), 78,733 food workers across meatpacking, food processing, and farms tested positive for COVID-19 and roughly 350 died, which is much higher than other sectors of the economy. This is largely because people had to come into work when procedures were not put in place. OSHA is supposed to create regulations for workplace hazards but did not create any mandatory standard for these jobs, so these food businesses had nothing to follow. Even in cases where they did issue enforcement against companies, they did it 6 months after a majority of the illness and death occurred. In September, OSHA gave Smithfield Plant and JBS Plant small fines for deaths and how workplace safety was handled in March and April. However, this is not a deterrent if you are addressing a problem after the fact. California, a state institution, fined ten times what OSHA, a federal institution, did. That said, we have learned a lot and in some cases, there is definitely a greater use of PPE and more standards put in place. Nonetheless, it is still a hard-hit sector with workers who often have the least, including unauthorized immigrants who do not want to speak out and marginalized groups who do not have a lot of leverage to advocate for themselves.

KT: What lesson can the U.S. agricultural industry take from COVID-19?

One big lesson was regarding the lack of a pandemic plan in the food sector, which was revealed in reporting by ProPublica. This was foreseeable; we did not know when or what it was going to be, but we knew this would happen. However, the food sector chose not to do anything. This was largely because of its structure, as it is very diffused and composed of many businesses and industries. Therefore, one big takeaway is that there needs to be more of a plan for natural disasters. Another lesson is that there has been programming during COVID-19 that would be beneficial to continue. One big success would be the implementation of universal meals for schools. Typically, for meals to be offered to students, they would either have to be low income or the school as a whole has to be enrolled in the Community Eligibility Program. There have been calls for years to implement universal free school meals, as it would get rid of the stigma and administrative burden. There have been countless stories of students not being unable to eat or afford school food. This would be amazing if this problem continues being implemented post-pandemic and has shown that it can be done. Another lesson has been the quick rollout of online access to the SNAP program. Since 2014, USDA has been piloting this program but now every state is allowing online snap purchases. However, a large issue is that in a lot of those states in the beginning the only vendors were Walmart and Amazon. If this continues, it would be a bad outcome of the pandemic because the two biggest retailers would be able to continue amassing wealth and power and smaller producers would be left behind. Additionally, in the recent stimulus legislation that passed, there was an increase in SNAP benefits. SNAP is an economic multiplier; every $1 we distribute in SNAP benefits leads to $2 in the community. Additionally, past USDA programs for distributing food have typically consisted of processed goods. The USDA through the Farmers to Families Food Box Program has finally shown that they can do the purchasing, procurement, and distribution of fresh produce.

KT: What food policy changes do you hope the Biden-Harris administration will implement?

Remove the unfair and inequitable snap rules, institute universal free meals for foods, implement a National Food Strategy, and ensure more safe food is donated by broadening some of the benefits to farmers and shipping companies. Also, state and local governments are bearing the brunt of COVID-19 in the food context. In Boston, the emergence of these backyard food pantries has arisen because the need is so great. In the federal government response, none of it has addressed the funding shortfalls of state and local government to support needs such as food security, food access, and supporting food producers. I hope that in the new administration there is a way to prioritize these important issues. In terms of food workers, OSHA in this current administration has not been responsive to complaints, as there was no standard for food workers and late response times to complaints, so there is lots of rebuilding that needs to happen in this agency. A few of my dream changes are reduced consolidation in the food and agriculture sector and less discrimination in the food sector.

KT: Do you have any current or upcoming research projects that you would like to share?

We just published a National Food Strategy report and the materials are on the website Right before the holidays, we released executive summaries of this report that target the current administration and Congress. Additionally, in February we released a report where we analyzed the Farmers to Foodbox program, suggesting how it can continue in the future, how to support more small producers, women, farmers of color, and how we make sure the targeting of where food is distributed matches the need. Thirty different stakeholders were interviewed such as farmers, distributors, food banks, local governments, and media workers. Furthermore, last Farm Bill we put out a series of reports that showed changes we wanted to see and score reports for each draft. Currently, we are working to publish reports in 2021 that provide a roadmap that addresses the current challenges of the Farm Bill and how to make the food system better for the environment, health, and climate. Additionally, we are analyzing food laws across the world that relate to food donation. Last summer, we published the first five countries and have ten more coming out in the next few months. Within the report, we analyze their laws about donating safe surplus food and provide recommendations showcased in an interactive map.

KT: Is there anything else you would like to add?

Not specific to food, but over the fall I ran a lecture series with a colleague of mine, Professor Martha Minow, featuring colleagues from across the law school speaking about how laws are changing due to COVID-19. At the end of the series, students wrote blog posts about how law is impacted by the COVID-19 pandemic.

Rescue Plan Includes Billions To Address Systemic Discrimination At USDA

Originally written by Ava Cilia, law student in the Harvard Law School Food Law and Policy Clinic, and published on Farm Bill Law Enterprise on March 17, 2021

Last week, President Biden signed into law the American Rescue Plan, a $1.9 trillion COVID-19 relief bill.

The Plan includes historic provisions to address generations of systemic racism and discrimination towards “socially disadvantaged farmers and ranchers” (SDFRs) by the U.S. Department of Agriculture (USDA). SDFRs are defined by USDA as individuals who “have been subjected to racial or ethnic prejudice because of their identity as members of a group without regard to their individual qualities,” including Black, Indigenous, Latinx, and Asian farmers and ranchers.

John Boyd, a fourth generation Black farmer and the founder and president of the National Black Farmers Association, recently said, “we’re quite frankly, faced with extinction. If we can’t get a new generation of young people involved in agriculture and farms, Blacks and other farmers of color into farming, you won’t see it.” That is why groups like the National Black Farmers Association have praised the inclusion of the provisions to address systemic racism at USDA in the COVID-19 relief bill. As put by Tracy Lloyd McCurty, executive director of Black Belt Justice Center, “this is one of the most significant milestones in Black agrarian history.”

Roughly half of the $10.4 billion set aside for agriculture support in the Plan is earmarked for SDFRs. The bill includes an estimated $4 billion in direct relief payments to SDFRs in amounts up to 120 percent of outstanding debt owed by each farmer or rancher.

In addition to debt relief, the bill contains slightly over $1 billion to provide technical assistance and outreach related to USDA’s programs to SDFRs; grants and loans to improve land access and to address issues related to heirs property; funds to support the work of equity commissions that will address racial equity issues within USDA; and money to support research, education, extension, and scholarships at Historically Black Colleges and Universities (HBCUs), 1994 Institutions that serve Native Americans, and Hispanic-serving institutions.

These provisions are drawn from the Emergency Relief for Farmers of Color Act, which was introduced by Georgia Senator Rev. Raphael Warnock in February. Sen. Warnock explained that the legislation, “will not only help farmers of color, but will also lift up the economies of our rural communities working to recover from the economic turndown.”

No Republican Senator voted to pass the bill. In fact, many prominent Republicans, such as Senator Lindsey Graham, were vocal opponents of the inclusion of the Emergency Relief for Farmers of Color Act. In response, Mr. Boyd said, “the lack of lawmaker support was a ‘sickening realization,’” that shows “how disconnected half the Senate is from Black farmers.”

Resistance to the Emergency Relief for Farmers of Color Act fails to recognize the decades of systemic discrimination against Black farmers and other farmers of color at USDA. As far back as the 1960s, the federal government has acknowledged that USDA discriminated against Black farmers by denying them access to credit, technical assistance, and the other agency programs available to white farmers. This legacy and culture of white supremacy has resulted in “massive transfers of wealth from black to white farmers.” Despite settlements resulting from class-action lawsuits brought by Black farmers alleging racial discrimination in USDA’s administration of loans and assistance, the federal government has failed to repair the harm done to farmers of color. As explained by McCurty, “Only 4.8 percent of Pigford I settlement went to debt relief. The vast majority of Black farmers were left with unconscionable debt and no legal recourse to save their land.” Today, Black farmers comprise just 1.4 percent of the nation’s farm owners and tend to only 4.7 million acres of the country’s farmland.

Black, Native American, and Hispanic farmers have been organizing to combat USDA’s racist policies, to reclaim their land, and to produce generational wealth. Organizers from these movements have noted that while the inclusion of the Emergency Relief for Farmers of Color Act is a promising development, it is only a first step. Additionally, others have cautioned that the way the debt relief and $1 billion in grants are ultimately administered will determine the impact of the provisions. “Hopefully the money won’t go to conducting studies,” Lloyd Wright, a former director of USDA’s Office of Civil Rights said, “Black farmers have been studied to death.”

The views reflected in this blog are those of the individual authors and do not necessarily represent those of the Center for Health Law & Policy Innovation or Harvard Law School. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

COVID and the law: What have we learned?

Originally written by Brett Milano and published on Harvard Law Today on March 17th, 2020

A discussion series hosted by Martha Minow and Emily Broad Leib examined the pandemic’s impact across many areas

The effect of COVID-19 on the law has been transformative and wide-ranging, but as a Harvard Law School panel pointed out on the one-year anniversary of campus shutdown, the changes haven’t all been for the worse.

Organized by 300th Anniversary University Professor and former HLS Dean Martha Minow and Clinical Professor Emily Broad Leib ’08, last week’s panel, “COVID-19 and the Law: What Have We Learned?”, focused on progress that can be continued going forward. Drawing faculty from across HLS, the panel looked at the pandemic’s impact on numerous areas — public health, food availability, criminal law, voting rights, predatory student lending, and labor issues. These and other issues have also been explored over the course of the year on HLS’ “COVID-19 and the Law” blog.

“Everything has been dramatic,” Minow said of COVID’s impact, in an interview before the panel. “I think it’s helpful to think about the pandemic as shining a spotlight on what works and doesn’t work in the society, specifically in relationship to health crises. We see the fragility of the networks of access, but it’s also more general with the inequities, racially and by class, with access to any kind of information assistance.”

“There are also the job situations — the conditions of the essential workers in Amazon warehouses, not just a problem for the pandemic,” she said, including issues of job insecurity, safety, and what she called  “over-work conditions.”

“I don’t think there’s an area that is somehow immune from this double lens: What does a crisis expose about what’s not working in the society? And how does the crisis actually show that in specific areas — health and healthcare access, prevention of disease — that we can be doing much better?”

The pandemic, Minow said, will also have an impact on students’ career paths. “I have no doubt that the faculty and students who’ve been involved in these issues are now immersed in reform issues and possibilities. And that’s true about housing and consumer protection, and criminal law, and access to pharmaceuticals. We will also have an update on election law. To have the confluence of a very momentous election along with the pandemic — it showed the possibilities of new forms of voting and the vulnerabilities of the electoral process to manipulation. So those are not issues that are going to go away anytime soon.”

The past year, she suggested, can leave us with some sense of accomplishment as well as a sense of further work to be done. “Some of those lessons are challenges that are still ahead of us. And some lessons are, ‘Gosh, there was more resilience than we thought.’ The public agencies and the courts pivoted pretty quickly, to being able to use remote resources. So, the lessons learned include both resilience and capacity for change.”

In a separate interview following the panel, Broad Leib agreed that the pandemic pointed the way to further necessary work. “The pandemic has made things possible that weren’t possible before. And maybe we’re not there yet, because we’re still in response mode. But maybe it shed light on these underlying challenges in the system that in most peoples’ everyday lives, they didn’t think about. My hope is that we have a foundation for the next phase, thinking about the inequality and planning for the future.”

As the faculty director of the Food Law and Policy Clinic, Broad Leib said she feels that the food industry needed to catch up with its lack of preparation for a pandemic. “We didn’t have a plan for this foreseeable thing. We always talked about the pandemic but there was no quick plan that could be implemented.” While there were some positive steps — such as changing food labeling so it could be diverted from restaurants to retail — these all began once the pandemic was underway.

Further, she said, the pandemic revealed racial inequity in the food industry. “There’s been a huge historic discrimination against farmers of color. Because of COVID and the fear these farmers have faced — and then George Floyd and the racial unrest — it led to this historic addition to the legislation that just passed [a billion-dollar payment to disadvantaged farmers in this month’s stimulus bill]. It’s a different style of activism, but things that seemed impossible a year ago are moving forward on the grassroots level.”

Such changes, she said, are likely to continue across the board. “It’s hard to imagine how they couldn’t. The question is how long-term and big-picture those changes will be.”

During the panel discussion, other professors pointed out some less favorable aspects of the year. Benjamin Sachs, Kestnbaum Professor of Labor and Industry, spoke of the government’s failure to adequately protect essential workers. “We saw acutely how working people really need the government, and how working people really can’t rely on the government. Essential and frontline workers were exposed in ways that many of us were not to the virus, and needed the Occupational Safety and Health Administration to step in and issue a standard for making work safe and healthy. As the New York Times said, OSHA was just AWOL.”

Lecturer on Law Ruth Greenwood focused on the past year’s crisis over voting rights. “The good news is that it wasn’t COVID that caused an electoral crisis, but there’s an implicit bad news there. … Prior to 2021, the vote suppressors of the world were saying, ‘We’ve got to stop people voting in person, so let’s introduce things like photo ID laws,’ and now it’s more like, ‘We’ve got to stop people voting by mail.’ I always like when the justification for these things changes.”  She named the pending HR-1 legislation as a potential fix for voting issues during the year.

Dehlia Umunna, clinical professor of law, pointed to COVID’s direct effects on her work as a criminal lawyer. She recalled shaking hands with a client, for the last time to date, before arguing his case. “The main lesson for us is that human contact, one-to-one interaction with our clients, is indispensable.” That’s especially true when addressing the needs of poorer or younger clients. “And if you thought talking to teenagers was hard before Zoom, try talking to them now.”

Webinar Review: “Exploring the Role of Liability Protection in Facilitating Increased Food Donation”

This post was written by Regina Paparo with support from Ata Nalbantoglu and Kerensa Gimre, FLPC clinical students.


  • Providing comprehensive liability protection to food donors and food recovery organizations has the potential to support greater food donation
  • Raising awareness among food donors and food recovery organizations of liability protection laws is essential
  • Relevant implementing regulations should be passed to facilitate increased food donation

The Harvard Law School Food Law and Policy Clinic (FLPC), in partnership with The Global FoodBanking Network (GFN) and Food Systems for the Future, virtually convened policymakers on February 25 to discuss policy opportunities to address liability protections for food donations. The meeting was part of a series of webinars organized under the Global Food Donation Policy Atlas project, a joint partnership between FLPC and GFN, with support from the Walmart Foundation. Featuring select government officials and food donation experts from around the world, the webinar explored concerns, best practices, and policy considerations to encourage the adoption of comprehensive liability protections for food donations. 

A significant barrier to food donation is the fear among food donors that they will be found liable if someone becomes sick after consuming donated food. Many countries do not provide any liability protection, or have unclear or fragmented policies with varying levels of protection. Even where liability protections exist, many food donors and food recovery organizations are uncertain as to whether they qualify for this protection and its scope of application. The Global Food Donation Policy Atlas project has found that concerns among food donors about liability protection impact the donation of safe, surplus food.

Moderated by Ertharin Cousin, CEO and Founder of Food Systems for the Future, the webinar explored key issues regarding the offering of liability protection, such as who should receive protection, applicable food safety laws, whether food must be given away for free in order to receive liability protection, the fault level at which a donor or food recovery organization should lose protection, and to whom donors must donate to receive liability protection.

Policymakers discussed various protections in respective liability protection laws and policies. Milena Battaglia, the Head of the Office of Supply Chain Policies and Circular Economy at the Ministry of Agricultural, Food and Forestry Policies in Italy, discussed Law No. 166/2016 that provides certain liability protections for businesses that donate surplus food. Milena also noted that the European Union adopted EU Guidelines on Food Donation which provides guidance to EU member countries on various food donation issues, including on liability protection. Natalia Basso, who leads the National Plan to Reduce Food Loss and Waste, in the Ministry of Agriculture, Livestock and Fisheries in Argentina, highlighted a 2018 liability protection amendment to Argentina’s Food Donation Law (Régimen Especial para la Donación de Alimentos) that provides broad liability protection to qualifying donors and food recovery organizations.

Further, policymakers underscored the need for the adoption of relevant regulatory implementation tools. Enacting a liability protection law is only the first step – implementation is also of utmost importance to ease food donation. Senator Santiago Valencia González, a member of the Senate of the Republic of Colombia, explained that Colombia passed a food donation law, Law 1990 of 2019 that provides liability protections for food donations – but a delay in publishing regulations has impeded the implementation of the law. Similarly, Gidi Kroch, the Chief Executive Officer of Leket Israel, the national food bank in Israel that was instrumental in awareness raising, alliance building, and research during the enactment of Israel’s Food Donation Act in 2018, noted that the Act has not been implemented due to a delay in passing a bylaw or regulations; however discussions regarding implementing legislation are ongoing with the Ministry of Health of Israel.

Finally, awareness among food donors and food recovery organizations about the protections offered by liability protection laws is necessary to encourage and facilitate increased food donations. Dr. Jean C. Buzby, the Food Loss and Waste Liaison at the United States Department of Agriculture, who discussed the Bill Emerson Good Samaritan Food Donation Act that provides civil and criminal liability protection for food donations – noted that a lack of awareness among food donors and food recovery organizations about the protections offered by the Act continues to curtail food donation, despite the Act’s very strong and comprehensive protections.

These remarks demonstrated that meaningful liability protections have the potential to support greater food donation – further emphasizing the importance of comprehensive liability protection for food donors and food recovery organizations in promoting safe food donation. Strong liability exists when a law provides for comprehensive civil and/or criminal liability protections for both food donors and food recovery organizations at the federal level. A detailed companion issue brief on best practices regarding liability protection for food donations is forthcoming. FLPC and GFN welcome the continuation of a critical and open conversation in the upcoming session, which will focus on The Impact of Date Labeling on Food Waste, Food Recovery, and Donation. FLPC invites government officials and policymakers from international and multilateral organizations to reach out for further information at

The shape of discrimination

Originally written by Rachel Reed and posted on Harvard Law Today on March 10, 2021

Daniel Aaron ’20 thinks high obesity rates among people of color may be another legacy of ongoing racism in America

Last year, as millions of activists marched for racial justice across the U.S., Americans scrutinized anew the role discrimination has played in shaping our neighborhoods, our schools, and our criminal justice system. But what if racism also shapes one of the most intimate things about us — our bodies?

new paper in the Journal of Internal Medicine, co-authored by Harvard Law School alumnus Dr. Daniel Aaron ’20, argues that disproportionately high rates of obesity in communities of color are a direct manifestation of systemic racism — not unlike housing segregation, the wealth gap, and inequality in policing and incarceration.

“Physicians and researchers have historically interrogated social determinants of health, which are elements in an individual’s environment that influence their well-being,” says Aaron, who collaborated on the paper with Dr. Fatima Cody Stanford, a physician and researcher at Massachusetts General Hospital. “But we need to go beyond the doctor’s office to examine the root causes of these issues. [Stanford and I] are interested in the discussion of legal frameworks and how they fit together to entrench obesity among BIPOC.”

Key to making change, Aaron and Stanford argue, is understanding obesity not as a personal failure, but one resulting from historic and ongoing racism experienced by communities of color. Factors like chronic stress from sustained interpersonal and systemic racism, coupled with a lack of access to health care, contribute to obesity and also make it less likely that a person is diagnosed and treated for their condition. A dearth of grocery stores, government subsidies for processed food, and targeting by fast food advertisers also contribute to the recipe for obesity, and Aaron says these issues are more likely to impact people of color.

“Most of these things go beyond an individual’s ability to address,” he says. “We have to move away from blame to structural causes of this issue.”

Aaron, now an HLS Heyman Fellow and an attorney at the U.S. Food and Drug Administration, was initially drawn to health care. He started at Boston University School of Medicine in 2014, but as his education progressed and he began working directly with patients, he noticed a distressing pattern.  Again and again, he saw underprivileged patients suffering from life-altering problems — diabetes, high blood pressure, heart disease — that resulted from obesity, alcohol, or opioids. And although he was learning how to provide care for a patient’s immediate needs, he felt helpless to make a difference in their life over the long term.

“I thought it was odd, because these issues were all stemming from the use of dangerous products that are freely sold and used with little consideration of their harms,” Aaron says, noting that he was expressing his own views and not necessarily those of the FDA. “As a physician, you treat a person’s acute problem and protect them in the moment, and then they are discharged, and that is that. Why are we not doing more to fix the systemic issues?”

Inspired to better understand — and challenge — the laws and policies behind entrenched public health crises, Aaron finished his medical degree and enrolled at Harvard Law School. As a student, he was co-president of the Harvard Health Law Society; a fellow at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics; and a researcher on the intersection of law and food, drugs, and tobacco.

Obesity in particular interested Aaron, because of its prevalence, and because it is linked to many debilitating conditions and diseases — and, ultimately, a shortened lifespan. Worse still, although obesity is common in all Americans, the U.S. Department of Health and Human Services reports that non-Hispanic Black Americans are 1.3 times more likely to be obese as compared to non-Hispanic whites, and Hispanic Americans are 1.2 times more likely to be obese than non-Hispanic whites.

“Obesity is a disease, and when you see big disparities between races, you have to wonder whether it is a result of systemic racism,” says Aaron. “To say that it’s OK risks papering over salient and important health disparities that affect people’s lives, their health, and their wealth.”

The consequences of failing to understand obesity as a systemic problem, Aaron says, have been especially deadly in the past year. Early on in the COVID-19 pandemic, public health experts recognized a link between weight and worse outcomes for those with the virus — a person with obesity is up to three times more likely to be hospitalized with the disease, and more likely to die of it. Researchers have also made a connection between high obesity rates in communities of color and the catastrophic loss of life suffered in places like New York City, Albany, Ga., New Orleans, and Detroit.

“Obesity is devastating to Black, Indigenous, and other people of color,” Aaron says. “It has a very real, negative impact, and many are asking for help. Harvard’s Food Law and Policy Clinic is on the ground helping communities develop policies to address obesity and its disparities. In our paper, Dr. Stanford and I take a wide lens to obesity among BIPOC with the hope of spurring change across multiple areas.”

Aaron says his understanding of obesity as another facet of institutionalized racism builds on scholarship by lawyers and activists like Kimberlé Crenshaw ’84, and Harvard Law School Professors Jon Hanson (faculty director of the Systemic Justice Project) and Emily Broad Leib ’08 (director of the Food Law and Policy Clinic). Aaron and Stanford’s paper, published on March 4, includes a wide-ranging set of recommendations for physicians and public health experts interested in furthering health equity. Central among them are advocating for research on the connection between systemic racism and weight, expanding healthcare access for people of color, and focusing more on the lived experiences of those with obesity.

“Public health and medicine have become expert-driven fields, and there hasn’t been as much attention to social organizing,” Aaron says. “I think our field can better form connections with existing social movements and ultimately help build power among people of color.”

Aaron says that he and Stanford intended their paper not as the final word on the topic, but the opposite: a clarion call for further work on how obesity and racism intersect.

“We are interested in continuing to explore the problems in law and medicine that exacerbate racial disparities and obesity,” says Aaron. “There is a lot more work to be done.”

USDA examining future of food boxes

The article was originally written by Steve Davies and published in Agri-Pulse on March 3, 2021. 

The Department of Agriculture is reviewing whether and how to continue the Farmers to Families Food Box program, as the effort begins to wind down after serving a critical — but often criticized — role during the still continuing food crisis caused by the COVID-19 pandemic.

The program, which has received close to $6 billion in funding, has resulted in delivery of more than 140 million boxes of produce, milk, other dairy items and meat since it was launched by previous Agriculture Secretary Sonny Perdue in May. It is ending April 30, but USDA’s Agricultural Marketing Service is looking at what form it might take after that date.

“We are phasing those down, but we want to take some lessons forward to (The Emergency Food Assistance Program),” Stacy Dean, USDA’s new deputy undersecretary for food, nutrition and consumer services, said in a presentation to the National Association of State Departments of Agriculture’s winter policy conference last week.

“We have to address this not just [from a] food insecurity perspective, but also a nutrition insecurity perspective,” Ag Secretary Tom Vilsack said in a conversation with reporters last week. “To the extent that a food box program and other programs at USDA could encourage and enhance the capacity of people that have access to nutritious, healthy food, that’s something we obviously need to think about continuing and looking at.”

But Vilsack and others who have been involved with and reviewing the program say improvements can definitely be made.

“The implementation of this program highlighted in some cases, circumstances and situations where perhaps the level of money paid for those who were putting the boxes together was pretty significant,” Vilsack noted. He said it’s important to review how the program could be made more efficient so “the vast majority of the resources are not going for the administration of the program, but are actually going for the purchasing of the items that go in the boxes and getting as much food good, nutritious food to people as possible.”

“Having distributors determine who received the food has led to a lot of confusion and duplication on the ground,” said Carrie Calvert, vice president, government relations, agriculture & nutrition at Feeding America. Her group, which has 200 member food banks, wants to see USDA, not distributors who received the contracts, take the lead role on deciding where food will go.

“USDA, with that broader view of where the food is going, will be able to ensure that areas of the country have equitable access to it,” she said.

Under the program, Calvert said there have been situations where “there could be oversaturation in one specific area, because maybe a distributor doesn’t realize that another distributor is delivering in that community.” But in many other cases, the leeway given to distributors has resulted in not enough boxes for the coverage area.

A report released last month by Harvard Law School’s Food Law and Policy Clinic (FLPC) and the National Sustainable Agriculture Coalition found more than 1,000 counties received no food boxes in May and June, and two states — Maine and Alaska — were left out of the first round completely.

“A more equitably designed program that also is more efficient and effective to distribute the food could be helpful in our broader work to address the on-average 55% increase in demand we’re seeing,” Calvert said. But she added that other changes are needed, such as the 15% increase in SNAP benefits that has been extended through June 30 and expansion of programs to get school lunches to children in need.

The program appears to have broad support among state agriculture agencies. A survey of state agencies in the Northeast found 64% support for the program, with 36% saying it would be “better as part of existing programs, and the Supplemental Nutrition Assistance Program should be a priority.”

“Undoubtedly, our agricultural industry and food insecure individuals throughout our region saw tremendous benefit from the Farmers to Families Food Box program,” a group of 13 state ag agency leaders from Maine to North Carolina said in a Jan. 12 letter to Perdue including recommendations to improve the program.

Some in the food bank community, however, believe increasing availability and benefits in the SNAP program is the way to go. “First and foremost, at the food bank, we feel like the SNAP program is a much better way to serve people than the food box program,” said Vermont Foodbank CEO John Sayles.

“Extending access to SNAP, increasing SNAP benefit amounts, and reducing the restrictions on how SNAP dollars can be spent on food (for example, allowing purchase of prepared and hot foods) is more dignified and will better meet a family’s needs than a prepackaged box only available at limited times and limited locations,” the food bank said in comments to USDA.

In addition, in the five rounds of the program, “Vermont has had five different vendors,” VFB said. “Each time we get a new vendor it means we have to go back to the drawing board, which has proven to be an inefficient way of spending time and resources.”

Dean agreed transparency around the boxes’ destinations is necessary. “There wasn’t a lot of coordination with states,” she told NASDA. “That is something we would need to improve on.”

Industry groups have been supportive of the program. “We are in favor of keeping the program running,” says Robert Guenther, senior vice president for public policy at United Fresh Produce Association. “Food insecurity continues to be a major challenge, so this program, for all the challenges that people want to highlight, still has served a very important purpose.”

“It’s worked incredibly well,” Guenther said, praising USDA for “standing up a program of this dimension in such a short order of time.”

The National Milk Producers Federation supports “continued food distribution to help the millions of families struggling with the pandemic’s economic effects,” NMPF CEO Jim Mulhern said in a statement provided to Agri-Pulse. “Whether it’s through food boxes or other approaches that directly assist food banks, we would support whichever methods are the most efficient and effective.”

Regardless of how USDA decides to go, “dairy will be a crucial part of providing much-needed nutrition,” but there needs to be “an appropriate mix of dairy products,” Mulhern said. “Last year, there were some unintended consequences for dairy markets created when USDA focused on cheese over other dairy products. A more balanced approach would avoid that situation and better serve families in need.”

A major issue revolves around the types of boxes being distributed. As the program has progressed, it has moved from offering boxes with one type of commodity — frozen meats, produce, or dairy — to combination boxes.

But that has created food safety problems. “We’ve heard from our network that there are a lot of food safety and food storage concerns with having combo boxes, because produce, dairy and frozen meat all need to be stored at different temperatures,” Calvert said. “Operationally, it’s hard to require foods that have different storage and temperature requirements, combined together to be distributed. It’s just not very efficient that way.”

Guenther also said that the program worked best when boxes contained specific commodities. “When they went to combo boxes, that’s when things started getting very difficult, so to speak,” he said. With combo boxes, less produce was needed, which made it difficult for produce distributors that may have had contracts, because to participate, “you had to find a dairy source and a meat source, and there weren’t a lot of cross-purpose companies that were able to do that.”

The Harvard/NSAC report included similar critiques, finding that after criticism of the high cost of food boxes in early rounds, USDA shifted to making price the sole criterion.

“However, this sole focus on price swung too far in the other direction,” the report said. “Most governmental procurement and other USDA programs today take into account other societal values including racial equity, geographical preference, environmental sustainability, and other goals.”

Along with USDA’s increased focus on “maximizing the number of boxes distributed, the program shifted away from its original goals of addressing food waste and supporting the livelihoods of smaller producers, meaning the sole focus on the prices was not the best solution,” the report said.

Health Equity Journal Highlights Pathways for More Effective Outreach and Engagement in Comprehensive Cancer Centers

Health Equity recently published two journal articles co-authored by the Center for Health Law and Policy Innovation’s Sarah Downer, highlighting key findings and recommendations on community outreach and engagement efforts of the National Cancer Institute’s Comprehensive Cancer Centers. The titles of each article and full abstracts are featured below. 

Special Convening and Listening Session on Health Equity and Community Outreach and Engagement at National Cancer Institute-Designated Comprehensive Cancer Centers
Patricia M. Doykos, Moon S. ChenJr., Karriem Watson, Vida Henderson, Monica L. Baskin, Sarah Downer, Lauren A. Smith, Neeraja Bhavaraju, Samantha Dina, and Christopher S. Lathan.Health Equity.Mar 2021.84-90.

In recent years, the cancer research and care community has been more attuned to health equity, increasingly pursuing coordinated and comprehensive action to achieve equitable health outcomes. In addition to its support of a joint research agenda for health disparities in 2017, the National Cancer Institute (NCI) has demonstrated its commitment to addressing health inequities with its 2012 requirement for cancer centers to define and address the needs of a local ‘‘catchment area’’ and the 2016 mandate for Community Outreach and Engagement (COE). With several years of experience with the COE requirements, there is an opportunity to reflect on the experience to-date and identify opportunities to bolster the impact of COE on equitable cancer outcomes for the future. To do so, the Bristol Myers Squibb Foundation (BMSF) hosted a special convening and listening session in April 2019. The session agenda was cocreated by BMSF and NCI leaders and staff. It brought together 41 individuals, including representatives from the NCI Cancer Centers Program, Division of Cancer Control and Population Health and Center to Reduce Cancer Health Disparities, 22 NCI-designated, emerging or affiliated comprehensive cancer centers, and the broader cancer community. This article captures key themes from that meeting, including an overview of current COE efforts, with a deeper look at how four cancer centers are embedding health equity and COE efforts into their institutions and work, and the successes and challenges they have encountered.


Recommendations from a Dialogue on Evolving National Cancer Institute-Designated Comprehensive Cancer Center Community Outreach and Engagement Requirements: A Path Forward
Patricia M. Doykos, Moon S. ChenJr., Karriem Watson, Vida Henderson, Monica L. Baskin, Sarah Downer, Lauren A. Smith, Neeraja Bhavaraju, Samantha Dina, and Christopher S. Lathan.Health Equity.Mar 2021.76-83.

While cancer mortality is declining in the United States, significant racial, ethnic, economic and geographic inequities persist. To help address inequities in cancer treatment, care, support and research, the National Cancer Institute (NCI) instituted the community outreach and engagement (COE) mandate for NCI-designated comprehensive cancer centers (CCCs). The Bristol Myers Squibb Foundation designed a convening and listening session on COE with NCI leaders and staff gathering representatives from CCCs and the broader cancer community. This paper captures recommendations from the listening session for the NCI and CCCs to further evolve the implementation and impact of the COE mandate on cancer control and outcomes.

While cancer mortality is declining in the United States, significant racial, ethnic, economic, and geographic inequities persist. A number of factors inside and outside of clinical care contribute to these disparities, including environmental, socioeconomic, and biologic factors, as well as historic distribution of the structural and social determinants of health (SDOH).1 The level of institutional commitment and capacity of cancer research and care organizations to effectively engage with and serve disproportionately affected and medically underserved populations have also contributed to these inequities. Yet today, with a confluence of factors, including scientific breakthroughs in cancer prevention, detection, and treatment, demographic trends toward growing racial and ethnic minority populations, growing cancer burden among these and rural populations, and reignited social justice and equity movements, mitigating these inequities has never been more critical.2,3

In recent years, the cancer research and care community has been more attuned to health equity and has pursued increasingly coordinated and comprehensive action. For example, the American Association for Cancer Research (AACR), the American Cancer Society (ACS), the American Society of Clinical Oncology (ASCO), and the National Cancer Institute (NCI) issued a joint position statement on the research agenda for health disparities in 2017.4 The Centers for Disease Control’s (CDC) National Comprehensive Cancer Control Program also cites health equity as a cross-cutting priority and highlights three areas for action: training a culturally competent workforce, promoting equitable access to resources, and using data measurement in research and surveillance to guide community-driven plans.5

The NCI has recently started to shift more fully in this direction with its 2012 Cancer Center Support Grants (CCSG) requirement for cancer centers to define and address the needs of a local “catchment area” (CA) and the 2016 mandate for Community Outreach and Engagement (COE).6 The COE mandate identifies seven areas of action for NCI-designated Comprehensive Cancer Centers (CCCs): (1) defining a CA and understanding the CA population; (2) performing research to address the needs of the CA population; (3) engaging the CA population; (4) taking action to address cancer disparities in the CA; (5) designing clinical trials to represent the diversity of the CA population; (6) translating research into policy recommendations; and (7) extending research and policy within and beyond the CA.7

While these mandates reference disparities and encourage CCC activity to address them, there remains significant opportunity to improve the effectiveness and impact of COE on cancer disparities. At a special convening in April 2019, the Bristol Myers Squibb Foundation (BMSF) hosted a dialogue between the NCI, 22 NCI-designated, emerging, and affiliated CCCs, and affiliated programs, and the broader cancer community to understand the current state of COE and identify opportunities to improve COE and cancer health equity efforts more broadly. NCI co-developed the agenda with BMSF. Presentations highlighted that early experience with COE points to several adjustments that could inform ongoing revisions to the CCSG guidelines, including a more explicit focus on developing and maintaining high quality, authentic engagement with the community, deeper understanding of the historic and current structural barriers that contribute to inequities and how to address them, and effective resourcing and evaluation of COE as a tool to improve equity. This article shares highlights of COE work across NCI CCCs and major recommendations that emerged from the meeting discussion for the NCI and for cancer centers to deepen their impact on cancer inequities.