 We're going to go ahead and get started. Welcome to the McLean Center for Medical Ethics series this week on gender equity and ethics. My name is Vanit Arora, Dean for Medical Education, and I'd like to welcome all of you who are here in the room as well as the broad community of those that are joining virtually this week. We have a special treat for all of us. Our speaker is Dr. Valerie Montgomery Rice, President and CEO of Morehouse School of Medicine. I actually did receive a bio from Dr. Montgomery Rice. She has asked that I read the briefest version possible. And I'm not sure that's possible. So what I will tell you is that she is very impressive. I'm going to go through some select accomplishments, but I encourage you to visit her Wikipedia page, which is a really impressive list of accomplishments. Dr. Montgomery Rice is the sixth president of the Morehouse School of Medicine and the first woman to lead the freestanding medical institution. She serves as the president and CEO and is also a renowned infertility specialist and researcher, most having recently served as the institution's president and dean from 2014 to 2021. She began her tenure at Morehouse School of Medicine in 2011, serving as the dean and executive vice president. And prior to joining Morehouse, she was the founding director for the Center for Women's Health Research at Mahari Medical College, one of the nation's first research centers devoted to studying diseases that disproportionately affect women of color. She is dedicated to creation of an advancement of health equity and has led numerous programs that really, you know, enhance the opportunities for academically diverse learners across the spectrum of medical education and science. She holds memberships in various organizations and boards. She's on the board of directors for United Health, Wealth Path 23andMe Care USA, the Josiah Macy Foundation and the Moffitt Cancer Center. In 2021, Governor Kemp appointed Montgomery Rice to the Georgia Commission, where she lends her in-depth knowledge and expertise as a women's health researcher to improve the life of women and their families in Georgia. She's also a proud member of the National Academy of Medicine and the Horatio Alger Association. She was named to the Horatio Alger Association of Distinguished Americans and received the 2017 Horatio Alger Award. There are numerous awards that I could read. I wanted to highlight one that was salient to our topic of gender equity, which is that she is the recipient of the American Medical Women's Association, Elizabeth Blackwell Medal, one of the highest honors for the AMWA group. A Georgia native, Montgomery Rice holds a bachelor's degree in chemistry from the Georgia Institute of Technology and a medical degree from Harvard Medical School, as well as several honorary degrees. She completed her residency and obstetrics and gynecology at Emory University and her fellowship in reproductive endocrinology and infertility at Hudson Hospital. So please join me in a warm welcome for Dr. Montgomery Rice. Thank you. Thank you so much for that lovely introduction. And I will try to live up to all of whoever that person was. You were reading about. And let me say it is an honor to be here with you all today and to actually speak to a group of sort of diverse scholars who have taken an interest in ethics. Because I think that is what aligns to care. It brings out our why. That should be aligned with our values. And so I thought I'd talk about there's no wealth without health. And it begins with closing the gaps. And once someone asked me, well, have you given this lecture before? I actually have not given this lecture before. And the reason I haven't given this lecture before is because I think that it is only recently for me become how striking it is, how impactful social economics influences everything that we have end up having choice about. And which which turns the slides this clip. Oh, scroll of Lordy. OK, all right. Scroll up and down with this. OK, OK, that that down. OK, here's my disclosure slide. And these are the things that I spend whatever time I have outside of Morehouse School of Medicine. These are the learning objectives. And they are about appreciating this longitudinal association between wealth and health outcomes and the impact of unrealized potential on gender and equality and earnings and the role of education as the equalizer to achieve and health equity. So I hope that you definitely get to see that. Just talk a little bit about wealth and health outcomes. And I define wealth and health here as terms that we are very comfortable comfortable with, wealth is measures this value of this accumulation of assets owned by a person, community, company, a country. And health by the WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease. And I love this this graph here, this picture, because health systems really do impact our societal well-being. And since we're at this wonderful institution, I did not want that to go unnoticed that the systems and how we integrate those systems really do influence a person's health outcomes and their well-being. So let's take a look at some of the inequalities in wealth. OK, and this is a slide that looks at the distribution of income and wealth in the United States. You know, you can clearly see that most of the wealth is concentrated in a small group of people, right? And that if you look at this bottom 90 percent, they clearly over the years we're seeing there be less wealth and more wealth concentrated in this number of people, which is a small number of people. When you look at the thresholds of wealth in this country and they looked at it by something called tax units as a in this paper, but you really can see that the top 10 percent wealth class, 1.2 million, top five percent, 2.4 million and then the top 1 percent, 10.4 million. That's a big difference in income, right? Young people have little wealth. Now, that's intuitive. However, what we're beginning to see is that we have a much ageing population that continues to have more wealth. And the question is, what happens to that wealth when they're gone? How does it get distributed? Can we have any influence on that? Do they end up donating most of it or is it passed back to a generation? Most of the data shows that it's passed back to a generation, but it's passed back to a generation that's not that younger generation. So in order for you to really realize the benefit of your family's wealth, it usually doesn't occur until your forties and your fifties over 50. If we look at the inequalities in wealth, we see that white families have substantially more wealth than black and Hispanic families. And you all, it is it is multifold. And that is not changing in this country. When you look at the median wealth of a US household by race and ethnicity. Two hundred thousand dollars for a white family. Less than twenty thousand dollars for a black family. About twenty eight thousand dollars for Hispanic or Latino. And then we have the other motor race. This is significant and it is significant because it influences what I would describe as choice. College graduates have more wealth than those without a college degree. That's not surprising. And so while we hear people talk about not stressing so much the importance of a college degree, there's clearly opportunities that are presented to people and advantages that they're able to take, take advantages of because of a college degree. And so we don't want to push everybody to get in a college degree. But we do want to understand that the data does reflect that even if you have some college or a social degree, your wealth is about equal to that of a high school diploma. Much of that, I think, speaks to opportunities that are created and people that you get to interact with. If we look again, education, age and race, this sort of just summarizes the couple of slides that I showed you is that when you look at race, particularly in the black and Hispanic, black and non-Hispanic, black non-Hispanic, you can really see the disparities there across race, age and education. And I believe a large part of this is due to the educational opportunities that we see people experience. Where do most rich people get their wealth? Did they work for it? Or was it given to them? Well, when you look at the top one percent, business equity is a large component of the wealth that this top one percent has when you look at net other financial wealth, you see it's critical, but the one thing that we potentially could have control over is home equity. It actually is one of the ways that you build wealth in this country. And it is really, really important. Retirement accounts. Now, some people look at this and say, well, did the top one percent even work? Or did they shift most of their wealth to their business? Right. Now, how do we make the connection? And this is data that some of us have seen before, but I tried to simplify these slides so that so you can see categories of wealth is in green, medium is yellow, blue is low and zero is negative. And regardless of how you want to look at this, when you look at people who have negative and low categories of wealth, they report, this is self reported, they report having poor health. When you take that same group and you ask them about psychological stress, they have more psychological stress. And you see, there's a significant difference between black and white. But even white persons who have negative wealth have more psychological stress. What about disease type? When you start to look at diseases and I thought, let's look at obesity. Which leads to a lot of diseases. Again, you see less wealth, more obesity. Let's look at another behavior thing like smoking. And it's a little bit mixed. But you clearly can see it's the low and the negative wealth. People tend to smoke more and we know that obesity and smoking does lead to a higher rate of chronic illnesses. And so the bottom line is, is that if you look at wealth as measured by net worth and health outcomes, what you really can see is the more wealth you have, the better your health outcomes. You report less diabetes, you report less obesity, you report less hypertension. Compared to others who have a much higher rate. If their wealth is lower. And we definitely see a difference based on race. I pulled this slide because I wanted to think about how soon, if we were to ever come up with interventions, could we have impact? And so I looked at obesity in boys versus girls, prevalent diseases. It decreases as income increases. Now, remember, most children do not have control over what they're going to eat. So it is clearly influenced by the family's social structure. And what we found was some things were not consistent across race and ethnic groups, so we did not always see the lower a higher rates of obesity in Hispanic children. Right at lower wealth, but we clearly could see a pattern in general that if you ended up with higher obesity, that was lower wealth in the families. And again, we believe that if we had interventions that impacted children, where they had increased knowledge and choice. Regardless of their wealth, maybe that would influence long term some of these outcomes. The other thing we wanted to look at was rural populations. What happens in locations where there are less providers and less access and clearly you can see that we looked at here, health professional shortage areas, doctors per 10,000 primary care doctors, etc. And you could see that there were more opportunities for where we need more providers in rural areas. And you could see whether you were in urban, you could see indicators of health status and the risk for disease, morbidity and mortality across all of these disease spectrums, obesity, smoking, whether they have public health insurance, etc. All of those were influenced again by the number of providers that were there and the fact that they were geographically spaced. Is there a way that we can look at this in a systemic way that we can begin to measure? I thought this was a great paper that was published that really talked about what were the contextual influences that influence wealth, health and civic engagement. So if you look at state in nature of the economy, public policies, many of those things that are forced upon us, state laws, the public policy for education, the public health challenges, biophysical factors, the environmental influences, exposures, diseases and then, of course, our values and our norms. The perception of discrimination. How do those impact wealth, health and civic engagement, which I believe is critical to any of the things that are going to occur on the right hand side. And so this work is still ongoing, but there are a couple of things that we have been able to ascertain and are used in this in our Satchel have a leadership institute as a tool to help us think about what drives people to be engaged in civic engagement and how likely is it that someone. Based on their wealth is going to go out and vote. How likely are they going to be involved with community problem solving and how likely is it that their income and education or whether they're on a house contributes to their wealth and what's the likelihood of them being engaged in civic engagement and how all of that influences health. And I think it it differs by communities, but I think it's worth exploring in every community because it gives you the opportunity to bring communities to the table, to engage in conversations that perhaps they had not thought about and the things that influence their decision and also can empower communities to understand that civic engagement really does matter in creating policies and opportunities that influence not just your wealth, getting rid of red lining in communities, but also your health, where you place hospitals, where you place integrated care delivery systems. What does an integrated care delivery system look like when you're trying to build access to care? Do we create systems that meet the patients where they are, regardless of where they are? That requires civic engagement. Next, I want to speak about the impact of gender pay gaps. So as you all know, we've seen some improvement, not much, but some improvement in narrowing the pay gap. But it really does still exist that a woman earns an average of 83 cents for every dollar a man earned in 2021. The good news is in 2001, it was 76 cents. So rule we up by seven cents. And guys, this pay inequity. Exist, regardless of which race and ethnicity that you belong to. And I know we can do better than that. When we look at this, it is influenced by the roles that we play. So this is looking at a significantly higher percentage of women work in minimum wage jobs and very few women are in the top roles. The top roles, ROLES of the Fortune 500 companies, and particularly the finance companies, Bank of America City, Goldman Sachs, JP Morgan, Morgan Stanley, they got a lot of work to do. If this matters to them, if this matters to them. But if we cut it across any industry, company management, construction, construction is getting better. Finance and insurance, health care and social assistance, manufacturing, retail. And retail, even when we have more women who work in retail, we still have this pay inequity. And so again, we have a lot of work to do in this area. And then when we start to look at the top 10 percent of earners, you can see women only comprise 27 percent of the top 10 percent of earners in the United States. And again, when you start to look at the top one percent is even less and clearly when you get down to the top zero point one percent is only they comprise 11 percent of those. Again, more work to do. If I start to look at this and say to myself, OK, what could be some of the causes of some of this that we see that in contributes to the race wealth gap? Yes, it is pay. But we also have been able to look at and see guys that black women have the largest amount of student debt burdens in this country. Now, this was surprising to me. I did not know that until I started to look at this data. That black women really do end up graduating from associate schools or college or medical school. And they have the highest amount of debt and clearly carrying that debt burden, even when you're advancing in your career, decreases your opportunity for wealth. We also know that women tend to have higher poverty rates across the board as compared to men. Again, thinking about a conceptual framework for how we can measure this cost of gender inequality. And the reason, guys, I keep showing opportunity here is because I think I don't think that we have identified all of the influences that lead to gender inequity. And we need to think about them not just from an individual or community, but from a national perspective. So gender inequality, fertility and population growth. When women choose to have babies matters. And they should have a choice of when they choose or desire to have a child. That influences. Educational choices, opportunities, job choices, types of jobs and where they are going to be on the trajectory. Health, nutrition and violence clearly impacts. Wealth and health, education, attainment and child marriage, labor, earnings and productivity. We just talked about decision making. How much authority does a woman have in her household, regardless of what that household is, or in her job to make decisions that will have a direct and indirect impact on her earning potential, whether or not she can budget and save. And all the other benefits that go with accumulating wealth. I give one example with covid. And this really didn't come out as much, guys. The majority of the frontline workers who didn't have a choice or whether they were going to stay at home or women, whether it was a government job or social work or health care. And then more women actually had to stop working during the pandemic when there were a two person household that worked. It was the women who had to stop working in order to care for the child. All of this significantly influences wealth accumulation. This slide sort of depicts how many extra days a woman works based on race and ethnicity, if she were to try to equal the pay of a man. Now, there's only 365 days in a year, right, today. And so that means they got to work two to three times more in a day in order to influence or equal their pay. And you all, again, opportunities. How does this impact our physical health? How does it impact our mental well being? And of course, how do we close this poverty gap? So now let's talk about strategies. Mentoring matters. Seventy four percent of women aspire to reach an executive leadership rank, even if they have children, even more so when they have children, because they want to lead by example for their children. And this doesn't matter what country you're in. Women have aspirations. And so we have to make women a part of the village in mentoring them to help them to be able to take all of their assets and combine it with the need of the organization and find the linkages for them. Career progression and influences. What are the things that impact a woman, a woman? Younger women who were far more likely to say their mothers had been their greatest influence on their career. While older women were more likely to say that nobody has been the greatest influence. Role modeling. When I was a junior faculty. And I went to University of Kansas, my first job. And they hired two people out of fellowship to start the division of reproductive medical knowledge and fertility. We hired a team and we hired a woman as our embryologist. And she had two kids already. I came to fellowship pregnant, so that was quite interesting. And I was just so guilty about the fact that I was going to have to take time off. You know, you have to take time off when you have a baby. You do you do have to do that. And so I was feeling guilty about it. And then the amount of time that it was requiring, you know, when you when you with a newborn, etc. And she gave me a book that says my mother worked and I turned out OK too. It's a paperback book and I've never forgotten that. That mattered. In giving me some sanity that I was not in this. I said, when I'm an OBGYN, I was going up to career ladder, etc. But all women have this fear that if they take this time away. Will they be forgotten? Is this going to harm their career? Is this going to harm their children, etc. And so that book really helped me. My mother worked and I turned out OK too. As leaders, we have to make sure that we address unconscious bias. We also have to look very closely at the data in our institution to really monitor whether or not women are being able to progress. And we have to understand the value proposition in diversity and inclusion. I spoke to two other groups this morning and I stress this all the time. There's a business case for eliminating health disparities. There's a business case for creating health equity. There's a business case for diversity and inclusion and it is tied to money. It is tied to improved health outcomes for our patients. It is tied to creating cultural competency and humility. And all of this matters, particularly for a health system, because in a health system, we are fortunate and blessed to get to participate in the most important times of people's lives, their joy and their sadness and everything else in between. And we can never underestimate the value of that in a health system. Unconscious bias is real. All of us have it. None of us are immune to it. We all must do self-reflection to recognize when it's there. That's why it's called unconscious. You don't know it's there until somebody points it out to you. And it doesn't mean that you're a bad person when you have it. It just means that you have an opportunity to make it conscious. And once you make it conscious, then you have an opportunity to change. So. I am a scientist first and data matters. I wrote this probably a long, long time ago when I was doing a talk when I was talking about the women in science and many hurdles that are ahead. I am a scientist first and I believe again in stressing to organizations. Look at your data. Don't be ashamed of it. Assess it and then determine what you want to do about it. But most importantly, ask yourself the question, why do we want to do something about it? Why do we want to do something about it? And so I will give you a little bit of insight into what I believe is the most critical thing that we can do. We are an institution of higher learning and I believe the education is to equalize. I look at things from a fundamental graph of public health, social economic status on the X axis on the Y axis is health. There's a line slope there, right? So my question is, how do you move people along that slope? Right, because if you move people along that slope, they're improving their social economic status and their health is improving. And why is that? It is based on opportunity and choice. Now, if you look, there are some things that you can do. If I take a mentoring program for inner city high school students. That program, I put it on that X axis. That program is going to possibly influence somebody in a way that moves them to the next level of education attainment or seeing a profession that perhaps they never saw themselves in like a white coat or being in a research lab. Or being a fireman or being a policeman. They began to have choice whether or not they want to smoke, whether they want to do illicit drugs, whether or not they want to eat healthy, maybe they move into a neighborhood that allows them to walk 30 minutes a day safely. What about if I do improve antibodies to prevent infections at the surgery? Really important. It doesn't necessarily lie about it to move along that slope, but it does improve the health outcome scholarship program to increase opportunities for low income students to go to college. Again, moving along the slope, ethnic diversity training for primary care physicians, that can move people along the slope. You know why? Because perhaps you're going to be culturally sensitive. I have cultural humility and you're going to share this opportunity with them to participate in a clinical trial or you're going to talk to them about. You have aspiration to go to medical school. Maybe I can mentor you to have you think about the choices that you need to make to improve your outcomes. So all of that does matter. And I will tell you about this little girl. That is me with my siblings and my great grandmother. In Rens, Georgia, about 45 minutes from Augusta, where I spent most of my summers. And this is how I moved along that slope. I increase my social economic status because of the educational opportunities that were presented to me and that I took advantage of. And then I had mentorship and sponsorship all along the way. And to my knowledge, I don't have any known medical problems today. But education and mentorship, that was the great equalizer. And everyone sitting in this audience has a similar opportunity to move someone along that slope. By touching their lives and sharing your story. And the data will show that with education attainment, you see improved outcomes in people. And this is looking at Georgia. And this first one on the left is saying, in Georgia, adults with less than a high school education were over three times as likely as those with a bachelor's degree to forego needed care due to cost. In Georgia, even after the implementation of the ACA, there was a significantly significant decrease in the reports of foregone care due to cost. So, yes, that made a difference. So policy matters. If we look at whether or not people had a personal doctor, again, people with a college degree have more of a likelihood of a chance of having a college degree. And again, we can look at medical care costs and all of those things. And it shows that the more educated someone is, you all, they make different choices. An important thing to me is that they have different choices to make. I was going to show this video, but I'm not. It is a video that I did for brawny commercial, which which was I don't know if it is show because I think I think we forgot to put it. I don't know if we did. But it was it was something that they asked me to do. And I thought it was on Women's International. And I was like, OK, I don't want to do this. But they said it is important that strength is indicated when you talk about strength has no gender anyway, but I'm not going to show it anyway. So the importance of wealth gives choice for health decisions. Now, just because you're wealthy doesn't mean that you're always going to have ideal health outcomes. And I show these four people, you all, because we perceive these people as wealthy and we perceive that they would have great health outcomes. But choice does matter and making good decisions as matter. And also what I believe each of these people could have benefited from. Is more research on the things that they lost their life to. So again, we have a critical opportunity, not just guys and influence and patient care, but also how we ensure research that democratizes the opportunity to deliver the promise of science. To the communities that we care about. And I'll just give you an example of precision medicine. We are a lot about precision medicine and it is being used in diagnostics, pharmacogenomics, clinical trials, new biology, new drugs, risk assessment and risk modification, and it's going to deliver better treatments. It's going to deliver benefits and it's going to have development of novel medicines. But if we don't diversify the genome that right now only has 2.4 percent of persons from African ancestry, we are not creating precise tools that we be reflective of the opportunity that precision medicine can give us. So we really have to make an effort and what we have to do in our institutions of higher learning is ask about the data systems that these tools are being developed from and whether they are really reflective of the communities that we are serving. I want to see disease burden significantly impacted by precision medicine. However, we are not there yet and we have to be more inclusive in this. So it is being practiced and used genomics is and the benefits of there. We got to make sure that we have to overcome the barriers in education, accessibility, regulation, reimbursement and also importantly, the diversity in clinical trials. Now, what can you do in your circles of influence? You can first understand that you have a circle of influence, regardless of you in a first year medical student, an MPH program, an ethics fellow, you're in residency training, junior faculty, there is somebody who thinks that you are the it. And so you have a circle of influence. And so you need to think about how do you help develop opportunities for people? You need to support the community infrastructure. You need to increase opportunity for people to learn and collaborate. You need to think about asset building over and across a community. And Morehouse School of Medicine, one of the most important things that we've ever done was 11 years we adopted Tuskegee Airman Global Academy, a K through five school that has 97 percent of the students are title one. And we have 100 and 150 of our employees are in that school all the time. That school is now a high performing school. They have a robotics lab. We have students who go to the Georgia State Fair. We do all kind of work with those students and they come to Morehouse School of Medicine, all 600 of them twice a year for a program that is about four hours long and we're doing science experiments and all kind of stuff with them. And we're envisioning for them what's possible for their future. And it is a wonderful opportunity for us. We also guys have to focus on this equitable learning environment. To begin to achieve equity and care delivery, we must address the institution or interpersonal racism, including implicit bias, and it has to be addressed at every aspect of care. This is very important when we're talking about evaluating our learners. This is looking at student factors, faculty and resident factors, personal and interpersonal and cultural and structural. But you are we have a lot of systemic things. My AOA, you know, we have a lot of things about how we grade students. How we end up creating stereotypes. How that ends up with people being labeled throughout the first of the four years of residency training. How that influences how people teach them. How they end up sometimes having lower expectation of them. And a lot of times. It continues to group think. And we as leaders have to put in opportunities for development and training that breaks that cycle. But we first have to be clear that it happens. And that it influences people, grades and their honors and their career opportunities. And I get back to something that we participated in with Josiah Macy. All learners have to have fair and impartial opportunities to learn. It's called medical school. It's called graduate school. It's called residency training for a reason. If they are not going to make any mistakes, then why do we have them in a learning environment? So let's not be punitive. Let's use those opportunities to coach, give feedback, assess them in an equitable manner so that they can graduate and be our ambassadors. And so that means we have to address our own biases that we have. And I go back to, I think, the most important thing on this slide is to examine your own data and to understand where you are and then be able to look at that data and think about your assessment and ask yourself, why? Why is it that 10 times the number of students, 10 times more students of color and surgical specialties go on probation and surgical residency training program? Why is that? Why is it that we see a higher percentage of black and brown residents having to repeat a year or being dismissed? You recruited them with a level of enthusiasm and then something happened that changed your mind. Well, as the leader and the teacher, you take responsibility. We take responsibility for ensuring that students finish and are successful. So it really does require us to continue to train and ensure that leadership is aligned with our equity mission. You got to pay attention to this learning environment. And finally, of course, I'm from Georgia. I go to Ebenezer Baptist Church. I get to feel the influence of Martin Luther King, Junior a lot. And so I use him on a lot of my talks because I do believe for someone who only lived to the age of 34, he has shared more wisdom with this country and given us a recipe for how we should treat one another and care for one another and think about social determinants and socioeconomic impact than anybody. And it moved well beyond race and ethnicity for him and his latter years. He really did understand that it was social economics that was the driver of many of the inequities that we and people were experiencing. The ultimate tragedy is not the oppression. The ultimate tragedy is not the oppression and cruelty by the bad people, but the silence over that by the good people. Use your voice, understand that it matters. Thank you very much. Thank you so much, Dr. Montgomery Rice, that was a wonderful, you know, for a and to really the connection between health and wealth and what we could do, leading from where we stand to improve equity. I'm going to open it up for questions from our live audience. And Bita, maybe you can help me with the Zoom audience up here. And we and I open the floor for questions. Dr. Peek and I'll repeat the will repeat the question. I'll repeat the question and I'll turn it over to you. Go ahead. Great. Great question. I'll do my best to summarize. So wonderful talk, really trying to look at that slide, looking at health, wealth and civic engagement. Dr. Peek asks, how do we reconcile that some of the civic engagement that we see is coming from those that are disproportionately affected with other health and wealth issues and how do we reconcile that to to ensure that everybody's sort of voices counting, if you will? Is that is that a good summary? OK, thanks. Thank you. So I will tell you that grass roots efforts by by persons, regardless of their wealth status matters. People who can empathize with people, even if they are not disproportionately impacted, but then the people who are impacted to raise their voice. So the civic engagement really matters. But how do you translate that civic engagement based on an acute situation to policies that actually really do lead to a sustainable change? And so let's just take one example. And I usually try not to be too political, but this is a health problem. Gun violence. In this country. We have a lot of civic engagement. About gun violence in this country, in this country, and any of us who work in a health system know that it does matter how many guns are out there on the street and whether or not people get access to those guns, etc., etc., etc. And so the question then becomes where is the power to affect the change? And so when I think about wealth in that way, I'm thinking about power. I'm thinking about the people who are sitting in the decision. And then this gets back to your civic engagement. That's why you got to vote. At the end of the day. So you share and raise awareness to your grassroots civic engagement. But when you go to the polls and you cast that vote, you then have power to put people in the seat who are going to manage your wealth. And that is your voice. If you are a person who doesn't have financial means per se. And so it influences by directionally. And we have to be very cognizant of that. It is very challenging to sit back and listen to the stories of an OBGYN of what's happened with Mepha Preston. I mean, it's very just 20 years of choice. And someone wants to take that away again, the voices of there. But again, the civic engagement has to go beyond just a cry. We have to have people who are sitting in these seats who understand that they got to listen to all of the voices. And a lot of times the majority of voices do win. And we got to make sure that our voices are heard and that we are putting people in places and spaces that are representing us. So that civic engagement matters and wealth is not just measured in dollars. Wealth is measured in sometimes power who's sitting in the seat. Thank you. I'm going to read the question that just came in from a virtual attendee. Thank you for your talk, Dr. Montgomery Rice, I really resonate with your point about equity and leadership. What recommendations do you have for residents in holding our leadership accountable to diversity and leadership? So first of all, your your leaders have to agree. That it matters. And if your leaders believe that diversity matters in the and who sits at the table. Then you have to understand they have put in systems in place that is going to bring more diverse persons to the table. As I've spoken to the two earlier groups. A similar dialogue was occurring. And guys, our biggest challenge is is that we have to graduate more black and brown students if we want more black and brown students to be in residency training programs and to become faculty or to become administrators. And we are at a flat line pretty much in this country. And then we have to ask ourselves the question is, is that how can we have eight percent black matriculants, but then we only have about three and a half, three point nine percent of residents who are black? What happens to that? What happened to that four percent of people? Where are they? How are they lost? And so we got to do better with not just a pipeline, but ensuring that people stay on the pathway and as a resident, when you are of chosen the place that you're going to come to, I think it's very important for you to ask for audiences with your leadership so that you can begin to have continuous dialogue and not dialogue that's always precipitated by a crisis. If you can create opportunities where because leaders are people too. And a lot of times, no matter how great we think we are, as soon as someone has a crisis or something comes to us and we have defense also, right, because we in our mind we think that, OK, we doing everything, checking off all the boxes, etc. And then things are not always coming out as we expected. How do you create an environment where there's continuous conversations such that you are anticipating and preventing crisis? So one of the things that I did early on when I was president, Dean, I had a dialogue box and students could put anything in that dialogue box and they did. And we would guarantee an answer within 72 hours. Somebody in the dean's office would have to they were looking at this and they would guarantee an answer in 72 hours. And many times, though, it was things that was a systemic thing. It depended on where it was in the year. But then when we had our quarter to meeting with the students, we would then address those in a systemic manner. The other thing that I still have even today is open door. And so I have an open door sign that anybody can go on and they can sign up for 15 minutes with me. There's only 15 minutes. But they can come and talk to me about anything. And I've had just some things that I would not have thought about. For example, I was we we we when this is when I was early on, we had about a thousand employees and I would have never thought about this is that payday was going to occur around the holiday on Christmas, unlike Christmas Day or Christmas Eve. And someone came to me and said, well, you know, that means that they're not going to get their check for people because everybody doesn't do direct banking. You know, everybody's not banked, right? They're not going to get their check. Is there any way that we could get paid on Wednesday? Yeah, we could. I mean, it's just a matter of us deciding to run the payroll then. Now, you may not can do that in a in a in a million person organization. I'm not even saying that. But in a small organization and so just listening and making that change was something I would never thought about. But for some people, that was the difference in what type of holiday they were going to have. And then, of course, the thing that I tell them that anybody who comes to talk to me, they understand that if it's anything that sexual harassment or discrimination, etc., I got to take it through the right channels because if they come and talk to me, that is as if they are reporting it. And they cannot come and talk to me about something that they're afraid to talk to their manager about. Because I believe it's my opportunity to facilitate that open engagement. And we work together to figure out how to do that. And I think that's going to shed a lot of engagement and access. Great, I'll read the last question because I know Dr. Montgomery Rice runs a tight schedule, so we want to get her to her plane. Dr. Lindow says, Dr. Rice, your message around engaging youth really resonates with me. So many people feel hopeless in the face of what seems like intractable problems, engaging with youth is something we can all do. And she actually just ends with thank you for your leadership. So not really a question, but I think just a wonderful way to thank you for your wonderful talk and time with us today. I know that many of our audience members got a chance to say hello earlier, but we will end a little bit early and recommend anyone who wants to say hello or ask a question, come to the front. So thank you so much, Dr. Montgomery Rice. Thank you for having me. Thank you guys.