 All right, so I'm going to cover health disparities in the COVID-19 pandemic, and I'll start by just giving a thank you to the various places in the university where I sit, including the McLean Center, also the Bucksbaum Institute for Clinical Ethics, obviously the University of Chicago Medicine and the Chicago Center for Diabetes Translation Research. So I'm just going to give a brief snapshot for COVID disparities, which is always in flux, but mainly want to talk about why the disparities exist and what are some of the things that we can do to address them. When the pandemic first came out, Chicago was one of the first cities that were naming the disparities that we saw by race. So despite having 30% of the population being African-Americans, 70% of the deaths, 72% of the deaths were amongst African-Americans. Within two months, we had decreased that death rate, that proportion of deaths, a COVID death, down to 42%. In South Carolina, 30% of the population was African-American, 51% of the deaths were amongst African-Americans. And so we see this consistent disproportionate rate of deaths by COVID despite the lower proportion of the population. In California, the Latinx population was 39%, 61% of COVID deaths. Another way that we also can be thinking about this is not just by race and ethnicity, but also by class. And so in California, where they have census tracts that are looking at low HPI levels, which is sort of a measure of well-being based on socioeconomics, 24% of the population live in census tracts with a low HPI, yet 61% of the case positivity rates for COVID are in those same census tracts. This map is an older map, despite the fact that we've only been in the pandemic for a relatively short period of time. On the left, we'll see states that have disparities in COVID infection rates. And on the right, we see states that have disparities in COVID deaths. And so we see that there's a lot of heterogeneity even within the United States. The states that are in gray are ones that have not been reporting data by race and ethnicity. And so what we do know is that there's a lot of variation by race, by class, by geography. And so there are a number of reasons that are that are driving some of these disparities that we're seeing in our country. And so what I want to talk about is why some of these disparities exist and what are the, again, some of the things that we can do to address them. My hypothesis, which is borne out by evidence, is that structural racism is a significant driver, perhaps the only but the most significant driver of COVID-19 disparities that we're seeing in the United States. So in multiple different ways. So structural racism causes biological changes. So there's a lot of debate about whether or not there are biological differences in race versus race being a social construct. And so I don't want people to misunderstand me in that race is a social construct, but racism is causing biological changes in people who are subject, so who are subject to racism. And so that is impacting our health. And so for as, for one example, structural racism increases people's likelihood to form chronic diseases such as diabetes, cardiovascular disease, chronic lung disease. And some of the mechanisms through that are through increased allostatic load, through changes in our path of physiology, such that we have alterations in our autonomic nervous system, alterations to our hypo pituitary thymic axis, alterations in our inflammatory system, in our endocrinology system. And so that those long term effects of prolonged release of cortisol, for example, increases our risk for diabetes and all of these other chronic medical conditions. We also see changes in our acute inflammatory responses. And so people who have been specifically studying that have been looking, for example, at our antiviral responses, and have attributed 50% of the black, white difference in the genetic immune response to racial discrimination. And so again, what has started out as a social construct has because of racism had biological has had biological and pathophysiological changes amongst those who are subjected to racism. And so we have seen that there are structural there that there are associations between structural inequities and health outcomes. And so if we look at things like residential segregation, community violence, food insecurity, limitations to the built environment, specifically racial discrimination, poor housing, these are all conditions, these kinds of structural inequities that have been associated with obesity, diabetes, hypertension, chronic lung disease, cardiovascular disease and asthma. And that is not a complete listing of kinds of structural inequities or the health conditions. But they're ones which are related as we think about risk factors for poor COVID outcomes. And so that is relevant to our conversation today, as we think about some of the mechanisms by which structural racism may contribute to poor COVID outcomes. And so these I'm just going to show you as a sort of a walkthrough as some journal titles that will allow us to just begin thinking about because we don't have time for a deep dive, some of the pathophysiological mechanisms. So this was an entitled accelerated telomere shortening in response to life stress. So telomeres being sort of the the capped ends of our chromosomes that help protect us against chronic disease. When those shorten, then we are less protected against chronic diseases. And so telomere shortening has been associated with life stressors, things like chronic poverty and other stressful situations in which marginalized people have been forced to live in. Chronic exposure to everyday discrimination and coronary artery calcification in African American women, this one heart steady. So everyday discrimination has been looked at as a key mechanism on the causal pathway in between the life stressors of chronic discrimination and the outcomes that we see for health. So how we how how persons of color are impacted by everyday discrimination and internalize that and how that may then in turn impact our our health. Another one is self reported experiences of everyday discrimination are associated with elevated C reactive protein levels, which we all know is sort of a chronic inflammatory marker. And we think about that as being related to cardiovascular disease in older African American adults, epigenetic signals of how social disadvantage gets under the skin, a challenge to the public health community. And then this last one, the fire at this time, and that's a reference to James Baldwin's work, the fire next time, the stress of racism, inflammation and COVID-19. And that specifically references the viral responses that I was referring to earlier in one of the slides. So in addition to thinking about how our pathophysiology might be altered as a result of structural racism, then there's then what we more typically think about as far as limitations and individual opportunities, and things like racialized residential segregation. So I'm going to talk a lot about Chicago because that's where I've been living for the past 20 years. And that's just the case study that we'll use for today. So Chicago is a city that is wonderful, which is why I've continued to live here. But it's a city that is extremely racially segregated by not only race, but also by class. And so if we take a look at this map, we'll see that any community that has more than 90% clustering by race or ethnicity has a specific color. And it's only those cities, I'm sorry, only those communities that are in white are ones that have less than 90% of racial and ethnic group that is mixed. And so Hyde Park is like the little bubble that's number 41 surrounded by green. So the green areas are communities that are more than 90% African American, which you'll see most prominently on the south and west sides, which is residential sort of layover from the Great Migrations. The orange areas are greater than 90% Latinx. The purple areas, primarily on the north side of Chicago, are primarily white neighborhoods. And then again, the areas in white are ones that don't have a predominant racial group that's more than 90%. It doesn't mean that it's necessarily segregated, but it's not more so than 90%. And then we have one little area of Chinatown that is non-Hispanic Asian, that's blue. So if we look at our COVID mortality rates by zip code, you'll see that the darkest blue, the highest rates are still in areas of our city that are imperdominantly African American and Hispanic or Latinx communities, even though we have made significant strides in reducing these disparities within our city. Okay, I'm just gonna, there we go. So we have to think not only about all of the individual path of physiology things that I was thinking about when we think about chronic diseases and things like that, but also think about geography and place-based risk, things like racialized residential segregation, the kind of housing that people have access to, particularly as relevant to COVID. So crowded housing, poor ventilation, communities that have fewer resources in which people can safely shelter in place, whether or not people are having to use public transportation to go out and get those resources to have to go to work, whether or not people have to work and leave their home, or whether or not they can work from home. All of these things contribute to whether or not there is a place-based risk that increases their chances of contracting the coronavirus and then subsequently having COVID-related morbidity and mortality. In addition, there is, and all of those things are related to structural inequities or structural racism. So there's that, then there's the individual risk. So things that we've already began speaking about as far as the individual risk for chronic diseases like diabetes, hypertension, asthma, obesity, chronic kidney disease, cancer, and then the individual risk that comes with not just a medical disease, but the individual risk from your social place in society. So whether or not you're an essential worker, and there's been a lot of conversation about that. Then the individual risk that comes with the structural inequities, structural racism of being overpoliced, more likely to be put in jail. And that has been part of the large part of the national conversation of 2020. Things that we as healthcare providers have always, not always, but have primarily been discussing as we think about racial inequities, disparities in healthcare access. And so these are things that contribute to individual risks for contracting coronavirus. So what I'm now going to do is, now that we have sort of a better sense of how structural racism may put individuals and communities at increased risk for poor COVID outcomes, begin thinking about or talking about how we have started from like, how we have 10 recommendations to begin to mitigate some of these disparities. And so this is a paper that I'm so excited that finally came out last month, I believe, that we actually wrote many months ago. So a special shout out to Will Parker, who I know is on the line because he has been texting me. I'm sorry. Also, to one of our medical students here, to several of my biathesis friends and to David Ansel and Selwyn Rogers, who lead our city's racial equity rapid response to the COVID disparities sort of phenomenon in the city. And so our work is a culmination of thinking about public health strategies and bioethical principles to address the COVID pandemic as related to racial disparities. And we draw upon some examples that the racial equity rapid response team has been putting into place. And so I'll go through 10 recommendations that we came up with. And then at the end sort of also highlight how this how some of these recommendations that we've made have been have examples from the task force. Okay, so first I would say we would recommend require the collection of race ethnicity data with COVID-19 reporting. And that would make sense. However, as of last year, 50% of patients have missing race and ethnicity data among US states. We saw in that first map some of the states had no data. So we could they were completely in gray. And so obviously, if we don't have data to collect, then we cannot track the disease that is the disease across areas, and also within areas, we cannot address what we don't know. And so we have to be able to have more information. Thankfully, what we do in Chicago, every day is have a daily summary that is available to the public on a website, you just go to it and you can track by demographics by zip code, cases, testing, deaths, age, gender, race, ethnicity. And so this is something that our city has decided to put a significant amount of resources into, not just the human capital to keep these numbers up, but the financial capital in order to keep these systems running so that anyone can see it any given day, where we are and the kind of progress that we're making and the progress that we need to be making, because for a while we were doing really good. Now with the surges, we're, you know, with the rest of the country and not doing so well. But we are at least able to know where we're going. And so we can target our resources more effectively. And this is something that has been more controversial for cities and areas and states that have not been able to embrace that strategy. Second, I would say utilize race and place-based strategies to decrease COVID-19 exposure. And that would be my big theme for today, race and place-based strategies. So in light of this, I would say we would recommend reciprocity for essential workers regarding PPE. So the very people who have been on the front line, we would say that they should at the very least all have access to PPE. And this was much more relevant earlier in 2020 when there was such a shortage of PPE, although I would say right now. To this day, many essential workers still do not have that kind of guaranteed access. We are thankful that essential workers have been highlighted as important as we begin our vaccine rollout. But there's still some controversy in which essential workers are going to be highlighted as part of Phase 1B. Partnerships with community-based organizations are going to be essential as far as dissemination of resources, as far as things like basic education, PPEs, hand sanitizer, fresh water. There are many areas of our country that don't have running water. And so you cannot wash your hands if you do not have water. And so we have to think at the very basic level what communities need in order to be able to abide by our very basic public health recommendations to minimize the transmission of the COVID virus, particularly in high-risk communities. And as we think about these risk and place-based strategies, we have to particularly think about congregate living facilities, and those include jails and prisons. And that has recently become more controversial, has taken more of a national spotlight as we began thinking about vaccinating older people in long-term care facilities and exactly how we're defining congregate living facilities. Because for socio-political purposes, there are many people who do not value the human lives that happen to be incarcerated. But yet we know that from not only an ethical perspective, from a public health perspective, that the amount of COVID that is occurring within prisons is accounting for a significant burden of COVID that we are experiencing in our country, and that we know that prisons are not closed systems. We also know that for people who are not in prisons but are being over-policed and cycled through our jail systems, that that is having a significant impact on the rest of the community. One of our recommendations is to release low-risk nonviolent offenders from prisons, which has been happening in some cities and states throughout the country. And so we're recommending that more uniformly, and we're recommending that we take active measures to decrease the jail cycling that has been happening in the country. We have evidence from a paper that came out that was done here in Chicago, lessons from Chicago's Cook County Jail. It was led by one of our medical students, who's also a public health student at Harvard, and looked at the impact of over-policing and cycling people in and out of Cook County Jail. And what they found was that approximately as of April 2020, so still fairly early in the pandemic, but that people getting arrested, put in jail, being released back out into the community, was accounting for approximately 16 percent of the Chicago cases, and accounted for about half, a little more than half of the variance across Chicago zip codes in case rates. And that as a single variable that exceeded race, poverty, public transportation use, and population density as a variable that accounted for this variance across Chicago zip codes. And so this is something that is a hugely important factor that we need to take account as we try to mitigate the impact of COVID in our community, recognizing that we are only as strong as the nation as the most vulnerable aspects of our community. We will only turn this tide if we are willing to embrace vaccinating those who are in the most vulnerable positions. And that includes people who are being over-policed, people who are being, you know, wrongly convicted and putting in jail too often, and people that are also in prison. I'll just leave it at that. We can talk more about that in the discussion. Utilize risk and place-based strategies to increase COVID testing. So not just decrease exposure, but increase COVID testing. So there's a study that looked at testing rates. And as a result, there is some press in the New York Times that said some areas of New York City are getting a lot more testing, guess which ones. So we can guess which ones. Or I'll just tell you, the higher, there are areas that had higher percentages of people that were white and had higher family incomes, despite the fact that we know that those same census tracts were much less likely to have rates of case rates of positivity for COVID. And that we also know that for community health centers, only 24% of them at that time had, were without drive-through or walk-up testing availability. And within the City of Chicago, testing site availability became available in predominantly white communities significantly sooner than it became available in non-white communities. So this is a map or a graph that became available to me, thankfully, because of Dr. Robert Vargas in our Department of Sociology. And it shows from April to May 15, the disparities and access, physical access, to COVID testing from April to May 15 again. So in distance in miles from the closest, the first closest to the second closest COVID testing site. And so you see that for white populations, which are ironically indicated in the solid black line at the bottom, their distance to the closest, first closest COVID testing site was about two miles, in comparison to approximately four miles for other racial groups. And then if you look at the dotted red line, that is the second closest vaccine testing site for African Americans. And that was about six miles away. So we look at a significant variation within Chicago when COVID was first sort of playing out. Those disparities, thankfully, significantly decreased within a relatively short period of time. But we see that the communities that are hardest hit were the ones that were least resourced at the very beginning of the pandemic. And we can see that actually in these next two slides, which I am praying will work when I press the button. Okay, good, they will. These are also videos that were made available to me by Dr. Vargas. And so this is looking at Chicago testing sites by race with sort of a motion in time video. And so this again is a map of our city. Areas in red this time are predominantly African American neighborhoods. Areas in yellow are predominantly Latin X neighborhoods. Areas in blue are predominantly white neighborhoods. And areas in green have no majority. And so we'll see as little circles pop up, those are areas that are COVID testing sites. And then on the top right hand side, you'll see the date. And so as time progresses, you'll see how COVID testing sites became available to the city of Chicago. So at the end of the day, we noticed two things here. One, there is a significant disproportionate mapping between where the testing sites are and who needs the sites in general overall. And the rate at which those testing sites became available. And so there's two kinds of disparities happening. One by sort of the pace and one ultimately by place. And so those are things that contribute to why African Americans are and Latinos are suffering disproportionately as part of the COVID pandemic. One contributor that is a reflection of what we call structural racism. And so yeah, so this is stark, but it's not unique to Chicago. The same team did the same testing in Milwaukee. Milwaukee, the very same day that Chicago released its numbers about racial disparities, Milwaukee was another city that had the exact same story. Same maps down the line occurred in Milwaukee. And there's another map that is almost exactly the same for St. Louis. And if they were able to map all the cities in the United States, my guess is that they would probably all look the same. This is another similar map, but what it does is look at testing sites by federally qualified health centers and federally qualified health centers are basically community health centers that have an additional status that allows them to get extra financial support by the federal government. And without sort of wanting to have a lot of details, so they just become federally qualified community health centers. So here again, we have a map of Chicago, majority African American neighborhoods are in red, Latino neighborhoods this time are in pink, white neighborhoods are in blue, and non-predominant neighborhoods are in white. As testing sites come onto the map, which again will be a video, they'll be in yellow circles. If they are an FQHC, federally qualified health center, that yellow circle will have a black ring around it. And if it's a federally qualified health center that does not have a testing site, that black ring will stay clear. And you see as we start the video or at least as we look right now, there are many of those circles that stay clear. It's going to sort of reboot itself when we start the video. And so many of those will come off the page. But right now, none of the FQHCs have testing sites. And then you'll see this change a little bit. All right. And so what this showed us is that many of the testing sites that came on board were not in community health centers whose primary purpose it is to serve the poor. And the poor are disproportionately racial and ethnic minorities. So if we're trying to get to those communities that are historically marginalized, have fewer resources and have higher percentages of racial ethnic minorities, we would go to the federally qualified health centers and make sure that they had sufficient supplies for testing. But what we have seen in this map is that many of those FQHCs remained under-resourced as testing sites. And as testing sites came online, many of them were not at FQHCs. And again, many of them were in parts of the cities that had lower rates of COVID and had superimposed a map of healthcare resources were in areas that already had many other healthcare resources and weren't over-reliant on federally qualified health centers for points of access for the community. All right. So what we need to do is have a greater investment of testing resources and infrastructure into areas with high case rates and test positivity. And so that's part of what the task force has been trying to do, is to realign need with resources. And so it is a voluntary sort of coalition of the willing with a number of academic medical centers. And I am thankful that the University of Chicago is one of them and a lot of small community health centers to large institutions who have banded together and said we're going to try and do our very best to reduce these COVID disparities and to try and share resources and say, I have this, I'll give you this. And how can we look at these hot spots in the city and lean in and provide extra resources to those areas that we know need more. And so that's one of the things that the task force has been trying to do. One of the things that I believe that we need to do more of and that we have not done yet as a city is to share patients. We have shared a number of kinds of resources, but the most vital resource that we can share is patients. And we have not done as good of a job as we can of sharing patients between health centers. And I will get to that in another point. So number four would be repurposing ambulatory infrastructure for COVID-19 prevention support and monitoring. And again, that is something that we have all participating organizations of the task force have been doing in lots of special and important ways. I lean here into Oak Street Health because they really took this on as part of their core mission when many of the health centers had shut down and were working remotely. And so with their decrease with everyone's decreased patient outpatient volume, they really took that as an opportunity to not only enhance their telehealth, but to really stand up their screening for social and medical needs around food insecurity, medications, home monitoring for blood pressure, diabetes, oxygen and temperature, and to really lean into people's behavioral health needs also. So all of their front desk staff who were not checking in patients, this army of social workers they had, and they have patient transport vehicles that were no longer then bringing patients to and from clinic, they utilize this as a new sort of army of people and infrastructure to bring goods and services for people who are now sheltering at home with COVID or trying to keep them from having COVID in a way that really helped support chronic disease management for those at risk for COVID and helped to help and helped people stay safe who may have actually been suffering at home with COVID. So that was a great model and a great sort of shout out to Oak Street Health for doing this sort of flawlessly. Five, I would say, safely isolate and support COVID-19 patients from high people who are living in high risk living conditions that they need to be safely isolated and supported. So who exactly does that mean? So when people are diagnosed with mild COVID-19, but we ask them to shelter in place, people who are coming home from the hospital for moderate cases, but may still be within that window where they could be infectious. And then people who are quarantining and may possibly have a case of COVID, but we don't yet know. These are people who may be living in the crowded living conditions with poor ventilation, with multi-generational housing that may have elderly people living in the home who are at increased risk for COVID. These are folks who could benefit from being safely isolated from the rest of the community who may also be high risk. And so there's an increased risk of community transmission in those circumstances. And so what we're talking about is housing support for unsheltered persons, the ones we typically think about as being homeless, but also potentially expanding that definition to how we think about high risk sheltered persons, if we're really going to try and have an impact, because we already know that it's not just homeless persons that are at high risk for disease risk and disease transmission. Number six, implement city and statewide protocols to share resources and patients. So this is what I was referring to earlier. We know now that there is significant hospital variation in risk-adjusted mortality anywhere from 7% to 81%. And so that is wide variation in how patients do in a hospital setting. And there are many factors that go into determining this hospital death rate. And we know that for hospitals that have fewer ICU beds, that patients do worse. So hospitals who don't have the infrastructure that don't have the medical expertise, the equipment, all the special things that some larger hospitals have that have more beds, more practice, more whatever, that are just more accustomed to taking care of these patients. People who are in those larger hospitals do better. And not because people in the smaller hospitals are not trying their best, they are frequently overwhelmed and may not be particularly, that may not be the expertise of that hospital. And so the odds of death are greater than three times for hospitals that have fewer than 100 ICU beds. And so this is something that has been playing out across the country and something that has been plaguing our city, our beloved city of Chicago, where we know we do not have a coordinated system of transfer for patients. So we can share resources, but we have not been transferring, we have not been sharing patients to the degree that we need to, and that is our most beloved resource, that is our most beloved thing that we can share. We have protocols for how we would share stroke patients, how we would share trauma patients, and we need a pandemic protocol in place. And it is way beyond time for us to have had that, particularly now, particularly now. This was the study that came out in JAMA that specifically was looking at factors associated with mortality for critically ill patients who are diagnosed with coronavirus and that called out various hospital factors such as ICU bed capacity. Seven, allocate scarce resources specifically to reduce inequities. So one of the things that we know, and that we're at least some of us know, and I say that because we have some manuscripts that are in under review that I have been working on with my colleagues that have been leading some of this work, like Dwight Miller and Bill Parker, that algorithms may exacerbate racial inequities. So for example, SOFA scores can overestimate African-American mortality. And so for using SOFA scores to determine who qualifies for scarce resources, and we are now in that situation that we thought we would not be in where hospitals are beginning to have to make critical decisions about who is going to get resources, where ambulances in California are being told patients who have no chance of surviving to the hospital don't even bring them to the hospital. We're going to have to pretty soon start activating some of these critical care protocols that are in place. And if they are ones that are biased against African-Americans, then they're ones that are going to decrease the chances that African-Americans have access to some of these life-saving resources. Knowing that it will only serve to undermine the trust that the public has in providers, particularly marginalized patients who have a deep well of well-earned mistrust in providers. And that trust is being tested right now as we are trying to encourage people to utilize the vaccine. And so we've seen the challenges that come with trying to rebuild that trust in a short time period as we are trying to push our way through phase one. We haven't even finished the healthcare workers and we already see that we are having challenges with issues of trust amongst our own hospital employees who have seen the ravages of COVID every day. And yet we still have employees for many reasons that are still hesitant about the vaccine. And so we have to take very seriously at every stage how we are doing our daily business and how all of our protocols, all of our policies, all of our actions take equity into consideration if we really want to move forward with everybody on board so that we can make sure that everybody to the best of our ability has access to all resources and is wanting to engage as much as possible in these resources. This is a paper that I cover up with one of my favorite bioethicists, Govind Prasad. And Zika Manuel about the fair, how we would see our make recommendations around how to fairly prioritize or allocate COVID vaccines. And one of the things that we particularly put in there was prioritizing the disadvantaged, particularly addressing issues of socioeconomic disadvantage and oppression to make sure that we are thinking about some of the mechanisms in which racism ultimately impacts the health and well-being of people of color and what that means for COVID and COVID outcomes disproportionately. And for the National Academy of Medicine, they have added the mitigation of health inequities as one of their key ethical values and have included equity as a cross-cutting consideration in their recommendations of their phased framework as we move through all the vaccine phases. Right now, here's where we are with ASAP in their COVID recommendations as we're thinking about moving from 1A to 1B. And there's a revision of plans from in December around age, moving from 65 to 75. And I had made sort of a head nod earlier to essential workers and restricting them from all essential workers to frontline essential workers. But how this is playing out in the States is sort of a wild west and I'm happy to sort of talk about that shortly. Let's see here. Blast. This is sort of a blurry box from the paper that I took and I can't tell if it was blurred because I'm not wearing my glasses and can barely see or because it's just really blurry. This is just a summary of their racial equity rapid response from the city of Chicago and what the overall goals are, sort of the big picture vision of what we need to do to meet these goals and how the response has been organized into sort of four key categories education, prevention, testing and treatment and support services and resources. And what I'm going to do now is just to give an example for each of these seven recommendations that I've went through. I just give an example of or and I've tried to sort of pepper them throughout but just to sort of as we close and move into the Q&A, talk about a tangible thing that the task force is doing, has done, is recommended, that lines up with these principles. So the first require the collection of race ethnicity data within COVID-19 reporting. I showed you that beautiful website that is kept up daily regarding COVID-19, the city's dashboard that have interactive maps and you can just do all of this wonderful, beautiful stuff. I'm not sure I've seen a city that does a better job of doing their COVID reporting. Number two, utilize risk and place-based strategies to decrease COVID-19 exposure. So partner hospitals and health departments work with community-based organizations for distribution of PPE and food and conduct contact tracing. Utilize risk and place-based strategies to increase COVID-19 testing. Clients and staff in congregate settings, so for example homeless shelters, nursing homes, senior buildings have been targeted in high-risk black and brown neighborhoods via aggressive testing and contact tracing. Here in Chicago, 30 to 40 percent of our mortality has been found to be in those settings and so those have been areas that have been highly targeted. Number four, repurpose ambulatory staff and infrastructure for COVID-19 prevention support and monitoring. I highlighted Oak Street Health because although I don't work there, I just happen to be a big fan of theirs. But I also noted that everybody in the task force really leaned into that and we had that was a key thing that we were prioritizing, our systemic outreach as is being conducted to high-risk patients for prevention, social needs and chronic disease management. And I will say that every partner organization made this a priority to try and figure out how to identify, again, high-risk patients of all the patients that were in the systems and particularly those patients who may have been in one of those four to six community areas, those within Chicago that we knew were having the higher rates of COVID deaths. How can we reach those patients for in-home monitoring, medicine delivery, other social care needs, etc. And again, starting with those from those highest risk codes. Number five, use multi-sector collaboration to facilitate safe isolation and support of COVID-19 patients from high-risk living conditions. And so the city has, I've been talking a lot sort of just about the medical aspect, but that was just one arm of this task force. There are multiple arms in play and so the city has established partnerships with many other organizations. Another major player in that was the Greater Chicago Food Depository, which I have the honor to be a board member of. And in Chicago alone, the baseline rate of food insecurity has gone from about 4% to 18% during the pandemic. So a huge jump. And so the city's response to that has been amazing. And we've done, I say we, like, the city has done things like repurpose city workers who may have previously been a librarian or working in a DMV, but while many of these city operations were closed, had them working on food preparation in Malcolm X, so one of the city colleges, so that people could call 311 if they needed food and partnered with the Chicago Food Depository, and then they had streets and sanitation workers deliver food to people who needed it. So this really coordinated, beautiful effort on the part of the city with in partnership with many other organizations to try and make sure that we were addressing issues of hunger and other needs that our residents had while we were trying to keep people safely sheltered in place. Number six, implement city and statewide plans to share resources and patients across hospitals, hospital systems. So regionalization of the treatment of the sickest COVID-19 patients is being accomplished by transfer policies that allow safety net hospitals to transfer their sickest patients to higher resource hospitals, often academic medical centers. So I will say that some hospitals have really kind of leaned into this, but this is on a voluntary basis. I think what we need, or I know what we need, is a policy that is in place to make this mandatory, so it is a system that is not something that relies on volunteerism. Seven, allocate scarce medical resources to reduce racial inequities, and so when remdesivir first became available, the city was allocating that in a way that was keeping inequities in mind. And even as the city was first allocating vaccines, the very first hospital that got their first shipment was Loretta Hospital. So a hospital that's based in a low-income African-American community, they're the ones who first got the COVID vaccine. And so I think that the city has been thoughtful in how they are trying to address racial and ethnic disparities in Chicago. And with that, I will end, and thank you all for your patience. I always say I have some sort of like horrible, you know, technological voodoo that just surrounds me and is always tripping me up everywhere I go. So thank you for your patience. And I'll open it up to Q and A. With that, again, thank you, Monica, for sort of opening our theme of health disparities within the pandemic. For the second time, yeah, let's just jump into a few questions that the opening of your talk prompted. One is, are all these physiological changes personal, or are they being transmitted genetically? That's a good question. So it's both. We know that some of these impact people's lives right now, which contributes to the current burden of chronic disease. And we also know that some of these epigenetic changes are passed on to people's children. And that some of these changes may last for generations. And so it's both. This is sort of in a similar vein. Do the biological changes show up in kids as well? So I think maybe not just genetically, but at the time that they experience this stress, or are they not apparent until adulthood? That's a good question. I am not an expert in that. My guess would say my guess would be probably a little bit of both. But I am not a pediatrician and not that I don't care about kids. I just I just don't know enough about children's and disparities to speak definitively on that. Okay. Would you mind telling us more about what you or they mean by sort of quote unquote life stresses? Is it just sort of mental stress? Yeah. So this is fascinating. So I would say that it is it is both. On one hand, it is it is really like mentally stressful, right? But it is how that stress is internalized. So what what people use the chronic everyday discrimination stress as is like a like a PTSD model, like a chronic stressor model. And what we know is that it is the everyday stress of racism that sort of slowly grinds you down more so than it is the major events of racism, because those are fewer and farther between. I've never seen somebody get, you know, lynched, although people in my family have been lynched, but those were generations past. I've never seen anyone, you know, like any of these horrible things that have happened are only hearsay to me, right? But I have certainly personally had all kind of racist incidents, too many to name, even at the hands. I mean, you name the situation in a bank in the health care system at the dry cleaners at the, you know, Macy's every place I have been in the educational system with my children, my sons, baseball coach. The list is endless. And one day I had so many, I was like, I might have a stroke. You know, because like I had had five events in a day and I was getting on the plane and the stewardess asked me to leave because there are two people with a ticket and she assumes that I'm the one who's got the wrong seat and she, I should get out my seat? Like, why do you assume that I'm, that was like, I think I might have a hypertensive stroke, you know. So it's like these, I'm getting off, but so it is, it is the chronic effect of these stressors that then in turn trigger these autonomic responses. It's the cortisol. It's, you know, you know, it's their fight or flight response. Like all of these are fine. If we're getting, I always say chased by the lion in the Serengeti, but black people are not getting chased by lions in the Serengeti every day, but it feels like it, you know, and so that is not normal. And so this being a black person in America should not feel the way that it does. I just started reading a book, which has been out for a while now, called what doesn't kill you makes you blacker. And I just started, it's hilarious, but only because it's so true. And it's like, you know, white people have to do all of these things to feel the thrill of near death experiences, you know, all of these extreme sports. All black people have to do is walk around in our black skin. And that is enough to feel the thrill of death. Because any minute we may get shot in the back by the police, we may get, you know, who knows what excitement, you know, lies ahead when we open our door and walk out, you know, trying to just go to work and come back home. And so like that is not a normal way to live. But that is how we are living every day, you know. And so that kind of chronic stress affects our health. I'm going to jump to a few more, or the questions are starting to pile up. I know we're sort of short on time. Will Parker notes that the current vaccine distribution map is the mirror image of the COVID mortality map, basically zero vaccination to date in most vulnerable communities. What specific strategies should the city use to prevent disparities in vaccine allocation going forward? Say that again. I know Will has already told me this and probably shared this. Yeah. So basically he's saying that vaccine distribution is sort of a mirror image of these other maps in terms of mortality. And so what specific strategies should the city use to prevent disparities in vaccine allocation as the rollout happens? Yeah. So Will and I actually have, thank you, Will, for the shout out, a paper with Govind, our other partner in crime, under review now, that advocates using a strategy that does not, that they try to take this into account. So right now what has happened is that we are allocating vaccine on a per capita basis. And so that we're saying basically that, I was just talking to the fellows about this earlier this morning, that using the term fair as in to everyone an equal share. But that assumes that everyone has an equal playing field, right? That everyone has an equal chance of getting COVID, which I've just made the argument that that is not at all the case. And that everyone, that the rates of COVID are equal throughout the country. And that is also not the case. When we see disparities in COVID case positivity and COVID death and COVID hospitalizations, when there's that kind of variation throughout a state, then we need to mirror what we're doing as far as resource allocation to meet that. And so rather than saying, everybody get one, we need to sort of cluster our resources for those areas that are hardest hit, not just because it's the most fair thing to do, but it's because we're also going to, that's going to be our best way to mitigate the pandemic for everyone, right? You see, I mean, I just, I cannot is, it is unbelievable to me that we are not able to distribute our resources in a way that most effectively mitigates this pandemic. And the only reason that we have not been able to do so is because we, as a country continue to not be able to reckon with our structural racism, because, because we cannot imagine giving more resources to those in need, when those in need are black and brown, you know, we insist on giving white people more, even when they need it less. And that is going to be the Achilles heel that if we have not gotten low enough, we'll continue to drag us down. We are one in five in the globe for cases of COVID. Who would have ever thought that that would be the case? That this country would be behind almost every other country in, in the rates of COVID. But it's because we refuse to do the right thing and care for each other socially distance and allocate our resources appropriately. And so I'll just. That said, are you hopeful that the the disparities that the harsh light of the pandemic has sort of highlighted that we all knew were there, but that I think have sort of bubbled up certainly more because of the pandemic? Are you hopeful that this will lead to meaningful change, that these discussions that are happening at higher levels will lead to appropriate resource allocation, policy change, political changes that will lead to meaningful closing of the gap of these disparities? You know, I have to be hopeful only because it is the only way I can get out of bed in the morning. It is, it is, I just have to have hope. We could leave it at that. I think we all need to have hope. We'll try to get to a few more questions because I know the fellows have have class at 130, but how much of the disparities discussed that you discussed are caused by one ongoing or present acts of racism versus two economic and other inequities that may be the consequence of past racism? You know, it is that that's a good question. And what I would say is that the impacts of our history are felt today. And so it is hard to disentangle those, right? Nancy Krieger just released within the past couple of weeks, and I should have put some slides in there, maps of residential redlining that happened at the time that redlining was taking place, and how they correspond to current maps of what we're calling the SVI, the social vulnerability index. And the SVI is what the CDC is recommending that we use to take into consideration as we think about COVID vaccine allocation for equity. So SVI is it's a measure that has 25 variables that go into four different themes for community around race, ethnicity, income, housing, and transportation. So basically how vulnerable is a community to external threats? And the maps are like this. And so basically what we did after World War II to restrict the ability for black people to get housing has directly impacted what we see today around the place-based risks that black people have and brown people have for getting COVID. And so, you know, the past lives with us every minute of every day. So it's not just that my current job is as an essential worker, you know, where I currently live is directly tied to policies from the past. You know, we cannot, I mean, the people last week were waving the Confederate flag from the 1800s. How more can you say that our past is not present? You know, we are living that past every day. The next question that I'll ask sort of I think gets this sort of thinking a bit about how the past influences how people think about the present. What's the difference in vaccination rates between black and white medical center employees? And how do you feel about that? I don't know if you have those rates, but we certainly know that within the black community, there's a higher degrees of sort of hesitancy. How do you feel about that? That's hilarious. I feel great. It's horrifying. How do I feel about that? So there is a lower acceptance rate. What we know is that hospital employees fall along class lines. If you say black hospital employees versus white hospital employees, what you're saying is EVS workers versus doctors for the most part, right? Because there are very few black physicians. The black physicians are taking the vaccine just like the white physicians. It is the EVS that right now are 18% uptake within our hospital. That's horrifying. I have made it my second job to go around and do town halls and talk to the food depository and talk to my neighbors. I find out people in my social network are hesitant and I call them on the phone. They're like, hey, I'm like, hey, I heard you weren't going to. And so it is everyone's responsibility. I take that very personally as my personal responsibility, but it is everyone's responsibility to try and make sure that we are moving forward together and that as we rush forward to move into phase one B, that we don't continue to leave out whole groups of people that look like me. Because at the end of the day, if everyone standing who has not been vaccinated is black or brown, what is that going to mean for disparities next year? When people are celebrating in the streets because we've reached herd immunity, but who hasn't been vaccinated are these other communities that have now been forgotten once the business has reopened and clusters of COVID are still circulating and people are still coming in with COVID, but now nobody cares. We've forgotten about it. That is my concern. And so now is the time for everybody to get behind this vaccine. And yeah, so I feel horrible and I feel highly motivated to write this injustice. And it's an injustice that is everyone's fault, not just the problem of the vaccine hesitant because it is a reasonable response to an unreasonable circumstance. And that is living life as a black person. And a question just popped up, and this will probably be the last question before I turn it over to Mark, is that how should we empower those physicians and leaders from diverse backgrounds to champion the vaccine? So what do you think the institution's responsibility is to empower individuals like you to have a larger and amplify your voice? You know, I would say I have not been given any shortage of opportunity to speak. What I would say is that there needs to be structural support for that. You know, I am a clinical investigator, so I have more free time. I mean, no one has free time, but like, I'm not in clinic all the time. But as our demand increases, for more voices, for people who look like me, we cannot continue to stack requests on top of persons of color who are already like going through our own emotional trauma like, oh, do I need to pack and leave the country? All these people trying to like take over the capital, should I leave now? You know, like, these are the questions that we're like struggling with as we then come to work and try to like take care of patients and like try and get people vaccinated. Like, we are traumatized. And so if we're going to be leaning more into physicians of color to, we need to also be, you know, setting time aside, we need to think about structural racism in a way that has structural policy solutions and not just say, hey, Black people, can you volunteer again? You know, no. I can do this if we have the same kind of support that other things that are valued by the institution are given. You know, that's what we need. Are you hopeful about that? Mark, I'll turn it over to you to just finish things up. I know we're sort of getting towards the end and I apologize for not getting to all the questions and we apologize for the initial technical difficulties, but Mark, I'll turn it over to you for the final word. Well, the final word is to thank Monica for an extraordinary talk. It was extremely illuminating and deeply moving. I did want to say very briefly that one of the persons you mentioned, Govind Prasad, who you said such nice things about, will be speaking in this series on March 3rd. And I think his focus will be on the allocation of the vaccines, at least at the moment, that's my thought. Will Parker will also speak in the spring quarter on things. I have one minute to ask you one very brief question. You had said that there was a decrease in the number of incarcerations for people who were at low risk and nonviolent offenders. And I wanted to just ask if you knew if that was just with regard to the local city and state jails, or if it included in Chicago, the federal jails also? No, I did not mean to say that. What I meant is that we should decrease that population by releasing people who are low risk offenders. So people who are, there are so many people that are in our prison system that should not be there, who are there on technical glitches, or who are no longer a risk. And so when other cities have gone through and just combed that list and said who needs to be here and who doesn't? Because they're, they, you know, some people could be released, but need to have a place to go. But they don't have family to go to. So they stay in jail, you know, well, maybe we could provide housing so that they could, you know, go to this place and not get COVID and die. They could be released, you know. And so when people have started doing that, they're able to decrease the prison population, which decreases the overcrowding. And so decreases the chances of spread, just all kind of stuff. And so that's what I meant, is that we should try and decrease that population. Thank you so much. And thank you for this brilliant talk. It was wonderful and moving. And it opens up the series of talks that we hope to have over the next two and a half months on disparities in healthcare relating to COVID-19. Thank you for having me. Thanks for all of us. Thank you. All right. Bye-bye. Thank you.