 Good morning, and welcome to the 28th annual Dorothy J. McClain Fellows Conference. We may start the first presentation, Monica Peaks presentation without the use of slides behind me. I want to thank you all for joining us, for taking the time from your busy lives to travel from around the country, and especially to be part of our annual gathering of past and current McClain Fellows. I know there's a contingent here from Hillman College in Michigan who drove three hours, raise your hands, and because they represent new people to the conference, hardy welcome to you. It's thrilling to see our numbers grow and our network expand each year. Over the past 35 years, the Center has trained more than 450 fellows. This year, the Center is training more than 30 fellows with backgrounds in medicine, surgery, nursing, psychiatry, philosophy, law, and I am just delighted to welcome all of you here today. As you know, this conference is the McClain Center's signature event. It remembers Dorothy Jean McClain, Barry McClain's mother. Dorothy Jean helped us create the McClain Center, was deeply committed to its work. I wonder if you join me in thanking Dorothy as long past, but thanking Barry McClain for his commitment to the Center and in recognizing our current Board Chair, who's in the audience with us, Rachel Kohler. I especially want to thank the McClain Center faculty and fellows for participating in this year's conference. An important highlight of the conference is the awarding of the McClain Center prize in clinical ethics and health outcomes. And that prize will be awarded tomorrow morning at 10 a.m. to Dr. Norman Faust, who's in the audience. Norman, welcome to Chicago. Dean Polanski will be here to present the prize to Dr. Faust, who's an emeritus professor of pediatrics, medical history, and bioethics at the University of Wisconsin. After Dr. Faust receives the award, he will give a keynote talk entitled, stop me if I'm wrong, Norm, the hermit, the mongrel, the swimmer, Bucky and the dwarfs, cases that changed medicine and me. I get that, right? I have two final announcements before I turn the podium over to Monica Peek. First, today's speakers are McClain Center faculty or former fellows. To each lecture, we encourage audience members to ask questions, if only if you can find the microphone. Thank you. And we ask you to walk to a standing microphone. I see one, is that the only one? We will have a second one. And identify yourself, please, by name and your home institution. Also important that this evening at the end of the conference at around 5.45, there will be a group photo up here on the stage for faculty, fellows, and board members. So I ask you to please join us for that at the end of this afternoon's conference. With that background and with fond hopes that shortly we'll be able to project slides, even though it looks like at the moment we cannot, I'm going to ask Monica Peek to take over. Monica. Absolutely. Good morning. I am delighted to be here for so many reasons. It's such an honor to participate in this annual conference. It's an honor to kick it off as being part of the first panel. And it really is just an incredible amount of fun to be able to share the panel with some of my most respected and beloved colleagues. I have the challenge today of speaking without my slides, which I think will probably be fun, I'm hoping, and what I think actually will happen is that it may leave more time at the end for questions. So I am a general internist here at the university, and my work really focuses on health disparities. And I came to the McLean Center several years ago because I believe at the very core of my being that health disparities are an ethical issue, not only for clinical medicine and all of us who practice the art of medicine, but also for our society and how we think about the distribution of resources. And so I chose this title, which obviously you guys can't see, but maybe you can read in your brochure, the Clinical Ethics of Health Disparities and Distributive Justice Analysis. I chose this about a year ago. Who knew that it would be as timely as it is today? So I'm excited to be able to talk about things that are important to me and the lives of people that are in our community and nationally, the most vulnerable among us, particularly against the backdrop of our recent political events. I want to acknowledge, so just to recap, I'm someone who's interested in health disparities and I'm very excited to be able to talk about those issues, particularly in the context of the political climate which we found ourselves in the past week. I'd like to acknowledge the McLean Center, which is one of the places that I sit here on campus, as well as the Bucksbomb Institute for Clinical Excellence, both of those centers allow me to think about the ethics of medical care delivery and how we can be better providers, how we can provide better care to patients. I'd also like to acknowledge the Department of Medicine, a general internist within that department, and the Chicago Center for Diabetes Translation Research. My main focus within health disparities is diabetes as I think about it as a social disease and how we interact with not just patients in the health system, but with people in our communities and how they struggle to manage their health. And so I'd like to just acknowledge all of those. My next slide is actually a picture of Hillary Clinton and Donald Trump to just acknowledge and to thank them for the heightened political awareness of our current environment and the urgent need for us to all take seriously what's at stake and to think more reflectively about our allocation of resources and what that means to promote the good of all of society, particularly those most vulnerable among us and whether or not we're going to take that road or a different one. So I think that my comments as I prepared my talks were largely informed by the events unfolding over the past several days. I'm going to talk a little bit about health disparities. So we're all on the same page about distributive justice and then hopefully end on a high note talking about some of the work that I do as part of a much broader network of team here in Chicago to try and address some of the disparities that we see in diabetes. Starting before that, just recognizing that, again, we're sitting at a McLean clinical medical ethics conference and to underscore the inherent relevance and centrality of social justice and health disparities to clinical medical ethics. So I'm going to read a description that Dr. Siegler has written to describe what clinical medical ethics is. It's a medical field that helps patients, families and health professionals reach good clinical decisions by taking into account the medical details of the situation, the patient's personal preferences, values, socioeconomic considerations and ethical concerns. So it's not only about patients in the health system, it's about the socioeconomic standards and conditions and environments in which they live that they bring with them to the health care setting that creates some of the ethical dilemmas that we see in clinical practice. So when we talk about health disparities, we use that as a catch phrase to mean two different things, both disparities in health care as well as disparities in health status or health outcomes. And clearly what we do here in the hospital in clinical care matters, but it really doesn't matter as much as we think it might, unfortunately. 15 to 20 percent of what physicians and nurses and all of us do within the health care system impacts health. The vast majority of the rest is determined by other factors outside of health care, poverty, education, access to healthy food, health behaviors. And so for us who think about health disparities, it really is incumbent on us to think about both of those things, disparities in health care as well as disparities in health status, one leading to the other. There is an important report put out by the Institute of Medicine years ago, 2001, called Unequal Treatment. And what it did was synthesize, sort of summarize and synthesize the status of the literature about the inequalities that exist within our health care system. And what we know without any doubt is that the health care that we deliver in this country is not equally distributed. That there are some groups based on their socially marginalized status, be they poor, have limited health literacy, racial and ethnic minorities, have insurance or not. There are a number of variables that mean that some people in our country are less likely to get equal health care than others. Some of that is determined by health insurance and some of it's not. So even for those who can get into the same health system, there are differences in the quality of care that people receive just based on who they are. So that obviously is inherently unjust. But thinking again about the impact that this has on health status, I would encourage us all to think not just about how we can change our health care system. And clearly, there's a lot of change that needs to be done, a lot of work to do. There's no shortage of work to improve the way that we deliver care to our patients, but also to encourage us to think about health changes and health systems that are outside of health care if we're ultimately trying to improve the health of our patient populations. So this change outside of health care we frequently refer to as the social determinants of health, which a number of us have some take issue with, because social sounds like such a positive attribute, who wouldn't want a social determinant of health. But really, it's more broadly thinking about those macro level factors that determine someone's health that I had talked about a little bit earlier. Those are the things that we need to incorporate in our thinking when we're thinking about promoting health equity. I have a few maps, which unfortunately I can't share. And it really is disappointing because I spent a lot of time on these slides. It's all good. Showing the city of Chicago, which is very segregated based on income, class, race, and number of other social variables. And particularly for those of us who study specific diseases, the maps of disease burden completely aligned with social variables. So the southern parts of the city, the western parts of the city where there is a lot of poverty, a lot of people who are black and brown have the highest rates of almost anything, including diabetes mortality, the potential years of life lost because of diabetes and diabetes related hospitalizations that could have been avoided, but weren't. So how is this conversation about equity, again, related to medical ethics and medical professionalism? And I would just remind us that it's actually core to how we think about both of those things. That part of our mission as medical professionals is to support policies that decrease health disparities and to be a good steward of society's resources. So these are things that I think are important, but not just me. These are these are things that are written up in codes of ethics from our professional societies. Dr. Siegler has written extensively about these. And so as a medical profession, as we think about clinical medical ethics at its core is an issue, the construct of equity and fairness and how we treat everyone, including allocating resources to everyone. I'm going to take a little pause and go back in time a little bit or maybe stray from clinical medicine and talk a bit about John Rawls, who may have been one of the most important political philosophers of our time. He's a 20th century Western philosopher. And he his notion of justice are really revolved around social justice where he talked about the establishment of equal liberties of equal opportunities and a fair distribution of resources and support. Although all of these things are necessary to see a just and fair society talks about the fair equality of opportunity. And so it's not just that we have equity, but people have equal opportunity to protect to become to sort of become their fullest selves. His principles talked about not just prohibiting discrimination or discriminatory barriers to accessing all these wonderful opportunities in life, but actually called upon us to require positive social measures, which counteract the negative effects on people's opportunities. So for example, the under development of skills and inherent talent that arise because of unfair social policy. We have so much wasted intellectual capital in our country, because we choose not to educate everyone equally, because we choose to put into the prison system a disproportionate amount of people who should not be there. So some of these unfair social policies that are legacies of historical racial bias or socioeconomic issues that linger in our society today, those are the kinds of negative things that negatively impact people's opportunity that Rawls the injustice calls on us to address, not just sort of thinking about not having barriers to place, but actually putting positive social measures in place. And I could not help, but think about the parallels between this and our US Declaration of Independence, and which says that we hold these truths to be sacred and undeniable, that all men and I'll use men as a placeholder for including women and minorities are created equal and independent that from that equal creation, they derive rights inherent and unenable among which are the preservation of life and liberty and the pursuit of happiness. Happiness were broadly defined, but we're not ensuring happiness, we're ensuring the pursuit of happiness, we're ensuring the opportunity to be happy and satisfied and to have a full life that reflects your full range of opportunities. These values that are core to how we think about medical ethics and just societies are really very American in nature. And it's just been striking to me to reflect upon these very American ideals in the middle of a lot of messy American politics. Norman Daniels took up this idea of Rawls the injustice and applied it directly to health and healthcare and included as a primary social good in addition to things like liberty, power and opportunity, income and wealth, the protection of normal functioning. Recognizing that we have to be fully whole, physically capable in order to pursue the opportunities in our life and that disease and disability should not impact our range of opportunities. In particular, he recognizes that the disease burden is disproportionately borne by marginalized populations. So we're not all equally sick and that often this disproportionate distribution of disease is due to the inequitable distribution of societal resources. Coming to the conclusion, therefore, that health disparities in themselves are inherently unjust, partially because they're derived by unjust policies that created them in the first place. And he calls upon us to provide health care vis-à-vis universal health insurance to everyone. And I would actually argue that it's not only the provision of health care goods and services to be that were called on to redistribute in a more equitable fashion that we treat the least among us as well as we treat the most among us when they come into our health systems. But we think more broadly about how to address these, how to more positively address these factors that can counter people's lack of opportunities that we think about housing and education, food, poverty, access to safe places to exercise, all of these things that impact people's health. So this is another beautiful slide, which I'm lamenting you guys cannot see. It's all good. I want to talk a bit about not just our health care environment, but the inherent built in social environment, what we physically create man, woman made physical structures there in our environment as well as the social environment. That includes things like discrimination and crime for which Chicago has become almost every day nationally known or international. I just came back from India and they were asking me about the crime in Chicago. Imagine my dismay. But how these things together impact people's health. We do Marshall Chen, who you'll hear from next, collaborate with a number of people actually in this room to work on some of these pernicious disparities in health on the south side of Chicago, thinking not only about the challenges, the negative impacts on people's range of opportunities, but also the positive assets that are in the community, trying to leverage resources that exist and the strengths, the positive social factors that exist within our communities. So for example, and then because the timer isn't set on and I don't have my phone, I feel like I'm just in free fall. Somebody should let me know if I'm like way over. How much time do I have? Oh good. All right. I'm coming around the bend anyway. We do things to think about the built environment as well as the social environment. So we have again lovely pictures. I'm gonna make sure that these get sort of posted someplace. These are pictures from a food pantry that we work in collaboration with that's here in Washington Park. So very close to us. Pictures of the farmers market that we work with to help provide food, healthy, nutritious food to people in the Washington Park community, health education, health screening. We do cooking demonstrations to help provide, when we consider resources knowledge, is a resource, knowledge is power. And to help people have a better understanding of what is available in the community, how to prepare healthy food. We do tours in low cost grocers so that people who have fixed or restricted resources can better navigate the communities in which they live. It can better shop in a more healthy way on a budget. We have food prescriptions that physicians can write at a number of locations that not only have the physician recommendation but have a financial resource incentive as well as knowledge as a resource to help them understand better how to identify the things that are low carb or low fat and have some financial assistance in obtaining those foods. I miss pictures from the farmers market where we have a food prescription that can be redeemed there as well. Pictures are our team at the farmers market giving tours where they're every Saturday. And again sort of this model which talks about the built environment and some of the mechanisms through which people can take better care of themselves and ultimately have better health as well as the social environment through social support, confidence, coping strategies, improve mental health and so we actually do a number of things for people who have diabetes to try and think about the social environment as well. So we have a culturally tailored patient empowerment class which I talked about a little bit last year when I was here that helps people have a better sense of their own humanity and their own abilities when they're interacting with the health care system and not only is their health improved but their mental health is improved and their sense of confidence is improved. They have a better sense of the social support network not only amongst each other but from the health care institutions which they may or might not ordinarily feel is a safe space for them to come. Let's see here once again having some challenges getting out of here. Well thank you Shui. I just need to get down to the next one. Oh sure so some of these pictures I just had up. Tomorrow we actually have a community cook-off we have one every year which always coincides with the ethics conference I'm usually toggling between the two of them where people come from the community to cook in a healthy way things that are diabetes friendly and so we're trying to activate not only patients but communities around the idea of health promotion and thinking again but not just what happens with the health care systems but what happens outside of health care systems to leverage resources and to promote health. So this is just another slide reminding us the two kinds of disparities and really calling on us all to think not just about change within our health system but change outside of our health system to ultimately promote the health of the most vulnerable. I'd like to give a shout out to our whole team those answers particularly highlight Marshall Chin and Stacey Lindow because you're going to be hearing from them in the next few minutes. They have the advantage of having their slides ready to acknowledge our funders and then to again acknowledge the places where I sit. Thank you very much. Mark says I get five minutes of questions. If there are any there are two microphones set up and it's so compelled you can just like yell loudly from where you're seated. I thought I was off the hook. Yes, Secretary Segal. How might the election affect the problem of disparities and it's one that the potential negative impact on has made me extremely sad. What I would say is that we were talking right before the talk is that I would hope that this is a call to action that for those of us who have had the the leisure or comfort of experiencing the best of medical care and not having to think about those who don't that we acknowledge the challenges that are coming our way and they are coming and news this is an incentivation or motivation to do better and to work harder. It's going to take all of us consciously every day working to maintain the gains that we've had and to try and push forward. It is it is a true challenge that we're facing. I didn't expect that question although I should have. Any more people are probably frightened that I'll cry some more or something.