 Marshall Chin, who will be moderating and speaking in the next session, is the Richard Parillo family professor of healthcare ethics and an associate director at the McLean Center. Marshall is a general internist with extensive experience caring for vulnerable patients, patients with chronic disease, and a national expert on health disparities in medicine. Marshall went to medical school at the University of California San Francisco and did his residency fellowship and public health master's degree at Harvard. He is the associate chief and the director of research for the section of general internal medicine here at the University, as well as the director of the Chicago Center for Diabetes Translation Research. Last month, just last month, it was announced that Marshall was one of 60 physicians throughout the nation who were elected this year to the prestigious National Academy of Medicine. Today, as I say, Dr. Chin will moderate the next panel and will also give a talk entitled Movement Advocacy, Personal Relationships, and Ending Healthcare Disparities. But let's just welcome Marshall again. Thanks, Mark, for the kind introduction. So this summer I spent two and a half months in New Zealand, and summer in Chicago is winter in New Zealand at the New Zealand Southern Hemisphere. And so my wife Noko and Toshi, a son, they came up for two and a half weeks, and we did a little bit of traveling, which included skiing in the summer. This is Queenstown area in New Zealand. It's a beautiful country. And about two years ago, we spent some of our winter holiday here in the States in Michigan, also skiing. Not quite the same view, but still wonderful to do the skiing. And you know how it is during a family vacation where you're not supposed to work? I actually found that there were a couple issues that were really sort of gnawing at me. And so I found that late at night, after the family went to bed, I would start going to laptop and writing. And I would get up early in the morning and write also. And what it was, was right around that time, a couple years ago, this is the height of the Black Lives Matter movement, as well as here in Chicago, there was a Laquan McDonald shooting. Naturally, there's got news also that a terrible video of a young black man being shot in cold blood by the police. And then here, close to home, this was one of the, again, it was the height of the protests regarding the lack of a trauma center here in Chicago. I don't even know if you remember, I think it was like one of the weekly conferences. I don't think it was the annual conference, but I remember vividly, Mark was introducing a speaker, I think it was for the weekly conference where the local protesters came and interrupted for about 30 seconds and then left. But it was impacted in the McLean Center also. And I think that the, it troubled me in a sense of that, like I tend to be sort of an in-the-system person, that sort of marching in streets isn't my natural sort of comfort zone. And yet, there were these huge issues in terms of police brutality, in terms of the lack of a trauma center on the south side. And therefore, I was at the computer screen during the vacation and in Michigan writing. And for this particular talk, I'm going to share that paper with you, that the three goals are to describe health as a human justice issue and the role of movement advocacy, second to outline the roles of interpersonal relationships and trust in achieving health equity. And third, and really this is core, is to discuss the tension between advocacy and building trusting personal relationships for achieving health equity. And really asking, is it possible to reconcile the two? And I had to say this is, I've written a lot of papers in my career, and this is the paper where I've asked for the most feedback. I got personal feedback from these 16 or so different folks, including I guess by chance, or maybe not by chance, all the speakers in this morning's panel. And so the paper, the paper is much better because of their input. And I've worked for the trainees here and fellows that the past two years were a good paper writing period for me. And I think that of all of papers in the past two years, this paper is probably one of the two or three most thoughtful ones I've written. It's also a paper that was rejected six times. So it's journal number seven. So don't give up in terms of like submitting. And also, I don't like to stew on it so that I would actually turn around rejection within one or two days so that I think from the time of initial submission to acceptance, it was about eight months. So pretty fast. So one of our colleagues in France, Monica Vella, who some of you know, she's a general internist here at UC. In the past dozen years, she's led a required health disparities course for the incoming first year students. She told me a story maybe six to seven, eight years ago where some of the students came up to her and said, Dr. Vella, but we so appreciate that you're giving this course. But to be honest, we don't need it, that we're the post racial generation that we're colorblind. We realized you and older folks like you is a different era. And there were these issues, but well, not for us. Well, this taro Pollock is going to speak a little bit later who who taught me that like, technology can be a disruptive influence. And so we have the ubiquitous cell phone with camera and we have now like the dash cams on the police cruisers. And so we saw them in the recent years, then vivid video showing that unfortunately, we aren't in a post racial society. And in some ways, our young students six or seven, eight years ago were perhaps overly optimistic. It's a famous quote from Martin Luther King that some of you have heard of of all the forms of inequality in justice and health is the most shocking and the most inhuman. It turns out it's not inhumane, which many people think, but the inverse includes inhuman. And if you think about like the civil rights movement, and then also then like police brutality now in terms of I guess race minorities, some ways it's a good test case for the question of when is movement advocacy necessary. And I would argue that there are three main criteria where when it reaches this point, then this type of advocacy is necessary. When the injustice is great. So again, think civil rights movement or police brutality, when the power differential between a presser and a press is large and with the willingness of a powerful to reform the system is low. So you may ask, well, for health disparities, so do these criteria apply? Well, I mean, as bad as police brutality is this far many more people that die or are harmed by health disparities. So the injustice is great. The others, well, you know, we do have a lot of mountains to climb to achieve health equity. I just put down a few here in terms of, well, you know, are we really working on these? So the battle over spanning health insurance been really tough. Do we truly tailor care to different populations? Some, but not enough. Do we address the social terms of health hardly at all? And what are we doing to reform the payment system of health care to so health equity is sustainable? Essentially nothing. So we do have sort of a long way to go in terms of people really caring about the issue and then this power differential. And there are important policy levers, both governmental in terms of regulation and then the free market in terms of then the policy levels of the free market. So really there was advocacy involved in terms of both levels. So also around this time I wrote this sort of bizarrely titled blog piece, Moonshots, Opioids and Incentives, which was accompanied by this picture actually. And when I got down to it, I actually concluded that so why do health disparities persist? A simple answer is that our country tolerates them. So early in the presidential campaign, some people may remember this, that there was a black lives protest where I think it was Bernie Sanders and then it was the Maryland's governor who was running for office where they interrupted the campaign event and they actually Bernie Sanders and that the governor could not speak. And so before when I got Senator Clinton's events, she actually approached the protesters and said, look, don't interrupt me now, I'm going to be happy to speak to you after my talk. And so if you Google the video it's really quite amazing that it says video and that's just a point of campaign where people were criticizing Clinton for being too passive. So the video is maybe like four or five minutes where she's just listening to the man on the right talk about the issues of the black lives matter and then she really sort of lays into it. I'll share two quotes from you. So Senator Clinton, you can get lip service from as many white people you can pack into Yankee stadium and a million more like it. We're going to say we get it, we get it, we're going to be nicer. That's not enough, at least in my book, says Senator Clinton. She goes on to say, look, I don't believe you change hearts. I believe you change laws, you change allocation of resources, you change the way systems operate. You're not going to change every heart, you're not. But at the end of the day we could do a whole lot to change some hearts and change some systems and create more opportunities for people who deserve to have them. So Senator Clinton was appealing to the issue of changing systems and systems are powerful and actually the other thing she says, she really does talk about changing the heart also, that this idea about appealing to the best in everyone, everyone's intrinsic motivation in a sense, both being very important. And another example right around this time was Missouri, so you may remember this story. So an example of advocacy for increasing understanding and motivation. So on the University of Missouri campus there were a number of racial and anti-LGPT incidents, these bigotry incidents. And then the University of Missouri school admission was quite slow in terms of response. And so you remember the national story was then the football team, before one of the big games was probably going to bring a lot of money to the university, they basically protested saying we weren't going to play unless you address this in more detail. And it was amazingly fast. I think it was literally one or two days and then the president of the university resigned. So an example of advocacy to increase understanding, to increase motivation for change. And back to Martin Luther King, a letter from the Birmingham jail, very famous, I have earnestly opposed violent tension, but there's a type of constructive, nonviolent tension, which is necessary for growth. This is an issue then of well, reconciling advocacy then with the interpersonal relationships and trust, which I believe are necessary to achieve health equity. Some of it is internal, so in terms of self-awareness and commitment. So clinicians understanding their subconscious biases and shared decision making with patients or administrators recognizing how their clinic delivers care, maybe systematically set up in a way that leads to these disparities and worse outcomes. So in some ways to have that type of self-awareness, it does require a trusting environment. The University of Chicago where like in year four of the equity initiative, James Williams, who is part of the leaders here, is here part of the initiative. One of the first things we did as an initiative was we actually had the people who were going to be leading the initiative have a two-day retreat basically to work through our own personal baggage regarding equity and biases and whatnot. It's thought to be such a fundamental part of it. It's also this issue that like when you do reforms of quality improvement or changes, when you try to have equity lens, the same thing that to address these fundamental issues, it requires then a certain amount of trust and a certain amount of developing good relations for the people that you work with. I mean if someone says to us, well, you know, you're a racist now, Marshall, let's work together to work on improving equity. Well, it's a difficult environment in terms of that type of context. So again, there's this tension between having a safe, non-threatening learning environment and discomfort to convince some of the need for change. So the woman on the far right, her name is Jennifer Smith, who's a physician, used to be at Cook County Hospital, recently retired. General internist, a wonderful person. She also is a palliative care physician and a geriatrician by background. And so I took this like a workshop, this breakfast workshop that she was leading on conflict, a conflict resolution. And I thought she had some really wise things to say and I want to share this quote from you. She said that, so Dr. Jennifer Smith explained that a conflict is a personal narrative with a beginning, middle and end. At the beginning, parties frequently experience powerful emotions such as anger, frustration, fear and surprise and often make assumptions based on their values and biases. The middle phase encompasses listening and telling, adjusting facts and clarifying options. In the end, one can hope for agreement, compromise and reconciliation, but at a minimum it should be possible to envision a new future with common facts, decrease the motion and more clarity moving forward. So you can think about her context that as a physician at Cook County working on end of life care decisions with a very diverse population, you can imagine that there being a lot of tough issues that come out, a lot of conflict. That was actually a very nice analogy for what we're talking about now. And so some may say to you, well, you know, Marshall or Dr. Smith, are you being Pollyannish here? The thing about our current sort of national environment where it is so partisan right now and some of our national leaders have had quite divisive rhetoric and clearly that has not helped. But I do think that when you break it down to an individual level, so when you talk to individuals or you bring in individuals who you may have a conflict with and learn their stories, their experiences, then my experience has been that that's what works in terms of when people have to, if you make progress, people need to understand and identify with the issues of the other person in their particular shoes. And so I do think that what Dr. Smith says here is reasonable and possible in terms of you're not going to solve the world in once a swoop or potentially have a lot of agreement initially, but that issue of understanding the other's perspective. And so a lot of my talks, I actually talked about when it comes down to like addressing equity, it requires an honest discussions about racism, colonialism, equity. So caveat here. So after this workshop, then I revised my paper. I was all happy about it. I had this line about, well, then one of the keys is dialogue. And then this is actually Monica Peaks feedback. It's one of the most important feedback she gave me on the paper. She goes, well, Marshall, he's still being a little bit naive here that you're forgetting the power differential. So I think about the University of Missouri sample. So if I said, well, you know, racial ethnic minority students, you just need to basically sort of sit down with the administration and have an honest discussion at all. And Monica's point was that it's a power differential between disparate populations and establishment, which make it difficult. So in terms of, like, if you circumvent them as potentially equal partners and then, therefore, the expectation, especially from the marginalized population of having equal seat at the table. So it's just like, if you're a marginalized population, you're also battling the weight of the status quo or the administration or the asset of God, all the power. And her point being that there also needs to be acknowledgement and appreciation of the difference in lived experiences of the different parties and encouragement of people to tell their stories. And also this is a point about the importance of strong community relationships, because they will be inevitably, and I think we find here in the University of Chicago, something like working on the trauma center or disparate in general on the South Side, they will be inevitably difficult conversations and storms that will require this type of honest dialogue within this context. So this is an iconic picture, a Japanese picture. So in the 60s in Japan, like in many other countries, there were a variety of different protests against the establishment. So this is a very famous iconic picture. I think it's sort of a lot embedded in this image. So I ended the paper by saying, well, I believe that movement advocacy can break down ingrained structural barriers and policies to impede health equity while clinicians, healthcare organizations, and advocates build trusting relationships and resolve conflict with mutual respect and honesty. We must combine advocacy and relationship building to end disparities. Achieving health equity will require policy changes and personalized critical care in organizational transformation that are dependent on good will and trust. So I'm going to end up with a story about Paul Farmer. And so this is a picture from Paul. And this is Jim Kim, who is the co-founder of Partners of Health. And both are amazing people. Jim is currently the president of the World Bank. But they did their residency. They're both medical students at Harvard, and they did their residency at the Brigham Women's Hospital. So my senior year, my third year of residency year, during my make you intensive care rotation, Paul happened to be my intern. So yeah, they got all these stories, like how Steph allows. So I saw Marshall, what did you do today? Well, I was so happy. I was going to get the IV into this patient that was a difficult stick. So Paul, what did you do today? Oh, my hospital in Haiti saved 1,000 people's lives. So looking at Paul is that he's an amazing clinician so that I remember there was this one patient. It was an older white woman who was quite sick. And she was depressed. And she wanted to die. She wanted to die. And Paul was so patient with her that he's one of the few clinicians that has that he can get away with calling a patient by their first name. So every day, he would spend so much time with her, sit in the bed, talk with her. And basically, a lot of us non-medical, basically sort of encouraging her and basically helping her to move on. So when I wrote it off the rotation, she was still in the hospital. And later found out she ended up pulling through. And later when she was able to speak thoroughly, she credited Paul for more that sort of emotional support in terms of really being so much the classic McLean Center physician. So the classic physician here. My last month of residency was the beginning of my fellowship when I was still in Boston. I heard Paul give a talk, which will probably be reasonably similar to the talk we'll hear this afternoon. And it's the first time I actually heard Paul speak in terms of the public health pet. And it's a different Paul farmer. I actually had a hard time finding the right picture for this, that you look on the web for Paul's pictures. Most of them, he's smiling. But it was a different emotion that he was projecting in this particular talk. And the emotion he was projecting was anger. It was a really angry Paul farmer. I'd never seen him that way before. And this is one of the quotes from one of his books that I think captured why he was angry. Structural violence is one way of describing social arrangements that put individuals and populations in harm's way. The arrangements are structural because they are embedded in the political and economic organization of our social world. They are violent because they cause injury to people. So aside from Fleckman over the years, in some ways I think Paul is able to reconcile these tensions I've talked about, that he's an amazing individual. And my guess is he's talking a lot, but it'll also come across in terms of him as a compassionate kind of physician. But he speaks out about injustice and these huge factors that do need efficacy. So I think it is possible to combine both in our lives. And so I'll end by saying that leadership matters. And it's not just the Paul farmers of the world that Paul, he's amazing. But in all of us, I'm increasingly convinced that all of us have a really important role in terms of addressing equity. So a professional responsibility as clinicians, administrators, and policymakers to improve the way we deliver care to diverse patients. We can do better. Thank you very much. Deborah. Hi there. Thank you. That was lovely. I guess I feel compelled to speak out for the people that I work with who I think are completely unrepresented. And that would be people with chronic psychiatric illnesses. They meet all the criteria that you list. They are disenfranchised. The injustice is enormous. We have plenty of data going back 50 years showing that white people and black people who present with the same symptoms are diagnosed differently and that black people are put on medications that serve to quiet them so that they can't articulate the real trauma they've experienced while white people are treated very differently and ferreted toward psychotherapy where they can express the trauma they've experienced. And I think there is nobody who is effectively representing these people. The city of Chicago a number of years ago closed half the mental health centers. The University of Chicago made a decision which had consistently reaffirmed that psychiatric patients have no place in our hospital. And who will represent these patients? I am struggling with that. And I applaud your optimism. But I'm struggling to join you in that optimism. And I wonder what thoughts you might have. Well, thank you very much, Deborah. And I'm lucky to look forward to you. I think I've encouraged you over time to do more speaking and writing about this. I think the first step is like more stories that we need to have more patient stories about how this plays out in terms of individuals' lives. And I think that type of combination with the detailed knowledge of people like you who understand the system factors than that are driving this. That combination of the two, the individual stories plus the knowledge of how the system can be changed. Some ways to get back to Clinton quote about like hearts and minds and systems. You know, that'd be a great first step. But thank you for the comment. You're right on target. Good. So we're going to move on to one more. One more. If you can name and where you're from, thank you. Yeah, thank you for the wonderful question. I'm going to refer you to a paper we have in the journal General Tournament this year on we call it high stakes for LGBTQ people of color. It sort of grapples with this issue of like advocacy. This is in brief. What I would say is that there's no right one answer that people have to figure out where along the spectrum advocacy is the right place for you. I think all of us would agree that we need to advocate for individual patients. Some people may feel comfortable at marching the streets. Some people may feel comfortable working with organizations. And so there's like three or four different domains you can think about in terms of patient care, in terms of teaching and mentoring roles for others, in terms of outright health policy, and then sort of systems change within your organization. All of them are very legitimate ways to advocate. And again, the right answer is that it depends upon you as a person, individual. I would encourage people though to not be afraid and to develop skills in each of the different areas because a lot of people don't feel comfortable because they don't definitely have done this before. So I think like a part of people that have experience and over time developing your skill set. And also, too, you have different roles in terms of your work role as well as your role as a citizen. So different hats will also mean different times, different opportunities. But check out that article. Thank you very much. And so our second speaker is Albert Huang, who was a professor of medicine here at the University of Chicago, a general internist. And he's one of the, I think, most thoughtful people here at the University of Chicago. And he, again, he's like a Paul farmer. He has the ability to sort of integrate sort of understanding of individuals and people with macro health policy. He is an international leader in terms of geriatric diabetes policy, cost policy, analyses for diabetes. And spent a year in the Obama administration after the Affordable Care Act. He was one of the people that wrote the regulations for implementing the Affordable Care Act. So Albert, geographic disparities and diabetes and obesity and the long arc of health policy.