 I now have the honor and privilege to introduce Dr. Stacey Tesla-Lindau. She's an associate professor at the Pritzker School of Medicine in the Department of OB-GYN and Medicine Geriatrics. She's an associate professor here at the University of Chicago, particularly in the Comprehensive Cancer Center. She's a practicing gynecologist. She translates her population-based research into clinical research. She is the co-founder and current chair of the Scientific Network on Female Sexual Health and Cancer. A global interdisciplinary network of clinicians, researchers and healthcare professionals who aim to promote sexual well-being in women and girls affected by cancer by advancing evidence-based education and practices. Dr. Lindau actively engages with policymakers, including her participation in the recent National Healthcare Reform Bates. She also wears two hats, only one of which was sort of described in her bio. She also is just an amazing population health researcher and thinks about issues of equity deeply. I think that her talk today is going to be more in wearing her second hat. So we'll go further, too. Thank you. Yeah, when the introduction goes down the path of sexuality and the title is Feed First, ask questions later, it could cause some confusion. I was once introduced as an activist professor here at the University of Chicago, and I'm pretty sure it was intended as something of an insult. Correction, activist associate professor. So it may be my activism that prohibits the progress. But the McLean Center has, and probably so, the McLean Center has given me cover in many ways, because what the lab I operate shares as a passion is the idea of engineering solutions to injustice. And the University of Chicago is neither a place, well, it's not a place known for its engineering, and I'm not trained as an engineer, but there are many of us here who care deeply about injustice as you've seen by Marshall and Monica and throughout the day. It's a room filled of humanity. So today I'm going to speak on the topic of Feed First, ask questions later. And the title is an ironic antithesis of another statement, shoot first, ask questions later. Does anyone know the origin of that statement? What does it make you think of? Wild West, did someone say? Clint Eastwood. I thought Lantos actually might know the origin just because you're so smart. When we publish the paper with this title, and you're going to hear the story of it, I was unaware of the origin. It comes from a man named Hermann Göring, the highest-ranking Nazi official to be sentenced to death at Nuremberg. Shoot first, ask questions later, and don't worry, I'll protect you. And surely it was a statement intended to shoot Jews, ask questions later. So I feel good that we've taken back the night on this concept. And it's a commentary on when we have to act first as humanitarians and then as scientists. And I hear a theme of call to action today, and I'm sure it will continue. The two are not necessarily in conflict. How do we make our activism look like science is the challenge of the tenured professor who wants to progress in her career. And when do we have to just act and worry about the science later? So let me start by acknowledging the supporters for the work I'm going to share today. The Greater Chicago Food Depository has been an incredible partner, as you'll see. And I want to acknowledge especially the Institute for Translational Medicine, which provided some pilot funding to help us do some creative work that allows us to maintain the dignity of the people we are feeding while innovating science. So this is Reverend Karen Hutt. Does anyone know Dr. Hutt? She was a chaplain here at the Comer Children's Hospital and has moved on to a new role. But she came to my colleague Dr. Dorian Miller, and I'm not, I don't know if I see Dorian in the audience today, with a concern, this was 2008, about the problem of parents going hungry at their child's bedside in our Comer Children's Hospital. She had witnessed parents and caregivers asking nurses and medical students for food. And in some instances, the generosity of people who handed over their own lunch or took money out of their own pocket. And in other instances, the terrible distress of care providers having to say no. And so she said to Dr. Miller, who was working with me and others under the rubric of the Urban Health Initiative at the University of Chicago Medicine, this is something you could help with. And Dr. Miller shared the story with me, and I happened to be walking over to give a lecture for the medical students, Dr. Monica Vela's course. And I was so moved by how hard we were working to think about the problems in the broader communities we serve on the South Side of Chicago and this problem right before us. And so I sort of changed my lecture and I said to the medical students, it was nearly their first day of medical school. You know, I just heard about a problem in our children's hospital. Parents are going hungry there. Do you think you could help? And a few students came up after the lecture, which had to do with health disparities and said we want to help. And within a few weeks, via partnership with the Greater Chicago Food Depository, we were stocking a closet in the chapel with food that the chaplain herself began to deliver. So when we think about hunger, we might think about what I call outdoor hunger. We all pass homeless people every day, most of us who live in cities, asking for food. And I bet many of us carry extra food just to share. And we see people standing in line outside soup kitchens or we serve food to hungry people. But what does indoor hunger look like? My lab is interested in the concept of the unvisible, a term that comes from a preface to one of the later editions of Ralph Ellison's book, Invisible Man. And he didn't exactly define the term, but what I took from the term, unvisible, is not what we can't see because of the physical limitations of our eyes. That would be invisible. We have microscopes and MRIs for that. But unvisible is what we don't see because of our biases. And indoor hunger to me is one of those problems of invisibility. What does it look like to be a hungry student, or a hungry worker, or a hungry athlete, or a hungry caregiver of a child in the hospital? Could it look like a student whose misbehaves, a bad student? Could it look like a lazy employee or an underperforming athlete? Could it look like a parent disinterested in their child's care, a parent who doesn't trust the health care system? How do we misunderstand hunger? And that has become part of the fascination of the work we've been doing, sort of in the fishbowl that is looking at hunger through the institution of the hospital. We started to look at what was out there. What were the models for addressing the issue of hunger in the hospital setting? And there were several. In fact, Boston Medical Center is really a pioneer in this area. Several more have popped up over the last several years as we've been doing this work. What differentiates the University of Chicago's approach from all of the others is that we are a 24-7, 365 free access to the pantries. And our pantries serve everybody who has a reason to be in the community that is the hospital. Because the pantries are on the patient floors and in the emergency department, we haven't figured out a way to securely, you know, allow others who don't have a reason to be in the hospital to come in and use the pantries, but everybody else is welcome. And that was intentional. All of the other programs use prescriptions or referrals or even require people to show up with bills, showing what zip code they live in in order to gain access. And to us, our founding principle was that everybody in need of food should have access. We would really not worry about people who really didn't need it using it in order to achieve dignity of the people using the clinics. So interestingly also, just in the last year, the American Academy of Pediatrics has started calling for pediatricians to engage in efforts to mitigate food insecurity at the practical level and beyond. And there's a call for screening for food insecurity now at the point of admission to health care or presentation for primary care. And this is representative of some of the themes you heard from Monica and Marshall. How are we going to operationalize the idea of concern for the overall health of the population? Not just the medical issues, but the really root cause issues for health. So here's a picture of one of the food pantries. Actually, this is the most recent food pantry to our knowledge, the first ever self-serve food pantry in an emergency department. We don't find in the literature a description of another one. It's very simple. It's modest. But now anybody who's hungry in our children's emergency department can come and help themselves to food. And there are some features I want to show you. First of all, the food is free. It's free to be consumed there. It can be taken out of the pantry space. And there are bags, but as much food as a person wants can be brought to home. We have a community health information specialist. Kelsey Paradise in my lab spends part of her time supporting people who call for additional help. Maybe they need to be connected to the kind of food services in the community that Dr. Peek talked about. Or they need other kinds of support services that often come with the problem of hunger. We invite people to give us their ideas about the pantry to leave suggestions, give feedback, and to get engaged. And many people have. And the only data we require from people in order to use the pantry is a self-report. How many people are being served? And what zip code do you live in? And these data have to be collected as part of our relationship with the Greater Chicago Food Depository. So a lot happens in these pantries. And I'll just share with you the engineering side. How does a science lab manage food pantries? Well, we use a collective social impact approach. We draw on the strengths of a whole variety of stakeholders who want to be helping to alleviate this problem. So our team has been trained in food management. We have an account with the Greater Chicago Food Depository. We use some of our time for service. We drive our own car over there. We pick up the food. We have medical student volunteers now for several years. Each year, a new cohort comes forward who helps stock the pantries. People use the food, hospitalized children and families. Staff use the food. And food doesn't just come from the Greater Chicago Food Depository. I'll tell you a little bit more about that. And then the inventory is managed by the medical students. So it's a complex system. And actually, we're working with some Booth students right now from our business school to help streamline operations because the program just continues to grow. I want to share the distinction between the concepts of hunger and food insecurity. And it has important implications for science. Hunger is an individual level physiological condition. We're all familiar with it. The uncomfortable or painful sensation caused by insufficient food energy consumption. There's hunger with a lower case H. And there's hunger with a capital H. And one way we can think about using our language is think how casually we say, I'm starving. We use starving for hyperbole, but we are rarely starving. And how we use language, I think, influences how we think. It influences that invisibility problem. Food insecurity is a household level, economic, and social condition, limited or uncertain availability of nutritionally adequate and safe foods and ability to acquire acceptable foods in socially acceptable ways. And these terms are orthogonal. We can think about people who are both food insecure and hungry. And can you imagine one in 20 US households? In households with children, it's closer to one in five or one in six. And it's about twice as high in African-American households with children than other households. There's food insecurity without hunger. These would be people who gain access to food, usually high-calorie, low-nutrient food. And it relates to the problem of obesity. Is it a lifestyle problem? Or is it a structural racism problem? I think we have to think about that. McLean Conference participants before lunch, we're hungry, but not food insecure. And then there's everybody else. And people move between these states. So after we built the pantry system and we've been feeding people in the hospitals for probably close to two years, Jennifer Makalarski, a brilliant epidemiologist in our lab, led this study with Daniel Thorngren and myself. Daniel was a medical student at the time. He was one of the founders of the pantry to study to conduct a needs assessment of the problem of hunger in the hospital. We knew there was a problem of hunger because the food kept coming off the shelves. And because we trusted what the chaplain's observations were. But we found something astounding. More than half the caregivers in the hospital were suffering food insecurity. 22.6% overall had only household food insecurity, meaning they were better off when they were in the hospital than when they were at home. 10% had only hospital food insecurity. These are people who were not food insecure at home, but who developed an inappropriate or lack of access to food while in the hospital. And 21% were in both states. Now my child had been hospitalized at the Commer Children's Hospital around this time. And I understand the hospital only food insecurity. I did not leave Hiv's bedside for days. And I had no appetite. So we can relate to some of the reasons why food insecurity develops in the hospital. Dr. Makolarski really was the first to describe this concept of hospital food insecurity. Hilary Seligman is an internist at University of California, San Francisco, and builds on the work of Bruce McEwen in the concept of allostatic load to help us understand the mechanisms through which chronic hunger, hunger with a capital H, affect our health. And while I won't go into detail here, I think if you're interested in this topic, I would be remiss if I didn't introduce you to this piece of literature. Because it's a exceedingly important framework for understanding not only the mechanisms, but also the points of intervention. Here are some data. Now these data are largely based on the self-reported numbers, the utilization data, our accumulation of people signing in. So that would be a conservative estimate of use, of course, because we know not everybody signed in when they use the, we just know this from survey research, that not everybody self-reports. But over the last several years, this is what we've accomplished by making food freely available to the community inside our hospitals. We've purchased more than 16,000 pounds of food. We operate now five food pantries run by volunteers. You can see the step function. So with each pantry, you see this valid increase in the number of people using the food. And we've served now about 10,000 individuals. This is a fraction of the people who need to be served. And we know that because of the needs assessment. And so we're now trying very hard to convince NIH that they should help us study how to close that gap. And the next step is then to figure out, how do we not discharge children who are sick enough to be in the hospital with cancer, with sickle cell, and other severe diseases? How do we not discharge them home to hungry households? It sort of raises the question of the value of our investment in care if we send people home to starve. So there are a number of barriers to hunger self-management. People oftentimes don't even recognize their hunger as a symptom. They've been hungry so long. They don't recognize their mood changes and their difficulty making decisions as a hungry. Sorry, something just changed, I think, in the microphone. And the one that I want to point out here is skepticism. I don't have an answer. I don't know who wrote this comment card. But it struck me so deeply. Why do you provide food? It's very nice, but why? I just want to offer that for thought. Maybe somebody wants to say what they think is being asked here. And then facilitators of hunger self-management are really facilitators of any intervention that works, especially in the health care setting. The intervention must fit within the workflow, and it must enhance the workflow. Anything that makes our jobs harder is very difficult to adopt. We believe that food or access to food should be freely accessible, and there should be an opportunity not just to take food, but also to contribute. And this, I think, gets to some of that incentive work that Marshall is talking about, and it gets to the motivations. What is a human motivation? We look to Abraham Maslow's work. Hunger is a basic physiological need that motivates human behavior. But if you look two steps up in the love and belonging level of the pyramid, what we see is that not just receiving kindness, but giving is also a very important human motivator. And here, what we see is an example of free pantries popping up like mailboxes in communities where neighbors can both give and receive food. And we've seen from the people who are using the pantry a stepping forward to give back, whether it's food, it's help stocking the shelves, it's participating in our advisory board, people have a need to give. And one person left a letter just around Christmas while our paper was already impressed at the American Journal of Public Health about what they did anonymously during their child's stay for cancer to support the pantry. And I want to say, back to Humanity Meets Science, Mary Northridge, who I don't know personally was the editor of the AJPH at this time. And I called her up and I said, is the paper, is the press done? And she said, no. And I said, there's a letter and you have to publish it. Can you add it? And I sent it to her. And it was literally, I think, Christmas Eve. And she figured out a way to get the paper added to the science. And I'll forever love Mary Northridge for that. So I'll wrap up by just sharing how we're addressing some of the scientific objectives in relation to the humanitarian ones as we address this problem of hunger. We want to understand hunger in the hospital. And we think it's an opportunity to understand how to mitigate hunger more generally. But we have to do our science in a way that minimizes hunger and maximizes dignity of the people using the pantries. And this is where the fun comes in. So we've developed a smart pantry in the emergency department in the Children's Hospital. Anyone who has access to the hospital can go see it. We're working with scientists at MIT in the School of the Art Institute. And we've censored up this pantry. So without impairing people's dignity, without videotaping their faces, we can now track how many people come in and go out of the space. What kinds of foods are they using? How does the ambient temperature and sound and light maybe affect the way people are consuming food? And it just opens a whole new area of science of how do we use sensors to understand human behavior in sensitive settings. And we're actually talking about how to use it to study sexuality. So in conclusion, how we measure injustice influence is the scientific dialogue. By shifting to food security and insecurity as a convenient measure of hunger, we may be lose sight of really the depth of the problem of hunger. And there's a big discussion about that in this field. The humanitarian practice in science breeds innovation. And that's my argument for why it's OK to be an activist professor. And I will say that repeal, there's been a promise for repeal on day one of the Affordable Care Act, will eliminate incentives that are enabling this upstream and root cause work. And I agree entirely with Dr. Peek that we must build a practice of activism into our daily lives if we want to the world to go in the direction that we thought it might a week ago. Thank you to all of the people involved, especially Dr. Maklarski, who spearheaded this work, and Kelsey Paradise, who does the front line work with the people who need additional help. And thank you all for giving me the opportunity today. I think I've gone over my time, so I understand if we don't have time for questions. OK, one question. Quick question. Quick answer. It's John Lantos from Kansas City. Great presentation. I was comparing the work here with what goes on at our children's hospital, which is interesting. It doesn't have these food pantries, but it does have a big Ronald McDonald parents space within the hospital, where every day, three meals a day, are simply available. And they're brought in mostly by volunteers, but also funded by the hospital. The hospital cafeteria also deliberately prices all meals below market. So meals are affordable, has banned sugary drinks, and has elaborate salad bars. So I wonder if you can talk a little bit about the difference between add-on programs, which is what yours seem to be, and programs that are built into the institutional culture. Yeah. I think Marshall's talk, certainly, I'm a believer in the impact of policy change to change the way we do things and the way we see things. And policy change, I think, is needed not only in our institution but others. It sounds like you work in an enlightened one on this issue. I've taken a disruptive grassroots approach. I mean, who can argue with what we are doing? And by doing the work we are doing, we've actually brought to the table all those stakeholders who would need to be on board for the higher level policy change, including Karen Stratton, who's a nurse PhD and a vice president who oversees the Children's Hospital, who's been an incredible champion. So rather than pushing from top down, I mean, I can't say this is our strategy. My strategy was really like people are starving. We need to do something. But by engaging people in this act of addressing a humanitarian need, those people have started to ask the question, well, wait a minute. Why can't people get affordable food in the hospital? So it's maybe a longer path, and we won't know because we didn't do the randomized trial. I think there's room for a guess and, John, and I'm gonna look to your hospital's policy as to bring to the table here. Thank you.