 I'm delighted to be here and to moderate this very exceptional panel. I'd like to first start by introducing Dr. Sarah Scarlett. She is a newly minted trauma surgeon with a strong interest in surgical ethics. She recently completed a surgical critical care fellowship at the University of North Carolina at Chapel Hill. She completed the ACS Surgical Ethics Fellowship at the McLean Center in 2017 to 2018. This month she will be starting her academic career at the Ohio State University in Columbus. She's interested in the intersections of trauma surgery, public health, and ethics. She studies the ethics of healthcare for justice-involved patients. Welcome Dr. Scarlett. Thank you so much for the invitation to present today. I'm very excited to help kick off the conference. When an incarcerated person becomes ill, experiences of receiving healthcare are quite different than those of non-incarcerative patients. After the decision is made that a person needs care outside of the correctional setting, they're brought to a non-correctional hospital. Oftentimes they arrive and they wait in rooms hidden from view, such as this decontamination room in an emergency room. They are often transported around facilities using alternative routes and entrances. In main areas their shackles are hidden by blankets. Correctional officers maintain presence at the bedside and patients are shackled throughout the entire admission, during scenarios such as general anesthesia, critical illness, and even parts of labor. Experiences like this are common and that's because today there are two million people incarcerated in America's prisons and jails. Not only do we incarcerate an enormous number of people, some communities are disproportionately affected and many people believe that racial health disparities in America occur in part due to mass incarceration. The relationship between incarceration and health is complex. Incarcerative people have a higher prevalence of infectious diseases such as HIV and even COVID-19. They share a higher burden of mental illness, substance use, experiencing, witnessing trauma, and even things like traumatic brain injury. Incarcerative people are physiologically older than their non-incarcerated counterparts. At some estimates their physiologic age is about 10 to 15 or people 10 to 15 years older in the community and some forms of incarceration such as solitary confinement actually lead to worse health outcomes. In 1976 the Supreme Court ruled that deliberate indifference to the serious medical needs of prisoners constitutes cruel and unusual punishment in violation of the Eighth Amendment and with this ruling incarcerated people became the only population in the United States with a constitutional right to some basic forms of healthcare. For incarcerated people understanding how healthcare is delivered and the quality of this care is very difficult to determine. This is because there are many different systems of incarceration. People are also cared for at multiple types of healthcare facilities inside and outside of correctional facility walls and there's little data collection regarding health and healthcare and much of the data we rely upon is actually self-reported by incarcerated people as with the 2004 survey of inmates and state and federal correctional facilities which is the last national study of the health needs of incarcerated people. SCAT data does suggest however that the burden of care is significant in terms of cost and need. An estimated eight billion dollars was spent on prison healthcare services by the DOC in 2015 and in some states the healthcare budget for corrections approaches one quarter of their total operational cost. Many people require this care as in North Carolina where nearly one percent of people were hospitalized at some point during their confinement. There is some data that suggests healthcare disparities for incarcerated people and these exist mainly in the qualitative literature. There are exceptions to basic attributes of patient-centered care such as physical comfort, health privacy and informed decision-making. Nurses describe correctional officers and shackles as inciting fear and posing barriers to forming therapeutic relationships with people and fundamental misconceptions have been observed regarding advanced care planning for incarcerated people posing significant barriers to providing quality palliative care and in some studies trainees actually believe that incarcerated patients receive substandard care. Some of the most compelling data comes from incarcerated people themselves. Now the slide isn't advancing again. There we go. As in this qualitative survey published last year when you're a prisoner you've no medical confidence it's open information for everyone that's there and you just get cut out and after a while they don't talk to you they don't see you they see authority of the prison officers and they bow down to it. For non-incarcerated patients many guidelines exist that guide healthcare and influence reimbursement and accreditation of hospitals. In comparison there's little guidance on appropriate care for incarcerated people. Many regulatory agencies have fallen silent on the care of incarcerated patients such as CMS who explicitly exempt shackles from restraint requirements and the Joint Commission who retracted requirements for hospital orientation for correctional officers in 2017. There are some guidelines related to the care of incarcerated patients most notably those related to the care of women during active labor but of these guidelines many relate to care within correctional facilities not outside of them. So when a clinician sees an incarcerated patient what guides their decision-making at the bedside it's likely a multitude of factors including ethical frameworks convenience and their own preferences or biases. Myself and my colleagues became very interested in what guides the care of incarcerated people and as we chose to study this we became interested in institutional policy. So why study institutional policies? Generally speaking they help us understand what we can and cannot do in the hospital they tend to be referenced in types of confusion and we know from the literature and anecdotal experiences that clinicians are often unsure of how to care for incarcerated people. Importantly policies convey what an institution believes is ideal behavior or in the case of incarcerated people ideal treatment. Policies may contribute to individual practice but this is likely variable. Hospital policies have broad implications across health systems and populations and each hospital can have hundreds if not thousands of policies and despite this there's little written in the literature regarding ethical analysis of these policies are suggested review processes. Some authors have even moved as far as to criticize institutions with policies that fall silent on important issues. Reflecting on this we became very interested in institutional policy related. We developed three main questions about the content of these policies. What is the role of hospital policies in the care of incarcerated patients? How do the policies identified varying content in town and are the policies contributing to structural bias? We evaluated a convenient sample of policies across a large health care system in the southeastern United States. We used a policy search engine through the institution to identify using seven search terms inmate, prison, prisoner, forensic, incarcerated, incarceration and jail to identify these policies and a code book was developed with the input of four reviewers with experience in clinical care ethics and care of incarcerated patients. We identified 106 total policies which came from 10 hospitals throughout the system. Of these there were 19 policies that had a primary focus on the care of incarcerated patients. On the right you can see that four of the policies are the primary focus on incarcerated patients who the authors were. The most common authors were nursing administrators and hospital police. We observed a lack of consistency among hospital policies and there was no general policy related to the care of incarcerated people throughout the health system and this is really important because for people in our system incarcerated people were cared for at a variety of institutions and based on the policies their treatment could vary significantly based on which hospital they were brought to. There was also a lack of interdisciplinary input. With regard to authorship there were no patient representatives and no physicians were involved in policy creation as far as we could tell from our review. We also noticed wide variation in how the policies described and discussed people who were incarcerated. Here's a collection of terms we identified that were used to describe people. Many terms are not consistent with recommendations for person first language and some terms such as correctional and inmate have actually been identified in the literature and discussed by incarcerated people as being derogatory and stigmatizing. We identified five major categories in our analysis in our code book. Facility, security and safety including what to do if a patient escapes or becomes violent. Administrative processes those mostly related to coordination of care and billing. Clinical services such as those including services provided to patients including things like nursing care, phlebotomy or transplant. Non congruent standards of care with specific recommendations in which it appeared to us that incarcerated patients care deviated from the standard of care or patient center of care and then patient rights which related to things like policies handling surrogate decision making or consent. This is a chart depicting the frequency of major categories and policies. Major categories on the x-axis and the percent of policies on the major categories on the y-axis and percent of policies containing these codes were on the x-axis and you can see the facility security and safety was the most commonly used category whereas patient rights were the least commonly used category. Now I'll share some excerpts from the categories to give you a better sense of the data. This quote relates to the care to the care of incarcerated people who die while in the hospital. The custodial agency is responsible for notification of the prisoner's next of kin and restraints will remain on the prisoner patient until the prisoner is observed by the county medical examiner. Some policies did acknowledge that despite incarceration patients retain the rights to consent or refuse treatment. Even so these policies acknowledge limitations on these patient rights saying things like access to treatment and to their authorized representative or subject to special procedures. In the hospital significant discretion was left to correctional officers at the bedside. In these policies they were given authority on a wide variety of topics. What items a patient could have at the bedside and even given the ability to do things like sign a patient out against medical advice. Perhaps the most illustrative category was non-congrate standards of care and we noticed three distinct themes here. Restriction of physical space. Policies prevented patients from walking without the order of a physician. They were not allowed to have items in their rooms even items typically allowed in correctional facilities such as books or pictures. There were modifications on clinical care. Patients were unable to communicate with family members or surrogates which is common place for people making decisions about their health. Patients were not able to be admitted to certain units such as the pediatric ICU irrespective of age and they weren't able to do certain clinical tests such as the six-minute walk test which is important for determining a patient's ability to have supplemental oxygen out of a correctional facility. Their diets were restricted. They were unable to choose what foods they were served and rather served a prison tray despite health concerns or dietary needs in the hospital. The policies also dictated significant modifications on staff. Clinicians were not allowed to directly contact patient family members or surrogates and one theme we encountered frequently was that non-correctional staff were asked to perform security tasks such as nurses securing rooms prior to the arrival of incarcerated patient and the opposite was also true where correctional officers are given clinical roles such as monitoring skin underneath shackles or other restraints and we felt that these policies often required people to act outside of their scope of practice and training. Some policies even explicitly discussed that shackles and other restraints used for incarcerated people are not safe and appropriate health care restraints. Reflecting on these policies we found that many contain specific language noting that incarcerated patients should receive the same care as non-incarcerated patients but these were often in the same policies that delineated limitations and modifications to this care and in our view the policies failed to reconcile a desire for patient-centered care and for preserving facility security and safety. To us the result of this was creation of a false dichotomy in which policies attempted to separate clinical care and security concerns but the distinction is often cloudy when one takes a more holistic approach elements of in-hospital care that were categorized as security don't seem that way such as what a patient eats or how and when we talk to their family about their care and we suspect this false dichotomy is a source of tension and confusion for staff. Unfortunately some of the policies seem to codify bias stigmatizing incarcerated patients. These policies reference people as manipulative and even warned staff against forming relationships with them. Other policies used derogatory language to describe incarcerated people calling them things uncooperative, abusive or insolent. Language such as this could further support bias and lead to poor treatment. In conclusion incarcerated people often require health care in non-carceral settings and unfortunately there's little guidance for clinicians caring for patients in these settings and studying hospital policy can offer insight into disparities in care and structural bias experienced by these patients. As we reflected on this study we couldn't help but think about what policy could do for incarcerated patients and other patients with vulnerabilities and we believe that policies should be written in a way that promotes health equity. Unfortunately many important factors related to the care of incarcerated patients were not mentioned in policies things like advanced directives, compassionate release. We believe that this is a missed opportunity and at best policies can and should be used to set a respectful tone, acknowledge vulnerabilities and protect patients, reduce staff conflict and confusion and engage in interdisciplinary collaboration. In recent years there have been increasing calls for justice for incarcerated people specifically to end mass incarceration and its negative effects on people, their families and their communities. Some of the most long-standing cries for justice have come from incarcerated people themselves. 50 years ago the Attica Manifesto written by incarcerated people demanded access to quality health care in which patients didn't experience prejudice. Perhaps it's time we listen. I want to thank my brilliant collaborators Shannon Gillespie and Elizabeth Driessen and all of my mentors at UNC and McLean. Thank you so much for the opportunity to present and for putting up with my technical difficulties at the beginning of this talk. Thank you so much Dr. Scarlett. That was an amazing presentation and despite our Crackerjack team of technical assistants here we had some issues. So thank you everyone in the audience for your patience. I want to make sure that everyone knows that we are not doing a Q&A after each presentation. We're going to save them all for an open Q&A at the end. We'll have a robust 20 minutes and so if you can take the time to enter your questions as we go along so you don't forget it'll help us have just all the questions sort of lined up at the end and help me moderate the session. So thank you again Dr. Scarlett. Next we have Dr. Marshall Chen. He is the Richard Perilio family professor of health care ethics. He's also the associate director of the McLean Center for Clinical Medical Ethics. He's a senior faculty scholar at the Bugsbaum Institute for Clinical Excellence at the University of Chicago. He co-directs the Robert Wood Johnson Foundation's Advancing Health Equity, Leading Care, Payment, and Systems Transformation Program and he was also elected to the National Academy of Medicine in 2017. Marshall also has a totally another side to him. He's a member of what's called the excited state. It's an improvisational comedy troupe. He's trained in improv and stand-up comedy at the revival theater here in Chicago at Science Riot and Cold Tofu in Los Angeles. He and his colleagues use improv and stand-up comedy storytelling and theater to improve training of students in caring for diverse patients and engaging in constructive discussions around systemic racism and social privilege. He'll speak on the stand-up comedy and the personal monologue to explore interpersonal bias. Welcome Marshall Chen. Thanks very much Monica. And Eric, do we have slideshowing? Right now I see this myself on the screen. Great. Thanks very much Eric. And so I'd like to recognize my collaborators who are co-authors on the paper that's currently under review. Mona Ebermeshan, who's a professional stand-up comedian and one of my stand-up teachers and mentors. And Mengxi Zhu, who is a statistician and data analyst. And so I'll first tell you the story of like how we started using stand-up to teach about health equity. The story begins about five years ago. I had given my wife Neko as a gift, a storytelling class at the local theater, The Revival. This is on Woodlawn and 55th, right next to Jimmy's Woodlawn Tap. And at the end of the quarter, The Revival has a student show of all their students. So the storytellers, the stand-ups, the improvisational comedy students. And I remember like in the student show, the first two students performed with the stand-ups. And I was thinking, there's no way in heck we're going to do that. It looks way too intimidating. The next students were the improv students. And my wife and I thought, hey, that looked like fun. And so we started to enroll in the improv 101 class, had great teachers, great fellow cohort of students, and ended up doing the complete five-course sequence at The Revival. And as I got more into improv, I began to realize that the skills you learn in improv really are great skills to have in other professional lives or in creative development in general, as well as for patient care. The most important improv principle is yes and, especially is be a good listener. So yes, you agree with what your scene partner is saying, and then you build upon that reality that your scene partner has started to create. But we're also taught critical to build relationships with your scene partner and important to make strong bold choices. And so about a couple of years ago, I had a paper come out in John Maternal Medicine entitled Lessons from Improv Comedy to Reduce Health Disparities. And talked about how the arts in a particular improv and stand-up have potential for health equity training. The arts in general help us understand human experience. They help us connect with people directly. And then this challenge of how do you teach about emotional and cognitive intelligence? I can think of a few things better than the arts or something like improv and stand-up to teach about emotional intelligence. And so Eric Topol, who at that time had 291,000 Twitter followers, tweeted out a line from the paper, I can't believe that you're doing improv comedy, but it's a good thing that he did. And the paper ended up getting a lot of dissemination. Probably one of my two papers I've ever written that's gotten the most attention on social media. It had about a million Twitter impressions, so it seemed to resonate in terms of the audience. And my wife and I had good timing that when we had finished the improv sequence, the theater was starting a house improv team, a science-based team called The Excited State, where besides the true performing, each monthly show, we have a faculty guest, often from the universe, Chicago, who will give a brief presentation on the research for the lay public, as well as participate in some of the improv games. From the McLean Center community, we've had his guest Monica Peek, Stacy Lindow, Albert Huang, and we're hoping that we're going to get noted improv comedian Mark Siegler on deck, potentially for July 2022, when the new fellas come in. Dr. Siegler has a very busy international tour, so he's been hard to book, but we're in touch with his people, and hopefully this will become a reality. And then some of our improv buddies got into stand-up, and they basically convinced my wife and I to do it. And so this is the cohort, the smartly crew, this is the cohort who we did the stand-up training with and started hitting the open mics circuit in Chicago with. That's me on the left there in between Cuddy and OC, and my wife Knuckles in the middle next to Mona. And the stand-up is different from the improv, that stand-up, these are scripted, rehearsed, jokes, and statements. And some of the key qualities of a successful stand-up are being authentic, willing us to be vulnerable, and willing to talk about the personal lived experience. And so you start to think, see how like some of these skills could be very useful then for difficult discussions about bias and racism, for example. And so before the pandemic, we started hitting the open mics. And so this is like Reggie's on the left on the south side, and Jimmy's on the right. We did some larger venues. This is the Den Theater on the north side. My longest set today has been 15 minutes set at Comedy Bowl, north side. And then Ward Alderman, Leslie Hirston, she has an annual laughter and local politics event. And at this most recent event in February, Mona and I were the two comics to perform. We had 10-minute sets. And after we performed, we actually did a variant of the exercise. I'll describe the rest of this presentation with Alderman Hirston and one of the audience members to really get into this issue of a discussion about identities and biases. And it went well in that particular setting. And so Monica has been one of my biggest comedy supporters. And so she tweeted out after this that I got at least her laughing while tackling the very serious issues of implicit bias and racism. And I discuss issues of bias and racism in most of my stand-up sets. And I found it to be a good way to get people thinking about these difficult issues. And so Mona and I actually came to very similar ideas from different starting points. For me, my prior project that has most influenced me in this sphere is a project aiming to improve communication and shared decision-making between clinicians and LGBTQ people of color. And so from that project, Monica led this terrific paper where she developed a conceptual model for this. And so on the left, you see that there's the clinician and patient talking to one other. There's the spoken word. But equally important is what's at the top, you know, what's in their heads. They're not saying this, but there are the thoughts they have as I as the clinician try to size up the patient. The patient is similarly trying to size me up. And these views aren't pure views in some ways. They're tinged by stereotypes and biases in some ways. It's very hard for each of us, ourselves, to have a clean view of ourselves because we see things through the lens of society's perceptions and values that society places on, for example, a different racial ethnic group, for example, in the media images and how groups are portrayed publicly. Monica and Monica Vela and I, we had a paper come out about a year ago in academic medicine, practical lessons for teaching about race and racism. I'll point out three, upper left quadrant, the importance of creating a psychologically safe learning space, upper right quadrant, second bullet. Imports of starting with stories, not numbers. We've often found that if we start an equity talk with statistics, people can tune out as opposed to stirring with the story and bottom right quadrant, the importance of engaging in free, frank, and fearless discussions about structural racism, colonialism, and white privilege. So, regardless if you're an international stand-up professional comedian like Mona, and she's amazing, she performs throughout the UK, European Union, South Africa, the Middle East, all throughout the US, or if you are someone beginning their stand-up journey like myself, the stand-up has the same challenge of having to read the room, so read the audience, basically able to target things for their audience at that time, and then begin to read yourself in terms of your self-understanding. And then just as the clinician controls the room in the patient encounter, similarly, the stand-up has a lot of power. The stand-up controls the room during performance. As far as we are aware, there's no pre-existing literature on the use of stand-up comedy to teach about advancing health equity. There is a literature on stand-up and into racism. So, for example, there was one study, a qualitative study of Midwestern comics, which found that successful comics share honest, revelatory, personal experiences as a prelude to thought-provoking jokes about racism that challenge stereotypes. No one can deny how you perceive yourself, and the audience getting to know you is the setup for dialogue around racism. So, about a year ago, we had a great team of colleagues who did a pilot with the entire first-year Pristra Medical School class. So, each member of the class did two out of the falling four art forms. Stand-up improv, graphic medicine, that was led by Brian Callender and Shirlene Obobi, a theater-y oppressed as part of the required health disparities course that Monica Vella led. And each of the students did these 90-minute Zoom workshops. The teacher ratio was about 10 students per instructor. At the end of the class, there was a quantitative survey with Likersdale questions, which also had open-ended questions. For the 40 stand-up students, there was a 42.5% response rate on the survey. The specific learning objectives were to humanize clinicians and patients, improve listening, observation, and empathy, and to recognize how diverse patients perceive you and how you perceive them, particularly for the stand-up module. More aspirational over time is to engage in these free, frank, fearless, and safest conversations about structural racism. Before the class, we sent the 40 stand-up students this email, which said, together we'll use principles of stand-up comedy to help you read the room and read yourselves critical skills for caring for diverse patients effectively. A comedian's job, like a physician's, is to always leave the room feeling better. So, we will create a conversation exploring how might thinking like a comedian help generate innovative skills for patient care, leadership, and life in general. And at the top of the workshop, we set a few ground rules. First, you don't need to be funny, and that really the workshop was not about comedy or being funny. Second, we don't want anyone to feel uncomfortable, so no one had to do any exercise if they felt uncomfortable. We said, for example, that would be fine if someone observes and then perhaps just could choose the discussion and comments. That'd be fine. And then third, everyone should feel comfortable disclosing as much or as little about themselves as they feel comfortable. The workshop consisted of three exercises, a fun naming exercise to learn each other's names. We then did a classic improv exercise called rank and frave. Each student was given an object and was asked to either rant about why they hate that object or rave about why they love it. The key exercise was a personal monologue, which is actually the very first exercise I had been taught in my stand-up 101 class taught by comedian Jonah Jerkins. And then here's the key exercise, the personal monologue. We explained to the students we'll be exploring our own personal monologue by first thinking and journaling for five minutes. Then volunteers would do 90-second maximum monologues. Students were asked to choose one of the following three options. Almost all the students did option one, which asked them to think about how do others perceive me when they first meet me? What do they get right? What do they get wrong? And so we did the workshop and then I'm going to show you first the quantitative data. So the point about this slide is that you see mostly green. Green means agree or strongly agree. These four questions like the workshop helped me become a better listener, more observant. It would help me take better care of patients. It helped me bond with my classmates. I'd better recommend the class to others. So overwhelmingly positive. The areas of more brown, there was one question about like a different module helped teach you about systemic inequities. We're about a third of the students said so, which maybe was expected as we were doing mostly work at the interpersonal bias level. Interestingly, about a third of the students reported feeling stressed during the module, although 100% all of them felt that the module was safe. So we actually think the stress is probably a good thing. There's some of the stress involved in like public speaking and presenting, then also the stress of having discussions about bias and self insight. So this constructive tension that Dr. King talks about. Qualitative themes went to one of these three buckets, self-identity, misperceptions and danger biases, safe space, and the value of stand-up and the non-medical context. So for example, one student said, I greatly appreciated having the opportunity to think about how I perceive myself and how others perceive me in a structured context. I feel that this is very important to breaking down my role in the clinical encounter. So self-identity, race and privilege was a critical factor. One of the white students said, this was a helpful reminder that I am not often forced to think about how people perceive me because I am in a dominant racial group. And thus, I am afforded the privilege of unself-consciousness. I'm not going to present this today, but we also did quality interviews of about 19 students. And this was also one of the themes that some of the white students talked about, like they somewhat had the privilege of not having to worry about identity because of their position. I think it forced me to confront my own blindness regarding others' perceptions of myself. This module made me reflect deeply on how difficult it is to separate others' perceptions of me from my own identity and how assumptions can have a huge and often harmful impact on people. And one of the key perceptions in this model is like Monica's paper. Everyone's individual stories definitely highlight the way in which other people's perceptions and assumptions of us can shape our own self-perception. So again, it's hard to have a clean view of yourself that is affected by others and most particular views are tainted by society's stereotypes and images. The security is important to understanding the barriers of care for each individual patient. I like that this module made us get uncomfortable in a safe space and reflect on questions about perception and assumptions. It was also really fun to be a part of. I love Mona's energy. I was surprised by how much I enjoyed this session. It helped me reflect and learn more about my classmates' viewpoints and how perceptions affect our actions. This made stand-up comedy a little less intimidating while at the same time increasing my awe just for stand-up comedians' storytelling abilities and resilience. I've realized that their work is indeed analogous to being a doctor and I think it is good practice for increasing self-understanding. I think the more different ways we try to think about our differences and our perspectives aside from medicine, more likely we are to internalize that lesson in turn, bring it back into medicine with us. So we conclude by saying that stand-up has a lot of potential and promise for engaging students in meaningful discussions about perceptions and interpersonal biases rooted in their own personal experiences and those of their classmates. A point that Mona keeps on emphasizing to me is, you know, be careful about getting too trapped in the conceptual models that for her, and I think she's right, it really comes down to heart that the power of these modules, I think for the stand-up and the other art forms in our overall project, is that they tend to appeal and get into a person's heart. You gotta do the mind as well as the heart and the heart leads to some powerful change. When the process of writing a commentary on our wider group for academic medicine, so thank you Laura Roberts. Talking about what we've learned from the four art forms, our pilot for teaching students about health equity, we're probably going to mention at least four of these issues I'll mention right now. One is that students are heterogeneous so they need to really be able to read students with different readiness to change, different capacity, different willingness to think about issues such as race. A second being that being very clear about the learning goals for each session, some students could connect with us very easily, some students want to have even more concrete how this connected to clinical medicine. There's more we can do in terms of establishing safe, brave spaces and then also the steam about how there were like some differences between the white students and then the students of color, which are going to be important to think through and work with regarding the best way to structure, exercise, and the discussions. And so we live in contentious times, a lot of partisanship and liberals and conservatives like Dave Brooks like in today's paper near Times Uphead talked about how community is important. So we end our paper by saying that in today's contentious times, breaking down walls between people will require self-insight honesty and emotional connection, a key requirement for establishing effective clinician patient communication and relationships across diverse populations. Look forward to the discussion. Thank you. Thank you so much, Marshall. It is always a pleasure being on the panel with you and learning from you and it has been particularly wonderful. I'm watching you on this journey. I'm watching you grow in this additional skill and how you've brought those skills to bear in the health equity work that you do. So thank you. And again, I'd like to remind everyone, people have been putting questions in the chat. Thank you for our prior speakers and I encourage you to continue to do so. So now my time. So my talk is entitled Black Lives Matter, Racial Justice as a Critical Issue in Clinical Medical Ethics. And for any of you who have seen me talk in this lecture series or anywhere else, I normally have a whirlwind tour with more slides than I can squeeze into the time allotted with lots of data. This is not that. I have very few slides and they're mainly photos. And so what I want for us to do during this period of time, and we may actually run short, which will give us just more time for the Q&A, is to slow down a bit and think more abstractly about where we are in space and time and what it means historically, how we have historically as a country valued Black Lives and what that has meant contemporarily as we value or devalue Black Lives. And how that interfaces with different institutions, primarily our healthcare institution and what that means for us as providers and clinicians for healthcare systems and ultimately for health inequities in clinical medical efforts. And so that's what we're going to try and dig into a little bit today. I'm going to see if I have the technical skills to advance this on my cell phone. Let's see. Okay, I did. So I always want to start by acknowledging the various places that I sit on campus. Today, the McLean Center, I'm honored to be an Associate Director here in McLean. I also am part of the Bucksbaum Institute, the Chicago Center for Diabetes Translation Medicine, also a part of this Center for the Study of Race, Politics, and Culture whose logo is not here in any other places. So thank you. I'm going to remind us of what the definition is of clinical medical ethics, because that's going to be the framework for discussing this. So 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, it also examines practical ethical concerns that arise routinely in encounters among patients, families, health care professionals, and health care institutions. So when Black Lives Matter first started, and these are just some samples of pictures that came up, it has been controversial that statement since its onset. And it arose out of, as a response to just generations of state-sanctioned killing, meaning police killing of unarmed Black people, primarily unarmed Black men, the Black people in general. And as a response, Black communities have been protesting because that is the primary means that we have to express our concern about these issues. And there is a lot of dismay at the response, and at the term Black Lives Matter. And so initially, there was concern that this is not the time and place to protest. This is not the way to do it. So, for example, rioting and looting and burning things, that's not the proper way, or having clashes with the proud boys, or clashes with the police. All of that is not advancing your cause. But these things came a little later, and so it wasn't the initial concern about the term Black Lives Matter. And each of these, I would argue, have validity in and of themselves. There's pushback I would give for each of those concerns. But putting those aside, this is a cartoon that started when I was in medical school. It's a shout-out to Huey Newton. But it says, we said Black Lives Matter. We never said only Black Lives Matter, or we never said Black Lives Matter more. Really, what we're saying is that Black Lives Matter also Black Lives Matter too. We know all lives matter. Of course they do. But in the face of all the evidence from the past and the current that is telling us that Black Lives don't matter, we want to say we're confirming for ourselves, for our community, for our children, that they do matter. And the fact that that is a controversial statement speaks more to who we are as a country than who Black people are in this country. So it reminded me of the sanitation workers in the civil rights movement when they were, had their protests with, and they were holding signs that said, I am a man. I may have a job that is lowly, that may not be worthy of respect. But I am not lowly. I am worthy of respect. I am a full human. I'm not your boy. I am a man. And to have to say that I'm a whole person, full of worthy of respect. And I have to put that on the sign. Black people have, since we have been here, fighting for our dignity and for our humanity. And to be able to say that I'm just a human. I'm a man. I'm a person. My life matters. And to make a simple statement of affirmation of that and for that to be controversial, for that to bring out the police, the riot guard, the white nationalists and haters. What does that say about us as a country? That we can't just say that I'm a regular person too without all the vitriol coming out to meet us. I believe deep in my soul that it reflects that we have yet to come to terms with the fact that we do not see African Americans as fully human. We have yet to humanize black people in this country. And that is part of our history. Since we got here in the United States, we arrived as non-humans as chattel slavery. That's the worst kind of slavery. It's what we sort of traditionally know in this country. There are lots of different kinds of slavery. Chattel slavery is the kind that by its very definition dehumanizes people. It takes you from any human agency at all to being nothing different than a piece of furniture. Or in those days, more akin to livestock and being very thought about as animal property. So that process of being thought of as not even really human. And for voting purposes, there was that, how should we sort of figure this out? We want to give landowners and people owners. Again, these aren't really people. They're more like land or livestock. But we want to give more priority to the wealthy landowners in the South. So we'll consider their slaves three-fifths of a person that affects the psyche for blacks and whites about what the value of black people is. The three-fifths human. So really not fully human. Maybe three-fifths for voting purposes. But that three-fifths has persisted in our common psyche about the lack of full humanity of black people in this country. So we get to George Floyd, who was one of many black people killed that year and the year prior. And his brother said that this was a modern-day lynching. People were like, what? That seems so full of hyperbole. But that is exactly what that was. Lynching is a public killing used for the purposes of intimidation and racial control. His killing was in public. You see the disdain and lack of concern by the police officers. You know that there was a crowd of black people watching who were in horror videotaping but did not step in to felt unable to intervene and save that man's life because they knew that they would probably be shot and killed. And this is what has happened generationally with typical lynchings. Black people were often forced to watch on plantations. Other blacks we lynched, you know, killed. So they would learn their lesson and to learn about their own powerlessness in being able to help others. Sometimes those lynchings were, often those lynchings were large, large events for the public. And this is a picture of one of those. So what looks like maybe a cotton field is actually people, thousands of people and you see the shadow of the person being lynched. So during reconstruction, which is really when it took off to 1950, which is not when lynching ended, there were lynchings that took place during the pandemic. There are about 4,500 documented lynchings, which meant that there are many more that were undocumented. And by definition, it's any sort of public killing, but most commonly it was hanging, often preceded by torture, and or people would be burned alive. And frequently over a period of hours for the enjoyment of the public. And so they would be sort of attached to some sort of scaffolding and dipped into burning oil or some pit of fire and then pulled back out, you know, to be dipped back in and pulled back out and it would last for hours. Photos would be taken and sent around as postcards. Kids would come. It was like going to a concert. And the pretext for this was the idea that black people were subhuman. They didn't really feel pain. And they were always sort of lurking around as a devolving species, looking for, you know, harm and violence and trying to rape white women. And that sort of theory of the idea of inherent violence of black people has persisted so much that ordinarily what we see is that police will shoot and say, I thought he had a weapon. And really, there's no weapon found. What they thought or what they thought was a weapon was really just black skin. That's what they were afraid of. And so what has become criminalized is black skin, not any weapon. And so the legacy of lynching has come in two forms. The disproportionate mass incarceration of young black men, which Dr. Scarlett talked about and how that has played out in interfaces with our healthcare system. And the disproportionate police killings of unarmed black men, which led to a lot of the racial unrest during the pandemic over the past two years. This was a study that was published last month in the National Academy of Sciences from the University of Virginia that looked at the correlation between lynchings historically and Confederate monuments, which just goes to show how where and what we value, the things that we hold dear, the ideas and the ideology, who we see and how is valuable and not valuable, how those ideas are associated with our actions. And so the places where most of the lynchings were taking, occurring, or were the places where people felt the most proud about the Confederacy, which was all about slavery. And so these things are tightly linked. And so when we were seeing the removal of some of these monuments and then the push back against that removal, there are reasons for that. And so this is just something that I'll also add about the redlining that occurred, that because this is not something that's just an individual issue. It's not just interpersonal racism. It's structural racism that our government had a lot to do with. So the racialized segregation that has put into play a lot of the current day structural inequities that we see started with depression era redlining, where neighborhoods were considered high risk if they had black people in them. So again, badness associated with blackness, black people couldn't get a mortgage, and then the government specifically developed suburbs and gave white people a mortgage. And that fuel that started the ongoing investment and disinvestment in white and black communities, respectively. So since then, we've seen a lot of efforts to try and push against that with efforts to try and get equal education, voting rights, equal access to goods and services. Yet we have not been successful. Today, this is a study in 2017 that showed that black children are still separate and unequal as far as being attending high poverty schools and largely racially segregated schools. And that has an impact on their performance. This is just one area and it's showing math performance in where students are attending high poverty schools that are predominantly schools of color. And we're seeing this year, these are pictures from this year, a big pushback against voting rights that we thought had been settled. But since the election where Donald Trump did not win, there has been a sweeping effort across the country and states to try and turn back the ability for marginalized people, particularly black people, to vote. And we also have seen in symbols, acts, deeds, things that again underlie the idea that black lives are not valued. So this is a study that is in press now at health affairs led by one of our Pritzker medical students, Michael Sun, the senior author of Liz Tong. And we were looking at people here at our medical school, at our medical institution and documenting the use of negative, negative patient descriptors, aggressive, non-compliant, et cetera, and found that there was around twice the odds of those being used for black people compared to white people over a period of time that spanned the pandemic. One of the good things that we found is that people who came in after March 1, in setting of a lot of this awareness around racial tension, structural racism, actually had a lower odds of having negative descriptors applied. So perhaps some of that was being internalized by the house staff and providers and was making a difference in how the things were being documented in the medical record. This is a figure from a paper, a review paper about implicit bias that's being led by Dr. Vela, myself and Dr. Chinner on that paper. And it's just showing the cycle between how external forces that structural inequities and structural racism drive, like disproportionate poverty and those kinds of things, how they affect individuals. So if you think about the red, that's the bad case. And so what we do is we see how a person has been just rolled over by society and has all of these health problems but as a provider, we just see that the person is sick and has all these social issues and that can lead to bias decision making, which can lead to worst clinical care that we give that person and then confirm the biases that we have about that person. Like, oh, it turns out that things don't really work out so well for them. And so if we have a different person who's experiencing different kinds of, if their environment is different, where they're living in a safe environment, where they have healthy food, where they have all these wonderful things, they're going to have better health outcomes and be seen differently by that provider. And so what we need to try and do is have more equity in the environment to help mitigate some of these biases. But we cannot do that until we start thinking about the ultimate humanity of black people and think about whose lives matter. If we continue to subconsciously think that it's okay that some people have less than others, that some lives don't really count as much, then this kinds of two systems of care, two systems of living will continue to be perpetuated in our country, in our lifetime. It will continue to have health equities. We'll continue to have differences in the way that we care for people and things will not change. This last slide is a shout out to what Marshall showed earlier, just how sharing in power and sharing in decisions really is more than just the desire to share information. But it's largely impacted a lot by the biases that we carry and our perceptions about each other. So just a final reminder about how we're defining our clinical medical ethics and how ultimately we are valuing black people. How we value everyone, but today, how we're thinking about valuing black lives and how just saying that black lives matter should not be a controversial thing. It shouldn't be something that we all want to affirm today. And that if we can't begin to do that without controversy, then I think we have much farther to go than we think we do. And with that, I will end my talk and now try to introduce Dr. Selwyn Rogers who is a widely respected surgeon. We are so happy to have him at the University of Chicago. He's also a public health expert. He's the founding director of the University of Chicago Medicine's trauma center. Dr. Rogers is building an interdisciplinary team of specialists to treat patients who suffer injury from life threatening events such as car crashes, serious falls, and gun violence. His team works with leaders in the city's trauma network to expand trauma care on the south side, which has long been a trauma desert before Dr. Rogers and his team came. Dr. Rogers has served in leadership capacities at health centers across the country, including most recently as vice president and chief medical officer for the University of Texas Medical Branch at Galveston. Dr. Rogers has also served as the chair of surgery at Temple University School of Medicine and as the division chief of trauma, burns, and surgical critical care at Harvard Medical School. While at Brigham and the women's hospital, he helped launch the Center for Surgery and Public Health to understand the nature, quality, and utilization of surgical care nationally and internationally. Dr. Rogers clinical and research interests focus on understanding the healthcare needs of underserved populations. He has published numerous articles relating to health disparities and the impact of race and ethnicity on surgical outcomes. Welcome, Dr. Rogers. Dr. Peake, thank you so much. Monica, it's been a pleasure and thanks for setting my talk up so well. It's really going to be a privilege to join this panel, but also I want to echo Monica Marshall's comments earlier. I want to thank Dr. Siegler for all of his efforts over the more than four decades in his work related to clinical medical ethics and his commitment to advancing this field. So if I can get my first slide. I want to start off by, you know, some of the reasons why we're here today virtually. I don't have to tell this room is related to the global pandemic. We've had over 750,000 Americans who have died from COVID-19 and it's probably been the dominant historical event for the past 22 months. But there's been another pandemic, the pandemic of violence. We've seen that throughout the United States for the past several decades, but especially over the past year and a half. It's led to discussions about having federal troops in cities like Chicago and LA. It's led to lots of discussions about what the solutions are as well as the impact that it has upon communities. But I want to frame this in the context of an important ethical principle that of justice. Justice defined as we have an obligation to provide others what they're owed or deserved, impose no unfair burdens, and look at the distribution of a limited resource. With respect to intentional violence in the city of Chicago, this is a schematic from 2014 from the Chicago Tribune that looked at the fact that for three decades there was no adult trauma hospital on the south side of Chicago. You can see this is a smattering of where gunshot wounds are, gunshot injuries and victims are over the past several decades. And notably, they had not been an adult level one trauma center in the south side of Chicago since 1991. The lack of access to adult trauma care was highly controversial for the great deal of community advocacy for adult trauma services. If you look at the city of Chicago, about a third of Chicago's homicides and violent crimes occur within five miles of the University of Chicago, medical center, and with a homicidal rate in the five mile catchment area, three times the rest of Chicago. So in some ways, this is an issue of equity and an issue of justice. Before the level one trauma center in New York, Chicago, medicine opened. There was a relative trauma desert as Monica alluded to on the south side of Chicago. With the advent of the trauma center in May of 2018, 2018, that trauma desert has been effectively reduced. But with respect to trauma care, that's after the event happens, after the violent injury, which is a center area. We talked a fair bit about hospital care, pre-hospital care, rehabilitation and recovery. But we often don't focus on the upstream factors such as people's lived experience and the built environment. By built environment, I mean the areas where people live, work, love and play, and how that infrastructure beats schools, businesses, quality of housing, public spaces, and connectivity affects their health outcomes. If you look in the city of Chicago at unemployment rates, the unemployment rates are the highest in communities of color, particularly among black and brown communities on the southwest side of the city of Chicago. Similarly, if you look at economic hardship index, the highest hardship index is found in the southwest side of the city. Similarly, if you look at high school graduation rates, they're much lower, where one-third of adults have not graduated in high schools and communities in the southwest sides of the city as well. And finally, something structural like housing levels and the housing stock, there's elevated blood levels in many of the communities in the southwest sides compared to other parts of the city of Chicago. And it's not surprising, therefore, if you relate that rate of economic and social factors, that that's also linked and correlates with higher rates of shootings on the southwest side. So I'm going to talk a little bit about that some more shortly when I look at the solutions. Does gunfiles is complex? We may focus on the final event, the shooting, on how that impacts the individual who is injured, as well as the downstream impacts to that individual with respect to their individual recovery, post-traumatic stress disorder, but also their acts of retribution and retaliation. But if you look upstream, there's so many environmental factors such as the impact of racism, segregation, educational disparities, economic outlook, and how that affects the ultimate outcome of being a victim or perpetrator of violence. Transitioning a bit, and I'm going to link the two shortly, we've seen COVID-19 affect the entire world. We're at over 6 million deaths globally, and 750,000 Americans who have died. But the impact upon African Americans has been disproportionate of the first wave of reports related to the share of COVID-19 deaths. Over 69% of deaths were among African Americans in the city of Chicago, even though they only represented 30% of the population. This trend occurred nationally, whereas similar rates of high rates of both being diagnosed with COVID-19 and suffering death and disability from COVID-19 being higher among Hispanic populations and African American populations throughout the United States. Here in the city of Chicago, we know that there are significant racial and ethnic geographic clustering. If the green communities are primarily African American communities, the orange represents primarily Hispanic communities, and if you have visual memory of what the maps before showing economic deprivation, they overlap in the areas of the Black and Brown communities in Chicago. When we look at COVID-19 mortality, similarly the burden has been disproportionately borne by African American and Hispanic populations in the city of Chicago, and natural question is asked why. This brings up the central issue of equity or lack of health equity. Health equity is a principle underlying commitment to reduce and ultimately eliminate disparities in health and social determinants of health and pursuing health activities strives for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health based on social conditions. In essence, this is an issue of justice. Equality is on the left, equity is on the right, where you lift up the needs of those who are less advantaged or disenfranchised in order to achieve equal outcomes. When we look at the impact of lack of equity, it manifests as health care disparities, which are differences in the quality of health care based on racial, ethnic language, wealth, education, or gender that are not due to clinical needs, preferences, or appropriateness of interventions. It's a lack of equity that drives health care disparities in the United States. This lack of equity manifests most dramatically in place-based mortality differences. In the street ofville area, the average life of expectancy in Chicago is on the order of 85 years of life compared to Washington Park, which is just half a mile from the University of Chicago, where the average life expectancy is 69 years of age, eight miles separating a 16-year life expectancy gap that continues to grow and has actually been exacerbated by COVID-19. This gap is driven by structural inequities, as Modika related residential segregation, impact of community violence, relative food deserts, limited built environment, and the critical impact of racial discrimination and racism, as well as impact upon poor housing. All of these factors relate to health, poor health outcomes, such as poor health outcomes related to obesity and diabetes, hypertension, chronic lung disease, cardiovascular disease, and asthma, and obviously all of those factors lead to higher rates of mortality. To relate to, we've had a very robust public health approach to COVID-19. Before the advent of effective vaccines that we have now, we basically use public health measures, social distancing, handwashing, contact tracing in order to lessen the impact of COVID-19 upon the population. If we apply the same public health approach to intentional violence, we have an opportunity to make an impact there on what may seem like an intractable problem as well. But what is public health? It's the science of protecting the safety and improving the health of communities through education, policymaking, and research for disease and injury prevention. And ultimately, that will lead to a healthier community. Tiger Peak and I published a article looking at using a public health approach to COVID-19, with respect to addressing the disproportionate impact of African-American disparities. And the plan basically recommended taking a public health approach, which involves these seven aims. Require a collection of race ethnicity data because what you can't, you can't affect, but you can't measure. Utilize risk and place-based strategies to decrease COVID-19 exposure, but also use that same risk and place-based strategy to increase COVID-19 testing. Repurpose our current resources for prevention, support, and monitoring. Isolate and support COVID-19 patients from high-risk living conditions in order to prevent recurrent transmission. Implement city and statewide protocols to share resources and patients. And then finally, allocate scarce resources to reduce inequities. Basically, apply the resources where they're most needed in order to have a lasting impact. Similarly, framing public health as an approach for addressing intentional violence will require three different approaches, deemed primary, secondary, and tertiary. Primary prevention involves basically addressing issues around gun safety, improving social conditions, improving mental health care, and reducing substance use and treatment, providing greater sources of treatment. Secondary prevention involves areas of creating violence prevention programs, violence recovery programs, and the use of violence interrupters and community outreach workers to help prevent retaliatory violence. Basically, interrupt the cycle of violence, especially related to retribution or retaliation. And finally, tertiary is what we have mostly focused on because it's the most approximate, but is the last intervention. It's really after people have been injured, trying to reduce the impact of that injury. We need to try to transition from thinking only about tertiary care with respect to providing care after injury and looking upstream at primary and secondary prevention. I look forward to the panel discussion, but basically my part and comments relate to the fact that we really need to reevaluate how we think about equity. We need to embed equity in all of our systems, be it education, criminal justice, health, legal, education, all aspects. It needs to be facilitated across all our institutions and in partnership with the communities that we all live and breathe within. I want to thank Dr. Siegler again, and I look forward to our panel discussion. Thank you so much, Dr. Rogers. I always learned so much from you. Now I am privileged to introduce Dr. Preston Reynolds. She is a clinician, educator, scholar, and tenured professor of medicine at the University of Virginia. She's been recognized with awards such as the UVA Martin Luther King Jr. Award and Master's in the American College of Physicians for her work in human rights, medical professionalism, and the history of American medicine. She was a founding member of Physicians for Human Rights and served on the board of directors from 1986 to 2002. In 1997, Dr. Reynolds was awarded the Nobel Peace Prize. As a medical historian, she has focused her work on the history of race discrimination in healthcare delivery and health professions education, principally in the United States. She was named to the President's Commission on the University in the Era of Segregation and is currently researching the history of structural racism in medicine at UVA Hospital in its health profession schools. Dr. Reynolds recently completed a two-year term as President of the Academy of Professionalism in Healthcare. She now serves as director of APHC's Faculty Development Program, Leadership Excellence in Educating for Professionalism. Since 2016, she also serves as medical director of the Albemarle-Charlottesville Regional Jail. That is amazing. We were so much. Dr. Reynolds, thank you so much for joining us. Thank you, Monica. I'm going to try to advance my slides. Okay, good. So, thank you for the introduction. I have to make one correction. I was not awarded the Nobel Peace Prize, Physicians for Human Rights, as one of six organizations that were founders of the international campaign to ban landmines was awarded the Nobel Peace Prize and as a member of the board and a founding member of the campaign, I enjoyed and celebrated that accomplishment. As you heard, I am a medical director of the jail and I do want to thank Mark Siegler as well as McLean Center for giving me the opportunity to really study ethics in action. And I also want to thank Mark for moving the McLean Center to not only dealing with clinical ethics, but ethics as it applies in the way we live our lives as professionals, particularly those that are of us who have grown up in human rights and are really committed to social justice. When I became medical director of the jail, one of the first things I was asked to do is address the fact that we had a transgender individual who was a woman who was in the area housed with men and the whole rape potential was ripe. And so, approaching her with a lens of ethics, a lens of human rights, a lens of prevention of rape, really called upon all of my skills as a clinician as well as an activist, as well as now a leader setting policies in our local jail. I really want to shout out to Sarah Scarlett and her work on policies. Hopefully this talk will advance some of those conversations as we dig deeper into the issue of mass incarceration. COVID-accentuated problems with healthcare for the incarcerated. And I want to highlight several resources if you're interested in diving deeper into this area. Thirteenth is a documentary. It is really one of the best that's been produced. It draws heavily on Michelle Alexander's book, The New Jim Crow, which is a must. And there is the Prison Policy Initiative. So if you're interested in developing policies based on really good data analysis, I would encourage you to explore this website. And there is a new effort to accumulate better data on COVID and its impact on prisons. And that's called the COVID Prison Project. I'm using all of these resources for this talk as well as personal experience. We live in a capitalist society and I want us to remember that incarceration is part of the industrial complex. It is very big business in the United States. And as the prison project estimates in its 2020 report, mass incarceration, the whole pie, we spend over $180 billion on the mass incarceration system. That includes lawyers, judges, court fees, administrative expenses, policing, and incarceration itself. And as you can see, the big ticket items are the judiciary, law enforcement, correctional facilities with expenditures on staff and healthcare. I'm trying to advance my slides. I'm not able to advance my slides. There we are. Okay. So the Prison Project in its 2020 report shows that we have over 7,000 correctional facilities in this country. We're going to focus part of this conversation on the 3,137 local jails. It estimated in 2020 that we incarcerated over 2 million people in U.S. detention facilities. This does not include military prisons, civil commitment centers, state psychiatric hospitals, and prisons in U.S. territories. So where does the U.S. stand relative to other countries around the world? We are the world's most incarceration-crazy country. We incarcerate more than all Scandinavian European countries. We actually incarcerate more than all repressive regimes. And with China, China and the U.S. alone incarcerate one-third of the world's population who live behind bars. From a Black Lives Matter, it is really important to understand that our incarceration system occurred and started just after the freeing of the slaves in the form of what were called Black Codes that were passed by white legislatures. And these Black Codes were designed basically to incarcerate the newly freed slaves. It allowed vigilante or early police forces to incarcerate the homeless, the jobless, and anyone that they perceived aimless. And this actually created our first convict labor population that then were hired out to work the land that was now empty because the slaves had been freed in the South. So from a Black Lives Matter perspective, we really need to understand that our present problem of mass incarceration reflects 250 years of slavery followed by a brief period of 15 years of reconstruction, which was followed by over 30 years of Jim Crow, followed by redlining that really was part of the institutional racism that we now are still trying to untangle. And as Michelle Alexander argues in her book, our present system of mass incarceration followed the civil rights movement and is the newest form of incarcerating what Monica had talked about earlier is people of brown and black color. In this country, the growth of the incarceration population grew over 800% from the 1970s and early 1980s. And this was fueled primarily because of increasing sentences that were imposed on persons convicted of drug possession and drug dealing. And you see here the increase in that population, but also marked with some of the major points along the time trajectory with federal legislation. In 1985, joblessness and crack swept inner cities precisely at the moment that the fierce backlash against the civil rights movement was manifesting itself through the war on drugs. The Reagan administration actively moved to create a war on drugs and did so to a massive media campaign. The director of the Drug Enforcement Agency at Reagan's request went to New York City to enlist the media giant to craft a new narrative. And in June of 1986, Newsweek declared crack to be the biggest story since Vietnam and Watergate. And in August, Time Magazine termed crack the issue of the year. And thousands of stories of crack flooded the airwaves and newsstands. And these stories had a clear racial subtext as they described crack babies, crack cores, and black neighborhoods as communities infested with violent drug dealers and crime. Upon this narrative came federal laws fueling massive growth in federal enforcement and the move of military equipment from federal stockpiles into local police departments and a slew of laws at the federal and local levels that granted police the right to search without warrants, stop and frisk, develop and implement SWAT teams that morphed into today's ongoing police brutality. Part of the problem also was longer sentencing for crack versus cocaine. It was 101 years if you were found in possession of crack or dealing with crack versus cocaine, which is the substance of the white community. Even though in 1910, the Fair Sentencing Act changed that ratio to 18 to 1, it is still perceived to be racially motivated and unfair. So when we think about neighborhoods, and as we've heard earlier, there was a 16-year difference in an eight-mile radius. I also want us to think about our neighborhoods as also predicting the risk of incarceration. It's no surprise that incarceration is now a problem of brown and black communities, which you can see here. One in three and one in six black and Latino men versus one in nine and one in 17. And for women, it's black women, one in 18, Latino women, 45 versus all women, one in 56, or white women, one in 11. And you'll see this in any correctional facility in the country. So that despite the fact that violent crime and property crimes decrease, our incarceration population has exploded. And the question is, why? So part of it is what I wanted to talk about before, which is the problem of drugs, but also now I want to shift to talk about jails, because I think our policies at the federal, local, state levels are driving our problems of incarceration that COVID has only accentuated and made more difficult to deal with. So jails are incarceration's front door. And while 600 persons enter prisons annually, 10.6 million people go to jail each year. And it's important to understand that in most correctional, in most jails, 60 to 75% of individuals are never convicted of a crime. So here we have these correctional disabilities that have exploded in the population of people behind bars, many of whom are never convicted of a crime. Why? So part of the problem is the bail bond system. So the average price of a bail is set at $10,000, which is far beyond the means of most people to pay. So we have a bail bondsman who negotiates. Usually people then are offered to pay one tenth or $1,000. And that's a guarantee that that individual will show up in court. So they are arrested. They are put behind a correct facility. They are given a bond deal. If they can make that bail of $1,000, they're released back into the community with a guarantee that they will show up for their court date. But it's important to understand, and you can see this graph, that the increase in population in correctional facilities is really because most individuals cannot make that pretrial bond payment. You find it on my slide. And here you see this increasing jump are all those individuals that are now incarcerated who are behind bars because of the bail issue. Bail accentuates community poverty. It also accentuates generational poverty. And so the graph at the bottom shows at the top, whites with no incarceration history, the lines on the bottom are of brown and black community members who have either never had a history of incarceration but their generational wealth is lower or those who have had a history of incarceration and their wealth is even lower. So poverty predicts bond failure. Poverty predicts incarceration. So does illiteracy. And so does residential neighborhoods. Here you see the rise in arrest because of drug possession, not even drug dealing. And as you see in the middle section of the upper left hand slide, local jails, about a third of the population of people in local jails are because of a drug possession charge. The next area that's really important to understand in this problem, as I tried to advance my slides, is the problem of technical violations. So while we think of parole and probation or pre-trial supervision in the community as more lenient, often the conditions that are imposed on people that are on probation or on parole are so strict they have to go to meetings. They have to pay fees. They have to maintain a job. Sometimes they have to pay child fees. And in individuals who are already living on the margins of the social determinants of health, maintaining these technical requirements is really perceived as onerous. So as you see in the yellow bars here, these are individuals who are re-incarcerated not for a new conviction or because of a new crime. It's because they have failed in meeting that technical violation. Misdemeanors also account for over 25 of the percent of the jail population, something as simple as jaywalking. So now I want to move just quickly to talk about COVID and it's important to understand that our legal system requires everybody in an incarceration environment to have access to comprehensive health care. As you see here, 750,000 people are incarcerated, but you also understand that there is a high flow of people in and out of correctional facilities. This is a COVID prison project that estimates that almost 450,000 people in correctional facilities have come down with COVID. It's important to understand that these are individuals in prisons, not even jails. This is a study that documented for the first time in April through May of last year, some correctional facilities actually had access to COVID testing and could begin to understand the prevalence of COVID within their correctional facilities. So what did we do within our local jail? Well, in fact, we did not have our first case in the general population of our jail until September of this year. So there were three strategies. One was to reduce the population. And in fact, we were able through a lot of advocacy and years of arguing that this is what we should be doing anyways, that we were able to reduce our inmate population by 30%. Nonviolent offenders, parole violations, bail bond difficulties were removed to home electronic monitoring. Unfortunately, we had to stop all entry of volunteers. We had to stop our work release program. We declined to accept new inmates from other facilities. And we had to reduce to a minimum the flow of inmates to UVA. All the area of courts closed and then may open with Zoom. We had to really implement very strict mask mandates, PPE for all personnel working in intake with anybody who was coming in and out of this ability. Mandatory temperature testing early on. And then when COVID hit our staff, we had educated them really aggressively to stay home, self quarantine, get tested when testing became available. And you can imagine in a correct facility, we had to create a culture that talked about safety of the inmates as a number one priority. So what did we do with inmates? We had to implement actually mandatory quarantine before we had the ability to test. So everybody was quarantined for 14 days. Once they were released into general population with no symptoms, they were kept in that area. When available, antibody testing was for everybody. We moved inmates with symptoms to medical and housed them in negative pressure room. And then when vaccinations became available, we have offered voluntarily vaccination. And I will say that we have over 50% of our inmate population who has received at least one vaccine. Was the public health departments helpful? I will say absolutely not. CDC was not reliable. And they were often incorrect. So we studied the literature, we talked experts and consistently we were two to four weeks ahead of expert recommendations. It's also important to understand that medical personnel in jail facilities were not considered essential personnel. So we didn't have access, early access to antibody testing, we didn't have early access to PPE, we had to rely on donated supplies and supplies we could get through the supply chain. And in fact, UVA early on refused to see our inmates, even though we were COVID free. What happened when Delta? While we had been really good at containing COVID within our facility, once Delta hit, we were really behind the eight ball. And we knew that the Virginia Chief Justice allowed all the courts to open without mandatory masking. Myself, my health director wrote a letter, opposing those decisions. Charlottesville remasked all of the courts, but the area courts still remained open. And you can imagine after 12, 15 months of intensive mask wearing, even our officers were sometimes COVID fatigued. And we're not always adherent in wearing masks. So we did have our first case on 912 with somebody who had gone to a local courtroom came back exposed, Gen exposed it to other people in the population. We were able to get antibody testing of high risk inmates at UVA. We created a COVID unit with daily visits, lung exams, asking the inmates to alert us if anybody had a change in symptoms. We had a massive review of our policies and procedures by the department of Virginia department, the Virginia department of health. And I could say that in fact, I think we got four or five out of five stars. And we also have now have created mandatory COVID testing for all unvaccinated staff. So I want to end with this slide because what this group is really trying to do is to use COVID to drive policy changes and mass incarceration because of the public health risk. And if you're interested, I would really encourage you to go to the website and find more and learn more. Thanks. I'm sorry, I was muted. So I'm going to say that again. Thank you so much, Dr. Reynolds. It is always a pleasure to hear from you. I noted that even if you're not a Nobel Prize winner, it is always a delight. Thank you so much for your words. It was very powerful and just in line with all of our previous speakers today. It's though we knew what we were going to be all talking about, but we didn't. I'm delighted to now welcome Dr. Erin Sullivan DeMartino. She is a graduate of Williams College in Dartmouth Medical School, where she also completed internal medicine residency. She completed her pulmonary and critical care fellowship at the Mayo Clinic, where she's now on faculty as an assistant professor of medicine. She's a 2016 graduate of the McLean Center Fellowship in Clinical Medical Ethics. Since the beginning of the COVID-19 pandemic, Dr. DeMartino has divided her energy between frontline patient care and the medical ICU. Thank you for your service and serving on the Minnesota's Pandemic Ethics Task Forces. Thank you for your service again. Dr. DeMartino, welcome to the panel. Thank you so much. So I have entitled my talk, Just Short of Crisis, Operating Under Contingency Conditions. I don't have any relevant financial disclosures. Today, I'll start with a brief history of triage and crisis standards of care and discuss challenges to those paradigms that we've encountered during the COVID-19 pandemic. And then I'm going to end with some suggested adaptations in view of the challenges we've faced over the last year and a half plus. So starting at the beginning of the 19th century, triage is a word that's actually derived from agriculture. It has a French derivation, truyet, means to cull or to sort. And it was first appropriated for use in a medical setting during the Russian campaign of the Napoleonic Wars. One of the surgeons described how those who were dangerously wounded should receive the first attention without regard to rank or distinction. And that concept cross-pollinated across the Atlantic Ocean and was used in different theaters of war, including the American Civil War and eventually both world wars. It wasn't until the 1960s that the concept took root in civilian medicine. And the first systematic review was of triage and the emergency department was published in the early 1960s. In 1992, the Joint Commission required that all hospitals establish policies for situations in which the patient load exceed optimal operating capacity. Two events in the first decade of the 21st century magnified the importance of planning for public health crises. And those are the humanitarian crisis following Hurricane Katrina in 2006 and then the H1N1 pandemic. In contrast to triage, the term crisis standards of care has a very brief history, having first been proposed just 12 years ago. And here you can see a PubMed graphic of publications using this phrase within their titles. In 2009, during the H1N1 pandemic, the Institute of Medicine convened a special working group to put forth guidance for establishing crisis standards of care, which they suggested each state do. And they describe crisis standards of care as a substantial change in the usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive or catastrophic disaster. They further described it as the optimal level of health and medical care that can be delivered during a catastrophic event. Lest we forget, an important component or function of a crisis standard of care declaration as originally conceived is actually to protect health care workers. With a formal state word declaration of crisis standards of care, health care workers are protected from liability stemming from allocation decisions or deviations from what is known as the conventional standard of care. Digging deeper into this recent history, we find that around 2009, 2010, there were a number of states who were beginning to draft their own scarce resource allocation or crisis standards of care policies. And as of March of 2020, 72% of states either had publicly available already released documents or they were in the process of developing them as we were bracing for and experiencing the first wave of the COVID-19 pandemic. Crisis standards of care are grounded in a concept of a surge continuum, which depicts this increasing imbalance between patient needs and available resources. Resources are often categorized in the emergency management literature as space staff and supplies. Under conventional conditions, usual patient care is provided in usual settings by usual staff with usual supplies. Under conventional conditions, care may occur in a repurposed setting, say an ICU patient receiving care in the PACU, the post anesthesia care unit. Staff may oversee care of more patients or practice outside their typical scope but with supervision and supplies may be adapted or reused. The foundational assumption during contingency conditions is that of functional equivalents. Under crisis standards of care, patients receive care in nonpatient care settings, trained staff cannot meet all the needs of patients, and critical supplies are lacking such that there is consideration at least for reallocation of lysosidium therapies, which may become appropriate. There is a commonly described shift in the balance away from individual patients autonomy toward communitarian interests. The problem is there is no bright white line separating contingency and crisis conditions. In fact, it can be remarkably difficult to distinguish between them. We'll return to this point. When I reflect on the ethics community's early response to the COVID-19 pandemic, there's little doubt in my mind that we focus too much of our attention on crisis standards of care. We focused on generating triage protocols and for ventilator allocations, scarce resource allocation, ethics guidance, and all of it was really or the vast majority was intended for use after an official declaration of crisis standards of care. So of the more than 3 million Americans who have been hospitalized with COVID-19 since the beginning of the pandemic and the many millions more who have been hospitalized for other indications since March of 2020, most have received care and jurisdictions that weren't operating under crisis standards of care. An untold number of people have actually been cared for under some stringency or some degree of contingency conditions. Yet we have dedicated relatively little energy to ensuring fairness and transparency to patients under contingency conditions. I think two particularly salient examples are ongoing confusion around recognizing when we are in a crisis and publicizing that and how best to track some of the more dynamic parameters that influence what resources we can devote to patient care and specifically the trickiness of tracking staffing. I'm going to leave for the purposes of this talk to one side the many lessons we have learned about fairness and health equity from socializing the triage plans that were generated in the various states and institutions with the general public and the ways in which particularly the early iterations of crisis standards of care and triage plans perpetuated harm to at-risk communities. My focus for this talk is instead going to be on a quest for clarity about our position in the surge continuum at any one moment in time and how we uphold our values along the way. First I'll start with the fact that some jurisdictions have already activated crisis standards of care and some are active at this moment. At various points in the pandemic others have been active and inactivated Colorado being the most recent to reactivate their crisis standards of care policies through executive order earlier this week. States have taken different approaches to activating crisis standards of care some with a general activation across the entire state impacting the whole population at least theoretically and others taking the approach and this would include Colorado and Alaska of authorizing individual healthcare entities to enact their own crisis standards of care policies but stopping short of enacting a crisis standard of care across the entire population of their state. And I'll just say that I want to make a disclaimer that although this slide is useful and depicting kind of the prevalence in the various mechanisms and geographic distribution of these crisis standards of care declarations it's very challenging to fully wrap your mind around or to depict in full detail all of the declarations across the country and so this may not be an exhaustive representation. In contrast early in the pandemic when I think clinicians looked to government leaders to make a formal declaration to help our clinical staff make sense of dizzying conditions I've actually come to regard this declaration of crisis standards of care as a blunt instrument to be exercised with great caution. Why? I think if we've learned anything is that conditions are constantly changing under foot so expansive a declaration may not accurately reflect conditions across the region or the state. A shortage of a particular piece of technology for instance dialysis circuits while it may be dangerous for a certain subgroup of patients with renal failure may not have far-reaching applications for the entire population whereas a severe shortage of critical care staff nurses would have much more far-reaching implications across the population. There are so many challenges here with communication communication with the public worrying about a chilling effect of publicizing the strain on hospital resources where people are deferring potentially life-saving care for other conditions and potentially balanced against the hope that setting expectation realistic expectations about the type of care that someone might expect to receive in the hospital or even influencing behavior outside of the hospital around distancing and masking and vaccination these are some of the tensions that are being negotiated by public health and public affairs there's also a challenge of conveying to staff members where we are in this continuum and what that means for the care decisions that they're facing with their own patients and they're navigating with their own patients to my colleagues to me and my colleagues in Minnesota a core concept which we've grappled with is what even constitutes functional equivalents and how do we know we're meeting that standard we've debated this definition for hundreds of hours probably collectively and we've arrived here that there should be a reasonable expectation of equivalent outcomes for mortality and major morbidity and in fact we've published on the minnesota department of health a 18 page document about the transitions between conventional contingency and crisis conditions we believe strongly that we can't just state that we expect to have a certain outcome we need to be affirming we need to be measuring to make sure that we haven't strayed toward crisis conditions unbeknownst to ourselves so we need active surveillance around access mortality and degradation and standard patient safety protocols or outcomes like central line infections pressure ulcers etc so if we used to assume that contingency phase was something of a inexorable maybe even unidirectional march toward a clearly demarcated state of scarcity known as crisis how do we now conceive of the surge continuum and a colleague and I from the University of Minnesota we kind of developed this graphic to help us wrap our minds around what we were discussing we would say that specific resource scarcity and here i'll use the example of a critical nursing shortage might tip the balance toward crisis conditions you can imagine that that would have a very impactful a very large impact on the health of the population and yet it might be remediated or addressed within the course of hours with transferring staff from one site to another or bringing in travel nurses etc and so it's important to recognize the fluidity with which the health system or region may fluctuate in and out of a crisis conditions we would argue that withdrawing or withholding or significant alteration in care that's motivated by scarcity isn't justified during contingency conditions and yet withdrawing or withholding or significant alteration in care motivated by scarcity may under narrow circumstances be justified under crisis conditions but we're worried about the conflation of scarcity and perceived inappropriate treatment in other words we're worried that clinicians recognizing system strain might use that to coerce or even force decisions to limit care on individuals who otherwise would have elected to receive that care while the system is still operating under contingency conditions so we've been operating in some some region of the gray zone off and on for much of the last two years how are we doing it so aside from the active mitigation strategies that we have been described elsewhere about the extension models for staffing and conservation and substitution of supplies we recommend expedited processes for conflict resolution we recommend when a panel a multi-discipline panel is not available to mitigate or opine on a specific resource scarcity that a clinician document a second opinion about the resource scarcity facing a particular patient there need to be rapid bi-directional channels of communication between frontline staff and the health system so that scarcities can be immediately recognized and intervened upon and there needs to be coordination across the state which we have in a critical care bed coordination system for load leveling we're re-purposing things that were originally conceived or of for use only under crisis standards of care like the multi-disciplinary triage teams which we trained last year that can now convene to look at specific resource shortages it's important that any deviation of care that's been necessitated by scarcity is both documented and then retrospectively reviewed by oversight committees again for the purpose of detecting a stray into crisis conditions that isn't recognized by frontline staff we need to be tracking our system strain so metrics like access all cross mortality and even emergency department boarding time and there need to be active engagement still with the community and efforts at transparently communicating where we are in terms of resource scarcity and what that might mean for their care were they to become sick i'll conclude with my fear so my fear as an ethicist whose feet are firmly planted in the intensive care unit is for a degradation and that care of our patients our obligation is to uphold the highest standard of care and i invoke that phrase intentionally for each patient and it's never higher than when resources are the most strained our profession can't tolerate an erosion and the standard of care we must always strive to provide the best most patient-centered individualized care that's possible within the constraints of resource limitation wherever we sit on the surge continuum COVID-19 has shown that now is the time to double down on our values the values that distinguish our profession and that have transcended centuries and the challenges that are posed by this and whatever new challenge we face in the future i'd like to just close by acknowledging the individuals and the groups that have influenced my thoughts around contingency care thank you thank you so much dr. de martino that was an excellent presentation so much of this past two years has been spent in contingency care while we're thinking about crisis standards of care and so i appreciate you sort of illuminating these issues that was fabulous um our last speaker um who i love dearly is dr. sacey lindau i'm so excited about what she's going to share with us today as it's always fabulous um dr. lindau is the kathryn linsey dobson professor of obstetrics and gynecology and professor of medicine and geriatrics as well as palliative care at the university of chicago and she's a practicing gynecologist with expertise in the preservation and recovery of female sexual function in the context of cancer and other complex illnesses dr. lindau directs the community rx program of research including several current current clinical trials focused on how and why connecting people and their caregivers to community-based resources drives health and well-being current trials focus on people with diabetes cardiovascular disease and caregivers of hospitalized children and home dwelling persons with dementia she also directs feed first a fully uh self-serve no barriers medical center-based system to mitigate food insecurity triggered or exacerbated by living with or caring for people with illness dr. lindau earned her master's degree in public policy at the university of chicago where she was also a robert wood johnson foundation clinical scholar she's an aspen institute health innovators fellow and a member of the aspen global leadership network dr. lindau has been honored by her academic and community-based peers for her community engagement in advocacy activities dr. lindau it is always a pleasure to share that share space with you i'll hand it over to you now so thank you very much for the opportunity to share this work and to be with all of you and i look forward to the passion thank you so much dr. lindau i am always inspired by the work that you do in all of your areas um be it food insecurity or women's health um you are a supernova and i'm delighted to know you we now have time to open the panel for a q and a so like all of our panelists to be present and just to remind everyone um we have dr. sarah scarlett dr. marshal chen myself dr. selwyn rogers dr. preston reynolds dr. erin d martino and dr. stacey lindau we have uh thankfully a lot of questions to get us started and so i'm going to start by asking one of you one question for each of you and we'll see how we do on time um dr uh i'll just call you by your first names sarah there are two questions that came in that were closely aligned around standards for care for persons that are incarcerated while they're in the hospital one um from bernie lowe asking if there's a role for the american hospital association or the amc in creating such standards for hospitals or another was uh came in uh from another person who said well the supreme court has mandated that these persons receive care shouldn't congress have mandated um standards around hospital policies for the ethical treatment so is there is there some space for the uh do these standards exist and they're just too low um or is there space for additional agencies and organizations and laws and procedures and policies to step in and raise that floor a bit for um incarcerated individuals who are receiving care in our health care systems thank you for that question um there are currently a very scant amount of policies offered by um groups that are interested in correctional health namely the national consortium for correctional health care um there are definitely gaps in these um policies a lot of them refer to health care for people who are in correctional facilities and i certainly think that there's a role um certainly among my colleagues we have a significant interest in developing policies that could be as broadly to um to guide care but it's definitely a huge gap in what exists right now thank you um marshal i have several questions for you um but because we know and love john lantos you can pass on this um but he is asked if you if you'd be willing to give your 90 second introduction um because he's interested in knowing um how you are you know how you're perceived and then how you use comedy to address implicit bias so if you would be willing to just do your 90 seconds right now you can give a pass and if you'd like to give a hard pass then i'll ask you and some other questions yeah okay john this is for you so when people meet me um they will say after a while like after they get to know me a little bit better um you're a lot more interesting than i thought you were uh which is sort of like a backhand of compliment that when people first meet me you know i think they sort of see think well you know um older asian-american man um very technical very reserved um not into emotion uh not very interesting um they think they're stereotypes in terms of um you know uh growing up i got like a lot of all the bruce lee kung fu type of of of of of of of taunting or you know everyone always associated with like like sulu in science and all um so you know people have like a superficial understanding which i think it reflects then like the media images people see or um the stereotypes we have in society and as they get to know me better well they see that i have different sides i like science um i like emotion um uh i like a variety of different things i actually did on the yellow belt in in in uh taekwondo from way back um and then i have my other stuff i mean people get surprised when they hurt i don't do the improv and stand up for example so you know we'll accomplish and we don't understand each other on the surface so thank you for the description um even though you've passed on the actual improv bit um so okay so there are a few questions for me um and i'll take the one um from dr miller about the role of allies in this work um and i cannot underscore the importance of that um and so that's why i've chosen to sort of tackle this one it's uh we will not move forward as a community or as a country until everybody's at the table um and that's that's partially because the people who have the power to move us forward um are the ones who boot heel is on black people's neck and so if they would lift that up a little bit we can breathe some more um and be able to sort of stand up more strongly but but honestly we um you know there's a there's a space for everyone this is not only a problem of marginalized communities um and so it's not black people versus white people this is you know a community of people who are concerned about how structural racism impacts everyone it impacts everyone um and how we are going to try to work against that um and work against those who are not interested in moving forward and having progress though that's the the who's against who um not not separated by you know clusters of racial groups um we need to all come together and decide that this is important um and particularly because allies have access to spaces and places and people that um minoritized communities don't you know i don't hear the things some ways thank god um that are said about me in quiet spaces um i don't have access to some of the things that are happening but allies do um and can um take a stand um and can do things in ways that i cannot and the load is very heavy like give me a break sometimes i you know like take some of this away from me i can you know i can use a nap and so there are so many different reasons uh that allies are a critical part of this struggle um that i um always want to make sure that i include that in my story and narrative and so thank you Dr. Miller for the opportunity um to to highlight that as well um i will move on to Eileen lots of questions for you about vaccines in the prison system um and why are the rates so low uh 50 seems pretty low um what are your thoughts about vaccine research um in the prison system and so maybe you can just comment on that on some of those things so thank you for the question uh first of all i'm gonna say that my local jail on the street the word on the street is if you want medical care dental care mental health care get arrested because you'll get whatever you need if you get to jail um and we are really really committed to delivering on what the supreme court has mandated which is comprehensive care so everyone gets a comprehensive intake physical everyone gets a dental examination everyone gets access to professionally trained mental health uh professionals um and we're able to do that because our superintendent has made a commitment for as long as i've been there to lobby every time he can with the board of supervisors to get the resources necessary for us to do the job that we do secondly we cannot do what we do which is hiv care hepatitis c care trauma care without the help of uva and the national correction accreditation system has come in and they said they've really never seen any other correctional facility in the commonwealth that has such incredible relationships with a source of specialized care so that said um we were the last correctional facility in the state of virginia to get vaccinations um because we had done such a phenomenal job in keeping the correctional facility covered free the correctional system simply wouldn't give us um vaccinations even though all the other correctional facilities had gotten them and even though we had been lobbying and lobbying and lobbying and lobbying we now have moderna johnson feiser and it's voluntary we cannot mandate vaccinations and so we have made vaccinations available to everyone who wants them we don't require it we offer them one of three they can choose what they want we also as you can imagine had a retraction in our health care staff we had a retraction or correctional also for staff so we now have been doing code vaccinations not only with our inmates or what i call our patients but we've also been doing with our personnel as well as our correctional officers so we have been the source of vaccinations for everyone we now do n95 fit testing for our correctional officers which was not available so we had to be especially trained to do that um and in fact it's interesting because we're now having inmates say well i got arrested so that i could come in and get my vaccination in the correctional facility so i don't think that that's a compliment to us i think that's an indictment of the community uh in not making the necessary resources available to do community-based mental health community-based uh you know drug treatment and all the other things that we do but since we are charged by the supreme court to provide comprehensive health care we do the best job we can because our superintendent our board of advisors and our community is willing to spend the resources to make sure that that's available and i think that's probably why you're seeing policies in hospital care different because not all hospitals are safety net hospitals and so they will treat that inmate who doesn't have access to public funding um accessing the kind of treatment that standard of care would require we on the correctional side in shrouds will mandate that when our inmates are inside the uva health system that is so incredible so much so it's a way to live ethics and human rights even though you're inside a correctional facility it's like oh you know i want to change these policies i want to keep people out i know that we could have a third less people at any point in time because we've been able to use covid to achieve that but it's also using that position of social justice and advocacy to make sure that people that we take care of get the care they need yeah and if everyone on the outside could do their job you wouldn't see people trying to get into the system to get basic human like in covid the homeless were put in hotels and the alcoholics were put in hotels they were not housed in correctional facilities because people wanted them off the street and so our broader community conversation has to change to find alternatives to incarceration and other systems of support yes erin um there are a couple of you had lots of uh comments and positive questions and just lots of love um you had two questions that were along the same lines i'm going to ask you about this um how do crisis standards of care consist of consider systemic health inequity um issues um mentioned by dr peacon rogers can you speak to distributive justice for these utility focus guidelines yeah that's a really important question um and a focus of my some of my other research so thank you for asking this question um obviously there is a huge spectrum in how crisis standards of care have been developed across the country and we're still learning about the variation from both state to state but also regions and institutions who have developed their own policies um one prevailing concern has been around the fact that many of these policies were generated in haste and more or less in a vacuum with a number of experts sitting at the table but to to dr peaks um or well actually around zoom for the most part but to dr peaks point there was at first maybe not an intentional effort to include populations that might um be at the losing end of some of the algorithms and equations that were being um promoted as ways of actually enhancing fairness and equity uh and uh leveling a playing field that um and i know that your own dr parker has spoken and will speak on this topic again i think tomorrow and so you'll be hearing more about this from him as well but um there are i would just echo the fact that there are a lot of concerns with the ways in which chronic medical conditions and um disability uh have factored into um supposedly um objective scoring systems for allocating scarce medical resources yes uh thank you thank you um stacey uh there are some comments around uh the troubling issue uh i mean there's always troubling when we talk about unwanted sex so one person asked is it a common occurrence to find the disclosure of abuse and if so what are the obligations of a researcher when you do find that and then i'm going to toss this other one in at the same time um they were someone asked about the taxonomy and when you had uh your sort of two by two table the upper left quadrant where someone may want sex um but it's not consensual and so still defining that as rape they wondered if another term might be used instead of rape and that would be a power differential and so i wanted to get your thoughts on that you're muted okay can we there we go okay i was able to do it on my end thank you um with respect to the first question no it's not comment well first of all most population-based surveys or population-based surveys especially where sex is the topic in my to my knowledge rarely um invite open-ended or qualitative type comments um in this case we were serving adults people 18 and older and we know from clinical care of women that even if a woman an adult person discloses rape or sexual assault um ultimately the decision is the individuals with respect to reporting the case is different when we are caring for minors and also um and their law varies across states but when we're talking about violation of a person 65 years or older in this case the quote comes from an individual who identifies it's 19 years old um it's terribly troubling the survey itself did point to resources because we were querying a number of vulnerable areas and so the hope would be that the individual would would seek help but it's it's in some ways uh perhaps a false hope we know that interpersonal violence including intimate partner violence domestic violence um was on the rise in the early pandemic um studies are limited in terms of the quality of data that tells us what happens in people's homes um during the pandemic but um there are very substantial reasons for concern that people especially women were at increased um risk of of rape and and coerced sex uh during the course of the pandemic the other question is um is a big one and the literature on unwanted sex is relatively scant um much of it happens in the hiv uh space including some of my earliest work where we were interviewing women who had given birth um knowing of their hiv status they had given birth uh two or more times following knowledge of their hiv status and actually one of the discoveries from that trial or that study um reminds me of a of a point that Preston made and and Monica commented on um and it was a quote from a person who said hiv is the best thing that ever happened to me why because for the first time there was a place for her her identity as a woman with hiv availed her the services and support of the core center here in chicago and just like you know it's an absolute tragedy that um you know imprisonment could be a better scenario for an individual than than living in the community um you know that hiv could be a better life for somebody than life without it because of the services they're availed it's just an absolute uh uh travesty um to the point about the you know should we call it power differential versus rape well um you know obviously this is a asynchronous discussion on a very charged and important topic but let me just reference illinois state law which says that consent means freely given agreement to the act of sexual penetration or conduct in question lack of verbal or physical resistance or submission by the victim resulting from the use of force or threat of force by the accused shall not constitute consent so we do have you know a challenging situation where a person may um feel that they're not consenting to sex but they are subject to the coercion of the other individual um in the form of you know being able to meet basic material needs and one one factor that got me interested in this topic was my experience caring for women with cancer my observation is that my clinic has been more full and better attended with women with cancer who are seeking help for their sexual function during the the biggest economic downturns we've seen including the COVID-19 pandemic why many of my patients say sex is extraordinarily painful i have no libido or interest but if i can't have sex my partner's going to leave me and then my children and i will you know i will have cancer and i will be homeless so are they having non-consensual sex or are they having extraordinarily painful sex um that they don't want in exchange for basic material needs that was the hypothesis and um whether we call that rape or whether we just acknowledge that to be a severe threat to the integrity of a person and their body uh either way cause for concern um and attention thank you everyone um for this really um meaningful and powerful session we are out of time um we've been here chugging along for quite a bit of time um and i feel like we could we've only begun to really scratch the surface um thank you for everyone in the audience for hanging in there with us for your very thoughtful questions yes uh people have asked several times will our presentations be made available um and uh if all i i said yes and i think probably most of the presenters um have agreed to have their presentations made available as well so no worries um they're usually um available online uh in the not too distant future um so thank you all for joining us um and uh thank you to my wonderful panelists as always it's a pleasure to share time and space with you even virtually um and for uh thank you for Dr. Siegler for the 33rd um conference and and i look forward to uh the rest of the session um so that's it thank you everyone