 Good evening. My name is Doug Hanto, and I am the chair of the Surgical Ethics Working Group in the Center for Bioethics at Harvard Medical School. On behalf of the Surgical Ethics Working Group, I would like to welcome everyone to our fourth and final Harvard Surgical Ethics Conference, Disparities in Surgery and Obligations to Correct. Over 1,000 individuals registered for the conference from around the world. And we would like to thank you for getting up early, staying up late, and taking time off from work or leisure to join us this evening. I believe we have an exciting and interesting hour and a half ahead of us. I would like to review a few housekeeping items before introducing our moderator, Dr. Teresa Williamson, who will introduce our topic for this evening, introduce our speakers and moderate a panel discussion at the completion of the talks based on your questions. First, we would ask that during any of the talks to please submit questions using the Q&A feature found in the meeting controls at the bottom of your screen. Please don't enter your questions in the chat room, enter them in the Q&A feature. These will be monitored and we'll be collecting these questions to be discussed after the presentations. Or you can also continue to the conversation on Twitter using hashtag HMS Bioethics. If you have any technical issues, please use the chat feature to send a message to all the panelists and a staff member will help. If you're interested in any of the upcoming events, news or education programs, then please subscribe to the Center for Bioethics emails at bioethics.hms.harvard.edu slash subscribe. Also at the completion of tonight's presentation, the talks and the panel discussion will be available on the Center for Bioethics YouTube channel. The prior conferences have already been uploaded into YouTube and are available for your viewing. And finally for all of those who attended all of the sessions within the next month, you'll be receiving a certificate for your participation. Now I'd like to introduce Dr. Teresa Williamson. Dr. Williamson is an Assistant Professor of Neurosurgery at Massachusetts General Hospital and Harvard Medical School in Boston. She is also the Vice Chair of the Surgical Ethics Working Group in the Center for Bioethics. She's a clinical neurosurgeon and surgical ethics researcher who cares for people with all types of spine disorders as well as brain and spinal trauma. Her clinical expertise includes tailoring an approach to best fit the patient and their disease, including minimally invasive techniques. Her research focus is neurosurgical decision-making and patient-doctor communication as well as healthcare disparities. She combines bioethics theory with empirical data and science to tackle complex decision-making problems in neurosurgery. Dr. Williamson is a member of the Center for Outcomes in Patient Safety and Surgery, or Compass at Massachusetts General Hospital. Dr. Williamson will be delivering our second talk this evening. I will be delivering the first talk tonight. And so without any further delay, I will go ahead and get started as I share my screen here. Thanks, Doug, for the introduction. As you share your screen, Dr. Hanto is the Chair of the Surgical Ethics Group here at Harvard and has a real keen interest as a transplant surgeon and professor in health disparities. Thank you, Dr. Williamson. This evening, we will discuss disparities in the care of Black, Indigenous, Latinx and people of color with an emphasis on surgical care, but not exclusively. There are important lessons we as surgeons can take from the non-surgical patients as well. This is a critically important topic for many reasons as we will see, but the Reverend Martin Luther King summarized it well when he said, of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death. I have no financial or other conflicts of interest to report. The international community has accepted health and healthcare as universal human rights. The US has not. In 1946, the World Health Organization's Constitution was agreed upon and defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It also stated, the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. The United Nations Universal Declaration adopted in 1948 states, everyone has the right to a standard of living adequate for the health and well-being of himself and his family. Now healthcare in this country is not anchored in health equity or social justice, but rather in the ability to pay. Consequently, achieving optimal health can be elusive, more so for some than for others. In 2003, the Institute of Medicine published its report, Unequal Treatment Confronting Racial and Ethnic Disparities in Healthcare that documented a large body of published research going back a decade, showing that racial and ethnic minorities receive a lower quality of care than non-minorities, even when factors that affect access such as insurance status and income are controlled for. Compared to whites and in some cases Hispanics, blacks were shown to be less likely to receive indicated cardiac medications, coronary artery bypass surgery, peritoneal dialysis and kidney transplantation and basic clinical services, including intensive care. These differences were associated with an increase in mortality among black patients. There are many other areas of medicine and surgery where disparities have been documented. The causes are multifactorial, but involve primarily social determinants of health, that is the circumstances in which people are born, raised, lived, worked and aged, rooted in slavery and structural racism. Provider stereotyping implicit and explicit biases and uncertainty also contribute to these disparities. Other barriers include patient trust in the healthcare system that has exploited black bodies for centuries and continues to do so, as well as language, geographic and cultural differences. The institutional environment, including the lack of minority healthcare providers is an important contributor. This figure is from a study we published on the disparities that occur along the continuum of care for chronic kidney disease to transplantation, demonstrating the complexity and multiple points of interventions required to mitigate disparities. Finally, the IOM report outlined multi-level changes needed to reduce these disparities. Dr. Bassett, who is the New York commissioner of health, wrote, there has not been a single year since the founding of the United States when black people in this country have not been sicker and died younger than white people. This slide details the data that illustrates Dr. Bassett's statement. Life expectancy at birth is a basic measure of the overall health of a population. And as you can see here, the current life expectancy of blacks is six years less than that in whites. There are glaring disparities in infant and maternal mortality. The infant mortality in black women is two and a half times greater than in white women. The maternal mortality is three times higher in black women. There are one and a half times more uninsured in blacks even after implementation of the Affordable Care Act. The underinsured are two and a half times as common in blacks as in whites. Health care disparities are related to social determinants of health. Blacks are markedly worse off in all categories, such as poverty, household income, median wealth, and home ownership. I think we have all heard how the COVID-19 pandemic quickly exposed the health and healthcare disparities that exist in the African American population resulting in higher COVID-19 infection and death rates in cities and states across the country and a greater drop in life expectancy. Within three months of the first case of COVID-19 being detected and only two months after community transmission was detected, it was shown in Chicago that 50% of cases and 70% of deaths occurred in black patients even though they comprised only 30% of the population. Similar disparities in cases and deaths were shown in Louisiana, Michigan, and New York. In St. Louis, Missouri, the case and death rates for COVID-19 infections are twice as high in blacks compared to whites. A follow-up study from Oxner Health in Louisiana noted that 31% of Oxner Health patients were black but they accounted for 77% of hospitalizations and 71% of deaths. These trends were the same when national data were analyzed. There are many causes for these disparities. The correlation between racial and ethnic minority status and lower socioeconomic status has been well described. Minorities more commonly live in poor neighborhoods and crowded and multi-generational living conditions have service jobs that cannot be performed remotely and are more likely to be dependent on public transportation, all of which contribute to an inability to socially distance, shelter in place, and a greater risk of exposure to COVID-19. Finally, marginalized groups are a greater risk for severe disease requiring hospitalization and death because of a higher chronic medical comorbidities such as hypertension, diabetes mellitus, morbid obesity, asthma, HIV, liver disease, kidney disease, and cardiovascular disease. The field of bioethics, although concerned with health and healthcare has been criticized from within and from without for not addressing issues of racism and inequality in medicine or its own lack of diversity. This has begun to change with a session held with the 2019 American Society for Bioethics and Humanities Annual Meeting on what does justice require of bioethics moving our field forward. Doctors Bassett, Dennis, and Brown called on the attendees to redress several neglected areas in the work of bioethics, including having inadequate focus on ethical and moral obligation to address structural racism. Having insufficient regard for the role of structural racism and its accumulating effects on the health and well-being of people of color. A lack of recognition of bioethicists of color and their work identifying structural racism as a primary cause of health inequities. And finally, for a lack of integration and application of interdisciplinary scholarship from justice-oriented fields to inform a braver, bolder, and broader bioethics. The examples of racial disparities in surgery, medicine, and other areas of healthcare are numerous and we only have time to scratch the surface. I want to focus on one surgical and one medical example that illustrates several common threads throughout the literature. The first is a study on the racial disparities in the use of surgical procedures in the US. Nine common surgical procedures performed during the years 2012 through 2017 were analyzed by Best and his colleagues. You can see here, they included angioplasty, spinal fusion, carotid endarterectomy, appendectomy, colorectal resection, coronary artery bypass grafting, total hip arthroplasty, total knee arthroplasty, and heart valve replacement. They found that the incident rate of all procedures were higher in white and in black patients in 2012. These disparities persisted in all nine procedures in 2017, although the gap narrowed somewhat where five of the procedures was unchanged in one and actually increased in three procedures. These disparities were present regardless of the US Census Division, for example, Northeast Urban, or their hospital teaching status or insurance status. The findings of this study are worrisome because healthcare disparities, as we have noted, have been well-described in documents since the 1990s. Furthermore, there have been many national initiatives to reduce healthcare disparities, some of which are listed here to reduce these inequities. We are good at measuring, but not so good at fixing. What can physicians do? Naysan Mani recently wrote that although, quote, many fundamental determinants of health are far upstream of healthcare and are deeply rooted in the distribution of money and power at the local and national level, physicians most enduring effect may be changing the conversation around health and responsibility for it because we are the most powerful and authoritative voices on health and can use this characteristic to champion health in all policies. Now, we can learn a lot from the disparities in total hip and total knee arthroplasty from this study. These are among the most common procedures in the US and are rapidly increasing in frequency. The disparities are worsening for both. Take total knee arthroplasty, for example. The rates for 100,000 in 2012 were 184.8 for whites and less than 79.8 for blacks. This difference worsened by 19.9% in 2017. For total hips, the disparity increased by 11.6 was 98.4 compared to 52.9 in 2012 and increased by 11.6% in 2017. This is an important observation because there's no biological difference for the difference. The prevalence of osteoarthritis in blacks is actually the same or greater than in whites. This increase in disparities has occurred in spite of efforts by the American Academy of Orthopedic Surgery and others to reverse the trend. In addition, these disparities persist regardless of insurance status. Some possible explanations that weren't further studies include variations in physician recommendations, socioeconomic factors, cultural beliefs, mistrust of the healthcare system, risk averseness to new procedures, physician implicit and explicit bias, decreased access to care associated with such factors as socioeconomic factors, insurance, geography, increasing medical subspecialization and fear of racial discrimination. Let's consider another example. Earlier this year, white nationalists protested outside the Brigham and Women's Hospital in Boston because they believed a new program to improve the care of black patients with heart failure was anti-white. What was the program and how did it come into being? In 2015, it was noticed that black and Latinx patients with heart failure, a hospital's most common diagnosis, were more commonly admitted to the General Medicine Service rather than cardiology subspecialty service where outcomes were better as well as having more private rooms and other amenities. This was confirmed by analyzing 10 years of hospital data. They also found it was not explained by insurance status, established links to care, medical comorbidities or an index describing the socioeconomic status of the patient's neighborhood. A subsequent study suggested that self-advocacy may have played a role in that white patients were perceived as arguing more for cardiology admission and the providers admitted being influenced by that. They decided to work toward a solution. There is not time to describe in depth their pilot program of medical restitution which is based on Darity and Mullin's reparations framework of acknowledgement, redress and closure or ARC, Ford's proposal for a public health critical race framework and applicative justice that Naomi Zach describes as applying justice to those who do not now receive it. The program is referred to as the healing arc and there are specific plans for each of the three aspects I'd like to briefly mention. The first acknowledgement quote involves recognition and admission of the wrong by the perpetrators or beneficiaries of the injustice. This entails disclosing to patients their findings, taking responsibility and engaging the community for ideas on how to correct. Second is redress which is quote not just a direct solution to monitor and end health inequities but to offer restitution for past and present injustices. The hospital is providing preferential admission options for Black and Latinx heart failure patients to the cardiology service rather than relying on providers to decide. They admit they may have some legal challenges. Finally, closure which requires in the future that the community and institutional representatives must agree that the institutional debt has been paid and a new system is in place to ensure that the problem will not reemerge. When this has occurred, we'll be decided in conversation with community groups. So in summary, health and healthcare are universal human rights. Longstanding disparities in health and healthcare are well documented. These disparities are rooted in structural racism and social determinants of health. Bioethics has not adequately addressed racism and inequality as a field. Racial disparities and surgical procedures have increased in spite of national initiatives to address these disparities. Programs such as the medical restitution program at the Brigham and Wimbus hospital may be effective in addressing unequal care due to institutional racism. And greater attention must be given to reversing disparities in healthcare by addressing the source problems of structural racism and social determinants of health. Thank you very much. I would now like to introduce Dr. Williamson who will give the second address. Dr. Williamson. Thank you so much for that introduction. I'm just gonna go ahead and share my screen. Let me know if you have any trouble seeing or hearing. So I'm gonna talk a little bit today about diversity in training. I think Dr. Honto did an excellent job of talking about all the issues that happen in terms of healthcare disparity. And really my goal is to talk about how we should be training people to do a better job in tackling some of these big issues that he brought forth. And just a quick reminder again to put questions in the Q and A, thanks. I thought I was going to die because no one was listening to me. This was a statement that one of my best friends made to me who's a PhD researcher after she had her baby. She's a black woman. And she was really exposed to everything that was coming up in terms of healthcare disparity as she was pregnant and getting ready to have her baby and knowing that as Dr. Honto mentioned the shameful and awful trends that we see in terms of maternal health in black women regardless of social status, education status or wealth. And I think that she was sitting there just wondering, am I gonna become another statistic? And I bring the story up to sort of set the framework for what it's like to hear and listen to healthcare disparity as a person of color and that we should be mindful of that as we go through training people about healthcare disparities. So today I'm gonna talk about healthcare disparity education, where are we? What are we doing? Some of the ethical dilemmas that might come up. The ethical obligations, what do we need to fix and possible solutions. So what do we teach at the moment? So this is an example of some of the big recent changes that have happened in medical school curricula which are really to be applauded. It's unbelievable how quickly we have changed sort of years and years and years and century of structural racism and even the attempt to try to fix it is unbelievable and awesome. And so medical schools are completely overhauling their curricula. There are schools that are requiring healthcare disparity to be taught in every module. So there's a real effort as many of you who are in medicine have probably picked up on to do a better job to address racial inequities in medicine and at least the education around the fact that they exist. Sometimes what we can teach though can come a little bit as a double edged sword when we are not clear or expert about what we're talking about. So this is an example of a study that was done and recently published in the double AMC about beliefs of white medical trainees about black patients. And so half of white medical trainees believed that myths such as black people have thicker skin or less sensitive nerve endings than white people. And so although like Dr. Hanco brought up there's no real difference in biological race that underlies these medical differences. There was certainly a belief based on potentially some of what we're teaching or some of what we're learning in society that there was a difference. So this is an example of what we might teach. So what is a health disparity? So a disproportionate number of people with health conditions might die from a disease. I think this disease is HIV. And so African Americans only make up 13% of the population but look how much of the new HIV cases they make up. So I think this is really important just to purely get the facts out there. But then what's missing from this slide? So I think what's missing from this slide is human stories making race and making racial disparity humanistic, social determinants of health. So what else is playing into the fact that African Americans are making up a disproportionate amount of the new HIV cases? And what are some ongoing efforts at solutions? So for example, in the year of 2023, there was an $850 million governmental effort to end such disparities. So some of what we might be doing at this point is familiar in the psychology literature. So what's the goal of surgery and so of learning about health disparity in surgery? And so in this particular example, you can know nothing really down at the bottom of this stunning Kruger pathway and you might be actually quite confident. So this is how much you know on the X-axis and this is how much, how confident you are. So when you know very little, like you get a slide at the end of each module, you might know very little, but you might be pretty confident in that and we refer to that or the psychologists refer to that as sort of the peak of Mount Stupend. And then you start to know some more. Like it really starts to be in every clerkship that you're learning about health disparities and all the problems and that's the value of disparity. So now I know enough to know that things are really bad but I don't really know much about the solutions. And I would argue that sometimes people with lived experiences like trainings of color may live a little bit in this because they may know a little bit more and they may have lived a little bit of that experience but they may not know how to improve those disparities. And then there's sort of this upslope where we wanna be of enlightenment where our competence, what we know starts to match our competence and we start to be able to sustain and to plan for change. And so what are some of the ethical dilemmas that come up when we start to talk about disparity and how are training disparities? So obviously there's issues for the patient and I think the overhaul of medical curricula is aimed at that justice. So what are the contextual features in which our patients are living that may or often include disparities or racism or structural inequities and how can we correct them. Beneficence, so how can we do the best for as many patients as we get and for the patient in front of us? And non-maleficence, how can we avoid doing harm by continuing to perpetuate stereotypes or disparity like happened to my friend when she delivered her baby? And then for the trainee, I think when we think of trainees of color but really all trainees thinking about non-maleficence so how do we avoid harm to our patients? When we think about justice and we think about contextual features and how we can do a better job of teaching about them. One of the things that I would bring up is this work from Tarana Burke and Brene Brown. You are your best thing. It's one of the several books that I'll recommend to you as reading from this evening as some homework. And what it really talks about is vulnerability and the black experience. And so how to really be transparent about the experience in order to share, in order to improve and in order to make things more humanistic. And so one of the quotes is my favorite from this book is, I'm just not interested in any of your diversity work if it does not see, acknowledge and embrace black community. Here's another example of how we can do better from our teaching standpoint and our research standpoint and how we can do a good job of addressing these systematic inequities while also acknowledging sort of the expertise and the issues beyond it. So this is a letter to the editor in neurosurgery. I do some health disparity research in neurosurgery so I think it's quite relevant. And it talks about diversity related studies in neurosurgery. So there's been this sort of idea of disparity tourism and making sure that you can, and many people publishing on the issue of health disparity but what this is a call for is let's include some experts, let's include public health, let's include public policy so that we can really take the data that we're getting that shows like that slide, this is how many people and this is how disproportionate and make some action items from it. And so there's this idea, the reason why I bring that up is because there is this idea that if we continue to sort of just continue to tell people the negative things about their race, it can have a negative implication from the damaging to individuals. This is from the sociology research as well as to their ability to sort of stay in the field and so stereotype threat and racial re-ification, this idea of placing someone in an exaggerated group in the public eye and sort of continuing to double down on that can be a real problem. And so what are our ethical obligations? So there's some solutions for the patient which I think I talked a little bit about in terms of context, in terms of humanism, beneficence and non-malficence and justice. But what about the trainee? So we talked a little bit about the solutions for the patient and this is one of the quotes from the paper that I mentioned about including more in the disparity literature and more experts. So we advocate for a formalized diversity review process and they're talking about literature, published literature to ensure that these issues are adequately evaluated prior to publication. The issues they're referring to are making sure that the data is well validated, that there are experts in the space and that there are potential asks or solutions and is it more important now than ever that we are aware, proactive and unifying our evaluation of the care we all provide? So I think another solution is to engage trainees to address healthcare disparities and that's trainees of all backgrounds. So right now we know that underserved communities are more likely to be served by physicians of color and so as we put these slides up and show what these disparities are, there's really a call for all of us to be dedicated in our practices to improve healthcare disparities. And so what I've circled here is using two large physician surveys, we find that minority and women physicians are more likely to serve minority, poor and Medicaid populations and so this is a real area where in order to improve justice for patients, beneficence for patients, we can call on all of our trainees to do better. And then when it comes to the trainees, so I think we do need to be sensitive to the fact that we're bringing in a lot of information at once and a lot of it that could be pretty pessimistic and make the world look pretty depressing. And so I think, this is my second recommendation of book, this is the Lightmakers Manifesto by Karen Ballrin and it talks about how to work for change without losing your joy. So work at these change points like health disparity in medicine that we have to work on while also maintaining your joy and so I think she asks this problem really well with all these problems, how can you do to your day to day? How do you put your white coat on, take care of the patient in front of you? And she has some really fantastic solutions about how to see joy, whether in every individual interaction and I think again points to that bringing the human side of a patient doctor relationship together. So on one side, we have this idea of falling short of beneficence either presenting information to trainees but not really doing anything positive about ever creating solutions or training them as to how to fix it. And then on the other hand, and I think is really optimistic is that we are overhauling curricula, we're doing a lot to change at least the way we teach things. And then the next step is really just a commitment to solving disparities and to supporting our trainees of color. There's some organizations that have done this really well Columbia University held a workshop on race and justice in which they involve story sharing and problem solving. So instead of, they went that step further and this is a slide from their meeting where they talked about building narrative power of racial justice and health equity. And this was really powerful, the participants found it really powerful and they came out with some tangible solutions or at least working solutions to address racial injustice and health care. So in review, I think, we talked about where we are in terms of diversity education. We have a huge movement and a huge opportunity. We talked about some of the ethical dilemmas when it comes to presenting information as well as teaching the information and finding in our obligations to find solutions both for patients and for trainees. And we talked about some possible solutions. Thanks so much. And with that, I will introduce our next speaker, Dr. Popar. I'm just a reminder, I think I see some questions going into the Q and A which is fantastic. So Dr. Popar is a trauma surgeon at Washington University in St. Louis and director of its Center for Humanism and Ethics and Surgical Specialties, also known as CHESS. Having earned her undergraduate degree in philosophy, she received a Woodruff scholarship to Emory Medical School. She trained in general surgery at Dartmouth in critical and acute care surgery at Yale and in medical ethics at Harvard. She has founded the Ed Directs, the Surgical Ethics Fellowship that watch you. Originally from Hungary, Dr. Popar is specifically interested in the cultural evolution of medical ethics and its specific application to surgery. So it's super appropriate that she's on this panel and I'm really excited to hear her talk. Thank you so much, Theresa. Let me see if you stop sharing and then maybe I can share. Give me one second here. Can you guys see my slides, okay? Let me know if any issues. Yes, you're great. Great, all right. Thank you so much. I'm so excited to be part of this panel. I'm very, very honored and I thank you for your attention tonight. Let me just see here. So I'm going to pick up where Dr. Williamson has left off and I'm going to talk about obligations to correct a little bit further. And I'm going to address, of course I will not have a clear answer for everything that's broken, but I'm going to talk about what are some of the things specific to surgery that we can learn and what are some of the things specific to correcting a crisis as we will talk about and what to think about as we think about reparations and repair. This is a fuzzy picture, but if you can see here, this is Azmin Green. She's a 49 year old, she was a 49 year old woman. Excuse me. Who had been waiting at the Kings County waiting room of the hospital there for over 24 hours. And at that point she died. Unfortunately, she laid there. Sorry. For another several hours before anybody actually attended to her. This was written up in the New York Times at the time and this was in 2009. So about a decade later, during the COVID pandemic, this is a photograph in St. Louis right here. This is Timothy Everline, excuse me. Really sorry. Who is our chair at the Department of Surgery at Washington University. And as you can see, he's holding a sign that says racism is a public health crisis. And we sort of mentioned this during the talks and I wanna talk about what does that mean specifically? And why now 11 years later between 2009 and 2020 at this point, it has become a crisis when obviously it was a problem before. Dr. Everline also became the chair of the American College of Surgeons, DEI Task Force. And part of his efforts and some other people's efforts. Just recently, about two months ago, the college came out with this request to ask everyone, all the surgeons to really view racism as a public health crisis. So that's what I will address. What does that really mean for us? As surgeons, we are really used to looking at one patient at a time operating sometimes under the microscope and really focusing in on one problem. This is how most of us were trained. And so it is very sort of counterintuitive for us to think about all these social determinants of health and the greater picture. But once we sort of zoom out and start looking at how do our patients get here? What are some of the social determinants to cultural circumstances that bring our patients here? And start really thinking about not just the patient right in front of us or actually the body part right in front of us, but the cultural changes that have pointed us here. And then we can get a better answer why in 2020 rather than in 2009 when Esmeen Green actually died and collapsed we now think of racism as a public health crisis is because of everything else that is happening in culture around us. As we have heard from our previous speakers there is clear evidence of healthcare outcome differences for black Americans over white Americans and in the training itself. So as we think about if we want to meaningfully discuss these ethical issues of justice and fairness in the delivery of healthcare let's take a moment just to understand the nature of healthcare itself. Otherwise it's gonna be hard for us to be fair about it. As we have already alluded to in previous talks healthcare sometimes is thought of as a universal human right. But how actual societies and cultures deal with delivering healthcare is widely different and varies according to from nation to nation around the globe. In the United States, unfortunately we can't quite come to the understanding that it's a human right despite bioethicists clearly thinking so and a lot of people thinking so. We sometimes treat healthcare as a commodity and other times we treat it as a human right. The reason this is really important to agree on or differentiate is because if you think of healthcare as a commodity then there is absolutely no obligation to correct anything because it's really just a question of purchasing things. And if we think of it as a human right then absolutely there's a full complete obligation to provide it to correct any injustice in it. So which one is it? Is it a right or a commodity? And we do this thing in the United States where we treat it the way we think of light and physics. Sometimes light behaves as a particle and sometimes it's like a wave. So we do the same thing with healthcare. Sometimes we think of it as a right and sometimes we think of it as a commodity whichever happens to sort of suit our purposes. And part of the reason for that is because healthcare is not one thing and surgery is not one thing. And as we can see from this image it really ranges all the way from elective cosmetic surgery which is more like a commodity all the way to emergency trauma surgery which is of course immediately life-threatening. And so accordingly when we are thinking more on the spectrum the optional end of the spectrum we're thinking more as a commodity and there is absolutely no government regulation social regulation of who should get it you simply pay for it. But the closer you are to a life-threatening emergency the more the government takes a role in defining it as a right. And to the point that in 1986 of course there was the congressional mandate and TALA which does not allow any facility to turn anyone away who is actually immediately in life-threatening danger. So with this spectrum our obligations also perhaps vary. Now with this context now that we thought a little bit about the nature of healthcare and how we think of it here in the United States what does it mean for us to say that racism is actually a public health crisis? And I think it's really important that it was phrased that way by the American College of Surgeons and not in a different way. And what I mean by that is obviously we're all intimately familiar with the pandemic and the public health crisis of that. And it is not accidental that this is named the exact same thing that this is also a public health crisis. So perhaps if we think about how did we approach the pandemic and try to provide justice and fairness in that we could learn some lessons and apply it to this other pandemic equally important and equally devastating. One of the things I see in one second as we change our standards of care from normal standards, normal care towards crisis care we really change the focus of our attention. The closer we are to normal care the more we're focused on individual patient care the patient right in front of us just like when we're operating in an operating room and focusing on that one patient. Whereas the closer we are to a crisis the mandate becomes more we need to save the most lives possible in order to protect the community rather than the individual patient. Now I would like to point out that this these efforts, this focus in the community really comes from all places. It comes from local governments, federal governments local institutions and there is an effort of some kind of triage that is similar to this chart up here at all levels. Whatever the approach may be and they do vary from hospital to hospital state to state there are the core principles are not that different. NASEM summarized the seven core principles that they thought that all systems who are trying to achieve some justice should pay attention to. And interestingly the VA added to these the duty to plan and the duty to palliate if you know that you're not going to be able to save that patient's life. The reason I have transparency and consistency highlighted is because these were the two principles that hospitals really struggled with actually putting into practice. And it is my opinion that if you have a non-transparent inconsistent system that will lead to more injustice than if you didn't have a system at all. And anecdotally at any rate the hospitals have really struggled with operationalizing these algorithms. When you look at the guidelines from hospital to hospital state to state you can, the guidelines themselves have been studied but there is zero data on how well they were actually be able to put in practice. I have looked and looked and there is nothing from my own experience and working in five different hospitals for COVID units there was a large distance between the algorithm and actually putting it into practice. What we do know this is data from the IFM is that the wealthier the country is the high income countries are up here and then the low income countries are down here. On the Y-axis we have life years lost per 100,000 people and then we have income on the X-axis. So the richer the country paradoxically the more life years lost and the US is right up here. And we know from our previous discussions that of course the burden is very disproportionately placed on minorities. So one hypothesis that I think we have reason to believe is that this lack of consistency has really contributed to this loss of life here. So as we are thinking about, well here, this is how we thought about the crisis for COVID and as we are thinking about the crisis the public health crisis for racism how are we going to think about our attempts at changing things? And this is just a standard way of evaluating any kind of criteria. So I would just like to keep in mind as we go forward are these efforts that we're trying to do are they effective, sustainable, relevant, efficient and have impact. When we think about governmental action this is back in the late 1960s, early 70s when busing was an effort to desegregate black children from white children. And this mandate at first was somewhat popular but quite quickly became very it caused a lot of friction and it led to a lot of riots and it was quickly ended. To this day, a lot of black people think that it was very effective 60% if you ask them. Only 17% of white people were in support. So once the federal mandate became it was stopped and it became optional for cities to continue to do it. Berkeley happened to be one of that city that continued to do the busing and this happens to be one potential impact that we see from this. But of course Kamala Harris who was one of the children bused at that time. Other social determinants of health that we have sort of made the case for it is there it's really tied to health outcomes is of course housing. This picture is of Andre Perry who studies the housing crisis and the difference in neighborhoods between blacks and whites. And even when you control for all the socioeconomic variables just how much the housing prices are different in the white neighborhoods versus the black. This happens to be in St. Louis. We have Delmar Boulevard and it's called the Delmar Divide. The hospital is just right near it and our main hospital. And you can see the Delmar Divide is very clear in population and in wealth and it has not really changed over many, many decades. So what can we do as an institution, as a local institution? Excuse me, lost. For some reason I lost my ability to, there we go. This is Barnes-Douche Hospital which is the main campus. It is Washington University's teaching hospital. And as you can see it's essentially a city onto itself. And the very north end of that divide that I showed you is Christian Hospital which serves the more disadvantaged population of St. Louis. And you can see it is not quite the same city that Barnes-Douche is. What our institution has tried to do is it has tried to send a bunch of physicians to work at Christian Hospital and make Christian Hospital part of Barnes-Douche system. And it has partnered with the community leaders and the community volunteers to increase cancer screening, diabetes screening and really try to have health awareness be more effective in this area. So far we know that the screening has been more effective. We don't yet know if it translates into any outcomes such as survival benefit. Now Christian Hospital actually has become part of BJC Barnes-Douche Christian now in an effort to try to equalize care. And one of the things that we struggle with is to reestablish the trust that has been broken over many years in St. Louis. The motto of Christian Hospital on their website is your best medicine right here. And I often think, do they mean your best medicine or your best medicine? Because it does still seem not quite equal. One of the things that I want to point out is when we're trying to reestablish trust sometimes we have unintended consequences of our sort of benign well-meaning actions. One might call it benign racism. And an example of that was during the COVID pandemic in the ICU's of Christian Hospital we as a community of physicians were not very supported and were very hesitant as an institution in providing palliative or comfort care for fear that people might think that we're giving up on them. So it actually paradoxically changed the care for the worse. Dr. Williamson actually has written on similar problems with brain injuries. So how do we measure success? How do we know that we're going in the right direction? And I just want to highlight a few things to consider as we are changing our infrastructure and our structural approach to healthcare. One of the important lessons comes from global health, global surgery, which is we need to ask the question who is telling the story because most of the research that shows success of global surgery comes from those who are providing it, 80% of it. And most of that is in the editorial format. So they're telling a story, it is not true research and they consider it successful but we don't really hear from the other side very much. So we must evaluate from the other side as well. Another caveat or something to pay attention to as we evaluate success is to not make the mistake of thinking that outcomes that we often measure such as survival or readmission is the same as patient experience. This study in Australia studied some orthopedic procedures and showed that at least in this case they were very different and actually in no way lined up. And especially in something like racism where so much of the focus should be on the patient's lived experience, we want to make sure that we are not conflating these. Finally, with the VA's imperative duty to plan, which I do think is a very important ethical imperative, we need to think about the downstream applications and implications of our policies. And we need to be mindful of these when we institute anything that affects healthcare. So most recently, of course, on Friday, we all know that Roe v. Wade was overturned. And as all the experts have already come out to say the people who this will affect most will be black women. And already we know that they are bearing a large burden and disproportionate burden of healthcare disparities. The American College of Surgeons on Friday put out a statement condemning this reversal and along with other medical professional organizations asks that the law in this way does not interfere with healthcare. I would just note that this was on June 24th that the statement came out and that was after the ruling, perhaps not being as effective as it could have been. There is some good news though. As I've said before, we are not in cultural isolation in healthcare. Whatever else is happening around us in the world strongly affects our patients, our patients' lives and our trainees. So one good news is this is Simone Lee. And in fact, she's a New York based artist who in fact was inspired partly by Esmond Green Story who we talked about at the very beginning the patient who had died in the waiting room. And Simone Lee is a sculptor who works with her subject is the plight of black women. And she was actually selected to represent the United States as the only artist representing the country in the Venice Biennial Art Festival currently going on in Italy. And with that, I thank you for your attention and I'll stop sharing and we'll be happy to take questions. Thank you so much, Dr. Copa, that was fantastic and really a tour de force on obligations and also some ways to think about correcting disparities. I really enjoyed your discussion of the close to home experience at Barnes and seeing how you could potentially meld those hospitals together. I think some of the questions that came up really had to do with that. So I'll start there. One of our participants asked racism is a common problem beyond the scope of healthcare, which I think you got to. How do you suggest we have further interdisciplinary collaborations to address this issue? Who are the key stakeholders in tackling this issue in the wider picture? I have a quick fix. Did I forget to mention it? That's on the next slide. I have since I've been thinking about this problem not just in the context of racism but just in justice in healthcare in general. I really think that until as a society we can agree on whether healthcare is a commodity or a right, we will not really make true advance. And the reason for that is because on the one hand we have a business model, on the other hand we have a model for providing a right and the two do not align and therefore I think we're actually taking away from both. So all of this is to say that I unfortunately think that this has to be decided on a larger governmental national level and without it, we can make efforts in local governments and local cities but I don't think it will be consistent, transparent and effective. Yeah, I think there's a lot of large scale changes and structural changes that need to happen. One of our participants kind of pushed us on some of our topics from last week about devices and how we combine industry with medicine and you hinted at that in various years and Dr. Hunter's opinion about can we ever if we have this system that's set up the way we do where healthcare industry makes a lot of money and then there's on the other side of things or together this idea of caring for the patient and making healthcare right, can we merge the two? Can we align the two? Or do we need a whole system restructuring? I think about that also a lot because of course the downside of socializing medicine altogether, which is really what we're talking about national healthcare is taking away the innovation opportunity, the competition for innovation. And I don't have a good answer on how to make them coexist other than with perhaps federal incentives or something along those lines or have sort of a kind of like in Britain a two tiered system almost where you have a basic care system that provides for what we consider basic human rights and then innovation can sort of act in this other realm of more advanced technology that could be a potential. Yeah, I think that first of all it certainly would support universal healthcare which I think is critically important but I do think the pendulum has swung too far for industry and profits. I agree that we, profits have certainly driven innovation but as we all know a lot of the research in pharmaceutical companies that they profit from is done in academic institutions and then transferred to pharmaceutical companies. And I do think that there have been a number of proposals to try to get a handle on drug prices which are a big part of the problem particularly for people who are low income and can't afford drugs but unfortunately these have not really made it through Congress. So I do think that there does need to be better cost control. We have too many instances where small modifications in drugs or devices are used to maintain patents and maintain profits rather than allowing generic and cheaper alternatives to be available. So I do think that there are a number of solutions that have been proposed and unfortunately they don't get too far because the industry has such powerful lobbying. Yeah, I think as someone who works in a specialty that partners with industry an awful lot one of the things that I think can be done as well is really pushing industry to take a role in eliminating some of these problems. And so to put their money where their mouth is a little bit when it comes to training, when it comes to who pays for these trainings, who pays for these conferences, who pays for these experiences and also making their devices accessible and their trials. I know J&J for example does have now, of course I'm sure they're pushed legislatively to do so but does have a panel of folks working on making sure that their device trials are equitable and that they're teaching surgeons how to enroll equitably instead of what we've currently have with the significant bias in our clinical trials. Another aspect that I've recently come across is even when industry is willing to step up and help with training, for example, in many of the robotic trainings, then you come across the problem that there is no quality control because basically the industry is providing these trainings over a weekend and then saying, here you are, here's your certificate, you can now do robotic surgery after having attended this course and of course it's in their interest to say that you can now do it but there is not the corresponding professional quality control that we see for surgery otherwise. Right, and we know that patients of color are more likely to get surgery at lower-level centers. You mentioned a hospital that you showed one hospital system and then you showed a hospital on the side. Lower-level centers more complications and so who has to take responsibility for that? I'd like to just push it one step further with this sort of health as human rights question because several people asked it, one of the participants asked, health and healthcare are fundamental human rights. How do we get nations to recognize this point? So now talking sort of for more of the lens of how do we advocate for this and some developing nations do not recognize this even though some advanced nations do. I guess I'll go ahead, Rosa. I was just gonna say, having come, I grew up in Hungary where this was a human right and you get to go to the hospital whenever you need it. Quality is much lower though because it's for everyone. So obviously it's not without problems but as far as one of the things about where ethics is different from morality, of course we all know this is that in ethics it has to be something that we as a society on whether it's a small society or a large society, we agree on these rules of the game. And so in our particular society, it's the right to life. And so that's why we see that split that I was talking about that the closer it is to a life-threatening problem, then you have a right. But the further it is away from that, it's no longer a right to life. So without us agreeing on it as a ethical principle, I don't see how we make progress. I think a lot of countries, the US being one of the uncommon exceptions have recognized healthcare as a human right but they don't always, they don't often walk the talk so that they state that they believe this is a human right but they don't actually provide universal healthcare or they provide a slimmed down version as Dr. Kopar mentioned of. So there aren't that many countries that really do provide the kind of level of healthcare that for example, the Scandinavian countries do provide but it is an expensive proposition but I do think it is something that we need to continue and we spoke a lot about it in the first conference that we had in this series in global surgery about our obligations as Americans, not only to provide healthcare in our own country but to assist in the surgical disparities that exist worldwide. And I think that touches on another piece of what everyone's asking when you sort of have this ethical obligation to care for all, I think some people asked about what about sort of poor populations, what about rural populations? I think that absolutely falls under those categories the absolute same ethical principles can be applied. There's certainly a difference potentially in lived experience, racial experience which is some of the topics of what we talked about but there's no reason why that wouldn't apply to answer that question. A couple of specific questions for you, Doug. So one that came up was talking about this, you're a transplant surgeon and what about the transplant list and disparities on the transplant list? I think you have a unique perspective to address that and then after you do that, if you could just clarify a little bit the arc system that you talked about and how it works, who how I think the question was like, could this potentially propagate disparity? Okay, yeah, in terms of disparities and listing for transplantation as the slide I showed you is multifactorial, there are a lot of reasons and Karen Ladine and I have studied this extensively particularly in New England. One of the things that we found was that actually the education of patients on dialysis is quite good so that there is a lot of information that people are exposed to but there is also a lot of mistrust within the African-American community based on a long history of human experimentation and poor access to care and the use of women as a source of children for slave labor. So, and I think one of the areas that Karen has subsequently looked into is that of social support and we found that social support is oftentimes used as a way of excluding individuals from transplantation and this particularly affects those of lower socioeconomic status and racial minorities. And unfortunately, although there has been a myth that social support affects outcomes, she has shown in her studies that the data supporting that is pretty flimsy and that in fact, we don't have adequate justification to use social, what we define as social support to justify not listing patients. What we need to do is find ways to make sure that people have adequate transportation, that they have community support but most people will find a way and we can't use this to deny patients for transplant. So that's only one example and I think that there are many others that people are looking at in order to facilitate the listing and transplantation of minority patients such as patient navigators is another excellent solution that many have Amy Wasserman and others have advocated. The second question, I did see the question, there was a question about the issue around closure and I think that the closure is really important and that when you go through this process of acknowledgement of the wrong and that you redress the wrong with a solution that eliminates inequity in a transparent and monitored way that the closure is really an agreement between the offender, which in this case would be us as physicians or the institution being the hospital and the community of those individuals affected that the solutions that have been implemented have actually solved the problem because we as a physician or hospital might view the problem solved but those on the other end feel that the solution has only partially solved the inequity and there needs to be general agreement before one can say problem solved. I hope that's a little bit more clear. Yeah, I think that's perfect. Thank you so much. I think that one of the follow up questions I'll just address really quickly. So as someone said, it's interesting where the focus of regulation goes. I think part of the reason America cannot decide whether health is a commodity or a human right is part because there's no shared definition of health. What is health? Is it the lack of disease or an ideal state of being and what are your thoughts? And so my personal thought, I like the definition of health and I like it because it talks about the complete physical mental state of wellbeing but also on the other side of things the absence of infirmary. So I think that it's not just the absence of disease which is I think how we're trained but also the wellbeing. I'm wondering what you guys think of that. I think it's particularly challenging as our technology gets better because if you think about it before the 70s there was no ventilator and even after the ventilator existed there is not that much difference between what you can do for someone at one hospital versus another. And now, and I'm sure this is only going to increase but think about a small rural hospital where you can maybe have one ICU bed versus academic centers like we're at where you put people on ECMO left and right. And so just the exponential increase in both life expectancy and technology's abilities I think is really stretching that range. And so I think that makes the agreement on what is sort of standard of care what should be available even more difficult. And then getting to know, oh yeah, go head side. Well, I was gonna say I agree with the definition. I do think that we talk about universal healthcare for example and I do think that it is more than an insurance card. And I attribute that rejoinder to Will Ross who I think we all know is a strong advocate for healthcare in the minority community. And Will has mentioned so many times that it is the ability to get to the position to have transportation, the ability to have childcare to allow you to go to the position. The availability of stores that provide nutritious food that allow you to have a diet that can provide you a healthy state. So there is a lot that goes into it. And I would just say many years ago, David Cutler at Harvard did a very important study that David Williams who is of course a leader in healthcare disparities at Harvard refers to frequently. And that is the importance of segregation. And what Dr. Cutler showed was that for a standard deviation reduction in segregation or about 13%, it reduces one third of the gap in all of these other outcomes that we talk about both in terms of health, life expectancy and so on. And I think that this idea of providing just an insurance card or universal healthcare is not the only solution we have to address this issue of structural and institutional racism. And that's why I particularly chose that example from the Brigham because that is looking at an issue of institutional and position racism and dealing with it in a very direct way. So I think these are all important components that we have to address in order to provide the kind of health and healthcare that we wanna provide. Just a quick follow up to that if I may. When we think about all the ways that we thought about how to be fair and just in the allocation of resources during COVID, even though people and institutions have differed on the best way, everyone agreed that what's terrible is to do first come first serve. And that's essentially what lack of access is doing is we're eliminating the opportunity to be there first. And although we don't agree on much, that is one thing that all societies and all bioethicists agree on that that is the wrong approach. So I do think any way that we can increase access will make a big difference. Yeah, I agree. And I think this actually gets us to one of our participants' questions about how best can non-minoritize clinicians, surgeons and otherwise and researchers best the allies to populations of color and those otherwise harmed by unjust practices. And I think the interesting idea around segregation is an important one here. So one of the things that I really liked that you talked about Dr. Kopar is that when Barnes noticed this big difference between hospital that was serving the vulnerable poor and predominantly black community versus the richer, more white hospital, instead of just saying like, here, come over here, it was a thoughtful reintegration. And I think that that's what Dr. Hadzah was talking about when you're talking about like, okay, segregation is at the basis of this, but certainly just busing is not gonna be the answer. Okay, let's just ship everybody back over here. There has to be some sort of thoughtfulness about what the community is, who the community is. I think the University of Chicago's new trauma center is an interesting example of that, right? Like the thoughtfulness about who is in the community, they're working together with the community to see what do you need and sort of some humility in that regard. One about the fact that like, we got it wrong the first time kind of in healthcare, at least here, you know, most places, but at least here in the US. And we got it wrong for these communities. And so, you know, often mistrust or is not gonna be overcome purely by a bus card or something to come, you know, but we really have to think carefully about how we integrate back with these communities in a thoughtful way that they can engage and get really good patient care. And sometimes that may mean, I think, going there and then certainly having the expertise in everybody available, but if you can have it in your backyard where you're comfortable where your parents were cared for, et cetera, I think that's a really great idea. And I think that, you know, that's my biggest sort of message when it's come to traumatic brain injury research for those who are, you know, not associated with the, or not don't identify with the population they're serving is you don't have to be that population to care for them, you just have to be sort of humble and able to admit maybe that you don't know everything about their culture and that idea of cultural humility, I think is really important. There's another, there's a couple of questions about strategies for health disparities research that I'm happy to talk about. I think, you know, a couple of people talked about how, you know, in this academic world, we value publication and then lots have come from equity. So what are the sort of guidelines and suggestions to prevent just racism from coming to that? And I kind of hinted at that in my presentation but I'm glad you brought it up because we are so publication driven and so grant driven. And so now when money goes in that direction, you know, government funding to health disparities, now everyone's like, okay, let me just throw a disparity lens on my research project and then it'll get published or let me just, you know, do this database and mine this database and show that black people did worse and then, you know, I'll get a publication. And I think that that can one be really dangerous because we're putting a lot of information out there that is usually, I think statistically rigorous but may not be thoughtful from a policy or a, or a sociology standpoint. And that's where I talked about that sort of like exaggerated racial groups and kind of repeating the same facts over and over and how that can actually be detrimental. And so I personally really liked that call from the neurosurgery leadership to in the review process as we're having all these papers come up, which are important, let's make sure that we have, you know, like just like you have to have a statistician on your paper because you know nothing about stats if you're me, but some of the recipe you may know. If you're gonna talk about disparity, maybe you need to have a sociologist or a public health expert or a policy expert or you need to have a background that specifically trained you to talk about that. And I think that that would help to make it so that disparities, you never want disparity research to sort of be the easy research or the low hanging fruit research because it's so critical and so important and so important to be done well. And so I think that that would kind of address and answer some of those questions about how to avoid racism in that process and then also how to make sure that we have more solutions focused research. I don't know if you guys have any other thoughts about that. How to make the research stronger and more solutions focused. Oh, I think those are all good points, Dr. Weinstein. I think in addition, just as the American Association of Bioethicist and Humanities noted, you know, we need to recognize the work of minority authors and researchers. We oftentimes don't and that needs to be corrected and we need to facilitate the training of more minority investigators who, you know, I think will inform the field. I mean, it is critically important that there be white voices, minority voices and all voices in this fight, but clearly we need more voices of those individuals most profoundly affected. Another way I have heard addressing this that I sort of spoke to me was like you said, we weigh publications so heavily in the academic, in academia and people who are actually putting effort into literally changing the culture and teaching and doing those medical school curriculum overhauls over publications are sort of being penalized because they're not advancing at the same rate because they're not publishing. So if we could somehow tie promotions not just to publications, but these actual efforts, then I think that would be helpful as well. Yes, I completely agree in the idea of adjusting promotion structure to more adequately. And I think one of our speakers from the Global Surgery session talked about that because I think that's so important that we align that so we get really good work. Maybe one last question, there's been so many great questions, I wish we could kind of keep going, but we'd love to continue the conversation either also on Twitter or by emailing us or on the website as well. So in terms of medical school training, is there or should there be national regulation on what includes in healthcare disparity curriculum? So my personal opinion is not necessarily a standard curricula, but I do think there should be standard milestones. I think there should be things that people come away with and I think it should be beyond knowing that there are disparities and that certain groups do worse. I think it needs to go beyond that to thinking about solutions, thinking about how to design research, thinking about how to advocate for policy. I know that if I was sitting on a medical school curriculum committee right now, they would tell me like, okay, but also we have to teach these 8,000 other things. And so it's certainly a challenge, but I think a really important endeavor. I'd love to hear from the two of you about your experiences. Obviously both of you have run a curricula, for us to run a curricula kind of related to this in surgical training, so please. Yes, I totally agree with you that it needs to be more than stating the problem. How to accomplish that of course is difficult, but the milestone approach I'd really like. WashU has just introduced the gateway curriculum, which sort of changed the entire curriculum and overhauled it in the last two years or so. And I happen to have the pleasure of designing their ethics curriculum. And this is where we will address these problems. And one thing, or a couple of things that I think will hopefully help us in this effort. One is that ethics is not this other class, right? It is integrated into physiology, into anatomy, into radiology, into literally every course, such that whatever ethical issues may come up in those pre-clinical and clinical problems, we talk about it there. And the other thing is, they sort of divide the course into pathology in the later years and health, not physiology, but health and the definition of and the thought, the thinking of, what does it mean to advocate? What does it mean to be a responsible citizen, a professional and integrate that with becoming a physician? That's fantastic. Any last thoughts, though? Or we have to unfortunately wrap it up. I think we are at the end. I think you guys have done a great job answering that question. So I would like to thank our presenters tonight, Dr. Williamson, our moderator and Dr. Poroska. I've got to co-part for their outstanding and provocative discussion of the ethical considerations and surgical disparities. I'd also like to thank all of you who listened tonight and asked questions of our panel. I would also again like to thank Dr. Williamson for moderating an excellent discussion. I'd like to thank Christine Mitchell, our Executive Director of the Center for Bioethics for her involvement and support to the Harvard Surgical Ethics Conference. And also Dr. Robert Trug, Director of the Center for Bioethics for his support as well. Finally, I would like to thank Ms. Trautman, Ms. Stephanides and Ms. Ramato for their technical, graphic and organizational support to this conference. On behalf of the Surgical Ethics Working Group, we thank you all for attending. We hope that you have enjoyed and learned from our series of four conferences. We hope that there will be information that you will be able to use as you address these important issues in the future. We wish you all a good night and Godspeed.