 Good afternoon. Today, I have the distinct pleasure to introduce Dr. Marshall Chin. Dr. Chin is a, is the Richard Perillo family distinguished professor of healthcare ethics at the University of Chicago is a practicing practicing general internist and health services researcher who has dedicated his career to advancing health equity through interventions at individual organizational community and policy levels. Through the Robert Wood Johnson Foundation advancing health equity, leading care payment and systems transformation program. Dr. Chin collaborates with teams of state Medicaid agencies, Medicaid managed care organizations, frontline healthcare delivery organizations and community based organizations to implement payment reforms to support and incentivize care transformations that advance health equity within an anti racist framework. He also co chairs the centers for Medicare and Medicaid services healthcare payment learning and action network health equity advisory team. Dr. Chin evaluates the value of the federally qualified health center program improves diabetes outcomes in South in Chicago Southside through healthcare and community interventions and improves shared decision making among clinicians and LB LGBTQ persons of color. He also applies ethical principles to reforms to advance health equity discussions about culture of equity and what it means for health professionals to care and advocate for their patients. Dr. Chin uses improv and stand up comedy storytelling and theater to improve training of students and caring for diverse patients and engaging in constructive discussions around systemic racism and social privilege. Dr. Chin is a graduate of Harvard College and the University of California at San Francisco School of Medicine, and he completed residency and fellowship training in general internal medicine at Brigham and women's hospital Harvard Medical School. He has received mentoring awards from the Society of General Internal Medicine and University of Chicago. He is a former president of the Society of General Internal Medicine. Dr. Chin was elected to the National Academy of Medicine in 2017 and is on the steering committee for the National Academy of Medicine paper series on structural racism and health, and is a co author of the Asian American paper and cross cutting solutions paper. It is my pleasure to introduce you today Dr. Chin and we all look forward to hearing your talk. Thanks very much Megan. So I have an ambitious agenda for us over the next hour that you can see from the title is pretty diverse but integrated and it reflects then a lot of the work that I've been grappling with over the past several years to addressing medical and social needs, racism and payment to advance health equity. So sort of the story that some of my general attorneys and I see patients in the outpatient setting as well as a two to four weeks of the year in the infusion setting. And it's not been maybe a year and a half ago that one of my patients came to see me and this is a retired professor of the social sciences here at USC person that's seven or 70s or getting close to 80 probably and a wise person. And he said to me, I'm concerned about our country, Marshall, and I remember he mentioned three things. One was income inequality. The second was lack of action on climate change. And the third was he said that we need to have two same political parties or two to say political parties will survive the country and he was concerned. And I do think we're entering a difficult period we are in difficult period and it could get more difficult regarding the partisanship in the sense of divide in our country. This Karen Dale, and she co-chairs this centers for Medicare Medicaid Services, health equity advisory team that I am the other co-chair of Karen is amazing she's a nurse by background, a counselor's background. She's now like senior leadership she's like CEO of one of the health plans and Washington DC. So very experienced and she's working Washington DC government also. And she has this phrase distinguishing between what she calls performative virtue signaling actions versus substantive authentic actions to advance health equity. So some ways health equity has become like the flavor du jour, and there's a lot of popularity now. And too often, we're perhaps seeing the former, which is performative actions that really maybe are checking a box in terms of well we're doing something with health equity, as opposed to something that will be truly sort of getting at root causes and addressing the situations. So free learning goals for today. I'm going to talk about addressing medical and social needs, racism and payment to advance self equity. Second, we're going to discuss then the underlying ethics for advancing health equity, and I'll end with a bit of a communication and describing free frank, fearless and empathetic discussion around health equity. Here's the agenda. I'll talk a little bit like my positionality defining health equity. What is equitable health care. I'll talk about anti racist approaches to care transformation and payment ethical issues and I'll end with a communication piece. So this is the young me. This is maybe, I don't know 20 years ago or so, one of my clinic patients at the time, typical patient middle aged, African American woman with chronic diseases. So if you look at this picture, you might superficially see differences. Dr white coat lay person young Chinese American man, older African American woman. And I had trained as Megan said at San Francisco and Boston and many of my clinic patients in Boston were African American from the Roxbury and Dorchester neighborhoods. However, I rapidly realized come into Chicago that that everything is contextual Chicago compared San Francisco or Boston has an absolute numbers many more African Americans and a much higher percentage of the population is African American. And then here in Hyde Park south side of course there was the history, the local history and better within a national history. And so I rapidly realized that well you know I need to understand this history and in this context. At the same time though, if you go beyond the superficial appearance. This actually I think a lot that I have in common with my patients and that I think all of us have across many of our patients. This is my mom and dad's wedding picture. Big immigrant family, like my dad I think it has like 12 siblings my mom, 10 or something like that is big big families. And these are the boys and my, my father's family is siblings. And they all worked in the laundries. So there's Uncle Winthrop on the left was a women ladies man of the group. My father's father in the middle who I've never seen smile in a picture. Uncle Roger who was a die hard Red Sox man and he actually passed away before the Red Sox won the World's Service unfortunately, Uncle George was incredibly good with kids, and then Uncle Gilbert. And many of my uncles were very talented people, but they clearly was a bamboo ceiling in terms of what they could do. And most of the game they be honest and uncles were in service industries, laundries, which classic for immigrant families. Only jobs you get. And so they worked in laundries for hard jobs. This is a Victorian trading card from the 1880s. These were used as advertisements. So in the backlist card would be some firm advertising. So some company thought this would be attractive image to use to advertise their products. So you see Chinese must go the Missouri steam washer, you have the Chinese laundry man with sack of money, Ryan the China the Chinese must go. And so this is a long historical and current interest for structural racism against minoritized populations, oftentimes with an underlying economic basis of you know why why is this so terms of economic interest and all. This is equity. So, many of you seen this diagram I like this, this Robert just foundation visual. So equality, everyone gets the same size bicycle regardless of the needs at the bottom equity, everyone gets the appropriate size vehicle to maximize their physical function. So at the top of the talk about equity being the absence of avoidable remedial differences among groups of people with those groups are defined socially, economically, demographic or geographically. And then importantly, they add the social justice component health inequities also entail a failure to avoid or overcome inequalities that infringe on fairness in human rights norms. So, the CMS group that I coach here, this is the definition that we decide to use for health equity, which is largely the US healthy people 2030 definition with the addition of systemic racism. And you'll see that this definition incorporates the elements of the prior definitions. So equity, achieving equity requires valuing everyone equally with a focused and ongoing societal efforts to address avoidable inequalities historical and contemporary injustices, which includes systemic racism and the elimination of health and health disparities. And the very top you see the attainment of the highest level of health for all people. So you see that again the different elements previously mentioned incorporate into this one definition with the addition of systemic racism. So there's equitable health care. So one way of thinking about it is well how people have thought about how do you measure this, because oftentimes looking health care you want to have a metrics, and you want to be reward ideally, what people have to do well with equity. And so national quality forum they they were these accreditation organizations for metrics. So now six years ago, different domains for health equity, access to care, high quality care structure for equity, more about that a culture of equity partnerships and collaborations such as with the community. So many of you have heard of NC QA so he just measures. So they in the California healthcare foundation and more recent paper from 2023. The amount of overlap in the domains they talk about overall in the middle, which bottom line is the overall well being patients of populations. And then you see around these different domains equitable social interventions like health, social media screening, equitable access, equitable high quality care, equitable experience of care. So for example, is a discrimination and equitable structures that here so for example, how diverse are the personnel at the hospital. Do you have good interpret services for example, but it's just a way of breaking down actual health care into different components conceptually. I think we look at the definitions of high quality primary care, often sort of tracks well with what is equitable here. So some national cash support from three years ago, provision of whole person integrated accessible and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual's health and well being needs across settings and through sustained relationships with patients, families and communities. And I think you start to see too that well, you know, these are things that basically there's no this little incentive in the healthcare system to do this. You know, this is one of the reasons why there's a crisis in primary care. So we've done about a dozen reviews system, the systematic reviews of the health equity intervention literature, and this is the slide that summarizes well the bottom line. And so some ways is not rocket science that they all devolved down to like the bold statement that these successful health equity interventions basically encourage close relationship with patients and the whole city address medical and social needs. They have close follow up monitoring. So when I give a talk to clinicians, they all say, well, yeah, we know that that makes a lot of sense. More specifically, there are these are things like multifactorial interventions that address different drivers of inequities, constantly tailored approaches better than generic approaches. Good evidence for team based care oftentimes nurse like team based care, community health workers lay health workers, and then not surprising involving families and communities in the solutions. So as Megan said, I have, I have these couple of national roles. And the next few slides, so much are a lot of lessons come from these, these learnings, and both of these efforts they try to identify best ways and practices to ensure that payment flows towards healthcare delivery structures personal and partners that provide equitable care and outcomes. So I call this my magic carpet slide. And so I feel like the one of the big problems and equity is that we don't do nearly a good enough job connecting the dots on the pathway to health equity. So the far left represents where we are the far right represents if we had an equitable system. We often will do some general intervention like we may say well we're going to do a cultural competency training right, and then we're going to magically think that's going to lead to health equity or, you know, we'll do a policy intervention like well we're going to change from fee for service payment to value based payment and you know that will solve things, but that's sort of like wishful thinking magical thinking in practice, we're trying to change the behavior individuals that behavior organizations, and it's going to be a large model of why a certain action, whether it's a training, whether it's a policy action, how that leads to a change with each another change was even much change, which would lead to the intended change behavior of the people in organizations are trying to influence. And so one of our Robert, but just one of your program officers her mantra for our program as well. It's not payment reform for payment reform sake, but it's payment reform that supports and incentivizes the care transformation. It's not just any care transformation but care transformation that addresses medical and social needs, advanced health equity. That's one example of we got one sentence, a little bit of a cake in the dots. And there that has to happen then for it to actually work. She like schematic slides here. So, and they both depict variations of a road map to advance self equity. This is from editorial from three, four years ago. So you see at the very top there that this is all moot unless we really are committed to the mission of improving equity, and that we are intentional about things and you can get back to that thing about virtual ceiling performative actions that is everyone from the front line of senior leadership that is kinky lip service. I truly have to prioritize and put the resources in it to be able to then truly advance of equity. You see in the middle there's this this line about implementing a road map to reduce disparities. So losses false quality improvement principle so identifying disparity do your root cause analysis determine why the disparities this designing your interventions towards restless root causes designing payment to support that. On the left, though, you see culture of equity, and oftentimes we tend to focus upon the technical aspects. So something like you know design the intervention. What we found is that if you don't address the cultural part, you're rapidly going to sort of reach a limit in terms of how far you can go, probably because you need to have a buy in again of the different parts of the whole party organization to work the work. So this culture of equity probably is to understand the in your own personal biases this is where the cultural humility train comes in. But then this is newer. Those individuals as organizations identify those systemic structures that bias against an oppressed marginalized populations. So the, you know, Chicago like like pretty much everywhere, you know, hasn't embedded. And I think to the unit there is just credit, we're doing more so than 10 years ago, regarding having that harder inward look and we have a long way to go, but we're making progress. In the middle, the bottom line is that every worker has to know how to operationalize advancing equity in your daily job. So the local story is that we're in like year 12 of our official DEI journey here at university. And maybe four years to the effort we have a survey of the different staff and at the University of Chicago medicine. And at that point, like much the training had been more of the culture humility training at all. And so the feedback we got was that well, love the training, however, we don't have a focus idea of how we actually apply that to our daily jobs. If we are like an accounting or data analytics, or for patient experience and all. So it has to be tangible in terms of how does it, what does it mean in terms of people's daily jobs. At the far right, you see the payment part and then you keep a lot of interest now in the social drivers of health, both addressing individual social drivers for individual people, as well as the partnerships communities to address the systemic structural drivers in the community at the very bottom improving health and health equity. Okay, so here's in some ways the same, the same concepts, organized in a slightly different way. So I talked about how ultimately we have to change the behaviors of individuals and organizations. And if the goal is sustainable change at large scale. No one has all the power. So that's why both like the Robert Johnson Foundation effort and the CMS effort involves multiple stakeholders. It involves the payers and involves the health plans. It involves the healthcare to leave organizations like a university college involved community based organizations. So they have to work together basically to align payment care transformation all. So in the middle there that again for the collaboration is the work that has to be trust and motivation. There has to be a great leadership that has to be well functioning teams. It's got to be a shared mission and purpose and buying it all. You see the roadmap steps around that with the QI steps for your mission. On the far left, you help build a little bit more detailed cultures of equity. And so what we're doing here at the University of Chicago and then we're incorporating a Robert Johnson Foundation program. That perspective on this. I'll talk to you a little bit more about this, but part of it involved specifically addressing structural racism. It's just the intersectional systems of oppression. Addressing power and hierarchy event. Very importantly, there's a relational part to it. A lot of change at a local level, really dependent upon relationships and understanding those power dynamics. If you look at the second to last column, these intermediate outcomes on the steps based on equity, look at the first two up at the top in particular. So on the first stop is the technical parts implementing the care transformation implementing the payment forms. The second one is equally important is shifting the culture is shifting the policies is shifting the processes by which we work and act. And again, we go hand in hand the technical part and the cultural part. And that's one of the challenges because like there's not a lot of efforts that try to do this or do it well. And oftentimes the people who are good at one don't have experience the other. That's less the challenge. Okay, anti racist approaches so we use this as an example of like digging the cultures of equity and then structural racism being just one of a variety of different types of systems of oppression. And we'll make it come through care transformation payment. So some definitional things. So, I'm, I like my Jones's work in this area. She's the best I've seen at being able to describe racism in late terms that everyone understand in ways that are as non threatening as possible. So I'll go over her global definition event or three levels of racism. Her global definition racism a system of structuring opportunity and assigning value based on phenotype, ie race that unfairly disadvantages some individuals and communities, unfairly advantages of individual communities, and undermines the realization of a full potential of the whole society to the waste of human resources. So that last bullet you start seeing the parallel to them the definition of health equity, everyone attending their maximum health potential. Okay, structural internalized racism acceptance by members of the stigmatized races of negative messages messages about their own abilities and intrinsic worth is characterized by they're not believing in others who look like them and not believing themselves. She's a great speaker. And so the example she gives her talks about African Americans use this the example of white white man's ISIS colder. The idea that if an African American had a stigmatize a view. They would think, Oh, I'm going to buy the ice from the white seller advice because the white man's ice must be colder. Personally immediate racism prejudice discrimination where prejudice means differential assumptions about the abilities motives and intentions of others according to their race discrimination means differential actions towards others according to the race. So immediate racism can be intentional as well as unintentional. It includes acts of commission, as well as acts of omission system type of racism I think people tend to think about when they hear the lay word racism so this interpersonal immediate racism. And then more recently there's been more awareness and recognition discussion of institutionalized racism differential access to the goods services and opportunities are decided by race. This is normative sometimes legalize and often manifests as inherited disadvantage. It is structural have been clarified in our institutions and custom practice and law. So there need not be an identifiable perpetrator. Indeed, institutionalized racism is often evident as inaction in the face of need institutionalized racism manifest itself both in material conditions and access to power. There's been a lot embedded in that one paragraph that intersectionality. So the classic Kimberly Crenshaw. So she's like the actual the consequence back centuries, Kimberly Crenshaw is probably the most famous of the modern writers about intersectionality and the University of Chicago legal form is one of the most cited other papers in this area. So intersectionality the combination of intersecting systems of oppression that perpetuate discrimination and disadvantage based on factors such as race, class, sex and gender identity. If you if you have more time Google, Kimberly Crenshaw New York Times Clarence Thomas hearings, then you'll get a sense of like her own personal role that that story and why intersectionality is important to her. And particularly she's looking at like the feminist movement and intersecting with racial politics. So how does this matrix of health care. And so I think like for our Robert Wood Johnson Foundation program for many years we would have what I would call a general health equity lens, which is the the dominant way that think most people have equity think about it health care think about the equity issue. So we might phrase a question, like on the left, why do black children with asthma have higher rates of hospitalization than white children with asthma and anti racist lens might change that to being phrased on the right. Why is our health system less successful helping black children with asthma avoid hospitalization and what children with asthma. So one of the, so I mentioned we had done like these dozen systematic reviews literature. And when you look at the equity literature, the vast majority of interventions address problems at the level of the individual. So there's a lot of good things about that. You know we want to be pitch centered and tailor the individual, but in some ways that it's worse though it falls from the trope of like blaming the individual for their problems as opposed to looking at the structural issues. For example, we don't do nearly a good enough job in terms of thinking about what are the organizational ways that we have a stacked desk against minoritized populations, what are better ways we can organize the University of Chicago to better provide more equitable care, let alone then like the policy aspects of policy level at the areas. So when you ask the question on the right see the different lens it takes you on a different route, terms of the root cause analysis and then the types of interventions that you come up with. There's a lot more about critical theory. So, I thought about like care transformation and payment with equity lens and care transformation with payment form with a criminal consciousness and anti racist lens. So these are three of my colleagues. So the bottom left, that's, so I'm supposed to show up sees the Israeli organization sociologists and and so by and I we thankfully similarly. And elsewhere on the slide this Scott cook in yellow and a totic. There to the left of me politically, and they have very strong background and critical theory. And I would say it took like about a year of discussions between the four of us, where we understood one another language is very important and you use the same word, but have different meanings. So it literally took both myself a year to understand Scott and Yelena and critical theory and more detail. And I had to say that like the more they explain and finally getting it. A lot of what they say makes a lot of sense. So critical theory that emphasizes power analysis as an approach to understanding and transforming structures by targeting the root causes of social injustice. First, the political, social, cultural, historical and economic forces that influence individual behavior and they create principal patterns based on social location. You may hear this phrase critical consciousness. Paulo Freire pedagogy that oppressed the ability to read the world critically and take action to transform it. And then there's the process in a technical term that you may have heard of also the ongoing process of reflection and action aimed at understanding and transforming the world. That's why, for example, and I see David Rubin here. But those of us who I do training of a very bright help professionals about equity. This training does involve some element of self reflection exercises and part of that is, is part of this process of practice. If the goal is to motivate change in action. So what are the implications of this then so at the very micro personal level. So, think about our each of us as individuals is our ability to recognize the structural issues. So the relationship of relationships among people and mentions a little bit earlier. It's addressing the relational dynamics addressing addressing a discomfort with conflict and earning trust and sharing power community. And this is something that, you know, we're trying to get better at like from then our own Robert Johnson foundation program, the power dynamic one is a tricky one for example that some like health care and medicine surgery, incredibly hierarchical structures and you know no sort of server we did. We just organizational survey they're like these four different paradigms of organizational structure. By far the most dominant paradigm at New York Chicago report by staff is a hierarchical culture. So we're embedded sort of in a culture in organization which is just based upon hierarchy. So, and we don't do a very good job of discussing this in detail regarding some ways they're sort of benefits to it. So something like experience and you know the patient care and quality and safety and all the same time. But in terms of having honest discussions about a variety of charged issues. Measel organizational level mid level, ensuring equity focus implementation operations of a place like UCM macro structural and acting policies that support the micro and measel level efforts. So again, just like Kamara Jones is she has like these three different levels. Similarly, it translates to our actions and the way we think about equity in terms of interventions, these different levels. So, this is to me, I sort of think about one of the best examples about racism in health care and interventions and so I think maybe one of the best, the best example I can think of is obstetric racism. If there are any OBGYNs here. So when you read this literature. So racism drives much of the black, white inequities and pregnancy related mortality rates, preterm births and low birth weight births. And then when you look at the different interventions. They tend to address the the interpersonal bias and racism as well as the structural elements. So for example, this intervention is so called community support persons lay people who would be present and accompanying the patient throughout childbirth. And then that has been demonstrated to reduce patient report experiences of obstetric racism. So this pretty horrendous literature regarding qualitative research and the experiences of African American mums with healthcare system. So, it's just sort of like the analysis of like if everyone had, you know, that family member or friend who's going to be the advocate that is going to stick up for the patient. There so the many people here have a health care background and so you know the role when you're playing that role to basically be the watchdog over sort of a loved one or friend or family member. On the bottom bullet. The obstetric equity literature that they talk a lot about sort of reproductive justice and there are those in our here in our university so what really core her talks and whatnot. I have a lot of this. And I'll be another person. So these community informed models that incorporate principles of reproductive justice, such as midwifery, lead and doula supportive care, and also at least improve black perinatal outcomes. So strong literature there. It can apply to payment also so Kim single Terry and I we have this paper and a major on that face from about a year ago. We talked about different mechanisms to which sort of racism is built on the payment and then solutions. I'll give you one example and make concrete. There's a sociologist like Cornell Jamila missionary who's a UC grad teaching sociology I believe, who she writes about this and she writes submission histories about this. So 1965 great society programs president johnson is negotiating with Congress. So medic here national program benefits all to get the southern votes he needed to pass the legislation. The deal that was cut was a trade off of Medicare, Medicaid. So Medicare will be a national program federal control, Medicaid joint federal state control, which allowed the southern states may take control then over their African American populations. So you look at these heat maps, for example, where the greatest inequities are in the US. Well, the South lights up when you look at issues like where this under financing of Medicaid where Medicaid is least generous. You know, again, the South lights up. So, you know, how can you sort of have policy reform without understanding that historical context, which lives to today in terms of thinking about then those dynamics to play out in terms of trying to change. So, again, the thing about like insurance and Medicaid, well, you could do things to improve the scope of insurance to meet medical social needs. So things like covering health related social needs, encouraging partnerships between the healthy liberalizations and these community based organizations to address structural social drives of health. There's another sort of insidious one here where is it double standard like this is so much inefficiency and what what's paid for in health care. Whereas when you think about Medicaid coverage of the poor and marginalized, there's a higher bar, well, you know, policies have to be cost savings or cost neutral. You know, and as we know, there are very few interventions in health care that are cost savings. There's a lot would be cost effective in terms of improving health at a reasonable cost. And the criteria is cost savings, cost neutrality. That's a much higher bar as opposed to something like, you know, you think about Alzheimer's drugs for example and what has been covered by in the past, you know, it's just like double standard. So I just want to slide so more generally about payment so payment, you can rapidly go down these rabbit holes where starts getting arcane and complicated. I think though if you understand these free bullets, they'll take you a long way when you think about any type of payment initiative. So you might think about how can payment can be used to advance health equity. One, the first one is what people tend to think about just create a over incentive to reward someone for reducing disparities, advancing health equity, so called value based payment and performance based incentives that reward equitable processes and outcomes. The second is upfront funding. So for example, a capitation or you have heard like these programs that have a per member per month fee that's given to a place like University of Chicago. So you have upfront money that money could go to different places. You could go to steer holders, you could go towards the orthopedic wing, right, or it could go towards community health workers, right, or the IT systems that link patients then to social services. The third is then risk-adjusting payment for social risks. And so this is what the University of Chicago sort of complains about that they be a larger well. We serve a high percentage of Medicaid population and we get killed because the reimbursement rates are too low. So once putting solutions risk-adjusting payment for more payment for populations at higher social risk. So, about five or six years ago, I spent a summer in Aotearoa, New Zealand, writing a paper with colleagues there, comparing the two countries about how they were addressing health equity. These were the authorship team. Notable things, upper right, that's my mentor for that project, Sarah Derritt. And if you look in the background, you see sheep. And it is true that there are more sheep in Aotearoa, New Zealand than people. The far left, those were three of the co-authors who are Maori, the indigenous peoples of Aotearoa, New Zealand. And one of the best things about the project was that we had like dozens of these tough conversations and they were great. And my experience has been that when you talk to indigenous peoples, whether here in the US or, you know, whether American Indians, L.S. natives or native Hawaiians, Pacific Islanders, or the Maori in this particular case, they often are tough in terms of like really having the tough conversations. I think because, you know, historically they have been treated so poorly. And what they taught me was that when you do the deep dive, the root cause of this type, deeper, deeper, deeper, deeper, the challenge about the assistance of oppression, the challenge about this conversation is that ultimately power is the issue. This control over resources, this control over the historical narrative. So I mentioned a little bit earlier, this issue, I'll talk about more about this issue of like, you can have a historical narrative about blaming the individual. You know, blaming the individual for, you know, their plight versus, you know, to what degree has the system been set up to basically create a no-win situation. Control over frame of equity. So, yeah, we literally had like in many discussions about structural racism, colonialism. This is, we don't talk about this much in our country. And I think I finally have a better sense of colonialism after talking to Maori about this. In the US, we don't have a great issue about this. So the American Indians or things like the Philippines, New York Times had a recent article about this, pretty hard article about our colonial policies. So if you look at the Philippines, why are they, one of the few countries in that area of Asia where there's not sort of a strong tech background, they're very agrarian still. And so really it's a tough situation, how are you going to create sort of an economy that will benefit many of the people that basically have subsistence living upon farming. It's not by chance. And a lot of it's like the post-World War II and earlier policies set up by the US and social privilege. So many of you may have heard of this term and heard of Robin D'Angelo. She's a white sociologist somewhere on the white West Coast. She defined this term that got a lot of lay press, white fragility. Racial stress can lead to defensive emotions and behaviors in whites such as anger, fear, guilt, argument, silence, which is rural. It can be weaponized. And so the way my Maori colleagues put it, and they insisted on the sentence in our paper, discomfort cannot be a reason to avoid dialogue, or then white fragility would in essence be a tool to change inequities in the power structure. Oh, we can't talk about it. It's too politically charged. We can't go there. It's going to make people uncomfortable. A Maori point out that is, you know, when it comes down to it, kind of a lame argument to make to basically justify continued persecution of the Maori indigenous peoples of the minor organized populations. So solutions, looking for racism, searching explicitly and be intentionally into racist solutions, integrating the medical and social. I'll talk about distributed justice in the moment. Engaging the community authentically sharing power addressing mistrust. You've heard this phrase progress moves at the speed of trust. And then communication and I'll talk more about this is storytelling and deep narrative. And this teaming up being like I call it on yesterday that if you don't speak up if you're not attentional about this, they're basically is invisibility. This is my wife and we wrote this paper about Asian Americans and a whole variety of reasons why too often all too often Asian Americans are sort of invisible regarding social racism. Okay, ethical issues, McLean conference talk. So, some of this is influenced by one of my teachers do the sclar, and I'll talk more about it later. And so liberalism, I'm talking about liberalism, not as liberalism assertive but liberalism the moral and political philosophy. This values individual rights and liberty. And it's a type of the US holds the individual responsible for their situation. The US downplay systemic structural factors that influence outcomes. One of the best course I took in college was a literature course, it was entitled the myth, the mythology of America. And so if you think about things like the Western and like the mythology of the the rugged individual law man right, or, you know, the old racial Alger, pull yourself by your bootstraps type of stories. Again, that US individualistic perspective downplaying the structural. And then government. So the US brand of liberalism emphasizes the role of government and protecting the freedom of individuals. You know, you can still be have a liberalism philosophy and say, Oh, we're going to prioritize using the government to enable individuals to maximize the potential, including health. But we have a former terms of protecting the freedom of the individual. That has economic implications. So we tend to favor the individual rights to property and take sort of as a given the value of the unfettered free market. So we accept the externalities in the in of a free market system in terms of the problems in terms of distributive justice. So paper, if you haven't seen this well worth reading the first author Joe brush was in the Department of Public Health Sciences senior office calling Rogan from social service administration. Short article very well done. It reviews the financialization of health care in the US. And then it's kind of a sad story the siphoning of healthcare dollars, many of them governmental like Medicare, Medicaid, into profit for shareholders outside the healthcare system. So it's not, I don't think what the, what the public or health or government had in mind then in terms of like a Medicare and Medicaid dollars. So I'll turn to ethical frameworks, I'll talk a little bit about distributed justice and utilitarianism to justice beings the socially just allocation of resources and opportunities society utilitarianism maximizing utilities. So, you know, we've, we've had roles here in terms of like the fellows. I saw him once so I went shopping shopping period I went to first one of one of his classes and it seemed like it's going to be over my head so did not go to class number two, but you know they talk about the veil of ignorance so that I do they might We developed a society based on before we knew our position society before with we knew if we're going to be rich or poor black brown right brown, whether we're going to be a man woman or gender fluid. We would come up with a fairer situation than the current system where inevitably those with more power tried to influence the system so that it accrues their self interest utilitarianism so policy wise we have this in the US, this inherent push back we all see provisions against using societal cost effectiveness analysis to allocate resources. Again, probably a large part is the self interest of organizations that stick special interest they benefit from not having cost effective analysis. And you know my healthcare industry I mean we're guilty also we are reluctant to allocate wasteful resource expenditures towards health equity. And I think you know the healthcare providers and staff here, we're all aware of the plenty of a race in terms of how we allocate our money. Okay, so this is to the sclar she's them. One of the two or three best teachers ahead in college. I am had her as a teacher towards and of her career. Physically short, I think probably less than five people, incredibly intimidating and absolutely brilliant. Wonderful teacher challenge you all the time. This was a course where we read like original texts like 300 pages of original texts, each week so Edman Burke, J. S. Mill, Michelin populism marks hitler we read my com for Nazism. And squires interesting because she was born Jewish in Latvia. And when she was about like 1311 13 years old, her family. I think it was like, somehow like the Canada, eventually ended up in the US but emigrated 39 so just missed Nazism and Stalinism. So it's the miracle that she survived. But I find her compelling because brilliant thinker abstract thinker event you can tell by her writings and her talks that she had her worldview was rooted in live experience of the excesses of the left excesses of the right. So it's a very interesting woman. And so during like like her eulogy or during like a special issue devoted to actually passed away one of her colleagues in Harvard wrote sclar once wrote there were two kinds of political scientists. Those who study power because they like to exert it. And those to study it because they fear it. Those who like to ride the horse of power and those who are scared being trampled by it. They make this distinction between Henry Kissinger being with the former, really a power guy, and then sclar would be the latter terms of like the fear of power. And sclar wrote that she that self that cruelty was the worst sin. She defined cruelty as deliberate infliction of physical and secondary emotional pain upon a weaker person a group by stronger ones in order to achieve some end. And then she argued that by putting cruelty unconditionally first with nothing above us to excuse or forgive as a cruelty. One closes off any appeal to any order and that actuality, and she specifically mentioned like religion or politics being sort of like these extending any arguments to put cruelty first their force to beat us not only with religion but also with normal policy as well. And then you think about it like in health care. Well, you know, I'd argue that two tiered under resource healthcare systems that lead to health disparities for marginalized populations are cruel. The healthcare delivery systems and payment systems that are not designed to meet the medical and social needs of marginalized patients are cruel and that systems that accept the status pool and ignore racism disparities are cruel. Credit to my wife Noko Muramatsu and then Harold Pollack from the epic center for help getting this SEO with a finished line that I kept rejection and rejection and rejection they said look rethink it so they become co-authors help me redo it and then get accepted. One of the great things about writing articles I found this article by Tony Morrison, the Pulitzer Prize winning novelist, which may parallels between racism fascism as tools consolidate power. So I think have and this was written in 1995 so that five 28 years ago, but I think it has incredible relevance for 2024. And so it parallels both say construct an internal enemy, isolate and demonize the enemy, and list and create sources and distributors of information, who are willing to reinforce in that demonizing process criminalize the enemy, reward mindfulnesslessness and apathy with monumentalized entertainment and little pleasures, maintain at all costs silence. So, you know I think like if you read that you would not know whether we're talking the sclar of 1939, whether we're talking today is equally relevant. We end our last paragraph of our articles a sclar understood that persistent cruelty, more frequently results from the failure of bystanders to intervene and what Dr King rightly called the appalling silence of the good people that it does from the outright ended by the few to be serious about American cruelty. We must all use our personal agency to address structural racism and other system oppression, medical and nursing social work and public health communities have special responsibilities to exercise this vigilance, even the severe health consequences of cruelty. So does everyone else. So, sometimes, you know I'll give her talk and people say well yeah so much a lot of sense Marshall sounds incredibly pessimistic so you know what what what glimmers of hope do we have what do you just move on ahead. And so I'm going to spend the rest of the time talking about some aspects of that, above and beyond the special things I've already mentioned regarding things like the payment and care for information. I think through communication. So, ran corporation survey 2016. Basically found that the public supports a fair and just opportunity for health. So question our society whatever is necessary to make sure that everyone has equal opportunity to be healthy. Two thirds of the population degree. So why does he has such as hard time than getting such legislation and policies past part of the problem is communication. And so this is a figure from AMA WC they have this language narrative about equity. And they talked about this pyramid of messaging. So at the very bottom you might have any given thing you you write or say there's a message right in their words images that convey that message. They have a story, you know, conveying a story above that that's a narrative, a collection of stories and messages that represent an idea or belief. They highlight the values, they define the problem, determine the solutions and actions. Then more seriously you have deep narrative, the deeply held values that have repeated and been reduced over time they're baked in. So for example, we're currently working on the structural racism paper Asian American racism, we're highlighting three non health sectors which one is the media. So we give countless example and I think it applies to just what any type of mark my notary's marginalized population of like the biases that stereotypes that are present about Asian Americans in films or Asian American the media and whatnot, you know, you would be able to identify what these stereotypes are. The problem is that like for the most of the population being exposed to this is part of deep narrative, so probably powerful in terms of like the beliefs that people implicitly have. So people that Monica peak of muckabella and I wrote from three four years ago, which while practical tips about teaching about race and racism most one of them is you start with stories you don't start with facts. The point being they start with facts and statistics. People because people are not a, they basically tune out when you start that as opposed to starting with stories and the live experience. So, how do you message. So the rock pretend that just foundation they, they hired a communications firm to do focus groups across the political spectrum so from the far right to the far left. And trying to figure out what was the best way to message about social racism. So this is the visual that works on the left you see the bridges barriers so structural racism will be things like industries put toxic dumps in neighborhoods. And this makes it easier to find liquor and healthy food. The far right you find the proactive part so you have anti air pollution laws, people can get quality healthcare from doctors who respect them public budgets funds schools and parks. And then there's actually words and ways of phrase and organize and message which works. So you have two examples and I'll read you one of them. Again, it's pulled well across political spectrum. So first you start with shared values. We all want to live in the United States where everyone has a fear and just opportunity to reach their best health and well being, no matter their race, ethnicity or class that's a shared value. You think segue into positive vision. That can happen by making sure everyone gets quality healthcare from doctors who respect them. It can happen when families living communities with well funded schools and parks, instead of included air and toxic waste dumps and in neighborhoods with access to safe and affordable homes. We can build society where people can move up economically and socially. Then problem statement. But this is not everyone's reality today. That's because there are barriers built in front of some of us that create an equal opportunity and threaten freedom and prosperity. And then end with call to action by joining together and then unity statement, we can unite create a better future for everyone's children and grandchildren. So you can mull that over and then when you think about it is a certain common sense that you go oh, I can see that working. And again, they empirically test this in these different focus groups. So I'll end with this. And so one thing Megan put in my the bio is that So my other wife, my wife and I started training and performing an improper standard comedy six or seven years ago. And one of the fun things is we found that the skills were learning actually translate well to the day job. It's translate well to teach you about equity. And so, so we published about this like in the fact like the fellows. We've done such some ethics fellows and prior years. And so anyway, like the Harvard's Kennedy School government. They have this project called the journalist resource where they try to they have this list of like 45,000 journalists and the overall part of that effort is to try to train a journalist to be more informed about different issues they can write better or informed articles. And one of the ways they do that is they participate with the called graphic journalism. And so this thought that this topic would be good for a graphic journalist article and then there's a gift a graphic journalist, Josh Newfield. They're not abridding this article that feature three academics with myself and two others. They're just online at this journalist resource and the show sometimes place in one of the Sunday editions, basically uses comics to then to introduce people to these companies have issues about communication and equity and whatnot. This is the Sun Times story. So classy sometimes a Sunday story, you know, your Chicago advertisement at the bottom, right. So the very top is the reference to our article right below that. So Chicago, Burke now 38th council member convicted in the half century. And then above us. So on the front made the front page, then the reference to article and then a six pages in the middle of the article. So again, that's me. So my my son's, you see, I say, Oh, the article. My son said, no, she says, you know, well, it made you look like the Chinese American Barack Obama in this picture. Yeah. But you can see examples very bottom for example you see like talking about improv and empathy and listening building relationships recognizing how the patient perceives you. And like the work of two of our graphic medicine folks, Brian calendar and Shirley obu obu who have this self portion exercise that's trying to help people understand and their, their colleagues lives better so that actually is my self portion of no artist but you're supposed to do a self portrait and the things that are important to in your life. And this but as an example. So, let's see if it was an PR here, WB easy local Chicago PR they have a week lunch hour show called reset with session and silence so they've heard about they saw this sometimes article, and they ended up interviewing and I think we got like it's like a 15 20 minute segment about that piece and then the water issues raised but equity and teaching and equity and racism, etc. So, you know, it's just a way to reach a broad audience. So a few questions and then then then we'll break and then we'll have time for fellows. So, so, so bad as first question. That wasn't intended so question was like did I intended definition of say that the health care is inherently health care systems inherently racist and is one of the sources of the structural racism. And I think it goes, you know, it's some ways that were the creatures of all of our environments and so it ranges from like as we talked a little bit of the media images and all to essentially how power plays out in regarding trying to create in other other rising people of which race is one way to other people, and to take advantage of that that that population group to enhance his own power so in the case of like race and African Americans well you know, a lot of wealth this country was built upon slave labor, you know. But, but, you know, but I think we're kidding ourselves if we don't say, if we don't admit that a lot of the ways that we have set up health care, the way we organize care, the way we pay for care. These racist structures are already sent in. And it's been organizational and policy level is the regulations to the policy since the way do we do things. So again, as part of this like hard anyways looks that organizations including your Chicago are trying to do now. You know, it's not comfortable and there's no one nice to sort of look at oneself in the mirror and say, you know, there were some things that we've done as organization or the way we're set up that are inherently racist or two tiered. And I'm going to go with them stories, you know, the same stories regarding BAS stories as well as in some ways like this is actually a great history of like on the clinicians and staff here. Saying no terms of like some of this. ED is an example in terms of those stories there. But it wasn't my intention to imply that well the source of the racism is the system. Yeah, so I think regardless of whether you're a conservative or liberal or whether we have a democratic Republican administration. There are a variety of potential ways to improve situations from a public perspective that could work. And regardless if you like if you're a part of a feder free market or or a regulatory approach. The thing to do is well how do you create a business case for doing the right thing, a business case for supporting is so called social return on investment. You know, in some ways, so there are those who are well you can't blame you know healthcare you can't blame your Chicago for playing by the rules the game, you know, this is the way that the system is set up and then so you hear this well no margin and then there's a certain truth to that well you know you have to have a positive revenue line to do the mission of the academic health center and all. But why not set up a set of free market rules and incentives a set of a set of relations where it's in everyone's interest to have search strive for then equitable outcomes equitable process peer equitable quality of care. Yeah. So, you know, it's one example. Why not have a pay performance incentive which is you are giving more money if you have reduced an equity in your care. Yeah. So lots of topics a lot you can ask about fire ahead.