 Good morning, everyone. Again, some of us have settled out earlier in the morning at the social equity caucus meeting. And we are now on YouTube, so this is the House Health Care Committee. Welcome. It's the 10th of February and 9am. So this morning, and actually today, our committee is focusing on issues of health disparities. And this morning, we are going to first hear from Susanna Davis from the Office of Health Equity, or not the Office of Equity for the State. Apologies, Susanna, I want to get your title properly. Executive Director of Racial Equity. And after we hear from Susanna, we're also then going to be turning our attention to the introduction of the Health Disparities Bill H210, which was introduced yesterday. And we will be hearing from Representative China, as a member of our committee, who is the lead sponsor, as well as a number of witnesses who helped develop that bill. So with that, I want to welcome Susanna Davis to our committee and invite her to share with us recommendations and information that has been developed as a part of her work with the Task Force, particularly focusing on health and health disparities and recommendations. So good morning and welcome. Yes, I am Susanna Davis, Racial Equity Director for the State. And I am pleased to be here today. I'm going to talk a little bit about the recommendations that came from the Racial Equity Task Force in its September 1 report to the governor that was also made public. And I think it was shared with the committee. The purpose of that report actually let me back up and talk a little bit about what is the task force, how did it come to be. So in June of 2020, the governor created the Racial Equity Task Force and assigned it three main charges. The first was to examine systems of support that exist in Vermont for communities of scholars generally. That was the first report. The second would include the following two items. First, any changes to state law that could be made to strengthen protections against hate speech, including displays of hate symbols such as Confederate flags. And the second item for that second report was the ways that we could get more diversity in public office at all levels in the state, including boards and commission. So the task force did complete that second report on hate speech, free speech and public office. It was made public, I believe last week and I, if it hasn't already been shared with the committee, I'm happy to do so. And I think that that second report really builds on the first one, which discusses systems of support generally. So that's the one, that first one that I'll be talking mostly about today. That first report has a lot of discussion around COVID-19. It was explicitly mentioned in the executive order to evaluate systems of support broadly, but also in the context of COVID-19 health disparities. So I'll talk about that today. The task force itself, we're very proud of its composition. We have about 12 members and designee. And of those 12, six of us are women identified, five are women of color, nine are people of color, and that includes members of the Indigenous and Asian and Latino and Black communities. At least five of us speak languages other than English, including people for whom English is the second language. At least three were born outside the US, including people who arrived to the US as refugees. We have three generations represented. We've got members of the LGBTQIA plus community, the community of people living with disabilities. We've got small business owners and each of us lives in a different town in the state across seven counties. We've got parents, grandparents. So it's a diverse group. And I don't just mean racially and ethnicity diverse. It's a group that has given a lot of consideration to these questions and has relied on lived experience. And those lived experiences vary widely. So let's talk specifically about the recommendations. The health related recommendations that the task force put out in its first report largely have to do with COVID-19 and the COVID-19 response. But something that we've got a shout from the rooftops and we can't say it enough is that COVID-19 exacerbated existing disparities, not just in health, but in other sectors. And so a lot of the recommendations that came through the task force about COVID-19 response are really things that are more systemic in nature and are going to move the needle on health equity beyond and outside of COVID-19. So, and I apologize if you're hearing background noise that sounds like someone is sawing wood. It is unclear to me why a person outside in the snow would be cutting wood. So here we are. So thank you for dealing with that. So let's talk about the recommendations. I'm just going to list them kind of rapid fire. And then, and then dealt deeper. They fall into four main categories. One is language access to access to testing. Three is data collection and reporting. And fourth is the economic fallout. Now, again, COVID-19 has created a lot of challenges for people, not just in health, but in a lot of other sectors. So when we talk about health disparities, those campaigns, right, we all know, and I don't need to preach to this committee. You all are well versed in this, but health disparities create economic turmoil to people. And the economic turmoil leads to things like misderemptain and evictions, dings to your credit score, medical debt that prevents you from being able to get credit for other things. It stunts your ability to seek certain kinds of employment, or maybe you can only look for employment that has employer sponsor healthcare. It has downstream effects. The impact of our health affect our work performance, our school performance, which affect our outcomes, promotional path, et cetera. So all of those things have to do with all of those things. I'm going to list through these recommendations and then go back and kind of explain them. There are 15 total that we have listed under COVID-19 response, and they are as follows. Mandate that all communications related to COVID-19 be translated into Vermont's most commonly spoken languages. At each testing site provide COVID-19 educational material in the most appropriate languages for the region and give out PPE. Ensure that COVID-19 related grants, whether awarded to or administered by the state, include line items for translation. Contract with or facilitate subcontracting with refugee and immigrant service providers and or translation service providers if the state or grantee lack cultural and or linguistic expertise to provide core COVID-19 related services to people with refugee and immigrant backgrounds. Continue to consult with entities such as AALD and USBRI to ensure that people with refugee and immigrant backgrounds can access unemployment insurance and pandemic unemployment assistance or future versions of that benefit in a timely manner with efficient troubleshooting. For COVID-19 tests administered to limited English proficient people, ensure that interpreters with all patients are relaying accurate information. Ensure that people experiencing homelessness have access to testing and support increased infrastructure for homeless Vermonters impacted by COVID-19. Address testing accessibility issues by collaborating with community organizations that serve marginalized groups locally to design and coordinate walk-in testing sites. And again, a lot of this has to do with testing because this is September at the time we were doing more testing and there was not as much vaccine work happening. Assess which locations in Vermont have not had access to free testing without referrals needed. Using that assessment, prioritize test kits and human resources to allow more focused testing for vulnerable populations and those in outbreak areas who lack resources for transportation. Conduct broader testing in prisons in state and out of state. Increase VDH resources in COVID-19 test results data entry specifically for efforts in collecting race and ethnicity data from COVID-19 test results. And retroactively include all race and ethnicity data including manually entering race and ethnicity data from TAPOR COVID-19 test results. And assess and ensure that moving forward hospitals are able to digitally transfer uniform data reporting on race and ethnicity data with their COVID-19 test results. Collaborate with community and health organizations to provide training on cultural humility and best healthcare form intake practices to providers that administer COVID-19 tests. Have VDA to work with the Executive Director of Racial Equity, the Racial Equity Task Force and other stakeholders to create a better system to collect, track and report race data regarding health disparities from the Vermont Health Information Exchange to monitor and analyze racial disparities in healthcare on an ongoing basis. There's two more, stick with me. Establish a state-level relief fund for remodels who were barred from receiving federal stimulus payments due to their or someone else's immigration status. And finally, ordering an in-depth assessment on people of color who have suffered income losses. This should include but not be limited to job losses and closure of minority undisputed. So those were the 15 recommendations that we expressly put under the COVID-19 response category. I do, of course, repeat the caveat that this was issued in September and deliberated between July and August. And so health related inequities today in February looks a little bit different than it did four months ago because now we're talking a lot more about things like treatment and vaccine and a little bit less about things like testing. I'm going to stop there because I just talked a lot at you. Just to pause and see if anyone has questions or anything to repeat something. Okay. Thank you. Suzanne, would you either now or later in your presentation or after as a part of your presentation, would you be able to update us on issues that have emerged subsequent to the report in September around COVID, vaccination, et cetera. That you shared some of that earlier this morning, but perhaps some of that either now or whatever it's most appropriate from your point of view. I can do so now. So the, I have had a lot of conversations with members of the community and with representatives from the health department and others and partners and other jurisdictions, et cetera, to really understand the landscape in Vermont and the vaccine, the a correct vaccine strategy. And you know, the thing about Vermont is that by comparison, the community of people of color in Vermont is small, but it experiences we experience outsized disparity in things like infection rates, death rates. I mean, you name it disparity and pretty much everything. So one of the things that is true nationally and the elements of Vermont is that people of color are disproportionately vulnerable to this virus, not because of things that are inherent to us from the genetic perspective, but because of largely factors that contribute to poor health outcomes. Things like living in counties that are more likely to have PPM 2.5 kind of particulate matter and for air quality, which means things like asthma, which then leads to things like less physical exertion because of asthma, which leads to things like diabetes, right, or living in a place that's considered a food desert or a food swamp, which means that your nutrition, your nutritional profile is probably more likely to give you things like diabetes obesity or heart disease. A lot of these epigenetics factors have to do with housing, it has to do with the siting of health deleterious or health promoting neighborhood amenities. It has to do with factors that are outside the control of whoever's got the vaccine and the people that said, even apart from that we have seen a lot of their evidence that show that people of color are at disproportionate risk of infection and death and therefore should be prioritized for vaccination if they choose to receive vaccines. So, in Vermont, the data show that the greatest loss of life to COVID-19 has occurred in the senior population. And so the state, I think initially took a strategy of saving the most lives by pursuing a primarily age banded vaccine strategy that prioritized people in higher age groups and then increase the pool of vaccine recipients going down in age. Now, the thing in Vermont is that people of color tend to use younger. And so if we're pursuing a purely age banded strategy, then we are necessarily putting people of color at the end of the line because we just are younger on average. And I can get some numbers about that. The median age for white Ramoners is 45 years. The median age for indigenous Ramoners is 47 years. And the median age for all other Ramoners of color is mid-20s, so 25, 6, and 7, depending on relationships. So, considering that it became clear that a prioritization strategy outside of or rather parallel to age banding would be necessary to ensure that people of color would not remain at an outside, outside vulnerability due to something like not being old enough to be vulnerable by age but still clearly being vulnerable. And another thing that's important to keep in mind is not necessarily everybody who is getting prioritized and a want a vaccine. And so a big piece of this is education and outreach. And so it has been really important not just to make sure that people have early access to the vaccine if they're part of vulnerable groups, but also to make sure that they have access to whatever educational materials they need. And so it's a form decision that's right for them and for their families on whether to get a vaccine. That said, this really necessitates a lot of language access, translation, interpretation, etc. One of the recommendations that the racial equity Task Force made separate from this report. I know it feels like I'm jumping around a lot. I'm sorry. One of the recommendations that the Task Force made outside of this report separately was to go to vaccinate to put priority for vaccinating cultural brokers and interpreters because these are folks who are often omitted from vaccination plans. For example, they're present in the room when patients are being tested or, you know, having an intake or being vaccinated or what have you. But they're not, they're often not part of hospital staff. So they're not part of the hospital staff vaccination plan, but they're not explicitly considered priority either because they may not be in the current age group. And so they're kind of flipping through the crack. They're very much frontline. They're very much in the hospital at these meetings with patients. So that was something that there was a community collaborative that strongly made that recommendation and the Task Force supported it. So thinking about where the folks who are helping the language access being realized and are we ensuring that their physical presence is not a jeopardy to their health was another important piece of this. So where we ended up is that it's very clear that communities of color are disproportionately vulnerable here. And as such, there should be heightened prioritization for these extra vulnerable people to be able to receive vaccination. That was a recommendation that came from the Task Force and also from the racial equity advisory panel, as well as a number of collaborators and ad hoc communities that were created on this topic. Thank you. We have, we will be also reaching out to Dr. Mercedes Avila to testify she testified with our committee during the last biennium about health disparities generally, but as she had just also presented in the social equity test for the social equity caucus. We will be reaching out to her to come and share some of her presentation with the committee as well. So I thank you for outlining some of those concerns and I think there was another, there was a, rather than continue with my questions, I think there was a question with did represent Goldman did you have a your hand up earlier. I was just wondering, I'm not an auditory person and you were, you know, listed a ton of recommendations which were important and I'm just wondering, is there a link to that. Yeah, absolutely. She provided that link to committee members from Colleen that was sent recently. So each, you should have a link to that report, which I did use in the last several days so may have. Are you looking at the September 1 2020 report is that the one you're thinking of. I believe that's the report, that's the report that is being referenced. Is that right. I was understanding that they were updated recommendations but maybe I misunderstood I'm sorry. Yes, let me clarify thank you for that. I just put into the chat the links to both task force reports. Report number one is the one that contains these recommendations that I've just discussed, and to save you. And to give you the stress, please note that the last two pages have all the recommendations summarized, so you don't have to read them in paragraph form. There was rep Goldman you're correct we did submit an additional set of recommendations directly to VDH. Those are not included in the report. They have to do more with vaccination strategy and I can forward those to the committee itself. Great. What would what would make best sense at this point. Would you like to continue to share some of the recommendations or are there other pieces of this report that you would like to bring to our attention this morning. Well, perhaps I could give an update on some of these a number of these recommendations have already been implemented. As a matter of fact, one, at least one of them was already underway at the time that this report was published that was the state level release for those who excluded from CARES Act funding through the immigration status. So I'm very pleased to announce that that is the economic stimulus equity fund that this body passed last year, and it is in the implementation phase. I think in our first two weeks, we must have gotten over 1300 applicants, which was more than a fifth of the total number of applicants we thought we could have. And it took a lot of work. The contract partner we have been working with is the Vermont Community Foundation. But they in their wisdom recognize the importance of working with community groups who have close ties to historically marginalized groups, so we would want to see apply. And so this has been a huge lift, a team effort that includes everyone from, and I don't even want to mention CBO because I'm going to forget some of them, but it's a lot of the folks you may be thinking about AALB and migrant justice and CBOEO and a lot of other organizations. So I'm very pleased with the progress from that. We have, as you know, moved away from mass testing and done a little bit more targeted testing. And of course, now we're doing less testing and more vaccination. So a number of these items were implemented over the last few months, but the focus has turned to testing. Now, I cannot say that there has been widespread and explicit focus on communities of color for the vaccinations yet to the degree that I think many of us would like. I am aware that there have been additional pop-up sites placed in places like Winnipeg and that we are vaccinating members of multi-generational households who may not be in the upper age band, which is absolutely some of the stuff that we should be doing. Because that's a way that you can get at those disparities. So I know that schools are underway and we're building that out, but I don't think that we're fully there yet. I have to say that because us having made the recommendations different than it being included on the ground. So I needed to say that. What else? Those consultations that we recommended with groups like USCRI and AALB were being done. We are working closely to do things like translation videos and written translations, which has been very helpful. And there was actually grant money, I think federal grant money that was allocated for improved data entry. We heard anecdotally from folks that some providers in some of our southern counties were still using a paper and fax system to deliver information to the state, which proved clunky and sometimes a little bit inaccurate. So there was grant money that was used to improve that so that we have a unified reporting system. So I suppose that those are the exciting updates on these recommendations. Are there other parts of this report or the next one that I would like to highlight to your question, Mr. Chair? And I think the answer is yes. Our second report, which was just made public, its first recommendation is that the state to clarify racism of public health emergency. This is something that has been done already in numerous jurisdictions. The city of Burlington has done it and places outside the state as well. And the biggest question that we get is why? What does this mean? What does it do? And what it does effectively is, first of all, acknowledges systemic racism exists and is a thing and that is huge. The second, and now that the state hasn't already made that acknowledgement, right? But doing so formally through a declaration of the public health emergency brings with it certain weight. For example, we know that systemic racism has a lot of downstream health impacts. Everything from mental health to physical health. We talked about the impact of nutrition. We talked about the impact of poor air quality, et cetera. So by acknowledging the downstream health impact, it gives us the responsibility to do something about it by recognizing formally that systemic racism is a cause. It then commits us to addressing that cause explicitly and directly. And so this declaration is more than a symbolic gesture. It is in fact a formal acknowledgement that systemic racism is not just a nebulous concept that everybody feels bad about. Not everybody, but we're working on that. But rather that it is an explicit cause of tangible and measurable downstream outcomes that are harmful to public health and that go against the aims of, for example, the 186 population level outcomes. So that's another item that came from the second report that does have broad health implications and just social implications generally. You will also find that a lot of these recommendations have big impact on mental health. For example, our second report talked about school discipline and oppressive disciplinary tactics. We talked about the importance of helping students to make sense of the world or rather having curricula in schools that teach against hate. We talked about the impact of harassment and bigotry and discrimination for people who may be considering serving in public office. It seems like every week there's a new story about a person of color who is in a position of leadership at the local level who has left that position of leadership due to poor treatment, harassment, threat. So the impact on mental health really cannot be overstated. And so a lot of these recommendations do not appear to be directly related to health in the way that the committee might be considering. But it's a huge impact on the emotional and social well-being of our community. It feels as if I'm talking so much, but there's a lot to say and I just want to pause to see if you'd like to refocus me or if there's anything I can expand on that. Well, let me say that I appreciate that the, from where we started where you started that the COVID pandemic has revealed the underlying system disparities of the healthcare system for people of color that this is not just a momentary point in time based in the pandemic, but something which requires ongoing attention and action, not just something we must address it during the COVID emergency, but that alone is far from sufficient. And so I think what I hear you saying as well is that it's making tying those connections to the underlying issues around mental health, around hate speech, around school, inappropriate targeting and disproportionate targeting of students of color in schools and discipline, etc. So I think those are the kind of important links that we need to be hearing about in addition to the specifics around COVID. And let me let me turn to several committee members have questions and then we'll come back and there's some areas that we I'd like to ask you to speak about further as well. Yes, thank you. Commissioner Davis, I wondered if you could give me a specific concrete example of systemic racism in the healthcare system. I am so glad you asked. I will give you an example of systemic racism in healthcare, not only in a way that directly impact health concretely but in a way that impacts our ability to trust data. So, a lot of people do not know that black Americans are overdosing and dying of opioids less than white Americans are. Well, that's great. We're one of the black people. But in reality, this actually highlights underlying discrimination. You see the reason that black Americans are overdosing and dying less opioids than white Americans are is because they're being prescribed opioids at a lower rate, and that is for two main reasons. Number one, it is often presumed by medical professionals that they will either sell or abuse those drugs and therefore they are not prescribed them even if it's appropriate for their treatment and care. The main reason that they are under prescribed opioids is because there are deeply ingrained stereotypes about patients of color that imply that they have that we have higher tolerance of pain, and that therefore we can take it, even if those treatments may be appropriate for our medical care. And those assumptions don't come out of nowhere. If I may, I'd like to just very briefly share one slide. Let's see if I can find it in a reasonable amount of time. And that slide is going to demonstrate where that preconceived notion about pain tolerance comes from. Where are you? There you are. I don't have screen share capability. Well, I will paint you. We can provide that. Colleen, would you provide Susanna with screen share capabilities, please? Yeah, she should be good to go now. Although I think, at least on my screen, Susanna has frozen up. Let's just pause. I'm getting a message. No, I think it doesn't like. Oh, dear. Oh, come on, don't do this. Susanna, you might turn off your video. It might be that the internet is not strong enough to both screen share and have your video going. Sorry, I forgot you could still hear me go ignore my outburst. I got kicked out of the call. Back. Well, now you're muted. I don't know. Yeah. Okay, my bad. I got kicked out, but I forgot you could still hear me, but please ignore that outburst. It doesn't appear that I can share, but that's fine. I'll just, I'll describe it for you. It's an image of a textbook, a published textbook for a nursing student that lists different racial groups and describe pain treatment for them. And it says things like Jews, Jews may be vocal and demanding of assistance. They believe that pain must be shared and validated by others. It says that indigenous people may select a sacred number when asked to rate pain on a pain scale. It says that blacks, blacks often report higher pain intensities and other cultures. They've been pain and suffering or inevitable. Chinese clients may not ask for medication because they do not want to take the nurse away from a more important path. Hispanics may believe the pain is a form of punishment and the suffering must be endured to enter heaven. So these are things that are being taught to medical professionals in their early education, informative time when they're developing their understanding of their profession. And so those are some of the underlying reasons, the systemic factors, if you will, that give rise to disparity in healthcare. That's just one of many, many examples, but it also is an example of why we have to make sure that we are being data driven, but thank you so much for that. Of why we're being data driven but not data hostage. Being data driven is recognizing the under prescribing of opioids because of these disparity or discrimination factors. Being data hostage means looking at a lower overdose rate of black Americans and saying, well, that's a good thing. So we don't have to do any work here because that's a positive, it's a positive data point without recognizing it's actually indicative of deeper disparity. It's a long answer representative, I apologize for that, but I hope that's one example that helps to clarify. Well, of these things you cite here being taught now, that's from right now, that physicians are being taught this. I would question that very strongly. And I would tell you that your example is not systemic racism, it's people being racist. If they're doing it, it's not the system, it's people. And I think throughout this whole thing, that's what it is. It's people being racist. I think the field is level. I think people need to be changed. That's my two cents. Thank you representatives. So our systems are made up of people. Our systems are just collections of individuals. And so individual racism is what creates individuals to create policy. And then that policy is systemic. It is enforced broadly and systemically, and it becomes systemic because it is the collection and the product of individual biases. To your earlier question, is it still being taught? This screenshot of that textbook is from 2015. It is relatively recent. That particular page was pulled from that textbook. I think it was McMillan with the publisher after backlash around it. But an important thing to note is that while this particular textbook has left this explicit page out of its future textbooks after that, up until this time, up until that year, it had been taught and it had been taught explicitly. And so when we look at the medical profession, we're not just looking at doctors who are nurses who are graduating after 2015 who are not seeing it in textbooks. We're talking about the body of professionals who, for whom that became deeply ingrained truth in their mind. So I appreciate your questions. Is it still being taught? I believe it is probably informally, though I admit I cannot point to any particular pages since 2015 that show it. But of course it's also considered part of the bad habit that many of our doctors who graduated before 2015 did receive. Okay, I just, yeah, I just would refute the idea that anyone would read that and then under prescribe medication because they feel that a black patient is more able to tolerate pain. I just, I can't imagine that. I mean, I don't know, I'm not a doctor, but I just find that very, very difficult to swallow. And I still maintain that the people of the problem, not the system, my two cents. Let's, let's, let's hear from other committee members who have questions. I think did representative burrows, did you have your hand up earlier? Is there something you wanted to ask? Or am I missing that? I was wondering whether you could describe or go into more detail about what immediate, what immediate steps you see being taken after the public declaration of systemic racism as a health emergency. I think I said that right. I think we tend to say a public health epidemic and public health emergency kind of interchangeably. I know that medically they're considered a few different things, but public health big deal, if you will. So some of the steps that can be taken are are easier. Some are more difficult. For example, it means that when we acknowledge that there's a public health problem, we tend to devote resources to that problem. That means that we might create, create staffing positions that are directly looking at that problem. For example, the, I believe the legislature created the role of Chief Prevention Officer sometime back. That's because we recognize that there was a public health emergency in the opioid crisis for the state. And we reacted by creating a leadership level position to address it. So that's one step that can be taken. Another one is to make sure that we're providing adequate funding, not only for state services that address the issue, but also for community groups, not for profits and anyone else around the state who's working to address the issue as well. It means, again, when we talk about systemic racism as a public health emergency, it's not just about systemic racism in healthcare, which we have many, many examples and rings of data, but also systemic racism in other sectors like housing and employment and education. So just as an example, if we know that your health is more, one thing that we used to say when I was at the health department in New York was that your health is more impacted by your zip codes than by your genetic code. Right. So, for example, we'll, we'll just take, we'll take the city of New York. I know it's not a jurisdiction that's comprehensive Vermont, but we know that in white neighborhoods, there are no waste transfer facilities. That is where we process trash. Those are all in neighborhoods inhabited by people of color. We know that homeless shelters are almost entirely located in communities of color. We know that the places where you can find green spaces, civic centers, rollo shop, gyms and libraries tend to be disproportionately located in wealthy areas, etc. When we look at places like Vermont, the picture is a little bit more fuzzy because we have a socio economic divide that is not as clearly divided by race and ethnicity as it is in some other jurisdictions. For example, we have a larger raw number of people living in poverty who are white in Vermont than who are of color. However, when you look deeper and this gets back to data hostage versus data driven, when you look deeper, you can see that the rate of poverty is so higher for people from communities of color. And so understanding that the, the raw number and the rates are two different things and recognizing that something like where you live could heavily impact your quality of life means that we can look at things like housing and transportation. Right. Do you how long is your commute? What is your commute like? Do you live along a major traffic corridor because that's the only place that you can afford to live, etc. These are some of the questions that we just look at and some of the sectors that need to be addressed in order to get at those downstream health impacts. I guess part of the thing that I'm wondering is I, if it's declared a public health emergency. I mean, what we, you and I and other people in this meeting are talking about is, is fixing some of these really deeply ingrained problems, but how can, on the top level of what a public health health emergency would besides resources. But some of the, I guess some of these things are so deeply ingrained that they will take a while to fix. And besides resources, what would declaring a public health emergency do and do you see the public health emergency as, as lasting decades until it is all fixed or do you see it as kind of push to get the work underway? I thank you for the questions. I see a public health emergency for this specifically lasting as long as it takes for us to fix it. We didn't get here overnight. We've been centuries and centuries down this track with policy that has been expressly designed. And that's not my anecdote. This is documented in state houses around the country policy that's explicitly designed to oppress and suppress the well being of certain groups. So when you have centuries of that at play, it's really difficult to predict how long or how short something like a declaration of public health emergency can last because it all depends on how quickly and effectively and sincerely really need to move on it. What are some of the other steps that can be taken aside from allocations and sources? It means policy change. It means maybe folks in state leadership or our friends in the legislature looking at those upstream causes and saying, hey, we may need to strengthen our protections around, I don't know, lending discrimination, or we may need to strengthen our protections for people who are living with questionable or no legal immigration status because they're not presenting in medical facilities because they're afraid of retribution. So that might mean getting criminal justice professionals and other administrative law professionals involved in order to craft stronger protections for people who may be under federal scrutiny for immigration reasons. It means really, it means doing the harder stuff. A lot of the solutions that we propose are often the low cost or no cost things, but I think to a large extent we've exhausted those and it's really time to step it up a little bit more. Again, we have a body of work from which to borrow because we're not the first ones to have done this. So I think that really working with our counterparts and other jurisdictions to be able to look at what's work and what hasn't. For those who have declared this sort of public health emergency would be beneficial. I guess it's really forcing a prioritization of these policies and resources. Is that right? Correct. Yeah, I mean, a declaration of emergency is not in and of itself going to reduce disparities. What it does is it commits us to giving a dam and doing something about it and I'm thinking about years ago under the Bush administration Bush junior. When Colin Powell referred to an ethnic conflict, and I hate that term because it really involves the global north of responsibility there, but ethnic tensions in Rwanda, he described it as a genocide. And I remember the Bush administration was very angry with him because he used the G word and once you call something a genocide, it triggers certain international protocols that then require you to do something about it in the U.S. Wouldn't necessarily want to do that. So the way that we approach it, the language we use and the way that we designate something in terms of importance or emergency can make all the difference in terms of triggering necessary follow up actions. And I think that community just gets that. Thank you very much. Thank you. I'm going to turn to representative Cordes and then representative page. And I want to be sure that I don't want to, I appreciate the questions actually are providing opportunities to fill in more of the needed information for our committee, Susanna, but I want to make sure I don't cut you off from anything that you are wanting to add as well. But first represent Cordes and then represent page. Thank you very much for your presentation and I, a couple of comments on the medical education issue. One is as someone who has grown up over the last more than 30 years within the system of health care in Vermont. I can tell you experientially that racism systemic racism is alive and well and whether or not you studied a textbook and with a professor 30 years ago or in 2015. Those beliefs superimposed on existing cultural learning that we all have taken on in this country perpetuate the system of racism. Again, whether it's really hard to unlearn them. It takes attention, it takes listening and it takes the amount of data analysis and responding to that to fix it and if I as a white woman and not willing or able to listen and and learn, then I will never know about systemic racism because I don't experience the deleterious impacts of it. So it takes effort like this I very much appreciate this conversation and this work. And I just wanted to pipe up as someone who still to this day witnesses the impacts of systemic racism in the care that we provide to patients on a regular basis. Thank you. Representative page. Yes, director Davis. I have a question regarding your initially us prioritization of vaccinations. And I was curious whether that level has been raised with the executive level, your concerns about people of color that are more susceptible to COVID and whether I mean you certainly have discussed it enough here in other places about those individuals that are vulnerable. Has, has this issue been raised to a certain level, like to Dr Levine, and pointed out your concerns for these individuals that perhaps they should be brought up to a certain level like right now I guess you're giving vaccinations for individuals there 75 years and older. So has that been raised to the Department of Health. Regarding your concerns there. Do I make myself clear. Yeah. And, and what is, what have they decided. The, I had numerous conversations with, with Dr Levine and with the deputy commissioner as well and have talked about it with the governor's office. Also, the health department has made it really clear that they want to narrow that gap for communities of color and that they want to create a vaccination strategy that that appropriately is being appropriately delivered to people of color. So, yes, they're all very aware of everything that I've said, and, and have stated that they're committed to doing it. But there's no movement as of yet to raise that raise those individuals to a higher level is that correct. I think there has been movement. I think there has been movement, it could be deeper. Okay, thank you. Representative Goldman. I would just like to echo the comments of representative Cordis as someone who has worked in medicine for decades to that I've had many opportunities unfortunate opportunities to observe racist practice and medicine. And I also agree emphatically that the individuals make the system. So we really have to accept the fact that the system allows it and reinforces it. Thank you for that representative and if I may, Mr. Chair, I would like to just mention something that I think is particularly important to you all as legislators, which is the importance of not falling for the myth of race neutrality in policymaking, because there are oftentimes in the history of this country and the state perhaps that we have created policy that on its face appears to be race neutral, but in reality is not I can think of a few examples one being something like the new deal that had a lot of worker protections, but it explicitly excluded agricultural and domestic workers and that appears to be race neutral because it's by profession but I find that was, it was an explicit compromise with the southern states and it was because agricultural and domestic workers were almost entirely black people. And so that was a way that we could say it didn't target black people it only targeted agricultural and domestic workers but at the time that's that's who they all were. And we see that today lasting a lot of I mean this is an agricultural state and the lack of certain agricultural protections that are afforded to other people in the country, by profession tends to just the person that we impact people of color specifically now Latino, as that demographic has shifted a little bit. Honestly, that's also why we don't tip slide attendance. And that that's a, that's a anecdote for another time. But oftentimes there are policies that appear, not to be targeting particular groups but are in fact, doing just that. I can think of a lot of other things like for example sentencing disparities between rock and powder cocaine which chemically are indistinguishable, but it took. It took 15, it took like 100 500 grams I think of cocaine to get you 15 years in jail because it tended to be used more by white people, and it took five grams of rock cocaine to get you put into jail because it tends to be used more often by black people. We have a system. We had a drug epidemic in the 80s that affected communities of color more often and we met it with law and order and crime and punishment and villainize a lot of people and tore apart a lot of families today we have the opioid crisis. 80% of its victims are white people and needed with compassion wrap around services we treat it like a public health emergency we create positions in government that have nice titles like Chief Prevention Officer, and we should be doing that that's how we're supposed to treat a public health but when we look at the evolution of policy in the country it just it becomes extremely clear that we have found very creatively to to create differences without appearing to be created. Thank you represent black. Thank you. Exactly what you were just referring to. You know under a CA certain preventative services must be covered at 100%. Those services are rated by the US preventative tasks. Prevention Services Task Force of a level a or B. Those levels are set by research and study. On the population of a whole as the whole but we know that there are certain conditions that primarily affect people of color. And also that studies have not been done in non Caucasian large enough studies to make recommendations so therefore certain conditions that we know primarily affect people of color are not considered a and B services so therefore they're not covered at 100% under an AC a compliant health insurance plan, which is a huge disparity. Correct. Absolutely. In fact, I am thinking about and this is true not just with racial and ethnic groups but also with other forms of discrimination I mean for example we all know symptoms of a heart attack right in the left arm things like that but that's actually not a symptom for women as a symptom primarily for men. Many people don't know that a symptom of a heart attack for women could be a headache, which I mean, come on, right. How can you tell if it's a headache or you water, but the point is is even the way that we internalize our understanding of common medicine is often reflective of people who are living in dominant groups. There's wonderful research about, believe it or not, office temperatures and the fact that the ideal office temperature is actually modeled on a study that was done in the 15 of 10 men at their resting resting metabolic rate. Those men were an average of 4045 years old or like 40 years old and 145 pounds. And of course I think this was in the 50 so everybody was wearing like three pieces back then. And somehow the resting rate of 1045 pound middle age men is what determines today's office temperatures where we have more seniors working longer, more women more young people, etc in the workforce. And so when you always ask why certain people always feel cold and certain people are always comfortable. Perhaps we base our formula and it's a complex formula I'm not a mathematician so I wouldn't dream of trying to explain it here but it's you know some guy decided that his math is good and now half of us are freezing all the time. So I think it's very important the way that we internalize research that's narrowly conducted. Thank you for saying that. Suzanne, I'm wondering, I want to just, if I may just say that in reading your September report. I want to just acknowledge that I continue to learn and appreciated the report and I'm going to just say out loud that in the area that you talked that your report talked about the need for the recognition of why there's a lack of trust for many communities of color with the healthcare system is and is it is it is an important piece for us to understand and acknowledge in that, frankly, as I was reading the section around the importance of understanding the historical trauma and why lack of trust within communities of color is an issue. I find myself needing to look up some names that I was not familiar with. There were some areas where I was familiar. But the the kinds of egregious actions that historically have been taken and directed at communities of color as outlined on page four of your September report, I think are important for us all, who may not have that historical background as complete to have us understand and to take a look and understand what some of this history has been within the healthcare system. So I welcome you to, if you're inclined to say a few words about the importance of understanding the history of the healthcare system and some of the traumas that have been actually imposed upon the communities of color and how that might impact current healthcare. Absolutely, thank you for that. Yes, it often I think for a lot of us feels like Lucy with the football, you know, how many times are we going to run up to it and try to kick it, and then be burned again. And I don't mean to imply that all healthcare has always been bad for people of color all the time. Western medicine has brought a lot of positive advances. But it oftentimes occurs either absent our participation or to our detriment. I'm thinking of people like Jay Marion Sims, who was largely for a long time regarded as a father of gynecology, who was doing some pretty just incredibly unscrupulous and unethical experimentation on color Mississippi appendectomy. It's what they used to call it colloquially but it was when in the United States we were doing unnecessary hysterectomy on black women for the benefit of medical students who needed the practice and the training. And before we go thinking that that's too far in the past as recently as last year it was revealed that we were performing non consensual hysterectomy on migrants at the border here in the United States, like last year, we were performing hysterectomy on brown people, because they were being held in the immigrant detention center. So basically saying, we've decided you can't have kids because you entered without infection. And I mean Vermont's not immune from that. We were not the people in this state were sterilizing Abinac women into the 70s. That is within the lifetime of the people in this call. So it is history but it is not as ancient as we would hope that it would be. Of course there are things like Tuskegee, which you know the former name is the Tuskegee study of untreated syphilis in the Negro male, but it's a 250 black men and either gave them or allowed them to get syphilis and told them they were getting free healthcare. When in reality they were just watching as that virus ravaged their bodies and they studied it in the name of science. We know that people like Henrietta Lacks had her genetic tissue taken without her consent after she was diagnosed with cervical cancer. She died at I think 31 or in her 30s from that cancer. But her genetic tissue that had been taken was used and studied and it led to so many great advanced medical advancement. And if not for her, we may not have discovered those things, at least not at those times. But of course, I mean these were things that were considered. These were things that were commonly done in the US in health, but they were certainly unethical and they weren't done for the benefit of the patient. They were done in the name of science, whatever that means. So yes, those are some examples of the reasons for which we need to build and rebuild trust. And I have to be honest, every time we screw that up and backslide once we're undoing decades of trust building. So we thought that maybe the hysterectomy in women's prisons was the last time or the ones on Puerto Rico were the last time or the Abinac women were the last time. And then last year we find out that we're still doing it to immigrants. So that sets people back a lot of times efforts and Abinac people in the state who have said, I do not intend to get tested or vaccinated because they had Indian registry really recently and I can't go through that again. So it's very real. It's very close to home for the state and I think that we have a moral imperative to do better at that trust building. And there's no one size fits all way to do it. There's no single thing that we can do to say you can trust us again. It's just continuous demonstration that we are in it for the right reasons. Thank you. I'm thinking as well that again we're getting to the end of our time but one of the issues that comes up and will come up as we look at the bill that's about to be introduced. H 210 which is addresses health disparities and addresses health disparities across issues of race as well as disability and LGBTQ issues as well that again if you any kind of there's a kind of intersectionality that that happens as well as I as we talk about issues of race. That if you are welcome you to speak about the the impact if you are a member of another group of with disabilities or LGBTQ community as an examples and our person of color the the layer being on of disparities and discrimination can be even more profound. Yes, absolutely. So, I can use myself as an example. I am the child of immigrants, first generation in this country. So, statistically speaking, I am less likely to have access to things like higher ed, or other advancement opportunities less likely to have access to things like home ownership, or, et cetera, then my counterparts who have roots in this country. As a person who is Brown, I am more likely to be murdered by the government, I am more likely to be to experience for health outcomes like some of the ones that we already talked about, as a female identified person, I am specifically less likely to make the same wage for the same work that my male counterparts are. And so when you layer all those things on top of each other it creates a picture that makes people who may look like me or come from similar background, doubly or triply vulnerable to things. I am more likely to die in the delivery room or have a child die in the delivery room, then a person who may be of my same sex, but not of my same skin color. If I am a person living with disabilities, not only am I more likely to live in poverty because I am Brown, but I am also more likely to live in poverty because I am a person living with disability. Intersectionality is a huge factor here. It can often be the difference between people, us thinking that we have provided a benefit to people, but in reality not having done so. Here's an example. We might say, oh, hey, you're a woman owned business. Why don't you come down to this workshop that we're doing at this particular location that is not wheelchair accessible. We will not be recording it and we will not be translating. So if I'm a small business owner who's a woman and I cannot get to your physical location, I am, I cannot participate in that in that affair. And so in a lot of senses, there's that. We know that people in the LGBTQIA plus community are more likely to experience assault and violence because of that membership. But we know that trans women of color, specifically have the highest rate of murder in that community, in that community. So it is very much the intersection of race and gender identity there that creates heightened vulnerability to being attacked and killed. There was something else I wanted to say, and I've forgotten it. So it's fine. That never happened. Thank you. Actually, I'm so sorry. I do remember it now. I wanted to say that, you know, I'm talking about all this and we're, I just want to make it really clear that equity work needs to be done, more of it needs to be done. It needs to be done better and it needs to be well resourced. But I have to say this and I say it often. Nothing will make me happier than the day that I get brought into a room, a conference room. And the governor and the pro tem and the speaker and the secretary are all there and they say congratulations, you're fired, because we don't need you anymore, because equity is so firmly baked into the state's work that you are now not needed. That is going to like, I'm waiting for that. I have a bottle of champagne waiting for that day. Because the point is that the point of equity work is we want to put ourselves out of business, frankly, and I'm sure there are some who would disagree with me, but it's my goal. I want the work not to be needed anymore because we will have reformed the foundations of our society in such a way that they're not landed from the start. And I think that a lot of times people see equity work as special treatment for the few, but in reality what it is is undoing the special treatment that has already existed for the few for so long. And so the standard that we know now the society in which we live feels regular to people because it's all that they've known. But in reality, it itself has been unjust for so long that any deviation from that, they see that deviation as uncalled for change, but in reality it's getting us closer to that neutrality. But because we've never known that neutrality in this country, people see that as a deviation from the standard, rather than approaching a correct standard. And I just think that that's really important for us to keep in mind that change doesn't have to equal loss. And for those of us who see life as zero sum, that is where the trouble lies. Okay. Representative Pierson, I see your hand is up. I wanted to bring this to a close. And I think I will. And we're going to have more opportunities as a committee to have committee discussion and talk with other witnesses. We're going to continue our work later this morning. And this afternoon again, Suzanne, I want to thank you very much for spending time with our committee this morning. And I look forward to the opportunity to work together. And hope that you're out of your job soon. I mean, in the best sense of what you were just saying, we could only be so fortunate. And also actually, I have a specific request. We will be turning our attention to House bill that's been introduced House bill 210. And I did not ask you to comment on it specifically because I wasn't sure if you'd had the opportunity to review the bill with or those who are bringing the bill forward but I would welcome your comments on that. Thank you very much for being with us this morning. And at this point in time. Once once the bill now that the bill has been introduced and after you have an opportunity to review the bill. As well. Happy to thank you. Thank you. So again, thank you. Thank you very much for being with us this morning. And at this point for our committee, I'm going to suggest that we take a break that we need. To reconvene at 1030 that's that's that's reconvene. Actually, let's ask committee members to be back at like 2720 25 after 27 so that we can start promptly at 1030 we have a number of witnesses and much to cover. So that let's ask committee members to be back on the zoom at 25 after but that still gives us a break. Thank you very much for that. We will go please do take yourself off mute and video even though we will go off YouTube briefly they will be we will go back on stay on the same zoom link. We'll be going off YouTube but we will be coming back onto YouTube at 1030 to resume the house health care committees deliberations on health disparities. Thank you.