Equity and Social Justice Webinar – Health Disparities and COVID-19

Equity and Social Justice Webinar – Health Disparities and COVID-19

– Good afternoon, my name is Joan Reede, DeanJoan Reede from Harvard Medical School's Office for Diversity Inclusion and Community Partnershipand I want to welcome you to today's program, Health Disparities and COVID-19.

Our Office for Diversity and Community Partnership, Diversity Inclusion and Community Partnership, has as its mission to advance diversity andinclusion in health, biomedical, behavioral, and STEM fields, and building both individualand an institutional capacity to achieve excellence, to foster innovation, to ensure equity, locally, nationally, and globally.

For today's program, Health Disparities andCOVID-19, it is a component of our equity and social justice series.

This series was started in 2016 from a planningcommittee.

– [Alexa] Just a moment, I didn't get that, could you try again? – Excuse me, that's Alexa.

From a planning committee of faculty, staff, trainees, and students representing our entire HMS community and really designed to addressareas of health disparities, social determinants of health, leadership, and health policy.

We have four key areas, history and context, culture and environment, health disparities, and leadership and skills development.

Our conversations, our speakers, our programming, our design to both define and describe issues of disparity, but also to discuss interventions, to think about solutions and inequities that impact our communities, our hospitals, andour healthcare system and at the policy level.

At the end of today's program, Dr.

Landrywill tell you more about some of the other offerings of our equity and social justicetheories, our offerings related to disparities in COVID-19.

In addition, Dr.

Landry is our moderator fortoday's program.

He is an emergency medicine physician at BethIsrael Deaconess Medical Center and Assistant Dean in our office.

Thank you, Dr.

Landry.

– Wonderful.

I hope everyone can hear me.

I wanna say thank you to everyone for joiningus for our iteration of our equity and social justice lecture series conversation aroundHealth Disparities and COVID-19.

When the COVID pandemic hit America, manycommented that it would be a great equalizer in that all Americans would feel the weightof the disease.

Be it through illness directly from lovedones contracting the virus to ourselves contracting the virus or to the changes to the way wework and the need for social distancing and physical distancing, as well as the economiclosses.

Unfortunately, disasters don't make disparitiesgo away.

In fact, the COVID pandemic has not been thegreat equalizer as many hypothesized, instead, it's been the great magnifier, showing theunderbelly of a healthcare system that is under prepared and the impact of racism onthe health and wellbeing on marginalized and disadvantaged groups.

On April 7, Dr.

Fauci spoke at the White Housebriefing room and talked about health disparities during the pandemic.

He talked about infection rates and deathrates and he talked about his experiences during the HIV/AIDS epidemic in the 1980's.

Those of us who focus our careers on healthequity, were somewhat relieved to hear someone speak from a leadership standpoint on thisissue, but we recognized that the words would only go so far as we see what is happeningin real time.

Addressing health disparities is not a passiveact and we must be proactive in addressing disparities We hope to use this webinar asa space to not only reiterate the fact that disparities exist and their result of optimalhealthcare as well as racism, both structural and implicit, as well as explicit racism, and talk about solutions, both short and long term to help address disparities as we improvecare for those marginalized and disadvantaged facial populations that we're seeing.

So with that, I wanna focus on introducingour speakers for today.

Before we get to our next portion, I wannabriefly introduce our speakers.

So we have four individuals who are joiningus to give us their insights around the COVID epidemic and talk about health disparitiesduring this time.

We're gonna hear from Dr.

Italo Brown who'sa graduate of Morehouse College as well as Meharry Medical College.

He's an emergency physician and a clinicalinstructor of social emergency medicine at Stanford Hospital in Palo Alto, California, and he's also the Chief Impact Officer of T.

R.

A.

P.

Medicine.

Next, we will hear from Dr.

Brian Williams, he is an Associate Professor of Trauma and Acute Care Surgery at the University of Chicago, serving Chicago Southside.

He's a graduate of the United States Air ForceAcademy and did his medical schooling at the University of South Florida College of Medicine.

He did his surgical training at Harvard MedicalSchool at Brigham and Women's Hospital and his Acute Care Surgery fellowship at EmoryUniversity.

Next we'll hear from Dr.

Erika Flores Uribe.

She received her medical degree from the Universityof California at San Francisco School of Medicine and her master's in Public Health at HarvardUniversity, Harvard School of Public Health.

She is currently serving as the Director ofInnovation and Language Access and Inclusion for the Los Angeles County Department of HealthServices.

And lastly, Dr.

Mary Fleming, who is an OBGYN, she received her medical degree from Vanderbilt University School of Medicine and completedher OBGYN residency at Meharry Medical College.

She also completed the Commonwealth Fund Fellowshipin Minority Health Policy at Harvard Medical School and received her master's in PublicHealth from Harvard T.

H.

Chan's School of Public Health, and she is also the Presidentof Reede Scholars.

Just to give you a quick look at what's happeningin the city of Boston, to set the stage for this conversation, as many of you know, Bostonis a leading city in healthcare in innovation and quality.

We have five major teaching hospitals, wehave three medical schools, we are home to 26 community health centers.

Boston is a very diverse city with more than50% of the population considered minority.

We have a thriving immigrant community aswell.

That said, Boston does share its unfortunateburden of health disparities and so I wanted to give you a quick snapshot of what Bostonneighborhoods look like.

And as you can see, this is a map of Bostonwith its many neighborhoods outlined.

The neighborhoods of Mattapan, Dorchester, Roxbury, and Hyde Park have the largest concentration of minority populations and not surprisingly, those neighborhoods have the highest rates of health disparities in disproportional shareof diseases.

Not to belabor the point, but this is a mapfrom the 2015 Social Determinants of Health Assessment from Boston Public Health Commissionand this map highlights the rates of unemployment in Boston.

As we know employment is a social determinantof health and the lack of employment often means the lack of private health insurance.

This next map is the current disease burdenof Coronavirus in Boston.

As you can see, those same communities, Roxbury, Dorchester, Mattapan, and Hyde Park have the highest rates of disease burden.

And putting these maps together, you can seethat COVID-19 is following the same pattern as other health disparities and social determinantsof health indicators.

And so with that, I wanna bring Dr.

ItaloBrown to the conversation.

He, like me, is a frontline provider and worksin the emergency department and so Dr.

Italo Brown, as an ED doctor, can you tell us aboutthe community that you're seeing, the severity of illness and also what you're seeing whenyou're providing care to those patients on the frontline? – I appreciate your lead in Alden.

For those that are on the line, Alden hasbeen a mentor and friend of mine for some time now, and I just really think that thisis a conversation that is timely.

Here in, I live in California.

I'm from Sacramento, born and raised, andI work in the bay area, particularly Palo Alto.

This is a different type of community, itis a well resourced community and I think that back in February, we also started seeinga lot of our international community members come in with cases.

And I remember saying to myself, like wow, this is starting to pick up.

And being in California, kind of in a positionthat was unique, meaning we're part of an international community, we were seeing casesearly on, we were able to get some operations, things in place, I realized very quickly thatthere were undocumented citizens that were coming in and I would see these with theseoutcomes and I'd say wow, what is the health disparities lens on this? So I started really trying to look for thesenumbers and that was where I really saw that there was going to be a downstream problem.

I couldn't find numbers on ethnicity and raceand as a social emergency medicine fellow, like that is something that I look for iswhat is the response, particularly from a health equity lens? So, I started trying to dig as deeply as Icould and I realized that data was being collected but it was not being shared transparentlyand in something like this, where you would expect the population of people of color tobe at a greater risk given known comorbidities, known preexisting health conditions.

I thought that that was going to be a prominentpart of the response.

So, I guess when I talked to my friends, whereI trained in New York, I trained in the Bronx, and their anecdotal evidence was enough forme to know that this was gonna hit communities of color in such an unprecedented way.

I felt very strongly about trying to figureout all right, how can I reach out to people? And the more I used social media and in thecontext of social distancing, I reached out to as many people as I could, to find outwhat they were seeing on the ground as well, and it basically confirmed what I expected, which is that people who were coming from communities of color were having like a fasterattack rate, they were seeing worse outcomes, and I think mostly everyone I knew, knew atleast two other people who had been diagnosed positive for COVID.

And then, I would say like finally, the partthat struck home for me was hearing my former co-residents explain what it was like treatingpatient after patient after patient of color and not seeing them improve.

So I knew that this was going to be somethingwe would be fighting for awhile and I guess my biggest kind of like disappointment, asa frontline worker is like, I represent a community whenever I walk into the emergencydepartment.

They see me, they see my natural hair styleand automatically, there's something that they identify with and it gives them hopeand I felt for once like I was in a place where I didn't have enough information totruly help them and truly get them to that, to try to like help and save that community, so I just reached out in every way that I could to increase the optics around data suppression, around the fact that this information was not being made transparent across every singlestate and county.

Eventually, the CDC released their report.

We saw that there was an increased risk forpersons of color, of mortality and also of cases.

And it corroborated what we knew all along.

– And Dr.

Brown, can you just tell me howhas knowing the data changed the way you practice in real time? – Well so, I think that the first thing thatit does, it informs screening.

You know, I think that it's important to lookat, just like you showed those maps in the beginning, where you can see the ethnic populationmapping, you can use that as a tool to design intervention, to design a way of approaching, like an appropriate response.

I think that's where the ball was droppedis that if you can see the communities of color bare the major burden of illness inthe US and you wanted to get as many resources as you can to help as many people as you can, I would target those resources to communities of color, to try to make it more equitableand give a fighting chance to people who are already predisposed to risk given systemicissues.

So that's the first thing that I thought about.

We started reaching out to community clinics, we started trying to equip them with appropriate testing materials, equipping their workerswith PPE because they are under resourced, almost by design, through federal funding.

So these are the things that at our institution, we have been able to extend and I hope that you're seeing the impact in communities ofcolor.

I know in California, we're seeing a littlebit of the flattening of the curve.

– [Alden] And you do a lot of work in thecommunity, focusing around education.

Can you talk about the work that you do andhow you're trying to promote health and wellness to minority communities specifically relatedto the Coronavirus? – Well prior to COVID-19, I was involved prettydeeply in barbershop health initiatives.

So this is where we would go into barbershopenvironments, which are traditionally safe spaces in the Black community and educatethem about health and wellness.

What obviously COVID-19 did was, it destroyedthat community environment, but we're still so interconnected as a people, that thereis ways to create virtual safe spaces.

So what I did was I harnessed social media, I started on the very second week of the announcement that it was like a National Emergency, I startedhosting town hall forums from my Instagram platform and would do this in conjunctionwith a brother named Jahmil Lacey, who founded T.

R.

A.

P.

Medicine.

We started talking about this and openingthe conversation so people were getting real time insight that bypassed media sources, 'cause I was taking information down a gradient, meaning, going from places like EMRA, whichis a local, like a podcast among specialists in emergency medicine, and Facebook groupsfull of physicians and taking that information and going directly to the people and sayinghey, you need to know about this.

Understand that we're having difficulty ventilatingpatients, understand that we don't have a clear understanding of what community is gonnabe conferred from this and whether or not these treatment regiments work better thanthese.

So basically, dispelling the myths that existedand providing verifiable information to a community that is often stripped from that, or rather kept sequestered from it.

So, that's what I started doing.

We started getting more of a following andI think that offline what I would find is that people really gravitated towards havinginformation through a lens that they could understand and that was linguistically appropriateto them.

– [Alden] And can you just talk a little bitmore about how communities are receiving this information and then also, as the communitiesof color are taking in this information and dealing with the misinformation that may bepresented and also these safe spaces like social media? – So, if you guys recall, in the very beginning, the common understanding among people of color was that this was not a disease that was gonnaaffect us.

We thought that we were impervious to it.

When, if you look historically at people ofcolor, we are almost most vulnerable to any type of major illness and it comes from systemicissues, right? But it took Rudy Gobert and Idris Elba forthem to have the COVID-19, for us to really understand the SARS-COV2 could affect communitiesof color and particularly, it did not discriminate, that you could be a wealthy person of color, you could be someone's auntie, and those things would be the exact same and you would seetheir outcomes be worsened.

And I think that what I really started tosee at that time was a shift in understanding, like, okay, so this is serious and then, nowthis is like life or death.

It became almost overnight and I felt likethere was several points among that timeline that we can look to and say all right, yaknow, we could've arrived here sooner if information was available, if we would've had platformsthat uplifted the knowledge of social determinants of health and really critically analyzed thatas a potential risk factor, 'cause you can't make an apples to apples comparison when lookingat China, Italy, and the US.

They're just not the same and that's likea basic understanding of epidemiology that'll lead you to that.

So I really felt like people in communitiesof color forced the issue, we wanted to be seen, and eventually, the data came and emerged, and it really, like I said, it reflected exactly what we've seen time and time again, whereillnesses that almost select for the poorest, for people who live in the worst conditions, who are under the most type of social oppression, they are decimated by it and my heart really, really aches because it took us a long time to get to that point.

– And one last question for you Italo.

Can you just talk about the layering effectof having health equity issues, social determinants of health issues, and then, on top of that, adding to the COVID-19 pandemic? – Sure, so the underlying issue has alwaysbeen equity, not being able to make multiple types of care or access to things even acrossan entire playing field.

We know the reasons why.

I mean for the last 30 to 40 years, peoplehave been basically knocking on the doors of the healthcare system and of federal fundingto say we think that there are non medical reasons why people of color are sufferingworse outcomes.

And, I think that the biggest issue from thatpart is, it's a philosophical thing.

It's like hard to understand something thatyou can't see, something that you haven't been around.

If you never been raised in a household, whereyou share a room with multiple family members.

If you've never been in a situation where, you know, literally live paycheck to paycheck and even then that's not enough.

If you don't understand those things, it'shard for you to put the context into picture.

So, then you add on COVID-19, which has noreal respect for any of those contexts.

It's gonna act the way it is because it'sa virus, it seeks hosts and unfortunately, these communities have a ton of hosts whoare essentially isolated in a sense because they all experience the same things but theyare literally like sequestered away from the other resources that could potentially improvethis.

You know, imagine being in New York and havingto get groceries with a mask on and you're in a Bodega and it's like, the aisles of theBodega are narrow, you can put both arms out and touch a product on both sides.

So how do you socially distance in that typeof an environment? It's almost, it's virtually impossible, ora unique situation like living with multiple family members because you have maybe a cousinor an aunt that doesn't have a job or who can't afford to pay for a place on their own.

So they live with you and those I would sayessential workers, we already know that they come from communities of color.

Once you strip away the context of medicine, meaning like not nursing or skilled nursing, or rather environmental services, there area ton of other essential workforce members who are from communities of color and theycome back to those same families, those same households, that are systemically depressed.

So that is how COVID-19 became such a, I wouldn'tuse the word virulent, but such a seeker of that social inequity.

– All right.

Thank you for that Italo, and I think that'sa great segue to Brian.

So, can you talk about, as a trauma surgeon, this is really an atypical time for your specialty, can you share what you're seeing in Chicagoas a surgeon and talk a little bit about how your practice has changed since the middleof March when we started to see an explosion of COVID cases across the country? – Thank you for having me Dr.

Landry.

So, as far as you know trauma surgeon, weare in a unique position because specifically with the gun violence and traumatic injuriesthat does not go on hiatus because of the pandemic.

Anecdotally, we are seeing a decrease in motorvehicle collisions, which makes sense with the shelter in place orders and less peopleon the roads, but as far as the interpersonal violence, our early data shows that that hasstayed the same.

And with trauma surgeons, we're somewhat ofa unique resource within hospital systems because we can do surgery, we're doing emergencysurgery, and we're also critical care specialists, so we can work in the ICU in these COVID units.

So trying to maintain that readiness on bothfronts, in the ED with our emergency medicine colleagues and with traumatic injuries andalso within the hospital, caring for COVID patients, becomes critical.

So, what we've done is doing what we can tomaintain readiness on both fronts.

Talking to my partners and some friends fromaround the country, we're seeing that we're kind of fighting two pandemics if you will.

There's a pandemic of COVID, and then thereis this pandemic of gun violence.

One of my colleagues wrote a really greatarticle in the New York Times a few weeks ago that talked about this very issue.

So, that is the challenge, but also I wouldsay the morale is pretty high within our group and everybody's come together to make surethat we can maintain a readiness on all fronts.

What was distressing to me, but not surprising, was still dealing with the number of injured black men and women that are coming in fromgun violence, or gun armament injuries, and also knowing that the majority of deaths withinChicago are also African American.

About 70% of the deaths are Black and Blacksmake up 30% of the population, so that disparity was shocking and distressing but not surprisingand so I asked my self what can I do in the short term and the long term? So clearly in the short term, it's just tocontinue to be ready and to continue to do my shifts and work together with our team, nurses, RT's and other trauma surgeons, but also think about, okay, when this is all over, what do I do at that point to do my part to ensure that this doesn't happen with the nextcrisis? That we have our community that suffers duringa crisis and is forgotten when the crisis passes.

We cannot let that happen this time.

– Great, and you know, you're pretty outspokenon these issues when it comes to structural racism.

Can you tell us what we as doctors can doto start to address these structural racism issues both in real time and then also whatchanges we can start to implement around the culture of medicine that can help reduce thesebarriers? – Absolutely.

The first thing we need to do in healthcareis to be able to have this discussion about structural racism openly with an eye towardsprogress and I mean, I get it, talking about racism is uncomfortable for many people, butthe reality is, we can't avoid it and we have to accept that structural racism is at theroot of what's going on right now with communities suffering, communities of color sufferingfrom coast to coast.

And as healthcare as being transformed inreal time and as a result of this pandemic, we have to recognize that communities of colorwill be making contributions to medicine by virtue of their suffering, so we should worktogether afterwards to ensure this doesn't happen again as best as possible.

I think there's a lack of education withinmedicine about the contribution, particularly Black Americans have made throughout medicaleducation, particularly in a form of medical experimentation without consent, that we havethese, we know about Tuskegee, we talk about Henrietta Lacks has been more in the newsrecently.

Let's go back to J.

Marion Sims who's a fatherof Obstetrics, we've had eugenics, so all these things that have been done to BlackAmericans contribute to the lack of distrust in the healthcare system, and which contributesto these long standing health issues.

But it's incumbent upon us within healthcareto teach generations of doctors about that legacy, not in order to make people feel badabout what has been done, but to recognize that yes, this is our history, it is not pretty, but let's take that, learn from it, and move forward, and now is a time we can actuallydo that and talk about the roots of structural racism and how that, as all these other impactson communities of color, whether it's housing, or economics, or education, and healthcare, they're all interrelated.

We need to unpack all of that and have a open, honest discussion about what that means to us as healthcare workers.

– And so how do we take this conversationupstream so it's not just us as physicians speaking to our communities like Italo isdoing, but also taking it so that we're talking to the leadership within the institutionsthat we work at and then also taking this so that it's more seen on a policy level andwe're communicating with leaders within the cities and politicians across the state andacross the country? – Yeah that's it, right, there's so much, there's so many pieces here.

There's talking to the community, we're gonnatalk to the community, I put that in air quotes, with one voice and we'll talk to our leadershipwithin healthcare with one voice and we're talking to policymakers as well with a differentvoice and the goals with each are different, particularly with policy makers because alot of what's happening is result of intentional policies that have been in place for decades.

Just for example, I've talked about redliningof neighborhoods and how that was an intentional policy imported by federal, state local governmentsto racially segregate neighborhoods that placed Black Americans at a disadvantage as far asinfrastructure and education and healthcare access, so that legacy has intergenerationalimpact on communities of color.

So to undo that policy will involve us becomingmore adept at dealing with policy makers and becoming policy makers ourselves.

The other part is educating the community, what they can do to keep themselves healthy, and then within healthcare, and those of usthat are delivering the care, those of us that are communicating between both camps, we need to understand our history as well and I think that one part of it should startin medical school because I don't know about you Dr.

Landry, but I never learned any ofthis in medical school, but I knew it, there was not a single discussion about the legacyof medical experimentation on Black Americans or communities of color within medical school.

So it can be done in a way that's instructiveand leads to progress, but not shame, right, it's just, this is our history, this wherewe're learned, now what do we do moving forward? – And I hundred percent agree about the lackof education in this space and what we're trying to do is increase the amount of healthequity education in medical school here at Harvard and then also in other medical schoolsacross the country.

I guess my one concern would be, we have areal time example currently happening of health disparities and how can we use this as anopportunity to make real time changes and I think part of it is having the conversationusing this as a teaching point, but also part of it is having the ear of the leadershipwithin the spaces that we operate in order to make these change.

One last question for you is how has the feedbackbeen when you go and speak to the leadership and you tell them what your concerns are? Are they giving you push back, are they opento the changes that you're suggesting? Are they interested in learning more abouthealth disparities issues and also, allowing you space to have opportunities to interveneor are you getting a different type of reception? – Honestly here at the University of Chicago, at least within the department of surgery, leadership's been very receptive to this andI would say actually kind of pushing the envelope on what we can and should do, and is askingus to think outside the box, I can't even think of a better phrase than that, but towhat can we do on an organizational level to have impact that is sustainable? So I feel fortunate that that is the casehere and you know, I've been in medicine for 20 years, considering going back to medicalschool, and I would say that has not always been the case.

When you talk about diversity and inclusion, that can be touchy, you start to talk about racism, I mean that's even making it moretouchy.

So to be in an environment where we're havingthese discussions that are uncomfortable, but are respectful and talk about what wecan do, like what actions can we take? Not just have the discussion and then walkaway, but have the discussion, then okay, what can we do next? So leadership here has been receptive andsupportive for what we want to do.

– Thank you and I next wanna turn to Dr.

FloresUribe.

So Erika, you're also an emergency departmentphysician and you are on the frontlines and taking care of patients with COVID, but youalso work with a large immigrant population.

Can you talk about your experiences in theED and then also can you talk about what you are doing to make sure that those patientswho, where English isn't their first language and they have a preferred language other thanEnglish to receive care, what type of conversations you're having with them and how you're providingcare for those individuals? – Yes, so thank you Alden and everyone onthe panel, thank you for an invitation for moving in a uncomfortable, discomfortableconversation that is critical right now.

I do think that the importance on this isthe proactive approach and so, as you mentioned Alden, I'm an emergency medicine physicianand I work for the Department of Health Services and practice at LA County USC Medical Center.

There are days in the emergency departmentwhere I don't speak English to our patients.

The Department of Health Services is veryunique in that way.

We are the second largest health system inthe country and we operate 24 clinics in addition to four large acute hospital sites.

We care for 750 thousand unique patient encountersand that leads to about 2.

5 million encounters.

What makes our particular system unique isthat we've actually shifted in terms of the majority of our population speaking a languageother than English.

So, at DHS, Department of Health Services, the majority of our population speaks Spanish, 49% prefer to have their care provided inSpanish, and followed by English and then a number of threshold languages.

So, from those 750 thousand patient encounters, 54% of our population would qualify to be described as limited English proficient, andthat is a population would need health interpretation services, detailed by the ACA, Section 1557.

This is 1.

4 million encounters a year.

So, this really makes a palpable need forour system to provide culturally and linguistic appropriate care and this is only been exacerbatedwith the COVID-19 pandemic.

So I wanna kinda share an example of whatthat looks like when we care for patients.

The previous graph showed the breakdown ofour patient population for the Department of Health Services.

And, when COVID started, I was working ona night shift and we established a COVID pod and that's one of our attempts to reduce exposureto providers and patients and I had a 73-year-old Spanish speaking, monolingual patient as Ido most of the time in our emergency department in terms of preferred language, and she presentedwith cough and some subjective shortness of breath.

You know, in addition to COVID, I did a heartwork up, I did a lung work up and I started to have the conversation with the patient, similar to many of the other hospital systems, our hospital has been encouraged to consider, who are the COVID well, who can go home, and not be admitted, and so, you know, I startedto have the conversation about strict return precautions and isolation.

And I'm a native Spanish speaker, it actuallywas my first language, and so I'm speaking with my patient about public health instructionsfor isolation and I ask her very candidly, are you able to self isolate if you were togo home today? And her answer was very candid, she said yeah, I can do that.

And so, understanding kind of the cultureand language background, I followed up with the questions tell me a little bit about whereyou live and who you live with? And she proceeded to tell me about maybe 10family members who live in a single residency home and a husband who she shares a bed with.

And I followed with, well how are you goingto isolate? She's like well I've shared a bed with myhusband all my life, it's not the time that I'm going to start isolating, or you know, not sleeping in the same bed.

And she also mentioned, you know, we've beenin the same space and six feet of distance is not something that we can do and when Idelved a little bit more deeply into that conversation with her, it was very sobering.

I mean these are the things that we sharewith our communities in terms of how to protect yourself from COVID, and the patients whowe're seeing at the LA County level at the Department of Health Services, the majoritydo not have the means to follow the precautions to protect themselves.

And I don't wanna say that this is isolatedto our patients, this is also our staff, right, we have a large custodial staff, we have alarge nurse assistant staff, that by all intensive purposes, do not have the means because ofthe cost of living in Los Angeles to self isolate and have six feet of social distancing.

They also don't have the means to have a jobwhere telework is an option.

So these are really challenging messages thatwe've been working through as a system to be able to be sensitive in terms of the messagingwe provide from a cultural perspective, from a socio-economic perspective, and from a linguisticperspective.

– You know, when I was taking care of patientsin the emergency department and English was not their first language, we were trying touse all this various forms of technology, using robots, using virtual telemedicine, other forms of technology to communicate with our patients.

But one of the things I was always lackingis a second language.

It was always done in English and it was neverconsidered in any other languages.

Can you talk about what you all are doingto make sure that as you build technology and IT and other infrastructure to supportthese patients coming in with COVID that we're not leaving behind patients where Englishis not their first language? – Yeah, and so I mean I'm gonna echo a lotof the things that Dr.

Brown mentioned earlier in terms of the challenge about being ableto provide trusting information for our patient populations.

We are working on a lot of efforts acrossthe system and I wanna say that this is a big challenge, even when technology is availableculturally, it's something that's very challenging for communities that tend to focus more infamily units, versus individual decisions.

And so, you know, one of the challenges thatwe've had and you can see across the country, right, you just log onto that Internet ornews, or listen to press conferences, the information is not being provided in multiplelanguages and when it is, it's either much less in detail or you know, very delayed.

It takes three, four days or something tobe translated if it is translated and then also carries certain assumptions that ourpatient populations are accessing the Internet or email to receive their information, aswell as that they have the same comfort level with technology of some sorts.

So, I will share that this makes it a littlebit more of an opportunity for us to understand how to create a safety net that can reachthose populations and that the diversity of languages tends to be concentrated in largemetropolitan cities.

So for example in California, we speak morethan 200 languages, and New York, that number is closer to 800, and even in Boston, right, you have 140 languages.

And so being able to provide care that's culturallyappropriate, translated, and meets the need of the communication platform that our patientsrequire in order to have a trusting communication line, it is a challenge.

With the Department of Health Services again, since our patient population shifted and our paradigm shifted to be majority non-Englishspeaking, we had been working pretty aggressively in establishing a comprehensive language accessservice program and integrating the voice of the monolingual or the limited Englishproficiency patient, into our patient family advisory councils, that inform our systemsand our goals for a facility.

So some of the things that we have been workingand since the time that COVID touched Los Angeles as a system is that we created a patientfacing communication task force and this was critical for coordination and accountability.

So that task force was responsible and isresponsible for providing communication that is appropriate not only in health literacyand the reading level, but also culturally and translated into Spanish every time, ifnot all the threshold languages whenever possible.

I realize that our system is unique comparedto other sites because we do have in house capacity to do translations, so as other hospitalsystems or hospitals may have to go to a vendor and it takes several days to translate, oursystem has made the investment for in house interpreters who have capacity to translate, to turn over some of these documents in an hour.

And we can reach some of our populations inthat way.

We also organized this task force as a wayto have closed loop communication with our leadership because that's also very importantin making sure that we have a pulse on what's coming in from the larger COVID oversightcommittee for the system.

In addition to communicating with our LosAngeles County Emergency Operations Group, the Joint Information Center that gets activatedduring emergencies like this, to really inform and support media outreach in multiple languages.

So, we took an approach of having centersof support in terms of being able to provide this information for patients and we focusedon forming areas, patient centered, provider centered, system centered, and county wide.

So from the perspective of patient centered, we did do robo calls and proactive calling and campaigns, text messages, bulletins, emails, patient portal messages, established a web page and all of that communication is translatedinto Spanish.

If we target Spanish and English, that's about94% of our population.

And whenever possible, we do translate intothe threshold languages.

And we also started engaging our patient familyadvisory councils and input on some of the materials that we're providing and how clearit is and where to disseminate that information.

From the provider perspective, we did encourageexpansion of remote language access services.

We understand that that has its limitationsand it's not as personal and in communities where family units are very important in decisionmaking, this has its limitations, but looking at the broader picture, being able to providea modality of access in these critical spaces was very important, and so, we expanded languageaccess services, both from telephone and video.

And from a system perspective, we are workingwith our contracts and grants group to expand applications that anyone can add to theirphone or their personal devices that would allow them access to video interpretationwherever they are, whether they're working telework from home, or if they're doing screening, and that's one of the areas that we're really kinda focusing on as a system.

And from the county perspective, we've reallypartnered and supported the Joint Information Center to provide media outreach in multiplelanguages and are starting to look at what kind of partnerships we can engage with toprovide this information to our patients.

– And I have a question that hopefully youcan answer quickly, though I'm pretty sure it's a loaded question, which is for our undocumentedimmigrants who are here in the country, and whether or not they're seeking care, how hasthis impacted that population and what are your thoughts on what we can do to betterengage our undocumented patient populations? – Yeah, so that is not a short answer.

It's very challenging I think that there isa lot of structural and system issues that were challenging for us before, so just totouch briefly on this, there are detention centers across the country and when publiccharge and all of that in terms of the political environment is present very palpably in thathealth system, in that we did see a reduced number of patients and being able to communicateabout resources and about when to seek care has been an area of opportunity.

In terms of even reporting, the detentioncenters are not local government or public groups and so, we don't have the numbers onCOVID-19, we don't work directly in terms of public health to be able to support thosewho are in the detention centers, but in terms of our undocumented immigrant populationsaside from those groups, we do have a program in LA County called My Health LA, and thatis specifically for the undocumented population and they tend to have pretty strong relationshipswith their clinics and where they traditionally seek care, so we've really partnered withthe directors of that group to make sure that the information is available to them and thatit goes to through the same process as the general information that we're providing forthe rest of our populations.

I think that one of the key areas and learningpoints for us is just really having that limited English proficiency integration and outreach, so including patients and family advisory councils as well as community based organizationsto be able to support and disseminate that information in trusting platforms.

– Great, I wanna say thank you Erika, foryour work that you're doing with our patients who have limited English proficiency.

Next, I wanna talk with you Dr.

Fleming.

And so prior to COVID-19, maternal healthwas a focus on and in the health equity space, but now the spotlight has shifted, but thedisparity hasn't gone away.

Can you tell us what you're seeing as an OBGYNand what we can do to ensure that we continue to move forward in addressing the disparitiesof maternal health, both during and beyond this COVID epidemic? – Thank you Alden.

So good afternoon everyone, thank you fortaking the time out of your afternoon to join us for a conversation that's very importantto me.

So I'm sure it's important to a lot of youall as well and thanks Dr.

Landry, Dr.

Reede, and DICP for hosting this event and invitingme to speak.

I think definitely that's a great start ofthe conversation.

There's been so much conversation recentlyaround maternal mortality and morbidity in general and especially as it relates to Blackand Brown women in this country and I think COVID-19 has both highlighted these alreadyknown disparities but also exacerbated the situation in some regards.

So there's a host of things that we typicallytalk about in the context of risk factors for maternal mortality, but the ones I thinkthat are most partnered to this conversation are things like preeclampsia, which are elevatedblood pressure during pregnancy, infection in general, so add COVID-19 to that, and also, blood clotting disorder.

So pregnancy as a baseline is what we calla hypercoaguable state, which means you're at risk for DVT's and PE's, so blood clotsin your legs, even in your pelvis, and in your lungs, and those are the ones that havebeen most I think influenced and compounded by the situation, so in general, we know thatnon Hispanic Black women are three to four times at risk for dying during pregnancy, or due to pregnancy related illnesses.

And that time period is anytime from pregnancyup until a year after delivery.

And so, as the women are coming into the healthcarecenter during that timeframe right now with symptoms, we're trying to figure out how tobest, how to triage them, is this a pregnancy related illness? Is this early symptoms of COVID-19? Can this person go home, or does this personneed to stay in the hospital? And just to kind of give you an example ofone of those.

So you know fever, fatigue, pain, nausea, vomiting, those are just general signs of infection.

Any type of infection in pregnancy, even somethingas simple as a urinary tract infection can cause a woman to have contractions and sometimesthose are preterm labor pains.

So as you can imagine, if a woman presentsto deliver, delivery, or the ER, with what we might can typically say, you're havingpreterm labor contractions, we'll give you some IV fluids, the contractions subside, can that woman go home safely? The answer now is maybe not, those might beearly signs of COVID-19 and that patient may need to stay for longer evaluation and monitoring.

But of course, we're running into the issueof keeping patients in the hospital for longer than need to be and then exposed to the virusand that context as well.

And the other interesting challenge with COVID-19in addition to the visiting process itself, is the changing of access issues, having availabilityof support persons in the hospital.

So of course visitation is limited duringthis time and historically, everybody who comes into the delivery room I've done deliverieswhere there were probably six or seven people in there, I wouldn't recommend that, but thereare those occasions.

And now we've been limited, some hospitalsare limiting to no visitors, or some places are limiting visitors to just one and thatperson has to stay in the hospital from the time you come in until the time you leave.

And so, of course that puts a strain on homelife and it changes the experience of the labor and delivery process as well, so you'rekinda getting different things from different perspectives of the experience.

– And so you also do a lot of work in theequity space beyond your work as an OBGYN.

Can you tell me what you think some of thefuture implications of COVID-19 and these drastic changes we've seen in hospitals, howthat may impact healthcare and health disparities going forward? – So there's a few things, so I'm also a Locumphysician, Locum Tenens physician by practice right now and so, I have the honor I'll saytoday, of traveling to different places to work and so I work in rural places, urbanplaces, suburban places.

And so, by happenstance, I was in a largeurban facility when this all started and one of the things that are happening in, it wasmentioned before about the invention of telemedicine right, and how telehealth can help alleviatesome of the strain just kinda along with COVID-19, but maybe a way to help reach patients betterin the future.

So I do think that that's one thing that'shappened that's a great starting place that we can have better access for patients outsideof the traditional four walls of the hospital and the outpatient clinics, but I also wantto make sure that we're cautious, to make sure that there are women who don't alwayshave access to reliable and consistent mobile devices and so, you know, we were rollingout pretty thorough telehealth and calling it video health plan for a lot of our ladies, but when we're calling them two and three times and you know, they're not picking upbecause you know, maybe the number has changed or they don't have access to the device atthe time, or they're sharing the device with a few different people, they're not the oneswith the device at the time, and so I think as we shift that way that we need to makesure that we're doing it in a way that's actually gonna service our patients and not provideor introduce a different disparity.

I think the other interesting thing, we talkedearlier about the distress of the medical system among minority populations, a lot ofthe conversations on when we were calling them on the phone is that we need to rescheduleyou to an outpatient full health business instead of coming into the office and makingsure the patients understand that we didn't not want to see them and so I think that wassometimes well, why can't I come in, why don't you wanna see me? I want to be seen, you don't wanna see meand that sometimes adds a different level of mistrust into the conversation that doesn'tneed to be there, so just making sure that the people who are calling and reaching outto our patients are mindful of that and have any type of help in communication alleviatethat as well.

I think the other thing that I thought ofwhen we were talking earlier about the number of healthcare workers who are women, and weknow that a lot of the essential workers and healthcare workers are minorities so we'retalking about a large minority population of women who have child care considerationsto talk about and to think about and we talked about the who lives at home with you and soif you're thinking about women who are essential workers who have children to take care ofand where are those children when they are at work and who is taking care of them andare they with family members who may be taking care of other family members and so, theycan't do the traditional social distancing in the traditional children in place thatwe're recommending and so, I think when we make these recommendations, as a couple peoplehave mentioned earlier, making them recommendations that are actually applicable to all populations, that can be amended to populations and not leaving large segments of the population out.

And so, I think we shouldn't change recommendations, the recommendations are what they are, but understanding how people implement them andif there's a way that we can make them better able to be implemented by larger populations.

– Great, and I see there's a number of wonderfulquestions that we are receiving through the Q and A and I think it's a good time for usto transition to that space, so we can start to take in some conversations from the audience.

And so, with that, I'll first start off witha question that I wanna give to both Brian and Italo, and so the question was aroundthe conversation that's happening about access to ventilators and potentially being in aspace where we may be allocating vents to those who may have a better chance of survival, and the conversation that we're seeing is that there's potential scoring systems thatare gonna be put into place to determine who's sick and who's not, who has a better chanceof surviving and often times those scoring systems include conditions, comorbidity, suchas high blood pressure, diabetes, high cholesterol and how that may impact communities of colordisproportionately.

So I wanna open that up to Italo first andthen Brian as well.

– All right, so what you're referring to isessentially like policies around scarce resource allocation.

So, I think that the first thing that we haveto acknowledge is that most hospitals have tried to put something in place prior to nowwhere they can equitably distribute by scarce resources, so for example, ventilators ina situation where there is a resource crunch or where the patient demand is higher thanthe actual supply of devices.

The concern is that the measures that peoplehave used to kind of create this have a certain weight to them.

And the weight is among communities of color, particularly, when you start to factor in major illnesses like kidney disease or preexistingcardiovascular disease, it will show a trend where people who are of color communitiesor communities of color, because of their increased disparities, have a likelihood ofhaving these issues.

Now, the data that they're using shows thatI guess survivability advantages for not having these conditions and if you're using a scoringsystem that takes these things into account, it has implicit bias in it, whether you tryto remove or strip financial status from it or insurance status from it or even ethnicityas one of the criteria, you still see color and I think that that's the part that peopleare not acknowledging.

Like, yeah you can say that we've made itas equitable as possible, but the moment I start to look at the patients who are gonnabe denied these devices, they're gonna look like me, they're gonna look like this panel, like that's the reality of it.

So, I mean I think that the first part wasyou have to make sure that the population, the general population understands like whata ventilator is, why it's a lifesaving device, and why it's scarce because you almost assumethat if I go to a hospital, I should be able to get on one of these.

Like if something is very bad, and I startto decompensate, I should be able to have access to this.

If you can't understand that, then it's veryhard for you to advocate for it for you to even be able to speak to other hospital administratorsaround that topic.

And then for providers, what we have to understandis like our implicit biases inform a lot of the things that we do.

And, if you can't get over that first hurdlethat yes you made a mistake in how you assessed the situation, because of something that you'vebeen systemically trained to see, which is the bias of the sicker patients shouldn'tget this because they will have a less likelihood of survival and not acknowledging that thereis a pole towards people of color, you've done a great disservice to trying to treatpatients equitably.

– And Brian? – Yeah so this discussion about the equitableallocation of scarce resources and as hospital systems become stressed is an important oneand what Dr.

Brown mentioned as far as implicit bias in healthcare informing our decisions, that's important.

There's a number of studies where that isthe case, the maternal fetal mortality rate in Black women I think is one of the morerecent ones that can gained prominence, showing that despite economic status, maternal fetalmortality rate amongst Black Women was higher than the general population.

Serena Williams was an example of how thataffected her during her pregnancy.

So and also the comorbidities that Dr.

Brownmentioned, so those are things that we talk about once they arrive at the hospital, right, when you get to the door, what decisions are made at that point to give you the scarceresources, and it's more than ventilators, but we'll talk about ventilators to keep thisquestion simple.

Now, how about getting to the hospital ifyou're sick, right, you need to get to the hospital.

So there are a number of structural barriersthat will impair that, one being essential workers, can you get the time off from work, do you have health insurance? Two, transportation, do you rely on publictransportation or do you have your own car? Three, proximity to a healthcare system, doyou live in a healthcare desert, or do you have to travel across town to get to the hospital? So, there are upstream barriers that willimpact communities of color when it comes to getting scarce resources, but also barrierswithin the actual system itself, so getting there, that's another hurdle, and once you'rethere, there are a number of other hurdles to overcome, so there are a number of ethicaldiscussions that are being had across the country.

I think the best article I saw was in theLumen journal, probably about two weeks ago that talked about allocating scarce resources, they had a number of recommendations in there that tries to encompass all of this, recognizingthat that all cannot be solved right now.

– Thank you both.

Erika, so, as we think about communities that, the vulnerable communities that are out there, often times there's a level of mistrust whenit comes to the healthcare system as far as whether or not they'll receive adequate levelsof care, whether or not there conditions will be dismissed, and so can you talk about waysthat we as healthcare systems, we as providers, can instill trust in the patient populationsthat we're doing our best to serve? – Yeah, so I mean I will, there are some reallysignificant challenges with mistrust and this is true of communities of color, Black communitiesor Latino communities.

There's historical issues that have happened, there's been sterilization that happened for our communities, Latino communities, in LosAngeles County.

And so, some of the efforts that we have engagedin is really partnering and partnering with our patients and partnering with our communitybased organizations whenever possible and places where patients already have trust, and being able to care for those challenges with the community.

I think in the patient encounter, right, inthe emergency department, a lot of our interactions appear to be transactional.

This is the first time I meet you and I haveto be able to create trust in a matter of 30 seconds to a minute, really coming in fromthe perspective of I want to listen and understand and hear what your challenges are and thecapacity for you to be able to meet some of these recommendations I think is critical.

So as an example that I gave with our patientpopulations, asking the follow up questions, right? I think that from the medical perspective, we do train for so many years that if we say hypertension and take your medications forthat, we take that for granted that many people understand what that means.

When we say social distancing and isolate, we may also take that for granted, and that is a bias in our educational privilege orcommunication.

Really taking the moment, in those times whereyou're sitting with your patient, to understand how will you take care of yourselves whenyou're at home? There are recommendations for social distancing, do you know what that means, or what could that look like from your home and your familydynamics? So, it is a challenging space, but be perspectiveof sensitivity and humility I think will serve a long way, and with the understanding thatif they come to the system, they're already coming scared and vulnerable and being ableto facilitate a relationship that makes them feel cared for and trusted is critical andif language is not, if language is a barrier or if they speak a language that's preferredother than English, being able to provide those resources in a sensitive manner andin a patient manner will create some of that trust, at least in the short term until wework on these larger, systemic issues.

– And Mary you know, piggy backing off ofthis conversation around trust and creating that level of trust between the patients andproviders and systems, there were some commentary that was made mostly around blaming individuals, particular blaming the victims of COVID.

And it came from leadership instructing usto stop doing certain things in order to protect our big mama's and our abuelas, and that tendsto make, put more blame on us as individuals about the decisions that we're making withoutreally coming into context of what else may be going in our communities, in the intergenerationalhomes or the need to be out in the workforce as essential workers, and so how can we bettertalk to communities to not blame them for the decisions that they're making but helpthem to make decisions that are gonna help flatten the curve that we're so trying todo? – That's a heavy question, but I think a couplethings, I mean as much as we can be visible as trustworthy people of opinion, right, oninformation, I assume that people understand that we're giving them true and accurate andappropriate advice and trying to as much as possible diminish, dispel the misconceptionsand the stigma even around COVID-19 and the Black and Brown communities that are out thereI think is helpful.

And I think also just kind of reiteratingwhat Dr.

Uribe just said and helping people make practical plans right? And so, I think if you have to go to workand if you have to drop your kids off at your mother's house, or your aunt's house, or yourcousin's house, how can you still least expose yourself and your family and making protectiveequipment more available, I mean that's still a big issue.

So, if you have to go to work and if you haveto go to the grocery store, then you have something to protect yourself, so making thingsavailable, making sure people know, understand how to use a mask and the appropriate wayto use gloves, right? So we see, even going to the grocery storenow, and you have the mask on but it's on your forehead or on your chin or not coveringyour nose and mouth, you had access to PPE, but you're not using it correctly, so you'renot best serving your family.

So I think as much as we can making sure we'regiving useful recommendations and adjustable if you will, recommendations so that evenif you have to do something that's less optimal than social distancing, how can you stillprotect your family? – Thank you.

And Brian, I wanted to go to you about thisquestion.

So there's a lot of discussion about thesemedications that we're trialing for treatment for COVID and thinking about where those trialsare happening and who gets access to those trials and those medications and then also, the concern that may happen in communities of color where there's distrust in the healthsystem, where we're thinking about being, you know, are we gonna be guinea pigs whenwe're getting a medication, or are we being withheld a medication that others are receiving, so can you just talk us through a little bit about the issues that go along with theseclinical trials that we're seeing? – Well this is something I've actually beengiving some thought to recently as the data comes out about the number of Black Americansthat are dying in these cities 'cause I think the untold story in there is that they'rejust walked to the hospital and then they die right? They are sometimes in the hospital for weekson a ventilator, two to three weeks some of these patients are, and what's happening duringthat time? We're trying unproven therapies, we're doingthe best we can during this pandemic, but we also have these clinical trials that arehappening as well for patients that cannot advocate for themselves, that cannot havetheir families in there to advocate for them, 'cause they need to keep physical distancing, so there's some ethical considerations there and knowing that the large number of thesepatients are probably African American just hearkens back to the history that we talkedabout before, about trying out unproven therapies on Black Americans without consent.

Now I recognize that we do have methods inplace to protect human subjects during trials, but the fact that we call them human subjectsin trials is somewhat dehumanizing and right now, this is happening on a national basispossibly, right, but we still don't have all the data.

So I personally, I want to do what's bestto advance medical science, I want to do what's best to serve humanity, but I do find myselfquestioning what is happening to my people right now that are sick and suffering as aresult of a number of policy decisions that were intentional to separate us from society, but now we're in a position to advance medical science in ways that are gonna make many peoplefamous right? There will be books and papers and grantsthat come out of the COVID pandemic and at the end of this we cannot forget the contributionsthat Black patients made to medical science.

– So Erika, one of the things that we're seeingand Italo alluded to it earlier in the conversation, is about people getting tested, and you mentionedRudy Gobert getting tested, the entire professional basketball team getting tested after potentiallybeing exposed to him, yet communities that probably don't have access to testing andas we think about how we are going to reopen our economy and get people back to work andback to school, can you talk about some of the concerns that you may have when it comesto access to testing, especially in disadvantaged communities, rural communities, communitieswith larger, undocumented immigrants, can you give me your thoughts on what we needto do in order to ramp up testing? – And so I mean, there's been challenges withtesting across the country and first it was limited number of testing and then it waschallenging and challenges in terms of real time results of testing, so we did have testingwith Public Health and we had it with Quest, over the last several weeks, we've had ourown capacity, we've built capacity to do internal testing at our hospital sites and there hasbeen a partnership between the city and the county to provide alternative testing sites, so the county and the city have partnered to create more than 10 testing sites thatare drive through type of testing where anyone can go in and have their testing done.

The important part in that way is that thecommunication has really been that it doesn't depend on your status in terms of citizenship.

If you have symptoms, you can go and get tested, as long as you have a name and a phone number, or a way for us to contact you with the results.

The testing is free and even in our communicationson our webpage and the patients that we do reach, we've been really assertive about statingthat the testing will be free and provided and we want you to come in to get the curethat you need, regardless of immigration status.

So I think there is more capacity to testnow, I think one of the areas that would be more challenging is gaining a little bit moreclarity and you know culturally appropriate messaging around when to go back to work andwhen to kind of integrate back into the community and some things that are practical, right, like my mother is a custodian for example.

If she was not working, they've told her thatit's an unpaid leave, and when you have unpaid leave, there's issues that come up in termsof just being able to function in your day to day life, in her very transparent approach, she says, well, even if I wasn't feeling that great, if I have to come back to work to makemoney, how am I not gonna do that? I have to pay my rent, you know, at this time.

And so, the county has been very supportivein being able to try to provide resources and communicate about unemployment and resourcesto help families stay home if they're sick, so I think really being able to get practicalplans and communications about that isolation period and when we're ready to reintegratewill be critical, especially now since we have a little bit more capacity to test.

– Great.

And Mary, some of the comments and questionsthat I'm seeing in the Q and A section, and for all of those who are on with us, I seea number of people raising their hands, can you put your questions in the Q and A sectionand we'll try and get to them that way as opposed to you raising your hand.

But Mary, a number of the comments that I'mseeing are around people feeling distressed because they don't know what they can do tohelp and whether it's individuals who are lay people, whether it is leaders in the communitywho have non-profits, or if they're leaders at a faith-based organization or a church, or even medical students, and so what can these individuals be doing in this time tohelp others? – I think there's a few ways you can lookat it.

I think I'm gonna go back to useful, accurate, and appropriate information, making sure that you're just, from one person to another, makingsure you're interpreting the recommendations the correct way and that you are encouragingyour friends and family to do the right thing as much as they can as possible.

I think in lieu of being able, something Iwas reading earlier that you know, one of the ways in which in small communities thatwe disseminate information, is often in small social settings.

So you mentioned the barbershops earlier, the beauty shops, barber shops, churches, these small places where we used to gatherand discuss pertinent, current topics, and disseminate information are not availableto us anymore, so, and as much as we can, creating those types of spaces virtually sothat we're supporting people who may be isolated at home and still have that ability to supportone another and relay the correct information.

I think another thing to think about, I knowthis is not a traditional medical role, but I know a lot of medical students have beenhelping the other healthcare workers who can't stay at home with things like childcare andgroceries and that type of thing because you know what the recommendations are and howto follow them, and so you can model some of that behavior, and so something as simpleas getting groceries for your family for the week might be something just small but thatyou can do.

And I think going forward, it's gonna be veryimportant, I mean so you know, this is a small window in time, and so going forward, equippingyourself with as much information so that we can continue this battle if you will goingforward, so making sure that we continue to support our local community programs thathelp connect people to services and so you don't wanna forget about your WIC's and yourPlanned Parenthood, but your Mother to Babies and other organizations like that that maybe going through decreased funding mechanisms right now, that we wanna make sure that wecontinue supporting the facts.

And so those types of services don't go awayand they can hopefully improve quality of care going forward.

– Great, and I have a touching question froma couple of people watching and it's related to all of us and the question is how are wedealing with this personally as providers and being on the frontlines, and so I'd liketo open up to Erika first and then I'll go through to each of you.

And how has this impacted you as an individual, as a physician, but also as a member of this community who's deeply concerned about healthequity issues? – I mean, it's a challenging time.

I think everyday is a bit of a rollercoasterand there's waves of emotions that come up.

If I'm in the emergency department, in someways, that's the area where I'm trained to kind of, to work with people, and I feel engagedand that my skill set is being utilized and in the most impactful way.

Coming home, like I am from a large Latinofamily, and the way that we provide social support is by seeing each other and there'smoments that I drive to my parents' house, not trying to do anything unessential, butif they have to go get groceries, I drive to my parents' house and I have them stepout and I look at them from my car and I wave at them, right, and our family is deeply rootedin connections and relationships that it's a challenging space to really feel that socialconnection and emotional support.

With our patients, I feel deeply when I'mhaving conversations with them about being intubated, again, culturally, there's thishuge strength in family and family support and that you'll get through anything withyour family, and there we are, me with a mask, with a gown, with gloves, they wouldn't evenbe able to recognize me in a different setting and I'm the last person to speak to them beforegetting intubated and we don't know what the outcome of that will be and there's no wayto really engage the family unit in those spaces.

So it is a very challenging space.

I also feel hopeful that this space is opento bring these issues up from a public health perspective, that at the end of this, couldcreate some real system and structural change.

So, I think we keep showing up and we do thebest that we can.

– Same question to you Dr.

Brown.

– I think that the first part for me was acknowledgingthat no matter where I was at, the more valuable asset was my mind and my ability to communicate.

I can definitely see 40 patients in a day, I could see a ton of rule out COVID-19 cases, but if I can, instead of just seeing those40, extend my reach to 400 or 4000 through messaging, I'd be as effective, and that givesme peace of mind.

Knowing that I can do more, not just on theclock, but off the clock, because I live by myself.

My father lives two hours away, I haven'tseen him, I try to talk to him.

My sister lives two hours away, can't talkto them either.

But I can speak to my colleagues who are shelteringin place or who have to stay in their garages when their family lives inside the home, orwhen they camp out in tents when their family is living inside the house, right, or in somesituations, sending their families to entire different states.

So these are ways that I found being helpful.

The second thing that I thought was extremelyhelpful for me was getting these ideas out, like acknowledging that I'm upset, acknowledgingthat this is something that I felt could've had a better response and then, turning thatinto some sort of concerted action like talking about real actionable steps, whether it'sincreasing screening in communities of color where you use population mapping to definewhat that need is or whether it's like hey, let's put more pressure on state based governmentsto do a second round of stimulus checks for essential workers, like being able to havethese conversations in a way that is thought provoking, but also with clear, actionablesteps, I find deeply satisfying, and it gives me a sense of purpose aside from just beingable to intubate a patient, aside from just being able to sit there and you know holda hand if somebody is like struggling to breathe, like those things matter on both fronts.

And I think that the last thing for me isrealizing that there's power in journaling, there's power in chronicling things, and makingsure that you are emoting, like actively emoting, so I've taken literal like time to write outthese thoughts and these feelings and encourage my colleagues to do the same because I thinkthat after this is done, society will be changed forever, but our field will be changed foreverand the way that medicine is perceived is gonna be changed forever.

We don't have the luxury anymore to be passiveplayers in a political environment.

We don't have the luxury to be quiet aboutour feelings on social health disparities rather and social determinants of health, and we have to pull these things into the light even further than they've been.

– Thank you Italo.

I wanna go next to Dr.

Fleming, same question.

– So, personally, I think the biggest adjustmentfor me, because I travel full time for work and having to adjust to the travel recommendationsand restrictions has been a big adjustment for me and so that's been challenging to saythe least, but one day at a time and I've been evolving with it as best as I can.

I think, kind of to echo what's been saidbefore, I am appreciative that some of these issues have been brought to the forefrontand I hope the conversation continues after we stop talking about COVID-19.

But for many of us, right, we've been workingin this space for a long time and we often feel like we are preaching to the choir 'causeit's such a close knit space and we're very excited and passionate about it, but we don'toften get a broad public or federal platform to speak about it.

And so I think a lot of people are dialedin right now and so I'm hoping that we continue the momentum and continue the conversationuntil that post COVID-19, we can actually implement some inches and solutions so thatwe make this a sustained change and not just a temporary platform on the calendar for today.

– Great.

And last, Dr.

Williams? – Yeah, I'll say that this time is, I don'tknow, maybe it feels somewhat inadequate and what I mean by that is, you know, despiteall the training and that we go through an education, I wonder like how do I scale upmy impact in recognition of what is happening right now.

What have I done over the past couple decadesthat could've mitigated what is occurring now? I ask myself that question and the answerto me is like I'm not sure how much I've done, you know, I know I've done quite a bit, butin regards to having large impact on communities and populations, I feel like there's so muchmore that I could be doing to have that sort of sustainable impact on a large scale andso now I'm driven to hoc use this experience I'm having now to have the sort of impactwhen this pandemic passes.

But I'm also, I mean this is like the breakside in entire medicine and it's why I love being a doctor is I'm just inspired by thepeople I'm working with that I've just stepped up and done the work under austere conditions.

You know, my colleagues in trauma, the nurses, but I mean especially, the residents that I'm working with.

When you're working epidemic medicine andyou're working with trainees and seeing the work that they're doing right now, I can'tcomplain about anything because they've just stepped up to the plate and they've knockedit out of the park every single time, so that inspires me and it makes me realize again, I have the best job in the world and this is a time that will test me personally andprofessionally, but I will become better for it and when it's all done, I will look forwardto using this experience to be a better contributor to the field of medicine and to society asa whole.

– Wonderful, thank you.

So we have just two or three minutes left.

So I wanna just very quickly ask each of you, maybe one sentence answer as to what is next on the healthcare front on addressing healthdisparities, based off of everything that you're experiencing now, what can we do tomove the needle to eliminate these disparities and so I'll go with reverse order from theway we started the panel and I'll put Dr.

Fleming on the spot first with that question.

– Alden, that's so not nice.

I mean I think one thing I was, that I mentioned, but I'll give you two things.

One, I think we need to work on incorporatingequity as part of the culture of medicine just like we would do safety, and so doingsomething to incorporate mechanisms to make sure that we're treating patients the same, despite what they look like on presentation.

And two, as we look at insurance and reimbursementand those type things, one, making sure that everybody has access to insurance and thosethat are insured have adequate insurance and I think to the pregnant populations, thatwould mean extending Medicaid coverage for at least a year after birth.

– Wonderful, Dr.

Flores Uribe? – So I will echo that integrating equity andco-design efforts will be critical.

Bringing the patients that you serve intodecision making of the systems and operations of your institution will help, in additionto creating communication platforms and being able to reach those populations.

On a more personal level, we all have a passion, right, there's something that we can each do to advocate and the more that we can connectwith one another, learn about each other, and create those partnerships, those allies, those relationships, those networks, the more that we can start moving this needle forward.

– All right, Dr.

Williams? – I think this having this discussion aboutstructural racism is important and a positive step, that just to get that into the lexiconand to name it so we can own it and work to end it and from that, it doesn't just helpcommunities of color, it impacts all of us, so let's have that discussion and take actiontowards eradicating it will be a benefit to everyone.

So I think that's one thing we need to domoving forward, continue that.

– And Dr.

Brown.

– I think that the most acute things thatcan happen, obviously, like I said, increasing screening, pay for essential workers, releasingnon violent offenders from prison, particularly from jails so that we can slow the spreadin those vulnerable populations that get overlooked easily, and overall, we need to increase fundingfor social determinants of health work.

The NIH tends to underfund this tremendouslyand this is a prime opportunity to use established community partnerships with academic centersand funding to leave a very large, resounding impact.

So that is what I would expect to happen.

– So I wanna say thank you to our panelists, this has been an amazing discussion.

You've brought so much to the table and Iappreciate the commentary that you've made.

And I wanna say thank you to all those whoparticipated with us for this hour and a half discussion.

This is a conversation that's ongoing andas Dr.

Reede introduced us earlier, this is a space where we're gonna continue to havethese conversations around equity and social justice, particularly related to COVID, butbeyond and talking about other issues.

I just wanna say thank you to our panelists, thank you Dr.

Brown, Dr.

Williams, Dr.

Flores, and Dr.

Fleming for joining us and I wannasay thank you to the staff at the Office for Diversity and Inclusion and Community Partnership, in particular Dr.

Teresa Carter, Mostafa and Dave Walla for helping to put this together, you all have been amazing at helping us to execute this event.

Just a couple things that you can see on thescreen, we have a couple other events going on tonight.

The biomedical sciences career program isworking in conjunction with the Tour for Diversity and Harvard Medical School to host a virtualtour for diversity in medicine.

It's gonna happen over four nights and a wayto encourage students from diverse backgrounds to consider careers in the health professionsand so if you need any premeds out there, please encourage them to sign up and participatein this webinar, it's gonna happen the next four evenings.

I know there are some conversations aroundmental health and questions that we weren't able to get to.

We're actually having our next iteration ofthis and we're gonna talk about the mental health and wellness for healthcare providers, so please look for that link register on the event, it's gonna happen on Thursday, April23rd at four p.

m.

So again, we're just looking for ways to continuethis conversation, use this space, use the opportunity, use the technology to reach outto as many people and have these conversations because we know we need to work to continueto address health disparities and promote justice.

And so with that, I want to end our event.

I wanna say thank you again to everyone forjoining us and we look forward to future interactions.

This webcast will be recorded and will beavailable on our website for future viewing, so please take advantage of that, as wellas we will post contact information for our presenters so you can reach out to them directlyabout some of the questions that you had that we weren't able to answer during this time.

So with that, I wanna say thank you to everyoneand have a wonderful rest of your day.

– [Erika] Thank you.

– Take care everyone.

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