#APSA50: Social Determinants of Health

Stay Current is a multimedia publication designed to keep health care professionals up to date on standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Alex Cassar, Alex Gibbons, and Ray Hankin and is recorded and produced at Cincinnati Children's Hospital in Cincinnati, Ohio. Hi everyone, this is Alex Cassar, and I would like to welcome you all to this episode of the Stay Current Pediatric Surgery podcast. This year my partners and I joined forces with the Behind the Knife team to cover the 50th anniversary meeting of the American Pediatric Surgical Association. In the next few weeks, we will take you on a journey exploring content you may have missed and some behind the scenes discussions with some of the amazing speakers we met along the way. This first episode is dedicated to social determinants of health, a topic that is being strongly embraced by the advocacy committee and was a cornerstone of this year's meeting. Social determinants of health are factors like economic stability, housing, transportation, physical and psychological safety, zip code, geography, literacy and education, hunger, poverty, community support and engagement, discrimination, stress, and even linguistic and cultural competencies from providers that affect healthcare outcomes like quality of care, mortality, morbidity, life expectancy, and even healthcare costs. We had the opportunity to interview Adam Foss, a lawyer, former district attorney, and founder of Prosecutor Impact, a nonprofit organization improving community safety in the United States through culture change in the criminal justice system. Here is what he had to say. Thank you for having me here. I am here. Because over the last 3 years I have developed a curriculum for prosecutors that looked at uh why we're having such disparate impacts on our communities in terms of racial disparity and socioeconomic disparity and lo and behold, um while I was learning about this and doing research on this I look across the street to the public health sector and the disparities are the same and it and it turns out the reasons, uh, many, many of the times are the same. And so as soon as I was able to uh sort of like share this insight with the public health field it started to become um something that people wanted to hear more about so there's a tremendous confluence between mass incarceration, what's going on in public health, and for me talking about any mass incarceration, you can't have the conversation while talking about uh solving the public health crisis. My first experience with social determinants of health as a topic was at a conference and the speaker was Sir Michael Marmot. I'm pretty sure you've heard about him because he's very popular in the field. And the statistics he was giving us, the US just had terrible, terrible numbers compared with so many other developed countries. Uh, how do you think specifically kids in the US, uh, are at a disadvantage right now? Uh, I think that, uh, in the United States in particular kids are at a disadvantage because of, uh, where do you wanna start, racism, classism, homophobia, xenophobia, where you see people who are not the dominant narrative of this country being marginalized in ways, um, that is reflected in every aspect of their life so culturally, economically, health metric health metrics, uh, criminal justice system. And uh the way that it affects children is that we continue we've been doing it to adults and we take adults out of communities we take adults out of the economy we take adults out of the health care that they need to be getting and obviously that leaves a void that uh children are not prepared to breach and when we force them to do so they start to fall into the same traps that their families did and it and it becomes intergenerational uh and in some places intractable. What are some things as uh pediatric surgeons and advocates for our patients that we can do to uh help uh solve some of these problems, whether it's in the hospital treating them or advocating that for them, uh, elsewhere. Yeah, this is a question I get a lot, uh, from, from everybody sort of like what do we do, uh, because it's, it's so bad and we see it happening all the time and we want we want like to solve for it and, uh, unfortunately or, or maybe fortunately, um, there's like pre-work that needs to be done before we start doing anything uh we all grew up in the United States of America, most of us grew up in the United States of America and as a result we've been like conditioned we've been programmed. To see people in certain ways and the and the the lens through which we look at people. Um, at the, at the very beginning is, is why these, these disparate outcomes happen and what I'm talking about is like cultural competency in the workforce, um, and so like the broad answer to that is we need to fundamentally re-engineer the way that we educate people who are on the front lines dealing with human beings, particularly marginalized human beings. Um, I went to law school for 3 years knowing full well that I was gonna come out and be a public interest lawyer. Um, meaning that I was going to go into communities that I did not grow up in and advocate for people and uh I was forced to take a bunch of classes and pay for them like property law and contract law and wills and trusts, but never once was I confronted with any topics about trauma even though for the rest of my career I was going into an environment into a community that was dictated by trauma. I never learned anything about poverty in law school and if I did it was because I elected into a course that I was not mandated to take even though I knew full well that I was going to come out of that place and be dropped into a community that again was dictated by trauma and so when I think about medical school and I don't know that much about it. Uh, I'm guessing that there's not a class on the history of racial bias in the United States of America and, and what do we do? What, what are the tools that we use as people who, uh, didn't get those concepts as a young person? How do we re-engineer sort of like how we think about race and class and sexual identity and gender and all those things. I think embarrassingly in medicine we have data that shows us that we are doing everything wrong. We have data that uh black mothers are dying in childbirth at rates that are ridiculous compared to the rest of the groups. We in pediatric surgery have numbers where we don't take black or other diverse group of kids, their pain seriously and they're getting. You know, fewer pain medications or they're getting ignored when they, uh, you know, reach out to their nurses for pain, and this causes not only them to struggle more during their illness, but also, you know, distrust in the system and it just, it creates a vicious circle of, uh, powerlessness and, you know, lack of support from the institution. We had an unconscious bias podcast where a cardiologist told us that Even in the type of stents people get when they have heart attacks. Uh, when they're like, oh, this person might not follow up because of their cultural or socioeconomic status. We should give them this other stent. Uh, and we're compromising our standards of care. We're giving them something that is not the best we have. Because we are thinking like, oh they won't show up or they won't take their pills or they won't do this, they won't do that. What is happening in the public health arena, uh, Legislative space or advocacy space right now that's already happened like that way maybe we could join or support in any ways that could get help from providers. Yeah, it's an interesting example that you just used because it's a, that's one of those things that like we don't know that it's happening to us when we're making these assumptions about poor people because we see like, oh, you didn't show up for your appointments. So in the, in the prosecutor space. You know, you're a domestic violence victim and you come in the day after the arraignment and you say something like I don't want to press charges, uh, instead of like thinking through that and understanding what it is to be in a domestic violence relationship in a place where you're living in poverty, we make judgments about that because we're like, I wouldn't do that. What like what, why are you saying this to me? And now I'm judging you and evaluating whether or not you're worth it for my attention to this case. And so if I set up an appointment and you miss it now, now that's confirmation bias and now I actually just don't care about you or this case even though I should know that you not showing up that appointment was the result of not you not caring but the fact that you don't have a car, you don't have childcare, you have lots of other things that are going on and unfortunately placing yourself at the top of that pile and going to this meeting is not a a a luxury that you have and so, uh, there was, um. An organization called there is an organization called Code for America who uh uh a bunch of nerds who are like let's make technology to solve social problems. And one thing they tackled was this idea that um when you put when you put steps in the process in the way of people who are living in poverty, the likelihood they complete that process decreases exponentially and so they looked at people um who were taking advantage of California's new laws around getting a record cleared and realized that like nobody was doing it. The law said you can now do this and in doing this you'll free yourself up to get housing and employment and nobody was doing it. Uh, and it was because there was like, you know, 15 steps in the process, and after the third one, it's, it's just not worth my time anymore. And so code code 4 took, uh, technology to try to cut 5 steps out of that process and I'm, I'm using willy-nilly numbers, but you get the point, and they realized that they increased the likelihood that people would complete the process by 44% just by like not making assumptions about people and just giving them tools. To accomplish their goals that we have the privilege of not having to worry about, um, and then I think, you know, I, I think just generally, uh, demanding it in the workforce from your people like managing up and saying, uh, this is, this will make us better doctors, you know, it's like 2 out of 3 of you are diverse in some sort of way in here and, and that is a critical mass, um. You, you can't look at the data that you're talking about and say, hey, we're doing everything right and this is what we're realizing the criminal justice system is like we can't look around and be like we're doing a great job, we need to do something different and and an easy and safe way in even though it's uncomfortable is talking about the things that we did not learn and giving us the tools to be effective. In your experience in the field, has diversifying the workforce, uh, made it better for the people out there? What I mean by this is, if we diversify our surgical workforce, do you think we can do better for our patients? Do patients do better when they are being seen by someone they relate to, someone that like them? Yes, um, I don't, I don't know that it's like the silver bullet just to diversify with, um, sort of like appearance. Uh, because for social determinants to me it's more about life experience and lived experience, um, and so while it is certainly important for inclusivity and you look at sort of like colleges and, and law schools, uh, having a really hard time recruiting diverse people to come there, it's because, well, I don't wanna go work there because nobody looks like me. The same is true for people who are seeking help if they go into a, a, a hospital or a doctor's office and they look around and nobody looks like them. Uh, you're already at a level, level of distrust almost that is going to ruin that first interaction with patients that are, is so critical to long term health outcomes, um, so there is obviously like the need to have more diversity in terms of, uh, appearance and characteristics, but what is most important is how do we build pipelines for people who are impacted to get to the finish line and this is what I'm like what I want to do is create pathways for. Kids who are in high school to get through law school. I, I appreciate that we concentrate so hard on getting kids into college, uh, but we, we like, we need to build the pathway all the way so that they're sitting here instead of me. This podcast is gonna reach, uh, mostly pediatric surgeons or aspiring pediatric surgeons, not only in the US but internationally. Ah, what, what is the message that you would like to give them? Uh, the message that I would like to give them is that, uh, learning never stops, and what is more important for you to be a successful doctor, a successful surgeon, has very little to do with like the books that you read or the tools that you're using. Uh, we need to all either individually or, or, uh, more preferably together, uh, relearn a bunch of things, unlearn lots of things and relearn lots of things and and doing so in ways that are creative and not PowerPoint slides at the front of the room like going to an unconscious bias training. It's not an appendectomy. Like you need to be immersed, it has to be part of your culture, um, you need to be talking about it all the time and instead of making it a, a checkbox like we've talked about it all of the time, uh, understand like to your fiber and to your core, the thing that makes you wanna be a doctor, makes you wanna be a surgeon should compel you to wanna know this stuff because it will make you. 10 times better. Adam Foss participated in the presidential symposium led by Dr. Ron Herschel and moderated a workshop organized by Doctors Marion Henry and Vic Garcia. Due to popular demand, we decided to include his talk in this podcast. We hope you feel as simultaneously uncomfortable and enlightened as hundreds of audience members felt during his presentation. Uh, I'm delighted to welcome to the stage, uh, Adam Foss. Adam was a former or was a district, assistant district attorney in Suffolk County in Boston. Um, he was awarded the 2017 Nelson Mandela Changemaker of the Year award. And uh the Next Generation Leader NAACP Award. He's a visiting senior fellow at Harvard Law School. He's a staunch advocate for criminal justice reform and has formed a not for profit along those lines called Prosecutor Impact. His, uh, uh, he's going to be speaking on swords and shields, a discussion of power, privilege, and opportunity. Adam, I'm in the enviable position of being like the 5th speaker of this, um, so. Hang in there. How are we doing? We're good? Comfortable, feeling good? Too bad I'm about to take the air out of the room, if there's any left in the room. I didn't expect like 3 of these talks to be talking about a lot of the things that I'm talking about. I'm glad that you've sort of like been saturated already, but we're gonna keep going. Uh, and it's gonna get uncomfortable. Sorry. Um. This is gonna be uncomfortable for some of you. It's going to be, uh, very resonant for others of you. Uh, for those of you who are uncomfortable, um, I'm gonna ask you just not to do the thing that we do when we get uncomfortable, which is like fold our arms or run for the exits or get that cup of coffee that we've been burning for. Just like sit in your discomfort. Because to be able to get up and walk away from it is a privilege that lots of people don't have. There are people who wake up uncomfortable because of the skin that they're born in. Or they're uncomfortable when they're out in the street because of their identity or their sexual preference or their religion. They can't run away from those things, so, please, just for the next 25 minutes, if you get uncomfortable, just like sit through it and listen. And if you find things that I say like offensive or uncomfortable or hurtful, um, please know that I do the most I can to make everything I say factual, so if you're mad or upset about the facts. That's a you problem. Process that. Try to figure out why it bothers you to see a slide like Doctor Newman put up about the diversity of ABSA. Why does that, why does that bother you so much? Uh, my name is Adam John Foss. If you have your phones out and you feel like live tweeting or snapping or whatever you millennials do. Go for it, um. To start the uncomfortable conversation though, I wanna talk about, uh, my travel habits. Over the last three years, I've traveled about 1.5 million miles, 1.5 million miles on the board. And as a result, I am like triple, quadruple, platinum, everything. And so I get to go on the plane whenever I want and I get to sit wherever I want, and I'm like, I'm, I'm an aisle person, just love the aisle. And with being in the aisle comes the responsibility that you're like the gatekeeper for the, the row. And so about 2 months ago, I was sitting in my aisle seat. I'm one of the first on the plane. I just like to be on the plane. And, uh, a young lady came up and said, excuse me, and I said, oh, hello. Window seat, cool. So I got up and she sat down. Then another young man came and he said, oh, excuse me, I'm in the middle seat, and I was like, oh, that sucks, but. Laguard, he sat down. And then I looked across the row and we looked at each other, and I don't know if they were thinking what I was thinking, but in my, what was going through my mind at that point in time was, man, this is the first time that I've ever sat next to two black people on the airplane. In 1.5 million miles, it was the first time that it ever happened. In fact, I've never sat next to a black person in first class. And the only time I ever see black people in first class, they're people who I recognize from television or sports. I've had the opportunity to be in some of the top Fortune 100 companies in this country in their C-suite offices, sitting across from the Mark Zuckerberg's and the Bill Gates and the Jeff Bezoses, Amazon, Airbnb, Google, you name it, I've been in those offices and the only time that people who look like me are in those offices are the people who are bringing in and out the coffee. I've had the opportunity to speak at about 90 colleges, graduations, uh, law schools, universities, and I've yet to go to one that has an African American population of over 5%. And unless we're prepared to sit here and think that somehow I was born with a genetic deficiency that made me less intelligent or less creative or less hardworking or less ambitious than all of those people in those places of privilege and power, then we have to have a very fundamental conversation about where everybody is. Look around in your group and think about the topics we're talking today and ask yourself like, who's not here? Who should be filling these empty seats? It's the 50th anniversary of ABSA, that's awesome. It makes me think of the way that we treated people who looked like me 50 years ago. When I think about the way that we treated people like me 50 years ago in this country, I think about the images that we have. First of all, I think about the images because we have like color photographs because it's such recent history. I think about the images of 4 little girls who went into a church one day and never came out again because somebody threw a pipe bomb on their Sunday school because they woke up black, and nothing happened for decades. The thing about the images of a 15 year old boy who was beaten so badly that his mother had the wherewithal to keep his casket open during his funeral so the rest of the country could see what they had done to his son. I think about the images of three boys who look just like me hanging from trees lit on fire in the middle of a public square in 1968 because they woke up with too much melanin in their skin. And when I think about those images, I don't just think about the 4 little girls, I don't think about Emmett's Till, I don't think about those 3 young men hanging from the trees. I think about all of the people staring around the periphery watching it happen. I think to myself, how could you just be standing there? What are you doing? I would have done something. Why aren't you doing anything? But here I am sitting in an airplane with no black people. Here I am giving graduation speeches to classes full. Of privileged young white people. Here I am watching millions of dollars being exchanged in our economy, and never once does that money ever touch the hand of the people who might need it the most. And I think about images 50 years from now when we're looking back on this time. And what are people gonna be asking about me? This is the greatest human and civil rights crisis of our time. And we're about to hand it To not just the millennials, but lots of other young people, we're about to leave this at their doorstep and say, you fix it. Because there's a reason that this room isn't more diverse and every other room that isn't more diverse, and it's not because we're less hardworking or less creative or less ambitious or less intelligent than you. It's that since the foundation of this country we've built structures to keep them exactly where we want them. And that's a travesty. Because we're missing out on their company. We're missing out on their ideas, we're missing out on their challenges, the diversity and their creativity. And as a result, we'll never know what we missed out on. Mass incarceration affects every single person in this room because one of these empty chairs represents someone who isn't here, who might have had the greatest solution to one of these ailments that you're trying to fix. And we'll never know unless we stop this problem. 2.3 million people in jail and prison right now. Another 5 million on probation or parole, one misstep away from the larger aggregate number. 1 in 3 black men born today will spend some time in jail or prison. I've gotten my time out of the way. 1 in 3 black women has a relative in jail or prison. 650,000 people come out of prison every year just to run into 50,000 collateral consequences of felony convictions that impede our successful re-entry into society. 70 million Americans have a criminal record. That means 70 million of us are out here walking around with a scarlet letter on our chests that will never go away. And will impede our reentry into society. And it's not just a criminal justice issue. Obviously you've heard many times this morning, this affects us at every social and cultural and economic and political and medical metric that you can possibly think of. The leading cause of death in this country of young black men 18 to 35 years old is handgun homicide. That is not true of any other people on any other place on this planet except the United States. It causes so much death, it accounts for the next 9 leading causes of death combined for that same age cohort. Can you imagine a country where we would be remotely allowed that to be true of young white women from the suburbs? I can't Cause we never would let that happen. There's a place on this planet Where black women are 12 times more likely to die during childbirth than white women. It's not in sub-Saharan Africa. It's not somewhere in the West Indies. It's in Manhattan. Black women and white women experience breast cancer at almost the exact same rate, but black women are almost twice as likely to die from it. Why? Because we care about our lives less. Because we're not trying hard enough. Or something else going on. Black women have a 71% higher chance of dying of cervical cancer. Again, why? OK. Because we don't like ourselves as much as you. In my lovely city of Boston, welcome to my city. Lots of great things here, except we're in one of the most racially and economically segregated, cities in this country. In fact, if you go out here to Mass Ave and you just go up a few blocks, there's an intersection there. We're standing in the middle of the intersection. You look one way and you look the other and life expectancy goes down by 25 years. One intersection. There are more segregated schools in this country today than there were on the Eden of Brown versus Board of Education. There's more representation in Congress until this year, and during the period of Reconstruction of people who look like me. There are more black people under correctional control today than there were slaves on the eve of the Civil War. And just to put a fine point on it, researchers estimate that over the 400 years of the transatlantic slave trade, 12 million Africans. were captured, enslaved, and killed. Last year, 11 million people went through our jails. We are recreating slavery every single year, and this is our legacy. We need a new civil rights movement. I don't know why the last one stops. But we need a new one. A lot of people blame the inertia on a lack of leadership. We're waiting for the next Malcolm, we're waiting for the next Martin, we're waiting for the next Rosa, someone, anyone to come and take us to the promised land, but it doesn't come. And every day that we wait, millions more of us are arrested, thousands more of us are incarcerated, thousands more of us are dying. We need a new civil rights movement. The good news is When I look out into this room, the reason that I'm here is that I do not just view you as professional medical caretakers and pediatric surgeons, I view you as the next civil rights leaders of our time. When I was 19 years old, I remember standing across from a police officer handing him thousands of dollars of cash that I had wadded up and stuffed up in the wall of my bedroom. I remember handing him the little scraps of marijuana that I'd leftover from the pounds that I was trafficking between Philadelphia and Boston. And I remember standing there looking at him and him looking at me and me registering the look on his face of one of contempt and disgust and frustration that I had become a statistic. And I remember looking at him and being like, oh God, I'm in trouble. But despite the fact that I was a black man in America in the 1990s standing across from a police officer having just been caught drug trafficking, Here's what trouble looked like to me. My mom and dad are going to be really mad. They might take away my brand new Razr cell phone. Remember that? That might take away the pickup truck that I bought with my 17th birthday money, and I remember the other dude who got caught on campus selling weed, he had to move all the way across campus. That was trouble to me. But here's what trouble looked like for everyone else in that position at that period of time. What I had done was a federal offense, I didn't know that. I knew that I'd broken a bunch of state laws, but I didn't know that one of them carried with it a 10-year minimum mandatory sentence. And because of that 10-year minimum mandatory sentence, the likelihood I pled out to that case was about 100%. And in pleading out to that case, being convicted of a drug crime in the 1990s, I would have given myself the moniker convicted drug felon. And in doing so, I would have deprived myself of the access to things that actually keep us safe, the access to housing, the access to employment, the access to education, the access to healthcare, the access to pro-social activity, and on and on and on. And depriving myself of the access to those things, the likelihood I'd commit another crime actually went up, not down. And each time I re-engaged with the criminal justice system, the likelihood I'd commit a further more serious crime went up, not down, until that time I victimized another person, at which point the government would have to send me to prison for double digit decades, and I'd never have the opportunity to be here. I didn't realize how close I was to the edge of a rabbit hole that millions of people fall down in every single year and never get access to chairs like these. I never understood how easily that police officer, if he wanted to, could have pushed me over the edge of that rabbit hole and down I will have fallen, disappearing. From this world Yeah. But I didn't. And I'm here. I got to go back to college. With my cell phone and my truck. I graduated from college and went out into the workforce. I worked for 3 years. I came out of the workforce and I went to law school. I went to law school for 3 years. I came out of law school, had a wildly decorated career at one of the best DA's offices in the country, so decorated, in fact, that one day John Legend reached out and said, hey man, do you want to do a TED Talk? I was like, Hell yeah, John Legend. I would love to do a TED Talk. We did a TED Talk and it blew up on the internet, and for the last 3 years I've, I've traveled the country and the world with every celebrity and artist and athlete and activist you can possibly think of talking about criminal justice reform. In 2015, I sat across from the forty-fourth President of the United States of America in his house and told him what I thought of his criminal justice policy. Last summer I got to sit in Oprah Winfrey's house and listen to Oprah tell me how dope she thought I was. Oprah In the last 6 months, I learned that I had a children's book, a rap lyric, and a documentary all made about me. And last year, just last year, Nelson Mandela's family chose me to be the Nelson Mandela Changemaker of the Year. I don't tell you any of those things. To humble brag, I met Kendrick Lamar. I don't tell you any of those things. It's a humble brag, I tell you them to make this point. None of that happens. None of that happens if I don't win the lottery. The police officer who pulled me over and pulled me over in my driveway. The police officer who pulled me over was a white man. The police officer who pulled me over was my dad. And after he took me down to the station and he sat me in a cell for a little while, he took me home and he loved me. Just like he did every time I screwed up after that. Just like somebody did when you screwed up. Every time. Just like maybe we need to love the people who we interact with every single day just a little bit more. Thank you, thank you. I didn't know it at the time, but my father in that driveway was handing me a sword and a shield. The shield was protection. In other words, the privilege that I had in that moment. To protect me from the bottom of that rabbit hole. And what I didn't know was that shield wasn't just for me. That privilege I could use for whoever I wanted, I could put people behind my sword, or even better, I could give them peace of mind to protect themselves. By building pathways for them to be here. And the sword was for the haters. Cause believe it or not, There are some haters out here There are people who still think that I should have gone to prison for selling their kids weed on campus in 1998, despite the fact that 7 states are now making billions of dollars doing so. There are people who ask me, well, how many chances are you gonna give these young people? How many chances are you gonna give these young people? And then I ask them, how many chances did you get, Chad? Or how many times did you just not get caught? There are people who will talk to me all all day about accountability, hold these people accountable, hold them accountable, but as soon as I bring up the fact that everything that we sit upon, everything that we have in this country is based on the genocide of one people, and the enslavement of another, and the subjugation of women and children and immigrants, all of a sudden the accountability conversation goes out the window. Hm. Swords for the haters. And I didn't know I had these things until I became a prosecutor. I got to use them every single day and it was a beautiful, magnificent exercise of privilege because I got to help people out the way that I wanted to. Here's the pro tip You don't have to be a prosecutor to use one. Any time that you get to interact with somebody that has less than you, you have the opportunity to reach down in your pocket. The privilege, power, and opportunity that you have to be in this room, your your employment, the fact that you're a part of this cohort, that gives you a sword and a shield too. The question is how are we going to use it. And how brave are you gonna be, because it's oftentimes when we have to be the most courageous, that people need it the most. Let me give you an example of how I use mine. I met Stanley for the first time when he was 16 years old when he came into my courtroom for stealing cellphones. Uh, all the juveniles in Boston all of a sudden started stealing cellphones, we couldn't figure it out, and we figured out that lo and behold, it wasn't because they were black and brown and bad. It was because Apple had put vestibules in all the malls so that we didn't have to take our um our, our iPhones that needed an update. And send them to Apple. They just wanted us to now put them in these little vestibules in the malls. And those little vestibules would do what when you put a phone in it? Give you $100. That created an economy that Stanley and his friends could participate in because the days of like getting a paper route or babysitting job and landscaping are gone in our urban core. So Stanley and all of his friends were stealing cellphones, putting them in the vestibules and getting $100. Why? To buy pizza and sneakers and kids stuff. So there I was, Mr. woke prosecutor, when I saw Stanley, and I said something like, Stanley, this is bad. You're bad. This is bad. You're gonna screw up your whole life, your future's nothing, you're bad, you're bad, you're bad, but I'm woke, so get out of here. A few weeks later, Stanley came back in my courtroom. This time he had escalated to stealing Vespas. You guys know what Vespas are? You have Vespas. For those of you who don't, Vespas are the little red scooters that uh gentrifiers take from our neighborhoods to their tech jobs downtown. And what they didn't tell the gentrifiers at the gentrifier store is that they're really easy to hot wire, red wire, green wire, go. And it created an economy in our neighborhoods because when they started to move in, our young people saw them as an opportunity because in the same neighborhoods, there are fences that you can drive a Vesper behind, someone will give you $200 and never ask you where it came from. And so there I was, Mr. Woke prosecutor, and I was like, Stanley, what did I tell you? You're bad. This is so bad. You're Bad. I swear to God I'm gonna incarcerate you. But not today because I'm woke. Go home. I was doing the thing that we all do as adults, particularly adults with high degrees and nice titles. I was telling Stanley what he needed to hear instead of asking him what he needed from me. And so a few weeks later, When Stanley came back into my courtroom this time not for stealing a cell phone, not for stealing a Vespa, but this time because he had posed on Craigslist as somebody interested in purchasing motorcycles. He convinced two men to drive up to the suburbs with those motorcycles on their trucks. Convinced them to take him and his accomplice out to the back of the golf course to test drive the motorcycles, and when those men took their motorcycles off the truck, Stanley and his accomplice would raise their jackets, revealing what appeared to be a firearm. And convince those men to leave. 2 counts of armed robbery, 2 counts of possession of a firearms, 2 counts of assault with a dangerous weapon. Uh, one of those charges is a life felony, the rest stacked on top of each other. There's not enough numbers to count the years that he was facing. So I said, what? What happened, Stanley? I, I just asked the question, like, what do you, what, what did I miss? What do you need? Stanley didn't tell me about a gang he was trying to jump into, he didn't tell me about a gang he was trying to jump out of. He told me about when he was 9 years old, emigrating from the Dominican Republic with him and his two older brothers to get a shot at a better education. Where would you go for that except for Boston? Now despite the fact that he had grown up in a developing nation, he had never seen the kind of violence and poverty and trauma that he did when he arrived at the Fidel's projects just down the road. And how that violence and poverty and trauma slowly took apart his family one by one, his two other brothers going to prison, his father having problems with law enforcement and running away because he was afraid of getting deported, leaving Stanley and his mother in this place. And he told me about when he came home and he found his mother laying on the ground crying and throwing up, not because she was sad, not because she was sick, but because she was so exhausted from the toxic environment that she was living in. Stanley told me about the feeling. Of putting that money that he got from those motorcycles on his mother's table, rubbing her back and saying, I've got you. I've always got you. You never have to worry. I said, I get that, I understand that, Stanley, but you gotta. You can't rob people. Weren't you afraid? Weren't you afraid of the police? Weren't you afraid of prison? We're supposed to send you to prison. Stanley looks at me and he said, is that what you think? Is that what you people think? That when I was out there robbing those men, the thought of prison ever came into my mind? I was worried about my mother dying. Do you think that my friends put handguns in their pants to go to high school in the morning, we're thinking about the 18 months in the house of correction that we might get? No. We're worried about what happens if we get caught without one. Stanley looked at me and he said, the criminal law is for the land of the living. We're out here trying to survive. The best piece of legal education I ever got did not come from the $150,000 piece of paper that now sits on my wall. It came from a 17-year-old kid in an orange jumpsuit, reading at about a 5th grade level. That is the opportunity that we get every single day working with people from impoverished communities when they are not represented in the power structure. We get to ask them things and figure our way out of this mess. Because what do we know about Stanley and the tens of thousands of people that I see every single day. In jails and prisons that are there because they didn't win the lottery ticket. Like them, I was born in a violent, impoverished neighborhood. Like many of them, I was immediately orphaned and spent my time in an orphanage. But unlike them, one day, two lovely people from white suburban Boston came and picked me instead of the other kid. I got to go home with them I grew up in their white working class home, in their white working class neighborhood. I had white working class friends in that shield of white privilege protected me from the bottom of that rabbit hole. And the fact that I spend my time traveling around prisons and juvenile detention facilities and homeless shelters. In impoverished neighborhoods, and there are so many people there that deserve to be here, and they're not because they didn't win that lottery ticket drives me crazy. Because what do we know about them? That it's much less about their individual bad decision making. It's much more about structures that have been put in place here forever. We know chil children who were conceived to mums, living in toxic stress, inherit that toxic stress epigenetically and it changes the way their bones, their brains, and eventually the way that they behave differently. And we can trace those changes all the way into prison. Those children are born into communities where they're suffering this toxic stress acutely, we call them all adverse childhood experiences. You heard a bunch about it today. But it leads to one result. 75% of the kids who were locked up here in 2015, 75% of them had on average 33 interactions with the child welfare system before the age of 3 for abuse, neglect, and malnutrition. Those are nonverbal children telling us, yo, pay attention to us down here or it's gonna get much worse. And we don't. Those children then go into underperforming schools, never learning how to read, not because they're black or brown or poor, but because we don't know how to speak their language, we don't understand the stress that they're coming to school with. And we don't do anything about it except for blame them and shame them and expel them. We send that message to them every single day that they come to school, you're a bad kid, you're a bad kid, you're a bad kid, this is what the good kids look like, this is what the good kids do, these are the grades that the good kids get, you're a bad kid, you're a bad kid, you're a bad kid. And then all of a sudden they're teenagers. And we hand them the autonomy to decide whether or not they want to come back to this building anymore. And guess what? Many of them don't feel safe there. And they leave. And we call them dropouts. The good kids who stay in school, they gather up and do what adolescents do, find people that are just like them. Is it the football team, is the debate club, is it the chess team, whoever it is, remember that period of your life when all you wanted to do was be with those people because that was your crew. Wildly, the children who leave school do the same exact thing. They looked for people who are just like them. People have been treated like shit by everybody. And for the first time they find a group of people who loves them and wants to protect them and show them something that looks like accountability. We have a word for that too, we call that a gang. And when that young person who's been growing up in a place of toxic stress and poverty and violence all of their life, when violence visits them or one of their friends, and they pick up a handgun, not because they're bad or black or brown, but because they're more accessible than a job in their communities. Because mass shootings have been happening in their communities for decades and nobody showed up with a sign or a hashtag. Where where they've lost more friends this year on the streets than any combat veteran in Afghanistan or Iraq combined. They live in war zones, so when somebody visits violence upon them and they respond to violence, that's when adults we say, OK, young person. OK Now I hear you. Now I see you. And now I will spend all of my time, all of my money, and all of my resources on just you. To arrest you, prosecute you. And lock you up forever. If an 18 year old boy in Massachusetts kills another 18-year-old boy, He gets a life without parole sentence. That means we hang on to him until he dies at a cost of $11 million. I ask you as a public health community, what could you do with $11 million for children between the ages of 0 and 3. I ask you as a society, how did we get to the place where we are, we are so committed to spending $11 million to keep a kid until he dies? But the thought that we take any of that and do anything else creative, all of a sudden we're pulling our hair out. This is the place that we are at. The social determinants of health are not the individual decisions of Stanley and his friends. They're the structures that we see and participate in are complicit in every single day unless we do something different. And we have to. It's our moral imperative, it's our responsibility, and frankly, it's an opportunity for us because if this place was full of more diverse faces, who knows what we could be doing in here right now. You have the opportunity every day to exercise your sword and your shield, and I guarantee you. That it feels really good. Shortly before my meeting with Obama, I mentioned, I mentioned that I met with Obama. Shortly before my meeting with Obama, I had a much more important meeting. I signed a letter of intent, or I sat with a young man as he signed his letter of intent to play Division 3 baseball at a school in New Hampshire. He texted me a few months after that and he said, I did it, bro. I say, what'd you do, Stanley? Stanley became the first freshman, uh, in the history of his college to stand on the pitcher's mound and pitch in the national championship game. He pitched 11 innings, 2 strikeouts, or 8 strikeouts, 2 hits, they lost, but the feeling that he had standing there on that mound that day could not. Even touch the, the feeling that he could get from being in a gang. He texted me a few months later to let me know that he had managed the Dean's list and he, and he couched it in terms of like somebody's playing a trick on me, and I said, why do you think somebody's playing a trick on you? He said, I've never seen a C in my report card, let alone A's or B's. So what do you think that's about, Stanley? He's like, I don't know, it's my environment. I wish adults would spend more of their time helping young people do good things and try to instead of trying to catch us to do bad things. Another profound piece of wisdom from Stanley. Just last month, Stanley's now a junior. stood in front of 2000 of my colleagues, as I was accepting an award, they wanted me to ask John Legend to come and introduce me. I instead asked Stanley, because he's way cooler. And Stanley stood in front of a crowd of 2000 adults, many of whom did not look like him, and told them why it was so important that he was standing there. He said, I want to thank Adam. For putting me back on the path that I was already on before. And it was so profound because we talked about rehabilitation and correction and healing, and really all we gotta do is like get people back on the path that they were meant to be as soon as they were born. And give them the same opportunities that we had. He also announced that he had changed his major to criminal justice and that he was applying to law school next year. Because he wants to be a prosecutor. And for a prosecutor There's no better feeling than hearing that from someone that you prosecuted. That is the opportunity that each and every one of us have. And we have to, we must. Because in 50 years from now we're gonna be looking back on this time the same way that we looked at 50 years ago. We're gonna be looking at images of this time and being like, what? Number one in mass incarceration? Number one in mass shootings, number one at racial disparities at every political and economic and social and health metric you can possibly think of. What? What were you doing? Why were you just standing there? I would have done something. Why aren't you doing anything? And in 50 years from now when people are asking those questions of you, how is it that you want to be remembered? Cause there's Doctor Martin Luther King said in the future, it's not the words of your enemies you remember, it's the silence of your friends. So do you want to be remembered as someone who looked in this room and saw these empty seats and heard all of these things and did nothing? Or do you wanna be remembered as someone who tonight, tomorrow, just did something different? That volunteered in a different community, that visited a different community, that visited somebody in prison or jail, that went to read to some elementary school kids, that helped a young mother find housing, that helped a young man coming out of prison get re-engaged, give voice to the voiceless, power to the powerless. Are you going to be remembered as someone who used your sword and your shield? Are you going to be remembered as someone who was one of the new civil rights leaders of your time? I guarantee you if you choose the latter. If you choose to join my gang. Wherever you are in 50 years from now, you'll be remembered as one of the wealthiest, happiest people that ever lived. Thank you very much. Thank you for joining us for this episode of the Stay Current Pediatric Surgery podcast. We hope you enjoyed listening and feel empowered to create change in your own communities to improve the lives of your patients. Our role as pediatric surgeons extends way further than the walls of our operating rooms. It is our responsibility as medical providers and community leaders to identify areas of opportunity within our reach and tackle them to improve healthcare outcomes. Join the conversation and share with us the steps you are taking to alleviate these disparities. Remember that your actions and commitment are contagious. Stay tuned for more updates from APSA 2019. See you next time. We hope you enjoyed this episode of Stay Current. You can listen, watch, or read our content at any time by downloading the Stay Current app. See you next time.