Dr. Olubukola Nafiu - Equity, Diversity and Inclusivity

One and good morning everyone and welcome to Grand Rounds for the Departments of Anacesia and Surgery. This morning's Grand Rounds is part of our department's quarterly equity, diversity and inclusion Grand Rounds lecture series, which is a collaboration with Dr. Ikbuda, who is our departmental director of equity, diversity and inclusion. It is my great pleasure to introduce our speaker this morning, Dr. Abouki Nefou, who is an anesthesiologist at Nationwide Children's Hospital and an associate professor of anesthesiology and pediatrics at the Ohio State University. Dr. Nefou is originally from Nigeria, which is where he attended medical school. He completed training and pediatrics and in anesthesia in Nigeria, Ghana and the UK, and then also completed an anesthesia residency at the University of Michigan. After his training there, he joined the staff and then in 2019, he joined the Department of Anacesiology at Nationwide Children's Hospital. And at Nationwide Children's Hospital, he's currently serving as the Vice Chair for Academic Affairs and Research in their Department of Anacesiology and Pain Medicine. Dr. Nefou has done a substantial amount of research and has published extensively on the topics of both childhood obesity and racial disparities and the impact of each on surgical and perioperative outcomes. His publication from 2019 raised post-operative complications and death and apparently healthy children is one of the top 10 articles published by the journal pediatrics. Thank you so much, Dr. Nefou, for taking the time to speak to us today and I will turn things over to you. All right, good morning everybody. Thank you very much for the wonderful introduction. It's really a great honor to speak to you this morning. So let me start by just saying that I don't have any conflict of interest to declare, although I'm always hopeful. But I should prefer this talk by saying that some of the things I would say this morning might make us squirm a little bit because it's difficult to have any conversations about race or racism or racial disparity without making, you know, without generating some visual emotions. And that's okay. I believe very strongly that that's it's when we feel pain that we grow because some of the things that I'll talk about today, particularly in our history, essentially relates to man's humanity or to man. So I have to kind of just put that out there so that if anytime you feel uncomfortable or if it's first to painful, you can always punch out, no, this is Zoom. I'm not going to know if you're there or not. The other thing I should say is that you obviously, from the introduction, that's a forum medical graduate with an accent. So if when I get excited, excited, I speak very fast. So that's the time for you to listen very fast as well. So my previous chair in when I was a Michigan used to say that every good talk was I have a slide that nobody understands. So I thought I would just get that out of the way now. This is my complicated slide of the day, simplified view of racial disparity, so you can outcome. It has nothing to do with this is about metabolomics, does nothing to do with. So these are some things I'm not going to be able to cover today. Equality of outcomes because that's a whole new, Dr. Ho, textbook on its own. It will be impossible to cover all of the isn't sexism, ageism. And I'm not going to talk about Black Lives Matter, QAnon, and income distribution, affirmative action. So these are the areas that I'm going to cover. We're going to go through some current definitions, go down, go down memory lane because I believe that history is very, very important if any other force to understand the prevailing context. We'll go over some data. But purposely, crafted this talk with the intention of, you know, the intention is not to just dump a lot of p-values and odds ratios, you know, likely ratio on the group, but you know, it's just a way for us to put things for us to think about. And more importantly, on just call the fact that systemic crisis in our belief is the lynching for a lot of the things that we are observing. Then we'll try to come up with some solutions together because who am I? I don't have all the answers. So this, I like to speak to you a lot because it just shows, I got it all, of the internet. These are two kids that showed up in class in the getting class one day with the same aircraft and said they were trying to fool their teachers into thinking that whether the teacher would be able to tell them apart. And so I call them John and Jamal. Now what we know is that when it comes to the health in the United States, the differences is as clear as daylight, what we get into all of that. But before we go on, yes, I know, you know, there was that introduction about me. I used to be known as the little guy that studied the big people because childhood obesity was kind of my area of interest. So how did I get involved in the healthcare disparity or health disparity study? So this started in December 2015 or so. I was still in Michigan at that time. And this email just popped up on my computer and there used some comments about people that have just been published in this titled Black Paint Matters. And this was in response to an article that Monica Goyle, who is an emergency medicine physician, published about racial disparities and pain management of children with appendicitis. That people got a lot of press. And essentially what Monica found is that for children presenting with acute appendicitis to the emergency department, that children were less likely to be treated appropriately, whether it's to be given any on our physics or to be giving opioids for even when it's documented CVAP. As it turns out, we were conducting a similar, well, we were conducting a totally different study at that time, looking at factors that predict post-operative pain in children. So we decided to essentially pivot and study to just look at the analysis of the patients that we recruited at that time. And we found no difference in terms of how pain is managed in for children that are recovering from anesthesia and surgery. So now what? It was the classic case of knowledge, breed, stignness. Like the more you know, the less you know. But this is what we do know. The disparity is all pervasive. We cheve our specialty, you look at whichever area, whichever age group you look at, disparity is there, whether it's anesthesiology, there was even a paper that showed that Black families were more likely to have positive security, cause them compared to every other racial ethnic groups. So really, the disparity is pervasive. Let's just go over a few definitions before we move on. The way the NIH defines a health disparity is that it's all those differences in the incidence and prevalence of diseases and other health conditions. That's, the preferentially affects a particular specific group of people. And of course, the WHO defines health as that state of complete physical, mental and social well-being of the human organism. In other words, it's not just the absence of disease or infirmity. In other words, it's not just taking out that appendix or taking out that foreign body. It is the complete state of physical and physical well-being. We always hear the words, equality and equity bandied around a lot. And because I'm an anesthesiologist, I thought this will probably be the best way for us to understand what equity means. Because we practice equity every day in the care of our patients. We use the appropriate size of the language scope for the patient. We just say, hey, I only have a mark for my public and that's what I'm going to use for everybody. That would be equality, because that is all we have and that what we're going to use. Well, equity will say, well, we're going to do whatever it takes. And I like this sort of statement a lot, where somebody says inequality and equality will typically produce disparity in outcomes. In other words, equity is kind of what we want to improve. And I think it's also important for us to understand that when I talk about systemic racism, I'm not referring to racism. Because in a lot of ways, that's kind of where we where we've been conditioned to think. If you look at the definition of racism, the dictionary talks about a bad person who is bigoted, who hates other people. And when people hear about systemic racism, that generates their visceral reaction. I'm not racist. I go to church and I'm going to marry to a black person or do my cousin marry to a black person or a person of color. So those two terminologies are not the same. And at this definition by Bailey et al, that was published in the Lancet in 2017 of structural racism. Talk about the totality of which in which societies foster racial ethnic discrimination through mutual or infusing in-equitable systems. And you just encapsulate a lot of the things that I feel is responsible for some of the outcomes that we observe. So like I said, Ella, I used to be a child's obesity investigator. And then I joined Nationwide Hospital in 2019. And just as I was getting my research apparatus established, COVID started. Of course, everything shut down. And so we all kind of had to just pivot and like you know, like give you lemon, you try to make lemonade. As it turns out, we had access to a lot of databases. So we started coming up, started trying to come up with a bunch of questions. The very first piece of work that I did at Nationwide Children's Hospital was this paper that was published in the pediatrics that looked differences in the post-surgical complications between apparently healthy African-American and white children. Because the prevailing narrative is that you know, black patients or black children do poorly because they come with a lot of a preoperative comorbidity burden. So the question we start to ask was whether if you have a cohort of children that are relatively healthy or that they were classified as being relatively healthy at the time of surgery, will their outcomes be the same or will there be any difference? So I can say this was a retrospective study. We looked at the mystery database to 2012 to 2017. Over 100, 170,000 relatively healthy patients. And by that we mean patients that were classified as ASA 1 and 2, you know, the standard analysis. But the key find is which is what kind of got everybody used attention. As expected, you know, complications rates were low when you compare that group with the other with the higher ASA status. 5.7% was the overall complication rates and mortality rates expected low was 0.02%. But what was striking was that African-American children were three, almost three and a half times more likely to die compared to their white peers. And they also had an 18% greater odds of developing post-operative complications. Needless to say, that got a lot of attention and got a lot of press. But you know, the, and during one of the grand rounds that I gave to a surgical department, somebody asked this interesting question. Now, okay, yes, we'll find all these disparities and in trying to solve this problem, how are we going to pay for all of this because stated, you know, the government or this is going to require a lot of investment. And then of course, even if let's say we come each to do something, can we afford another five years of, or if let's say we do a five year policy, can we afford it, and can we sustain it, and who is going to pay for it? That was when the idea came to me that holding a name, maybe we already paying for this because disparity is kind of, it doesn't just affect the people that suffer the complications or the mortality, it affects all of us. And that was the impetus for the following study that we published later a few months ago, again, in pediatrics. In the, just a moment, we decided to look at a very common surgical phenotype and I was, I gave appendicitis. And we looked over a couple of decades just to see what is the trends in the complications rates as well as the cost of care for children presenting with appendicitis. And we looked at whether the, we stratify them based on whether it's perforated appendix or not because we know that perforated coincides is always going to be more, this is going to be more, that's a higher complication rate, cost of care is going to be higher. Or what's interesting about this, if you look at the panel A is as you expect, the surgical complication rates, that's the patients with perforated appendix and other complications, at no time throughout the year that we looked at, the square, the black squares are complication rates and black children, at no time that those two lines meet, the second or the ones are the white children. So, whether it's complications or or or or complicated appendix, the rates are higher for, for black children. So, when we looked at the median hospital costs for the two groups, it's essentially as expected, the median hospital cost of care for children presenting with appendicitis was higher, was significantly higher for, for black children. And that line has not, there is no indication that that line is, is approximating, how that those lines are coming, any way, are close together, since 2001, up to, up to present moment. So, whether we like it or not, we are really painful for the, despite in care. So, my team and I have essentially, you know, we've stopped the message, if you, don't change your winning team, it's kind of the, what is often said, we've looked at various aspects, I'm not going to bore you with, with all these data, you know, this last 18 months or so, we did about about 10, 10 disparities related papers. So, we are a very small group of the disparity, and as I like to call it, as I yesterday, when I looked at published articles on racial disparity in children, I came up with just over 1600 articles, but when you look at periodic cervical disparity, just over 200, which to me, which just tells me that we do need a lot more work here, we need to recruit more, and money, what disparity, like I said, we're not the only one that's playing in this space, there's a lot of work that's been done by other investigators, including your differential rates of ECMO utilization, following cardiac surgery, black patients are less likely to have black prescopy intervention for appendicitis cases. In this interesting paper from the investor Michigan by Anne Betel, that showed that black children were being abdusified in the period of pretty setting. In other words, they're less likely to have child life support going into the operating room, and less likely to be giving anecdotally going into the operating room. And then, like I said, there are lots and lots of other investigators that have looked at this longer, which time for black children compared to their white peers. And I recognize the fact that there are many, many types of disparity, there's gender disparity, various other types of income or religious disparity and things like that, but I will venture to say that, or for the forms of disparity, perhaps the most malignant and the most consequential one is disparity in race and ethnic outcome. So, the question of course is what's raised about to do with it? Now, like I said earlier in the beginning of the talk, I said there's some part of this, I mean, make us uncomfortable, I'm about to get to that part now. So, please fasten your seat belts for the next part, but I mean, make us a little bit uncomfortable. So, when the American public started their 1790, the young nation wanted to kind of know who is within their borders, and the plan at that time was to figure out how to sort people. First people were categorized into those who were taxed versus those who are not, and then you had three very basic groups, you had Europeans, you had Africans and Native American. This statement, this statement here is credited to Jefferson Davis in 1860. He ordered this word on the floor of the Senate in Mississippi, and he said, black inferiority has been stamped from the beginning directly onto the bodily frames of Africans at the moment of creation. By the way, Jefferson Davis eventually went on to become a president of this country. That picture on the right is, you may have not have heard of this, the story of Otabanga, who was a young Congolese man that was brought to the Bronx Zoo in New York, and was being made to pose with monkeys and live with the monkey. Basically, the Bronx Zoo was parading as being related to monkeys, and we were making not money off this young man. This was in 1906. Eventually, a few years ago, the Bronx Zoo apologized for this, but this is just to tell us where we are from. Just to also underscore the fact that the fact that we both swore on the hypocritical both, it hasn't immunized us against some of these practices. Of course, when people hear about problems, medical apartheid or medical racism, the one that comes to mind is the Tuskegee experiment. That is just one of many. If you look down on history, you may have heard about Professor James Marion Sims, the father of Silicon Valley College, who was famous for discovering the repair of the physical vagina fistula. He carries a lot of these operations, a lot of experiments on black women without anesthesia. He was also credited with saying that the nature of tetanus is caused by laziness, when that is when slip babies developed the nature of tetanus. It's because the mothers were lazy and that got passed on to them. Professor James was probably a very brilliant but again, that suspect was mixing racist with racism. We are all familiar with the issue of how black people don't feel pain. They have different biological differences, no endings. The black race coefficient for estimated GFR, which is costing a lot of problems. Now a lot of discussion is ongoing in that now. As a matter of fact, there is a strong push to be a way with that that kind of categorization. And then of course, the famous Hockinsinser's Fireometer. Again, these are very very brilliant individuals that came up with this sort of thesis. In essentially Hockinsins Fireometer suggests that non-white have lower biotech capacity and his take was that hard labor is needed for good long development. So it was good for slaves to work hard in order for their longs to develop. Then there was Dr. Samel Katwright, who was just just look up Dr. Katwright but perhaps the most interesting one as far as I could, as far as I was reading about him, was he coined the term, I published it in a popular Southern medical journal. I came up with the term the Petomanian, which is a condition that afflicts slaves that's run away. It's a medical medical condition. And of course, if you medicalize that, then it's easier to treat. So that's why race matters. We know that newborns are assigned the race of their parents. That has been the position since the beginning of time. If the parents of a different ratio of group and one is white, the child is assigned the race of that or their parent. It's impossible to cross over. As you're looking at me, I can't, for me say, tell you, I don't hold on to many guys, I think I'm white. People who start looking at me like, okay, what have you been, you've been sneaking some of that to a civil flurry or something. And I think it's also very important for us to understand that it is not so much how you see yourself. It is how society sees you. That is important. This is how racial categorization started. The U.S. census keeps doing every decade. So in 1800, a slave was three feet of a person. In 1920, that was how those were the racial groups that were available in the United States at that time. But what's important about 1920 is that the country was still within the groups of pandemic then, just like we are now. And it was so felt important for people in their places for racial categorization to occur. So I talked about all these historical perspectives, not because I want to, I just enjoy reading history. And just on the call, the fact that history is not just a bridge to the past, but it helps to eliminate the present. And if you don't look at where we are, we're never going to understand who we are now. I like this statement from the American Sociological Association that was published in 2003. Essentially, I'm talking about, you know, raised being a social concept that changes over time. Placed major consequential roles in a lot of things, including the health system, where you live. And if we don't acknowledge it, then we are not going to be able to deal with the issue of racial disparity in whether it's in healthcare or in outcome. The way I like to put it to people is that you don't see gravity or you can feel it. And it's a very, very racist, a very powerful social currency. You don't have to like it. You don't have to like this, if you, it's just like any currency. You don't have to like the smell of it or you don't have to believe in it. If you have it, you can spend it. But just like, well, race is particularly interesting because it's resistant to a lot of things. Infraction does not affect it. Wars and pandemic doesn't affect where you stand. I want to encourage you to, if you can, to reach these two books because this, I found a lot of eliminating information in this book. There's the stamp from the beginning by Ibrah Kendi and Herod Washington's Medical Apothec. This is probably one of the most comprehensive historical books about medical apothec, you know, they were read. So really, racial categorization on its own is not bad because it's a very, very easy and very cheap, on a structural way of people sorting. You kind of want to know what people look like or what's where they are from and things like that. So it will be benign if not for racism, if not for the for the accompanying part differential and economic differential that is associated with with with their people sorting. This next couple of slides is what tells me that for the people that say, oh, we've moved the long way, the things that things are different now or good intentions. Everybody has good intentions and we'll just going to be fine. I want to try and just to look at this next couple of slides. This paper came out in 2019 and this, this, this author's just looked at the, that was the, that was when the COVID pandemic was just blooming and it became clear that the mortality rates for minority populations was significantly higher. And what this authors did was to just look at the longer-juster mortality pattern and life expectancy for Black and White says the 1900. And as you can see, those two lines have never met since the 1900. The longer-juster mortality rates for Black and always been higher than for white patients or the order for white person. The life expectancy has always been lower for Black persons than for white person. So they also did another really interesting clever thing looking at hypothetical excess white mortality that will raise white mortality or lower the white life expectancy to the best ever life expectancy or longer-juster mortality rate for Black, which was in 2014. You can see the number of people that will have to die in order for those lines to meet. I wrote an editorial for CNN about this, this particular article, which I thought is a very, very interesting sort of look at the picture and why we must not be complacent, where we must continue to just understand that good intentions are really not enough. So let's change my, let's change gears a little bit and move on to the solution mindset in the next 15 minutes or so. So how do we reduce the surgical health disparity? This is kind of like this, it's very, very difficult, it's very confusing. But I will say that these are some things not to do as investigators or as providers, we must not make it all about biology. We spend a lot of time exploring biology, that was the basis for Dr. Katzheim's Pyramidia and a lot of other things. It's not all about genetics, let's start looking, let's stop looking for needle in the history. Yes, I understand that genes are important, metabolic is important, enzymes and biologists important, but we should not make it all about that. This was another comment that came up when I presented to one of the surgeons that's, oh, don't I think that all of these studies will make it such that people will now start up coding the African-American patients or racial minority patients and I said, well, that's unfortunate because that's not the point, that's not what we should be doing. And then some people will also come up with with these ideas, oh, that will show absolutely stop collecting race data, that this is just generating more, more heat and light. To me, that is like kicking the can down the road, because how are we going to know what is going on? It is not that we should stop collecting race or ethnicity data as a matter of fact, if anything, we need more people to be doing studies like this. And I will say, this is definitely not the way to handle it. This is a statement that was credited to the deputy editor of JAMA, that was the pandemic was raging. And Dr. Lewinson is a very, very brilliant man. He says, oh, no physician is racist. So how can there be structural racism in healthcare? Again, that is mixing, that's just mixing those two terminologies, who is a racist and structural racism. Needless to say, this generated a lot of controversy and leading to changing the editorial leadership of JAMA. And then of course, you know, there's all these terminologies going around. We spend a lot of time just throwing names around which we call people black, we call them African-American. We use lowercase or uppercase or what should we be doing? Is it Hispanic? Latino? Latina? Latin? Latinx? Asian? To me, these are all this is just taking our eyes off the ball. Because really, what I call myself, like I said, Ella, is not what is important. It is how the society sees me. It is how the society interacts with that patient that comes in. We need to understand that what you call yourself, it sort of doesn't matter. And those, so we need to move away from those terminologies. Yes, they're good for categorization and adequate for research, but we should spend our energy trying to come up with solutions. So just like every department does, you have research, you have education, and you have service. So in terms of research, there's need for us to to have more research that are focused on exposing some of these disparities. And some of the big data, big databases that are out there being really, really useful in this instance. And this is where I give a big shout out to the American College of Surgeons, which are expected to make the industry database readily available to institutions that are participating. And then there's the multi-center-operative group database. It's important for us to have clear outcome and predictor variables. And I think when it comes to research, we need to, institutions need to come up with targeted and strategic recruitment of disparity researchers. That is not based on your skin color. And I feel very very strongly about that because there's all these talk about people who, who not ethnic minorities coming in and doing a health care disparity research. To me, that is totally missing the point. You call off your skin to not, as long as you're passionate about the research and the research you're doing generates their appropriate answers and their has their appropriate impact. Then really, we should be using research for advocacy, not just talking about who has what, who looks like what. What can, what can journals do? Well, it's very important for journals to, because they get journals and journal editors that get keepers of a lot of the information. What we do in the medical profession is dictated by the general population, but we also dictate what the general population does with the information that will put out in our journals. And so, the general, general editors need to come into highlighting the role of structural racism in healthcare. And it's very important to encourage diversity among reviewers, editors, and diversity of thoughts. I'd like you to say that the snafu that happened with the camera editorial board would not have happened if there are other people that, other people only editorial boards that will, whether will have called the doctor, the assistant doctor and say, hey, the whole tournament, you can't really say that. This is going to generate a lot of backlash. So, it's very important to have a diversity of opinions at this journal editorial board as well as a general reviewer. Of course, it's very important to extend the opportunities for reviews to early minority and general faculty. What can we do about education? Well, this is one of those things, having ground downs, but not just seen as another diversity initiative. Because to me, it's because health disparity is now the sort of sexy thing. Everybody is now on the diversity bandwagon. And oh, I want to talk about the diverse. What can we do? I think it's important for us to go beyond that. Whenever that book just comes from Berk, it became apparent that it's possible to actually go through your educational experience in this country without learning about racism or learning about our history. And if we don't know what we are being, we're not going to know where we are going. So, I think that's going to be very important for us to incorporate that. As uncomfortable as it is, it's important for us to be able to do it. We all need to understand cultural competency, disparity focus, the ground runs like these are important. Many institutions are recommending implicit bias training for their staff. But we must understand that that's not the end goal and be your for it. Very important to understand the role of personalized medicine that is truly personal, race and ethnic based sensitive protocol of driven care is going to be important. But we have to acknowledge the existence of disparity in surgical health and we need urgent smart solutions. So, the next couple of minutes before I open it for questions, I'm going to challenge that. We'll help disparity research desperately needs on forcing allies. What do I mean by unforeseen allies? We're unforeseen allies or unexpected allies are people that just to all intentions and purposes have no skin in the game. All the contacts that can generate. As you can see, I'm a black man, so I have a skin in the game. But through our history, if you start from as far back as the Holy Bible, even the good Lord uses on an unexpected ally in the form of a soul and Christianity. A soul was a persecutor of Christians. His job was to capture Christians and kill them until he got recruited and became by far the most effective Christian evangelist. So that's an unexpected ally. Abraham Lincoln, if he was not interested in emancipation, well, that's what that will not have happened. And if Lincoln had a lot on his place, so that's an unexpected ally. If Congress was not interested on women's rights but Congress was made a predominant of men only in 1920, that would have happened. So, men were the unexpected allies to women at that time. If JFK had not been interested in the civil rights movement, that would have been pushed by a few other decades. And more recently, if John McCain hadn't cast that singular vote, the Affordable Care Act will have perished, well, at least it will have been substantially delayed. If Obama hadn't been interested in married equality, married rights for everybody, that would not have happened. And of course, all these people, they did that knowing fully well that all the things they did, it was not the politically experienced thing to do. So unexpected allies do what is not politically experienced. And as a matter of fact, it may even be costly to them. So that's the one side of the story though. But I also want to challenge the racial and ethnic minority colleagues to understand that all our hip requires trust. It is a two-way dance, it's a two-way street. We need to see people for what they profess to do or what they for the desire or what they want to do rather than just say, hey, because you're not experiencing this, you cannot understand racial disparities. Therefore, you cannot do healthcare disparities. Therefore, you cannot be the diversity or the vice-chair for diversity. So it's a two-way street. We all need to get involved in this. So this is my final thoughts before I open this for question. All these things that have been talking about all these numbers and odds ratios and things and proportions and things like that, P values and all of these things only happen in journals, on the pages of journals or during ground grounds. But behind all these numbers, I want us to think and look behind all these numbers. These are human beings. These are that they can do, that will never be lit again. These are skills and resources that we are not going to benefit from as a country. And these are people that came to hospitals. These are children that came to hospitals and left in body bags. So that's what is behind all these numbers. And I want us to think that as a country, we're hemorrhaging human and physical resources. It's time for us to stop the hemorrhage. I'll leave you with this words from this time. Let's watch one Dr. Martin Luther King Jr. where he says, we are now faced with the fact that tomorrow is today, we are confronted with the fierce urgency of now. In this unfolding conundrum of life and history, there's such a thing as being too late. We cannot afford to procrastinate. The time to act is now. I want to thank you for the opportunity you've given to me to speak to you. I really wish this wasn't person because I feel I feel strongly that we will be able to connect more, we'll be able to move around more and be able to interact more on a personal level. But hopefully this will happen again in the future. Thank you very much for listening. I'll open this for questions. Thank you Dr. Nafiw. That was a standing and truly powerful presentation. If anyone has any questions or comments, feel free to chime in or into them in the chat box. Yep. That's a very interesting comment in the chat. The Henrietta Lax, the Henrietta Lax story. That's another one about a medical or a medical or a patent. Okay. Thanks for the great talk. The question I had is about the educational system and education or children educating our children about these historical events. Any thoughts on that? John, that's a loaded question. I know where that's coming from. Now, there's a lot going on about. There's a lot going on now about, okay, what is, should we really be telling our children about what has happened in the past? Do they really need to know? There was a speaker who was listening to her some years ago about this physician who was married to a Belgian. She was from, she was a Congolese woman and married to a Belgian. And her child came home one day and talking about the glorious things that the Belgians have done for the Congo and how the Congolese government is helping the, I'm sorry, the Belgian government is helping the African countries and things like that. And she was, she was living in the, she was like, they're teaching my kids all of the good things that Belgium is currently doing without seeking to teach him about what can be afforded these two Belgians. You know, can be afforded with the one that was chopping off the, yeah, the arms and legs of Africans who were not working hard enough to under the rubber plantation and things like that. So, I think we need to be sensitive about what we teach our kids, but we also need to make them, let them know who we are because really that without that, without letting, even as adults, without knowing where we've been, we're not going to know what, we're not going to be able to come up with solutions as fast where we currently are and where we're going to be in the future. So, I'm, long story short, I think it's important for, for kids to know, for kids to know our history, or we need to make it age appropriate. Yeah, we recently were watching King Richard. Oh yeah. And the, it was a reference to the Cluclex clan and my daughter, and so one of my daughters had no idea what that was. She said, isn't that some sort of Asian rap group? I said no, that's the Wu Tang clan. So, you know, educating her about this has, has been interesting that they, they, they never heard about this in school. And it's something that I think is lacking. To that point, to speak to that point as well, I, as a, as a, as a, as a, I grew up in Nigeria. A lot of these things, I'm having to learn as an adult myself. And I, I have to, I have to be, to be upfront, upfront, about the, as a matter of fact, I didn't know I was a black man until I arrived in the UK, because there are no black people in Africa. Period. That's just the way, that's just the way, that's just the way it is. It was, you were either, when I was growing up, my, what my parents told me is, hey, just make sure you're in the top 5% of everything and life will be good, and you're going to be fine. But then I arrived in London 1997, and that was the first time I, that was my first time of a plan for a job, and that was when I realized I was holding it in, this things are a little bit different. So, it's all, it's all about perspectives and, and, and circumstances. So, I see, I see comments in the chat box about the American Academy of Pogetics, has made health, like we see one of its three key issues. Yes, yes, that's, that's great. And period of creative health was also selected as one of the top 10 issues during the unordered conference. Then these, these are some of the things that organizations and societies need to be doing. And, and just to put a plug out there for our, our journal, the Anesthesia and, and Analgyzia, has just established a section for healthcare, the spray team research. So, again, those, those are some of the things that, journal articles and, you know, journal articles and and establishments need to be doing, that just, just to, for us to keep keep the conversation going, another for us to be able to come up with that, with workable solutions. Okay, one last question regarding anesthesia practice. So, in Anesthesia, we give a lot of drugs, we treat a lot of pain. Is there any evidence that there's any, there are any disparities specifically in anesthesia practice? So, so, when we did, when we did that to a pain, you know, paper in 2016, one about published in Pediatrics, I was, I went, because it was local data, I went into, prior to the analysis, my heart was in my mouth, because I was worried that what we were going to find is, it's going to be similar to what was observed in the emergency department literature. But I was pleasantly relieved to find out with, I think as far as practicing Michigan was concerned, we did not find any disparity with respect to documented, moderated to severe pain. So, that's one, that was reassuring, but that's, I'm not naive into thinking that that's, that is, that is all there is to it, because, and Betzel did a follow-up study, where she found that her disparity in the care, in the prescription of Betzel and the use of child, use of child life and things like that. So, we just need to, we just need to keep asking the question, when it's to keep looking. I see someone's, please go ahead and ask your question. Yes, I very much enjoyed your talk and thank you so much for this. I wonder if you could give us some advice. Our institution has just created a, named after our recently retired CEO, a pediatric health equity and inclusion institute. And we've endowed it to the tune of well, into eight figures, tens of millions of dollars. And I'm wondering if you could give us some advice as to how we could get started in doing impactful things that will falter the health of children, rather than just being an expensive bumper sticker for us, looking like we're doing the right thing. Is it Dr. Fishman? Yes, yes, Dr. Fishman, thank you very much for that excellent question, because it's, someone asked me that question a little bit ago, that, oh, what would you do if you had a blank check to how you're going to tackle this? So, it's something I spent quite a bit of time to think about. And I think it's, it's just following, just following that, you know, sort of basic schema of research, education and service is going to be important, which is a speculative research. Just finding, of course, trying to recruit people who are interested in those those kind of questions, but making it clear that the focus is not just, it's not just to try to come up with a mechanistic proposals or mechanistic discussions or things about trying to look for impactful, whether it's social, social research that is going to, that's going to impact, that's going to change lives rather than trying to just look, oh, let's look for more genetic code thing that is going to affect stuff. So, recruiting health disparity investigators and making, and giving those individuals the appropriate time, away from, whether it's away from the, from the, from the, from the opportunity, if they're surgeons or if they're anxious, away from, away from the opportunities so that they can focus on research. In other words, protected time for health health disparity investigators. Also, making, helping, or, or, or disparity investigators kind of, you know, is sexy thing, like, endowed care for health, health disparity, health care disparity investigators. Then, which are sweat to education, we need to start very, very early. I would venture to say that even, even as far back as high school, but even if, if you don't have that, to go to the, to the medical school, the M1, educating them, giving them opportunities to participate in health, health, health disparity research. Same thing for our residents, active recruitment for residents, whether they be, whether they be, and seasonal residents or surgical residents, those who are interested in health care disparity research. And on this call, they find that, did you not have to be, did you not have to be of a certain, uh, uh, uh, learning, uh, or, uh, component? Yes, it's important for us to uplift, um, passionate, um, ethnic minority investigators. But if we find people who are willing to come up with workable solutions that, that can affect everybody, like I have also improved things, then we should, we should totally, um, focus, uh, efforts on that. And then with respect to, um, to care, to, um, providing service, we need to make it, we need to provide, um, service, some of that money to provide services for, for, uh, parents, um, and children of ethnic minorities, uh, to just make it easier for them to access the care that will provide. It's one thing for, for us to, to work in, uh, I would tell us, uh, uh, but if patients are presented to us when they're so far down, when they're so far gone, uh, for, who have a range of reasons, either they can't, and they're not getting referred to us on time or they're not getting, uh, they don't have access to the care, then it's, uh, in 10 years time, we're still going to be, we're still going to be, uh, going to be here. And then of course, uh, if you want to write me, uh, a million dollar check out of that, out of that, uh, endowment fund, I'll be, I'll be happy to think of that well. It looks like we have a, thank you. We have a couple more questions in the chat. Maybe just time for one of those, as I know everyone has to get us to, to get their, um, operating room started. Uh, let's see, let's see, yeah, thank you for great presentation. Any similar disparities noted with native Americans and South Asian East Asian, uh, Americans? That's a, that's a great question. As a matter of fact, I just, um, I, I know that people have started, as, as, as it turns out, you know, the more questions, the more questions you, you kind of tend to, uh, you kind of tend to, uh, generate. But there is increasing activity in, uh, in looking at, um, disparities, further than the black, white, uh, the black, white disparities. I was venture to say that the reason why that is, why the black, white, uh, disparities mean, uh, so, um, prominent is because that's where you have the, that's where I'm, well, apparently you have the biggest signal. And people tend to go towards where you have the, uh, the loudest signal, so to speak. Uh, but, yeah, people are beginning to, uh, the beginning to look, look at disparities as it affects other racial, ethnic care, uh, groups as well. I think we might have to cut things off there. I apologize. Um, if there are any other questions, certainly I can, I can, um, if, anyone can contact me and I can send them along to Dr. Neff, Dr. Neff, you, um, thank you again for speaking to us today. It was a fantastic presentation and thank you everyone for joining. Um, have a great day. Thank you very much.