Dr. Camila Mateo - Know History, Know Self: Racism in Medicine

Good morning, and thank you for joining us today for Combine Grand Rounds with the Departments of Anesthesia and Surgery. This morning's lecture will be part of actually a quarterly Grand Rounds lecture series aimed at incorporating more didactics into our departmental curriculum that address health disparities, racism, and social injustice. And I just want to briefly thank Dr. Edgouda, the departmental, our departmental director of Equity, Diversity, and Inclusion for her collaboration and helping make this lecture series possible. I'd also like to acknowledge Dr. Stein for her help with this as well. With that is my great pleasure to introduce our speaker this morning, Dr. Camilla Mateo. Dr. Mateo is a primary care pediatrician at Martha Elliott Health Center and Boston Children's Hospital who focuses her work on the care of underserved children. She received her MD from Columbia College of Physicians and Surgeons and then completed her residency here at the Boston Combined Residency Program, which was part of the Urban Health and Advocacy Track. After residency, she completed a chief resident year followed by the Harvard-wide Pediatric Health Services Research Fellowship where she received her Masters in Public Health from the Harvard School of Public Health. She joined the faculty this year after completing her fellowship and is currently the associate director of Anti-Racism Curriculum and Faculty Development at Harvard Medical School. Her medical education work focuses on anti-racism, teaching in medicine, health equity, and diversity and inclusion. She also serves as the diversity officer for the Boston Combined Residency Program in pediatrics between Boston Children's Hospital and Boston Medical Center. Her research interests include studying the effects of discrimination and intersections of identity on the health of youth and young adults as well as medical education research focused on resourcing bias and discrimination and health professions in the health professions and learning environment. This morning, Dr. Mateo will be speaking to us on the history of racism in medicine. Thank you, Dr. Mateo, for giving us the inaugural Grand Rounds presentation of this equity diversity and inclusion lecture series. Thank you, Dr. Mateo, for having me. I'm very excited to hear about this division-wise sort of effort to include more didactics on this topic. I think it's wonderful. I'm really humbled to view the first of that series. Thank you again for having me. Before we start, I do want to give a few disclaimers about the lecture today that I tend to give at the beginning of this lecture. First, I'm thinking about what are we going to be talking about today? How far are we going to get into this? In general, what we're going to be really focusing on is trying to create a space where I can talk a little bit about this shared history that we have as healthcare providers and a part of the healthcare institution as it pertains to racism and how that history can perpetuate into our practice today. We're not going to have as much time to dive into what can we do actively to combat this. And I feel like a lot of times when I'm talking to healthcare providers, myself, the healthcare provider, a lot of us are doers. Like, what do we do? How do we fix it? How do we like, you know, get in there and start dismantling the system? Which is absolutely the right question and questions to ask. I think to kind of slow ourselves down a little bit, what this lecture is going to do is try to provide some of that content background knowledge for us to be on the same page. To then start asking those questions together, but we likely will not be getting into sort of those tangible, how do I in this particular one hour? Okay. The next is that, you know, racism is a pervasive system that exists globally and affects a diverse array of communities. And I'm limited in my ability to cover this topic to the time that we have together this morning. And we'll be discussing examples highlighting certain histories and certain communities and not others. And so, if you've talked, I'm going to be introducing the role of the medical institution and contributing to institutional racism that we see today by specifically focusing on the United States and on anti-black racism. And I realize that by doing so, some may feel that their experiences are not reflected here. And while curating which discussion points I make allow me to more pointedly show the history of racism in medicine, I certainly acknowledge the limitation that comes with not being able to speak to all of these histories and so just wanted to name that at the start. And finally, I do recognize that there is likely a great deal of variability in our audience today with many of us having lived experiences and other expertise on this topic while others of us may have never attended a conference focused on racism before. And so because this lecture is designed to create this shared foundation from which you can continue to discuss racism and explore ways to combat it in your community, there will likely be repetition within this lecture for some of you. And this repetition is here not because I'm not mindful of the varied experiences that each of you bring, but instead because I do not want to make any assumptions about what folks may or may not know regarding this topic. So kind of just want to start from the same point. And so with that, I want to also go over a couple quick ground rules because discussions about race and racism can be emotional charged, emotionally charged. And ground rules is something that if you all are going to be having discussions moving forward among yourselves in smaller groups and larger groups, I do recommend coming together and putting together community agreements or ground rules that you can use as you enter these discussions. So these are a view that I like to throw out there that I think are really helpful when I'm entering these spaces. So first is to consider intent as well as impact. Because we're in a community where we're trying to learn from one another and grow together as a department, as a division, as a group of healthcare providers, we can assume that there is good intention in this space. I find it helpful to sometimes think about that because oftentimes we focus largely on the impact of words in discussions about race and racism. And that's not to say that we shouldn't. But it is to say that sometimes when we're able to also keep in mind the intentionality of the space to learn from one another, we may have more emotional room to be able to engage in conversations if and when someone says something that kind of makes us feel a little bit like, oh, I didn't really love the way that that was said or that really bothered me, it might create a space where we're able to actually verbalize that and be able to learn from one another in that way. So please consider that intention to learn from one another and grow as well as the impact of the words that are being said. Next, don't assume shared values or beliefs. There are many things that this group probably has in common given shared interest and practice. But when it comes to race and racism, it's good for us not to make any kind of assumptions on shared values and beliefs in order to try to jump the gun or try to assume where someone is coming from, especially since we're all coming from very varied spaces and places. Next be comfortable with discomfort. Conversations about race and racism are uncomfortable. Something that I think can be really hard is sitting with that discomfort. And so I like to put it out here because one, I like to name it as a normal part of these conversations. And two, I like to kind of point out that it is really comfortable to not talk about health disparities, to not talk about health inequities, to not talk about racism and other systems of oppression. That's a big reason why we often don't talk about it, right? And so that discomfort that we feel when we're engaged in these conversations, even if we've talked about it a million times before or have never talked about it before, that discomfort is normal and is actually something that I think really reflects that you're meeting with your growing edge. You're going into a conversation, trying to learn how to talk about it and train with humility. And that discomfort is sort of a sign that you're pushing yourself and challenging yourself to learn. Next everyone has something to contribute. Controlling the system of racism in order to undo it is everyone's work. Sometimes some of us can feel like we can or can't participate in these conversations because of how we identify racially or ethnically where we're from, et cetera. But I like to kind of say from the start that all of us have work to do here. And all of us have something to contribute to this conversation. And so now that we've gone through the ground rules, let's pivot to discussing a little bit of vocabulary. So first, what's race? So when I talk about race, I think that there are so many definitions that you can find out there. This definition from Dr. Camara Jones who I recommend looking into if you haven't already is one that I use often and really like to use. And so she describes race as the race noted on a health form is the same race noted by a sales clerk, a police officer or a judge. And this racial classification has a profound impact on daily life experience in this country. She means the United States. That is the variable race is not a biological construct that reflects any differences, but a social construct that precisely captures the impacts of racism. And so there are a few pieces of this definition that I like to highlight. First, that race is a social construct, which means that it's defined and redefined by society. And so what does that mean? I was someone who went right through, you know, in like a health science kind of track, into medical school, I didn't have a lot of time to dive into sociology, history, etc. And so when I first heard that, I was like, what does that mean in social construct? And what it basically means is that this definition is not something that's related to biology. And so very much so race has changed over time and place because it's context dependent. And so what's an example of this? So one is that race as it's defined here in the United States is different than race defined in other nations. An example that I like to use for my own personal life is that the idea of sort of what constitutes as white or black here in the United States is very different from how racist categorized from where my family is from, which is the Dominican Republic. And so someone considered black in the United States is not necessarily considered black or perceived as black in the Dominican Republic, which gives you a sense of sort of the context dependence of how race is perceived by the society in which one lives. Another example is that over time in the same place, you see the definitions of race change in terms of what groups of people are considered a certain race or not. An example of this we could look into or think about is how the sense has changed over time significantly or how groups that were immigrating to the United States in the 1800s and were not necessarily categorized as white in that moment as new immigrant communities now 100, 200 years from then are now classified as white. And so you see these differences and how race actually changes in adapts according to the society in which one lives and the time in which one lives. And so I think that that's a really important part to think about to untangle or not think about race as a biologically defined entity, but instead as one defined by society. Now sometimes when I mentioned that books will be like, well, if it's socially constructed in the community, then what is it even like why are we even talking about it? Now while race is socially constructed, that does not mean that it doesn't have their real consequences. And the reason that race has consequences and concrete effects on our health is specifically because of the system of racism. And so I think it's really important for us to, if we're talking about race to always be talking about racism together. And so when I say racism, how do I define that? So racism is an organized system that differentially allocates desirable societal opportunities and resources to different racial groups. And so this system often leads to the development of negative attitudes and beliefs towards racial out groups or prejudice and differential treatment of members of these groups by both individuals and social institutions. And so it's important to note that the system of racism does not treat anyone neutrally. Oftentimes when we talk about racism, we talk about how racism disadvantages people of color. I think it's also really important to remember that there is no neutral. People of color systematically disadvantaged by racism. People who are identified as white are systematically advantaged by the system of racism, right? And so here in the US, because of our unique history, individuals who are white have collective structural advantage in power to carry out systematic discrimination that other racial and ethnic groups do not. And again, I'm talking about a system structurally. And so therefore, people who are racialized this way get these systematic advantages, those who are not systematically disadvantaged. And racism also has several levels on which it operates. And so one is institutional racism, which I'm sure many of you have thought about, are thinking about, have heard about, especially in recent months. And institutional racism reflects the laws, policies, and practices of society. And it's institutions that provide advantages to racial groups deemed as superior, while differentially oppressing, disadvantaged, or otherwise neglecting racial groups that are viewed as inferior. Personally mediated or individual racism is what we might think of as someone more to ask us, give me an example of racism. So these are these examples of prejudice or discrimination that we can see pretty clearly and explicitly. And discrimination in particular has been shown to be associated with many adverse health outcomes from depression and anxiety, to lower birth weight, mortality, coronary artery calcification, and elevations and blood pressure. And then finally internalized racism, which is the acceptance of negative social stereotypes of beliefs about people of color, by people of color. And I think about this a lot because I think that that internalization is something that especially in primary care, working with kids over time, we can see a lot of those internalized, negative feelings about one's appearance, one's worth, and the effects that that can have on an individual. And so this is a helpful way to kind of think about the different levels in which this system of racism can operate. It can operate through an individual, right, personally mediated. It can also operate in an individual by being internalized by the person that is being oppressed at the time. And so if that's racism, what's anti-racism, which is a word that has been used more and more often in the last few months and is certainly a word that has been around for decades, but I think is relatively new to medical and health professionals. And so when I think about anti-racism, a lot of times the discussion about anti-racism is focused on policy. How is it that we can look at our policies, policies on a local, state, federal level and think about how to create policies that close racial ethnic gaps? And when I'm thinking about medicine, health, professional medical education, I'm like, okay, how can I think about that in a way that is a lot of people who are not in a good mood, I think about that in a way that applies to sort of my work. And so I kind of adapt it, adapt that definition to mean that anti-racism is essentially a collection of actions that work towards racial health equity while acknowledging the structural roots of inequities, specifically racism as a primary driver. So what does that look like for providers? I think some examples to just kind of keep in mind in many of which you probably are working on in this series that you are putting together is the knowledge that we need to be able to identify and dismantle systems of racism include reviewing the historical roots of racism medicine, which I hope will be able to do today, creating a shared vocabulary to make sure that when we're using these words, we're using them and meaning the same thing. Understanding race as a social and not a biological construct, which will dive into a little more. And then what skills might include, I think it also includes self-reflection and mitigation of personal racial biases, right, and critically evaluating the use of race in medicine both in our practice, but also in the literature we read the evidence that we apply. And finally, I like to include the vocabulary word intersectionality. You know, myself, I live at the intersection of several identities, I'm a queer, Latina. I feel like a lot of times when we're talking about systems of oppression, we talk about them individually, like I'll talk about racism here, or I'll talk about LGBTQ health here. But I like to put this in here, I like to put the word intersectionality in here, because I think it really is important to remember that these systems of oppression that we're talking about, that are based on identity, interlock and intercept, and mutually reinforce one another. And are always working together. And so even though I'll be talking about racism today on its own in order to be able to clearly communicate about it, I just like to put at the start that we need to think about all of these different systems of oppression and the way that they work together to shape health. And I like to put this quote by Audrey Loury, because there is no such thing as a single issue struggle, because we do not live single issue lives. And I think it's just a really important piece to think about as we move forward in health equity discussions. And so with that shared foundation, we're going to dive into a little bit of history. And so this is a quote that can be found in a lot of activist spaces. And so the whole quote is no history in itself, no history in itself. And in tracing its origins, it appears to be a loose translation of a quote written by a Filipino writer named Jose Rizal, who was an activist in the Philippines. As I died into it more because it was a quote that always really spoke to me, I actually found out that he was also an ophthalmologist, which made a quote, directly with me even more as sort of a physician activist. And the reason that I put this in here and often title my talks, you know, history in itself, is that to me, this quote has always been a little radical because it challenges us to look at ourselves and understand our history in order to address what's going on in the present because without this perspective, you can come to conclusions with only part of the picture. So for example, in the case of racism in the United States, an individual waking up in our present society, we'll see it organized by race with people of color having less power and white individuals having more. Without putting this into historical context and understanding how this system was intentionally built to allocate power in this way, that same person could conclude that this is how it's always been, or this is the natural order of things. In this quote, I think really pushes back on that assumption, says, no, we all have a history that informs the way that we see the world. And when it comes to systems of oppression, like racism, understanding the construction of that system over time is essential in order to be able to understand how to pull it apart. The system of racism was designed by people in power to stay in power, and there's nothing natural about it. And as health providers, we see differences in health outcome among every health quality indicator even today. And only by looking at ourselves and understanding our history, do we stand a chance to changing things to the better. But unfortunately, many of us don't have a great understanding of the historical context of race and racism in the United States. And I think I like to highlight the importance of understanding this history with a question that I post. And so answer this question to yourself. You don't need to share with anyone. It's not a poll or anything like that. But I'd like you to think to yourself when I asked what came first, slavery, or the concept of race, which of these answer choices you would answer. So let's give you a minute. Okay. And so everyone probably has an answer. And so the majority of folks, including myself when I first was asked this question, typically answered that they either are not sure or that race came before slavery, when really slavery far predates race. Now for those of you who did answer that correctly, many of you very well may have you likely did not learn that in grade school when you were learning American history for those of you who went to high school here in the United States. You probably can think to yourself where you might have learned that which may have been a faith, faith, faith. And so many of you may have been later on in schooling may have been at home. And I think that that really highlights a difference between the way that we talk about slavery and the way we talk about race and how we don't really dive into how race was really constructed in the United States. And so slavery has been present since ancient times and prior to the 17th century, slavery was not based on race, but instead was based on class language religion or reserved for prisoners of war. And so these individuals were often quote enslaved for life. They could often usually stop being enslaved if they converted to Christianity or other cultural norms, which is by no means an easy thing to do, but is different from the slavery that we learn about in the United States, starting with the colonies. And so, in the other hand, did not appear in written texts until 1508. And so why don't we know the answer to this question more collectively? And I think it's multifactorial, but I think part of it is a misconception that races in the way that we see them today have always existed in this way, which is not the case and reflects our lack of knowledge around that social construction of race in the United States, which is very closely tied to the institution of slavery. There are a lot of us that don't know our history in this detail. And we only have part of the picture of understanding racial ethnic health inequities and other inequities between groups. So we're going to take a little bit of time to review this part of American history in a bit more detail here. There was a unique set of circumstances that made slavery in the United States different from those in other nations. And so in the early 1600s, the American colonies were growing and needed more workers. At this time, the labor force was made up of different groups. So this included indentured servants from Europe and Africa and enslaved people of African and indigenous descent. It is important to note that slavery was different in a lot of ways at this time from what those of us who grew up in the US learned about an American history. So slavery was not based on race. It was not intergenerational and enslaved people had certain rights, including the ability to own property in the colonies. And in the mid 1600s, there was a decrease in the immigration of laborers from England to the British colonies due to local issues in Europe, including a civil war, a London fire, and the plague, which is happening at the time. Indentured servants also became less attractive because they were living longer and demanding better conditions. And they were also more costly. There was also a significant decrease in the enslavement of indigenous populations while at the same time, there was an increase in the importation of enslaved Africans due to investment by colonial powers in the Africans' slave trade specifically. And so suddenly, over the course of that 17th century, enslaved Africans went from being one of several labor sources to the primary force labor source on which the colonial economy was based. And it was here that we start to see slavery become the traditional chattel slavery that we learn about in the United States. So there are different parts of this history that have been pointed to by historians over the course of the 1700s to explain that change over time. And so first, that's often brought up is the fear of cooperation among poor, unfree peoples in the wealthy class and using racial ethnic divisions as a way to weaken the power of this group. There were a series of rebellions in the late 1600s, the most talked about is usually Beacons rebellion, were poor unfree peoples work together to rebel against wealthy landowners. And the idea here that historians have sort of hypothesized is that race as the way it's been used has been used to sort of divide that power and divide the ability of poor unfree people to work together. So the next slavery begins to be based on skin tone rather than religion. And so we see slavery no longer be tied to something that could potentially change, but instead is tied to something that is unchangeable. So we close that that ability to become a freed in that way. We also start to see words like white and black replace words like Christian and he then in descriptions, laws policies and the colonies around enslaved peoples. We also start to see slave codes, which are specifically laws and policies in different colonies that are talking about enslaved peoples not as people, but as property. And so slowly over the course of like the mid to late 1700s, we start to see slavery become race based, hereditary and lifelong when it was not before. And so we're going to fast forward a little bit to get to this particular portion of our history. This is an image of the Declaration of Independence in 1776. And so keeping that construction of race in mind and keeping that construction of slavery as as we know it in mind. Our new nation, the United States, was built around an idea that all men were created equal, but at the same time the nation's economy, especially in the South relied on race based slave labor to function. And so this was a blaring contradiction, a blaring contradiction that actually existed at the time, not just by historians now looking back retrospectively, but actually was pointed out by many European powers at the time to try to point out the ways in which the United States shouldn't be. You know their own nation kind of pointing out this blaring contradiction as a point of contention. And so there was an effort to try to rationalize this particular contradiction. And so this is Thomas Jefferson's notes on the state of Virginia, which was written in 1781 just in the beginning years of the United States becoming a nation. He wrote about the sweeping landscapes and ingenuity of Virginia citizens. He also wrote about a lot of different sort of ideas that he had. And it was written largely to try to create relationships between the United States and France at the time. Sadly, he also opined about race as follows. For centering a half we have had under our eyes the races of black and of red men. They have never yet been viewed by us as subjects of natural history. I'd been so therefore as a suspicion only that the blacks are inferior to the whites in the endowments both of body and mind. This unfortunate difference of color and perhaps the faculty is a powerful obstacle to the emancipation of these people. There's a pivotal moment. There's a lot to unpack your selects run through it. But before we do, I want to acknowledge that here Thomas Jefferson mentioned both black enslaved peoples and indigenous communities. And while we will not be focusing on the medical rationalization, while we're going to be focusing, excuse me, on the rationalization of enslavement of black peoples by the scientific community. I want to acknowledge that indigenous communities were and are deeply affected by racism through cellular colonialism, the ceiling of land, genocide and other atrocities that still influence this community today. And so breaking down this quote a bit first, Thomas Jefferson becomes one of the first prominent Americans to write down that black identified individuals were innately different and inferior to white individuals. Now this certainly reflected common beliefs of the day, but he was the first to write it down and was also writing it down as a prominent member of this community as a forefather of the nation, which made it especially waiting. Then not one breath later, he uses this quote suspicion as the reason that these enslaved peoples cannot be freed from the institution of slavery at this time. And I think that this is sort of one of those pieces where the apparent naturalness of the position of black enslaved people and the benefits afforded to this man and many other white slave owners completely erase the social history that had produced race based slavery, the history that we just reviewed. And instead uses the effects of being enslaved at this point for more than 150 years as a reason to justify the need to continue being enslaved. And it was not enough, however, to state this, but times had changed and science was starting to rise in the late 18th century and here Thomas Jefferson states that blacks are inferior, but he takes it one step further by asking science to prove it. And we, the institutions of science and medicine do exactly that we set out to prove the inferiority of people of color over centuries. The Smith of difference continued throughout the 1800s and by that time the scientific debate focused on whether races were genetic variation between the same species or whether they represented entirely different species altogether. No matter what ideology was described to you, there was always an inherent hierarchy noted of races with white individuals at the top and black individuals at the bottom everyone else in between and health disparities between racial groups were seen as a reflection of inherent biological difference. And the poor health of people of color was pointed to as evidence of inferiority and not as evidence of the conditions in which people of color were living enslaved enslaved and robbed of opportunity. And examples of physicians who shared these views include names that are not completely foreign to us and also were folks who were incredibly prominent in the United States. And so for example, Samuel Morden who is the founder of Craneology, the pseudoscience that tried to use the skull size of skulls to try to determine biological difference between races was not a fringe scientist or someone who was doing this work outside of academia, but instead was an internationally known, you pen school of medicine faculty member and naturalist who toured different areas and was asked to speak on this topic in many medical schools. And influence many folks who became providers and entire generation of providers Paul Broca of Broca's area fame and for those of us who remember neuro anatomy. Also measured in comparative bodies at autopsy to look for biologic difference between races in the 1870s. And these scientists like many, these are just two examples, laid the foundations for different pieces of our history that relied on this idea of biological differences specifically inferiority of non white individuals to flourish. For example, laid the foundation for the eugenics movement in their early 1900s, which eugenics was a set of beliefs and practices that sought to quote improve the genetic quality of the human population, not surprisingly, there was a belief in the superiority of white races. And this was widely accepted in academic circles with many courses and medical schools actually offered in eugenics, talking about eugenics as a quote science. And so we see scientists positions are our profession health professionals supporting perpetuate the myth that races are immediately biologically distinct and given the cultural and societal value that was placed on scientific inquiry and evidence at this point in our history, that was incredibly powerful. Also by distancing themselves from people of color using the concept of race as biology white individuals that made up the majority of health professionals and scientists at the time rationalize the centuries long exploitation and experimentation on communities of color. And unfortunately these stories are also quite familiar. J. Marion Sims is regarded by some or had been regarded by some as a great figure in women's health because he created a series of surgeries and tools that decrease the morbidity and mortality of childbirth, many of which are still used today. However, these surgeries were developed through the repeated experimentation in torture on several individuals including three enslaved women, Lucy Betsy and Annarga, often without either which was the anesthetic at the time. It was only in 2018 that a statue in this man's honor was taken down in Central Park in New York City to reckon with this history and try to acknowledge the stories of Lucy Betsy and Annarga and start to wrestle with the history of the health professions and the way that racism has deeply been embedded in it. And of course, one of the most infamous examples of experimentation on people of color was the Tuskegee syphilis study, which started in the 1930s. And when we learn about this egregious study performed in the by the US Public Health Service, we often discuss the lack of informed consent and the lack of treatment of this group of black sharecroppers despite the development of penicillin in the late 1940s. We also learn about how it helped launch a lot of the work like the IRB to try to protect human subjects in research moving forward and was really a pivotal moment for ethics in medicine. What we often don't discuss are the many racist beliefs and stereotypes that were part of this study's development, including the idea to withhold treatment being rationalized by believing that black Americans would not seek treatment even if offered despite their participation in this study. And we are also planning under the rules of routine preventative medical care. We also don't always think deeply about the objective of this study, which was to determine how untreated syphilis, men of us, that in black Americans, and how it was different from what was known about the disease in white populations, presumably because of biological differences. We are also planning to evaluate it on this myth of difference that we've been talking about. Originally planned for only six months, this study continued for 40 years with significant morbidity and mortality within this community. But I think even more troublesome is that the study did not finish until 1972 and was widely published about throughout its 40 year history and was even reviewed by the CDC for appropriateness in 1960s. And deemed appropriate to continue. It ended after the details of the study were leaked to the press by whistleblowers within the US public health service. And only then was it stopped. So this history shows us that providers, health professionals, the health care institution is made up of people, made up of people who are influenced by the societal beliefs of the day. And that being able to look at ourselves, look at our history constantly be asking questions and critiquing what we're doing and how we're doing it is a really important way to make sure that we are perpetuating injustices in the past. I think what is worse is that our support of this myth of difference serves to legitimize the thoughts around race in society at large, just as we're influenced by society, what happens in medicine often will influence society back. It's definitely a bi-directional relationship. And I think that we can see it's some of this when we look at different policies in our own history and think about how institutional policies can shape the health of populations. And so there are countless examples of racism baked into our policy. And these are only some of them. But each of these laws excluded individuals based on the social construct of race, but those earlier in our history being very explicit and those later on being a little bit more subtle. And I point this out because racism changes over time. It is insidious and sometimes is not as obvious as some of the earlier examples of racism that we have been discussing. And so I want to spend a little bit of time talking about the Federal Housing Administration, specifically around segregation and institutional segregation as a tool that can help explain differences between racial groups that we see today. And so the Federal Housing Administration was made in the 1930s to essentially be able to give loans to people to purchase homes. So before 1930 individuals would have to put down about 50% of the cost of the home to purchase it. With these new terms, you only needed to put down 10 to 20% down and get a loan from a bank for the rest with the idea of being to open up the opportunity to own home and be able to generate wealth to the quote average American. Not surprisingly, this opportunity was not available to everyone in an equal way. And so in the setting of lower mortgage rates and wider availability of loans, these brand new communities were springing up outside of cities and suburbia was born. These new communities were primarily made up of white families as loans were denied to people of color through racial discrimination individually, which certainly was rampant. But also because the FHA underwriting manual that would determine property values and whether or not you should give a loan or not to a property in a specific space, clearly stated the negative effects of minority families on property values, specifically in a chapter called protection from adverse influences. And so I wanted to show you guys a few examples and quotes from this. So first, the value waiter of the person evaluating the property should investigate areas surrounding the location to determine whether or not incompatible racial and social groups are present. If a neighborhood is to retain stability, it is necessary that property shall continue to be occupied by the same social and racial classes. A change in social and racial occupancy generally leads to an instability and a reduction of values. Deed restrictions should run for a period of at least 20 years and recommended restrictions include prohibition of the occupancy of properties except by the race for which they were intended. And schools should be appropriate to the needs of the new community and they should not be attended by in harmonious racial groups. And so we can see sort of how explicitly integrated spaces or minority spaces were devalued in this system and those that were not were deemed a higher property value. And this system was institutionalized into an actual property appraisal system that was included within the FHA and led to areas being categorized. And so you can see here areas that were higher, had higher communities of color were outlined in red and deemed quote hazardous. Whereas those that had higher home ownership white individuals were outlined in green and deemed quote best. And this is sort of the process of redlining that we learn a lot about and talk a lot about in terms of where people were investing in communities. And so this is Boston right here you can go to this website mapping inequality and type in a lot of different cities in the United States where they've been able to take the redlining maps from the 1930s and overlay them over large metropolitan cities. And I wanted to point out that we really do kind of see the repercussions of this process even today. So this process of redlining was in place from the 1930s until the Fair Housing Act in the mid 1960s. So for 30 years for a generation there was this disinvestment in these areas and these neighborhoods. And I feel like we can really see a lot of that when we look at sort of our patient populations our neighbor has here in Boston. For example, here's Dorchester here in the red. Whereas here is all stand to kind of keep in mind outline sort of in blue yellow a little bit of green right. And so I want us to keep this in mind because the ways in which this can be perpetuated or the mechanisms by which this can affect. Health now are many and so segregation in general can work through many mechanisms to explain a lot of racial ethnic differences between communities. And population so first segregation can determine socioeconomic status by affecting the quality of education because schools are funded by property taxes and by restricting or providing employment opportunities. It can also create negative housing conditions which are closely tied to negative health outcomes and can also adversely affect access to medical care and to high quality care. And so for example, by segregated formally redlined areas oftentimes will have higher environmental positions less green space less parks and less access to healthy foods are be more likely to be a food desert. And here we see a map of Boston from Boston Public Health Commission when they do their healthy communities surveys. And the first panel here we can see sort of obesity rates the next panel we can see COVID-19 rates. And the last panel we can see sort of the proportion of folks who have less than a high school education in that are residents of that neighborhood. When we look at those same two neighborhoods here's all stand with a lower adult obesity lower COVID-19 rates higher of lower rates of having folks not graduate from high school. And then we have doorchester here in these areas with a higher proportion of these negative health outcomes. Now, right, these patterns are multifactorial, right, but I can't help but see the similarity in the pattern and can't help but think about how that history can very much lead and create the conditions that could partly explain the disparities and inequities we see today. So all this to say that the large racial ethnic differences and socioeconomic status that we see are not something that happened on accident, but instead reflect the successful implementation of social policies, many of which in the past were rooted in racism as we have just reviewed. And so we can also see the way in which this history can contribute to the negative stereotypes about people of color that we see today in our present society. And I'm mentors Dr David Williams at the School of Public Health has a TED Talk title how racism makes us sick, which I encourage everyone to watch where he discusses the effects of racism on health through his research and those of his fears. And in it, he mentions the Beagle project, which looked at a sample of all readings, a college level student in the United States would read in their lifetime 10 million words worth of books, magazines and articles. And they then ran correlations to see what words were most associated with the words white and black and found the following. Now, when you look at these two lists, it's no wonder that there are negative perceptions about communities of color. And stereotypes are particularly tricky because you don't need to believe a stereotype to know a stereotype and you don't need to believe a stereotype is true in order for it to affect your behavior. And these negative stereotypes about people of color can become embedded in our subconscious and affect our behavior. And this process is often described as implicit bias. Implicit bias has been linked to more to more differences in our clinician practice, specifically clinician verbal dominance, lower patient positive affect and lower perceived quality of care for patients when it comes to us as healthcare providers. And so I think a piece of this that can be so hard is that sometimes we can't see the ways in which this history and our biases can affect our care. And this phenomenon has been described by Dr. Beverly Tatum as the negative stereotypes and beliefs around people of color that we see in society and are kind of swimming in as a smog that all of us breathe. And that sometimes this smog is really thick and you can see it clearly and other times it's more subtle, but no matter what we're breathing it in and these exposures impact our biases, these shape our biases and we're not immune to this just by virtue of wanting to be the best most equitable healthcare providers we can be. We carry this baggage into every encounter and into everything that we do and part of our work is having to acknowledge this, be mindful of it and work to be able to address it in our own practice as well as as a collective in the system in which we work. And now this can seem very overwhelming to try to address right it's so big it's so large it's hundreds of years in the making what it's important for us to also remember that there's a strong and really long history and legacy of anti racism by healthcare professionals as well. For example, John S. Rock was a black dentist and physician and lawyer in the 1850s who was a passionate abolitionist and civil rights leader who used education as a tool to fight for anti racist change in medicine. So he would lecture in different medical schools on the unity of the human race pointing out that the focus of the health professions on an individual's blackness ignored the blade and poverty and slavery that strongly contributed to health disparities between races. So exactly what we've been talking about right. Dr. James McGrune Smith was a physician who contested the definition of race as a quote natural category and instead asserted that it was a social category. And he argued perhaps for the first time that apparently intrinsic traits could be the result not of the eight factors but have inherited socially created environments. He essentially argued that racial disparities for the effect of racism not race and this was in the mid 1800s and so you see there is a long legacy of these ideas in our history as health professionals and in all of us using our voice our intelligence and our excellence to improve the institutions in which we live and work by being able to call out what's going on and try to work together to improve it over time. And so one way to change our legacy and to work on this is to have our work be rooted in health equity, which is a lot of what you all are already thinking about doing. And this is from the Boston Public Health Commission is their health equity framework that shows a lot of the social determinants of health that we often talk about. But specifically shows the root cause of a lot of these social determinants of health, which include racism but also other systems of oppression like sexism, xenophobia, transphobia and ableism and allows us to kind of zoom out and think to ourselves as we try to work to close health gaps between racial ethnic groups. While we need to think about addressing the social determinants of health, which you can think about as sort of the symptom of the underlying system of oppression, we also need to target that root cause by thinking about talking about and being able to understand and undo racism and other systems of oppression that create these conditions. I think another great part of this framework is that it sort of shows that the reason that race is associated or driving force of why race is associated with health outcome is largely because of that system of racism and not through other means. And so we can think about this as we hypothesize different ways to try to answer questions, knowledge generation, etc. So this is a photo that I took in 2014 and this is the state building down by the common and I took this in December of 2014. I was a junior resident in residency. I was on my own college irritation at Children's and I was deeply affected by the creation of the Black Lives Matter movement after the murder of Trayvon Martin and other folks at that time. And you know, it was winter time. I was a second year resident. There were a lot of things that probably were kind of coming together. But this what seemed like this steady drum beat of violence against black and brown communities and the way that it was just kind of always on my phone, always on my computer when I opened it up really affected me. I think like many of us, you know, I was angry. I was sad. I was ashamed that I wasn't doing more. And I carried that with me to work. You know, I would come to work and I'm usually pretty smiley, pretty upbeat. But folks were like, you know, like, hey, what's up? What's going on? And I noticed that I just couldn't find the words. I didn't feel comfortable talking about racism and sharing how I was feeling at the time. And in that moment, I kind of paused because we brought me to medicine in the first place was trying to work specifically on closing racial ethnic gaps. And if I wasn't able to talk about racism with my peers, with my colleagues, how was I supposed to change the systems that were creating these conditions and these inequities in the first place. And I found such a disconnect between my inability and training and work and being able to address racial disparities and talk about racism, which was largely just not present in my curriculum at the time. Largely contrasted by the wonderful learning opportunities I was having on oncology at the time specifically, learning how to have a day one conversation with a patient. I was having a fellow help me with that and attending was being able to support me with that. I had debrief sessions after I tried it myself with one of my patients having this difficult conversation where I share the news as someone's child has cancer. A difficult conversation that I as someone who is going to be a generalist knew that I wouldn't have terribly often, hopefully, but knew that I needed to know how to do well in order to do a good job. And while I was getting a lot of care and time dedicated to that learning space. In this moment, I noticed that I didn't have the words or the tools or the ways to try to talk about, think about and address the racism in the way in my practice and the way that it affected my patients, something that I saw at least once a day every day. And so I sort of started this path in residency as a seminar and changed my path completely to work on this topic specifically focusing on how is it that we can have conversations. How is it that we can talk to one another about this topic in a way that can use our collective strength to close these racial ethnic gaps. And I think that I mentioned this because I didn't start this out as like a historian or a sociologist or something like that. I was a resident. I'm a provider. I went straight through. And I know that in a lot of different groups when we're trying to do this on an institutional departmental or division level, there can be a lot of hesitancy and a lot of fear that, oh gosh, I don't know if I'm the right person to do this. Maybe I'm not the expert. Like I don't know if I can engage in this. I don't want to say the wrong thing or do the wrong thing. And so I mentioned this just because we all start somewhere and talking about this and starting anywhere is the right place to be. And it's really about kind of creating that open communication and humility to engage in these types of conversations with one another to be able to move towards that shared goal. And I think that being able to take some risks with one another to trust each other to push ourselves and remain open to growth and also correction is really the way that different moments really become movements within divisions departments and institutions. Thank you. And I'll stop sharing my screen here and see if we have a few minutes just to chat if anyone has any questions. Thank you, Camilla. Thank you so much for an outstanding presentation. I just want to also applaud you for your work so far and educating us and others and medicine. And before we delve into any more questions or comments, I know we only have a few minutes. I just want to let everyone know we're actually going to stop recording the presentation. As Dr. Mateo pointed out, several times it can be a sensitive topic and can be somewhat difficult for people to talk about. So to make everyone feel more comfortable contributing. Any comments or questions will stop recording at this point.