Social Determinants of Health

Well, welcome back, everybody. Um, the next session we have is a, is a really important session. Um, it's one that there has been increased light shed upon this in the recent past in, in the United States after the, uh, the killing of George Floyd. So anyway, we're fortunate to have, um, 3 great people to help lead us through this next 45 minutes of discussion. Uh, Doctor Marion Henry, Doctor Erica Newman, and one of my, uh, mentors, Doctor Victor Garcia, uh, to help us think about the issues of race and, uh, diversity and inclusion. So I'm not sure who's starting off, but, uh, it's Marion or Erica or Vic can take it away. Thank you, Doctor Van Holman, um. I'm starting off for the group, uh, as we embarked on the discussion of what aspects of the broad topics of social determinants of health we would like to discuss today, it was clear in the setting of COVID-19 and the great inequalities and discrepancies that we witnessed with regards to impact on different communities and with the backdrop of the Black Lives Matter movement growing out of the tragic and unconscionable events of the spring and summer. That we should discuss the impact of race on the care of our pediatric surgery patients. Conveniently and coincidentally, a recent article published in pediatrics has made the headlines of national newspapers recently suggesting that black children are more likely than their white peers to die or have complications after surgery. Despite the flurry of news attention this article received, it is not the first to suggest racial differences in outcomes in pediatric surgery. A number of studies have shown that African American children are more likely to die after surgery and have different risks that need to be considered when risk stratifying. They are more likely to die after congenital or heart surgery or neurological procedures, experience delays getting onto kidney transplant lists, and are less likely to receive those transplants. And they are more likely to have complications from appendicitis, from solid tumors, from extremity sarcomas, and even from gastroschisis output, outcomes. Previously, many of us have really focused on poor or less access to care and additional comorbidities as being a primary underlying cause for these disparities, including the discussion last year at this conference on social determinants of health. But while delayed presentations and additional comorbidities and access to care may have played a role in these, in some of these studies, this newer study looked at children who were all healthy, ASA 1 or 2, and undergoing inpatient surgical procedures, thus hoping to eliminate the impact that poor baseline health might be playing. And even among these healthy children, race still had an impact, with African-American children having a higher risk of postoperative complications and mortality. So now we really want to ask, why do we think this is? So we really wanna, I'm interested to, um, Todd, if you could help me sort of man the comments and the questions from the audience because that really is the, uh, question of our session is that, you know, why are we seeing disparities and particularly what is quite disturbing is that these are healthy children. And, um, you know, when we are controlling for asthma for, um, presenting symptoms that, um, you know, children that are otherwise healthy, ASA class 1 and 2, die more frequently and I really think we ought to pay attention to this study. It's not, uh, new. There have been other studies as Marian pointed out about disparities. But I think that this should really ring the alarm for us as pediatric surgeons to try and understand, um, some of the root causes and so we, um, Marion and Vic and I talk about this quite a bit and so we are putting up what we think might be two things that are contributing to some of these disparities. Um, one that we can't overlook, Marion, if you could, um, advance the slide is bias. I think that that has been um Talked about quite a bit, it's becoming somewhat of a um code word now, implicit bias, explicit bias. I'm on a call the other day and somebody said that, you know, that they posed the question, is bias really a code word for racism? Uh, and sexism, and are we, um, somehow, um, making racism and sexism. Are we covering that with the word bias, and so I'm interested in what my colleagues think about that. But I think bias is a real problem. Next slide. It's a great question. So let me just stop there. I mean, is bias and racism synonymous? When do you, how do you differentiate between bias and racism? I'm curious if anyone on here has a thought about that. I think I'm, I, I think racism is a bias, sexism is a bias. I think, you know, but I, I don't know. It's Erica brings up a great point. Is it just a code word that we're using? I agree. I mean, I think we, there are lots of different biases you can have, but certainly, uh, The, the fact that the thing that's wor, that's, that's bothersome about this is the, for me personally, is that sometimes I think there's bias that you don't recognize. And that is sort of this normalized deviance concept where uh behavior that is inherently biased or racist, uh, more specifically, just has become the norm. And we don't recognize it when it happens. OK. So, I, um, I would raise the question, um, is bias in and of itself a bad thing? And do we, don't we all have biases, um, you know, the developmental psychologists would suggest that, uh, children, um, from the get-go have biases. Uh, uh, they have a bias where they prefer, they would prefer their mother, for example. Um, they have biases towards those that they are, are raised with. Uh, and, um, to me, the real question or a, a, a real component of this is, Uh, to, to what extent is bias, which to some may be, you know, natural, uh, becomes harmful, and if we act on that bias, uh. Uh, then, um, are we there? Um, Yeah I'll meet that person, yeah. Uh, OK, um, so, uh, let me, I mean, it's interesting that you bring that point up, Vic, because when you look at medicine, forget race, ethnicity, just talking about how we evaluate a patient. When you take someone who is considered to be a, uh, very experienced, um, uh, surgeon. Who is much better than a medical student at picking up on a disease. They're using clinical biases, things that weren't in the book, but they say, well, I know what I've seen in the past, and so I'm coming to my clinical conclusion based on a bias. So, it's kind of ingrained in our heads. To use biases. The problem is what happens when it turns the, the wrong direction. Yeah, and, and that's my point. Uh, I mean, that's part of my point. I mean, you know, uh, and so, to what extent then does bias morph into racism? Uh, and then within, within the medical institution, um, there's also the concept of misinformation. Uh, you know, the concept that, let's say Black people have thicker skin, uh, or they can endure pain, uh, or they don't, uh, and so, therefore, they don't require as much pain medication. Uh, and then how that influences the outcomes, because we know that, you know, pain is another vital sign in some respects. So, It's, um, yeah, it's a, it's a, it's a complicated, if not complex, and certainly a very nuanced uh question that Erica brings up as far as bias. I think the other thing is. You know, imagine if, and I, I do think that this would be, you know, when we're looking for solutions and action items is, you know, well, how do we incorporate this into our daily lives and our daily practices? I think we have to keep challenging ourselves, so we talked, we're talking about an example the other day where, you know, Thinking about a disease process like non-accidenal trauma. So this is something I've been trying to observe over the last couple of months because I've been paying more attention to, um, trying to check my own biases and just think for a minute about the families that come in and you know, something like non-accidental trauma is a very subjective thing, right? I mean, they come in, the kid fell off the bunk bed. And we as trauma surgeons and care providers have to make a decision as to whether we believe the mom or not if the kid fell off the bed and now has a subdural. And I can say that, and a couple weeks ago this situation came up and I use this as a teaching rounds, you know, with the residents, and that how many times has there been a black family that has been Put through child protective services has been called, they need to go to the house, they then, they need to make sure that there's a bunk bed in the house that the kid fell out, um, we keep the child there, you know, after we've deemed them medically fit for discharge, waiting on disposition from the social worker, and so, um, you know, how many times has that happened to a black family whereas, you know, an, an, a majority family or a white family has come with the same story and It's very noticeable that those families are not put through the same scrutiny, and I posed that question to our students and our residents and our nursing team to if they had noticed any difference in differences in that, not saying that we did as, as a healthcare institution, but just posing that question because it was something that I sensed and not just at Michigan but in other institutions as well in my training, um, and even as a medical student. And the question was yes, and that the many more it seemed, and this was all anecdotal, so somebody somebody should look at the data, but it was anecdotal that the families that have been scrutinized or um at least uh. Um, queried the most about whether this was non-accidenal versus accidental trauma, um, leading to a subdural head bleed was, um, people of more ethnic minorities. So, you know, it's just, I think we have to really push ourselves on this and, um. And begin to ask those tough questions of ourselves because again this is not something that as um Doctor Garcia pointed out, these are very complex issues, so this is not something that we're going to be able to look in the look on Epic and look in my chart and determine if somebody has been discriminated against or if a bias, you know, some bias thing has happened to them. Um, but the data shows that all healthcare providers have bias that, um, favors whites. This data came from the IAT, the Implicit Association Test, where, um, they are collecting data from millions of participants, um, to understand bias. It does affect our medical medical decision-making and so who we refer for things, who gets surgery, who doesn't. Children and adolescents experience bias not only in healthcare but in education and the criminal justice system. And the good news, I think the thing that is promising is that biases are not hard-wired. We can change this, we can change our thinking, and they can be replaced with new associations. And so I would encourage us as pediatric surgeons to really pay more attention to this and to really start incorporating this into our developmental plans, our professional development, and I think it's our responsibility to do that, particularly with data arising now that healthy children are dying, um, based on the color of their skin. So, Erica, I'm gonna stop you for a second. Um, so this is gonna be a weird, um, time, this presentation, because I know you have a lot to present, but I also I almost want to sacrifice some of your slides to make sure we get conversation going. So, um, we may have to do a little of that because there's some discussion regarding, um, when you talked about non-accidenal trauma. Uh, there's a couple of things I wanna bring up. Marion brought up a great question about do your institutions have standard protocols to eliminate bias. Uh, I know that Rich Falcone taught me about a great study to show that if you try to think that you can Predict NAT, you are wrong and so a protocol has been put in place. It's not up to the doctor to make that decision. If you're under a year of age, you get worked up, uh, just like anyone else. And, uh, and, and I, we've instituted that now, uh, in Akron as well. So, I, I wanna bring that up. And then the second thing I want to have, and you, you, uh, Erica, Vic, and uh Marion know this, that we need to pay attention to the fact that this is a very different audience than we're used to talking with. This is an international audience, and it's so different in every region. The, the cultural norms are different, the demographic makeup is different, and the biases are different. Uh, so I want to keep paying attention to that in the audience because I see people from many different countries, uh, involved here. So we can probably skip this guy in the preference in the um sake of time and then this one was just showing um the uh IAT this is that implicit association test. I would encourage. Folks, if you haven't done that, it's really, um, I find it fun. I go on there and do it every now and then because it really does, um, you know, you can do racial bias, you can do gender, you can do gender and science, you can do, uh, elderly versus young. And it really does give you a good idea of what your own biases are. Next one. Hey, Erica, can I interrupt for a second just to ask, I, you know, I've done these tests, and I, it's fascinating, and uh I, I, I personally think they're great, but there are a number of folks, including one of the ethicists actually at our own institution, who questions the validity of this test. Is there, can you help us understand, or, or do you have data to suggest, um, The value cause I personally find it very valuable, but I think some people question whether this is actually a useful test or not. I, I, I agree with, with that. It's I think it's one of those things where um there's nothing, there are very few other reliable ways to understand our own biases and it's such a subjective um topic that, um, you know, I, I think from a scientific standpoint it's been, um, I think it's probably the only evidence-based um. Um, data, um, that backs, um, that we have, that people have these, um, sort of unconscious associations based on stereotypes, so I don't think it's perfect. I think that it's what we have right now, um, and probably the most comprehensive test out there. And so what it does and the way that we use it in our institution is that it at least gets us talking about bias, it gets people interested in the topic, they'll go on, take the test, get some results back, and then there's a book that goes along with this test that the, um, the, the people that at Harvard that, um, spearheaded the test called the Blind Spot, the book I find that book pretty interesting because it just talks about, you know, taking Um, you know, how we have these, they're automatic associations with, uh, based on race and based on, um, you know, gender and so forth, and so I just think that if nothing else, it gives us an opportunity to begin to talk about bias and then give, it does give you some insight. I, I'm not sure about the, I never thought about it really from an ethical standpoint. I have to think about that a little more. That's great, that's very helpful. Thank you. Next time Oh, I just put this up here, um, you know, the Institute of Medicine, you know, there's still when we, when we, um, discuss these topics, you know, people always say, you know, what do doctors, you know, have to Why should we be so concerned as doctors and surgeons, and I think this is definitely our lane. Um, the Institute of Medicine, um, conducted a, a pretty broad study and found that there are definitely disparities in all, um, specialties with regard to race and ethnicity and that, um, people, um, of African descent. Um, have, you know, unequal treatment in America and so, you know, how we address that as surgeons and how we care about that is really, I think it's not optional. I think it is a part of our responsibility as, um, you know, as surgeons. Next one. And then I think this is the last one I'm gonna pass it off to Vic, but I put this slide here. I really like this picture of this kid, um, because it reminds me of, you know, we should ask questions of our, you know, children when we see them. So an example would be how are we to, um, people are always wondering, you know, how do we incorporate social determinants of health. Into our daily practices and so imagine this kid, um, we see in the ER, he has a lac on his leg, and I will say for the most of our, most of the time we sew up the lac, send the kid out, we don't, we have no idea what he's going home to. Um, and so just, I think we should start asking more questions, you know, why does he have a lock on his leg? Well, he has a lock on his leg because he has a junkyard, you know, next door to his house and he plays in that junkyard. Well, why does he have a junkyard next door to his house and why is he playing in it? Well, because his mom's a single mom and she's working and there's nobody to take care of the kids all day. And so, you know, perhaps if we start to learn these stories, we as individuals and as our, as institutions and health systems, perhaps we can intervene and perhaps, you know, there are things that we can do to be more engaged to our community and more socially conscious and be able to impact our kids in a more holistic way than just um sewing up the lack on his leg. Next slide. And now I'll turn it over to you. Yeah, Erica, thank you for, for that, um, um, you know, for that introduction. Um, what, what I'm gonna do here is, um, Sort of posed a question as far as uh Uh, basically, you know, the overarching question is, why do minorities, and when I talk about minorities, I'm talking about not only African-Americans, but also, uh, for the purposes of this conversation, uh, Hispanics or Latinos. Um, and, uh, the question, the overarching question is why do minorities have, uh, the, uh, disproportionate disparities that we see, and in fact, that are actually increasing. Uh, and I'm gonna list several of these. And, uh, the related sub-question is, is it nurture, uh, or is it nature, right? To be more explicit, is it where somebody grows up? Uh, or is it something about the individual or the family, uh, specifically? And so, the questions that I would pose for the audience, uh, and to respond in the chat. is why is it, uh, that, uh, African-American women, uh, even a healthy woman, uh, has a greater likelihood of giving birth to a premature baby, even though that child, that mother may have excellent Uh, prenatal care and may even have achieved a, uh, college education. Uh, a related question is, why is it a black mother with a college education has a higher risk of giving birth to a premature baby than a white woman who has only, uh, graduated from, has not even graduated from high school. Uh, why is it that African-American children and minorities who are poor, uh, have lower cognitive abilities, or at least as evidenced by educational achievement, as well as economic attainment? Why is it that both children and adults, uh, because we need to sort of in considering this, talk about adults, why is it that they have a higher incidence of cardiovascular disease? Uh, strokes and high blood pressure. Uh, why is it that black children actually have in these neighborhoods, higher incidences of high blood pressure? And are we looking for that when we see a child coming in for, let's say a hernia repair? Uh, so let me pause there, OK? Why is it that we have these disparities? Uh, why is it that we see these disparities not only among children, but also about adults, uh, their parents, their caregivers. Uh, and, um, with that, uh, I think if we can answer that question, or at least maybe even exposed the, you know, the nuances of the question, we can even begin talking about what can we do about it. So, uh, so, Vic, I'm gonna read, so there was some discussion before you brought it up. Uh, Tara Lou, uh, uh, mentioned this from Tampa. She, she mentioned that this is not a, um, this is, uh, nurture, not nature. Um, and it's a, it's an interesting, I, I always, again, I wondered how relevant this would be across international, across the globe as a discussion, and the question you just brought up is incredible, is incredibly provocative, which is We love to dismiss things as Genetic, um, makeup. So why do Ashkenazi Jews get diseases? Why do Amish get diseases? Why do African-Americans get diseases? Why, and we just, our initial instinct is, oh, it's because of the, that's just genetic makeup, and it's too easy for us. To dismiss this, and we've never challenged it before that we need to stop just dismissing this as, well, that's just how it is. And um I'd be curious to know if you, you know, I, I, um, Malcolm Gladwell's book, Talking to Strangers really pointed out how you can go to a region with a totally different makeup of people and you find very different biases. So it, it really um supports that, uh, it's learned. And Tara, I'll just read what Tara just wrote. Yes and no. Uh, and this is to Marian's question, I think, uh, but let me see, she wrote, yes and no, suppressing the bias. Go ahead, Marian, were you gonna say something? Oh, I, well, I said that, um, that's why it's important to become aware of our biases and create systems that, you know, stop the subjectivity and, you know, can prevent us from coming from a place of bias, and her response was yes and no. Suppressing the bias keeps it under covers, and it's really important and maybe more effective to bring it to the surface, become aware of our own racial biases based on our personal, individual and local regional cultural milieuu, and work towards changing the upstream conditions that create it, which I completely agree with. Can I, can I stop for two seconds, Vic, before we get back to you? Um, I wanna call on Miguel or any of the other people that are not living in the United States. Um, do we, do you see similar situations in your region, um, Is this a US predominant thing? And Well, from our point of view, we start seeing this bias or problems with, because the last two years we have a high number of people coming from uh the Caribbean countries that are from Americans and definitely there start to be a, uh, we start to see a bias or, or, or problems in that point of view with this uh population in Chile but it didn't have any history of that. So even we know, we, we know that there's problems and we see that mainly in the US maybe we start seeing even in our own society now at any level, uh, to start with those problems. So, what happened is we hear what you all said, uh, uh, but I'm, I'm sure it was very profound. Um, what, what I would also, what I would contribute here is, is that, yes, it is, it is prevalent in other countries. I mean, we see that in Brazil. Uh, and we have to look historically about, um, About what, what happened as far as slavery is concerned. Uh, many of us don't really realize that slavery first happened in the Caribbean. Uh, and, uh, and so there were African-American, African slaves taken to Brazil. And so, Brazil is struggling now with, uh, with this issue as far as racism, uh, in that, in that country. But also related to that, one of the things that I was gonna bring up as far as Hispanics is, is that there's a difference in the outcome, uh, from life expectancy and disparities between Uh, uh, Mexicans who come from Mexico to, let's say, Chicago, and Puerto Ricans, uh, and Dominican Republics who come to, let's say, New York City. And I would pose the question, does anybody know why? Did you hear that at all, or no, nobody jumping out with, uh, with very profound answers, Vic. So I, I think, uh, that's part of the complexity of this is they're very hard to understand why these things happen. Yeah, well, um, perhaps an oversimplification is, is that when you look at Puerto Ricans who come from and Dominican Republics, is, is that you see they're an admixture. You see African Americans. My parents both are from Puerto Rico. Uh, and I can tell you that from observing my father's experience coming to the, to the United States, uh, he was not treated as a Puerto Rican or Hispanic or Latino. Uh, he was discriminated against because of his darker complexion. Um, and so, that is one of the realities as, as far as touching on the question as far as his racism. Uh, you see racism in the United Kingdom, um, and, uh, that, that's been written about as, as, as well. So, Not a uniquely American phenomenon, but what is uniquely American is the way, uh, slavery has, uh, has contributed, uh, to this, and how long-standing, uh, it was before slavery was abolished. But we still see the, the, the, the, the traces of, uh, discrimination. So, um, we do have a lot of comments, but I, I wanna make sure you guys can continue on with your presentation. There's questions for you, Miguel, about, I don't want, is it mupuches? Uh, I don't know, but, uh, uh, in Chile, I, I, but I wanna make sure you, Miguel, if you have a quick answer, go. If not, I wanna move on with their presentation. Which is the question, sorry. It says, can you, what about the Mapuches in Chile? Oh, the Mapuches. Certainly this, uh, native, uh, Chilean people has a lot of issue that the history has never settled. Uh, we made a huge mistake with them, you know, 200 years ago. that until now we didn't settle down with them, so we still have a problem in that issue. Certainly, there, there, there is some problems in terms of a society and how we interact with them and how the interaction if, with them, with the Chilean, they, they don't feel like they're from Chile. They, they still look at us as, you know, the foreigner people that came to their country. So there's still some very, very important issue with them. And, and it's interesting, uh, uh, we have, um, Doctor Ajayi, uh, uh, who is from Nigeria, and, uh, talking about the bias is mostly ethnic, but in academia, it's subtle. Um, so, um, It's, it's interesting how everyone in a different region has different answers. And there are different groups. I would suggest that if you ask any one of the women on this call about, uh, bias and academic. they would be happy to, uh, expound on that. Exactly. Vic, why don't you go ahead? So, um, my friends and colleagues, so, um, you know, one of the things that, uh, I would share with you is, uh, the fact that, uh, What has perpetuated the uh disparities as far as excess deaths, not only that we see that, but also disparities in health, is the differences in the proportion of African-Americans or minorities that are living in neighborhoods. And uh the excess deaths uh for African-Americans in Greater Cincinnati, for example, depending on what neighborhood you live in, you will have a twenty-year life expectancy that's shorter uh than somebody who's living in a more affluent neighborhood. And then globally, or globally, nationally, Uh, what we see is, is that African-Americans, uh, live in conditions that are not even, uh, degrees difference, but of absolute substantively, uh, different kinds of neighborhoods, such that the worst urban context, uh, in which whites reside, uh, and this is fairly recent data from Rob Sampson is considerably better than the average context of black communities. So that picture that That Erica put up, uh, that's not, uh, just an isolated instance. That's something where the vast majority of African-American children grow up. So, um, with that, um, With that, uh, it, it becomes now apparent that it's, uh, not only linked to racism, uh, but also ethnic segregation and it's by neighborhood, such that you now see fairly commonly in the literature that your zip code is more of a predictor of your life span and your quality of life than, than um your genetic uh makeup. So, um, So the question then that I also want to address, and that's talking about health. You know, we talk about the importance of education. And so, uh, for my colleagues, to what extent, uh, do you believe that if, um, there was, uh, parents, African-American parents, black parents, Hispanic parents pay more attention to education, uh, that, that would help address the disparities. That, that in and of itself, just increasing the quality of education, um, would be, uh, really the silver bullet. And, um, and then, uh, you know, making sure that you have quality schools. Let's say that the schools are, are, are of equal quality. Well, to what extent would that eliminate this gap? Those who say it would, um, you can sort of raise your hand. Those who say it's much more complex than that, uh, offer some Some explanations I guess my vote would be that it is much more complicated than that. Education is certainly a component of it, but uh there are so many other factors uh related to, uh, the, the whole spectrum of social determinants of health that, that would be my, uh, my guess. I was gonna say my bias, but I'll say my guess. I agree. Yeah. Uh, so this slide is from an article from Paul Krugman, uh, really, that features work that was done by Martha Farah. And for me, it was an insight. Um, I thought that poverty was just sort of, uh, you know, hampered your material, um, uh, capabilities, uh, and contributed to material deprivation. But what, uh, neurocognitive scientists and, um, Uh, uh, anthropologists and others are finding out is, is that concentrated poverty by neighborhood impacts every organ system. And if you just take a quick glance at this, You'll see that the prefrontal cortex is affected. And what that means is, is that you see that in evidence as far as the child not paying attention in school, the hippocampus, so that their memory is impaired. Uh, amygdala refers to the fact that they will be more likely to fight than fight. Uh, and so a whole host of things. And what was particularly interesting is, is that the incidence of chronic inflammation, uh, for parents and even for children is significantly higher. So you helps to understand why African-American women have a higher prevalence of lupus and autoimmune diseases. Um, but if we go to the next slide, um, you'll find the disturbing fact that when you look at the order of, of, of magnitude of this issue, uh, 95% of black children, 95% of black children grow up in these concentrated environments that are not only, um, Materialally deprived, but toxic. Uh, and That's something that I think most, for me, it wasn't as widely appreciated. Particularly when you look at what toxic means is uh not only exposure to air pollution or from traffic, Uh, but also lead poisoning. OK. Uh, and so you look at the, the, the compound deprivation, as well as the toxic environments, uh, there's very little surprise as to why, uh, children in these neighborhoods are challenged as far as performing academically. And um it's something that uh has not improved, uh, despite the optimism of the time as far as the civil rights movement. So, the question then remains, next slide, please, so. Um, uh, we, we can skip that, and we've touched on that already. Uh, here is something that I think, uh, would help put to rest the the, the, the question about nurture versus nature. And what we see here is a study that was taken by Raj Chetty. And if you're a child born in Cincinnati, and he looked at Every urban setting in the United States, some 20 million individuals, that if you don't move out of that environment, i.e., move out, and I would argue the better approach would be move up, i.e., change the environment before you're 10 years of age, you'll see a steady decline as far as the likelihood of uh improving your adult outcomes, adult outcomes. So, what do we do now, Todd? Uh, do we then, uh, look to move children out to less poor neighborhoods? Or do we move them, uh, I guess that was a child expressing his, uh, his desires. Uh, or do we invest in the neighborhoods where, uh, children, uh, are living in right now? You know, that, so we can wait for the question, the answers come in. Again, these are, these are very profound, provocative questions that you're probably not gonna get some quick answers from, but we'll see if people write things. I think. If you're asking me, I think it goes along with the same thing that Dan said before. It's, it's not as simple as, uh, any of these solutions. Well, I, Uh, and I don't have access to the chat box, at least, at least I'm not seeing it as quickly as you. But, um, I think that when you think about the fact that it's estimated that 350 million jobs globally are gonna disappear with the automation and AI. Uh, there's some urgency to answering this question. And it's not gonna be, uh, an answer that's gonna be provided by the federal government. I would submit that it's, uh, those of us on this panel, and those of us in this session, need to be thinking about this, uh, because if we don't solve it, um, the worsening disparities is gonna be economically unsustainable. And if we think of what happened with the pandemic, with COVID pandemic, and how it paralyzed the economy, this left unmet, this challenge left unmet is going to compound what we're gonna see with the next epidemic or pandemic, rather. So Vic, that, that raises the question for me, um. That I had even before, you know, when I was thinking about this session, uh, it's, many people have commented about the fact that we've, we have had this recent uptick in interest and, and engagement, uh, following George Floyd and some other horrible events, uh, but it always seems to just fade away. How do we To your point of we have to change the environment, that is not a, that's not uh something simple or something that happens quickly. What are the things that we need to do as a society to make sure that we continue to focus on this and that we, uh, affect real change over time? And I know you've been very, very involved in the community and trying to, um, and had significant impact, uh, but it's taken 20 years to get, uh, you know, to, to get the things that you've achieved, which are fantastic. But I, I guess the only, uh, optimism I have relative to the pandemic is that it shows us that we can do things fairly rapidly if we have to, if you look at the way we've changed medical care and such. So, what is gonna be the pandemic or how are we're gonna recognize the pandemic that's already here that is, uh, racism and, uh, and our failure to appreciate, uh, inclusion and diversity is something that's critical to our own survival. Yeah, so why don't we move along with the slides. Uh, uh, thank you for that question, Dan. Uh, shall I jump to the, um, economic mobility slides, or you, yeah, but wait, let me, let me just touch on this. So, so I decided to then take a look at the economic distress indicators, uh, for, for where we live, where we work, and that's 452-29, um. And uh what I want to point out here is, is that, uh, not much has changed, despite $68 million a year being spent by nonprofits. Um, and, um, I would propose, I will pose then later on, a reason, but this is just to sort of demonstrate, uh, our reality. OK. Next slide. Um, and, um, and then this is again for 45229. So, we've, you know, announced that we've dropped black infant deaths. Uh, but we also have not made a big dent on teenage birth rate greater than 50%. And this is recent data from Uh, the Raj Chetty's group. Next slide. Uh, but here's something else that's also interesting, and that is, this is school absenteeism in Rockdale Academic, uh, Elementary School. Again, 452-29. The chronic absenteeism is 39, uh, 39%. Uh, so Todd, I think he froze. Yeah, I know sometimes he, he freezes and comes back, but I, I also think we're going pretty over on this session, so I wanna make sure we get the high points in, Marion. So why don't you take us home with sort of the high points. OK, uh, while we wait for Vic, I'll, I'll move us forward to, um, The discussion of sort of what can we do next and and that uh Doctor Van Alman sort of led us into and how do we affect these neighborhoods and and and work towards change and the contextual mobility um yeah can you so moving. Hey Vic, I, I think your internet's going in and out, so we're just gonna move on to Marian's session. Yeah, go ahead, my, because my internet is just frozen. Go ahead. Well, this, uh, I just was moving us ahead to get to the discussion at the end, Vic, which really is, is your discussion. So please, if you're there, lead it. But moving towards the question of What can we do and how do we implement these changes in, in the idea of increasing economic mobility and improving neighborhoods, and how do we improve neighborhoods without just causing gentrification and causing the very people we're trying to impact to no longer have that neighborhood, so. So, there are thoughts about how do we move ahead, and that is transforming neighborhoods, uh, taking uh, um, taking into account the, the racism and how that affects, uh, the work that needs to be done. Uh, but less, it's really changing the economic ecology of that neighborhood. Next slide, uh, and, um, I'm not gonna be in a position to be able to say, uh, one thing that's gonna be doing this or taking care of this, because it's a complex issue. And one of the failures, I think one of the reasons why we haven't seen as much progress is, is that we tend to look at one thing, uh, and not look at the multiple things that need to be addressed concurrently. And the next slide for further discussion, and this is where complexity science comes into play, as to telling us then, what, what are, where are the key leverage points that need to be addressed, uh, to give us a, a, a large effect at not only the individual, but also the collective levels. Um, so, let me pause here and just suggest that, uh, there might be, um, next slide, uh, some opportunity for, for discussion about that. Because what I'm proposing is a social lab strategy that is uniquely, uh, structured to really address these complex challenges. And how many of you are familiar with complexity as a science, uh, or the social lab strategy? So yeah, I don't think many people are um have responded um. So, um, to, let's sort of round out the session. I wanna just make sure we take home the important points for this, uh, wide audience to, to take home from this. Um, and, you know, there are, I also wanna ask, um, the three of you to address a lot of these comments. I know Marion has been, um, in, in the chat. Um, you know, What, what, what are the take-home points, uh, for the three of you that we should be paying attention to? I think, Todd, it's become pretty clear from the chat and from some um research done leading up to this is, well, the situation in the United States definitely is, um, Impacted by our history of slavery and racism, it is not a unique situation. It's not, you know, I've been watching all these discussions, and there are issues in many countries, and so, while we initially were like, wow, we're being very, you know, uh, United States centric in this discussion, I think actually there's a lot of issues around the world that um That many people are, are dealing with. So I think that some of these ideas and concepts really can be applied wherever one is working. Um, that, that's one take-home issue. And the second is that, um, that I had was that it, it's not just about access to care, because, um, I know a lot of emphasis in the past has really been on, well, it's, it's health disparities due to lack of access, and therefore poor, poor, poorer health. But Even in countries with universal healthcare, we see that the, this neighborhood effect is still in, uh, still happens. So there's a study out of Sweden where they have universal healthcare, but they see similar disparities based on neighborhood locations, on health outcomes. And so, um, that really goes to there's much more involved, and it's a much deeper and more complex issue, and I think That's where, uh, Vic's expertise on complex systems has really helped me take a step back and look at, you know, There's a lot more involved here and we have to take a bigger, sort of more advanced look at what we can do and there's not a simple, there's not a simple fix and thinking you can go in with a simple fix is probably gonna have an outcome you're not expecting or not have an outcome. Here's, here's what I would say. You know, the update course is a rapid-fire event where we touch very superficially on a lot of things and fly through. I think what we're finding from today is a great desire to have some of these as much more in-depth conversations. This is one of those. This cannot be adequately addressed in 45 minutes. Um, you know, this, this is one of those that I think, given the, the incredible intensity within the chat, given the complexity of the topic, we need to have an event, um, that's dedicated to this without, um, you know, with real-time, because what I wanna get down to is Yes, we just got to awareness, but how do we make measurable change? What, what specific things can we do? So awareness. Improving awareness, but how can we collectively, I have to be impressed with the pediatric surgical community. I can't compare this to other spaces cause I don't know. But we, there's a great deal of interest and energy on this right now, which we can't let drop. We have to keep this ball in the air and figure out how to keep moving this forward. So, you know, I guess, Vic, Yeah. So, let me just, uh, you know, 3 minutes. If there is one thing that I would love to do is to do, really do the social lab in neighborhoods, uh, and that is in doing it in a way that you engage the people who are in the neighborhood to co-create the solutions that need to be. And the reason it has to be by neighborhood is because every neighborhood is different. There's no two ghettos that are alike. And the fundamental thing is really something that WEB Du Bois said in 1899. The issues that we're dealing with as far as minority, infants, etc. etc. are due as a consequence of their economic plight. And we need to think about historical, as far as the slavery, uh, but also the ongoing racism and discrimination that takes place, uh, in this country as far as African-American males, uh, not being able to have the same level of, of work opportunities in females, uh, so that their economic plight then, uh, could be, could be improved. So, some would say moving out of the high poverty neighborhood, the other ones say transform that neighborhood. Uh, there are not that many low poverty neighborhoods that are gonna be able to be welcoming, Black people coming in, uh, because of the biases that are inherent, which is why I say, transform that inner-city neighborhood, uh, and doing it in a way that uses a complexity lens. So, that, that's very helpful, and I think we also need to, so there's comm, there's so many different things. I'm seeing people talking about vote. We see, we see a lot of different comments about how we change this. Can I put a question out to the audience as we close this session out? Please let me know either by email or chatting here if this is a session that you would be interested in attending or even being involved on the panel. Um, I really want to encourage not just Ameri, you know, people from the States, but anywhere around the world, uh, let me know if this is an area that, that you would be interested in. Uh, attending. So, um, Vic, Marion, and Erica, um, again, very provocative session that we did not have enough time for, to be honest. We, we already went over, it's already been an hour, but I, I still think, um, there's so much more, obviously, and it, I knew this would happen. I mean, when you try to tackle a topic like this in a fast-moving event, You're just never gonna feel satisfied that we got to it, um, but I'm glad we did this in an international arena because all the other ones I've seen have been in the United States. So, um, thank you for presenting, uh, but I just wanna highlight there's one great comment here to, to, to, uh, tie up and Uh, from Tom Reynard, it says the issue is very complex, but as an individual practicing pediatric surgeon, we can look at cross-cultural communication, which helps in all areas of patient care, staff interaction, and how one treats others within their, uh, facility. And I think that's really important is, you know, we talked about the complexity and the challenge, but it doesn't mean there's not stuff we can work on right away, today, tomorrow, in our own, uh, practices in our own facilities that can improve this. That, that's a, a great way to, uh, I, I mean, that's a great comment to address in the final moments because, and I, I'm, I'm There's, there's so much more to discuss. I mean, I know, we could go on forever doing this, the comments are great. They're, yeah. So, all right, well, thank you, thank you so much, and, um, I think, I think we need to go on to the final session, um, but if you all could answer these, I, I still want the chat to keep going, so we don't, we have to end the verbal conversation, but let's keep it going in the chat, um.