Diana Lemos, PhD, MPH: The program manager here at the Center for Health Equity, and I'm your guest moderator today for today's Prioritizing Equity: Structural Racism, and the Latinx Community. I'm grateful to our panelists today for joining us and to the AMA for hosting this series. Prioritizing Equity is hosted by Dr Aletha Maybank, the AMA's Chief Health Equity Officer and GVP of the Center for Health Equity. And the series is focused on addressing relevant health equity topics in a conversational tone with key health equity experts. The Center for Health Equity, the center, or CHE, is charged with facilitating, strengthening, and amplifying the AMA's work to eliminate health inequities, which are rooted in historical and contemporary injustices and discrimination. Before we get started, I'd like to also remind you that we have Health Equity Resource Center for COVID-19 on AMA's website, and we also invite you to download the copy of the center's Latinx COVID-19 report, which is now available, and we will be linking it in the chat.
And this report illuminates the inequities facing the Latinx community and provides valuable insights for physicians, health professionals, and others working to serve the community in a more equitable manner. We also encourage everyone to visit our previous installment of Prioritizing Equity, Chicago's response to COVID-19, and to view the YouTube playlist of the prior panels, and also to alert you that we will have, on October 29th, our next installment of Prioritizing Equity focused on examining race-based medicine. On a final note, I like to acknowledge that the Hispanic heritage Latinx heritage month ends today, and we continue to pay homage to the many pioneers of Latinx heritage, not just this month, but beyond. And today we'd like to elevate and expand that conversation. We acknowledge the use of Latinx as a gender-neutral and non-binary term that promotes inclusivity, and we also recognize that the Latinx community is multiethnic and a multi-racial population, and that it is one of the fastest growing racial and ethnic minoritized groups in the US. We've recognized that folks may use Hispanic, Latinx Latino, or even refer to an ethnic identity during our discussion, and we encourage you all to use what you feel most familiar with.
So now I'd like to start with just some introductions. When I say your name, please wave to the audience, and I will go down the line. I'll start with you, Rita. Rita Carreón is the Deputy Vice President of Health at UnidosUS. Ms Carreón overseas the organization's strategic direction in health, including community engagement and programming, addressing social determinants of health and advancing health equity. And thank you for joining us. And now I'd like to turn it over to Dr Ray Mendez, who is the founding physician of MiMedico, a primary care clinic that's located in Chicago's predominantly Mexican neighborhood of Pilsen. Dr Mendez also works at the emergency extension at Ingalls Memorial Hospital and is on the Board of Directors for Health and Medicine Policy research group.
And finally, I'd like to acknowledge Dr Ruth Enid Zambrana who is a distinguished university professor and the interim chair in the Department of Women's Studies. She's the Director of the Consortium on Race, Gender and Ethnicity, and an adjunct professor of family medicine at the University of Maryland Baltimore School of Medicine.
Thank you all for joining us today, and I'm deeply grateful that you're all here. So I'd like to start with just asking you all how you're all doing and start by telling us where you are dialing in from today. And I'd like to start with Rita, if I can kick it off to you.
Rita Carreón: Sure. Thank you, Diana. Thanks for having us today. I'm very excited to be here with such distinguished guests and panelists. I'm actually calling in from Silver Spring, Maryland, and our headquarters are in Washington DC. So not too far away from us.
Lemos: Thank you. Dr Mendez, how are you doing today?
Ray Mendez, MD, MA: Hi, Diana. Thanks for having me. Hi, everyone. I'm doing really well today. I think everything's going pretty well. A little colder here in Chicago. That's where I'm calling from, but I'm very excited to join this panel and start this very important discussion and hopefully many, many more.
Lemos: Great, thank you. It's relative. What's cold in Chicago, right? And I'd like to end with Dr Zambrana. How are you doing today? I think you're on mute, Dr Zambrana.
Ruth Enid Zambrana, PhD: I already said my piece, wasted. Okay. Good afternoon, everyone. I am thrilled to be here. I want to thank Dr Lemos with the distinguished panelists and all of us who are bringing something new, and I am so excited that the AMA is tackling the issue of structural racism. It is key to everything. Thank you.
Lemos: Thank you for being here with us. And what I like to do before we get started, I'd like to invite Dr Zambrana to really take the opportunity to ground us in defining what structural racism and what the other relevant terms are as we get started in this conversation. And with that, I know Dr Zambrana has a couple slides to share, so I will pull those up now.
Zambrana: So first, like I just said, I'm delighted to be here. My experience over the last few years is that language is power, and the power is derived from either confusion and ambiguity in language, which then usually requires no action or ineffective action or the importance of when you start a conversation we have learned it's important to sort of define what terms you understand and what they mean to different people and help people understand the meaning and impact of language and the actions it takes. I'm aware that one of the confusions currently in society is that everyone has a different definition of language, like diversity, like equity. So there are a lot of debates around this, but there are clear definitions that we can think about in terms of their relevance, particularly in the fields of medicine and public health and what this means for underserved populations and particularly for Latinos, Latinas.
So to me, this conversation really seeks to understand the why of the severe impact of COVID-19 on the Latino community and who they are. So what we know generally of the entire Latino community is about one third are poor, about 60% of high school graduates or less, and 20 to 50% are without health insurance, depending on place and time, and more, recently, with the job loss. And these data, we have no time, but they vary by national origin and by different types of statuses. But I am speaking to the significant population of Latinos or its socio and economic disadvantage. So I have two slides that I wanted to look at definitions that signal the need for clarity and action. Again, a cautionary note, we can debate all of these definitions because there are many different interpretations of what a definition is. Next slide, Diana.
So you can read the first one. And I think the important point there is that racism is about one's view of capacities of human traits among different racial and ethnic groups that produce an inherent superiority or inferiority of a particular race. In the United States, that is very much related to Mexican Americans and Puerto Ricans are historical groups here that were incorporated in the sense of intellectual and social inferiority compared to other groups of superiority. Structural racism refers to policies, practice and norms that have created and maintain white supremacy. And some of the examples of that, of course, are segregation, poor educational systems that have created barriers to wealth accumulation, upward mobility, and in health care, it has been about the lack of health insurance, which is connected to employment. And as we all know, Latinos are not in job sectors that usually provide good health benefits. We're talking about domestic workers, farm workers, small businesses, many of the communities have their own businesses, so oftentimes they cannot afford health care.
And systemic racism is the policies and practices entrenched in institutions. I think a good example of that has been the exclusion of Latinos from clinical trials throughout the history of clinical trials, and the other one is the quality of care of how and what Latinos receive or don't receive. So there are lots of examples. We can't go through all of them, but I'm sure the other speakers will address some of these. Next slide. Social determinants and equity are both public health terms, but that also very much apply to medicine. And it is an acknowledgement and recognition among all of us. I mean, we never thought about this, but the environments in which we live, work, play, and worship and age so much affects our health. Segregated housing, bad water systems We know this thing in Michigan. Lead in the walls, the tenement homes, the lousy food, the food deserts, the food swamps in our neighborhoods, all of those things impact our health.
And the last one is equity, which at the moment is the one that is the most controversial and has the most definitions by everyone. But equity is really creating opportunities for these populations that we know Black and brown, Native populations in particular to have equal access to and participate in programs And this is from the association of American colleges that are capable of closing the achievement gaps in student success and completion. So education is related to what we can buy in terms of a house, where we can live, what types of educational opportunities we have. I want to give the example here of the gross under-representation for decades and the gap that continues to widen in the development of the Latino Latina workforce. Things have not changed considerably in 40 years. So right now, Latino Hispanics represent across fields about 5.8% of medicine, about half of which are foreign born physicians, 6% in dentistry, and 10% in nursing. And most of these do not represent those individuals of the disadvantaged communities who need this workforce so desperately. So equity is a response to structural racism. And now we will begin the conversation with Ms Carreano speaking first about issues of structural racism. Carreón, sorry.
Lemos: Thank you so much for your definition. As we said, definitions are important. And as you mentioned, language is power. So we appreciate you taking that time. And again, to direct the conversation to Rita, in what ways does structural racism show up in the way that the response to the COVID-19 pandemic has impacted the Latinx community?
Carreón: Thanks, Diana. I think it was super important for us to really kind of ground ourselves in terms of the language and the definitions and kind of where we're starting from. And for Latinos, we know that it's important to recognize that our health is one of our most important assets, and it's influenced by various factors including kind of where we live, where we work, where we learn, where we play, even where we pray. So when we think about the diversity of the workforce, like Dr Zambrana mentioned, we know that the structural barriers that Latinos face in the health care system is often because of a lack of diverse workforce, is a lack of bilingual services within the health care systems, within the provider offices that continue to play a major role in really limiting communities, limiting individuals and children of immigrant parents to fully really understand and grasp the treatment options, the information, the health information, how to navigate a health care system, which is super important.
Even those that speak English and speak it well are still very—have problems with a very diverse, a very fragmented health care system. So I think it's super important for us to really understand that even policies such as pay for performance models that are created for providers don't take into account the patient profile, the resources that need to be invested in those communities and within the offices. And I'm sure Dr Mendez will talk a little bit about that. I think for many structural barriers for Latinos, transportation, the ability to access quality equitable affordable health care continues to be major kind of a limited barrier. And when we saw this or we continue to see it with COVID, it is especially around who's receiving tests, who's getting the tracing that and how it's being done in a culturally responsive way. How are we thinking about if I do receive a test, what if I come out positive? What are the treatment options for me and can I afford that?
And so a lot of the things that we think about and what COVID has done has really exacerbated, unveiled multiple disparities. And I think we know that from the start, and we knew that from before, but it's even worse now than ever before because of the, not only the health impact it has made within our communities, but also in regards to the economic impact. And so what I do want to say, even with Latinos who make up about 18% of the US population, we account for about 28% of COVID cases across the country. And those are the cases that we know about in terms of the data collected on the race and ethnicity of that individual, and about 16% are of deaths. And even among children, it's even worse. According to CDC, the Latino children account about 38% of cases and 37% of deaths among children between the ages of five and 17. These are remarkable, not just in terms of numbers, but these are human grief and loss in terms of families. And so it is no surprise to us that when it comes to health care, it is the number one in the forefront issue, not only for Latinos, but also for kind of how we are really going to think about responding and re-imagining something different for our communities.
Lemos: Thank you so much for really laying the groundwork in terms of how we're seeing this play out in the Latinx community. And what we're really seeing is this decimation of generations of our families disappearing or dying from COVID or having severe impacts around that. I wonder if, Dr Mendez, if you can just talk to maybe what you see in your work, in terms of how you're seeing this structural racism really play out in working and caring for your patients.
Mendez: Yeah. I think we did had a great summary from Dr Zambrana and Rita about how the social determinants of health actually represent all the barriers, all those structural barriers to obtain care for all people, especially Latinos. I think it's important to just acknowledge that, the two points, the structural barriers are a direct result of centuries of racism in our society that persist still today. And that those barriers really have not changed since before the pandemic. I think they've only become more apparent and more severe, which is making everyone form a call to action now. I think two of the most important points that Rita touched upon are health insurance access, right? And that's a critical structural barrier that I think that needs to be remedied here in this country, because we do have about 29 million Americans that still lack insurance, which is little over half of what it was before Obamacare. And that includes a lot of Latinx community, and I'm sure that misses a lot of the undocumented patients as well.
But lack of insurance, frankly, is an injustice. Government and health care systems and hospitals, they have a social and financial imperative to provide everyone health insurance, because it doesn't benefit anyone for people to lack health insurance. It doesn't benefit the patients, the clinics, the hospital systems, health care systems, the government. It just makes a more expensive health care system for everyone that raises premiums for everyone's insurance, because that also, it costs more to get care to those people because some of those health insurance plans are being charged for additional costs. Hospitals will charge higher rates to kind of compensate in their financial projections to compensate for that uncompensated care or unpaid for care. And so it is raising the cost for everyone.
I think in addition to that, we also have to remember that there are biased treatment of those patients without insurance and then those with Medicaid as well. And I think it's important that we acknowledge that and we take the time to investigate these things. We'll talk about it a little bit more what specifically we can do, take the next steps to address these issues. Importantly, I did want to mention that Illinois did take the first step in the country providing coverage through Medicaid, not Medicare for those undocumented Latinx members or all undocumented members over the age of 65. They're the first state in the country to do that for elderly, undocumented seniors. And they did provide Medicaid instead of Medicare, because I think after they did a financial analysis, they realized it was a lot cheaper to pay about $2 million. I think it was like one and a half to two and a half million dollars that they estimated it would cost in 2021 to provide that coverage rather than paying the several millions to even billions estimated for those same seniors. So they were pretty smart about it. They identified their financial imperative and then they realized they didn't want to keep wasting health care dollars on treating only emergent conditions or complications from chronic illness because of the lack of access to adequate primary care and preventive medicine.
I think that's one of the important points. The other one is access to government aid, right? And so our Latinx community did not have, a lot of the undocumented or legal members, even citizens but married to undocumented individuals were completely left out of the government aid. And so already that places a financial burden on those individuals, because when you don't have papers, of course, you have restrictions in terms of the types of employment you can get. You're mistreated in those positions. You have to go to work every day because you have no backup. You have no health insurance. So you have to make money to see about for that rainy day, when you do have to go to the hospital. And so being left out of those government aid programs really did take a toll on people's health. They continue to go to work despite being called illegal. Our undocumented patients were considered essential workers, and yet they were completely cut out of public aid during the pandemic. And so there's obvious disparity there and the mistreatment there. I think I'll leave it at that.
Lemos: Thank you. There is a lot of complexity, and I think that's important in continuing this conversation beyond today. Anything else you would like to add Dr Zambrana, before we move on to the next?
Zambrana: I just want to say one thing both based on this study and on Dr Mendez's comments that we cannot forget the impact on the number of people that this affects. We're talking about 18.3% of the US population. And we could probably easily say that 60 to 70% of that population has been adversely impacted by this. So it's not one person or two person, or just my family. It is 60 to 70%. Does anyone know the actual million? Of 18.3% of the US population. I want us to emphasize that because everyone—that's all I want to say. Thank you.
Lemos: Thank you. No, and I think it's really important to continue to hone in on that because we forget that this is impacting a whole portion of the US population. So with that, I'd like to maybe spend a few minutes just talking about what are some of the responses that we're seeing in terms of responding to the COVID-19 crisis, from a perspective that includes addressing structural racism. So first I'd like to start with Rita, if you can maybe provide us some insights on what's happening at UnidosUS in terms of how you're responding to the issues that we covered today.
Carreón: So thank you. I think, UnidosUS, formerly the National Council of La Raza for those of you who know us more on the national, NCLR, La Raza. And we've been in existence for over 50 years. We're the largest Hispanic civil rights and advocacy organization working to really increase the opportunities for the 60 million Latinos in the United States, and our communities, our affiliate network, and the families have really been in the front lines of making vital contributions for our country's ability to function, such as providing health care, helping put food on the table, delivering essential key services, making sure that at the same time, not only that we're trying to stay safe, unfortunately what Dr Zambrana, Dr Mendez mentioned is that we are often the most vulnerable to getting sick and dying. All Latinos are overrepresented in essential jobs and places at highest risk of exposure to COVID, industries like the agriculture, the food industry, the meat packing, transportation. These are all powered by Latinos, by Black and brown communities. And so despite kind of the essential country's health and safety measures, or the lack of, right, we continue to really get up every day, try to go to work and make sure that we stayed safe.
And so, one of the things that UnidosUS is in terms have been doing is really to help to mitigate the impact of COVID in our communities. We've set up one of the Esperanza/Hope Fund. Excuse me, and it's a public health response to addressing COVID. And we did this by really listening to the community where we have a nearly 300 community-based organizations, health centers, charter schools, Chamber of Commerce that serve Latinos and really focus on the disproportionate impact of where there are in the communities. Having some listening sessions, ensuring that our trusted messengers, like a community of promotoras, community health workers, are part of the solution. And so through that network, we've really been trying to dismantle misinformation, conspiracy theories, or information about just myths, and trying to get some facts out there in terms of what COVID is, the basics of COVID. Being able to support not only with communities but also health systems in this approach, and making sure that that information is not only simple and clear, but also in the language that somebody understands.
One of these collective efforts through our fund have also been working to find support some community-based organizations. We've seen some numbers in terms of where small businesses and local CPOs are not going to make it through this COVID. And so how do we keep those doors open when the demand and services for food, for financial aid, for housing support are needed because they are trusted sources? So we provided some emergency assistance to families through our affiliate network to include not only just cash assistance and housing and financial counseling, but also food. And a lot of it is also providing some technical assistance, providing computers and laptops to ensure that children are able to have a learning environment at home to be able to have our promotoras, to be able to have a laptop, to be able to have these charlas and conversations online and still stay safe. And then the third effort that we've been doing is really boosting our advocacy and mobilization efforts. Dr Mendez talked a lot about how many of these stimulus packages left behind a lot of our communities, undocumented communities. And so ensuring that in those packages and the continuance of packages that follow that everyone is brought together and no one is left behind.
And so for our communities, we know that even in the poll that we just released yesterday, that 61% of Latinos believe that the worst of the pandemic is still to come. But the good news is that there is some hope. There is some hope in terms of the majority of the Latinos that we polled, they recognized the need to do social distancing, the need to support mask wearing, the need to avoid large crowds. And while we're a huge family and want to be connected, and we know how to protect ourselves, but we also have important policies that need to be addressed so that we're not left behind.
Lemos: Thank you so much for addressing all of these different ways and strategies. I know we're running a little short on time, so I'd like to just allow an opportunity for both Dr Mendez and Dr Zambrana to share some insights on what are some additional ways or opportunities for physicians, the medical community, to also begin to really center on the Latinx experience and also really center on structural racism and how we can do these responses. So I'd like to start with Dr Mendez first, and then we can move over to Dr Zambrana for some closing remarks.
Mendez: Awesome. All right. Thank you. I'll speak more general then specific. But generally, I think when it comes to all health care professionals, academic faculty, health care professionals like nurses, doctors, and everything, I think you have to start by being inquisitive and just ask questions about things that are a little bit funny. If you notice some things out of order or somethings, some people are being treated differently, just inquire about it. And then second, once you investigate, you're probably going to find some mistreatment of certain individuals. I think it's important, definitely, to begin challenging the institutional policy and culture that you see where you work, and that's going to be present in all institutions. Some of the ivory tower institutions, locally and nationally, and even some of the more smaller hospital systems You know, you got to look at how people are being treated by their ethnicity, sex, race, orientation, health insurance, the types of clinics they're being shuffled to, if they're being seen by just residents are actually being seen by the sub-specialists, if they're given long wait times for appointments.
For example, we see that all the time with my Medicaid patients, because my clinic is a good majority Medicaid. Whenever I do refer out some of the sub-specialties like psychiatry, it's about 9 to 12 months wait, but some of my private insurance patients, they can get in within a month to some hospital systems locally. So, we have to start challenging those things. And then lastly, generally you want to join these organizations that advocate for your passions, that address inequities, whether it be the AMA, or the Latino Medical Student Association, or Physicians for National Health Care Program, if you do understand the importance of that. And specifically, we have to begin mandating some equitable outcomes and just measuring them. And so just like we measure quality outcomes, we have to start looking at some of the performance standards when it comes to just making appointments for patients with Medicaid, seeing outcomes with patients with Medicaid and seeing if the length times for their appointments did impact their recovery time or their clinical improvement. Integrating anti-racism training into all levels of education from grade school to high school, but definitely into medical school nursing school and every other graduate program you can think of and professional studies. Because the sad truth is that the majority of those students are going to be white still. And so beginning that training from early on, it's going to be vital to changing the culture in the future.
And I do want to mention something that's interesting that I heard a couple of weeks back that—stop relying on minorities to challenge the system all the time. I think non-minorities need to start being stronger advocates because it is pretty exhausting for minorities to always sit there and challenge everything at the risk of their future careers or their academic positions because obviously if their bosses and their faculty members are Caucasian non-minorities and they start to challenge things that they think are unfair or even racist, they can be mistreated or penalized for that either in their grades or their opportunities or letters of recommendations. And so they are putting themselves out there all the time. And so I think it's important that we address that non minorities need to be advocates for our minorities.
And I guess the last thing I'd say is we should advocate for a universal health care system. It doesn't mean that we need a single payer system, just to clarify that it means that. It means that everyone deserves and should have health insurance. The way we pay for that is a different question and a different challenge. So I think being able to implement this in this country, would accomplish alleviating a lot of the disparities that we see here, and advocating for this as fairly important for the future. Thank you.
Lemos: Thank you. And I know we're very short on time, so Dr Zambrana, do you want to make some closing remarks?
Zambrana: Let me just—yes. I'll be brief. I wrote them down. That's the only way. I agree with, I mean, the community work is amazing. What Dr Mendez said is amazing. The universal health care, et cetera. So I just want to add, I think that the issue is around equity, it is providing the resources particularly in the educational pathway. We need to help students not only in high school but in college and through graduate school to train and educate people in medicine and public health and research. And we need to target and provide equity, which is providing additional resources so that they can compete successfully against the upper middle class predominant culture and the quite elite foreign born. We cannot compete unless we have equity. And we need to focus on the underserved communities, which is predominantly bringing into the pipeline, Mexican Americans and Puerto Ricans and disadvantaged central Americans as priority populations in public health and medicine.
I think we need to train researchers. We need to start knowledge production on the impact of not only this condition but other conditions on these underserved communities. So that's really important. We need to make ourselves visible. It is a crime that the American Public Health Association, the National Academy of Sciences, Engineering and Medicine have had so few Latinos on their webinars, sort of bringing us into the public agenda, into the national public discourse. So we need to insert ourselves. And I'm why do a shout out, because Rogelio Saenz talking about researchers. We're trying to make the impact visible. He's in the Cesar Chavez Research Center in San Antonio, Texas. He has been trying to get the data out because place, race, ethnicity and class map over each other and we are leaving that out. So, we say only 20% don't have insurance but in some places it's 60%. We say that COVID is 18% or 20%, but in some places, 40%. So the mapping and the place and the state and the policies that Dr Mendez talks about all impact the rates and the mortality and morbidity patterns. So I think we need equity. And I think this panel has done a fabulous job in defining from the front lines and the community, what we need to do. Thank you.
Lemos: Thank you all so much. This is such a rich discussion. And obviously we can probably do a whole semester of just this conversation. And this is a very brief, brief introduction into how the structural racism is impacting the Latinx community. We encourage you to continue to learn and continue to stay involved with what the center is doing at the American Medical Association, but also to continue this conversation and make it something that's relevant, not just for Latinx Hispanic heritage month, but throughout the year, and to prioritize this. Thank you all for joining us. I appreciate your input.
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