Aletha Maybank, MD, MPH: Well good afternoon, everyone. Good, you got energy. I'm so excited. Yes, I'm so…oh man, I'm very excited right now. I really am and just really happy. I just welcome you all to the Health Equity Forum. Welcome to all of you who have never experienced the House of Medicine as it's referred to here. We are very honored to have you as guests. This is something new for AMA. As folks know, you know, I definitely work to push norms so that we can learn and grow in better ways that help the work that we do as it relates to health, and just really the affirmation of the humanity of other people I think is absolutely critical, and many of us who have been doing this work knows it's essential to be able to do that to advance equity. So thank you.
I am, if you don't know, Dr Aletha Maybank. I'm the daughter of a mother from the Caribbean and the islands who taught me-- yes, that's right, Antigua, specifically, if you know Antigua—who taught me from an early age and really from example and experience of what means to really sit and listen and be with and be present with other people that weren't like us as I was growing up. And I was in many homes based on not even the work that she did, but the intention that she had to see the lives and help support, be with and be in community with many others and to advocate on their behalf as well as my behalf. And so that is who I am. I happen to have a job here too as senior vice president and chief health equity officer of the American Medical Association.
So again I welcome you here so as a commitment and is really as stated in our theory of change in our AMA equity strategic plan we recognize you know a dominant and malignant harmful narratives have disenfranchised voices and people and experiences, ideas, and expertise of those who have been most historically marginalized. And these voices are most harmfully impacted by inequities and most frequently excluded from many of the conversations and decision-making processes, whether in our institutions or in our structures and our laws. And our work must explicitly center the historically marginalized voices and ideas and ensure that we promote and honor their inherent power, autonomy, storytelling, community narrative and leadership for the most affected in health and justice. As practice, it is common that this discussion in the field of equity begin with a recognition that our country and the systems used to create wealth in this country for the exclusive few, capitalism, was built on the land and laborers of people in ways that violated the fundamental principles of equity. We recognize the contributions of many people and identities to this country, and we center those who have been most historically marginalized. So therefore, we acknowledge that we are all living off of the stolen ancestral lands of Indigenous peoples, specifically today on the land of Peoria, people which they have cared for since the time of the immoral, and we acknowledge the extraction of brilliance, energy, and life for labor forced upon people of African descent for more than 400 years. And we celebrate the resilience and strength that all Indigenous people and descendants of Africa have shown in this country and worldwide. We carry our ancestors in us and we continue our call to be better as we lead the work.
So now we're going to enter the equity programming. First up, our first conversation is around Rise to Health Coalition. To kick us off, we're going to learn more about this with one of our partners, the Institute for Healthcare Improvement. We're going to begin from hearing from Camille Burnett, who is vice president of the health equity at IHI. She has an extensive professional health career experience within the US and in Canada in the areas of public health, health equity, research, and academia. And she'll be joined by Dr Emily Cleveland Manchanda, an emergency physician and AMA delegate from Massachusetts, who serves as the director of social justice and education implementation at the American Medical Association with us in the Center for Health Equity. They will give a brief overview of the coalition, and then they'll introduce our wonderful moderator, who is our current president, Dr Jack Resneck. So Emily and Camille, would you both like to come up here? Great. Thank you.
Camille Burnett, PhD, MPA: Good morning, good afternoon, good evening, wherever we're being televised and welcome again. It's a pleasure and a privilege to be here in community with all of you. So I'm going to get started by talking about the context of the coalition and really what it is that we noticed and why we're here. And Dr Maybank highlighted some of the challenges that we faced for many years, for many generations, especially around inequity and injustice. But we also recognize that we are facing a landscape of multiple pandemics, of social, of political, and of racial unrest. And as a result of that, we recognize that all of us are trying to do the best that we can to mitigate a lot of these inequities. However, it is sapping our collective resources and it also is impacting our collective impact. And so as a result of this notion, we decided that it was important for us to have a real harsh look at the environment in which we're all practicing in. And we noticed that many of the individual organizations and the health care organizations have been doing this work, but we've been doing it in a very siloed and very patchwork approach. As a result, we noticed that there's limited opportunities for us to learn from each other's strategies that we're doing, and we also recognize that that activity that's happening is uncoordinated. And as a result of that lack of coordination, it's impacting our ability to gather consensus for us to really make far-reaching impact, and it's also affecting our ability to be clear and to set a common direction for all of us.
So as a result, the opportunity that we're going to talk about today is the coalition, the Rise to Health Coalition, where we're bringing together individuals from across many sectors of the health care ecosystem. And we're also coming together so that we can have a shared goal, a common North Star, to work together around a shared framework of understanding so that we can produce a greater impact and results that all of us would like to grow across our health care system.
And the way we're going to do that is we have this vision. We have a vision for transformed health care ecosystem where all of us, all people, can have the power and the circumstances and resources to achieve optimal health. And the way in which we plan to do that is we plan to build, we plan to change, and we plan to transform our health care system. By building, we're speaking about the capacity. We all have a great wealth of resources and knowledge that we can share with each other, and concrete skills and tools that we all know that we have, that we can mobilize collectively to really have deep impact on equity and racial justice.
In terms of change, we want to change policy. Yes, we want to influence, but we also want to change policies and payments and education and practices towards having a transformed ecosystem where we have a changed mindset, and as well we have a changed narrative around what health and what health equity and racial justice is in this context.
Emily Cleveland Manchanda, MD, MPH: So through the Coalition, we are seeking to mobilize five key audiences to equip each of them with the skills that they need to advance racial justice and equity across the health care ecosystem. Those audiences include individual practitioners, that's each one of you, everyone who provides some care within the context of the health care system. So the health care organizations, the places where we all get medical care. It's also payers and the pharmaceutical research and biotech organizations, as well as professional societies because of our outsized influence on how we practice medicine. Each of these audiences will be working together and mobilized to advance equity in four key impact areas. Those are around access to care, access to resources. It's around workforce development and diversity and thriving. It's around quality and safety, because we know we can't have high quality care without equitable care. And it's around addressing those upstream drivers of health, the social and structural drivers, the things that are not within the context of what we have historically considered to be health care, but which shape opportunities for health across the country.
I'll say that IHI and AMA are not doing this alone. We know that neither of our organizations have centuries of experience advancing racial justice. We have therefore partnered with and shared power with some of the organizations that are leading racial justice work and have been doing so for decades. Many of those partners are here with us today and I'm excited for you to meet them all at the reception that follows the open forum. But one to specifically note, Race Forward, the Groundwater Institute, HealthBegins, as well as PolicyLink, who are co-leading this work with us, along with some of the other leading organizations across the country that are working in the health sector, the health ecosystem. Our group of advisors has been incredibly influential—again, many of them are here with us today—in shaping not only what we are asking people to do, but how we're asking them to do it. And I want to specifically highlight that for the professional societies pillar, which the AMA is leading in collaboration with the Council of Medical Specialty Societies, that we have been supported by and influenced by leaders from a wide array of organizations across the country, specifically centering the voices of people and the organizations who represent people who've been historically left out of these conversations in the past.
And so what this coalition will do is guide each of these five pillars or each of these audiences through a staged journey for collective and coordinated action. It begins with an open commitment to advancing equity and also with getting grounded in our local and historical context for what creates inequities. We'll then move people through the opportunities for improvement, identifying those in systematic ways, making equity a strategic organizational priority, and taking initiative not just by ourselves but in collaboration with others. And finally, perhaps most importantly, we'll help organizations to align, invest, and advocate for thriving communities, creating more anchor mission organizations like the AMA has recently become.
And so I will invite each of you to join us today. There's a QR code here. You can enter your information on our landing page, that's risetohealthequity.org. We'll, of course, share this information with you after the fact as well. There will be multiple on-ramps for individuals and organizations who are seeking to advance equity to work with us as part of the coalition. So I invite you to sign up certainly as an individual, and then eventually we hope also as your organization. We know we have many of the organizational leaders in the room with us here today to join us in this journey. Don't worry, you'll see the QR code again later.
It's my pleasure now to turn the stage over to our AMA president, Dr Jack Resneck, who will share some of his thoughts on the importance of the AMA co-leading this work, and then moderate a conversation with some of the other leaders of coalition member organizations that are leading this work, as well. Dr Resneck became president of the AMA in June of last year. And for more than 20 years, he's demonstrated an unwavering commitment, both to organized medicine and to advancing equity across the health care ecosystem. And so with that, I'll turn it over to Dr Resneck. [APPLAUSE]
Jack Resneck, Jr., MD: Thank you so much, Emily and Camille, as well. And I want to thank everybody who's here this afternoon for joining us. As you heard, I'm Jack Resneck, president of the American Medical Association. And it really is a pleasure to be your host to be the moderator for this afternoon's entire, well for this session, and I'm excited about the whole afternoon as well. We've really gathered what I think is a pretty exceptional panel of accomplished health equity experts to talk about the significance, specifically of our Rise to Health Coalition and how its goals really align with the ongoing work in each of the areas that you heard a little bit about a few minutes ago. And I just want to start by saying, I approach this conversation personally with a great deal of humility. The panelists that I'm about to have up here really bring a great deal of lived experience that I do not, as do many in this audience. Among my many, many privileges in life are that I have benefited from teaching from several people in this room and several people elsewhere. I'm really excited about this work. I'm really excited about today's conversation. The AMA is really proud to be a partner in Rise to Health and to help leverage the power of organized medicine to transform our health care system around a unified vision for health equity. Really a system where people have the power, the circumstances, and the resources to achieve their optimal health.
It's well established, many of you in this room know this through research and science, that structural and systemic inequities within society, many of which clearly rooted in racism, play an enormous role in people's opportunities for a healthy life. We see it in big cities, we see it in suburban neighborhoods, we see it in rural communities, we see it everywhere. And we know that system-level and structural changes are necessary and in fact really the only way to address systemic disparities and improve health in these historically marginalized communities. We also know that physicians have a very important role to play here, not only as patient advocates, but as leaders who care about the health and well-being of the communities that we all serve. It's rooted in our code of medical ethics, which calls us to this work when it says, "Physicians must always strive to deliver medical care "with compassion and respect for human dignity and rights." And as one of our panelists I heard say recently, working in broken systems that leave patients behind is part of what is driving moral injury in our physician workforce.
So the AMA has not always been a part of this conversation. In fact, a lot of decisions that have been made in our over now 176-year history helped exacerbate inequities within our profession and across medicine, inequities, some of which continue to this day. But we at the AMA aim to do better. Part of that has been through reckoning publicly with many parts of that 176-year history and through recognizing that the real work of change cannot be siloed uniquely in our Center for Health Equity, but that this work really does belong to all of us. At the AMA, that really means permeating every unit of our organization, every mission area, whether it's advocacy or litigation or medical education or science or our innovation group, public health, communications, I could go on and on. This is not the work that we silo in our health equity center. This is the work that we look to our health equity center to inspire and inform and lead us to do across the organization. And personally, in my role this year as AMA president, I felt a whole lot of joy seeing so many institutions, so many individuals engaged in the hard, messy, complex work of change. And I've also felt some sadness in recognizing that there are still some who just aren't ready to acknowledge the effects of systemic racism, or the data about different care outcomes for historically marginalized and minoritized communities, or who sometimes don't think that the upstream determinants of health really are our problem as physicians in our clinics and our hospitals every day are some who just see this as a zero-sum game when we know it's not a zero-sum game because equity matters and it means reliable high-quality care for everybody.
So we have been thinking a lot at AMA and with our partners that you've heard about how to scale this work. How do we move hundreds of thousands of hearts and minds and bring them really to meaningful action? How do we take things that we know are proven to work and have them implemented by physicians and professional societies, health care organizations, payers, biotech, pharma, across this country? I think that initiatives like Rise to Health are the answer where we work collaboratively to advance health equity and racial justice in medicine really under a shared vision. Because together we know we can create health care that cares for each and every one of us.
So to dig deeper in this conversation, I'm going to ask my fellow panelists to come on up. This is going to be a panel conversation. Sorry that we're having to use our stage here for reference committees, but just picture that we're sitting here in cozy chairs, gathered around a fireplace. Maybe we can project a fireplace on the slide up front. And while they come on up, I'm going to start introducing folks. So as we get ready to dig deeper into this.
So with us today, start with Dr Kedar Mate, president and CEO of the Institute for Healthcare Improvement, which is one of the foundational partners in Rise to Health, and he's also a member of the faculty at Weill Cornell Medical College. Also joining us today, Helen Burstin, CEO of the Council of Medical Specialty Societies, a coalition of 50 specialty societies from across the country. Dr Burstyn is a clinical professor of medicine at George Washington University School of Medicine at Health Sciences, nice to see you. We also have Dr Michael McAfee, president and CEO of PolicyLink, a national research and advocacy institute dedicated to advancing economic and social equity. Next, Consuelo Wilkins, a tenured professor of medicine, senior vice president and senior associate dean for Health Equity and Inclusive Excellence at Vanderbilt University Medical Center. And finally, we have Dr Karthik Sivashankar, AMA's vice president of Equitable Health Systems and our Center for Health Equity and a psychiatrist at the Justice Resource Institute. Thank you all for joining us and we are looking forward to taking questions for myself and our panelists after some group discussions. So be thinking about those and we'll be using the center microphones a little bit later for that.
So with that, let's get started. And I just maybe want to start by inviting each of you and we'll have all five panelists answer this one maybe. Tell us a little bit about why you think the work of the coalition matters to you personally, to your organization. Karthik, maybe I'll start down at the end with you. Is it okay if I use…I actually forgot to ask consent to use first names. I want to make sure everybody's okay with that. All right. –
Karthik Sivashanker, MD: Thank you, I was hoping I'd be last in this area, but well first, thank you to Aletha, really I'm not sure where she's at right now, but just for everything that she has done to establish the center and the work that we're doing and all of this really wouldn't be possible without it. So in terms of why this work matters to me, I'll share a little personal story. I was born in Columbus, Ohio in 1981. My father was a family physician, came over from India in 1979 and went to Delaware, Ohio, where his practice was literally built by farmers who needed a doctor. So they came together, the whole community, and physically built his office, and he worked there for many years. And I just remember growing up there that they would oftentimes pay him with goods, like vegetables, and I ate a lot of deer meat with shotgun pellets in it. That was like a weekly staple. And so I remember a lot of good things, green fields and farmers.
And I also have deeply imprinted in me a lot of not so good things. And I just remember every bathroom that I ever was in growing up and every school with the words KKK etched in it and nooses and the N word. Maybe it wasn't every bathroom. We form our memories retrospectively, but it felt like every single bathroom. And so racism was a part of my childhood as a small brown kid growing up from the very beginning. It impacted my father, who ended up having to leave his practice because of racism, which was really hard for him because his patients really loved him and he loved his patients. And one other little example: I was, my freshman year, I was the rookie of the year. I was undefeated in tennis. And I was also the team's sand, and then fill in the blank with the N word. So why am I sharing that about why it matters? Well, I think we have to start asking the question why it matters to me or us each individually. And so that was not home for me. Columbus, Ohio was never home. And in fact, what I was experiencing made it such that my body was not even my home. My brown skin didn't feel like home, to the point where I never learned to swim because I was ashamed to take my clothes off.
And so this has been a journey for me of healing and having a daughter has been an important part of that. And I'll happily say I learned to swim last year. I can only do about a lap, but I can swim a lap, yeah. (Audience applauding) And I went sunbathing this year for the first time, Something I never did because I noticed that when I was darker from the sun, I got treated worse. Just something that tangibly has impacted me. But I went sunbathing for the first time. I thought that I was impervious to being sunburned. It turns out I'm not. I got a horrible sunburn and learned my lesson. But what I also learned is that my skin is just as fragile as everyone else's skin. And so what this all brings me to is that quote that Aletha shared by Isabel Wilkerson, which is about the homes we inhabit. What kind of homes do we want to build and inhabit? We all inhabit this house. This is the house of medicine, right? But what is that house built on? And our homes have been built on centuries of problems and really toxic problems, like a mold infestation that is literally eating away the foundations of our homes. Has anyone here had mold in their house? Who here would like to live in a moldy house and breathe in that air every single day and get sick from it? And some of us are getting sick differentially at higher rates, but we're all getting impacted. We can just look at the data. Every single one of us is getting impacted. Look at our life expectancy data. We're not doing well in this country in terms of health care.
So the question is, why does this matter to us? Well, it should matter because of what kind of home we want to inhabit and build together. And that means uprooting some of these infestations that we're breathing in every single day. I will note that the fact that it's making some of us sick more than others has led some of us to become callous to that. Because, well, at least it's killing them more. And that's what hatred does. It actually makes us blind to our suffering of the people next to us, but also to our own well-being. So I'll pause there and hand it over.
Resneck: Karthik, I mentioned the gift of teaching and just want to say thank you for your vulnerability and talking about those painful childhood memories. And on a less serious note, as a dermatologist, we'll talk about sun exposure and skin risk later. All right, Consuelo.
Consuelo Wilkins, MD, MSci: Incredibly hard to go after you, Karthik. Thank you for sharing that. So as a Black woman born into poverty in the rural Mississippi Delta, so many things about our health system and health outcomes are incredibly personal to me. I was born into a community with so many people who are amazing, thoughtful, brilliant, who didn't have very many opportunities to thrive. The health of the community collectively was horrible and poor. But thinking about how I grew up and how I lived, and oftentimes not really understanding some of the things that we went without, it was very clear to me that I lived in a town that was segregated in the 1970s in the United States.
So just hearing so many things now about our reluctance to accept history and thinking that so many things happened decades and centuries ago, but they're still happening right now or certainly in the very recent past. Those are the things that impacted my family's health, my community's health. And living in a town where there was one physician and most of the people who looked like me didn't get to see that person. Where there was one dentist and you only saw the dentist if you were actively having an infection or needed to have a tooth extracted. Hearing and seeing the lives of so many people that I loved and cared about cut short or the quality of their lives really suffering is what made me want to be a physician, what made me want to be a clinician. And so this work is deeply personal to me. I still think about the family members, the community members that we visited who died at home because they didn't have access to health care or who were rushed to the emergency room at times to still be turned away and told there was nothing to be done. It's hard for me to imagine still that in 2023 that there are still so many places in this country where people from marginalized backgrounds are still having these experiences.
So that's why it's important to me. That's why I became a physician. That's why I stayed in academia because I thought that that's where I would have more of a chance to actually impact change, to set up structures, to start an office of health equity in late 2018 and really be able to think about how we can put together strategies that have more impact, to change policies, to open doors, to expose truths that have been hidden. And being able to do that as a coalition, I think, will relieve some of the burden that many of us feel and the challenges we face, the times when it's hard to go into yet another room and hear people minimize the work or devalue it or want to shift funds to something newer, shinier, and brighter. This is the kind of work that we'll be able to be more impactful together. So I'm really thrilled that we have this opportunity as a coalition.
Resneck: Thank you. Kedar.
Kedar Mate, MD: Well, thank you so much. First of all, let me just add my thanks to the AMA for hosting this panel, to Jack yourself for leading us over the last year in this incredible work. I don't know that we would have the opportunity to have a forum like this without your leadership, and of course, Aletha Maybank's leadership. So thank you to the AMA for joining us in the Rise to Health Coalition and to setting the stage for this conversation and what I hope will be many more to come.
I'm quite invested in this issue and this challenge because I think it's the sentinel health challenge of our time. And I think it's a challenge that we know how to address. We actually can do something about this challenge. So there's many reasons, there's many challenges that we face in health care. I'm certain in the rooms and in the sessions that extend beyond this room, there'll be conversations about the many challenges that face American medicine today. This one is something we can do something about. And despite the fact that there have been many years, 400 years or maybe even longer than that, histories of racism and structured injustice in this country and elsewhere, there are lots of signs from within the house of medicine and elsewhere of what we can do about it to change it. So that's part of why I'm interested in this.
At a personal level, I can share stories about my upbringing and childhood as well. I know we've got limited time, so I won't try to consume the whole clock here with that. But I will just say that right now, my mother-in-law is dealing with a significant bone marrow problem that requires a bone marrow transplant, a myelodysplasia that requires a bone marrow transplant. And for someone like her, an Indian woman, the rate of discovering a transplant match is about a third the rate of someone who's white in America. And to me, and it's even worse if you're Black in America, the rate is about a fifth of the likelihood of finding a match. And so for things like this that we see ever present in our lives every day, there are these kinds of disparities that are present that shape our context, our environment, and the futures, not only of our parents, our grandparents, but also our children's future going forward. So for me, this work is a justice issue. It's the opportunity to create new conditions in health and care that have the possibility of changing the landscape in health and care for the better for our future generation. So that's why I'm in it, Jack.
Helen Burstin, MD, MPH: Wow, thank you, Jack. Thank you, Aletha, for really bringing us together. This is a powerful moment. And I have to say, we weren't sure how many people would come, and it's just extraordinary. I just have to say, to see this unbelievable attendance at this equity forum. So thank you for your leadership. Thank you, Aletha. This is really heartwarming to see how many people came out to hear this today.
So as I thought about that question, I also reflected on it as an individual and then as our organization. And I think it matters to me personally, really, at three levels. One is as a clinician who practiced for many years in community health centers and free clinics and has seen far too many inequities that should be closed. We know what to do, we just haven't had the will and put the resources into it to make it happen. Secondly, interestingly, as a researcher, I led the first National Healthcare Disparities Report at AHRQ 20 years ago, and I had the sense that if we demonstrated these stark disparities, things would change. And I have to say, I've been really sobered by showing that, showing the inequities doesn't change things, and we need this kind of action to actually move that forward. And finally, just as a personal note, I'm a child of Holocaust survivors who endured so much injustice, and we should never, ever have anyone go through that again.
And then lastly, just as an organization, this matters so much to us as CMSS, partly because we've been down this journey for the last couple years, as AMA has as well, and we had the privilege of working with ACGME on a remarkable program called Equity Matters, where we brought 31 of our professional societies and program director associations through an 18-month longitudinal learning process. That was deeply powerful. And part of the vision that Bonnie Mason and Bill McDade really brought to the table was the idea that it should be the leaders at the table. So we required the CEO and the president of each of those organizations at the table. Don't bring somebody like you were just talking about to the table who then becomes their responsibilities. No, you empower them, you ensure that the folks at the top have the knowledge and the skills and the tools they need because they then have the power to implement change. And we've really seen what happens when you can actually empower those in leadership with the right knowledge, the tools, and the expertise to make a difference. And we're really excited to get to co-lead the professional societies pillar with AMA, bring what we've learned to the table, but really importantly, help all of us on this journey. There's just too much work to do for us to be duplicating resources. This is just not the time to duplicate our work. We have to work together, and the coalition really gives us that opportunity to work across our silos and really drive the change we know that we desperately need. We can and we must do better, and the only way to do that, I think, is together and breaking down our silos. So, thank you.
Resneck: Thanks, Helen. Michael?
Michael McAfee, EdD: I too want to thank the AMA. I remember a few years ago when this work was being advanced and wondering where it would go. And it's powerful to see where it has gone. You know, this is a leadership moment. You know, this nation wants very different things. There are leaders in this nation who want very different things, and we shouldn't begrudge folks because they want different things. We should recognize that contestation does not mean retreat. And my heart is full today because you all are not retreating. And it's really important to recognize that, that just because someone has a different point of view does not mean we step away.
And so the personal and professional reason why I do this work is inextricably bound. It's inextricably bound because I remember as a little boy, I used to watch my dad tuck his pistol under his seat as we would drive to West Point, Mississippi to visit my grandmother. I would also watch his strength from driving from Kansas City, Missouri to West Point, Mississippi diminish. As we got to West Point, Mississippi, I watched his light and his strength dim a little bit. His relationship to whiteness changed. And I don't know why, but I resented that. It repulsed me, and I said I would never do that. I would never, ever do that. And it's meant that I got fired in Kansas City for not doing that. But I stand on that today. And I stand on it today because too many of us stand on the shoulders of folks who have paid that price for us to do this work.
And what this work is, this is a nation building moment. The quote by Isabella Wilkerson is absolutely right. Each and every one of us must have a founder's orientation to this nation. This nation is a living organism and it doesn't change without our deliberate action. And I have a right, the birthright—even when this nation didn't consider me as part of it in the beginning—I still have the birthright to own having a Founder's Orientation. That Founder's Orientation is so important because my parents did teach me one thing that was really powerful: they taught me the power and the salvation of the all. While they were discriminated against, while their light had to dim, mine doesn't. And the gift that they gave me was the importance of being able to see the humanity of everyone. And then to have the courage and the confidence to recognize that my work now is to live into the promise of the equity definition, just and fair inclusion into a society in which all can participate, prosper, and reach their full potential. And to get there, that means our laws, our regulations, our customs, and our institutions have to be remade. And there's nothing wrong with that. That is the continuous work of perfecting our democracy.
So that's why I do this work. Because this is the last frontier of the equity movement. 24 years ago, PolicyLink helped put equity on the map, and now we are at this place where each and every one of us in this nation gets to decide, do we want to have a founder's spirit? Do we want to have a founder's consciousness that can see the all in each and every one of us and then set about doing the work that is the liberatory work that will make this nation be all that it can be?
Resneck: I'm inspired by inspirational words, Michael, from you and from our whole panel about the why. I'd love to talk a little bit about the what at this point. And Kedar, maybe I'll start with you. IHI is not new to the equity space and has been doing great work for some time now. I just wonder if you want to share maybe some learnings from those past efforts and how it maybe led to the development of this particular idea.
Mate: Yeah, sure. Thank you so much. And thank you to all my panelists for those words of what makes this work so central to who each of us is and how the work matters to each of us. IHI, as you rightly say, has been working on health care disparities and inequities for a long time. After Helen wrote the report, IHI ran some of the first AHRQ disparities collaboratives, HRSA disparities collaboratives and AHRQ disparities collaboratives, sort of trying to address some of the challenges that we found in the work. And we did a lot of great work during that time, responding to the documentation, responding to the urgency and the calls for action to try to reduce the inequities that we saw, but it wasn't enough. And as we started to continue, as we started to do that work and started to look at some of the results of the major efforts that have been conducted in quality, patient safety, in population health, we observed that even some of our best endeavors, our best projects, our best work—which we routinely celebrated in the media and in our publications—what we actually found was when we looked at who was benefiting from those incredible projects in maternal and child health, in cardiovascular care and cancer care. When we looked at actually who was benefiting from those efforts, the benefits often accrued to those that already had power. They often accrued to those who were in cities, those who were white, those who were male in many cases, and they didn't necessarily benefit the folks who needed the help the most.
And that led us to the conclusion that without making equity into a strategic priority for our quality improvement efforts, our safety improvement efforts, our resilience efforts, our population management transformation efforts, unless we made equity a central part of what we were trying to pursue, we wouldn't necessarily make the kind of progress that we wanted to make. But when we did, and this was the important revelation, when we did, when we guided our quality teams and our hospital leaders to start working on equity, we saw quite an incredible response. And there are stories from here in Chicago, I saw David Ansel rolling around here earlier, we saw stories from Chicago of when equity became a central theme in what a health system was pursuing, that the system could marshal the energies not only of the staff internally and the teams internally, but also the wider community that surrounded the institution to start to take action to try to remediate those inequities that they saw.
And it proved successful. There's story after story of institutions taking action, closing equity gaps that they found in cancer care, in cardiovascular care, in stroke care. And it's from that result that we discerned that there was a need for something bigger. Because provider organizations and physicians alone can do a lot to reduce inequities that are present, but we need payers to come alongside of us and support these actions. We need government to regulate and set new policies and create different conditions for what it would take to improve the inequities that we see. We needed professional societies like yourselves in the room to guide us with different guidelines and create new professional pathways so that we could advance the work that we were seeing in health equity. We needed a whole of ecosystem approach, not just the delivery environments alone pursuing these efforts in a silo. And that's what led us to partner with the AMA and all the organizations here on the stage to launch the Rise to Health Equity Coalition, which is an ecosystem approach to addressing health equity. We won't solve this problem from delivery alone, from hospitals alone. We will need community organizations. We will need the professional societies. We will need pharma to make its products available to us so that we can make them accessible to people that need them. We will need payers to pay us differently. We will need government to regulate us differently. And it's those conditions, if we take that kind of whole of health approach that we think might just lead us to reach a pivot point, an inflection point, to move us from documenting the problem to doing something about it.
Resneck: Helen, you mentioned the work of CMSS, and I know some of that has also been around misuse of race in clinical algorithms, and it's been a big topic of conversation among our delegates and work of our Center for Health Equity as well, and obviously a big part of a national conversation, you want to share a little bit of?
Burstin: Yeah, absolutely. And it's interesting how we're talking about data and research and then implementation. And I think what we've traditionally had in this nation is this huge gap between what we know and then how we're actually going to fix it. And I think that's the example here. There's lots of evidence of multiple clinical guidelines and algorithms that have caused harm to some patients because race or ethnicity was included in those guidelines and clinical algorithms. So there has now just recently been an ARC evidence report was put out, I was a technical advisor to that report, clearly demonstrating that there are algorithms that cause harm. There are some when you're intentional about including race to narrow a disparity that are actually really useful, but there are far too many where it is race was included unintentionally and it is not a biological, you know, it is not a biologic construct and should not be in our clinical guidelines and our clinical algorithms.
So we've been working with many of our societies, and you've probably already heard about some that have already made some massive changes. I mean, EGFR, for example, the American Society of Nephrology is a great example of where that community came together and saw the harm of what happened in particular when Black patients were denied transplantation until much later times based on their EGFR that that needed to change. The pulmonary function test is now being changed as well. Vaginal birth after C-section was changed. A really interesting example, when they pulled out race, they discovered that some of that variance was because of chronic hypertension, which just logically makes so much sense that we should think about this clinically and not just put inappropriate constructs in. So, we are now working with funding from the Doris Duke Foundation and the Gordon Betty Moore Foundation with the National Academies, and we're going to be having a convening on June 27th. I'm really delighted with Dr Maybank will be speaking at our convening to really think about what do we know about the process to remove race from clinical algorithms? How do we do it in a way to get widespread implementation? And really think about it as well in the context of going all the way back to data and research. How do you get the research standards in place about when it's appropriate or not appropriate to include race and ethnicity? How do we pull it out of AI and machine learning algorithms, a new and emerging area that many of us are now working in?
So I think it's the right time for us to really come together as a community. We are responsible for those clinical guidelines and algorithms as the house of medicine, our specialty societies put those out. We need to own that, we need to figure out when we're in fact causing harm, change those algorithms, and we're hoping to come out of that meeting on June 27th with a very clear call to action and a timeline for what each stakeholder group will do to make a difference, because we just have to move forward on this issue. We should not be inflicting harm because of our sense of the clinical spaces that we all work in. So thanks.
Resneck: Great to see that work moving forward. Thanks. Consuelo, I'm going to come back to you for a second. You were a participant in another, I think recently completed AMA pilot known as the peer network to advance equity through quality and safety. You want to tell us a little bit about that experience and what other individuals or leaders or health care organizations can learn from that?
Wilkins: Well, first thanks to Aletha for the vision for the center and the work and to Karthick and Tam, back to Ryan, so many folks on the team who really did an incredible job with that peer network. It was a year that sometimes seemed like it was just incredibly short, just, But we learned so much and it was really a catalyst for the work that we've been doing at Vanderbilt to move into the clinical space and the quality and safety space. I would say if I had to think about, if I had to prioritize, you know, the things that were, that stick out to me that were really important from the work would be the systematic approach to bringing us all together, the sharing of the best practices, and also the normalizing of the strategy.
So from the systems approach, the team—we were required to have at least six individuals, and those roles were very clearly defined. The person who leads quality and safety at Vanderbilt needed to be at the table. And so that was really important for us, because as I mentioned, we started the center in 2018. We've done a lot of work in community engagement and community health needs assessment and education and research, but getting into the space, the clinical space, where we have six hospitals and millions of patient visits was very challenging to bring everybody together. So that opportunity to actually make the QSRP chief also responsible and accountable for some of the work was incredibly important. And then, you know, seeing across the others in the peer network that they were having similar experiences and how they worked through it was great, but also seeing some of the role modeling happening with folks at MGH and how they just approached it, that was really very valuable to us. And then from the normalizing standpoint, you know, the way that the team came together And, you know, initially, you know, we had to describe ourselves. We had to say, you know, our positionality, what- how are we approaching this work? And for some people who are new to equity work, it was a little bit challenging for them to even, you know, say what their race, ethnicity, gender, put their pronouns on the slide was. And so seeing other people do it effortlessly, And every time we met, it was expected. I think really sort of normalizing some of those things for people who are working outside of equity was very helpful. And then to see later colleagues now doing it effortlessly and being able to say words like racism, I think effortlessly. It looks more effortlessly than it did before. So I think that really has been a catalyst for our work. and I'm thrilled that we're continuing it and we have milestones and activities and accountability that's built into some of our other strategies.
Resneck: Cool, it's great to hear about. Michael, I'd love for our audience to hear a little bit about PolicyLink and some of the learnings from there about what success might look like.
McAfee: Sure. So PolicyLink is a research and action organization. It's based in Oakland, California. It was established 24 years ago, and our peers are like Brookings and the Urban Institute. And the reason we were established by a woman named Angela Glover Blackwell is because she felt that the DC think tanks did not really carry the voice, wisdom, and experience at that time of everyday people into the policy deliberations, thus the policy and the link in our name. When we walk into rooms, we're carrying the voice, wisdom, and experience of that 100 million plus in America who are living at 200% of poverty. And our job is to design policies and programs that work for them. You know, things that we have learned, I would say at this moment, probably the most important thing that we've learned is that we will lose this moment if we do not act right. There's a level of arrogance that is beginning to grow up around the equity space. None of us have the right to judge each other. You know, there's a lot of in our space right now. You're not Black enough. You're not gay enough. You're not white enough. You're not this enough. You didn't use the right language. So I get to beat you up about it.
Folks, there's a key word in our equity manifesto that's called grace. And in the first sentence, it says it begins by joining. And we've got to remember that. That in order for equity to continue to take root in advance, we've got to be willing to join with each other, not just those who fundamentally agree with us, because we've done that work. Now the tough work at hand is to continue to expand beyond those who simply agree. As hard as that is, that is the work for our generation. And that means that we have to have the grace and the consciousness to be in rooms where folks don't get it, quite frankly. We'll lose this moment if we don't get this point. Doesn't matter how smart you are, it doesn't matter how many more papers you can write. We will lose this moment if we don't get it. So the thing that we are learning is that all three sectors have come to racial equity. Who would have thought that would have happened 24 years ago? And now we've got to be caretakers of this moment as you all are being. Caretakers to continue to join, to do the work, caretakers to have the grace to be able to hold the difference that is necessary for us to learn how to do this work where everyone can be a part of it and we can do the structural reforms that are necessary in the nation.
Resneck: Great answer. Karthik, this could be for you or anybody, but as we've been speaking about the work of this coalition, one of the questions, speaking of grace really, is we have all these data and as we know, they have been important but insufficient in getting us to this point in the work. But sometimes we get accused of doing this from an academic standpoint. And what do we do to make sure that we are in communication with affected communities and that they have a seat at the table? How are we working that in to this approach?
Sivashanker: Everyone looking at me. I think I kind of look back to the group. Does anyone else want to? I have a response, but I'd like to open it up for someone else first. Go ahead.
Speaker: He called on you, go for it.
Sivashanker: So it's actually really an honor for me to just be here listening and just taking notes. That's what I'm doing this whole time is just taking notes. And for example, Michael, I've never heard you speak and it's just been really powerful. And that's why we're partnering with the organizations that we are. This is an example of how we're seeking to share power in doing this work. We have PolicyLink, we have Groundwater Institute, Race Forward, HealthBegins, these really incredible racial justice organizations that we have intentionally brought to the leadership table with us to lead the work and to hold us accountable to the work because, as we know, AMA has not been on the right side of social justice for much of its history. I think we're on the journey now in a very important way and leading the journey in many ways, but we really can't do it alone safely.
And then as I'm looking around, I'm actually seeing some of our advisors here who are incredibly important to this work. These are our national field advisors who are representing different communities and organizations and have informed of the development and the design of the actions that are at the core of this work. And all the other partners that we've brought to the table, which are many, which also includes, for example, our non-physician organizations. So we need to be engaging our nurses and our other allied professionals, but also our environmental services workers and our food services workers. In the middle of the pandemic, when I was a director for quality and safety, we had our frontline employees getting COVID at 10 times the rate of our other employees. And so we actually can't function as a health care system when those that are critical to the delivery of care are unable to even keep themselves healthy and their families healthy. And so there's lots of different ways that we need to do this in community with each other. I'll pause there. Want to see what others have to add to that.
Wilkins: One thing I'll add is that I think as far as data and involving community, disseminating the community, I think anything we do with community has to be bidirectional. And we have a lot of data, but it's not always the right data. And we need to understand from communities, what that data, what data might be missing, how we might be misinterpreting the data, and how we can also link to better data that they have. There's so many assets in the community that we overlook or misunderstand. And so I think anytime we're engaging the community, engagement means it's bidirectional and we have to make that a priority.
Mate: Yeah, I guess I'll just add that I think that this idea that, first of all, I was struck by this idea that there's a moment here that we can't waste. This concept I think is so central to why we're doing this now. This is the time to seize this, you know, the opportunity in front of us is to seize a narrative and change the narrative towards, bend the narrative towards justice and reframing. You can't do that without understanding what matters to people in their communities and families and homes. And so, so much of what the Rise to Health Coalition is through the structures that Karthik outlined and suggested, we've built kind of mechanisms for formally engaging with community participation, but there will never be enough. And we will continue to do what we can to bring voices of community members, not just to the table, but formally into the mechanisms of the coalition. So that the coalition is about creating more justice and power, just as much as it is about health transformation and changing the narrative fundamentally about inequity in America from something that we've seen as something that's baked into our society to something that is actually completely changeable and something we can do something different about.
Resneck: Well, I promised an opportunity for audience questions. So let's open things up and share the microphones a little bit. So we're going to use the center microphones two and five. Anybody would like, we've got this amazing panel up here. This is your moment.
Sarah Coffey: Hi there, I'm Sarah Coffey. Thank you all so much for the work that you all are doing and really instilling a feeling of hope into this conversation. You guys have spoken so much about some real tangible ways for us to continue to move this conversation forward. A question I have for you, just kind of thinking about as an individual, what would be something you all would think on an individual level that each of us could be doing to continue to move this conversation forward? Thank you.
Sivashanker: Sign up. That's the first thing I would say. And I say that sincerely, because not everything we do in this space is worth your time and energy and effort, but I do think this is one of those things. And that very first action of signing up, it's a commitment to being in solidarity with others. Because doing this work is really difficult. As an individual, doing it alone is almost impossible, and it can be dangerous, in fact. And as an organization, it can be. So for example, my home institution, previously Brigham and Women's Hospital, you may know that as they were trying to do some of the work around addressing inequities in cardiology care, they ended up having—and if you're not familiar, I'll just give you a quick one-liner—they ended up, they were trying to resolve these differences in referral patterns. Basically, if you were white with heart failure, you were more likely to get referred to the cardiology service. If you were Black with heart failure, more likely to get referred to the general medicine service where there were differences in outcomes. So in trying to resolve that inequity, they ended up having neo-Nazis that organized around the hospital handing out the pictures and contact information of some of our beloved colleagues who are leading this work. And so it can be isolating, even as an institution, to do this work. So we need thousands, tens of thousands of people and organizations standing up in solidarity because that brings power, strength, and momentum for the work. And then in signing up, you're now joining a community of people who aligning and coordinated action through this longitudinal journey over the next 18 months. I want to see if anyone else has anything to add.
Burstin: I'll just add one thing, which is I think there are remarkable resources now available and yes, please use the QR code and sign up. We've pulled some of the resources, for example, from equity matters and Dr Mason, who really was her brain child, often refers to this really is there's a basic science of DEI and equity and it's a core competency of all of us. So I think we need to go just like we study for other tests, actually go online, learn about DI, learn about equity and there's free CME so take advantage of that.
Resneck: So thanks to say allyship to with those who are doing the work. I mean it was such a dark day seeing those photographs from Boston of those protests and what colleagues doing the work to advance health equity were enduring so that allyship is something we can really do as well. Microphone 5.
Harbhajan Ajrawat, MD: Harry Arjawat, I'm from the state of Maryland. First of all, I want to thank all the panelists and all our president for doing this. Listening to you, I heard two words, consciousness and moment. I feel the efforts are great to have this inequity going on in the health services, but I think the root cause is that we need to recognize who we are. For me, you all are perfect being. You are perfect because you are one of a kind and nobody can recreate you. This is a conscious thought. And the only purpose of life is to maintain your perfection. But your mission should be to let another person know that you are perfect born. A person who cannot be compared to anybody, I can tell you that I check your DNA, it will match nobody. And there is nobody in this universe who can recreate you. So the very important part is this moment is to make that conscious thought that accept people the way they are because they are perfect being. And if you don't touch that part of it in this moment, that is the most important. You can do all the data. You can create everything saying, "Till your gray matter does not recognize next to me people are sitting perfect, you are not going to treat them and nobody, there is no color, there is nothing like that, you are all perfect." Thank you. "And your purpose of life is to maintain perfection, but your meaning is that every other person and this is the only truth, remember there is no truth in life other than you." So I'm just going to say, please bring that conscious thought that everybody is like you and treat him, you will get equity everywhere. There will be no inequity.
Resneck: Thank you for sharing those thoughts. Microphone five again.
Eric Steele, DO: Eric Steele from Maine. I'm curious as to whether the coalition can help us as we think ahead to a statewide conference on this topic and how we can start lifting our efforts. Do you have that kind of capability in the organization to help us do that?
Mate: I suppose I would say the short answer is yes, and we will help you with one way or the other to build the kind of momentum needed in your state and elsewhere across the states. The goal of the coalition is to create a national dialogue on this, and that's going to start with local conversations around these issues. And so the short answer is yes, and how and what and the specifics will have to work out.
Daniel Resnick: Hello. My name is Daniel Resnick, MSS delegate, a region delegate. So last year I got to serve on AACOM's Council of Osteopathic Student Government Presidents and we were really working on some major initiatives in this area, specifically a nationwide JEDI program, really trying to encourage every osteopathic medical student to get involved in the work. And we just kind of, I just was wondering if you had any insights into where you would recommend medical students might start in getting involved, if you had any specific resources that came to the top of mind to kind of share to kind of launch those initiatives faster or more ways to get involved with the work you're doing. Just wanted to see what you had.
Mate: This QR code is going to be helpful. I don't know if it's showing on the screen, but all of these questions are when you when you sign up for the initiative and send us information about what your specific questions are, then there there's a team of people from the IHI, from the AMA sitting here in the front of the room. To find where they are, come to the front of the room, we can talk about this during the reception or otherwise. But there's a lot of guidance around what we can do at individual practitioner level, what groups of students and residents and trainees can do. I venture to say that a significant portion of the transformation efforts in individual health institutions are actually motivated by students and residents and trainees. The Brigham, the story that Karthik told, a lot of what happened at the Brigham was driven by residents and trainees actually motivating for those efforts. And so, you know, the short answer to your question is absolutely, there will be specific guidance and suggestions and supports that we will be putting forward through the coalition and please come to us and sign up and help us spread that message.
Resneck: Given this brilliant and inspiring panel, I would love to take more questions. I would love to sit up here for about four or five more hours and continue to ask questions and learn, but we are out of time and have a great afternoon ahead of us.
So first of all, just please join me in thanking these amazing panelists. >> [APPLAUSE] >> I've been inspired by the themes I've heard this afternoon. >> [APPLAUSE] >> I can't do any better than that. We don't see that long standing applause as it may very often. It says it all. Thank you. I have been inspired by the themes this afternoon of grace, of bending the arc of history towards justice, of sharing power. I want to thank our audience for not only being here and the great questions, but for being engaged in these issues. The importance of this work is really only continuing to magnify. And we need everybody, everybody at the table doing this work. [APPLAUSE]
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