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Addressing Diversity, Equity, and Inclusion in Health Care and Medicine

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From the JAMA Network, this is JAMA Author Interviews, conversations with authors exploring the latest clinical research, reviews, and opinion featured in JAMA.

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Phil Fontanarosa: Welcome to this JAMA Author Interview podcast. I'm Dr Phil Fontanarosa, Interim Editor-in-Chief of JAMA, and we are pleased to have this discussion today with authors of articles in the August 17th issue of JAMA. This issue of JAMA includes a collection of research and opinion articles on the topics of racial and ethnic disparities and inequities in medicine and health written by authoritative authors, including those with us today. The moderator for this podcast is Dr Ebony Boulware. Dr Boulware is Professor of Medicine, Chief of the Division of General Internal Medicine in the Department of Medicine, Vice Dean for Translational Science, and Associate Vice Chancellor for Research in the School of Medicine at Duke University. Dr Boulware is a member of the JAMA editorial board and also authored a Viewpoint in this issue of JAMA. Joining us for the discussion today are three other distinguished Viewpoint authors: Dr Francisco Cigarroa, Dr Howard Koh, and Dr David Satcher.

Dr Cigarroa is Professor and Director of the Transplant Center at the University of Texas Health Science Center at San Antonio, the Carlos and Malú Alvarez Distinguished University Chair, and holds the Ashbel Smith Professorship in Surgery. From 2000 to 2009, Dr Cigarroa served as President of the University of Texas Health Science Center in San Antonio. From 2009 to 2015, he served as Chancellor for the University of Texas system. Dr Cigarroa is a member of the JAMA editorial board as well.

Dr Howard Koh is the Harvey V. Feinberg Professor of the Practice of Public Health Leadership at the Harvard T.H. Chan School of Public Health in the Harvard Kennedy School. He is also co-Chair of the Harvard Advanced Leadership Initiative, and Director of the Leading Change Studio at the Harvard T.H. Chan School of Public Health. From 2009 to 2014, Dr Koh served as the fourteenth Assistant Secretary for Health for the US Department of Health and Human Services. Dr Koh also is a member of the JAMA editorial board.

Dr David Satcher is the Founding Director and Senior Advisor at the Satcher Health Leadership Institute at Morehouse School of Medicine. From 1993 to 1998, Dr Satcher served as Director of the Centers for Disease Control and Prevention. From 1998 to 2002, Dr Satcher served as the sixteenth Surgeon General of the United States and also served as the eleventh Assistant Secretary for Health for the US Department of Health and Human Services. Dr Cigarroa, Dr Koh, and Dr Satcher, thank you so much for joining us. And Dr Boulware, thank you for serving as moderator for this podcast.

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Ebony Boulware: Hi, Doctors Cigarroa, Koh, and Satcher. First I'd like to thank you for taking time to create a space for this very important conversation about race and ethnicity and how they impact our communities to help with individuals within our communities at our clinical practice. Each of you has written a very powerful piece about the experiences of specific racial and ethnic groups, some of the health inequities they're experiencing and how these experiences and inequities relate to clinical care and the medical profession. I'd like to open up our dialogueue to ask you each about why this is important to us in medicine. Could you each speak from your own perspectives, particularly about the diverse groups that you've written about, why this is an important conversation for us to have right now? Starting with Dr Koh, why is this important to have right now with regard to individuals who've been categorized as Asian-American, Native Hawaiian, and Pacific Islander?

Howard Koh: First and foremost, Dr Boulware, thanks so much for moderating, and I'm delighted to join my dear friends, Dr Satcher and Dr Cigarroa, on this very important panel. And this is a really critical time for our nation to look at the disparities and health equity issues for Asian-Americans, Native Hawaiians, and Pacific Islanders. I'll use the acronym AANHPI for short. Through COVID-19 we've seen a long-simmering history of prejudice against Americans of Asian descent. Now it's going to boil over in a state of hate and we've all witnessed this on the media and through a pandemic that exposed widespread health inequities, it's particularly triggered this rhetoric blaming COVID-19 on the AANHPI community. So I'm Asian-American. I'm Korean-American. These are issues that I've thought about my whole career as a physician and as a public health professional.

Our community is the fastest-growing racial ethnic group in the U.S., but it's still poorly understood. Most times it's quite invisible, quite honestly. But then in times like this we need to understand why this hate has erupted, why the AANHPI population is too often viewed as foreigners in our own country and as outsiders. Try to understand what's behind these assaults. Try to put this in a context of broader health disparities that have been slowly described over a number of years. And then try to address all these issues as a country that's becoming increasingly diverse. I know, Dr Boulware, through this broadcast we'll talk about many of the dimensions. One major part is the AANHPI population is not monolithic. We are profoundly heterogeneous. It's a community that is linked to some 100 languages, and 50 ethnicities, and some 19 countries.

About two-thirds of our community is non-U.S. born. About a third have low English proficiency. So there are multiple challenges here and disaggregating the information, being more focused and granular about understanding the diversity of this population, putting a brighter light on disparities in health equity is going to be really critical for the future of this country. As I end my opening comments, I just want to say that as an Asian-American physician, when I was young- much younger- I looked for data on these issues and I couldn't find any. Often the response back to me was, "There is a lack of data". Fortunately over time we're getting more and more information but not enough. And so I'm hoping these issues of data, and research, and dedicated understanding of disparities and health equity strategies for the future will be very, very important for our listeners.

EB: Thank you so much. Dr Cigarroa, could you follow on with why is this an important discussion to have right now with regard to individuals who have been categorized as Latino or Latinx?

Francisco Cigarroa: Absolutely. Again, just as Howard stated, very grateful to be on this panel. As Howard stated, COVID certainly put a spotlight on health care inequalities. And the spotlight actually demonstrates that in fact these issues have existed long before COVID. When I was asked by Phil to write a Viewpoint, I was a bit saddened as I looked at the statistics of medical student and nursing student enrollment. When I was president of the Health Science Center and overlooking the Medical School, you know, we spoke about the importance of diversity. And we saw that essentially Hispanic students in large part only included 6% of medical student matriculates. And 20 years later those statistics have not really improved to any significant degree.

And so when you take a look at the [inaudible] younger population today, those who are 16 years of age or younger, over half of them identify themselves as racial or ethnic minority. And so the changing demographics demand our society to embrace diversity, equity, and inclusiveness really as our responsibility to better navigate their future, as our responsibility to better improve the social determinants of health. And in our responsibility to assure that our nation is not only healthy, but also in regards to our economic success as a nation and our security. So it is absolutely incumbent upon us to significantly improve the issues of diversity, equality, inclusiveness in every aspect of our lives in our nation.

EB: Thank you. Dr Satcher, following with you, why is this important to have a discussion about this for individuals who have been categorized as African-American or Black?

David Satcher: Well, I thank you for allowing me to participate in this outstanding panel. Something tells me I'm a little older than the rest of you. But anyway, I grew up in Anniston, Alabama, during a time of really strict segregation. I recently wrote about an initial experience that I had when I had saved money to go buy an ice cream cone and only to discover that in that particular case they didn't sell ice cream to African-Americans. So we've come a long way from there, of course. I also was a student at Morehouse in Atlanta during the time of the student movements so I became quite involved in the student movement, rose to a leadership role in that movement, went to jail. I went to prison. And so medicine for me has been very important and I've tried to respond to the challenges of race and racial inequity in health care throughout my career.

Let me just say that I think we've come a long ways in a lot of ways in terms of medicine and medical practice, and yet we still face significant challenges. And when I wrote the article 50 years ago about race and the doctor-patient relationship, it was a different time but some of the same problems still exist. Clearly we've made some progress, and yet we still have a long ways to go in terms of dealing with these issues. We talk a lot about the disparities and I think it was in 2000 when I was responsible for providing leadership for releasing Healthy People 2010 and there were only two goals in Healthy People 2010. One was to improve the quality of life for people as they age. And the second one was to eliminate disparities in health.

And so there has been sort of a continuing struggle in the area and that struggle continues today as we deal with COVID-19. And I've been asked why it is that there are disparities in COVID-19 and how it impacts different populations. There's an interesting correlation between disparities in health and predisposition for COVID-19. In other words, if there are disparities in heart disease, hypertension, diabetes, et cetera, those same disparities predispose individuals and groups to COVID-19. And that's what we've seen I think in this pandemic, differences in predispositions to COVID-19 that correlate with disparities in health.

EB: Thank you so much. I think you each brought out why this is such an important dialogue to have right now. As I read through all of your pieces, I feel that there's several common threads. And I want to start off with the common thread of historically marginalized groups of individuals being invisible with respect to their health experiences and their health care. And each of you provide an historical context to that in your pieces. And I want to ask you each, starting with Dr Satcher, how have societal or structural racism -- and by that I mean the policies and practices that occur at the societal level to contribute to this -- how have they played a role in generating that invisibility of these historically marginalized groups of individuals? Dr Satcher?

DS: Well, I'm not so sure that I would agree about the invisibility. But let me just say that in the case of African-Americans there's a long history here, I mean like 400 years. And so that history sort of has moved to different stages of our relationships, from slavery to segregation. I grew up in a period of strict segregation in the South and I grew up in Alabama, one of the most segregated places at the time. And I think the transition for me, of course, was college. It was Morehouse and the Atlanta University Center. It was the student movement and the opportunity for the first time really to sort of fight back and to confront racism I guess I would say. So the idea of confronting racism is something that I didn't experience in Alabama as much as I experienced when I became a student at Morehouse College in Atlanta.

So I think I've tried to continue that tendency to confront racism as opposed to just experience it. And the whole issue of race and the doctor-patient relationship was my attempt to confront not just racism, but how race impacts the doctor-patient relationship.

EB: Thanks. And when I say "invisible", it's sort of how does it show up in that doctor-patient relationship? Traditionally has it shown up for Black individuals in the context of us thinking about our connections with our patients, and your thoughts?

DS: I think when I wrote the article in 1973, I tried to describe how race impacted the doctor-patient relationship. I can just give you some examples. My first patient -- and this was in Cleveland at Case Western -- my first patient happened to be from Mississippi and I did like every other diligent student, I did a thorough workup. And the next day, of course, this patient checked out of the hospital. He was from Mississippi and the idea of having a Black doctor didn't set well with him. But it was not new to me. I should say that. I- being from the South prepared me for those kinds of experiences. And I can tell the story later on, of course, that patient's family contacted me and when I was Surgeon General and said that he wanted me to know how proud he was of me for being Surgeon General. And his daughter wanted to know if I could forgive him for what he did. And I told her that I forgave him a long time ago because, you know, as a physician, I think my responsibility is to understand the shortcomings of patients, whether it's in their health or their attitudes, and to try to deal with it.

EB: Wow. Very powerful. Thank you. Dr Koh, how would you place this concept of invisibility with regard to the AANHPI community, or communities?

HK: Well, thank you and maybe I should start by saying I had the great honor of succeeding Dr Satcher as Assistant Secretary for Health in 2009 through 2014. And I also had the honor of unveiling Healthy People of 2020. And now there's a Healthy People 2030, of course. So with each successive iteration of Healthy People there's more attention to diversity, to health equity, to social determinants of health so that makes these issues more and more visible. But for the AANHPI community, usually you don't hear much about our communities' issues regarding health or having anything to do with daily societal life in the U.S. until years like last year. You all know, for example, that the most dramatic example of these hate incidents was the shooting of eight people in Atlanta in March of this year which included six women of Asian descent.

And then in tracking these hate crimes, which is done through some of my great colleagues in California, there has been explicit documentation of xenophobic slurs that are uttered through these assaults that are verbal or physical. So when an American of Asian descent is hearing slurs like, "You brought the virus here," and, "Go back to where you came from", what do you do if where you are from is the United States of America? And I'm a son of a very proud Korean-American family so these are issues I've thought about every day of my life, but most times in the professional setting we don't get to talk about it too much. So through this crisis there is an opportunity for the AANHPI community because our numbers are growing. We are contributing more to the American social and political scene on a daily basis. So I think the more education we do about the heterogeneity of our group right now is very, very important.

And this spills into health care, of course. Some 20% of U.S. physicians are of AANHPI background and they are not exempt from the discrimination and hatred that's going on right now. There was a very well publicized incident of an Asian-American medical student in New York who was going to the hospital and work and was subjected to physical assaults and so she's mobilized that community in a very powerful way there. She is somebody that we admire very, very much. If I can say also within the health care community I think there's an opportunity for every health care professional, physician, nurse, or otherwise, to just examine their own biases toward patients of Asian-American, Native Hawaiian, and Pacific Islander background. I say in our Viewpoint, which I had the pleasure of co-authoring with Juliet Choi and Jeff Caballero, that if we do nothing else, clinicians should try to identify their own biases and assumptions about any patient of Asian-American, Native Hawaiian, Pacific Islander background.

Don't assume their ethnicity, their birthplace, their first language, their culture, their spouse, their sexual orientation, or world view. Don't assume anything, just ask and listen. That's what true patient centered care is all about. And if I have a little more time, I can say that on a national scene we're seeing some leadership from the President of addressing Asian-American hate and activating his White House initiative on the Asian-Americans and Pacific Islanders. We try to do this in a more integrated function nationwide.

EB: Thank you. Dr Cigarroa, can you comment about the visibility or lack thereof of these inequities with regard to the Hispanic, Latino, Latinx community?

FC: Well, as I did the research on the Viewpoint in regards to national media related to COVID, only 2% of all national media related to Hispanics and their risks of developing COVID. So even from a social media perspective pretty anemic. I actually had a difficult time whether selecting invisibility or lack of presence as an emphasis point in the Viewpoint. And at the end of the day I decided to focus on lack of presence because there have been so many of our ancestors and individuals who have been quite visible and have been, you know, advancing the cause. But you also spoke about structural issues that result in a lack of presence or invisibility, not only for Hispanics, but for other under-represented minorities. And a couple of structural issues come to mind that actually impact all of us today. For example, you have a first generation student, often who are under-represented minorities in college, and perhaps they're interested in pursuing a field in medicine or science.

And a lot of times that requires summer programs. And many summer programs these days aren't paying for a variety of reasons. And so an individual who actually has to work during the summer to support themselves in college the following year are sometimes left out of these very important summer programs that could actually be advantageous in the acceptance process in medical school. And the second issue is are admissions committees really taking a look at students in a holistic way? And what have they actually accomplished in the three years prior to their application versus strictly an MCAT score? And so admission committees really need to take a look at an individual in a holistic way. If that hadn't been the case for me, I would not have gotten into medical school. The third issue is tenure policies are changing. You know, less and less medical schools are actually implementing tenure and so this also results in a sense of disparities among under-represented minorities.

And so I did mention in the article about how important it is to actually hold boards of trustees and regents also accountable to make certain that their leaders of their academic health centers understand the importance of diversity, inclusiveness, and equality. So, again, when I was being considered for President of the UT Health Science Center in San Antonio, the first search committee that came about actually did not have a single member or candidate who was either a woman or an individual of under-represented minority background. And there was a single regent who stepped up and stated, "This is unacceptable". And leaders at the time told the regent there aren't any qualified candidates who were of under-represented minority. Well that one regent didn't find that argument acceptable and actually challenged the system to identify somebody who was also under-represented background to be at least interviewed.

Well, if it wasn't for that one regent who actually called the call, I would actually not be having this conversation with you today. So it's so important for governing boards to hold their leadership accountable if we're really going to solve this problem.

EB: Thank you for that. It actually leads right into a discussion I wanted to pull you into with Dr Satcher in particular around the lack of diversity in our workforce. And in the light of what's happening with the COVID-19 pandemic, with the health inequities, the profound health inequities that we're seeing, start with Dr Satcher. Can you talk about why it's important that we have a diverse health care workforce and how that impacts the patient-physician relationship? And then ask you the same, Dr Cigarroa, just to pull that in your comments. So, Dr Satcher, can you talk about that in light of what's currently happening COVID-19, why is it important that we have a more diverse health care workforce?

DS: Well, I think there are a few reasons. I could start with medical school and say that I think physicians in training need to have interaction with a diverse student body. That's the first thing because I think by interacting with a diverse group of people, I know my experience was that way, you're educating each other. And you don't see patients as just patients, but as human beings like your classmate or what have you. And so that's an important point, I think, to make is that the diversity that we experience cannot just be doctor-patient. It has to be also doctor-doctor. And I've gained a lot from that kind of interaction. For example, getting to know a person like Howard Koh, it makes a difference in terms of how you approach life and how you approach patients. And so I think diversity is important. But also I think in terms of understanding something like COVID-19 and asking the question why is there such diversity in the experience with this virus and outcome?

And in great part because there's diversity in health and diversity in terms of what we call disparities in health. And understanding that disparity helps us to understand a disease like COVID-19, or even violence as far as that goes I was -- . Howard's discussion of the violence that took place here in Atlanta, you know, in terms of the murders, just so dramatic and just sort of paints the picture of what we're struggling with as a nation, and especially in a place like Atlanta. We've got to stay on this problem. We can't just read about it. We've got to see our role in it. And I think the doctor-patient relationship has to reflect our understanding and our caring. Here at the Satcher Leadership Institute, we say that there are four components of leadership that are critical. One is, you know, you have to care enough to really provide the kind of leadership that's needed. Secondly, you need to know enough. Thirdly, you need to have the courage to do enough. And I think those of us in medicine, we have something to do and we have to have the courage to do that. And finally, we must persevere until the job is done.

EB: Thank you so much. Dr Cigarroa, would you like to add to that about the importance of a diverse workforce when it comes to, and particularly times like this COVID-19 where we're seeing such profound health disparities and health inequities?

FC: Well, it's critically important, Dr Boulware. First of all, I believe that having the medical school classes reflect only 6% Hispanic enrollees and 4% Black enrollees is clearly unacceptable. And that needs to change. The second thing is that, as Dr Satcher stated, having a diverse medical student body and health care workforce, you know, beyond physicians, you know, really provides a trust factor for many patients, especially in that patient-physician relationship. Understanding backgrounds of under-represented minorities actually allows you to have a better handle on improving social determinants of health. And social determinants of health often predict, you know, whether patients have access to health care and at least understanding what the challenges are, you know, for those patients.

For example, we also have, as we stated, unconscious biases. A clear example would be, and this has been written about, that under-represented minorities are less likely to be a living donor for a patient in need of a transplant. Well, I believe that at the Health Science Center at San Antonio, we've disproven that. Our patient population is over 75% Hispanic and yet we have one of the largest living donor liver transplant programs of which the large majority are Hispanic living donors. And I believe that's been made possible by really helping address some of the challenges that our community has which is really focus on social determinants of health, really providing better financial support for somebody who wants to be a living donor, providing better access to the transplant center. And so if you don't have health care providers really understanding the challenges that various populations have, it's pretty hard to actually advance important aspects in medicine.

And so for all those reasons, I really believe diversity is critically important to preserve the health and wellbeing of our nation.

EB: Thanks so much. Dr Koh, I'd like to turn to you and you specifically in your piece talk about the importance of asking patients about discrimination, social isolation, or things like financial hardships as a way that physicians and other health care professionals can signal their support. This, again, seems to speak to the quality of the care that we deliver and the patient-physician relationship. I'd like to ask you what do you think our current state of cultural competency is with care and what needs to be done to improve it with this regard?

HK: Thank you, Dr Boulware, that's a great question so here's where I think the invisible theme unfortunately arises. If you're a clinician and you have a patient who is Asian-American, Native Hawaiian, Pacific Islander background, that's something you sort of note but don't really address. And at a time like this, can I assure you every member of our community is thinking about these issues and hoping that we can get beyond it and get to a better place in the context of COVID. So if a clinician simply asks about discrimination and acknowledges that might be complicating that person's quality of life and health right now, that's a big signal and that could take literally under a minute and be a starter for conversation, and would really signal a sense of commitment to the patient from the clinician that he or she cares about them as a unique individual. We talk about this term patient-centered care all the time, and I think for patients of Asian-American, Native Hawaiian, Pacific Islander background that's one way to start that conversation.

In our piece we mentioned that the AANHPI community is sometimes included in diversity and equity inclusions efforts in hospitals and medical centers, but sometimes not. People often point out that we are well represented among not just doctors, but nurses, but the leadership in our community, in the medical centers is actually still quite low. And so clinicians hopefully can have more visible leaders that look like them. Patients can have more clinicians that look like them and understand them. And I think all of us, regardless of our background, can recognize how profoundly heterogeneous the AANHPI community is, commit to overcoming implicit biases and giving everybody true patient-centered care.

EB: Thank you. Couple of last questions I have for the group. First, I'd like to ask Dr Satcher, you write very powerfully about how current political, legislative, regulatory, and legal systems feel and perpetuate the health inequities that we're seeing. Could you elaborate on that a little bit and then help us consider how, as physicians and health care professionals, we might act as agents to begin to change these systems.

DS: Well, my colleague, Daniel Dawes, recently published a book on the political determinants of health. And I guess about ten years earlier I was a part of a group that wrote a report on the social determinants of health. But what is very clear is that health outcomes are not just dependent on medical care. They are dependent on the political environment. They are dependent upon social environment and when one is born, the extent to which one is poor and where one might be on this social level. But by the same token, as John Lewis often pointed out, politics in many ways impact upon how we relate to each other and therefore how we treat each other. And that includes health care. That includes health outcomes and to what extent are we managing the factors that determine whether or not we're healthy.

And this is something that we've got to continue to work on in terms of health outcomes. And it's not just COVID-19, but all health outcomes. The life expectancy for African-Americans is expected to decrease by 3.3 years, for Hispanics by more than 3.6 years. These outcomes are obviously related to the pandemic but they're also related to our general socioeconomic status and interactions.

EB: So in light of that and those comments, I'd like to ask each of the three of you to just tell us what do you think some of the most important steps for us to move forward as a field in medicine are. How are we going to ensure that the current and next generations of physicians and other health care professionals are operating in a different way, and how will we know that we've made a difference? So I'll start off with you, Dr Cigarroa, any thoughts on that?

FC: Yes. Well, I think it's first important for leaders in every sector of society to understand the lack of presence of very important individuals reflecting our under-represented minorities in this nation. And so it does behoove us for our academic health centers to really become more innovative and more progressive in enhancing the diversity of their classes. It behooves us to definitely identify talented individuals of under-represented backgrounds to lead our hospital systems and our academic health centers. They are out there and they need to be given the chance. I believe that even in corporate America, to look at the Fortune 500 companies and to see that less than 4% of their trustee, independent director positions are those under-represented minorities. How can we actually address important economic decisions that would actually improve our nation? How can we actually make certain that pharma is addressing important health care issues that affect under-represented minorities? How can we actually be in positions of leadership to actually tilt social determinants of health to a better place? And so there's still a lot of work to be done but we can't just say this is for others to solve. We need to solve it beginning now.

EB: Thank you. Dr Koh, any thoughts, final thoughts?

 

HK: Sure. First of all, Dr Boulware, thank you again for moderating this wonderful panel. You know, I want to conclude by saying as challenging as these inequities are, we can make progress if we work together. And I have some experience in that that I'm so proud to share. When I was Assistant Secretary starting in 2009, not only did I serve through the last pandemic, the H1N1 pandemic, and we tried to guide the nation through that, but then, of course, the following year the Affordable Care Act was passed in 2010 and so much activity in that regard ever since. One major advance through the ACA, through something called Section 4302, was the requirement that all federally funded health surveys of self-reported information collect disaggregated, granular data for Asian-Americans that includes Chinese, Indian, Filipino, Vietnamese, Korean, and Japanese, and Pacific Islanders. That includes Native Hawaiian, Guamanian, Samoan, and others. So that was progress.

And since then we're seeing much more dedicated research in this area that identifies specific disparities affecting subgroups and then trying to address them. So one major example I have that I'm so proud to share is that our administration worked so hard on establishing the Affordable Care Act under Secretary Sebelius and President Obama, and trying to advance health insurance coverage issues, and disparities are part of that discussion, of course. I worked hard on that in DC. And I'll never forget a couple of years ago when I came back to Harvard my graduate student came to me and we had done a quick literature review and said, "Dr Koh, there's never been an analysis of health insurance coverage disparities affecting Asian-Americans, Native Hawaiians, and Pacific Islanders". And I said, "What? Can that be true?" And so we double-checked and yet again this was an example of how our community was overlooked. So we embarked on that and subsequently we published in JAMA Internal Medicine the first analysis showing that the health insurance coverage gap between Asian-Americans, Native Hawaiians, and Pacific Islanders and whites essentially disappeared as of 2016.

And that was a reflection, if I can say, of incredible national cooperation with advocates, with community based organizations. We saw a rise in health insurance coverage for our community overall but also with respect for the many subgroups. So this can be done. There were lots of advocates doing outreach in multiple languages and respecting different cultures. So if we can recognize that is just one example of how we can address the health equity challenges of our increasingly diverse nation, that would be one I think we should look at as a great example as we move forward. Maybe my final comment here is we also admire Reverend Martin Luther King, you know, he is somebody who has inspired me through my career. And he used to say that he wanted all people to enjoy what he called "the sunlight of opportunity". I love that phrase. Some of us have that privilege and others don't. And then he also said, and I quote, "We may have all come over on different ships, but we're in the same boat now," unquote.

I mention that saying of his often. I think that's where we are right now in our country.

DS: Yes.

EB: Thank you. Dr Satcher?

DS: Well, first let me agree with Howard that I think that's a very important point in terms of where we are now and how we move forward together. And I think we probably need to have more discussions like this across racial and ethnic boundaries to really appreciate both the challenges and the opportunities that we face. The Affordable Care Act, I just want to add how important it was also to access to mental health care. In a lot of states it dramatically improved the access to mental health care. There are still some states, of course, who have not responded to that tremendous opportunity. But we're making great progress there and the Affordable Care Act has had a lot to do with that.

FC: Ebony, Francisco. If I could just follow up on what David Satcher stated regarding mental health. That's another really important aspect of providing culturally competent health care. And having a diverse health care workforce also helps us better address in many of the mental health issues that our population is facing.

DS: Yes.

EB: Thank you. Well, I'd just like to close this session by thanking each of you for your roles as national leaders in this area to really advance the purpose of improving health equity, and also for this wonderful discussion where you've provided wonderful insights and pointed us in the right direction for the future. Thanks so much.

FC: You've been an outstanding moderator.

HK: Wonderful job. Thank you.

EB: Thank you.

DS: Agreed

PF: Thanks to all of you, Dr Satcher, Dr Koh, and Dr Cigarroa for sharing your powerful comments and compelling perspectives about these critically important issues affecting medicine and society. And thanks to Dr Boulware for serving as moderator and so expertly facilitating this wonderful discussion. This episode was co-produced by Jesse McQuarters and Lisa Hardin. The audio team at JAMA includes Daniel Morrow and Shelly Steffens. Dr Michael Berkwits is the Deputy Editor for Electronic Media. I'm Dr Phil Fontanarosa, Interim Editor-in-Chief of JAMA and the JAMA Network. For more podcasts, please visit JAMAnetworkaudio.com. Thank you all for listening.

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