So, on behalf of the Program Planning Committee, I am thrilled you are joining us for today's plenary session. Dr. Camara Phyllis Jones is the 2019-2020 Evelyn Green Davis Fellow at the Radcliffe Institute for Advanced Study at Harvard University and a past president of the American Public Health Association. She is a family physician and epidemiologist whose work focuses on naming, measuring, and addressing the impacts of racism on the health and well-being of the nation. She seeks to broaden the national health debate to include not only universal access to high-quality health care, but also attention to the social determinants of health and the social determinants of equity. Dr. Jones was an assistant professor at the Harvard School of Public Health before being recruited to the Centers for Disease Control and Prevention, where she served as medical officer and research director on social determinants of health and equity. Most recently, she was a senior fellow at the Satcher Health Leadership Institute and the Cardiovascular Research Institute at the Morehouse School of Medicine. Dr. Jones has been elected to serve on many professional boards and is actively sought as a contributor to national efforts to eliminate health disparities and to achieve health equity. This includes her current role as ACGME's Collaborative Addressing Health Care Disparities. Highly valued as a mentor and teacher, she is also an adjunct professor at the Rollins School of Public Health at Emory University and an adjunct associate professor at the Morehouse School of Medicine. Please join me in welcoming today's plenary speaker, Dr. Kamara Jones. Well, good morning, everyone, and happy physiatry day. Yeah, you guys look good in your green. So I am delighted to have been invited to address you and share some of the tools that I've developed when I was president of the American Public Health Association and launched our association three years ago on a national campaign against racism that had three goals or three tasks. The first is to name racism because we're in a setting where many people are in denial that racism continues to exist or have any impact, much less profound impact, on the health and well-being of the nation. So the first of our three tasks in this campaign that I rolled out for my association was to name racism, to say the whole word. But even as we get people convinced that, yes, racism exists, we then need to move to ask how is racism operating here if we want to understand how to intervene and set things right. And finally, when we understand the lovers, the mechanisms on which we need to intervene, we need to organize and strategize to act. So as president of the American Public Health Association, I traveled all around the country, red states, blue states, purple states, all of that sharing this mission and helping people, equipping people to engage in a national campaign against racism by sharing allegories, cartoon animations and the like to invite people into the conversation and the work. So in the bit of time that we have today, I'm going to share with you some of those communication tools. The first, which I call my cliff analogy, helps us to understand why am I at an annual convening of physiatrists talking about racism, right? People be like, oh, that's not in my sphere. That's not what I do. So this cliff analogy helps us understand different levels of health intervention and squarely places being anti-racist and being anti-ableist and being anti-all of these systems of structure and equity clearly in the role of medical providers. So let's go. Somebody just fell off of the cliff of good health. And if that were you or somebody in your family, you would be delighted to find an ambulance there at the bottom of the cliff to speed them on to care. But if we were concerned about other people who are coming along that cliff face, so if we were concerned about population health, community health, public health, we might well ask ourselves, what else could we put in place as a health intervention besides just stationing lots of ambulances at the bottom of the cliff? So somebody in the room is going to say, I know, I know. Let's put a net halfway down. That way, even if people fall, we can catch them before they get crunched up at the bottom. And that is, of course, an excellent idea. Although the more you think about it, nets do have holes. So some people might fall through the cracks. But never mind that. Let's make that a trampoline halfway down the cliff. No holes in a trampoline. But even if we have a trampoline halfway down that cliff, we might well find ourselves with lots of people just bouncing up and down at half functionality, not really able to get back to the top of the cliff. So what else could we put in place as a health intervention? Well, clearly, we need to be thinking about a fence at the edge of the cliff to keep people from falling in the first place. But even that fence has to be a very, very strong fence if there's a lot of population pressure against it. So what else could we do as a health intervention? Well, we need to think about moving the population away from the edge of the cliff. So let me label these interventions that I've depicted so far. With the ambulance at the bottom of the cliff represents acute medical care and what we on the public health side of things describe as tertiary prevention. Because I'm a family physician and a Ph.D. epidemiologist, right? So I straddle the clinical side and the public health side. So this ambulance represents acute medical care and tertiary prevention, which, as you all know, is preventing complications from diseases or conditions that have already manifest. I often say it's like preventing amputation from diabetes, but in the physiatry setting, it's preventing long-term lack of, you know, regaining abilities and the like after a stroke or an accident or the like. That net or trampoline halfway down represents our safety net programs, often in our social services as well as secondary prevention, which is early detection, screening programs. The fence represents primary prevention, keeping bad things from happening in the first place at the individual level. And moving the population away from the edge of the cliff is about addressing what many people describe now as the social determinants of health. Those determinants of health and illness that are outside of the individual, that are beyond our individual genes and beyond our individual behaviors. These are the context of our lives, which include individual context, like individual education or occupation or income or wealth. So addressing poverty, for example, is a very important way of moving the population away from the edge of the cliff. They also include neighborhood context. So whether or not you can, you know, get fresh fruits and vegetables in your neighborhood or do you instead live in what some people call a food desert or a fast food swamp. Whether or not there are, even in your neighborhood, are there sidewalks at all? Are there ramps? You know, are there, can you exercise? Can you walk in your neighborhood safely? What is the relationship of police officers to people walking in your neighborhood? What is the quality of the housing in your neighborhood? Are there jobs there? And even if there isn't a job right there, is there transportation to a job? So all of these addressing adverse neighborhood conditions is another way of moving the population away from the edge of the cliff. Of course, environmental hazards and the like, and even opportunity structures, that's all part of these social determinants of health. So if I were to take an outcome, and I would love you guys' help in terms of outcomes within the, you know, physical medicine rehabilitation, you know, the physiatry sphere, I actually was going to take some of your, you know, healthy people 2020 objectives and display them along the cliff. I haven't done that yet, but I will. The reason I haven't done that is I'm just getting back from five days in Kigali, Rwanda, so I'm just like in a, but anyway, but even when I look at something like infant mortality as an outcome, for us to understand what the ambulance would look like, what the net would look like, what the fence, what moving the population would look like, well, with infant mortality, you know, trying to address our babies dying before their first birthday, the ambulance would be our neonatal intensive care units. The net or trampoline would be prenatal care, which is actually, you know, secondary prevention screening pregnant women. The fence might be excellent maternal nutrition, so our women, infants, and children programs. Moving the population away from the edge of the cliff might be excellent educational opportunities so that young girls don't feel that having a baby is their only option or a living wage. So we can see that in many different settings, this might be a useful diagram to help understand that yes, we need some of all of this, but we need to be aware of the other levels, but as useful as this diagram is, even for having a community conversation, going into community, how should we be spending our health resources? How much in ambulances, net fences are moving the population? As useful as the diagram is in many levels, as I've presented it so far, it has a huge fatal flaw, and the huge fatal flaw is that it does not yet equip us to talk about how health disparities arise. So I want you to keep this cliff analogy in the back of your mind for a minute while we shift to addressing how health disparities arise on three levels. And health disparities arise along many axes, race, ethnicity, gender, ability, status, all of that. But especially when we talk about racial ethnic health disparities, which have a very long history in our nation, we unfortunately have lots and lots of evidence about differences in the quality of care received within the healthcare system by race. So when the Institute of Medicine in 2002, which is now already 17 years ago, and now the name is changed to the National Academy of Medicine, but when that group pulled together what were then hundreds of studies documenting differences by race or ethnicity, for example, in how vigorously your chest pain was investigated or treated, even if you found yourself in the same healthcare system or with the same insurance coverage, everybody in the VA system or everybody covered by Medicare or Medicaid, differences in how vigorously your chest pain would be investigated or treated by race, or differences in how much pain medication you might get walking into an emergency department with a long bone fracture by ethnicity. They pulled together what were then hundreds of studies documenting these differences in the quality of healthcare received within the same system. If we were to do the same thing now, we'd be pulling together thousands of studies documenting these differences. But that panel said, we understand, yes, these differences occur, but that's not the end all and be all of how health disparities by race and ethnicity arise, because we're looking at people in the healthcare system. There's some people who can't even access the healthcare system. So that's a second level at which health disparities arise, differential access to care. But then I'm hoping that everybody in this room recognizes that health is not created within the health sector. So there's a third level at which health disparities arise, which are differences in the conditions of our lives, differences in our life opportunities, exposures, stresses, which are making some individuals and communities sicker than others in the first place. And if you think about these three levels at which health disparities arise, differences in quality of care, differences in access to care, differences in underlying exposures and opportunities, we could represent that, couldn't we, as a pyramid perhaps? Or better yet, we should understand it as an iceberg, where the huge hidden base are the differences in the conditions of our lives. And then very often, the people who've been made sicker are frustrated by limited access to the healthcare system. And then unfortunately, even the lucky ones who get into the healthcare system are sometimes further injured because of differences in quality of care. So remembering these three levels at which health disparities arise, we're going to go back to the cliff. But now we're going to recognize that we're really not dealing with a flat two-dimensional cliff, but actually we are dealing with a three-dimensional cliff. And at some parts of the cliff, there's an ambulance there, but maybe that ambulance has a flat tire. So it's slow or goes off in the wrong direction. Or maybe there's no ambulance there at all, and maybe there's no net nor fence. And usually at those parts of the cliff, the population is being pushed closer to the edge. So let me label these observations about the three-dimensional cliff with how health disparities arise, where the differences in quality of care are represented when there's an ambulance there, but it has a flat tire, so it's slow or goes off in the wrong direction. Differences in access to care are no ambulance, no net, no fence. And differences in underlying exposures and opportunities are represented by the closer proximity of that greeny population to the edge. So now that we recognize that we're really dealing with a three-dimensional cliff, there's a whole new set of questions that arise. The first question, of course, is how did the cliff become three-dimensional in the first place? And that's usually because of historical injustices that are perpetuated by present-day contemporary structural factors. But given that the cliff is three-dimensional, we also need to ask why are there differences in how resources are distributed at different parts of the cliff, and why are there differences in who's found at different parts of the cliff? Why are the orangies back here in a way and the greenies being pushed closer to the edge? And when we start asking and addressing those kinds of questions, we're now doing something that differs from addressing the social determinants of health, which I described as moving the population away from the edge of the cliff. Now we're addressing what I describe as the social determinants of equity, which includes systems of power that can differentially distribute resources and populations, where these systems of power include racism, sexism, heterosexism, ableism, economic systems like capitalism and the like. So with this cliff, I've actually distilled, if you will, three different dimensions of health intervention, where if you, you know, remember your junior high or high school geometry, one dimension is a line, two dimensions is a flat plane, three dimensions is space. Well, along the line at the edge of the cliff is where we can display all of our curative and preventive health services, that ambulance net fence right there. In fact, anytime we say the word health in this country, people usually complete that thought for us and go immediately to health care or health services. Even our descriptions and discussions about the Affordable Care Act and, you know, trying to get to universal access to high quality health care for all, which is an important goal, right? But that's still an edge of the cliff conversation. Now we need to join the rest of the, most of the world in having universal access to high quality health care, and the reason we need to do that is because that's how a civilized society values all of its people equally, right? But even when we get there, we can overwhelm any system if everybody's pushed up against the edge. So we must move into that second dimension, which we can display in a flat plane. We need to be addressing the social determinants of health. We need to be moving the population away from the edge of the cliff, addressing poverty, adverse neighborhood conditions and the like, if we want to have large and sustained improvements in health outcomes. But the trick there is if you're about moving the population away from the edge of the cliff, but you don't recognize that we're really dealing with a three-dimensional cliff, then we are at risk of moving some of the population, but not all of the population, and actually making health disparities worse. So we need to acknowledge and address the three-dimensionality of the cliff. We need to be addressing these social determinants of equity or inequity, including racism, sexism, heterosexism, ableism, capitalism and the like, if we want to achieve social justice and eliminate health disparities. Now if this were not such a big room, right, and if we weren't so scattered and if we had mics set up, I would stop right about now to get your reactions or, you know, enhancements or adding to this cliff analogy. But we don't, we're not set up for that right now. So what I thought I would do is share with you three questions that have arisen in previous tellings of this story. The first question is, if this is indeed a useful way of understanding levels of health intervention, and if we agree that an ounce of prevention is worth a pound of cure, why are we as a nation spending so much money on ambulances at the bottom of the cliff? And there are many, many levels of answer for that. The first, maybe the most glib answer is that there is a lot of money being made on ambulances at the bottom of the cliff by health services, health care providers, pharmaceutical companies, medical device companies and the like. But I think, I mean, we could also talk about sometimes it's hard to demonstrate how many accidents your fence prevented or how many cases of measles your vaccine prevented and the like. So sometimes it's hard to make the case for prevention, although it really shouldn't be. But I really think that at its core, we're spending so much money on ambulances at the bottom of the cliff because we as a nation are so narrowly focused on the individual that we don't even recognize that there's been a health problem until somebody's fallen off the edge of the cliff. We do not recognize the proximity of a population to the edge as a health problem, right? We don't even routinely use our aggregate measures of health and well-being, which could include income inequality or social cohesion, lots of aggregate measures that we could use or develop. We don't use those as health measures. So we're busy collecting and counting folks in our nets or scraping them up off the ground and running them in our ambulances. So the second question is sometimes put this way. Why are the greenies launching themselves over the edge of the cliff? That is sometimes asked when people say, well, why do those people do that? Why are those people eating so much fried chicken? Or why aren't those people reading to their kids? Or why are those people not wearing their seatbelts? Or why are these people, you know, like about behaviors of those people? Sometimes it's a blame the victim type of thing. That question also comes from our very narrow focus on the individual, right, in this nation, which makes the systems and structures that are pushing the population closer to the edge either invisible or seem to be irrelevant, right? But that question also, so I'm actually going to be illustrating three kind of cultural barriers to achieving health equity with these three questions I'm raising. So the first cultural barrier is this narrow focus on the individual, right? Which means that health is individual, and it also means that systems and structures are invisible or irrelevant. But a second huge barrier to achieving health equity is that we as a nation are ahistorical. We act as if the present were disconnected from the past, and as if the current distribution of advantage and disadvantage were just a happenstance, right? And so then we're blaming the greenies for their position at the edge. But here's a third question that people don't usually say out loud. This situation looks fine to me. What's the problem with the three-dimensional cliff? People don't usually say that out loud, but many of us acted in our day-to-day lives when we might leave a lovely home in a lovely neighborhood, drive through a stigmatized, disinvested, kind of oppressed community, get to our safe job, and not feel a strong sense of urgency to do something about the conditions in that neighborhood through which we just drove, right? And this question actually reflects a third barrier to achieving health equity, which is our endorsement as a nation of the myth of meritocracy, the story that goes something like this. If you work hard, you will make it. Now, I give you that most people who have made it have worked hard, right? Although not everybody who's made it has worked hard. We have very prominent examples of that right now. But most people who have made it have worked hard, but there are many, many other people working just as hard or harder who will never make it because of an uneven playing field which has been structured and maintained by these systems of structured inequity, right? So when we say to the greenies, why don't they just take a step back, right, and blame them for their position closer to the edge, we don't even recognize that perhaps it's more slippery at the edge, and every step that they try to take back is much harder than the step that an orangy tries to take back. We say, well, why don't they build themselves some fences and nets and ambulances without recognizing that perhaps they built all of the fences and nets and ambulances and then things were taken from them or they were pushed down the edge. So I am not going to delay there. I just want to say that the usefulness of this cliff analogy, I'm sure that each one of you has something that you could use to expand upon with this. It's a living image, so I welcome it. Every time I do a talk, somebody adds something to it. But I also want to say that wherever you as an individual, wherever your day job is on this cliff, what this is to say is that all of these interventions are legitimate health interventions. I think we need excellent ambulance drivers, right, we need that, we need strong nets, we need strong fences, but wherever you're working as your day job, even if you're trying to be the best ambulance driver that there is, and that's where most clinicians are, right, you need to wonder, is there a net above me and how strong is that net? Is there a fence at the edge of this cliff? How strong is the fence? How close is the population to the edge? At what part of the cliff am I operating? And even do I act the same way when I'm working at different parts of the cliff, right? So, and wherever your day job is, we need to understand the importance of all of this, but all of us outside of our day jobs, as global citizens, I would suggest, I would strongly urge, need to be concerned about recognizing and addressing the three-dimensionality of the cliff. So that's the citizen job. That's the citizen job of valuing all individuals and populations equally, recognizing and rectifying historical injustices and providing resources according to need, which is how we address the three-dimensionality of the cliff. So I'm going to carry on. I also need to just say, though, sometimes when I'm speaking to a lay audience, I don't go through all of this that I just went through. I just stop with the cliff and I say, I've said the word racism two or three times. Nobody fell out of their chair, so let's go. So now, this is where we are in the talk. Let's go. We're going to start talking about racism. But even so, I'm not going to define racism for you yet without first telling you another story. This is one of my allegories that's based on my own real-life experience. I call it dual reality, a restaurant saga. And if I only have five minutes to talk to a group about racism, this is the story I tell to help people understand that, yes, racism does exist, even if you have never had to acknowledge that in your personal or professional life. The story is based on my experience as a medical student. I was very studious as a medical student. So one Saturday, I was with some friends in my apartment and we were studying for something and we were studying long and hard and it got late and we got hungry and I had no food in the apartment, which was typical. But my friends knew, so they were like, okay, nevermind, Kamara, let's go into the town and try to find something to eat. So we do. We go into town and we find a restaurant and we walk in and we sit down and the menus are presented and we order our food and the food is served. And here we are, eating. And you're like, really, Dr. Joes? That's supposed to tell me something about racism? No, not yet, okay? Most of us in this room have had this kind of experience. But as I sat there eating with my friends, I looked across the room and I noticed a sign and that sign was a startling revelation to me about racism. So now I've intrigued some of you and you're like, okay, Dr. Joes, what did the sign say? What did the sign say? The sign said open. So now I know I've lost most of you. So let me recap. Here we are, sitting in a restaurant, eating. I look across the room. I see a sign that says open. If I hadn't thought anything more about it, I would have assumed that other hungry people could walk in, sit down, order their food and eat. But because I knew something about the two-sided nature of those signs, I recognize that now, because of the hour, the restaurant was indeed closed. And that other hungry people, just a few feet away from me, but on the other side of the sign, would not be able to come and sit down, order their food and eat. And that's when I understood how racism and other systems of structured inequity structure open-closed signs in our society. That racism structures, if you will, a dual reality. And for those who are inside the restaurant, sitting at the table of opportunity, eating, and they look up and they see a sign that says open, they don't even recognize there's a two-sided sign going on because it's difficult for any of us to recognize a system of inequity that privileges us. It is difficult for men to recognize male privilege and sexism. It is difficult for white Americans to recognize white privilege and racism. It is difficult for all Americans to recognize our American privilege in the global context, except we got a little taste of that with Ebola, did we not? Yet those on the outside are very well aware that there's a two-sided sign going on because it proclaims closed to them, but they can look through the window and see people inside eating. So back inside the restaurant to those who ask, is there really a two-sided sign? Does racism really exist? I say, I know it's hard for you to know when you only see open. In fact, that's part of your privilege, not to have to know, but once you do know, you can choose to act. So it's not a scary thing to name racism. It's actually an empowering thing to name racism. It doesn't even compel you to act, but it does equip you to act so that if you care about those on the other side of the sign, which is an if, but if you do, you could even talk to the restaurant owner who is, after all, inside with you, and you could say, restaurant owner, there are hungry people outside. Why don't you open the restaurant again? Let them come in. You'll make more money and owe the conversations we could have. Or maybe what you do is pass food through the door, or maybe you try to tear down the sign or break the glass, but at least what you won't be doing is sitting back saying, huh, wonder why those people don't just come on in and sit down and eat, because you'll understand something about the two-sided nature of that sign. So I use this to talk about how racism and sexism and ableism and all of these systems of structured inequity structure a dual or multi-reality, and of course, it's not just the sign. It's the door and the lock and all of these things, but I acknowledge, well, I have to just say this. I once had a three-hour conversation with a group of people from Flint, Michigan. I was just gonna start a dinner talk with this story, five minutes. Then I threw out the question, how could people who are born inside the restaurant know something about the two-sided nature of the sign? And actually, we had a three-hour conversation about that because there are many, many ways to know, right? But we're not gonna stay there. I'm going to shift gears now to finally define what I mean when I say the word racism. Are you guys good? Are you with me? Okay, good. Okay, because you're so far and you're a little bit scattered toward the back. You know how people do, right? Anyway. So I can't lock on many eyeballs. But anyway, so defining racism. When I say the word racism, I'm clear that I'm talking about a system. So I'm not talking about an individual character flaw or a personal moral failing or even a psychiatric illness, as some people have suggested, but I'm talking about a system of power. A system of doing what? It's a system of structuring opportunity and of assigning value, of doing two things. On what basis is the opportunity structured and on what basis is the value assigned? It's based on the social interpretation of how one looks, which is what we call race in this country, right? And I'll just take a little sidebar here to say that when you look at me here in San Antonio, I actually don't know, you know, what I clearly am. I know that in Atlanta and in Boston, I'm clearly black. I also know that in some parts of Brazil, you'd look at me and I'd be just as clearly white. I know that in South Africa, you'd look at me and I'd be just as clearly colored. So here I am, same physical appearance, but the social interpretation of my appearance in those various settings would assign me to different racial groups. And furthermore, if I were to stay in any of those settings long enough, then my health outcome would probably take on that of the group to which I've been assigned, even though I'd have the same genes in all of those places. It's not just because I'm a light-complected black woman that that's true. For every single person sitting in this room, there is some other place on earth where your so-called race would be quite different from how you are living it today. So we need to understand that race is not biology. We certainly know that it's not genetic, right? It has biological impacts because of racism, but that race is the social interpretation of how one looks in a race-conscious society, and racism is the system that operates on that so-called race to do things, to structure opportunity and assign value. What are the impacts of this system? Well, when we do think or talk about racism at all, we understand that racism unfairly disadvantages some individuals and communities, right? But it shouldn't take us long to recognize that every unfair disadvantage has its reciprocal unfair advantage, so that racism is also unfairly advantaging other individuals and communities, and that's the whole issue of unearned white privilege that we hardly ever talk about in this country, and we hardly ever talk about it in this country because it makes some people, especially some white people, uncomfortable, and I used to say, you know, I'm not trying to make anybody uncomfortable. If you feel uncomfortable, you know, shake it off. I'm gonna tell you some more stories, but now my stance is actually that if you feel uncomfortable, lean in to the discomfort because I have come to recognize that for all of us, including myself, the edge of our comfort is our growing edge, right? But there's a third impact of racism that many of us miss, and that is how racism saps the strength of our whole society through the waste of human resources. There are many examples of that. I'll just give you two. First of all, the fact that we as a nation are still not vigorously investing in the full, excellent public education of all of our children because the blinders of racism have made some decision makers feel like, oh, well, you know, there's no genius in the barrios or the ghettos or on the reservations. You know, we can get along very well, thank you, without those kids. Of course there's genius in all of our communities, and if we were to only vigorously invest in that genius, we could be doing so much better as a nation or even as a world. We might already be up on Mars farming if that were a good idea, right? Or even wouldn't have to go to Mars. We could be solving the problems in our communities today if we were to invest in all of that genius. Well, those same blinders that make us differentially value one another have also resulted in our complacence as a nation with what I describe as a wholesale warehousing disproportionately of so many black and brown men, especially, and women in our prison system as if that did not separate us from human potential. And if you know folks who are either stuck in the prisons or cycling in and out, because if you come out with a felony conviction, it's hard to get a job. It's hard to get housing. In some states, you can never vote again. So we need to interrupt the disproportionate incarceration. We need to interrupt the cycling in and out. We need to welcome our returning citizens. But as I was saying, if you know anybody who is involved in this system, then you know that there are many geniuses caught up in this system that if there had only been some other way could be contributing quite productively to our society. I actually think that that third impact of racism, how it saps the strength of the whole society is where we need to be spending more of our time and effort talking about that. We need more media stories about that. We need more data collection about that. We need more conversations around our dinner tables about that so we can have more people filled with a sense of urgency to dismantle this system and put in its place a system in which all people can know and develop to their full potentials. Before I leave this slide, there's one more thing I need to say because you heard that I was at the CDC for 14 and a half years. I had a wonderful career at the CDC until toward the end, and that's why there was an end, where I had moved to a different part of CDC and I encountered folks who did not feel that I had been recruited to CDC to bring attention to racism to the nation's lead public health agency. But then I moved to a different part of CDC and it was new. And then the people who were swirling around, they figured racism shouldn't be addressed anywhere at CDC, but if it was gonna be somewhere at CDC, it shouldn't be there. And I had one person who had to clear my presentations, tell me I needed to take that point about unfairly advantages other individuals and communities off of my slide. And the compromise for several months was, well, if I took the word unfairly off of the first two points, then maybe I could keep the reference to unfair to advantage. That was a very important learning experience for me because what it taught me is that in our country, for many, many people, there are two states of being, disadvantaged and normal, right? And the reason that people think that there's disadvantaged and normal is that we as a nation are ahistorical and people do not understand that their so-called normal is built up on a whole mountain of unfair advantage. I'm going to shift gears. I'm going to, in just a minute, generalize that definition of racism to be a definition of any system of structured inequity, including sexism and ableism. But before that, I wanted to give you a sense of how racism or any of these systems of structured inequity can impact health. And to do that, I talk about three levels of racism, institutionalized, which now I would describe as structural racism. The paper on which this work is based was published 19 years ago, so I'm staying with the language of the paper. But when we talk about institutionalized racism, it's what now is referred to as structural racism. Personally mediated racism, which some people refer to as interpersonal. I'll tell you in a minute why I don't use that term. And then internalized racism. So I'm going to briefly define each of these levels of racism because they help us understand how could racism turn into differences in asthma prevalence or differences in stroke rates or mortality and the like. And then I'm going to illustrate them with my gardener's tale allegory. Could people who have heard the gardener's tale before wave their hands wildly so I can sort of see? So just a few. Okay, so for you guys, whoops. For you guys, when I tell the story again, you need to listen with different ears, right? So that you can listen to the nuances of the storytelling so you'll feel confident in telling it again. But for everybody else, when I tell the story, just sit back and relax. But first, the definitions. So institutionalized or structural racism is the system, if you will. It's a constellation of structures, policies, practices, norms and values, which taken together result in differential access to the goods, services and opportunities of society by race. So this is the kind of racism that does not require an identifiable perpetrator. Because it's been institutionalized in our laws and customs and background norms, it shows up as inherited disadvantage or it's reciprocal inherited advantage. And we see it in terms of material conditions as well as in terms of access to power. So examples include differential access to quality housing by race or differential access to excellent educational opportunities by race or differential access to employment opportunities or even the same level of income at the same level of employment. And clearly those things impact health. Differential access to medical facilities, including linguistic access. And access in terms of just physical access. Differential, you know, to exam tables and the like. Differential access to clean environment in the whole issue of the disproportionate placement of toxic dump sites or bus transfer stations in communities of color. Differential access to power as information. So information that's health information or information about our own histories. Differential access to resources which include capital resources as well as social networking resources. Knowing somebody on the board. And differential access to voice in media, voice in government and the like. Before I leave this slide, I want to say that sometimes people ask me when we have the opportunity for give and take, Dr. Jones, would you look at your first set of examples when you talk about housing, education, employment, income? Dr. Jones, isn't that really what we call social class? So why do you even have that on a slide about racism? Are you talking about racism or are you really, really talking about social class? This is a very important question. My answer starts with the observation that it doesn't just so happen that people of color in this country are overrepresented in poverty while white people in this country are overrepresented in wealth. That's not just a happenstance. And for each marginalized or stigmatized or oppressed group of color, there's been some initial historical injustice. So for example, for American Indians, the initial historical injustice was the taking of the land and the near genocide and then moving survivors to reserve lands, reservations. And then in some instances, something good was found under one reservation. Oops, you gotta take the people and move them somewhere else. We could talk about, so usually I have time, I see my time. I talk about folks who for centuries lived in Mexico, never crossed the border. The border crossed them, right? And they find themselves in New Mexico or Texas, right? And their grandchildren, great-grandchildren are being harassed. I can talk about our interesting relationship to labor, not just the enslaved labor of Africans. I'll talk about that in a minute. But when we brought Chinese laborers over here to build our railroads, Chinese laborers who were unable by law to bring their families and unable by law to marry. And then we think about internment camps. So we think about Japanese internment during World War II without the internment of Italian-Americans or German-Americans. But who thought that we would be interning children and families at our border right now? I mean, these are echoing things. But when we talk about the initial historical injustices for people of African descent in this country, that started with the kidnapping of West African people. And then our importation across the Atlantic with tremendous loss of life in the Middle Passage. And then for the survivors, what I describe as the coerced usury of our unpaid labor for centuries to build this country. But then people hear me talking like that and they're like, oh, Dr. Jones, there you go talking about slavery. Dr. Jones, we all recognize that slavery was an unfortunate chapter in our nation's history. But Dr. Jones, don't you recognize that the enslaved people were emancipated by 1865 and we're in 2019? So that makes it 154 years ago, right? So they say, all else being equal, Dr. Jones, don't you think the impacts of slavery would have washed out by now? But the key phrase is in their question, all else being equal. All else has not been equal since 1865. All else is still not equal today. And there are contemporary structural factors that are perpetuating that and all of these other initial historical injustices where these present-day contemporary structural factors are part and parcel of institutionalized racism. So when people ask me, are you talking about racism or are you really talking about social class, my response is that institutionalized racism explains why we even see an association between social class and race in this country. And that's a very important aha. Before I leave this slide, I wanna say one more thing, that institutionalized racism can be through acts of doing, acts of commission, as well as acts of not doing, acts of omission, and very often institutionalized racism shows up as inaction, lack of action, in the face of need. The second level of racism, personally mediated racism, I define as differential assumptions about the abilities, motives, and intents of others by race, and then differential actions based on those assumptions. So this is what most people think of when they hear the word racism, somebody did something to somebody. It includes the different idea, the prejudice, and the different action, the discrimination. Some people call this interpersonal racism, I call it personally mediated, because I still understand racism as a system, and this is the system mediated through people. Many examples of how it can impact health, I'm not going to, I'm looking at my time, clocking down, but police brutality, physician disrespect, which can be as subtle as a physician not giving a patient the full range of treatment options, because the physician figures that patient couldn't afford, or wouldn't comply, or wouldn't understand, or whatever they assume. Or it could be actually, so that's a subtle manifestation, it could be quite blatant, like sterilization abuse, you know, which has many iterations in our nation's history, and I'm sure all of you can think of other examples of physician disrespect. Shopkeeper vigilance being followed around the stores, waiter indifference, not getting quick respectful treatment, these are what some people call everyday racism, or some people call these microaggressions, the subtle communication of disrespect, which might be related to elevated blood pressures in communities of color, blood pressures that don't even go down at night. And then teacher devaluation, which I want to highlight as a very important manifestation of personally mediated racism, because if a teacher looks at a young child and thinks, that child can't learn, and puts them off in the attention deficit, hyperactivity disorder track, that child won't even know their full potential, much less have the opportunity to develop to their full potential. Personally mediated racism, like institutionalized, can be through acts of doing, as well as acts of not doing, but even more important to highlight here is that it can be unintentional, as well as intentional. That is, you don't have to have meant to do something racist to have had a racist impact. The third level of racism, internalized racism, I'm defining on this slide from the point of view of members of stigmatized races as acceptance by members of stigmatized races of negative messages about our own abilities and intrinsic worth. I, of course, agree with many of my colleagues who are doing anti-racism work that the internalized sense of entitlement that many white people walk around with is also internalized racism. I don't have it on this slide, really, because for a long time, I couldn't even understand how an internalized sense of entitlement could cause bad health outcomes, except I'm understanding now that an internalized sense of entitlement thwarted might be related to what people are describing as the diseases of despair and elevated suicide rates and perhaps the opioid epidemic, which became an epidemic now, wasn't an epidemic 40 years ago, but anyway, that's for a side conversation. But anyway, so from the point of view of members of stigmatized races, internalized racism shows up as self-devaluation, feeling maybe I'm really not as good as, maybe I shouldn't try to graduate from high school or apply to that college or try to live in that neighborhood or get that job. The white man's Isis-Colder syndrome, that phraseology comes from my parents' generation, and what it meant then and what it means for many of us today who are people of color is say you're a person of color, say you're black, and you need a lawyer. You might actually go and seek out a white lawyer over a black lawyer, or say that you are, you need a doctor. You might prefer the white doctor over the black doctor. In fact, if your lemonade were warm, you might go way down the street to get the white man's Isis over the black man's Isis, deeply believing that the white man's Isis-Colder, deeply internalizing the myth of white superiority. It turns into resignation, helplessness, hopelessness, which turns into a lot of self-destructive health behaviors, turns into not registering to vote sometimes, sometimes it turns into not voting even if you are registered, and all of these things have health impacts. It really is about members of stigmatized races accepting the limitations to our own whole humanity of the box into which we've been placed, so that when you hear young high school students of color teasing one of their friend group who's trying to be the valedictorian by saying, well, you know, so-and-so is trying to be white, we need to challenge that, because since when did white people claim exclusive access to excellence? They did not. But now I'm going to tell the gardener's tale, and, you know, I'm going to come here. I've been using this as a little crutch, but I'm going to come out here. This story is also based on something from my own real life. Maybe I should go over here, maybe I should stay behind, because this is sort of central for the room. Okay, I'm going to stay here. This is, I'm going to tell you what happened in my own real life first, and then I'm going to make it a story about three levels of racism. So in my own real life, my husband and I had been married about a year, and we moved back down to Baltimore so I could finish up my Ph.D. at Hopkins. And we buy our first freestanding house, cute little house, big wraparound porch with flower boxes all on the porch. And we bought this house in October, so it wasn't really the time to plant flowers in Baltimore, but when spring came, my husband, who loves to garden, ran out with our marigold seeds, going to decorate our cute little house by planting in all these planters. But then he came right back in and he said, Kamara, I need to go to the gardening store because some of these boxes have dirt in them, but some of the boxes are empty. So he goes down to the gardening store, and he hauls back big old bags of potting soil, and then we fill up the empty boxes, and then we take equal numbers of our marigold seeds and we put them in all of the boxes, and we water all of the boxes equally. And then because I am not the gardener in the family, by this time I'm exhausted, right? So I'm going to just sit back and be delighted. Well about three weeks later, I'm finally paying attention to these boxes as I walk out of my front door, and as I looked at them, what I saw made me stop in my tracks, literally. Because what I saw made me think we had planted completely different species in some boxes versus others, because some of the boxes were full of plants, and they had tall, vigorous looking plants, and some of the boxes just had a few plants in them, and they were scrawny and scraggly looking. And then I realized what had happened. That potting soil that we had bought turned out to be rich, fertile soil. So all of the seed planted in that rich, fertile soil had sprouted. The strong seed had grown very tall and vigorous, but even the weak seed had made it halfway up. But that old soil that we had found in the flower boxes turned out to be poor, rocky soil. So the weak seed planted in the poor, rocky soil just died, and even the strong seed in the poor, rocky soil had to struggle to make it to a middling height. And I do see some of you guys nodding in the room, and so maybe some of you guys are gardeners. Maybe you've composted half of your garden. Maybe you've seen this image with your own real eyes, and the image, of course, is about the importance of the environment, the importance of the soil. But now I'm going to make this a story about racism by introducing a gardener. So now we're going to have a gardener who has two flower boxes, one which she knows to have rich, fertile soil, one which she knows to have poor, rocky soil, and she has seed for the same kind of flowers, except some of the seed is going to produce pink blossoms, and some of the seed is going to produce red blossoms. And this gardener prefers red over pink. So what does she do? She takes the red seed, puts it in the rich, fertile soil, pink seed over in the poor, rocky soil. Three weeks later in her flower boxes, she sees what I saw in mine, that rich, fertile soil, all the red seed sprouts, strong red seed tall and vigorous, weak red seed makes it at least halfway up. In the poor, rocky soil, the weak, pink seed dies. Here comes the strong, pink seed, struggling to make it to a middling height. And then in those two flower boxes, those flowers go to seed. And the next year, the same thing happens. And then those flowers go to seed. And year after year, the same thing happens until finally, about 10 years later, the flower gardener is looking at her flower boxes, and she says, you know, I was right to prefer red over pink. Hmm. So we interrupt the story to say the first part of this story is how institutionalized racism works. Well, you had the initial historical injustice of the separation of the seed into the two types of soil. You had the contemporary structural factors of the flower boxes keeping the soil separate. And then through inaction in the face of need, perpetuation of the inequity. But let's pick this story back up to say, well, where is personally mediated racism in this garden? Well, the gardener is looking at the red flowers thinking, oh, red is so beautiful. And then she looks at the pink flowers, and she says, oh, those pink flowers sure are scrawny and scraggly, so she plucks off the pink blossoms before they can even go to seed. Or maybe she notices that a pink seed has blown into the rich, fertile soil, so she plucks it out before it can establish itself, which is some of the anti-affirmative action stuff that goes on. And where would internalized racism be in the garden? Well, the red flowers are just living their lives, enjoying being red. Many of them, you know, not acknowledging or maybe even understanding that they're benefiting from enriched soil. The pink flowers are looking over at red, thinking red is mighty fine, and wishing with all of their hearts that they, too, could be red. And here come the bees. The bees are just minding their own business, collecting nectar, but of course pollinating at the same time. So here comes a bee into one of the pink flowers, and then to another pink flower, and to this pink flower, and this flower's like, get away from me, bee, do not bring me any of that pink pollen. I prefer the red, because the pink flower has internalized that red is better than pink. So now the question arises, what do we do to set things right in this garden? Well, we could start by addressing the internalized racism. We could go over to the pink flowers and say, pink is beautiful, power to the pink, right? And that is an important intervention. But if that's all we do, it's not going to change the situation in which the pink flowers find themselves. Or maybe we say, okay, okay, we understand that. Let's address the personally mediated racism. Let's have a conversation with the gardener, or better yet, let's have a workplace multicultural workshop for the gardener, right? And it's all good. So we have our workshop. And in the workshop, we say, dear gardener, would you please stop plucking those pink flowers? And maybe she will, and maybe she won't. But even if she does, it's still not going to change the situation in which they find themselves. What we really need to do if we want to set things right in this garden is address the institutionalized racism, which means we have to either break down the boxes and mix up the soil. Or if you want to keep separate boxes, that's all right too, although it makes it easier if we have that same gardener for the gardener to continue segregating resources. But if you do keep separate boxes, then it means you need to enrich that poor rocky soil until it is as rich as the rich fertile soil. And when you do that, the pink flowers will flourish. They'll be looking beautiful, grand, and glorious. So that in that intervention on the institutionalized racism, you'll also have addressed the internalized racism. Pink won't be looking over at red, thinking red is better, or wanting to be red. And in that intervention, you may also address the personally mediated racism. Now, the original gardener may have to go to her grave preferring red over pink. But her children who grow up seeing the flowers equally beautiful will be less likely to have that kind of attitude. So this story has been to illustrate these three levels of racism, and to strongly suggest that if we want to set things right in the garden, we need to at least address the institutionalized. Good to address all the levels at the same time, but at least address the institutionalized, and the other levels may take care of themselves. But there's one more important question that I haven't raised yet, which is, who is the gardener? After all, the gardener is the one that I gave the power to decide, the power to act, and control of resources, which are actually the elements of self-determination. Who's the gardener in our context? Well, surely, government is a huge part of the gardener, but not the only part. No, media, corporations, foundations, communities, to the extent they have self-determination. But whoever the gardener is, it is dangerous when the gardener is allied with one group, right? I painted her red. That's why she prefers red over pink. And it's also dangerous when she's not concerned with equity, when she looks at her flower boxes and thinks that her garden is beautiful, thank you, because she's not even counting the pink flowers as part of her garden. And so our challenge is, what do we do about the gardener? Do we make the gardener striped, or polka-dotted, or fuchsia? Do the pink flowers have to grow or recruit their own gardener? Lots of questions that can come out of this. I have just a few more seconds, but I'm going to carry on a little bit if I might, just maybe five more minutes. Can I have five more minutes? So I want to share with you two questions that have come up before, when other people have heard this gardener's tale. And then I wanted to do a few more things before we close. One question that I love, and now I tell it every time I go and speak somewhere. Somebody was like, wildly, Dr. Jones, Dr. Jones, excuse me, but why should the red flowers share their soil? I loved that question when I heard that question, because it showed me the power of this story to start conversations about racism that would be otherwise difficult if we were talking about racism between you and me. My answer to the question, why should the red flowers share their soil, is that actually that soil does not belong to the red flowers, it belongs to the whole garden. Here's another question. Okay, we can all talk about that later, I'm just going to whiz through. Here's another question. What if that's not the original gardener that we're looking at? What if that's the gardener's great, great, great, great grandchild? Here we are. And the great, great, great, great grandchild has always seen the flowers looking like this, may not even think there's a problem to be solved. Very quickly, three things. First, we must make the differences in the height and vigor of the pink and red flowers a problem requiring urgent solution. Second, in order to solve, we need to make those flower boxes transparent. We need to be talking about the differences in the quality of the soil. Third, as we make those flower boxes transparent, we need to make sure that everybody understands that the pink seed did not just go launch themselves into that poor rocky soil. So we need to talk about history, we need to talk about the gardener's agency in setting up the whole situation, how the gardener's initial preference for red over pink, which some people call cultural racism, I've sort of, you know, included in my institutionalized racism. In our setting, it's white supremacist ideology. We need to talk about how that set up the whole situation, and we need to address it. Because if we don't, even if we were to compel the red gardener to enrich the poor rocky soil today until it's as rich as the rich fertile soil, if she continues to prefer red over pink, she will continue to privilege red over pink going forward. I just wanted to, I had a few more things I wanted to share with you. I told you that the three tasks for, you know, this national campaign against racism included naming racism. I've given you three stories that should equip you to name racism, right? Why are we as physiatrists talking about racism? Well, it has to do with the fact that we're dealing with this three-dimensional cliff. You know, what is racism? Well, it's this system, and it creates two-sided or multi-sided signs and locks and doors. How does it impact health? Well, the gardener's tale helped us understand that on three levels. The second and third elements, I'm just going to gloss very quickly over, but the second task was how is, to ask the question, how is racism here? Which is a legitimate question, because racism is not a miasma that we can't get a handle on, a cloud. It is a system with identifiable and addressable mechanisms which are in our elements of decision-making. These mechanisms are the structures, policies, practices, norms, and values, where structures are the who, what, when, and where of decision-making, especially who's at the table and who's not, what's on the agenda and what's not. Policies are the written how of decision-making. Practices and norms are the unwritten how of decision-making, and values are the why. And I actually encourage us to take this question, how is racism operating here, to all of our settings. How is it operating in my workplace, in my children's school, in this city, in this nation, and use it to identify levers for action. Then I told you that I recognize that racism is one of many systems of structured inequity operating in our society. We can generalize my definition of racism to be a definition of any system of structured inequity. So what is sexism, for example? It's a system of structuring opportunity and assigning value based on gender that unfairly disadvantages some, unfairly advantages others, and saps the strength of the whole society. What is ableism? It's a system of structuring opportunity and assigning value based on ability status that does these things. In fact, there are many axes of inequity operating in our society today, intersecting in communities and in individuals, and all of these are operating at least as risk markers for how opportunity is structured and value is assigned, even as a smaller set are also operating as risk factors in the progression to disease. So why did I spend all this other time talking about race as an axis of inequity and racism as a system? I'll tell you. It's because racism is foundational in our nation's history and continues to have profound impacts on the health and well-being of the nation, while many people are in denial of its existence. So I actually encourage all of us to become actively anti-racist, even as we also engage in these other struggles, and to the extent that we're able to dismantle some of the structures of racism, the other struggles will benefit as well. So I had a quick three-part definition of health equity, understanding it as assurance of the conditions for optimal health for all people, recognizing that if you're wanting to do something about health equity, if you want to take that citizen role, achieving health equity requires at least these three things, valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources not equally but according to need, and recognizing that health disparities, which are differences in outcomes, will be eliminated when health equity, which is differences in opportunity, is achieved. But I wanted to close with one last story, a very quick story. This one, and I will come out here for this one. This one I call Life on a Conveyor Belt, Moving to Action, and it's based not on something I saw from my own real life, but something that was sparked by an image from the book, Why Are All the Black Kids Sitting Together in the Cafeteria, and Other Conversations About Race, by Dr. Beverly Daniel Tatum. In her book, she explains that for people who are wondering, like, does racism really exist? And saying, I couldn't be racist, well, many people are living their lives, going to work, going to school, but they're living their lives on a conveyor belt that's moving inexorably through racism and toward racism, and they're kind of passively racist, right? Not trying to be racist. I'm going to take that image, and I'm going to expand on that image to talk about how we become actively anti-racist. So here we are, many of us are on top of the conveyor belt. Some of us are being ground up by the motor of the conveyor belt, but here we are, many of us on top of the conveyor belt, just going to work, going to school, trying to be our best person, you know, religious, all of this, moving inexorably through racism and toward racism. There's even a big sign up there, flashing racism, racism, racism, but we don't see it because, you know, we're so involved in our lives, or maybe we look up and we see, racism, so we close our eyes because we're in denial and we keep going, or we see racism and we go, oh, and we turn around, but we don't do anything else, so maybe we're colorblind, right? What if we don't want to be those people? I have to go over here. I ran out of conveyor belt. Okay. So here we are in the conveyor belt, and we've just been living our lives, but now we see racism. We do need to turn around, right? But if we don't do anything else, we'll still be swept away, so we need to take a step, right? We need to take a step, and we need to start walking at least as fast as the conveyor belt is moving just to stay in the same place, that is, we have to become actively anti-racist. Now let me ask you this. What happens when you're walking backwards on a crowded conveyor belt? You start bumping into people, and it becomes uncomfortable for them and uncomfortable for you, and they're like, hey, buddy, watch out. Where are you going? Which is your opportunity to do the first of the three stages of being actively anti-racist, which is to name racism, to say, do you see where we're going? Do you want to go there, or will you turn with me? Well, most people do not want to be disturbed out of their comfort, so they'll just say, get out of my way. But maybe one or two will turn with you, so now you have two or three of you walking backwards on this crowded conveyor belt. You keep bumping into people. You keep naming racism and inviting them to turn with you, and more and more will turn. Never 50%. Don't even hold out for 50%, but more and more will turn. So now you're developing like a critical mass. So what can you do? Well, first of all, you don't have to stay in the same space. Now you can sort of make some headway on this crowded conveyor belt, but it's not just to get away from the sign. What are you trying to do? You're trying to get to the motor that's making this system work, right? So now here we are at the motor, and now it's time to do the second of the three stages of being actively anti-racist, which is to ask, how is racism operating here? Looking at structures, policies, practices, norms, and values. So I think it's this lever. So I'm going to pull on the lever, and the whole system starts shaking, and I've done it. I've done it. Except racism is a very fancy system, so it reconfigures itself, and it keeps on going, which talks about the importance of the third stage of being actively anti-racist, which is to organize and strategize to act. So as I'm pulling on that lever, you need to push a button, and you over there, you need to pull on a pulley, and you right there, you need to swing that pendulum, and all of us need to take a piece of this system. And I really do believe that all of us working together can dismantle this system and put in its place a system in which all people can know and develop to their full potentials. It's always been an urgency in this country, but especially now, I hope that you will join this effort. Thank you very much.

racism

health

society

action

dismantle racism

health intervention

access to care

structural inequity

racial disparities

health equity