Conferences & Events

Transcript

John Williams: Good afternoon and welcome everyone. I'm John Williams, the president and CEO of the Federal Reserve Bank of New York. I'm here to kick off what is now the eighth installment of a landmark series on the topic of racism and the economy sponsored by the 12 Federal Reserve Banks. These events examine structural racism's toll on the economy and identify potential actions that can improve economic outcomes for all segments of society. There's no facet of our society immune to racism, health included. This afternoon we'll be looking at key issues around race and the economy through the lens of health, a focus never more urgent and critical. Before we move on with the program, I'd like to share more broadly why this is so important for the Federal Reserve, what we're learning and what we're doing. With that I must give the standard Fed disclaimer that the views I express are my own, do not necessarily reflect those of the Federal Open Market Committee, or anyone else in the Federal Reserve System.

Having poor health is a challenge on many levels. We're keenly aware that health can be a huge driver of economic inequality, and that people who lack good health or health care often struggle to participate fully in the economy. On top of that, social determinants of health, economic stability, housing, and education can be barriers to employment and affect the kind of jobs that people get. Of course, we at the Federal Reserve are neither health care workers nor health care policymakers, but a major part of our core mission is to foster a strong economy and promote maximum employment. To put it simply, we need healthy people to have a healthy economy and workforce. That's why understanding the nexus of race, health, and the economy is central to achieving our goals. We're deeply committed to doing so, both in this series and beyond.

The pandemic demonstrated just how acute many of the connections are between physical and economic health for individuals and for communities, and it exposed just how dramatic racial disparities can be, especially in accessing health care and other critical resources. The convergence of a health crisis, business closures, and job losses created tremendous hardships for many Americans, and it was especially devastating for communities of color. We know that people of color, and Black people in particular, experience higher rates of illness and death. Significant representation in essential services work, jobs that required close contact with others, contributed in part to these tragic outcomes. Over the past 18 months we learned how these issues played out for families through regular conversations with community leaders in our District and beyond. Separately, our research shone a spotlight on many of these painful realities. For example, a team of New York Fed economists published a series earlier this year aimed at understanding the gap in COVID-19 intensity by race and by income. Last month, they shared their findings around racial differences in ICU stress during the third wave of COVID-19.

There's no single or simple solution that can fully address these problems, but as a nation we can build a stronger foundation so that everyone can fulfill their economic potential, thus better enabling the Federal Reserve to fulfill its mandate. That's why at the New York Fed and across the Federal Reserve System, a key area of focus is to better understand economic drivers of health and well-being, and to champion promising solutions. We're able to do this in large part through our community development efforts to better understand the needs and issues of low- and moderate-income communities throughout our District. Our community development team recently adopted a new strategy to concentrate on three key areas: health, household income, and climate. Our aim is to connect people, programs, and proposals, especially those folks focused on fostering racial equity with the funding needed to promote equitable growth and tackle economic inequality.

We're already doing important work in this space, and there's so much more planned for the future. A few months ago, we brought together mental health and policy experts to examine the pandemic's impact on mental health and communities of color, including the correlation between depression, anxiety, and economic factors such as lost income. Next week, we'll be hosting an event in collaboration with New York University's Rory Meyers College of Nursing, the New York City Department of Health and Mental Hygiene, the Low Income Investment Fund, and the Robert Wood Johnson Foundation to discuss the need for investments in maternal and child health. Our goal for convening this coalition of thought and civic leaders is to find innovative ways to ensure that all mothers across the city have the care they need to fully participate in the economy and that their children are positioned for a healthy start.

Today, you'll hear from an exceptional lineup of panelists, leaders in the medical, academic, and policy worlds. We'll close with a panel of my colleagues, fellow Reserve Bank presidents, who will share their reflections on what we've learned and discussed today. With that, I'll hand it over to Marielle Segarra of Marketplace who will moderate the next part of the program. Thank you all again for joining today's event.

Marielle Segarra: Thank you so much, President Williams. Hi everyone. I'm Marielle Segarra. I'm a senior reporter for Marketplace, and I am so glad to be here today moderating this conversation. We are going to get into some of those dramatic disparities that President Williams was talking about. But first we really want to give a sense of what this looks like on the ground. We will have videos from people in various communities throughout the event, and we're going to start off with a video from Dr. Ana Valdes of HealthRIGHT 360. She's going to talk about how the community she serves have been affected by the pandemic.

[Begin video]

Ana Valdes: I'm Dr. Ana Valdes. I am the chief health care officer at HealthRIGHT 360. We're a health care organization that provides medical, dental, behavioral health services, which includes substance use treatment and mental health throughout the State of California in 10 different counties. The communities we serve within those counties are people who are homeless or suffer from housing instability, people with a criminal justice background, either currently or recently incarcerated, people who suffer from substance use disorder, or mental illness. They may be uninsured. They may be part of marginalized communities, not only socioeconomically, but LGBTQ and other things like that. They definitely suffer from some of the predominant health disparities that are out there.

When this started, it was very clear to us that the communities we serve were going to be really impacted by this pandemic. The communities that we work with do not have a lot of trust in the health care system for many historical reasons, which I'm sure a lot of people have heard about, especially in the face of COVID where there was so much information that came out quickly, and then it changed as I mentioned earlier, one week it's one thing, the next week it's another. People start thinking, "Oh, here we go again with the health care system trying to dupe us," et cetera. We really work to treat them with dignity, respect, non-judgmentally, and to really be authentic about information and transparent. We also seek champions that are in the community. These are the peers that I'm talking about. These are the people with the lived experience. They have been incarcerated themselves. They have history of substance use. They have a history of mental illness. They live in the community; they do this similar kind of work. We take a lot of feedback from them. We also send them out with messages and then they come back and let us know that's landing, that's not landing, however it's going.

A lot of our workforce, our peers, because their lived experience is really, I think, key to the treatments and services we provide to our communities. Trust and relationship are key to community health. Growing out of the community really helps to build trust and relationship. Unfortunately, we're also part of a larger health care system that has created mistrust by experimenting on people, by not letting people know exactly what they're getting involved in, but also some very glaring disparities around not offering appropriate medication, or treatment options, or things like that. It's really incumbent upon us, if we want to raise the health of the community, that we have to rebuild that trust and relationship.

[End video]

Segarra: That was Dr. Ana Valdes from HealthRIGHT 360. That last part, what she said about rebuilding trust, that is going to come up again and again today. Right now, we're going to hear from four public health experts who will lay some foundation for us about structural racism, which includes the economic conditions that many people of color face and how that affects their life trajectory and their health. At the end of their comments, we will take questions from the audience. If you have any, you can ask them on Twitter using #racismandtheeconomy, or by email at racismandtheeconomy@bos.frb.org. We will start with Dr. Tony Iton, who is senior vice president at The California Endowment. Dr. Iton, welcome.

Tony Iton: Thank you, Marielle, and thanks everybody for being here. I have a few minutes to try to give you a little bit of context around this issue. I think the best way to do that is to just describe my own experience in confronting the issue of health disparities and health inequities. About 15 years ago, my colleagues and I decided to take a database of about half a million death certificates in Alameda County, California, and map them using a GIS system. We mapped across Alameda County's 150 census tracts. Each census tract in Alameda County has about 10,000 people in them. We calculated on average how long somebody could expect to live in those neighborhoods. What we found was a dramatic range of average life expectancies, including just in the city of Oakland, a 22-year life expectancy difference between the Oakland flatlands and the Oakland hills.

We were pretty surprised by that. We published it. It ended up on the front page of the San Francisco Chronicle. We ended up working with about 15 other health departments around the country to replicate that analysis. We worked in Baltimore, Maryland, New York, Cincinnati, Chicago, Dallas, Los Angeles. Everywhere we looked, we found the same pattern of dramatic life expectancy differences across neighborhoods in the same city, sometimes contiguous neighborhoods. The reality is that in health, in public health, we oftentimes try to use what I refer to as micro concepts to explain macro phenomenon. In economics, we know that there's a very developed field of microeconomics and macroeconomics, but in health, we don't really have a good way of understanding macro health phenomena.

We try to explain these differences in life expectancy across cities, as the product of differences in behavior, the product of differences in genetics, or the product of differences in access to health care. When you look at that data, you see that none of those three things explains these dramatic differences across cities. One thing that does explain it is political power. Quite frankly, it doesn't take a lot of deep analysis to recognize that our history in this country of separating people, of segregating people by race largely, but also by class, has produced this phenomenon where communities are spatially separated from access to opportunity, which means that they find themselves in segregated housing, segregated neighborhoods, segregated schools, and that constrains their opportunity trajectories. Interestingly, it was a handful of economists that had really popularized these concepts, Raj Chetty being one of them, who's done a lot of very good work looking at opportunity trajectories for Americans. Then, of course, Angus Deaton and Case at Princeton, who popularized this concept of deaths of despair.

Let me just try to wrap this up for you into a nice little package. One way to understand what's happening in these low life expectancy communities is to think of them as incubators of chronic stress. In these places, virtually every meaningful amenity or institutional resource is on life support in some way. You might find a difficulty finding healthy food, finding access to parks, finding access to decent housing. You might be policed with militarized tactics; folks may even have difficulty finding potable water coming out of their taps. Folks living in these communities are essentially enshrouded in this fog of chronic stress. In medicine, we refer to that as allostasis, or allostatic load, but it's basically the cumulative and synergistic impact on people's lives when they don't have the resources that they need to pursue the opportunities.

The bottom line is chronic stress is avoidable, it's preventable, it's fully policy mediated, or I should say it's more often the absence of health protective policy in the face of abject need. That may be things like the lack of universal health care, the lack of universal childcare. These basic elements of the social contract that exist in virtually every other developed country against which the United States compete, we experience a very tattered social contract in this country, whereas those countries have a very robust social contracts and many more universal policies.

I'll conclude by just pointing to some wonderful data by two researchers, Elizabeth Bradley and Lauren Taylor, who have shown that while the US spends on a per capita basis roughly twice the OECD average of other countries on health care, that we actually underspend on social benefits and services. And those countries that spend roughly $2 on social benefits and services for every $1 on medical care, actually have the best health. This research has been replicated by RAND, and they have shown that if you want to improve health in a country, you have to invest in social services and social benefits, i.e., you have to repair and rebuild the social contract. Let me turn that back to Marielle, that's some context for this work.

Segarra: Thank you for that, Dr. Iton. Next up, we're going to hear from Dr. Elena Rios, who is president and CEO of the National Hispanic Medical Association.

Elena Rios: Thank you very much, Marielle, and for the organizers for inviting me. I'm Dr. Elena Rios, president and CEO of the National Hispanic Medical Association. I'm here really to amplify on what Ana Valdes talked about, the lack of trust and the lack of services among the Latino communities and other poor communities in our country, and the importance of what we've done through our organization's efforts working with other partners. We work in a Hispanic health professional leadership network that includes the National Association of Hispanic Nurses, the Hispanic Dental Association, the National Hispanic Pharmacists Association, the Latino caucus of the American Public Health Association.

I could go on and on and on, but let me just tell you that there are mental health groups, dieticians, social workers, and others, scientists, who have captured a small group within our different professions that have come together over the last decade because we believe in advancing leadership and advancing ideas for groups like yours, on how to reach our communities through trusted messengers within health care. We believe they are the health professionals that people see, whether it's the family doctor or the OB-GYN, or it's the nurse, or the pharmacist. We become trusted messengers without a network of, let me say of being activists, and we need to be become better activists by being utilized within corporate America, or public health America, or rural America. Oftentimes we are overlooked. Hispanic families don't necessarily have the wherewithal. My grandparents were from Mexico, I'm from the Los Angeles area originally. Most of our immigrant families have had very poor education, but our parents have a very strong will to have their children do better than they did.

What that means is our community, Latinos that have become health professionals, are very unique in that they have had strong love and support from their parents to be able to go through the rigors of an educational system that their parents knew nothing about. I think that the leadership potential is incredible within our health professionals. I just wanted to say that in terms of the Hispanic population, we come from different parts of the world, the Caribbean, the Puerto Ricans, the Dominicans, the whole Southwest used to be Mexico up until 150 years ago. No wonder 63 percent of all the Hispanics in the United States are Mexican, Mexican-American, but then there's Central and South America, and, of course, people from Spain and other places.

What's important about this heterogeneity is that you have to be regional in your approach and programs. You have to be regional with role models. People like yourselves are the ones that are going to be able to have a better chance of coaching and mentoring our communities into higher-level aspirations, let's say, and for those that are Hispanic health professionals, we need much more mentors at all levels. I was just talking to the AAMC leader for the chief diversity officer there, Dr. David Acosta. He said, we have pipeline programs from college to medical school, we have programs within medical school that have been there for 50 years, but we haven't made a dent in our medical education because we don't have the role models that are the faculty, or the role models that are out in the community, the doctors that are... they're too busy. We need role models that can be on boards of directors of our hospitals and clinics in our philanthropy, in our health systems, who can get the next generation to be those role models and mentors to help us move up.

The importance that I'll leave you with is that we have programs, and I'll name a couple. One is the National Hispanic Medical Association Leadership Fellowship, and it's an executive training program we've run for 10 years or over. We have doctors that have become commissioners of health in New York City, that have gone into the public health departments, have run for Congress, who are a Congressman, who have gone into state health departments and who are running clinics, who are medical directors of clinics, but without training, without understanding what a leader is and the responsibilities, and also how do you work with the stakeholders in our communities like media, especially having changed the media in our communities about how great the asset model of our communities that we do have aspiring professionals, not just gang members. We need to work with stakeholders and philanthropy to learn how to accept and how to write proposals. We need to work with all these different types of stakeholders, that's what our leadership fellowship is all about.

On the other hand, we have a program for college students, the NHMA College Health Scholars Program, and we have a scholarship program for medical students and nursing and public health with all our sister organizations that I named earlier because we believe in giving back. I do think that it's so important for all your companies to think about Hispanic leaders to join together because we're very isolated, and we'd be happy to help if there's a health professional diversity effort, where you're looking for a recruitment effort for diversity, we'd be happy to help just with the sending our speakers from our speakers bureau of Latino professionals from the health care world to talk to your employees about COVID-19, or other issues of importance right now. Anyway, I'll leave you with that. And again, we're the National Hispanic Medical Association. Thank you.

Segarra: Thank you, Dr. Rios. Now I'm going to bring in Dr. Bill Frist, who is, speaking of congressmen, a former US Senator and a surgeon and professor at Vanderbilt University.

Bill Frist: Marielle, thank you. As Dr. Iton and Dr. Rios have both just emphasized, good health is so, so much more than access to good health care. We know today that structural racism against the historically marginalized populations and communities is a fundamental cause of persistent health disparities in the United States. I'd like to focus my remarks on just one example, and that is food, and I want to do so through the three lenses of my life, a doctor in medicine for 20 years, clinical medicine, a policymaker for 12 years in the United States Senate, and then for the past 14 years as a businessman building companies mainly directed towards vulnerable populations. Yes, food. Food is a social determinant. Food creates racial disparities. Food compounds social inequities. It pulls down our workforce. It affects the productivity of each one of us, and the economy of our communities and the country. It affects how, with structural racism, individuals manage and respond to what Dr. Iton mentioned, those incubators of chronic stress.

The bad news is that we abuse food, and then the wrong food abuses us. It can destroy health. This abuse disproportionately affects people of color. The good news is that we can fix that. Our policies, our doctors, our science, our creativity, and innovation from the private sector, all together, if we can work together, can eliminate many of these causal aspects of health disparities, but it does mean action, it does mean, as we just heard, working together. Food, a social determinant, unless you're a heavy user of tobacco, or drugs, or alcohol, the number one thing that has the greatest daily impact on your health is what you eat, what you have for breakfast, for lunch, for dinner, for snacks tonight. Access to healthy foods is determined by where you live, where you play, where you go to school, where you worship, where you age, by your socioeconomic status, and yes, by the federal laws and the agriculture and dietary policies your elected leaders, who we all elect in Washington, decide.

How does food create health disparities and add to the health inequities that we've heard mentioned today? This whole intersection of social determinants of health and disparities by race and ethnicity is rooted in structural racism that results in what ends up being uneven access to health insurance, to quality of medical care, and to food. When we think of diet, we think of it usually as a personal choice, but today's science tells us something very different. It reveals the tremendous healing power of food, and we need today to begin to think of food as medicine. It's well-documented that people of color on average have far less access to healthy foods. I think when I say healthy foods, I immediately think healing foods, and that it's not surprising that recent studies right here in middle Tennessee, as they would be in your communities, reveal that, for example, Blacks have much, much higher rates of diabetes, of hypertension, of respiratory conditions, of obesity when you compare them to their White counterparts.

How does food affect the economy and jobs? First, a very direct impact on productivity and job performance. It has a direct impact on cognitive performance. A 2014 study in the British Journal of Psychology followed the food intake of participants over two weeks. What they found was that more fruits and vegetables consumed the happier, the more engaged, the more creative, the more productive they tended to be. Doctor, policymaker, businessman, let me go through them quickly. The physician lens, poor quality diet drives obesity, our number one killer in this country today. Here in Nashville a large trial of self-reporting nearly half of African Americans reported being obese compared to 24 percent White and 32 percent Hispanic. I just throw those out as an example, don't pay attention to the specific figures, but obesity is the leading risk factor. Most of the major chronic conditions, and these chronic conditions out there account for 80 percent of our health care spend translating into our economy. The burden on individuals. Obesity increases an individual's medical costs approximately $1,500 a year. Obesity is also linked to discrimination in the workforce for both hiring and promotion; it's associated with mild cognitive impairments and dementia. I think back to my daily life as a heart and lung transplant surgeon, every day I operated on hearts diseased by these ravages of too much salt, too much processed food, too much fried food, too much sugar. Then the lens of the policymaker, 12 years in the Senate, there I learned that federal policy matters, and I'm sure we'll hear more about that in the next panel. Our food choices aren't made in a vacuum, it's an ecosystem; they're heavily influenced by federal agriculture and dietary policies.

The good news is, as Dr. Iton mentioned, we can change that. For example, about 80 percent of government agriculture subsidies today, everybody knows they're huge, go to soy and corn, instead of subsidizing things like fruits and vegetable production. This heavily influences what our farmers produce and thus impacts what we eat. Policy includes food stamps, the program known as the SNAP program. It has a disproportionate impact on low-income populations. It's been successful in addressing the original problem of undernutrition, but today it needs to be radically changed in order to encourage what we know today are the healthier, the more healing choices of food. Again, changes can be made. All of this is reversible over time, especially these policy changes. We elect the people there. Not too long ago, a decade ago, I was working with Dr. Dean Ornish and we laid the groundwork for what ultimately passed for Medicare reimbursement to help people to have access to lifestyle programs, which include food as medicine for reversing something as specific as heart disease. That's huge progress; that was the first federally reimbursed program of its kind. The last lens is that as a businessman in the private sector and I'll wrap it up quickly. PurFoods is an example. A company based in Iowa, it began as a startup and this is the private sector involvement in idea of venture capital. Private equity is an example of how the private sector with access to capital and a focus to improve help can reduce the health disparities and reduce the inequities around food.

You know, the structural discrimination and racism and the food and the larger health ecosystems, meaning that vulnerable populations, including those of color and socioeconomic status, do not have access to affordable, healthy food when they're sick or in their hospital. PurFoods addresses just that. Designed for lower-income populations, it provides these medically tailored meals, home-delivered, affordable meals, where they are needed. They're affordable, less expensive than fast food, and that took a major initiative in Washington to change Medicare and Medicaid so that food would be reimbursable for populations in need. PurFoods indeed has stepped up; it's now in 42 states. The private sector has delivered. Still a long way to go, but they delivered maybe 55, 60 million meals last year.

A final thought. I have an overview of thought to achieve health equity. We must really first fix, I guess, first identify the institutional racism in places it exists. That's what in part this program is about. Then consciously dismantle the structural racism that is out there. The racism that shapes the policies. The upstream governance and policy and social structures and other policies that perpetuate these etiologies of one group being superior over another. At the community level, we got to intervene to achieve equitable access to social and economic resources that we know can improve health equity for all historically disenfranchised groups. Finally, as others have said, we are all in this together. Marielle.

Segarra: Thank you very much. I'm going to just keep the conversation moving and turn it over to Dr. Abdul El-Sayed, who is a policymaker in residence at the University of Michigan.

Abdul El-Sayed: Thank you so much, Marielle. And thank you to the Minneapolis Fed for hosting this incredibly important conversation. I want to say thank you to the three previous speakers, for their insights and their perspectives. My goal here as a former health director in a city that has been affected by systemic discrimination in the ongoing segregation of peoples based on that systemic segregation, the City of Detroit, is to give you a viewpoint on what we are talking about specifically, when we talk about the relationship between racism and health. It is easy to define and limit the scope of racism to be one-off interactions between people that carry a level of prejudice or xenophobia that's outward and specific, but the kind of racism that does the major damage to population health tends to exist in the ways that racism has embedded itself into the structures, into the policies, into the choices, into the political power structure, that limit access to basic resources that can improve health.

The other point here is that it's easy to focus on what happens inside a clinic and or inside a hospital. But really when we're talking about clinics and hospitals, it's already too late. People are already sick. To understand where racial inequities in health exists, you have to leave the clinic in the hospital to put yourself in the places where people live and learn and work and play for 99.99 percent of their lives.

I want to tell you about a little boy I got to meet. He was three years old, fourth child of a 21-year-old mom. He'd met his father, maybe four times in his life because his father's in jail. His mom worked two jobs and he was taken care of mostly by his grandmother, herself who suffered from multiple chronic illnesses without the basic health care access that she had. Not because she didn't have health care. She was a senior on Medicare and also Medicaid eligible. But because hospitals and clinics just weren't available in the local community in which she lived.

To get back to this little boy, he had this big, bright smile, kind of confidence that you don't see in 3-year-olds. As a father of a 3-year-old, I'll tell you, it's uncommon to see a kid walk up to you and shake your hand. The minute this kid did that, I had to think to myself, he's either the most confident or the most rational 3-year-old I've ever met in my life. But if you think about it, the challenges he faces completely undercut that confidence. To begin with, he lives in the air shed of a local petroleum refinery that is emitting pollutants that go on to cause climate change but are sieved through the lungs of that boy.

It's a big reason why people in his community are three times as likely to be hospitalized for asthma. He lives in a house built before 1978, meaning that there is lead in those walls. It's a big reason why in the zip code, in which he lives, the lead prevalence, the lead poisoning prevalence is upward of 10 percent. If you think about the circumstances of his life, he's been robbed of a father figure by a carceral system, a criminal legal system that disproportionately polices Black and Brown men that has seen incarceration as a solution to poverty, because we have been unwilling to engage with the problem of poverty to begin with. That home in which he lives is not owned by his family, instead, it's owned by a landlord. Because people are worried about getting evicted from that home, the probability of getting a lead test is substantially lower, because of course, if you had a positive lead test, it might be a reason why a landlord could illegally evict you.

It also speaks to the challenge of housing and housing in affordability and housing in access and housing insecurity. That is the subtext in the context for so much ill health. You think about the challenge of even getting health care for that little boy who receives his health care on Medicaid. He may have Medicaid coverage, but the reality is that the number of pediatric clinics that he has access to is limited simply because trying to run a pediatric clinic on Medicaid, which reimburses at some 50 percent the rate for a primary care visit, means that people don't locate in communities like his. While he may have, in theory, health insurance, he does not have real health access, similar to his grandmother.

You think about the jobs that his mother works, that up until recently didn't pay more than $15 an hour. She had to work two to make ends meet. Her work times were not decided by herself, but rather they were decided by managers. Trying to toggle between multiple different jobs, each of which puts you under the time control of a manager, means that you may not have access to your children and the ability to engage with them. Think about the cost of childcare and the fact that for too many of our young people, they don't get access to high quality preschool, let alone childcare that allows a mother or a father to know that they can work those hours to make sure that they're bringing home enough to afford a good roof over their children's heads and a good meal. The food that Senator Frist talked about just earlier.

You think about the picture of this and the system of insecurity that's wound itself around the life of this child and you start to appreciate all of the ways that we have robbed young people from the get of the basic means of a healthy long life. In this moment when we ask about racism and health, we have to remember that in the end, to go back to the point that Dr. Iton made, health is a limited resource. Not everyone in our country has the means of a long, healthy life. The folks who do tend to be people who have means and have resources to be able to insulate them from circumstances like the ones in which that little boy lives. If we're serious about taking on racism and its role on health, then we have to be serious about unwinding the consequences of structural racism that leave our children breathing poisoned air, at risk for drinking poisoned water, living in insecure housing that may lead poison them. That their parents can be available to them because we've unwound a carceral state that over-polices Black men's bodies. That allow people control of their lives and livelihoods in an economy where we don't systematically underpay people so that they have to get two, three jobs to be able to survive.

As the Fed and other institutions of our economy are thinking about long-term public policy, the question of full employment gets at whether or not families like this little boy's have the means to insulate themselves from those circumstances, even as our public policy unwinds those circumstances to begin with. With that, I'll look forward to the questions that I know our panel will receive, and I appreciate the opportunity to share some perspectives.

Segarra: Thank you, Dr. El-Sayed. That was great. We're going to go into discussion now; we have just a little under 20 minutes and we are taking questions from the audience as a reminder. If you've got questions, you can share them on Twitter or by email. I want to start with Dr. Iton because you talked a bit about the chronic, toxic stress that often affects people of color. I wonder if you could say a little bit more about that, particularly the kind that's caused by economic anxiety and financial insecurity. How does that affect someone's health?

Iton: Marielle and others, I really do appreciate my fellow panelists' comments just before me. The concept of allostatic load is basically you can simplify it to think about the idea of having risks in your life and having resources in your life, and the balance between those risks and resources really kind of sets how much stress you experienced. If the risks are high and the resources are low, you're constantly activating your, essentially your stress system in your body. That stress system, when it's chronically activated, actually has the opposite effect that you would expect. It actually causes changes in your cardiovascular system, it causes changes in the way your body processes insulin, it causes changes in the way your brain functions. It actually changes your physiology.

Folks living in these communities are actually physiologically different than folks that are not experiencing that level of stress. Those stressors, that change in your physiology, can actually be passed onto your children, shockingly. We like to think about how the absence of health protective policy is actually rendering physiological harm in many of these communities across the United States.

Segarra: You talked a bit, Dr. Iton, about the social determinants of health, which can mean things like economic stability, access to education and health care, water pollution experiences with racism and discrimination. I want to turn now to Dr. El-Sayed. It seems like this has a lot to do with the story you were telling of the boy you met. It seems to me these things don't just happen, like the systems are built this way. What do you think solutions have to look like?

El-Sayed: I think it's been in vogue over the last 20 years to say that so long as we eliminate the barriers to equity today, then we've done our part and we can all move forward into the sunset. The problem with that is that, unfortunately, the consequences of barriers in the past compound to create a circumstance where people are left so far behind that only thinking about what we do to address the barriers to equity today is only actually half the solution. Just to offer an example, you think about the ways that we fund public education. We fund public education in part, it depends on differences in the state. but most of the time it's some combination between state funding, that is fed by federal block grants and local funding. Local funding is a function often of property tax. Property tax is a function of the amount of investment that our government put into properties through the Federal Housing Administration over the past 50, 60, 70 years.

When you look at that, and you take that into account with the fact that Black people were systematically barred from living in communities where FHA loans were offered, what you realize is that the way that we fund what we call the so-called engine and mobility, our public schools, itself ports the historical racism, structural racism around housing. We have to be thinking about what are all of the seemingly equal ways that we offer funding that tend to create systematic inequity that port the racism of the past. To me, I actually think that we have to be quite serious about asking what are all the circumstances that have pondered racial inequities in all of the experiences that a little boy, like that boy I told you about, experiences. What is it about zoning laws that means that Black children are systematically more likely to have their lungs used as sieves for pollution from major corporations?

What is it about the way that we fund our public education, or the way that we've oriented our food system, that means that you're far more likely in a city like Detroit to have access to a liquor store than you are to have access to a grocery store. That the school district that the child goes to is funded in a way that has left it in effect destitute. The system itself has been stripped out of local control, which is what happened to Detroit public schools, so that's one part of it. The other part of it, though, is also, I think, thinking about invested solutions that can take on the consequences of systemic inequity today. One of the things that we did, for example, when I was at the health department was build a program to give every kid a pair of glasses. Now, a pair of glasses does not take on the systematic inequities that kids are exposed to. What it does mean is that we can make sure that what's happening at the school board gets pushed into a child's brain because they can actually see what's happening at the school board. I think it is a meeting of these local solutions that take on the consequences of inequity, while pushing our policy apparatus to actually take seriously the inequities that we create every day by porting historical racism into our future.

Segarra: Thank you for that. Along the lines of solutions, Senator Frist, you talked about food and we've gotten a few questions about this. Looking for a really concrete answer to how can we better address the health and economic impacts of harmful commodities. For instance, like tobacco, highly sweetened beverages, ultra-processed foods, and alcohol. Considering that these products often disproportionately harmed the health of people of color.

Frist: It's a great question. One of the reasons I wanted to answer, I spend my minutes on medicine, policy, and innovation, those three areas, because it's going to take all of that. When I closed, I said, it's upstream those big policies. There are controlled, but we all elect who is there. If you look at the big policies, like what is subsidized, what is reimbursed through Medicare and Medicaid? Those things are all changeable today. People need to understand that they are a driver. It goes back to your first question to Dr. Iton. If you look at stress, and the American psychological society, it looks like a lot of this in health care, about 70 percent of the stress, not all the chronic stress, but distress comes back to something financial. Yes, it goes through housing and it goes through food and it goes to access to hospitals, but it is a big chunk. The flip side of that is the problem of responding is also a finance barrier, in the sense that if you look at the number one reason people don't get their prescriptions filled, the life-saving prescriptions to treat hypertension today, diagnosed and initially undiagnosed, is that they don't have the money to fulfill that. That takes you back to the policy level and looking at not just food policy, which was the example, but things like Medicare, Medicaid, coverage of the uninsured Medicaid expansion in this country.

Segarra: Another area that we talked about is how the pipeline basically for health care because it's not just about improving conditions in these places, and for people of color, but also about making sure that there are people of color serving them as nurses and doctors in the health care field. Dr. Rios, you talked about that. We have a question from the audience: how do we get more minorities, and other allies, more quickly into the broad pipeline for health care? Doctors, nurses, public health policymakers, insurance industry professionals. Specifically, this person asked how do we get more funds to historically Black colleges and universities that graduate the larger share of doctors and other health scientists?

Rios: In general, our country has done a great job in educating more students about STEM, math, and science, and you can't get doctors and nurses without having good math and science background. STEM has been a great improvement in education. The policy level and the federal level under President Obama actually consolidated the STEM programs to have more programs to community colleges and to high schools and in our communities and in middle schools. On the other hand, the issue of the pipeline, it's a leaky pipeline from all the way up. If you're talking about medicine, which I know best, you go from high school, to college, sometimes a community college, but you have to go to a four-year college to get all your pre-med requirements. Then you get into medical school, but then you have to go to residency, and then fellowship.

We need faculty in our academic world, but we need doctors to work in the private sector too, whether it's insurance companies or what have you. I think what's important to realize is that what we don't have in the federal programs at HERSA, at the U.S. Department of Health and Human Services, have been good at giving money to the professional schools like the HBCUs, historically Black colleges, medical schools, let's say the Howard, Meharry, Morehouse, Charles Drew. They've been real good about getting money to that level, but what we really need is more, not just level of money for students, to recruit students to those medical schools. We need money for faculty. We don't have the role models, and the mentors who sit on the admissions committees to expand the number of students to get into our schools, to the medical schools. I think faculty development would be a way to go.

We have so many students, we've been funded by the Office of Minority Health for five years, we have a college health scholars program, and there are so many Hispanic and Black students that don't have families that are doctors. They thrive on meeting others and having group meetings and conferences and mentoring. If we could develop more mentoring programs, using our alumni of the HBCUs, the National Medical Association, the National Black Nurses Association, and our alumni from the Hispanic Health Professional Associations, I think we've been an untapped resource in this country. The money is going to the big medical schools to recruit, but here we've got nonprofits and alumni that are willing to step up too.

Frist: Marielle, I want to just jump in real quickly. I have, in policy, in Washington was a huge supporter of the historically Black [colleges] and aggressively so, and everybody needs to listen to this. When I graduated from medical school, I'm embarrassed to say it was long time ago, 1978, 2.9 percent of all medical students in America, this was 1978, were African American or Black, 2.9 percent. After everything that we've tried, after the focus on it, and the light, and some affirmative action, and the mentoring programs and improvement in K-12, all the things we have to do today... It was 2.9 percent. Today it’s 3.1 percent. I think I got it backwards because I use it so much. I think it was 3.1 percent back then, and 2.9 percent, but we're not making the progress. That's why everybody has to be in this together.

Rios: It has to be a more of a regional approach, with stakeholders from the school districts and the community colleges and the teachers and the advisers. I mean, sometimes we're our worst enemy. We have advisers who don't want to counsel students to become a doctor because they just don't think they have it in them, and it's just terrible. I agree.

Frist: K-12 education. I just got to throw it in there because we've got to get that right.

Segarra: On that note, I'd really like to hear from Dr. Iton and Dr. El-Sayed, if you have any thoughts on this, on solutions for this problem, maybe start starting with Dr. Iton.

Iton: Well, I mean, very consistent with what Dr. Frist and Dr. Rios were talking about, and there's a pipeline. We've studied this issue in California. We put $150 million into it several years ago, to try to facilitate the strengthening of career health care pipelines across the state of California. We supported a statewide commission on workforce, which has come up with a whole bunch of recommendations in California. When you look at the actual leakiness of that pipeline, as Dr. Rios talks about, it's fundamentally much earlier on than where we're making our big investments. I mean, it's really happening in that transition from high school to community college. That's where we have an incredible drop-off of African American and Latino students who otherwise are interested in STEM careers, but for a whole host of reasons can't make that transition into four-year colleges and then from the four-year college transition into medical school.

Looking at this issue and the data that Dr. Frist cites is heart wrenching. I mean, it really is. It makes your blood boil that we really haven't performed on this issue at all. Ultimately a deep, early look and investment at that early, late K-12 and early college, strictly community college, that's the critical link in the chain if you want to keep people on that path towards health care careers.

Segarra: Thank you. Dr. El-Sayed, we've got about one minute, if you've got anything to add.

El-Sayed: I really appreciate that perspective on pipelines. I think a lot of that gets back to some of these structural questions about how do you invest very early on and make sure that Black and Latino students are graduating from high quality high schools to begin with. The other point I'll make is that, we wrote a paper a couple of years back looking at medical student debt and Black and Latinx students, have substantially more debt coming out of med school than their counterparts. Investing in a free public college, and frankly medical school, the fact that Medicare pays for post-graduate education, it really ought to just pay for medical school because those folks are going into the same pipeline. When we know the capacity to take on this kind of debt, because of systematic differences in wealth, may be a barrier for Black and Brown students, it ought to be a place where we invest.

Segarra: Thank you to all of you. I feel like this has been really concrete and I'm so glad that you were able to talk today. Next up, we have another video from Richard Raya, director of Mission Promise Neighborhood, and he will talk about how the pandemic has affected Latinos in San Francisco.

[Begin video]

Richard Raya: Hi, I'm Richard Raya. I'm the director of Mission Promise Neighborhood in San Francisco. We're based in the mission district, which is a traditionally Latino working class, immigrant community. When COVID hit, it hit the Latino community in San Francisco the hardest. Latinos only make up 15 percent of San Francisco's population, but they were 50 percent of the COVID positive cases. We attributed that to families living, multiple families in the same household, unable to isolate or quarantine when one was sick. Living in multigenerational settings and also not being able to work from home.

We immediately started working with the city and the school district to reach out to families and to connect them to emergency services, housing, income, and also what we're calling Right to Recover. The Right to Recover fund in San Francisco was a fund that was created with local philanthropy and our city, and the city's public health department, to find families that were COVID positive but could not afford to quarantine and were living in a multigenerational setting, in a multifamily setting in one unit, were crowded, living in overcrowded housing. What we did as a community with the Right to Recover fund was provide that COVID-positive person with some funding so that they could number one, stay away from work, feel like they didn't have to go to work to keep bringing home money because they have a right to recover like anyone else. They have a right to stay home from work and recover, but then to make sure that they were not exposing the rest of the family and the rest of the household. We then worked to find them temporary housing, usually in a hotel room, so that they could isolate or quarantine. Community trust is foundational to the successful implementation of these types of programs. You may remember that there were plenty of scams happening around the time that the rescue package was being released. In particular, with us working with a low-income, largely immigrant, often monolingual community, they were often a target of these types of scams. They are justifiably wary about things that sound almost too good to be true.

To hear it from a community-based organization that they'd been working with for years, the community trusted us. They didn't bat an eye. The conduit of that community-based organization and the longstanding relationship that it had with that person, with that family, was just critical in getting resources out into the community very quickly on a very large scale. It's civic infrastructure; it's a coordinated response to a legacy of inequity. Building those systems to get resources out the door and being successful in doing that was inspiring.

[End video]

Segarra: One big takeaway here is we know what many of the problems are, but where are the solutions, and what concrete actions can be taken? We're about to hear from three panelists who have ideas, each of them will share a brief outline of their proposals. And then later on, we'll have some other experts here to respond and give feedback. I'm going to start with Dr. Wayne Frederick who's president of Howard University.

Wayne Frederick: Thank you very much, Marielle. This has been a very engaging conversation. Again, I thank the host for the kind invitation. When we think of our society and we think of doctors making house calls, while that practice has vanished, I would say the elderly citizens among us still struggle to recall the days when that was certainly involved. I must admit that the ideal type of health care structure, the medical system, should be centered around the patient. For too long, doctors have been at the center of our medical system. I think that we must obsess about the patient. My mentor, Dr. LaSalle Lefall, had a saying that the object of our affection is the patient. With that in mind, one of the things that I'd like to propose is a system that brings our focus back to the patient and have all of these other access points that allow for the patient to get their care where they are.

Our medical system, while it has been sensitive on the health care provider, with patients scheduling appointments, for instance, on our doctor's calendar, they must travel from their home to hospitals or medical offices, sit in waiting rooms until our physicians are ready; I think it's a broken system. That health care structure allows for doctors to see more patients by prioritizing the number of patients seen per hour. It also optimizes the physician's time by requiring less traveling, et cetera. Over the course of a day, a year, a career, more patients get care. As that system matured, retaining the best interest of the patients at its core, as they were still afforded a time believed necessary to address the issues. But about 30 years ago, the economics of this physician focused system was disrupted. Reimbursement for physician services began to drive the emphasis further toward greater volumes of patients served rather than higher quality of health care administered.

As the reimbursement with paid systems declined per visit, the physician needed to increase visits to maintain the same proportion, and profit margins quickly became the mantra for practice operations. Of course, it was not long before this spread to hospital operations, as you can imagine. Rather than staying in a hospital until well, it was a volume-driven operational cycle that got set in place. That current health care system, which is now centered on a pay-for-service model where the doctor submits a bill that must be paid either by the patient or by insurance, regardless of whether the patient improves has to be changed. Decreased reimbursement to providers also increases the incentive to focus on patient visits rather than outcomes. The immediate downside is that those who don't have insurance or can't afford more than one or two visits often, unfortunately, don't receive adequate care.

How can we put the patient back at the center of our system? As we think about putting the patient back to the center of our system, we think about racism and the big divide. You heard before from Dr. Iton about major cities having wide disparities and outcomes that happened right here in the nation's capital. In ward seven and eight, the life expectancy of a Black male is about 22 years less than that of a White woman in ward three, for instance. Those two words are separated by just a couple of miles. We clearly have an issue that we must address. There are multiple ways for us to do that, but to make sure that we're clear what we're addressing, African American individuals and African American communities experienced stark disparities in those outcomes. Black women have the highest rates of pre-term, single-term births at 11.1 percent. Black individuals are 30 percent more likely than White individuals to die from heart disease at an earlier age than expected.

Black men are more than twice as likely as White men to die from stroke. These are the inequities that form the basis. Howard University and Howard University Hospital have overcome some skepticism in the medical system to become a trusted health care provider and messenger in the Black community. We must continue to empower highly trusted institutions to provide health care services to more patients in a variety of ways. You heard earlier about concerns with respect to pipeline and Howard University sends more African Americans to medical school as an example. With that in mind, there are four things I'd like to suggest.

One is we should deploy more middle-level health care providers into communities to identify and assist those most at risk. When you look at residents of majority Black or under-resourced communities, there's a need for greater access to health care providers. Getting more of those providers into those neighborhoods where they can see those patients and do more preventative care is important. We've not only deployed health care providers around pharmacists, et cetera, but we've also looked at sending our nutritional science students into some of those communities to shop for healthy foods, and not just in groceries, but we send them to corner stores as well. Deploying a network of mobile health units to deliver primary care within communities, students that are heading back to school for instance, have to get a wide variety of vaccinations making it easier to get those kids access by taking mobile health units, having regular screenings through these mobile health units, I think would be helpful.

Building a national telemedicine network so people can be consistently monitored by a physician and receive our care advice I think is important. We saw what happened with the pandemic when we had to shut down and therefore putting things in place structurally, including Wi-Fi for rural communities so that people can participate in telemedicine is critical. The fourth one, again, delivering food to communities that have limited access. I agree with Senator Frist and his earlier comments about what we should be doing around that to ensure that patients can get access. Ultimately, when we look at solutions, one of the solutions that I would like to submit is that the primary issue is bringing more services and care and meeting the patients where they are versus having them come to us and using all of the providers. If you go into the pharmacy, we should be able to have screenings in our pharmacies, as an example. Thank you, Marielle.

Segarra: Thank you, Dr. Frederick. I'm going to move on to Dr. Stella Yi, who is an assistant professor at NYU Grossman's School of Medicine. Hi, Dr. Yi.

Stella Yi: Hi everyone. Thank you, Marielle. It's really a pleasure to be here today to share my thoughts on this topic. I'd like to talk about racism and health from a slightly different perspective and perhaps one that is not readily visible to the general population. It's the idea that the data infrastructure in this country disproportionately harms racial and ethnic minority communities in terms of health planning and funding decisions. It's an issue that has been particularly brought to light during the COVID-19 pandemic. By data infrastructure, I am referring to any and all systems that collect and use data that is broken down by race ethnicity. With the COVID-19 pandemic, of course, our health data systems are most salient, but really, the recommendations that I make today should ideally be extended to all data systems, including housing, income, and education, which would allow us to uncover and address the root causes of health disparities in a more holistic fashion. To illustrate what I mean by the racist nature of data infrastructure, which we posit affects all racial, ethnic groups, I'll provide a more concrete example that highlights the Asian American experience during the COVID-19 pandemic.

The underlying problem is that the current race ethnicity data driving policy decision in this country is of poor quality in two major ways. First, for example, as of yesterday, September 8, 2021, race ethnicity data was missing for 36 percent of cases and 17 percent of deaths at the national level, demonstrating that our present data systems cannot reliably track the overall impact of the COVID-19 pandemic for different racial ethnic groups. Yet these flawed data are being used to drive funding decisions, policy making, and resource allocation. Why is this racist, then? Because these errors in racial ethnic category are more likely to impact Asian Americans and other minorities as has been shown in Medicare and electronic health record data from large hospital systems. Therefore, any COVID-related data points on these groups are unclear, which allows for local state and federal government to exclude these individuals from social service provision and other support.

This is exactly what happened in September of last year. At that time, the National Academies of Science, Engineering, and Medicine, or NASEM, announced their framework for the equitable allocation of vaccines. It did not include Asian Americans in its priority lists of racial ethnic minority groups. This happened despite our submission of a 10-page letter during the NASEM public comment period that had been cosigned by 80 national partners describing the disparities being observed in Asian Americans during the first six months of the pandemic. The second issue with current data collection of race ethnicity is that it indiscriminately groups unlike people together into arbitrary category. For example, grouping Chinese Americans with Asian Indians into a larger Asian American category, or Arab Americans with Whites. Mexicans with Cubans in the Latin x/o category, or Caribbean Blacks with Black African Americans. Subgroups within larger racial ethnic categories have different histories, cultures, and demographic patterns that can greatly affect health outcomes and access to care.

We need to be able to unpack and appreciate these differences to enact policy in a meaningful way. Yet most data systems only report on these larger racial, ethnic categories. Given these concerns, we offer a few recommendations: first, we recommend that adoption, requirement and enforcement of a standard, or collection and reporting data for a specific racial ethnic subgroups be enacted across all state and federal agencies. This is not new. We have excellent models to learn from, to guide these changes, including the recent census experience and the preparatory work led by the Robert Wood Johnson Foundation and policy link leading up to the census. State level examples in California, Oregon, Michigan, and our experience in leading these efforts from New York State and our large academic health system.

Second, we also would like recognition that updating race, ethnicity data collection is a complex, time-consuming and expensive undertaking. Policy change, or simply changing categories, is not enough. It needs to be a multi-sector initiative with community-based organizations, community members, data managers, health care, clinic staff, government, and academia equally at the table for it to be properly implemented. Importantly, trust needs to be built in communities of color for them to want to report such information to government and other institutional entities.

Finally, we advocate for efforts to not only focus on how race ethnicity data will be collected in the future, but to be mindful of what efforts can be made to improve the quality of data that we already have in hand by reclassifying individuals who are misclassified in the first place. Close: poor quality race ethnicity data is systemic racism. We must capitalize on this period where there is political will for inclusion and data equity. The time is now to update our data infrastructure at the state and federal levels in the US for improved public health and for the economic prosperity and productivity for our country's citizens. Thank you.

Segarra: Thank you, Dr. Yi. Last up we have Dr. Zyan Malawa, who is perinatal equity medical director at the San Francisco Department of Public Health. Dr. Malawa, welcome.

Zyan Malawa: Hi, thank you so much for having me. I'm really excited to be able to participate in this conversation. I'm a long-time fan of health equity, so I'm really glad to be with this panel of experts. I'm going to talk to you today a little bit about racism and its impact on birth. In the United States, too many Black families are shut out of the resources and the opportunities that they need to have for healthy pregnancies and births. In San Francisco, and across the US, as a result one of our worst health disparities in this country is impacting some of our smallest residents.

In the United States, Black babies are more than one and a half times as likely as White babies to be born premature. When babies are born even a few weeks premature, it can have tremendous impacts on their entire lifetime of health and wellbeing. Additionally, Black mothers die as a result of childbirth at a rate four times as high as that of White mothers. I want everyone to just consider what that means. That means that Black families are four times as likely to come home from their birthing experience at the hospital without the mom. In cities with high income disparities, like San Francisco, these birth disparities are even wider.

A lot of times, people assume that these differences that we see in birth outcomes are due to differences in behavior. Differences in things like who is smoking during pregnancy, or what kind of food are people accessing during pregnancy, but the data say otherwise. Increasingly, we can identify that racism and the stress that is related to racism are really at the root of these disparities. We know this because this issue is impacting not just low-income moms who may not have access to some of the health resources that they need, but it is also impacting middle- and upper-income moms. That being said, we know from data that in particular, economic stress from poverty that impacts Black people is a particular driver of these racial disparities. In San Francisco, for instance, the median income is around $3,000 for families on an annual basis versus for White families, the median income is around $121,000. That level of annual income disparity is one of the critical drivers of these birth outcome disparities that we see in the city. As a result, in San Francisco for instance, we can say that 23 percent of Black pregnant people are homeless or don't have a place to sleep during pregnancy. That's in comparison to less than 3 percent of San Franciscans on average. We know, after decades of evaluating this issue, that medical interventions are not going to be helpful. Neither educational campaigns or home visiting programs have been proven to be successful in reducing these birth disparities.

This isn't surprising to me because I know that there is no pill for centuries of racism, and there's no educational flier that can fix systemic economic exclusion that's impacting Black families. What can we do about racism? How can you begin to shield Black birthing people from the impact of structural inequities? I think I know one way. My team, we are proposing cash during pregnancy as a potential solution for addressing this very serious issue. We're proposing that we could provide $1000 a month of cash to Black pregnant people from as early in pregnancy as we can get to you to two years postpartum as a way of really reducing your stress levels during this critical time of your life. The money would be available for both low- and middle-income Black people, because we know that middle-income people in a lot of these cities with high levels of disparity often make too much money to be able to use public benefits, but don't make enough money to meet their daily needs.

The money would be provided on a renewable debit card, and the cash would be unconditional because we trust birthing people to know how best to meet their needs. This program would have a low paperwork burden as another way of reducing stress for birthing people. Also, it would only require a proof of pregnancy and a proof of income once a year. We think that a program like this could alleviate stressors during pregnancy like financial worry and food insecurity. Also, things like housing insecurity and the ability to pay for your medications might be impacted by a pregnancy cash supplement.

We also know that a lot of Black mothers are trapped in low-wage, physically intensive jobs, and often have to work more than 40 hours a week to make sure that they're making ends meet. We think that an intervention like this would allow Black mothers to have more of an opportunity to rest during pregnancy, which is critical to produce healthy births. While we have never seen a program like this in the United States yet, data from international studies, for instance, the Oportunidades program from Mexico or a pregnancy cash supplement from Manitoba, Canada makes us feel very hopeful that this might make a big difference. In Canada, they were able to reduce preterm births by 17.5 percent with a relatively modest monthly cash supplement. For context, we in the United States would be thrilled if we could reduce preterm birth rates by as little as 5 percent with our medications. An impact level of 17.5 percent would be huge.

We've been talking a lot in this country about social determinants of health, and yet there are so few interventions that are actually addressing the social determinants. I believe that when we invest during pregnancy, we're not just investing in Black mamas and babies, we're investing in educational achievement and neighborhood stabilization by allowing these families to be able to reach their maximum capacity. We're investing in local small businesses by putting more cash into areas where there generally isn't a lot of access to capital. We are also actively combating racism in our communities and taking corrective steps for the racial harms of the past. Also, when we invest in pregnancy, we are investing in our future and I desperately want to live in a future where Black mamas matter and every baby, regardless of its race, has a healthy start. Thank you.

Segarra: Dr. Malawa, thank you so much for that. We are going to get responses to these policy proposals, but first, we have a video from Harold Frazier who's chairman of the Cheyenne River Sioux Tribe in South Dakota.

[Begin video]

Harold Frazier: My name is Harold Frazier, and I'm chairman of the Cheyenne River Sioux Tribe. Our reservation is 3.1 million acres. We probably have about 15,000 to 20,000 residents. We have probably about 90 to 95 percent unemployment. It's really hard, but because of the limited number of hospital beds, we felt that prevention was key. Not only did we educate our people in COVID, but we put up some health check points to try to limit visitors from coming through or coming into our reservation. We know the numbers out there when it comes to Indian health services with high poverty, and we've got a lot of diabetes, I mean, big time diabetes, moderate respiratory issues. Even now, when we look back, it has impacted that type of population. One of our biggest challenge was jurisdictions. We have to deal with the state of South Dakota, and they didn't play very well with us.

One of the things that we learned is that they don't have any right of ways or easements for any type of roads on our reservations, so that was really helpful. It just got pretty bad where even the president's chief of staff personally called me, tried to make deals and whatnot. It even got to a point where the Bureau of Indian Affairs had 55 BIA police units in Fort Pier, and they were trying to come in and take over our reservation. I really wished that we could've worked together, but it is what it is. The only way that they look at us Indians is that dollar sign. Some of the people don't get the right care. They're kind of pushed in the back of the, I don't know, the room, I guess. I'm saying it mildly. We don't have specialists, heart doctors. Just things like that.

Again, we're such in a tough area where you have to go 90 miles for your nearest Walmart and it's really hard to recruit people. There's a lot of limitations with the government rules on how much you can pay somebody. A lot of unfilled positions, a lot of services that are not going to be met or not available here because we don't have number one, the personnel or even anything else. We have an eight-bed facility that is not fully staffed, so we don't have all the services there. I think all the measures that we've done, particularly with checkpoints and contact tracing have really, really done a lot.

I'd like to say our biggest strength is our people, and it's a good... I've lived here nearly all my life other than going away to college, but you know our people. I mean, there's times of need and everybody stands together, and we walk through whatever challenges that we faced. I think their biggest thing that makes me proud is the people that stood for sovereignty when we put them checkpoints up. I've been saying this, the president of one of the most powerful countries in the world couldn't remove our checkpoints and with the threat of taking funding away from our law enforcement, and our people said, "Go ahead and do it, we'll do it ourselves." That has really made me proud.

[End video]

Segarra: That was Harold Frazier, chairman of the Cheyenne River Sioux Tribe. We're going to move on now to the response portion of the event. We have a few panelists who will give feedback on the proposals that you just heard, and share thoughts based on their own experiences. Just a quick note on that, Darlene Lambos was unable to join us today. Dr. Abdul El-Sayed, who was on our first panel, will be standing in for her. At the end of all this, we will take questions again from the audience. If you have any, you can continue to ask them on Twitter or by email. We're going to start with Stacy Bohlen, CEO of the National Indian Health Board, a nonprofit that represents and advocates for tribal governments on issues of health care. Stacy, can you just tell us a little bit about the work you do as well as what stood out to you in these proposals?

Stacy Bohlen: I just wanted to give a traditional greeting. My native name is Turtle Woman, and I am Stacy Bohlen, the CEO of the National Indian Health Board. I'm a citizen of the Sioux St. Marie tribe of Chippewa Indians in Michigan and our organization serves and represents all 574 federally recognized tribal governments, American Indians, and Alaska natives in the work to uphold the treaties, the trust responsibility, and the government-to-government relationship, the promises of health care that were traded for lands, cultural lives. We work on that every day, health care, public health facilities, construction, and so forth. You had a first question that you wanted to ask?

Segarra: I just want to know what stood out to you from these proposals and what you thought you could see working possibly in your community.

Bohlen: I thought that the proposals were very much intelligently and elegantly developed for the problems and challenges that each of the presenters was specifically looking at. I think that the realities in Indian country are quite different. May I talk a bit about the structural racism topic today as it pertains to Indian country?

Segarra: Of course.

Bohlen: OK, thank you. When you think about the United States of America and all that we have and all that we are, this whole continent was very well populated by American Indian, Alaska native people prior to first contact in 1492. When Columbus stumbled upon this continent full of people, very capable people, rich with indigenous knowledge and generous people, he went back to his funder, which was Spain, and said we need to do something about these folks that are all over this continent, because we're all about the gold and the land, and they're in the way.

I'm truncating what was likely said. Along with other countries, including England, leadership went to the Vatican and went to the Pope and requested help with how to bring about ownership of all of these lands. The Doctrine of Discovery was established at 1493, and it was a document that basically said if there are no Christians running a country that you encounter, then they are people without souls, and you are free to take whatever you find, including them, because part of what was included in the Doctrine of Discovery was the establishment of the right to take African people out of their countries, because they didn't have souls either, says the bull of the Vatican, and put them into permanent slavery. The words in the document are permanent slavery. In this regard, I don't know that many Americans are aware that American Indians and African Americans from slavery are inextricably linked in history. We are wound together like the roots of a great tree in this saturated foundation of racism and systemic colonization which persists today. I want to give you a visual of how I see this. I don't know how many of you are familiar with the French physicist who created Foucault's Pendulum. It used to be actually in the Smithsonian, a replica of the pendulum, but it was moved for a giant American flag. Anyway, in the last 30 years. Foucault's pendulum, the physicist, Dr. [Léon] Foucault, believed that he could create an apparatus that would run into perpetuity solely on the magnetic force of the earth with very little prompting, and he was correct. This is how I see the very elegant construct of colonization because once the doctrine of discovery was put in motion, put into play, and Portugal, Spain, England, Denmark, all kinds of folks from Europe jumped on the opportunity to... oh, France, of course, jumped on the opportunity to take full advantage of that doctrine of colonization.

It's interesting. If you look today at health disparities across indigenous people who were colonized, like by England and Spain, the political constructs in which we live are all very unique, but our health disparities are identical. I don't want to get into a race to the bottom because unfortunately American Indians and Alaskan natives always win that race, as of today, anyway. I mean, when you have suicide as the number two cause of death of your children, you're getting tuberculosis several hundred times higher rates than anyone in America, you have a health system that was promised on the condition that you get off your land, your way of life, your life, your culture, and then it's funded at 40 percent of need. It's no wonder we're three times more likely than anyone in America to die from COVID-19.

Segarra: Yeah, I'm going to stop you right there.

Bohlen: I'm sorry. Thank you.

Segarra: But I do appreciate the background. It's helpful and I think maybe towards the end we can come back to the policy proposals and whether you think any of them might work with the groups that you work with. For now, I'm going to move to Dr. Abdul El-Sayed, and I'd love to hear from you. You've got five minutes. I'd love to hear what you thought of the proposals and any feedback you have.

Abdul El-Sayed: Yeah. I want to say thank you and kudos to all of our presenters and Dr. Bohlen for her really thoughtful description of the structural circumstances under which Native American peoples have been foundationally discriminated against. When it comes to the first proposal, I really appreciate the idea of centering the people in the work that we do in public health and in medicine. As you think about it, right, the beginning of the description starts with that idealized image of the physician doing house calls. Obviously, anybody who's interacted with the health care system knows that's not the way the system works anymore. It does remind us that we have to locate health interventions in the places where people learn, live, work, and play.

There are a lot of ways that we do that today. They've just been systematically disinvested in, whether it is, the federally qualified health center that is intended to live in the neighborhoods in which people live or it's something as simple as a school nurse in schools where people are learning and teaching. We have to rethink the way that we provide health interventions. I'll also say that it's not just the clinical intervention, right? It's not just ministering to someone who is ill. It's also asking how do we change the circumstances so that people never get sick in the first place. You know, you think about things like school meals, free school meals, and the debate that we had a couple years back, nearly a decade ago, about whether or not that the tomato sauce on school pizza was a vegetable.

To echo points that Senator Frist made, thinking about food as a health intervention and asking why we subsidize corn to the degree that we do and why we allow corporations to put foodstuffs or simulacrums of food into places where we know that our children may in fact spend money on them, whether it's sugar-sweetened beverages or, you know, Little Debbies cakes, when we could just as easily provide better services. Or, thinking about, you know, where you put a farmer's market. This is an important framework and I appreciate that being brought up. The second intervention that was discussed was about collecting health information. I say this as an Egyptian American and, despite the fact that I've never really been treated as White for a day in my life in this country, I am labeled as White and health information collected about me and my family group us, at best, as part of an other. At worst, clump us in with the White experience. As someone who started my career studying Arab American health, it reminds me that you cannot fix what you do not measure.

The second point here is to remember that race and ethnicity themselves are not health exposures. They unfortunately are a marker for exposure to racism, and we have to get smart about the way that we measure racism rather than simply being lazy and measuring race as a marker for this. Then, the last really important intervention that we talked about was thinking about providing non-conditional cash transfers for newly pregnant people and particularly newly pregnant Black folks. I think this is a really, really important point, and frankly, there's a lot of validation for this idea in the childhood tax credits that we're seeing now that deliver a monthly check for children.

I also think that there is an important viewpoint that is being offered here about the responsibility to target people who have been the victims of structural discrimination, particularly as we think about the handoff of life, right? Going from pregnancy to early childhood and doing so from a municipal level. I do hope that in San Francisco they will well study the outcomes of this because I do believe that it's going to have real impact. You know, one example from our city, in the city of Detroit, as a part of a program that we built around preventing prematurity and infant mortality, we simply provided Lyft rides for pregnant women to get to their prenatal visits. [We] found that over the course of two years we were able to reduce both infant mortality overall but in particular disparities in infant mortality because of a massive reduction in infant mortality among Black pregnant people and Black infants.

These kinds of interventions can have huge impacts and I'm really grateful for having heard about them. Thankful to our innovative thoughtful leaders in offering perspectives on how we can center people themselves in the provision of health, health care and public health, and the opportunity for us to really focus on measuring the right thing and being thoughtful about how we measure. Then, lastly, really thinking about the power of unconditional cash transfer at the handoff of life.

Segarra: Thank you so much, Dr. El-Sayed. I want to now bring in Andrea Walsh, who is president and CEO of HealthPartners. Andrea, if you could just briefly tell us what HealthPartners does, and then I would love to hear your thoughts on the proposals and how they might work from where you sit as the head of a health care company.

Andrea Walsh: I appreciate the opportunity to be here today on the panel and to share some perspective. Like Dr. El-Sayed, I really appreciate the thoughtfulness and the creativity in the proposals that were shared and the dialogue and discussion that's happened throughout the course of this session today. HealthPartners, as some of you may know, is a consumer-governed health system. We're located in the Twin Cities, the Minneapolis-Saint Paul area and serve the Upper Midwest. We provide care through our care group to about 1.2 million patients and provide insurance coverage and health support to 1.8 million people who live across the Upper Midwest. Our mission is one, as a nonprofit, of health and well-being, and we put a particular emphasis on the importance of building trusted relationships with the people we serve and the colleagues and the communities that we serve in. I think this theme of trust is definitely one, and trust-building is something that I take away not only from the policy proposals but the earlier dialogue as well.

At HealthPartners, we have a strong commitment to equity and inclusion, eliminating health care disparities gaps, and in the past year have put a particular emphasis on what it will take to build ourselves as an anti-racist organization. We view this work as long-term work. We've got a long history of working in the area of health equity. We've made some progress as it relates to closing health care disparities gaps in preventive screenings and we have a long way to go. We've also had a focus on maternal and infant health, so I was particularly encouraged by the comments related to the importance of a healthy start for all of our children, particularly for our children of color.

As I think about what I heard today and the importance of health care and health equity and addressing health inequities, there were a couple of themes that I just want to highlight. The first is I think they're part of best practice. The first is that data matters. It helps you to know where you're at and whether or not you're making progress. At HealthPartners, we've collected data on language, on race, and on country of origin for our patient and our health plan member populations. It's been incredibly helpful for us as we build relationship and work in community. We've also led community-wide efforts in the State of Minnesota on efforts to consistently collect this kind of data. The appeal for standardization in data collection across the country is something that is important.

The second theme is the importance of diversity of team and leadership, that as we look at our ability to serve an increasingly diverse population, we need to have our teams and our leadership teams reflect the diversity of the people that we serve, and it's something we're working hard at.

Third and finally is this area of trust building. Dr. Frederick's point about building a system that is patient-centered and focused on outcomes particularly resonates with me and I just want to share a couple of examples of some work underway within our organization and within our community that I think speaks to that vision of patient-centered care, patient-centered health focused on outcomes and built with community, not for community, not to community. This whole notion of co-designing with community is something that I saw in both of the proposals of Dr. Frederick and Dr. Malawa, and I think are really important.

My two quick examples. The first is our region's family birth center. We want a healthy start for all babies, just as the conversation goes in San Francisco. Today, more than 60 percent of our patients delivering babies in Saint Paul come from diverse backgrounds and approximately 25 percent of our patients speak English as a second language. We've had considerable work underway as we built a new birth center, a new family birth center, to know and understand the populations that we serve and to have our patient populations help us design the experience of care to best meet needs. We worked in partnership with Penumbra Theater, which is a theater that is focused on the African American experience, and actually engaged in experience learning that I think helped us codesign a birth experience that's had a marked improvement for our African American woman delivering their babies at Regions Hospital.

I see my colleagues are joining me on a panel discussion, so I'm going to pause here, and I'll build my stories, if they're applicable, into the rest of the conversation. Thank you.

Segarra: Thank you, Andrea. We have maybe about 15 minutes left, so I want to bring back the policy presenters from before to have a broader discussion now. And, one place to start is ... Andrea, you talked about this as well. What does it mean when someone distrusts the health care system? This is a question we got from the audience. What are the implications for that person's behavior or health outcomes or their community's health? Also, what's the source of that mistrust? Maybe I will start with Andrea because you brought this up. Like, what are your thoughts on that? What does it mean when someone distrusts the health care system?

Walsh: You know, I think when someone distrusts the health care system, they choose to not work with the health care system. I think about women who are pregnant and choose to not seek out prenatal care, despite the fact that we know part of a healthy birth experience starts in the care that's delivered during the course of your pregnancy. Within our system at HealthPartners, we know once we're able to reach our patients of color and engage with our patients of color in prenatal visits, we're able to establish relationship and rapport and people stay with us. We've got to build that trust on the front end and engage in relationship building. Otherwise, we don't have the opportunity to help meet needs and meet patients where they're at, to Dr. Frederick's point.

Segarra: Dr. El-Sayed, I would ask you to respond to the same thing, and particularly this person's question was, what is the source of that mistrust and is it primarily because of people's personal experiences with doctors or is it historical in nature? What are your thoughts on that?

El-Sayed: I think there's a couple ways to look at it. One is the path dependency and the justifiability of it. The second is the ways in which our current system of conversation and public discussion may increase it, whichever way it comes. I think for a lot of folks, there is a real and justified fear about what the health care community and the scientific community have done in the past which underwrites a certain mistrust. If you have read about or heard firsthand about people who look like you being abused in the name of so-called science, that's going to make you think twice about whether or not you trust. For other people, there is a moment in our politics right now where there is a deep and profound mistrust not just of the health care community, but any system of authority, whether it is expertise or government or major organizations, that I think is part and parcel of a political discourse that is taking hold.

It's impossible, honestly, to talk about mistrust without talking about misinformation and disinformation and the nature of social media in creating a system where we basically incentivize the most alarmist types of information to go about as viral as they can go because this drive clicks, this grabs eyeballs, it makes money for a lot of the platforms that I think are part and parcel of this moment of mistrust.

What's operative is two things. Number one, I think it's incumbent on health people, and I say this in a number of different ways, whether you're a pastor of a local church working on COVID vaccines or you are a clinician or you are a public health authority, to think differently about the way we message. I think in the past we used to be able to rely on authority to assume that we were going to be able to earn people's trust. I think those days are long gone. The other part that doesn't work is wagging a finger and telling people that they ought to make the good decision for themselves and their family members. There has to be a level of empathy and a dialectical conversation that listens first and speaks second. The second point, though, is also from a public policy framework. I think there needs to be a rethinking about the power of these platforms that have the ability to maximize and potentiate the kind of mistrust that we're seeing, and I think we've got to take this on in a two-pronged way.

Segarra: Thank you so much. I also want to come back to you, Stacy, to ask you about the idea of implementing some of the proposals we heard earlier in the communities that you work with. Would that be difficult? What might that involve? And does jurisdiction conflict come into play there, as Harold Frasier mentioned in his video?

Bohlen: Thank you for that. Well, understanding that the short answer is yes. Of course, you can implement programs like this as long as they are something that any particular tribe wishes to take on and make it culturally competent and relevant to the community in which it would occur. Particularly interested in anything that increases infant mortality and the health of mothers throughout the pregnancy process. We have very, very serious challenges in Indian country around that. Financial incentives may work for some tribal nations, but it won't be a one size fits all in any of the scenarios that were mentioned, unfortunately, or fortunately.

Segarra: Gotcha. I would also like to come back to our policy presenters. Dr. Yi, we got a question for you from the audience, which is how can media and other messaging systems better and more accurately report disaggregated data to help the general public understand the importance of how different subgroups within racial categories are impacted? And what is helpful there and what is harmful?

Yi: I can speak from this perspective because we work primarily with Asian American communities. I see it particularly with racial ethnic groups that are underrepresented within health systems or health data or any data, to be honest. There's a tricky balance between, you know, reporting on data that's in the aggregate form because it's available in that form. Maybe it's Asian Pacific Islander. Maybe it's Asian American. Maybe it's somewhere else. Versus not reporting it all because you don't have any disaggregated data available.

At a minimum, Asian Americans and other smaller groups that are not well-represented and very often misclassified in data, should be reported on within media, within research articles. You would be shocked to understand and to see, like, on a day-to-day basis as researchers where you are presumably working with others who are looking at data in an objective fashion are 100 percent putting the data through a filter and then reporting out what it is that is a reflection of their implicit bias about different communities.

Number one, I think at a minimum, reporting the data that's there and addressing the implicit bias that you may have about a community and why or why not that community should be in the data to begin with. And then, secondly, yeah, ideally we would have data that's disaggregated by subgroups, and in the cases where you can't do either of those things, there should at least be a comment, whether it's in the media report or it's in a research article, about why those groups are not included in the first place. It is like a kind of complex thing because we are working with data systems that all collect this race ethnicity data in a different way, which is why it needs to be more standardized.

Segarra: We also got a question from the audience that I think it would be really interesting to hear a response from Dr. Malawa and Dr. Frederick. So, the question is, social determinants of health, changing those is crucial to improving health in under-resourced communities, but so is addressing racism in health care on the part of practitioners towards patients. How do we create change in these systems and take the concentration off the habits of patients? I'll start with Dr. Malawa there.

Malawa: Ooh. I have so many thoughts about this as somebody who practices with a number of providers who have wonderful intentions and a lot of racist impacts. I think that one of the challenges that we have in this country is that there isn't any kind of accountability for providers and health care systems that are creating racist impacts. There isn't any kind of financial incentive for hospitals to meaningfully take on racism within their walls, nor is there any kind of financial consequence for health care systems or individual providers who are reproducing racism.

I think that when you look at how racism is impacting birth in Black... and, thank you so much for naming indigenous communities when you look at the ways in which racism is impacting us. I think we recognize that centuries of racism are not going to be solved by, like, a single solution. Yes, we need to put back what has been broken, and cash is a good start to that. But also, yes, we need to create accountability across health care systems and criminal justice systems and educational systems and these other systems where birthing people are frequently interacting so that racism is no longer tolerable or profitable. So, I really think that developing systems of accountability is going to be critical to the effort.

Segarra: Thank you. Dr. Frederick, what are your thoughts on this?

Frederick: Being the president of Howard University and having the undergrad campus that sends more African Americans to medical school, I would say impacting the pipeline. We need more physicians who are willing to go to those communities to participate in providing care. AAMC [the Association of American Medical Colleges] has shown that the historically Black medical schools are the top three leading schools in terms of social interest, in terms of where people go to practice after, and I think we have to encourage that.

Every Black patient or patient of any race or ethnicity doesn't have to see a physician that looks like them, but I do think that we have to provide cultural competency training as a standard aspect of what we do, especially in our medical schools. I think the Black curriculum should be standard, and I also think in our residency training programs, we should do that as well, and if we put more effort there, we could certainly have an impact on that as well.

Segarra: Thank you.

Walsh: Can I just build on that a little bit?

Segarra: Of course. Yeah.

Walsh: I do think this issue of cultural humility is so important and creating health care systems where everyone is welcomed, included, and valued starts with each individual that works within a system and then the teams that support patient care and the teams that work in community. I think one of the most important changes we need to see to really advance more health equity is better partnership between health care institutions and community, and creating cultural humility is really about codesigning with patients, with community, as opposed to super imposing a definition of what a good health outcome looks like through a Western medicine traditional White view. A lot of the reframing that needs to happen starts in the dialogue and in building cultural humility, a journey we're all on.

Segarra: Yeah. I think one thing that's come up again and again here is trust, this question of trust. And, I've just been reflecting on like how you rebuild that. I want to throw this question out. We have about a minute left. Maybe I'll throw it to Dr. Yi. Do you have any thoughts on that? I mean, you had very concrete ideas for like data collection. The trust part can be a little squishier, you know? But have you done any thinking about that?

Yi: One of the cornerstones of the center that I work in, which is the Center for the Study of Asian American Health, is working directly with communities for their input, and data collection is no different. It's a complicated process where you really want to have all of the different parties at the table because on the one hand, we're working with clinicians where they're like, "Well, you can't have too many choices because then the form gets unusable and it's not really a streamlined process for check-in." Right? But then, on the other side, you want to build the trust between the patient and the hospital system, and you want that patient to go into the system and see themselves within the data. You know?

To talk about Abdul's point about being Egyptian American and being invisible in data, right? That is the experience of many people that are watching this panel and that may be listening in. There's a balance between having community input, having those categories that are available be driven by census data, but also bringing community members to the table to input on to whether or not those are the right categories to be including in the first place.

An example of that, just to be more specific. Here in New York City, there is a large proportion of immigrants who are Afro Caribbean and Indo Caribbean that are from Guyana. When you talk about having different people reporting on the subgroups from the countries that they're from, where do you put that category? Do you put it under Asian? Do you put it under Black? Where do you put it? That's where the community conversations are important. You can't just be going by paper and going and relying on census data and other administrative data. You really need to bring the community into play to make those decisions for themselves for them to actually be visible and ultimately for the data to be usable to be beneficial to them as a whole.

Segarra: Thank you so much, Dr. Yi, and thank you to all of you. This has been really interesting, and I think a great discussion. It is now time for me to hand this off to Vayong Moua at Blue Cross Blue Shield of Minnesota for a panel with several Fed presidents. But first, we have one last video from the community, from Lashyra "Lash" Nolen, a Harvard med student and founder and executive director of We Got Us.

[Begin video]

Lashyra Nolen: My name is Lashyra Nolen. Most folks know me as Lash. I'm a Harvard medical student and I'm also the founder and director of an organization called We Got Us. We Got Us is a Boston-based empowerment project where we are here, primarily in the communities of Roxbury, Dorchester, Jamaica Plain, really talking to folks about the vaccine, getting their questions answered, making sure they have access to the vaccine. We were formed out of recognizing the need to make sure that our communities had access to this public health tool. A lot of these communities are predominantly people of color, a lot of Black folks, Latinx folks, indigenous peoples, and those are the folks that we're predominantly working with. Before we decide which communities we're going to go into, which communities will vibe with a certain event, which communities have the most need, we're talking with community activists and organizers. You shouldn't be doing anything for the community without the community's input. I think the way that they've received it is quite positively because they've really been the guiding voice and the guiding light behind all of our work. I think that as long as we allow community members to be at the forefront of the change they want to see, then you can't go wrong. I hope that the lesson that we learned from this pandemic is that we have a systemically oppressive system where you have folks who have a lot and those who don't. Who has access to quality health care? Who has the privilege of paid leave?

I think that when we think about this idea of the essential worker and who is the essential worker, who are the folks on the front lines risking their lives to keep our economy going? Those are the individuals who were being disproportionately impacted by the pandemic. All that was broken before was exacerbated. When you think about this tool, like a vaccine that comes out and you expect people to come to you when you haven't a) acknowledged the pain and suffering that you've caused their community, and b) really taking the time to explain the technology behind this and really getting on folks' level.

I think that, of course, you're going to have an issue with trust. I think that trust is something that's built with time and it starts with acknowledging the wrongdoing. It's going to take our entire society to come and really have this reckoning in saying, "Look, we've done wrong. What are the steps that we can take to do right? And how can we tangibly do so?" Not just for the pamphlets, not just for the hashtag and not just for the clout. And I think once we get to that space, we'll really be making real progress.

[End video]

Vayong Moua: Good afternoon. My name is Vayong Moua and I'm the Director of Racial and Health Equity Advocacy at Blue Cross and Blue Shield of Minnesota. I want to first begin by thanking the Federal Reserve Bank for hosting, not only today's conversation, but the entire series of conversations. Connecting structural racism with education, with criminal justice, with multiple systems. There's strength in recognizing that racism is both occurring at the personal level as well as the structural level. I applaud the Federal Reserve Bank to making this an ecological issue and connecting the dots.

Before jumping into today's conversation with three presidents of the Federal Reserve Bank, we have Neel Kashkari with Minneapolis, we have Robert Kaplan with Dallas, and we have Eric Rosengren with Boston. Before jumping into that conversation, which I look forward to, I wanted to offer a few reflections on what we heard today.

There are many themes to draw upon, many data points, many stories, that in my view are both very haunting, disturbing, and also very inspiring. I look forward to hearing how our panel responds to the data, to the stories, to the perspectives that have been shared. One key takeaway I want to lift up from the conversation today is that racial and health inequities are political. That we're not only dealing with social determinants to health, we're dealing with political determinants to health. When I say political, I don't mean partisan. I mean that these social conditions that we're dealing with did not just arise out of thin air. They're not just inevitable conditions in society, that they were decided upon. That there are policymakers, that there's power at play that shaped and created these inequities. Which then leads to the other point I want to really reemphasize, which is the very definition of health inequities, which is a difference in health that is preventable avoidable and unjust.

I just want to hold those realizations in mind, that everything that we're talking about today, the structural racism, the racial health inequities that we're dealing with, are preventable, avoidable, and unjust. When you dissect the social determinants of health, if you could see the infographic that creates health, most of what creates health happens outside of health care. Most of that is created by people. These are human constructs I just want to remind us of both the tragedy and the triumph that is revealed in the understanding that health inequities are created by us, and so we do have the ability and the accountability to change that.

With that preface, I'm going to jump into this conversation with Eric, Robert, and Neel. We can take this in many ways, and I just want to say from the outset that in conversations about structural racism, we have to be comfortable with non-closure. We're not going to get through everything today, but I want to at least initiate this conversation with you all.

This question is for all three of you, and maybe we can begin with Neel. What stood out to you today in terms of resonance as well as disturbance? Whenever we talk about structural racism, I think it's easy to think about the devastation intergenerationally, but what stood out to you in terms of resonance and disturbance?

Neel Kashkari: Thank you Vayong for hosting this conversation, this panel, and thanks to my colleagues. Three things really jumped out at me. As I have more time to reflect on it, I'm going to have more takeaways, but these are my three initial ones.

One is, how little I know about the health care sector. I heard this from staff as they were planning this, the health care sector is 18 percent of the GDP. It's a really important, big part of our economy. I think, at least for me, I don't think it's an exaggeration, I don't think I'm out of school to say, the Federal Reserve doesn't know as much about the health care sector as we do about other sectors in the economy. I knew that we had a lot to learn about criminal justice, but this session opened my eyes, that I have a lot to learn about racism in the health care sector but also just about the health care sector, which is a big important part of our economy. This is the beginning of my learning at least and there's a lot more work to be done. I'm glad that we're able to get so many experts who have deep lifelong knowledge to draw from for this conversation.

That was one. Second, something you touched on in your introduction and that Bill Frist touched on, some of the racism that we've explored in this series are about racist policies of the past that we're trying to undo. Think about FHA's racist housing policies after World War II, there are still legacies of that today, but those policies were actually changed decades ago. As you said in your intro and as Senator Frist said, our food policies and our ag subsidy policies are ongoing drivers of disparate outcomes in our economy and in society today, and that's what he talked about and you've talked about. This is part of our political process saying, "We need to address this." We've addressed some of the racist zoning policies of the past, but we have active, ongoing policies that need to be addressed now that are leading to disparate health care outcomes. That was an important takeaway, I learned that today.

Then third, education. At the Federal Reserve, we have a big initiative. We really want to hire more, for example, minority PhD economists. We especially want to hire more Black PhD economists. That's an active strategy of ours. When I heard that we had made no progress as a country in 40 years in producing Black doctors, I was shocked by that. I confess, I naively assumed that the medical profession was doing much better than the economics profession and that they were making progress and we could learn from them. Well, we now need to learn from them on, "What have you been doing and why has it failed?" because we need to do better. We don't want to just go repeat what their medical schools have done unsuccessfully and then be surprised when we don't make any progress in the economics profession. Those are just three quick takeaways that are eye-opening for me and I need to take more time to digest it.

Moua: Thank you, Neel. I'm going to pass the baton to Eric. Same question posed to you. Your reflection on key takeaways from today's conversation.

Eric Rosengren: Like Neel, I took away three things, at least initially. The first one is one word that didn't come up nearly as much in our previous series, and that is the word trust. Just like Marielle highlighted the importance of trust and how frequently it came up, I think there's something special about health care and the relationship between a patient and a doctor that is so tied to the ability to have trust. We all know that trust and relationships are critically important, but I think that came through with a number of the participants today. I would also emphasize with that trust, where people are getting information. I think it was Dr. El-Sayed who commented that too much of the information is coming from the internet and not enough of the information is coming from community health organizations as the primary source of information. Finding a way for those organizations to have much more of a megaphone, I think is incredibly important because right now I think many people go to the internet first and go to other sources second, and we need to do something to reverse that.

The second thing that I would highlight is something a fellow Bostonian, Ms. Nolen, highlighted which was, solutions must be developed with target communities not for target communities. I think that also gets to the strong community-based care that we need and the importance of partnerships really growing out of the community if we truly want affective care.

The final comment is just on outcomes. Several people referenced the pandemic, but the disparate outcomes that we've seen in this pandemic, the statistics on infections, hospitalizations and deaths by race and ethnicity are horrifying. And if ever there was a time for us to focus on these different outcomes, it's now. I think this is really a call for action to do something differently than we've done in the past.

Moua: Thank you, Eric. We're going to move on to Robert sticking with the theme of key takeaways and then we can move on to the next question after this.

Robert Kaplan: I'll talk about something that has already been mentioned and I did find it very interesting this discussion of trust. We're all living in our communities right now in trying to fight this COVID battle. One of the things we're learning every day is vaccine hesitancy. Eric mentioned sources of information, so called withdrawal from the health care system. I think COVID in its impact and where we are now has laid bare these fissures and trust. That resonated with me because we're fighting this battle every day, including with our own employees, based on race and ethnicity and in our community, and we're suffering for it as a result of it. That resonated with me.

Number two, this issue of social determinants. A lot of it is not about health care. It's about food, education, financial situation, whether you're employed, benefits and so on. I think the more we think about this as an ecosystem, the better off we're going to be. That then leads me to... there was some talk about creative interventions. Going to the communities where they are. There wasn't as much talk about diet, exercise, but that's an example of a creative intervention that is central to health care. Also, kids tend to mirror the behavior of their parents and so this is really challenging to get in at schools, obesity, diet counseling early at schools, especially in a lot of these challenged communities, but we've got to be more creative in interventions and then we're a leadoff.

The reason this is so fundamental for the Fed and the country is, GDP is made up of growth in the workforce and growth in productivity and you need a healthy workforce that's able to go to work. We're living through that every day right now and we're suffering from decelerating workforce growth in the United States. It's going to affect the entire country in growth and prosperity. This is really all of our problem. I liked what you talked about, accountability. We can do something about it and it's more than a nice thing to do. If we don't do something about it, we're going to just have a less prosperous society.

Moua: Thank you, Robert. I really appreciate your supportive points around the economic imperative to address structural racism. My next question is really around prioritization of racial equity. We've been waiting for more than 400 years and racial equity enlightenment, obviously we can't wait for that. There isn't the luxury of patience for that to occur. Clearly the moral imperative has not sufficed. How can we expand the case for racial justice without abandoning the moral imperative? You just named the economic case for it. What do we need to do collectively across systems, across sectors, to make sure that racial equity is not an amenity, is not just a lofty ideal? How can we actualize it and make it a common good priority? We can rotate back to Neel.

Kashkari: I'll build on what Rob was talking about, about the case of the economy. In our region here in Minnesota, our community is quite rapidly diversifying. Historically Minnesota was a very overwhelming White state. If you look at any type of demographic forecast, where's the growth coming from? It's really coming from communities of color. As I meet with business leaders in our region and they say, "Where is our workforce of the future going to come from?" Either we educate and close equity gaps and we take advantage of all of the growing population that we have here or we're going to continue to be a two-tier society and we're going to have to import labor or businesses are just going to go elsewhere. To me, I'm with you and we've got to make the moral case, but it's also just about our own self-interest case and it's about our own economic futures and the economic vibrancy for my children and for other children in the future.

The economic argument that Rob was talking about certainly resonates with me and I'll give you one quick example. I go around my region pre-COVID and I talk about what Rob said, "Where does economic growth come from?" One place it comes from is population growth, right? More workers to produce things, more customers to buy things. As our fertility rate has gone down over decades, our structural growth rate is going to go down too. I always say to people, "What do you want to do about that? Do you want to just accept slower growth? Do you want to try to subsidize fertility?" Japan is trying that, it's very hard to do. It's unclear if you can even do it. Or embrace immigration. And all of a sudden people say, "Well wow! I didn't realize those were my choices." And I say, "That's math. That's literally math." I think making the hard economic case of why a growing economy and a vibrant economy is in all of our interest. That's what I've found to be most persuasive but certainly open to everybody's ideas.

Moua: Eric, do you have any thoughts on what is necessary for critical mask prioritization of racial equity?

Rosengren: I do. Dr. Malawa made the comment that medical interventions are not enough. I think what she meant by that is that only looking at medical interventions as a solution to some of the disparities we're seeing for people of color in medicine is not enough. We each need to be accountable for what we can individually do. You have three Fed presidents on this panel. What can we as Fed presidents do to change medical outcomes that people are talking about? I think there's actually very concrete ways we can do that because in many outcomes, particularly medical outcomes, it's tied to labor market outcomes. Black and Latinx were coming out of a recession and they've experienced disproportionate unemployment. That unemployment unfortunately, is also tied to their access to health insurance. If you lose a job, you frequently also lose health insurance. When we're trying to get back the maximum employment, we're also trying to get back in some sense the maximum health insurance.

A second element is not just how many jobs, but the quality of jobs. For many workers, particularly in the service sector, they have a job, but they don't have the critical benefit of health benefits. It's not enough just to have a job, you have to have the kind of job that generates benefits. I think that too is tied to full employment because you're much more likely to get a good benefit package if labor markets are tight. Part of what the three of us can do, we're not medical doctors, at least. There's not much we're going to be able to do for medical interventions, but I think there are economic interventions that have critical components to the disparate medical outcomes that were discussed about over the course of this day.

One other aspect that I'll just briefly hit and that is sick leave. I think that came up a couple of times in our discussion. Again, that's a benefit that's taken for granted by many Americans, but many people of color do not take for granted that they get sick leave. That's particularly a problem if you're in a service sector, which means you're going to work sick and during a pandemic that has horrendous outcomes for communities of color. Another thing we can do as we think about benefits packages that are critically important is thinking about making sure that part of that benefit package, sometimes it's done by state law but in many states it's not required, that you actually have that sick leave benefit. I think we need to think more concretely about how each of us can do this. It's a complex problem and this isn't a problem for doctors to solve or hospitals to solve. It's each of us contributing in our own way because the complexity of these problems, they're all intertwined.

Moua: Sometimes it's easy to get overwhelmed with that complexity. I wanted to move on to another question but Robert, you looked like you wanted to chime in.

Kaplan: I'll say one final comment. I've learned there's a tendency when someone is different than you, to project on them, "They must feel the way I feel. They must have the same experience I have." There's so-called visible and invisible differences, and this is why inquiry... we've spent a lot of time on this at the Fed, and this is why this conference is so valuable. Ask a question and try to understand. We've spent a lot of time doing that over the last year. What's an example? Why isn't someone getting the vaccine? Rather than tell them, "Here's why you..." Ask questions, try to understand inquiry, and try to understand where they're coming from. The more we do that, there are differences that are just not visible, and I think a lot of those differences are key to how to unlock improving this situation.

Moua: Your point reminds me, Robert, of a tenant from intercultural competency. Don't treat others as you wish you would be wanting to be treated but treat them the way they would want to be treated. There's a question from the audience that I want to field. Before sharing that I would want to just preface this question by trying to draw upon your ancestry, to your leadership application, both to your daily life and to the way you approach and manage large institutions. This morning, I sent out my 5-year-old daughter to kindergarten for the first time. I whispered to her, I said, " Ishi. You are the dream of our ancestors." This is something I've heard many times from my own parents. Knowing that you are a president of your respective organizations, how do you apply racial equity personally and systematically?

Kashkari: That's a big question. Since I've been at the Minneapolis Fed, and I know all of my colleagues in the System are doing similar things in their institutions, we have a multifaceted approach. We want our institution to look like the community we are charged to serve. Ultimately, we think that that is vitally important and so we have very active strategies in recruiting people, in mentoring and developing people. We always hire the very best caliber person available. What we've learned is if we are more intentional about reaching out to a much broader set of potential applicants, we end up drawing both more diverse and more talented applicants so we can improve our talent while we're also improving the diversity of our organization. I'm proud that we are making progress and we ask our employees, we survey them. "How do you feel? Do you feel that this is an inclusive culture?" We still have more work to do, but I am proud that we are making progress. I think that we can all be leaders in our communities showing that this progress is possible.

On a personal level, I don't know where to begin. My parents are immigrants from India. My wife is an immigrant from the Philippines. My daughter and my son are mixed race little toddlers and babies, and we're all just trying to figure it out together. I'll give you just a quick anecdote. When that anti-Asian racism really flared up as a factor partly in response to COVID, for the first time my wife and I had to pause and think about my wife's exposure. When we were hunting to get a vaccine for both of us when they first became available and I was able to get her appointment out in rural Minnesota at a pharmacy in some town neither of us had ever been before, that's just where it was available. Guess what? I drove her just because I wanted to make sure that she was safe because we were going to a community where we didn't know anybody, and racism was flaring up against Asians. I'm thinking about an Asian woman going by herself, might something happen. It ended up being perfectly safe. People were wonderful and welcoming, and it was great both times we went for her two shots, but these are things that just flare up that we hadn't had to think about previously.

Moua: Thank you, Neel. I just want to recognize that what is personal is often structural as well and where we need to just see that kind of continuum. I just got the one minute warning and so I'm going to test your brevity. Robert and then Eric, if you could just bundle your response into your closing remarks, that would be great.

Kaplan: To me, this has been a great day and a great session but the key to leadership to me is to be open to learning. To be able to ask a question with an open mind and be open to learning. And I think that's the most valuable thing we can do after we leave here and to try to understand and to ask more questions I appreciate the opportunity today to be part of this.

Moua: Thank you, Robert. With that, I'm going to turn it over to Eric for closing remarks. It's been a pleasure to have this conversation and I look forward to continuing the conversation. Eric.

Rosengren: Thank you for the conversation as well. This conversation really is at the intersection of health, racism and the economy. It reflects a series of complex issues, and I think the series was really well-designed to really put together. Simply put, poor health is often the result of an aggregation of challenges that are worsened by structural racism. I'm just wanting to tie this back to some of the previous sessions and why it's so critically important as we think about the previous sessions in the context of the health discussion we've just had.

Black and Latinx workers are much more likely to experience unemployment and not only is unemployment incredibly stressful, but because health insurance is tied to jobs in the United States, it can result in an inability to get adequate medical care. Second, I love some of the points that Dr. Anthony Iton made about spatial segregation and the Boston Fed's has done a lot of work on housing discrimination and redlining. I think he was spot on, on the importance of thinking about those issues. Mr. Raya emphasized density with housing and intergenerational living posing particular problems in a pandemic. If you have problems with discrimination and housing, it quickly morphs into a problem with health as well. Access to education remains unequal, which often results in lower quality jobs with fewer health benefits for disadvantaged populations. Finally, poor health begets poor health. Those without local access to high-quality care can find themselves in a vicious cycle in which the compounding effects of poor health have increasingly negative impacts on their employment and financial stability.

Speaking as an economist, as long as there are strong racial and ethnic differences in the various inputs into the health system, it will be very hard to close the gaps in health outcomes discussed today. Unfortunately, the racial and ethnic differences in medical outcomes have never been clearer. Consider for instance the striking statistic that Black Americans have a life expectancy about four years below that of White Americans. The COVID-19 pandemic has widened this gap to nearly six years. As policymakers, we must understand that closing the racial gaps in health outcomes means focusing on longer-term holistic solutions, many of which have been discussed in earlier sessions of the series. In the short term, we're in the middle of a public health crisis that continues to affect the health and financial wellbeing of families. Supporting and bolstering the existing community-based response is of utmost importance.

Finally, I want to thank all the participants for sharing their expertise and wisdom. And I want to thank our audience for joining us today for the conversation. I hope you will join us again for the next Racism and the Economy event. It's Wednesday, October 20, and we'll focus on once again, accumulation of disparities, but this time focused on wealth. We look forward to seeing you then. Thank you very much.