Health Inequities in the Time of COVID-19

Transcript

• 00:00Dean Vasquez, so that way we can
• 00:02give her the most amount of time
• 00:05for her wonderful talk today.
• 00:06So Dean Marietta Vasquez is
• 00:09a professor of Pediatrics,
• 00:10general Pediatrics and infectious disease,
• 00:12vice chair of Diversity, Equity,
• 00:14and inclusion in the Department of
• 00:16Pediatrics, and founder and director of
• 00:17the Yale Children's Hispanic Clinic.
• 00:19Has been appointed associate Dean of
• 00:21medical diversity as of May 3rd, 2021.
• 00:25In her role as Dean,
• 00:27Vasquez will work closely with
• 00:28PSM's Office of Diversity,
• 00:30Equity and inclusion to advance MD and
• 00:32MD PhD program programs and initiatives.
• 00:34And I believe, if I'm not mistaken,
• 00:36that will also include the PA program now.
• 00:39She will oversee the strategic
• 00:41deployment of resources and coordinate
• 00:42activities of the Office of Diversity,
• 00:44Inclusion, Community engagement,
• 00:45and equity, or DICE.
• 00:47There's a recruitment,
• 00:48retention,
• 00:48and professional development of
• 00:49students who are marginalized
• 00:51or underrepresented in medicine,
• 00:52and she has extensive experience as
• 00:54an adequate advocate for diversity
• 00:56and inclusion,
• 00:56and has led efforts to recruit and
• 00:59retain underrepresented minorities
• 01:00and academic programs.
• 01:01She as well,
• 01:02has mentored numerous medical students,
• 01:04and for the past year,
• 01:04she's directed all DI activities
• 01:06in Pediatrics, designing, building,
• 01:08and implementing an ambitious.
• 01:09Strategy for.
• 01:12The department's training faculty and staff,
• 01:14which encompasses support,
• 01:15education and recruitment.
• 01:16Dean basketball education is crucial
• 01:18to her role and has had multiple
• 01:19education initiatives on diversity
• 01:21and inclusion within the department
• 01:22on such topics as unconscious bias,
• 01:24microaggression,
• 01:24and equity in the workplace,
• 01:26which has led to Pediatrics
• 01:27becoming the first department
• 01:28within the School of Medicine to
• 01:30make diversity training mandatory.
• 01:32Deep ASK is this a served as the
• 01:34associate director of the Pediatric
• 01:36residency program from 2010 to 2018.
• 01:38Director of the LP Metrics Global
• 01:40Health track from 2010 to 2019.
• 01:42And at the Yale Pediatric Primary
• 01:43Care Center, she precepts residents,
• 01:45medical students and nurse practitioners,
• 01:47utilizing her expertise in refugee
• 01:49and immigration health research on
• 01:50clinical epidemiology of infectious
• 01:52disease in children focuses on the
• 01:54efficacy of vaccines and she has had
• 01:56direct impact on clinical practice.
• 01:57Finally,
• 01:57she is the first Latina to be
• 01:59appointed by the Secretary of the
• 02:01US Department of Health and Human
• 02:02Services to be a voting member of the
• 02:04Advisory Committee on Immunization Practices.
• 02:07Thank you so much for taking the
• 02:08time to speak with us today,
• 02:09Dean Vasquez,
• 02:09and we're really excited to get
• 02:11to hear your talk.
• 02:13Thank you Ariel for that very
• 02:16nice introduction and and for the
• 02:19and really for the invitation.
• 02:21I hope you can hear me well I'm.
• 02:26I'm connected from my home Wi-Fi and I
• 02:28have my dog next to me who goes wild
• 02:31every time somebody knocks on the door.
• 02:33So let's hope that nobody knocks on
• 02:35the door and I'm going to talk about.
• 02:38I decided to go sort of merge a little
• 02:41bit about health inequities with a case,
• 02:44and I'm going to talk about health inequities
• 02:47in the times of of in times of COVID.
• 02:53And a little bit about about.
• 02:57Some of the objectives, um.
• 03:00I want to use sort of our time
• 03:02so that we can through the
• 03:05presentation of a clinical cases,
• 03:08I'm going to talk about actually a real case,
• 03:10one of my patients.
• 03:11We can have time to identify and
• 03:14sort of reflect on the effects
• 03:16of implicit bias and structural
• 03:18racism and how health inequities
• 03:20affect the health of our patients.
• 03:23They have a some an opportunity
• 03:25to sort of go back and we're not
• 03:27going to have a lot of time to
• 03:29talk about historical context.
• 03:31But really think about the present
• 03:33day role of structural racism in our
• 03:36healthcare system and towards the end.
• 03:39I will point out some of these, Umm,
• 03:42how implicit bias affects what we do
• 03:45for for patients and towards the end
• 03:48talk about some strategies that all
• 03:51of us can use in trying to combat
• 03:53social racism at the institutional
• 03:56level and at the patient care level.
• 03:59I have no conflict of interest to disclose.
• 04:02But when I talk about this,
• 04:04I always say the one thing that I
• 04:05want to disclose is my patients are
• 04:07near and dear to my heart and many.
• 04:10There most of the things that I'm
• 04:12going to talk about today I'm very
• 04:15passionate about and those will become
• 04:18quite obvious throughout throughout the talk.
• 04:21In terms of health inequities,
• 04:23the COVID-19 pandemic really has
• 04:25has exposed or deviled some of
• 04:29these structural barriers that drive
• 04:32health inequities and there are many.
• 04:35And when we talked about health
• 04:39inequities pre pandemic,
• 04:41I felt like I needed to explain
• 04:42a little bit more what we meant.
• 04:44But one of the things that that
• 04:46has really come to the forefront
• 04:48and COVID has been a great example.
• 04:51Is how through the last three years,
• 04:54we can see how.
• 04:58Die or things can be we can see what
• 05:01impact an infection can have in the health.
• 05:05But we've also all been witness to
• 05:08how the impact is not exactly the
• 05:12same for for everybody's differences
• 05:14in health, differences in, in,
• 05:18in the economic impact and and how.
• 05:24Something as simple or as complicated
• 05:27as an infection or a disease can
• 05:31exacerbate existing social vulnerabilities.
• 05:36And this slide is it, it kind of
• 05:39walks you through structural racism,
• 05:41disparities and equity.
• 05:43So it's important to understand that
• 05:45how structural racism impacts health by
• 05:48presenting sort of a working definition of
• 05:51his of health disparities and inequities.
• 05:54And we know that there can be inherent
• 05:56differences between populations and
• 05:58the quality of healthcare and that's
• 06:00kind of represented by the different
• 06:03heights in the bars in this graph.
• 06:05And these differences between the
• 06:08healthcare quality of one group and
• 06:11the other can occur for multiple,
• 06:14multiple reasons.
• 06:15It could be because of patient preferences,
• 06:19right.
• 06:19If you choose one therapy over the next,
• 06:22it could be clinical appropriateness.
• 06:24So some patients go to the ICU and
• 06:27get ICU level care and that can be
• 06:30based on their severity of illness.
• 06:33But their structural forces,
• 06:34such as the design of healthcare systems,
• 06:38public policy,
• 06:39legal and regulatory climate,
• 06:41and bias and discrimination that also
• 06:44play a role in healthcare disparities
• 06:47are the differences in the quality of
• 06:50healthcare between populations that
• 06:52are not due to patient preferences
• 06:55or clinical appropriateness.
• 06:57So in the case of healthcare, differences
• 07:00between race is structural racism.
• 07:03Contributes to these systems,
• 07:04policies and regulations that
• 07:06then create these disparities,
• 07:08these disparities disparities.
• 07:11So in the ideal sense,
• 07:15right?
• 07:18The differences, right?
• 07:19If you eliminate the disparities,
• 07:23then the differences between two
• 07:26populations should only be based on
• 07:29things that they can actually control.
• 07:33So now I'm gonna go.
• 07:35To our case presentation and
• 07:37this is I want us to sort of
• 07:41move us back to August of 2020.
• 07:45And I'm going to talk to you about
• 07:48an 8 year old male Hispanic male who
• 07:51presented to a large urban pediatric
• 07:54health clinic in New Haven with his
• 07:57mom and it was again the end of 2020,
• 08:00I happened to be in clinic.
• 08:04This is the pediatric clinic.
• 08:06And I actually was taking
• 08:08care of somebody else.
• 08:09And it's like I walked through the corridor.
• 08:12I could see this young man with his
• 08:15mom who was being walked into a room.
• 08:19And what struck me was that he seemed a
• 08:22little bit out of breath and he had to stop.
• 08:26While walking a very short distance,
• 08:29and as I always tell the medical students,
• 08:31Pediatrics is the art of observation.
• 08:33So it's not about what patients tell us
• 08:36often is being in tune to what's around you.
• 08:39And I immediately detected this and
• 08:41ran to one of our members of our team,
• 08:44one of the nurses, and I said,
• 08:45what's going on and where is
• 08:47that patient going?
• 08:48And she said, well, the mom says that he's,
• 08:51he's here because he can't breathe
• 08:53well and he has a hard time walking.
• 08:55He probably has.
• 08:57Has asthma.
• 08:58So I saw as they moved him into that room,
• 09:01I finished taking quickly,
• 09:02taking care of the patient that
• 09:04I was taking care of.
• 09:06And I said I I want to sign up for
• 09:09that patient, what's going on?
• 09:11So I go in and indeed it's the bomb says,
• 09:15well,
• 09:16he can't breathe well and he's
• 09:19been having difficulty walking.
• 09:21She brought him into the clinic
• 09:23because of of this chief complaint,
• 09:25and she had told the nurse through the
• 09:28interpreter he was supposed to get better,
• 09:30but he didn't.
• 09:31I was supposed to be here before
• 09:33so that he could be seen by many
• 09:35doctors that he was supposed to see.
• 09:38He was recently hospitalized
• 09:39and I called several times,
• 09:41but nobody called me.
• 09:44I was told that over the phone that he was
• 09:48OK and to wait for for for an appointment.
• 09:52This patient came in part by
• 09:55bus part walking.
• 09:56The mom said that he probably
• 09:58takes about five or six steps and
• 10:00then they have to stop for him
• 10:02to kind of rest a little bit and
• 10:05then they walk again and he rests.
• 10:08She talked about how he had
• 10:10problems sleeping,
• 10:11that this 8 year old slept upright,
• 10:15that she would prop him up with
• 10:17a lot of pillows so that because
• 10:20that made it a little bit easier
• 10:23for him to to breathe.
• 10:26Talking to her a little bit more,
• 10:27I learned that he had COVID-19.
• 10:30He had COVID-19 relatively
• 10:32recently and since he was in
• 10:36the hospital and was discharged.
• 10:39They haven't really left the house very much,
• 10:41so Needless to say, this raised all sorts of.
• 10:46Times and concerns in, in my mind,
• 10:50getting a little bit about his recent,
• 10:54pertinent recent history.
• 10:56He's a school aged child.
• 10:58He developed COVID-19 two or
• 11:00three months before his visit,
• 11:02and at that time his symptoms were fairly
• 11:06common for what we would call adult COVID.
• 11:10He had fever.
• 11:11He developed cough, wheezing.
• 11:13At that time.
• 11:14She called the clinic.
• 11:15Now we're talking about.
• 11:17June of 2020,
• 11:19very early during the the pandemic
• 11:21and she was told that if if he had
• 11:25those symptoms that he should not come
• 11:28into the clinic that he should stay
• 11:30home and to call if he was worse.
• 11:33So so they did and.
• 11:37He stayed home. He got worse.
• 11:40Eventually he was so sick that he had to
• 11:42be brought into our hospital by ambulance.
• 11:44And when he came in,
• 11:46this is in his admission,
• 11:48his oxygen saturation.
• 11:49His was so low. He had had fever.
• 11:52He had increased work of breathing.
• 11:54He was found to have COVID-19.
• 11:58He had a chest X-ray that showed
• 11:59that he had pneumonia and had
• 12:01multiple laboratory abnormalities.
• 12:03He was admitted to our hospital.
• 12:05He stayed in our hospital for about five
• 12:07or six days on his until his fever improved,
• 12:11until he didn't need any
• 12:13more supplemental oxygen.
• 12:14And then he was sent home a little
• 12:17bit more about this young man.
• 12:19He has a history of asthma.
• 12:22He has a high, high,
• 12:24high BMI.
• 12:25His his body Max Index is way off the chart,
• 12:29so much higher than the 99th percentile.
• 12:33Alongside with that he has
• 12:35obstructive sleep apnea.
• 12:37He has high blood pressure and
• 12:39pre diabetes so as an 8 year
• 12:41old he has the weight.
• 12:43Of you know what,
• 12:4430 year old basically he has as you
• 12:47can see some of the medical problems
• 12:50that we oftentimes see in in adults.
• 12:55When I spoke to the mom,
• 12:58she related to me well.
• 12:59He was supposed to follow
• 13:01up with infectious diseases,
• 13:02my specialty pulmonary
• 13:04cardiology and endocrinology.
• 13:10In terms of his social history,
• 13:11he was raised by his mom, single mom.
• 13:14They're of Hispanic origin.
• 13:17The patient had not been in school.
• 13:20He had been doing school virtually,
• 13:22but since he got sick, he hasn't been
• 13:24able to keep up with their work.
• 13:26And this family suffered from food,
• 13:30transportation and financial insecurity.
• 13:33The patient spoke English.
• 13:35His mother spoke a little bit of
• 13:37English but preferred Spanish,
• 13:38and this mom worked full time.
• 13:40And she felt quite guilty because
• 13:45during very early in the pandemic,
• 13:47she was not able to stay home.
• 13:49She had to go out of the home and work.
• 13:52And not observe sort of the guidance of
• 13:55staying home and show and sheltering.
• 13:57And she got COVID at work and she
• 14:01was the one who gave our patient.
• 14:05COVID so,
• 14:06so take a step back and and I said to
• 14:09myself well you know how how did this happen?
• 14:12How does this 8 year old who was
• 14:15in the hospital very early on for
• 14:18almost a week with COVID leave not
• 14:21get better and not have follow-up
• 14:24like what you know what happened
• 14:27here and this is kind of a timeline
• 14:30from the time that he was diagnosed
• 14:33to he was admitted to the time.
• 14:36That he was discharged and these orange uh,
• 14:40stars represent times when the
• 14:44mother called several.
• 14:50Telephone numbers that she had for
• 14:52the for the clinic and for whatever
• 14:55reason then it's what we reflect
• 14:58referring to is lost to follow up up
• 15:00until the time when he shows up to
• 15:03to our clinic at discharge a patient
• 15:05like this should have left with clear
• 15:08guidance on when to follow up with
• 15:10the primary pediatricians when to
• 15:12follow up with infectious diseases.
• 15:14He did have one video call with infectious
• 15:17diseases should have had follow up with.
• 15:20Echnology, pulmonary and cardiology.
• 15:22But but that didn't happen.
• 15:27Some of the things that.
• 15:30I struggled with and talking to her well,
• 15:33she she thought people would call her back.
• 15:37And when she called, they said,
• 15:38well, there aren't any appointments.
• 15:40Somebody will call you.
• 15:42Why didn't she push?
• 15:44Why didn't she demand on the
• 15:46phone that her son be seeing?
• 15:49How did things fall through the cracks?
• 15:51How? Why? Uh.
• 15:57While was while he was impatient,
• 15:59what was communicated, how was.
• 16:03How was that message of?
• 16:06All the medical problems that he had
• 16:09and and the importance of a follow-up,
• 16:13I wondered how much time
• 16:15was dedicated in that.
• 16:17During the discharge process.
• 16:20What did those discharge papers look like?
• 16:23How complete the information was?
• 16:26What was that plan like?
• 16:28In how much detail was it
• 16:31discussed and in what language?
• 16:36How would you feel if you were
• 16:39the patient's mother? And I know
• 16:42where this is all virtual but.
• 16:46I can tell you about how I would have felt.
• 16:49I can tell you about how I felt.
• 16:53I used the word. Apology.
• 16:56I am sorry. I am so sorry.
• 17:02So many times, so many times
• 17:06apologizing on behalf of.
• 17:10Anybody that I can think of,
• 17:12I felt frustrated.
• 17:15I felt angry.
• 17:17I felt embarrassed.
• 17:23And and a little bit powerless.
• 17:33At one point I remember hearing.
• 17:37One of the members of the medical team
• 17:41during the visit say, gosh, you know,
• 17:45she probably didn't care enough.
• 17:47To bring her son. Take care.
• 17:52And and I want us to sort of
• 17:54take a step back and think about.
• 17:57When we talk about missed appointments,
• 18:00you know, delays in follow-up care,
• 18:03how often we use the term.
• 18:06To kind of explain ours errors,
• 18:11our shortcomings in explaining
• 18:14to our patients, to our families
• 18:17in a way that they understand.
• 18:20How often we try to hide the lack of not
• 18:24our lack of knowledge and our lack of
• 18:27understanding by reflecting it into oh,
• 18:30this patient is limited
• 18:32or this mom is limited.
• 18:34She just didn't understand we did.
• 18:36Everything right and and they didn't and.
• 18:41What I what I would love for,
• 18:43for all of us to reflect on is.
• 18:47Going beyond that understanding
• 18:49and I and I oftentimes use this
• 18:52visual of the iceberg that what you
• 18:54see or or that that trigger to say
• 18:57well they just missed appointments.
• 18:59It's you know it's it's their fault.
• 19:02That is the easy answer because we
• 19:05just see the reality in an in in
• 19:08somebody else as the tip of the iceberg.
• 19:10Well, they didn't show up.
• 19:11They must not really care as much or or or.
• 19:16That that we don't sort of take the
• 19:19time to understand that situations
• 19:21are very complex and I'm the 1st to
• 19:25tell you that I didn't understand
• 19:27the entire reality and the fact all
• 19:30the factors in in this revolving
• 19:33around around this this case and
• 19:36that it really takes time and effort
• 19:39and opening one's mind and trying to
• 19:42understand our own biases and and.
• 19:46Acting with cultural humility and
• 19:48with humility. Period.
• 19:49To understand that maybe there are
• 19:52other factors that led to this problem
• 19:55that led to this an 8 year old who
• 19:58left the hospital and months later
• 20:01comes back and can barely breathe.
• 20:03Umm.
• 20:05Understanding and equities and care,
• 20:07structural inequities,
• 20:09understanding that.
• 20:10Maybe it's CC for me to get in a car
• 20:16and get to my appointments that if.
• 20:20My kids miss an appointment or
• 20:23if I'm not called by my child's
• 20:27providers that I have the ability to.
• 20:32And the power.
• 20:33To get on the phone and if they don't answer,
• 20:36then, you know, I'll send an e-mail,
• 20:38I'll go online and I'll you know,
• 20:40I'll, I'll make things happen but that.
• 20:44Perhaps just because that's what I
• 20:46would do and that's what I can do,
• 20:48it doesn't mean that those who don't
• 20:51act in exactly the same way don't.
• 20:54Don't care. Umm.
• 20:57Some of the barriers we can
• 20:59easily identify well,
• 21:01you know it's hard to get to healthcare
• 21:04if you don't have transportation
• 21:07if if you're poor and you,
• 21:10you know all of these treatments,
• 21:13even getting to to a clinic is
• 21:16is is expensive.
• 21:18But poverty might play a role that
• 21:21language barriers play a role.
• 21:22The lack of health literacy
• 21:24very well may play a role within
• 21:26some of the health inequities.
• 21:27That that we know, not knowing
• 21:29how to navigate the system.
• 21:33But we can't stop there.
• 21:35We can't say, well you know why
• 21:37she spoke another language and she
• 21:40didn't understand the beautiful
• 21:42and well executed follow up plan
• 21:45that was shared with with this mom.
• 21:48We can't just stop there because
• 21:51that might be just the tip of
• 21:53the iceberg and we need to
• 21:55understand situations as a whole,
• 21:57as complex as they are.
• 22:01So to think about sort of disparities.
• 22:06There are many, many factors,
• 22:08many more than than, even more than.
• 22:12I'm sharing here that it could be,
• 22:15you know, lack of access to doctors,
• 22:17systemic racism, negative stereotypes.
• 22:19You know, this mom doesn't understand
• 22:21or this patient doesn't really.
• 22:23They have they,
• 22:24they have distrust of the medical system,
• 22:26so they don't come.
• 22:27So I shouldn't, you know,
• 22:28why should I bother?
• 22:29Access to transportation.
• 22:30I talked about how for them to come to clinic
• 22:34even though the clinic is relatively close.
• 22:36Buy in. In New Haven,
• 22:38it takes taking a bus and and walking.
• 22:43Communication barriers? Stress.
• 22:46Um.
• 22:46Financial or insurance barriers.
• 22:49Multiple things can.
• 22:52Can play.
• 22:57Play a role. Nice this snap. OK.
• 23:03So. Think I alluded to this before.
• 23:07After discussing the medical plan and
• 23:10making sure that he was OK, you know,
• 23:13that he needed oxygen, etcetera,
• 23:15I overheard somebody say, well,
• 23:17I just don't understand why some people
• 23:19don't take good care of their kids.
• 23:22And I asked the question what are the
• 23:25racial implications of that comment?
• 23:28Are there policies that lead to
• 23:30poor access to care and and how
• 23:33are those relevant to why this
• 23:36patient now has presented twice?
• 23:38What put this patient at higher risk of
• 23:41pulmonary complications and I was very,
• 23:43very concerned not only about pulmonary
• 23:45complications but cardiac complete
• 23:47on undetected cardiac complications
• 23:48from COVID and an 8 year old.
• 23:50We didn't know a lot about the
• 23:53effects of COVID on children at
• 23:55that time and how do you raise these
• 23:58discussions with the team members
• 24:00after you know the the comment that.
• 24:04Umm.
• 24:05That that I overheard.
• 24:08So we need to think about a few
• 24:12things that that play a role.
• 24:15The idea that racism is more than
• 24:18prejudicial attitudes and actions,
• 24:19that there's sort of a structural
• 24:22presence in in systems.
• 24:26Sorry, I'm having a hard time.
• 24:30Forwarding the slides. Ah. There.
• 24:39Umm. Let's think about some of
• 24:44the policies and access to care.
• 24:47So think about what you read in the CDC
• 24:49and the Centers for Disease Control,
• 24:52which is, you know, where?
• 24:54Most of us get our guidance,
• 24:58especially during during the pandemic.
• 25:00Think of the CDC guidelines.
• 25:02So if you have COVID.
• 25:05He should stay at home.
• 25:07Isolate. Wear a mask.
• 25:10Not go to work, not go to school.
• 25:14You should stay in your own room.
• 25:18Preferably use your own bathroom and have
• 25:22family members come and bring you the meals.
• 25:26And we're in 90 fives to
• 25:29try to decrease the the.
• 25:31Contagion to other family members,
• 25:34and I ask you.
• 25:37Who were those guidelines for?
• 25:40How do you think?
• 25:42Individuals who like my patients,
• 25:45mom in the middle of the pandemic.
• 25:47Couldn't stay home.
• 25:49They had to go to work. They.
• 25:53Couldn't stay behind and just, you know.
• 25:58Stay in their home to try to decrease
• 26:01the likelihood of getting infected.
• 26:04Just did these policies or
• 26:08recommendations guidelines.
• 26:09Speak to um.
• 26:12Refugee and immigrant families who?
• 26:16Live two or three families in apartments.
• 26:20Did these guidelines speak to
• 26:22individuals who all lived in in
• 26:25one room and were simply not able
• 26:27to to isolate and and follow them?
• 26:30So I think it's important for us to
• 26:34understand that perspective that even even.
• 26:38From the Center for Disease Control,
• 26:41who's putting together guidelines there?
• 26:46In a way, these guidelines were
• 26:48not for for for everybody.
• 26:51And I also wonder,
• 26:53would things have been different
• 26:54if this patient was white?
• 26:56Would it have been different
• 26:58if his mother spoke English?
• 27:01And I've shared a little bit about how
• 27:04I felt as the healthcare professionals
• 27:06seeing him in clinic and and sharing
• 27:10some of my feelings of frustration
• 27:13and sadness and anger and and.
• 27:17And shame towards.
• 27:19What I stand what I stood for at
• 27:22that at that time and realizing well
• 27:25you know is this mother going to
• 27:28trust me and and what we are doing
• 27:31given given what what has happened.
• 27:36There are clear disparities in COVID-19
• 27:40survival and there are, as I mentioned,
• 27:43in equities and how we communicate.
• 27:45There are different differential
• 27:47experiences causing distrust
• 27:48in the medical field for sure.
• 27:51And there is stereotyping of
• 27:53not only Latina individuals,
• 27:54this this patient happened to be Latina,
• 27:57but stereotyping with with.
• 28:00Many other groups,
• 28:03and there's some facts that COVID
• 28:05has affected populations of color.
• 28:07Way more than other groups,
• 28:10black individuals have received
• 28:11smaller shares of vaccination.
• 28:13So if you think of all the vaccines,
• 28:15if you look at shares of vaccination
• 28:18and compare to the rates of
• 28:20COVID infections and deaths,
• 28:22to the proportion in each one of the
• 28:25populations that has received vaccine there,
• 28:28there are tremendous inequities reflecting
• 28:32the disproportionate level of infection.
• 28:34So similarly to blacks,
• 28:36Hispanics have received.
• 28:37Smaller shares of vaccination
• 28:39compared to the share of cases in
• 28:41most states for which we have,
• 28:43we have reports.
• 28:45And if you compared whites to other
• 28:48groups those who identify as wife have
• 28:51why white has have received higher
• 28:54rates of vaccination compared to.
• 28:59To their to the number to the number
• 29:02of to the number of cases and and this
• 29:05was shown this is just a clip from
• 29:08Florida where we know and and and these
• 29:10are data from the government that
• 29:12blacks and Hispanics had lower access
• 29:16to monoclonal antibody treatments
• 29:18even though their rates of infection
• 29:21were were were much higher so and
• 29:24again this slide tells you that if
• 29:27you know if you sort of look at.
• 29:29Burden of disease to.
• 29:33To availability and and actual
• 29:36receipt of some of the treatments
• 29:39and preventive measures.
• 29:41They're they're not.
• 29:43They're not equitable in that,
• 29:45in that in that sense.
• 29:49California's close to 40% latinae,
• 29:52but they made-up about 45,
• 29:55or over 45% of the COVID-19 cases.
• 30:01And my colleague and mentor,
• 30:04doctor Peter Hotez of
• 30:06Baylor College of Medicine,
• 30:08this is a quote that he
• 30:10shared with me, he said.
• 30:11This is the quote referring
• 30:12to the COVID-19 pandemic.
• 30:14He said this is robbing Hispanic community
• 30:16of a generation of mothers and fathers,
• 30:18brothers and and sisters. Umm.
• 30:26So about as I mentioned if you look at.
• 30:32These are updates.
• 30:33As of August of 2022,
• 30:35about 16% of COVID deaths were among Latinos.
• 30:39And if you think about the weighted
• 30:42population, it accounts for about.
• 30:45If if you do a weighted estimate,
• 30:48it's about 33% of the of
• 30:51the deaths from COVID.
• 30:54And this is really another
• 30:56way of sort of looking,
• 30:58looking at it that if you compare
• 31:01compared to white non Hispanic persons,
• 31:05those of black American non Hispanics
• 31:10had about a 3 three times the
• 31:13hospitalization rates and twice
• 31:15the number of deaths and and these
• 31:18these are the proportions in in
• 31:21Hispanic or Latino population.
• 31:25Looking, looking at us.
• 31:27Because I always say that it's.
• 31:30A good first step is to sort
• 31:32of look at our own home.
• 31:34We know that the impact of racism
• 31:36is across the board and that
• 31:39it it continues to to occur.
• 31:41And there are data both from
• 31:43the US and from our own center,
• 31:46of how this turns out.
• 31:48What does this mean?
• 31:49Well,
• 31:50there is a an article.
• 31:52That came out last year to show
• 31:54that black newborn babies in the
• 31:56US are more likely to survive
• 31:57childbirth if they're carried
• 31:59forward by black doctors.
• 32:00So this idea of of of ethnic concordance.
• 32:04But there are three times more
• 32:06likely than white babies to die
• 32:08when looked after by white doctors.
• 32:10And again these are this is this is
• 32:13an article that came out in 2020.
• 32:18Data from our own hospitals from
• 32:20my department of Pediatrics.
• 32:22This is a study that was conducted by
• 32:26right here at Yale that showed that
• 32:29in our pediatric emergency medicine,
• 32:32there are disparities in the use
• 32:35of physical restraints depending
• 32:37on what your ethnic group,
• 32:40racial or ethnic group so that if you are.
• 32:44Teenager coming to the emergency
• 32:46room and you're a person of color?
• 32:48You're more likely to have
• 32:51the staff use restraints,
• 32:54so.
• 32:57You know, this is not just the
• 32:59shine of light on negative aspects.
• 33:01This is to to bring up these issues that.
• 33:06We need to take into account when in in
• 33:09our spaces not only in the clinical space.
• 33:13I think some a lot of this.
• 33:14I mean of course this is focused on a case
• 33:17but a lot of these concepts also relate to
• 33:20how we communicate with each other at home,
• 33:22in our communities within our
• 33:25workspaces in our offices.
• 33:28We know that there's a big role and
• 33:31implicit a big role for bias in in in
• 33:34all of our interactions and. I don't.
• 33:37I don't think I need to go into much detail.
• 33:40We all know that we all have biases.
• 33:43These are sort of prejudices that
• 33:45we have towards one thing,
• 33:46person or group.
• 33:47And the biases can be our own
• 33:50individual or they can be grouped
• 33:53biases and healthcare workers.
• 33:54Just because we're physicians,
• 33:56healthcare providers,
• 33:57it doesn't mean that we don't have biases.
• 33:59We have the same biases as
• 34:03the general population and.
• 34:05These biases do impact the care that
• 34:08we that we provide to to patients.
• 34:12So if we think about how does.
• 34:15By us connect to structural
• 34:17or institutional racism,
• 34:19we can think of sort of structural racism.
• 34:24As something that's overtime,
• 34:27normalize and legitimize and it sort of gives
• 34:32one group advantage over over the other.
• 34:35And it's the result or the compounding effect
• 34:39of societal norms that are often invisible.
• 34:42Cultural representation right in the media,
• 34:45how people discuss or define race.
• 34:49Ideologies. And many of these are sort of.
• 34:54The foundation Foundations institutional
• 34:57practices, so in the educational
• 35:00or criminal or justice system,
• 35:01and somewhat like policies.
• 35:05Oh my. Said it, and there it is.
• 35:10Um. So all of these sort of
• 35:16work to reinforce various ways.
• 35:19Are you gonna stop?
• 35:21Umm, sorry.
• 35:23So the they reinforce waste to perpetuate
• 35:26these racial inequities for persons of color.
• 35:29And, you know, bias is.
• 35:33Relate conceptually related
• 35:35to structural racism,
• 35:36because operation of explicit and
• 35:38implicit biases at the population
• 35:41level then leads to this accumulation
• 35:44of discriminatory practices.
• 35:49You know, getting back to sort
• 35:51of this comment on, on, on.
• 35:53Well, you know, could it be that
• 35:56this mom didn't have time for, for,
• 35:59for the patient, for, for the child?
• 36:02I think I want to take a moment
• 36:05and talk about cultural humility
• 36:07because there's always common ground,
• 36:10right, regardless of your race,
• 36:11ethnicity or socioeconomic factors.
• 36:14We all care about our children and
• 36:18and just because I care about my kids
• 36:21or I care about my own health. It.
• 36:25Doesn't mean that other people do or
• 36:28don't in the same way that I that I do.
• 36:31And I think that the word and
• 36:35the term humility goes along way.
• 36:38We need to be aware that.
• 36:43My views and how I approach my health
• 36:45might be very different from somebody
• 36:48elses and and and we need to approach
• 36:51each other with the humility to
• 36:54understand that I don't understand
• 36:56everything about somebody else's reality.
• 36:59Because if we think for example if I
• 37:03think that I understand everything
• 37:05there is to know about Hispanic
• 37:09patients if I assume that.
• 37:12I got it down by the mere fact
• 37:14that I belong to that group.
• 37:17Assuming that can can be can be problematic.
• 37:23Oh my God.
• 37:25Um, so,
• 37:27so again getting back to
• 37:30getting back to our patient.
• 37:34He was seen by all of his subspecialists.
• 37:38He continues to struggle with
• 37:41his increased weight that.
• 37:43Continues to be and I think that
• 37:45continue to be a struggle for him
• 37:48throughout his the next three years.
• 37:51He has slowly improved.
• 37:52He's able to walk better and sleep better.
• 37:57He's now back in school and attending
• 38:00all of his follow up appointments.
• 38:03So I'm happy to sort of report that
• 38:05in terms of his overall health,
• 38:07he's better, he's now able to
• 38:10to get the care that he needs.
• 38:13But now sort of for the last few minutes,
• 38:16if Stella stops barking and
• 38:19you guys can hear.
• 38:21How can we provide communication
• 38:23and overcome stereotype threat?
• 38:25Well, the first thing to to
• 38:28to acknowledge is that to know
• 38:32thyself is the beginning of wisdom.
• 38:35So start by sort of taking a deep dive
• 38:38into who you are and what are your biases.
• 38:42I have them.
• 38:43I I work in this, in this area,
• 38:45and I'm always the first to
• 38:47say I have my own blind spots.
• 38:49I have my own biases,
• 38:51and I.
• 38:51We need to recognize our own
• 38:54and there are all sorts of sort
• 38:56of tests that that there are.
• 39:01Umm.
• 39:06Sorry. Let me. I'm sorry, Ariel.
• 39:09Oh, there you go. Somebody's taking her.
• 39:13To build the best therapeutic
• 39:15relationship with with your patients,
• 39:17you really need to sort of understand
• 39:20your biases and find ways to to
• 39:23mitigate these and how you do
• 39:25it is really through hard work.
• 39:27So the bottom line is that.
• 39:31You need to do your work.
• 39:35Go to as many training sessions,
• 39:39read, talk to people.
• 39:41Start having the tough conversations.
• 39:44Don't just say, well,
• 39:45you know what, I know it all.
• 39:48Is somebody missed?
• 39:50In their communication with their patient,
• 39:53they're wrong.
• 39:54And right now I think I think we all
• 39:57need to sort of do the hard work and be
• 40:00humble enough to understand our role.
• 40:02And that the only way that we're
• 40:05going to to achieve mitigating
• 40:08these biases is through hard work.
• 40:11Some of the strategies that you
• 40:14can that you can adopt causing
• 40:16most of the times when I've or
• 40:19most of my mistakes have been.
• 40:22When I don't take that pause and and
• 40:24try to reflect and say well what are
• 40:27what are we trying to accomplish here?
• 40:30Who else needs to come to the
• 40:32table huddling with your with
• 40:34your team members not assuming.
• 40:36Well,
• 40:36if they didn't give this patient
• 40:38a follow up appointment it means
• 40:40they're wrong and we're right.
• 40:41No trying to get information.
• 40:44Who else needs to be at at the at the table?
• 40:47Who else has information and always bringing.
• 40:52Persons of trust and individuals who
• 40:55can help you build trust with the with
• 40:59the patient and plan communications,
• 41:01right?
• 41:02Just when you communicate with others,
• 41:05try to have a plan of who else
• 41:07should be there and what are
• 41:10some of the best practices.
• 41:12I like this slide because it.
• 41:14Breaks sort of our are some of the
• 41:17strategies that we have to mitigate
• 41:20biases by organizational strategies.
• 41:22Individual strategies which you can
• 41:25do on your own, and some of these.
• 41:31Strategies that include some of the
• 41:33ones at the level of institutions
• 41:36and some of the ones that you can
• 41:39that you can do on your on your own.
• 41:41But but you know I'll I'll end by
• 41:45saying many of us find ourselves
• 41:48struggling to talk about these concepts.
• 41:51It's it's not easy to to talk about
• 41:55the impacts of race, ethnicity, racism.
• 41:58But it's important to have.
• 42:00These conversations and it's not until we
• 42:04start doing that hard work first on our own,
• 42:08educating ourselves and having going
• 42:11through that period of discomfort
• 42:15of talking about our mistakes and
• 42:17and how the ways that we can improve
• 42:22and improving our knowledge.
• 42:27That that we then get to to to ensue,
• 42:31change, read articles,
• 42:34watch documentaries, or.
• 42:37You know as much as you
• 42:39can and and you know not.
• 42:41Be afraid to sort of say you're wrong.
• 42:45Apologize often.
• 42:48And in the end I think.
• 42:54We've learned a lot about
• 42:57health inequities during COVID.
• 42:59COVID is still with us.
• 43:01There's going to be hopefully not
• 43:03as bad and not in the near future,
• 43:06but there will be other times
• 43:08when we will be challenged.
• 43:10By situations like what we've
• 43:13experienced in the last three years.
• 43:16So these challenges are going
• 43:18to continue to to occur.
• 43:20And I think this has been sort
• 43:22of a wake up call to for all of
• 43:26us to think about how prepared
• 43:29are you and what are you going to
• 43:32do when faced with challenges.
• 43:34Again, thank you very much.
• 43:36I'm going to apologize for my loud dog I.
• 43:41I didn't realize she would
• 43:42be barking so much,
• 43:43but it's been a pleasure and
• 43:46if you have any questions I'd
• 43:48be happy to to answer them.
• 43:53Thank you so much, Dean Vasquez,
• 43:55for that incredible talk. It's just.
• 44:00Incredible to me how much reflection and
• 44:02teamwork and being able to learn from each
• 44:04other and just staying humble can make
• 44:06such a huge difference in people's lives.
• 44:08So thank you so much for sharing that.
• 44:11And about the dog, I think she's
• 44:13adorable and very sweet and never need
• 44:15to apologize for a dog in my book.
• 44:17So. But that being said,
• 44:20disclosure statement,
• 44:21I have my own dog that also decides
• 44:24that she when she wants to bark so.
• 44:27If anybody has any questions,
• 44:29please feel free to put them in the chat.
• 44:33There is a question and answer option and
• 44:35we can go through them with Dean Vasquez.
• 44:43Or if we'll give it another minute or so,
• 44:46but if nobody has any other questions,
• 44:49I just want to thank Dean Vasquez
• 44:51incredibly much for her time and all
• 44:53the incredible work that she does.
• 44:54This has been a great way to continue
• 44:57our MSN perspectives, which our theme
• 45:00is equity and inclusion and access.
• 45:03And so this is a just another
• 45:05great opportunity to hear from you.
• 45:07All right, we do have one.
• 45:09What did it take to connect the
• 45:10patient to all the specialists?
• 45:15Well, that's a that's a good question.
• 45:18In the era of electronic medical records,
• 45:21you can request new appointments,
• 45:25but I'm a little bit old school.
• 45:29I. Looking at the patient,
• 45:32obviously you're going to you know take
• 45:35care of of of the patient then and there.
• 45:38I was very concerned about his heart and
• 45:42his lungs so I picked up the phone and.
• 45:46I looked online to see
• 45:48who was who was on call.
• 45:50Um, and I directly.
• 45:51I used my resources.
• 45:53I called directly attendings and
• 45:56fellows to try to advocate so.
• 46:00So I think youth resources that you
• 46:05have in hand, don't be afraid to
• 46:08pick up the phone and talk to people.
• 46:10This was back at the time
• 46:14when the only faculty member,
• 46:15so the only physicians in
• 46:16the hospital were those.
• 46:18Call people will not in their offices.
• 46:20Before I could have just walked
• 46:22up to somebody's office so.
• 46:26So reaching out and and pleading
• 46:29the case it wasn't you know a
• 46:32lengthy explanation but if you can
• 46:35summarize the case in A2 liner
• 46:38a child post COVID who's working
• 46:40hard to breathe and I think may
• 46:43have restrictive lung disease post
• 46:44COVID or who I think may may have
• 46:47you know congestive heart failure I
• 46:49need this child to be to be seen.
• 46:52So that was sort of the SOS and
• 46:54that was my approach in in sort of.
• 46:57Because I have I'm lucky enough
• 47:00to have the resources I use them
• 47:02to advocate for my for my patients
• 47:05and and and then it's follow up.
• 47:07So it's not just making those
• 47:10appointments it was. Letting the mother know.
• 47:15I know every time you come here you
• 47:17see a different provider because that
• 47:19that's the reality that happens, right.
• 47:21We're not in private practice
• 47:22and with a solo practitioner,
• 47:24but making the connecting,
• 47:26making the connection and making
• 47:29the commitment.
• 47:30So I asked her if it was OK for
• 47:33me to have her,
• 47:34her Direct Line and I told her
• 47:36I'm not in clinic tomorrow,
• 47:38but I will call you tomorrow because
• 47:40I want to know did they call you
• 47:43to give you the appointment and.
• 47:45And and and using that and then
• 47:47you know you can't be the one
• 47:50following up with every appointment,
• 47:52but then relaying the message to
• 47:54those involved trying to work as a
• 47:57team and sending messages through
• 47:59the electronic medical record or
• 48:00one-on-one to those who I knew
• 48:02would see him and say.
• 48:06Follow up is important.
• 48:07If the patient doesn't show up, I want
• 48:10to know and and you and you let me know.
• 48:12It's difficult.
• 48:16Because so much more of our
• 48:20communication is electronic and you know,
• 48:23work hours with the work hour
• 48:25limitations especially in in.
• 48:27Training institutions where residents
• 48:29can't be on for long periods of time,
• 48:33then there's a lot of turnover
• 48:36and we need to, I think,
• 48:38work harder to ensure that the
• 48:40sign out contains some of these.
• 48:43You know, the.
• 48:45The message is that we want to
• 48:47relay not only what medication
• 48:48this patient should have,
• 48:49but please make sure that this
• 48:51patient is not lost to follow up.
• 48:58Thank you so much. Any other last questions?
• 49:07Alright. Well,
• 49:08thank you very much Dean Vasquez.
• 49:11We really appreciate your time
• 49:13and sharing this incredible story
• 49:15and I hope everybody has a great
• 49:17rest of your day. Thank you.