Yale Psychiatry Grand Rounds: September 25, 2020

September 25, 2020

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Lee Pachter, DO, Professor, Pediatric & Population Health, Sidney Kimmel Medical College of Thomas Jefferson University: "Racism, Adversity and Child Health"

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00:00Racial and ethnic minority children and
00:03other vulnerable population that we
00:05don't always think about it in terms of
00:07the impact of racism and discrimination
00:10on their health and well being.
00:12With that, I'm extremely pleased
00:14to introduce Doctor Leap Actor.
00:16He is a professor of Pediatrics in
00:19population health at Thomas Jefferson
00:21University and senior physician,
00:23scientist and director of mentorship
00:26and professional development at
00:28the Value Institute at Christiana
00:30care health system in Delaware.
00:32Doctor Pachter also is the editor in
00:35chief of the Journal of developmental
00:37and behavioral Pediatrics.
00:39He received his DO degree from the
00:42Philadelphia College of osteopathic medicine.
00:44He was a pediatric resident at
00:47Saint Christopher's Hospital for
00:49children in Philadelphia.
00:51And completed a fellowship in
00:53academic general Pediatrics at
00:54Children's Hospital of Philadelphia.
00:56He was a faculty member at the
00:59University of Connecticut School of
01:01Medicine for 20 years before returning
01:04to Philadelphia to become chief of
01:07general Pediatrics at Saint Christophers
01:09Doctor Pachter's research has been
01:11in the area of cultural competency,
01:14cultural informed care,
01:15social determinants of Health,
01:17psychosocial stress and adversity,
01:19racism and discrimination,
01:20and Health Inequities and disparities.
01:23He's received grants from the NIH,
01:26CDC,
01:26hersa,
01:26and private foundations for research
01:29and program development.
01:30He received a grant from the CDC to study
01:33the effects of parenting maternal depression,
01:37the home environment and poverty are.
01:40Children's behavioral health in
01:42different racial and ethnic groups.
01:45His NIH K Award was used to study
01:48racism and minority children,
01:50and has resulted in the development
01:53of the precis,
01:54which is the perceptions of
01:56racism in children and youth.
01:58A psychometrically validated
02:00questionnaire to measure perceived
02:02racism and discrimination in youth.
02:04As a founding Co leader of the
02:07Philadelphia adverse childhood
02:09experiences or Asus task force,
02:11he was part of a team that developed
02:14the ace Philadelphia aces questionnaire,
02:17which included community level
02:19adversities such as experiences of racism,
02:22witnessing community violence,
02:23low social capital,
02:24and bullying.
02:26In addition to the traditional aces.
02:29He was also the piona herself funded
02:31project aimed at developing clinical
02:33an community approaches to trauma
02:36informed care in the state of Delaware.
02:38We also developed an was founding director
02:42of the academic pediatric associations.
02:45New scholars century program and
02:48national mentor ship program for
02:50underrepresented in medicine.
02:52Pediatric trainees interested in
02:55developing academic careers in
02:57health disparities research.
02:59The program, now in its 16th year,
03:02has been funded by the NIH,
03:04the US Office of minority health,
03:07the American Pediatric Society,
03:09the Kellogg Foundation,
03:10and the Aetna Foundation.
03:11Please join me in welcoming doctor Lee
03:14Pachter who's talk is entitled racism,
03:17adversity and child health.
03:19Thank you Doctor Cousteau.
03:21Thank you
03:22so much. First of all for inviting me and
03:25also for making sure that this subject is
03:28really front and center in your Department.
03:32So it's great to virtually be in New Haven.
03:35As Cindy said, I spent 20 years in Hartford
03:38at Saint Francis hospital as well as the
03:42Connecticut Children's Medical Center.
03:45And yeah, I have ties to New Haven as well.
03:47My wife, who is a psychiatrist,
03:49actually went to undergrad and medical
03:51school at Yale and my sister in law,
03:53who I believe is in the audience today.
03:55Heather just retired from the School of
03:57Nursing where she was a professor at the
03:59school of their scale. So it's great.
04:01I wish I was up in New Haven.
04:03The one bad thing about this virtual is that
04:05by virtual slice of Peppes Pizza isn't as
04:07good as my regular slice of Pepi's Pizza,
04:09and I really missed that.
04:11But anyway, but we'll take,
04:12we'll take it from here.
04:13I'm going to try to share my screen I.
04:16Please give me feedback if you don't
04:18see it or if slides are not advancing.
04:21You should now see a slide that says racism,
04:25adversity and childhood shop
04:27will take your fear.
04:31So. What my goals today are, first of all,
04:35to place this this topic of racism within
04:38the context of social determinants of Health.
04:41In other words, racism being a psychosocial
04:44stressor that can contribute to poor health
04:47outcomes in children and adults of color.
04:50Like to review the scant literature
04:52unfortunately on the relationship
04:53between racism and child health,
04:55hopefully, maybe advancing that.
04:58Also discuss how common is it?
05:00How common is racism in the lives of
05:03children color in the 21st century?
05:06I think what's really important to discuss
05:09the potential processes and mechanisms
05:11through which stressors such as racism
05:13may contribute to sub optimal health.
05:16And then finally, propose that racism
05:17should be considered within this grouping
05:19of adverse childhood experiences or aces.
05:21Now, I understand that this audience is very,
05:23very diverse in terms of everyone from
05:25medical students to America by professor.
05:27So I apologize if some of the things I've
05:29talked about their background to you,
05:31but I just want to make sure
05:33that we're on the same page,
05:35so we'll start there.
05:36But actually where I'd like to start
05:38this where I live now in Philadelphia,
05:40as much as I love Connecticut,
05:42my home now is in Philadelphia.
05:43It's a fun town and I'm sure
05:45many of you have visited either.
05:47For vacations or family or education,
05:50and if you've come to Philadelphia,
05:53probably at least partially stopped in the
05:56area of Philadelphia called society Hill.
05:58Very common place for people to go.
06:02It's beautiful old cobblestone streets,
06:04very much like New Haven colonial buildings.
06:07Our Roe homes and a lot of clubs
06:10and restaurants.
06:11Great place just to walk around.
06:13There are large condominiums.
06:14This one was designed by IM Pei.
06:16It's called Society Hill Towers.
06:19Of course we have all the historical
06:21stuff that goes on in Philadelphia from
06:23Independence Hall and the Liberty Bell.
06:25So that's probably with a lot of people.
06:27Think about when they visit or
06:29when they think about Philadelphia.
06:31Now there's another community in Philadelphia
06:34with another sort of colorful name.
06:36Very very close.
06:37Called Strawberry Mansion.
06:39Many of you,
06:39some of you may have visited them certain.
06:42Many of you have not let's,
06:43let's talk about a little bit of difference
06:45of these two very close communities.
06:47In Society Hill,
06:49the average adjusted gross income
06:51is a little bit over $150,000.
06:54In Strawberry Mansion,
06:57the average income is $24,000.
07:00In Society Hill,
07:019% of the residents live below the
07:04poverty line in Strawberry Mansion,
07:0641% live below the poverty line.
07:10In Society Hill,
07:12the percentage of residents with a
07:14bachelors degree is a little bit over 70%.
07:17In Strawberry Mansion's 4%.
07:22The unemployment rate in Society Hill
07:26is 3.7% in Strawberry Mansion's.
07:29It's 25%. 2% of the residents in
07:33Society Hill receive food stamps,
07:3535% in Strawberry Mansion.
07:3878% of the residents of
07:40Society Hill are white.
07:42And 93% of the residents in
07:45Strawberry mansion are black.
07:46Now here's the most all
07:48those stats are interesting,
07:49but here is I think the
07:51most interesting stat.
07:53In Society Hill,
07:54the life expectancy is 88 years.
07:58In Strawberry mentioned it's 68 years.
08:02So we're not talking about the difference
08:04between the US and some third world country.
08:06But we're not talking about the difference
08:09between New England and Louisiana
08:10or Mississippi were talking bout the
08:13walkable distance within a city. 20 years.
08:15Think about with 20 years is within a
08:17walkable distance. Life expectancy.
08:19So I guess the question is. Why?
08:22These are the usual suspects.
08:24Obviously from my slides you've seen
08:27that the housing stock is very different,
08:29as well as the stats on incoming education.
08:32I can tell you that neighborhood safety is
08:35quite different in these two communities.
08:37An power of neighborhood safety is
08:39allowing kids to go outside and do
08:42healthy activities like exercise,
08:43not that available in Strawberry Mansion.
08:46Should I mention is considered a food desert?
08:49You know most people get their food
08:52from corner stores which don't have
08:54the most healthy and nutritious food.
08:56A toxic exposures, you know,
08:58driving to work everyday.
08:59I drive on the Roosevelt Expressway,
09:01which is above its its its height
09:03and it's above Strawberry Mansion.
09:05I'm thinking of all the cartoons that
09:07are raining down upon the residence.
09:09Also,
09:10strawberry mansion has the highest
09:11rate of lead exposure in kids.
09:13Believing that 21% of children in
09:16Strawberry mansion have high lead levels.
09:18And obviously access to transportation and
09:21access to quality preventive healthcare
09:23are all potential reasons why we see
09:27this difference in life expectancy.
09:29If you take a step back and look at
09:31just the overall determinants of Health,
09:34they could be grouped into these
09:35type of categories.
09:36And again, if these slides aren't showing up,
09:39someone raised their hand,
09:40but there should be a slide that
09:42says determinants of Health and
09:44fix different categories.
09:45We all know biology,
09:46genetics and medical care are
09:47important determinants of Health,
09:49but as as we know as well
09:51the physical environment,
09:52the social environment and behavior,
09:53specifically,
09:54health behaviors are also important
09:56determinants of health care outcomes.
09:58So what was surprising to me when
10:01I first looked into these issues
10:03is that biology.
10:04Genetics, according to most studies,
10:06only account for about 30% of the
10:08variability in health outcomes.
10:10And Healthcare, which were all apart of.
10:13And we probably are little bit
10:16egocentric about.
10:17Many studies have shown that healthcare
10:19only contributes about 10 to 20% in
10:22the differences in health outcomes.
10:24So between biology,
10:26genetics and medical,
10:27it's really not that much whereas
10:30those top three categories,
10:31the physical and social environment
10:34and health behaviors they contribute.
10:36Anywhere from 50 to 70% of the
10:39differences in health care outcomes.
10:41So if you look at it this way,
10:43it really is true that your zip code
10:46is more important than your genetic
10:48code when it comes to health outcomes,
10:51you zip code is more important
10:53than your genetic code.
10:55Now by far my medical training
10:57emphasize those bottom three areas
10:59and I think I was woefully unprepared
11:01to really practice medicine.
11:02Because, you know,
11:0380% of my medical education has to
11:05do with biology,
11:06genetics in the healthcare system.
11:08It's changed a lot since
11:09I've gone to medical school,
11:11but we still have a long way to go.
11:14It's not only the professional training,
11:16but look at spending.
11:17Let's follow the money.
11:19Of the two point 9 trillion at
11:21the United States spends every
11:23year in health related costs,
11:2697% of the grows to Healthcare.
11:30So what that's saying is that
11:3297% of the expenditures is going
11:34to a category that only accounts
11:37for 10 to 20% of health outcomes.
11:41That also means that only
11:433% of health expenditures.
11:45Go to the areas that attribute that accounted
11:49for 50 to 70% of the health outcomes.
11:52So it's not surprising that with all
11:55the health spending that we have,
11:57probably the most in the world,
11:59the United States ranks 31st
12:01in life expectancy. So.
12:07What do we talk about when we talk about
12:10these social determinants of health?
12:12You know, these include things such
12:15as you know, income and wealth,
12:17social class, food security,
12:19housing, security,
12:19preventative and risk taking
12:21behaviors and things like Education,
12:23Community, neighborhood,
12:24which also included in the
12:26social determinants of Health.
12:27Obviously our race and ethnicity.
12:30So race and ethnicity a demographic
12:32factors that are mentioned as
12:33social determinant of Health.
12:34But what we really mean when we
12:36talk about race and ethnicity as
12:38a social determinant of Health.
12:40So we all know now that it's commonly
12:42accepted that race is less of a
12:44biological issue as a social construct.
12:46That's why it's considered a social
12:48determinant of health, right?
12:50So if we agree that race is mostly,
12:53if not all, a social construct,
12:55then the next question is through
12:57what mechanism do we account for
12:59the racial and ethnic factors
13:00contributing to health outcomes so well?
13:03I would like to propose.
13:05So when we talk about race and
13:07ethnicity and health care in particular,
13:09it's the health disparities in outcomes.
13:10What we're really talking about is
13:12racial discrimination or racism,
13:13and that I hope to make that argument today.
13:18So. Common definition of racism.
13:21It's the negative beliefs, attitudes,
13:24and actions resulting from categorizing
13:26individuals or groups based on phenotype,
13:28heritage, or culture.
13:29Actually divided into 2 racial prejudices,
13:32our beliefs, attitudes and assumptions.
13:35And discrimination are actions and behaviors.
13:37Another way of breaking down racism
13:39is in terms of levels of racism.
13:42So this comes from a wonderful physician,
13:45Public Health Epidemiologist named
13:46Kamari Jones, who is the president of
13:49the American Public Health Association,
13:51and she is divided levels of
13:53racism into these three levels.
13:55Interpersonal, structural and internalize.
13:58So interpersonal racism,
13:59what we typically consider as racism,
14:01it's racial prejudices and discriminations
14:03that car on the personal level between
14:06two people or between the person and the
14:09group that he or she has prejudice against.
14:12Structural racism,
14:13which we're talking more about
14:14because of the because of the issues
14:17happening in the United States today.
14:19Structural racism is a system of
14:22organization that includes policies
14:24and practices and norms that contribute
14:27to an reinforce cultural inequality.
14:30So unlike interpersonal racism,
14:31this is not something that a small
14:34group of people or person can decide
14:37to participate in or not.
14:39It's intimately woven into the
14:41fabric of our culture.
14:42Basically,
14:43it's a pervasive feature of the social,
14:45economic, and political environment.
14:47So institutional racism is racism is
14:51one part of structural racism, and that
14:54occurs within large sectors of systems.
14:56For example, the education system,
14:59health care,
15:00or the judicial or correctional systems,
15:02and other structural racism component
15:05is residential segregation,
15:06for example.
15:09Now internalize racism is a
15:12somewhat controversial term which
15:14denotes negative beliefs and
15:16attitudes towards one's own group.
15:19And it could include beliefs in
15:22racial and ethnic stereotyping.
15:23Haven't once group,
15:24but internalised racism is thought
15:27to carve someone unconsciously
15:28because of constant exposure to
15:31interpersonal in structural racism.
15:33You know the classical example
15:35of internalised racism.
15:36That's partly children is the famous
15:38doll studies by Kenneth and Mamie Clark.
15:41You may remember that this study,
15:43which was conducted actually in the 1940s,
15:46demonstrate that African American children,
15:47when given the choice between dollars with
15:50white skin color or Brown skin color,
15:52consistently showed a preference
15:54to the white bells,
15:55and these results were interpreted
15:57as demonstrating internalised racism
15:59in these kids who are subject to
16:01segregated schools and high degree
16:03of structural and systemic racism.
16:05And as you probably know,
16:07this study was used to as evidence in
16:09the Brown versus Board of Education case
16:12that struck down school desegregation.
16:14So if you think about these levels of racism,
16:17they kind of somehow map to those
16:19three different categories of
16:21social determinants of Health.
16:22Structural racism,
16:23particularly residential segregation,
16:25and its effect on unequal distribution
16:27of resources fits within the environment,
16:30the physical environment.
16:32Interpersonal racism is obviously
16:35a social construct.
16:37And internalize racism can influence
16:39behaviors, particularly health,
16:41promoting behaviors and risk
16:43taking behaviors.
16:46So this is the back on the topic of my talk.
16:49Is racism in children?
16:50So let's start talking about kids.
16:53So does racism affect Children's Health?
16:55There's not a lot of data on this,
16:58but there is enough to make
17:00some assumptions so awhile back,
17:02about 10 years ago,
17:04we did a systematic review of the literature.
17:07On the effects not effects,
17:09but the Association.
17:10I'm sorry between racism and
17:13Children's Health in general.
17:15We looked at all the medical literature,
17:17the social science literature,
17:18and that includes, obviously psychology,
17:20public health, etc.
17:22And what we found is that in the whole corpus
17:25of the medical and social science literature,
17:27we found at that point about 2000 seven 2009,
17:31only 40 papers that dealt with racism as it's
17:34associated with Children's Health outcomes.
17:37By far the largest part of the
17:39literature had to do with mental
17:41health and behavioral health.
17:43There was a small literature
17:45on birth outcomes,
17:46as many of you know,
17:47there are black white differences in things
17:50such as low birth weights and prematurity,
17:53and there was actually one study
17:55that showed that when you take into
17:57account maternal experiences of racism,
17:59the black white difference in pre
18:02term birth becomes insignificant.
18:03So maybe when looking at these racial
18:06ethnic differences in birth outcomes,
18:08we really talk about racism.
18:09And then there's a very,
18:11very small literature on some physical
18:13effects in kids mostly having to do
18:15with diabetes and cardiovascular health.
18:17When you look at the behavioral mental
18:20health literature on kids and racism,
18:22you know the suspects are, you know,
18:24higher degree of perceptions of racism,
18:26higher depression and anxiety.
18:28Lower self esteem,
18:30more behavioral problems.
18:32Delinquent in conduct disorder problems.
18:35Racism in adults have been shown to
18:38be associated with worse parenting
18:40practices and maternal depression,
18:42and it's also been associated
18:44with substance and alcohol use.
18:49So from a methodological perspective,
18:51I found something really interesting.
18:52When all these studies having
18:54to do with racism and kids,
18:55when you look at how they actually measured
18:57races and how they operationalized it,
18:59it was all over the board.
19:01There were 30 different questionnaires.
19:03An most importantly,
19:04most of the questionnaires were developed
19:06and tested in adults and they really
19:08didn't show there was no validity,
19:09reliability and kids.
19:10And as we all know,
19:12kids aren't little adults so this was
19:14something we'll talk about a little bit
19:16later when we talk about the crazy,
19:18but this is what we found.
19:20About 10 years ago,
19:22not a lot of literature,
19:24and the literature really was using.
19:28Questionnaires which were
19:30inappropriate for kids.
19:32So we know there is some Association
19:34between racism and kids health outcomes,
19:37but how common is racism in children?
19:39Is this something that's really
19:41common or not that common?
19:43So again as part of my K Award
19:46in developing our instrument,
19:47we interviewed alive kids and we
19:50did a study of 277 kids in actually
19:53in Hartford and Providence.
19:55These kids were between 17
19:56and 18 years of age.
19:58Most of them were Latin X,
20:00an African American.
20:00Although we did have some West
20:02Indian Caribbean kids and some
20:04multiracial multicultural kids.
20:06And what we did is that through
20:09our instrument development,
20:10we identify common situations where
20:12kids have been have been told us
20:16to that they experience racism.
20:18So we asked them quite.
20:20We asked him 24 questions, questions such as.
20:22Will you ever watch closely or
20:25followed around by security guards
20:27or clerks at the store at the mall?
20:29Do teachers assume you're not smart
20:32or intelligent because of your race?
20:35Are you watch more closely by
20:37security at school? Will you be?
20:39Will you treated unfairly by
20:41a police officer?
20:42When you're walking down the street
20:44to people, hold their bags tight.
20:47When you pass them.
20:48Has someone made an insulting or
20:50bad remark about you, your race,
20:53your atmosphere language?
20:55And did you get poor service
20:57at the restaurant?
20:58This is just an example of the
21:0024 questions that we asked, so.
21:02Usually when I'm in the audience,
21:04Tyler asked for show of hands.
21:06I won't do it today, but how many?
21:09How many kids do you think of the 277?
21:11What percentage of kids said that they
21:14experience at least one of these situations?
21:16I know I see some of you smiling,
21:18so I think you all know that's
21:20on the lower end of this scale.
21:22Actually it was 88%.
21:25245 of the 277 kids experienced
21:28at least one of these situations.
21:31In this group,
21:32the average number of experiences
21:34were six out of the 24,
21:35and really concerning is at 12%
21:37answered at least half of these
21:39questions positively.
21:40So this is the elephant in the room.
21:42This is really a very common experience.
21:44This study provides data that
21:46confirm what we already knew.
21:48That racial discrimination,
21:49even today is all too common in
21:52children of color.
21:53So if you wanna know what some
21:55of the other questions were,
21:57the most common with someone
21:58made a racial remark to you
22:00called you an insulting name,
22:01again security guards.
22:02Being accused of something
22:04you didn't do at school.
22:05Now this one is really concerning
22:07to me as as a developmentalist.
22:09Did you have you?
22:11Have you ever seen your parents be
22:13treated badly because of the color of
22:15their skin because of their race etc.
22:17So these are kids who are seeing
22:19their their their authority
22:20figures being treated this way.
22:22It's pretty sad.
22:24So these were some of the
22:26some of the answers now.
22:28So these 24 questions were part
22:30of our instrument development,
22:31so we wanted to develop an
22:33instrument that measured perceptions
22:34of racism in children that that
22:36was developmentally appropriate,
22:37and we used mixed methods
22:39where we first started by doing
22:41key informant interviews.
22:42Qualitative key informant interviews
22:44with a number of children to I
22:46just identified talk about their
22:48lives and talk about how they
22:49perceived discrimination and
22:50racism and whether some of the
22:53context with which they would.
22:54With which they experienced it.
22:56From that from those key informant
22:59interviews we developed this
23:01proto questionnaire of 24 items.
23:04And then from those 24 items we did
23:06some psycho metrics to tighten it
23:07up and to make a much smaller and
23:10more clinically and research useful
23:12instrument of Justice. 10 questions.
23:14And that's what the prices.
23:16So the crazy is the perceptions
23:18of racism in children and youth.
23:20And we actually have two different forms.
23:23We have a precis for younger kids,
23:25meaning between, let's say,
23:26the ages of eight and 13.
23:29An adolescent version between
23:3114 and 20 or whatever.
23:33I'll show you what the we did
23:35factor analysis and confirm atory
23:37factor analysis and different
23:39type of psychrometrics,
23:40item response theory etc and he
23:42came up with these questions as
23:44being the most psychometric valid.
23:46So for this crazy 17 younger
23:48version again there are similar
23:50questions to what we just went over
23:52having to do with school stores,
23:54restaurants and again,
23:55have you seen your parents or other
23:58family members being treated unfairly?
24:01There wasn't much difference between the
24:02younger version in the older version.
24:04The only two questions that were in
24:06the older version where you're being
24:08treated unfairly by a police officer.
24:10And people assume you're
24:11not smart for intelligent.
24:13So these are the 10:10 items on
24:15the different crazy versions.
24:16Now many people just use it as a score.
24:19You know a scale of 1 to 10.
24:21What we do in addition to that,
24:23for every item that a child says yes to,
24:25we asked additional questions to get a
24:27little bit more into the experience itself.
24:29So the first thing we asked
24:31is how often did it happen?
24:32What was the frequency?
24:33Is this a one time deal or
24:35did it happen more often?
24:37You know weekly, once a month, once a year.
24:40Secondly,
24:40we asked about Attribution.
24:41I'm interested in racial discrimination,
24:43but as we know, kids can be discriminated
24:45against for many, many different reasons.
24:47So the 1st, four or five have to
24:49do with racial discrimination.
24:51I was it happened because of
24:52the color of my skin, my race,
24:55my culture, language and accent,
24:56but it could be because of my age,
24:58my gender, the clothes I wear,
25:00the music, I listen to, etc.
25:02So we got frequency.
25:03We have Attribution.
25:06Emotional response when this happens
25:09you has it make you feel I got angry,
25:13sad, depressed, hopeless, powerless,
25:15strengthened, etc.
25:16And finally, after emotional response,
25:19we asked about coping response.
25:20How did you deal with it?
25:23I ignored it. I accepted it.
25:26I spoke up, I kept it to myself.
25:29I lost interest in things.
25:31I prayed in this positive and
25:33negative coping responses right?
25:34I tried to change things.
25:36I hit someone I worked
25:37harder to prove them wrong.
25:39So these,
25:39you know,
25:40for those people who are just interested
25:42in associations and Correlations,
25:43you can use the one to 10 scale
25:45if you're more interested in some
25:47of these more dynamic variables,
25:49you can look at coping response.
25:51Emotional response because I truly
25:52think that racism is a toxic stressor
25:55that all children of color experience.
25:57What makes some sort of not rise above it,
25:59but I think that coping emotion response
26:02really kind of separates out some of the.
26:04Outcomes, and there's very very common
26:07psychosocial stressor of kids. So.
26:11We know that racism effects health.
26:15We know that it's common in kids lives.
26:18We decide to do with just a
26:19few really basic studies on the
26:22Association between racism and health,
26:24and the first one we did I actually
26:26a medical student in mind who
26:28now is a pediatric gastro.
26:30Inter ologist did this with me.
26:32We looked at the relationship
26:33between racism and depressive
26:35symptoms in some children.
26:36So we interviewed 52 minority youth.
26:38Actually at the boys and
26:40girls clubs in Hartford,
26:41and we want to look at the relationship
26:43between racism and oppression.
26:45But also we want to look at Self Esteem.
26:48Lation ship between self
26:49esteem racism and oppression.
26:51My hypothesis going in is that there
26:53would be a relationship between racism
26:55and oppression which would be mediated
26:57through self esteem and interesting Lee.
26:59Although there was a significant
27:01relationship between racism and oppression
27:03and self esteem and depression,
27:04there wasn't a significant Association
27:06between racism and self esteem.
27:08You know,
27:08it's a very very small sample size,
27:11so I'm not going to put a lot into that,
27:14but this is what we found.
27:17Another study that we did which didn't
27:19then use the pricey but we looked at
27:21the National Survey of American life,
27:23the NSA L,
27:24which is a very very large data
27:26set mostly in minority individuals,
27:28and they have an adolescent supplement.
27:31And what we want to look at is
27:33the Association between racism
27:34and mental health in teens.
27:36So the NSA L had about a little bit over
27:39thousand African American and Afro Caribbean
27:43youth between the ages of 13 and 17,
27:46and according to this questionnaire,
27:48again, 85% discriminates.
27:49Xperience discrimination as expected,
27:51and when we did analysis
27:53logistic regressions,
27:54we found that discrimination was
27:57associated with major depression.
27:59With anxiety and with social phobia,
28:01both lifetime and last 12 months.
28:05Interesting Lee.
28:05When we set out to do this, I really.
28:08My hypothesis was that.
28:11We're gonna see these associations,
28:12but they be different among African
28:14American Afro Caribbean Youth.
28:15I mean, there are some data to suggest
28:18that the social context between Africa
28:20Caribbean and an American born African
28:22Americans might be a little bit different.
28:25But interesting,
28:26we didn't find any differences
28:27between these two groups.
28:29Now the sample of Afro Caribbean
28:31were second generation living
28:32in the United States for awhile,
28:34and further so that might be the
28:36thing that you know living in a
28:38racist society as United States
28:40Trump's any positive potential.
28:42Positive cultural aspects of effort.
28:44Caribbean youth culture.
28:48OK. So now I guess the question
28:50is how does racism affect health?
28:53You know, we we see that their associations
28:56were not quite sure you know what it is,
28:59but. You know what?
29:01How we have to look at different
29:03levels of how racism affects health.
29:05Really, from the macro to the micro,
29:08from neighborhoods to neurons, really.
29:10So if you think about it,
29:11let's go down these levels.
29:13The first level is the macro level as
29:15we discussed as we started this talk,
29:17you know separate residential segregation.
29:19Segregation increases exposure to
29:20things that are unhealthy and that could
29:23contribute to poor health outcomes.
29:24In addition,
29:25in addition to residential segregation,
29:28structural racism causes resource inequities,
29:30resources such as jobs, education,
29:32health care and Justice.
29:34Again, these can all contribute
29:37to poor health outcomes.
29:39Let's take it down to the intermediate level.
29:42Again, interpersonal racism
29:43causes psychological distress.
29:44As the data shows,
29:46as well as risk taking behaviors.
29:49And for me, the real interesting
29:51points of this micro level.
29:52Psychosocial distress,
29:53such as racism, can actually,
29:55as you will know,
29:57cause physiologic dysfunction.
30:00So it's talking about is that racism
30:02is a chronic psychosocial toxic
30:04stressor that can cause dysregulation
30:06of normal Physiology and biology.
30:07We all know about allostatic load, right?
30:10So this is the allostatic load
30:12theory as pertaining to racism.
30:13Now again,
30:14I don't need to talk about
30:16allostatic load to this audience,
30:17but there may be some who may
30:19not be as familiar with it,
30:22so I'll just give a general overview of
30:24Al Allostasis and allostatic load we
30:26all know about the stress response system,
30:28right?
30:29This is the normal stress response system.
30:31You're exposed to a stressor.
30:32Annuar system ramps up to
30:34address the stressor.
30:35OK,
30:36usually it's cortisol.
30:37Sympathetic with ever and then
30:39once that stress was out of your
30:41environment you get recovery.
30:43You get ramped down and shut
30:44off and you wait until the next
30:47stressful episode karsan again.
30:49This up and down occurs so this is
30:51adaptive its physiologic you know.
30:54Think about you know the greatest
30:56example high school example is you know
30:58prehistoric men and the wooly mammoth.
31:01You know you come.
31:02You come across a predator.
31:04Yeah,
31:04your stress response system
31:05jumps up and fight or flight.
31:07You know your cortisol goes up,
31:08your heart rate goes up,
31:10your respiration goes up.
31:11You either fight the mammoth
31:12or you hightail it out.
31:13When that man myth is out of your
31:15environment it shuts off and you
31:17back to normal until the next
31:18exposure to the woolly mammoth.
31:20So that's why it's been adaptive
31:22and physiologic.
31:23The problem is,
31:24is that stress these days isn't
31:26like that anymore.
31:27It's not as acute as we notice
31:29in the Strawberry Mansion's case.
31:31Yes, stress is more chronic,
31:33unremitting an unbuffered,
31:34so it happens overtime.
31:36Is that when that happens,
31:37there's not enough time for this
31:39recovery of the stress response system.
31:41OK,
31:42this normal allostatic stress
31:43response system.
31:44So you have a stressful response.
31:46You're bout to come down,
31:48it goes back up again and up
31:50and up and up and up enough,
31:52and one of two things happen.
31:56If you get a prolonged hyper response.
31:59Or you burnout?
32:00OK, so these two these two ways of dealing
32:04with stress is called allostatic load,
32:07which is this regulatory and non
32:09physiologic pathophysiologic.
32:10So again, you know all these chronic
32:13psychosocial stressors which every
32:15now and then you could you know the
32:18stress response works well you have
32:21the possibility of either having
32:23a hyper response or burning out.
32:27I'm going to very quickly because this
32:29audience knows exactly the role of
32:31stress on brain structure and function,
32:33but if you think about it with kids,
32:35you know the stress and the
32:37changes that the brain changes
32:38occur in areas which are really,
32:40really important for development
32:41in education.
32:42It makes a little hippocampus,
32:44the Prefrontal Cortex we talking
32:45about executive function,
32:46emotional regulation, etc.
32:47So obviously you you've done the
32:49cutting edge work on all this work,
32:51so I don't need to talk about that.
32:53But as you also know,
32:55there are other allostatic systems.
32:57Immunity, inflammation,
32:58endocrine and metabolism and growth hormone,
33:00as well as, you know,
33:03epigenetic changes changes in
33:05Metalation and teal in your life.
33:08So basically,
33:09in summary,
33:10you have these allostatic systems such as
33:14the HPA sympathetic immunity metabolism.
33:17Which get disregulated because of
33:18this chronic psychosocial stress
33:20or any type of stress and overtime
33:22results in dysfunction and disease.
33:24So So what are the diseases that
33:27these systems may be able make
33:30contribute to by becoming dysregulated?
33:32Well.
33:33Things such as diabetes, obesity,
33:36asthma and inflammatory disease.
33:39Cardiovascular disease and depression.
33:41So aside from these diseases
33:43in these chronic illnesses,
33:45being potentially caused by dysregulation
33:48of these allostatic mechanisms,
33:49what else groups these diseases together?
33:54Well,
33:54one thing is that these are the
33:58exact diseases that we see racial
34:00and ethnic health disparities in.
34:03So here we have a model where we
34:05have a chronic psychosocial stressor.
34:09Which gets under the skin.
34:11To cause physiologic dysregulation
34:14which overtime.
34:16Contributes to chronic illnesses.
34:18The same chronic illnesses that
34:20we see higher rates in racial
34:22and ethnic disparities.
34:23So I believe this model can be
34:26used these to be racism as that
34:31psychosocial stressor shuttle.
34:33Here's a conceptual model for
34:35how racism may decrease.
34:37May increase I'm sorry.
34:38Disease risk.
34:42I think that you process
34:44the social environment.
34:45You have perceived racism
34:46with other moderators,
34:48such as individual and community moderators.
34:50Throughout time, causes physiological
34:54and psychological stress.
34:56And through chronic unbuffered experiences.
35:00Cause physiologic dysregulation.
35:04Allostatic load.
35:06Altering HPA sympathetic
35:10inflammation immunity epigenetic.
35:13Which contributes to increase incidents.
35:15An increase morbidity in
35:17these chronic illnesses.
35:18Again the same chronic illnesses where we
35:20see racial and ethnic health disparities.
35:22So this is my model on how racism
35:26actually gets under the skin.
35:28Be cause health disparities and increase
35:30prevalence of health conditions now.
35:32This doesn't happen overnight.
35:34This allostatic mechanism takes years and
35:36years, and maybe that's the reason why.
35:39If you look at the literature.
35:41Um?
35:42The effects of racism in children are
35:46mostly psychological and behavioral.
35:48Where is the literature in adults
35:51show that in addition to racism's
35:53effect on psychology and psychiatry,
35:56it also affects physical health.
35:58So again this allostatic mechanism
36:00Hopsin and overtime these kids,
36:03when they become adults,
36:05suffer the consequences of allostatic
36:07load due to psychosocial stressors.
36:10Such as racism.
36:12Now I have perceived racism in this
36:14model and I've come to understand
36:15that you don't have to perceive
36:17racism for it to affect you.
36:19There are as many people know
36:21microagressions that happen everyday
36:22that many people of color aren't quite
36:25sure whether it's racism or whether
36:27it's them and it's just like this.
36:29It's all these.
36:30Microaggressions is micro hits is weathering.
36:32Whether it's perceived as racism or
36:34not certainly affects the allostatic
36:36Michalis static load mechanisms.
36:39OK, I'll give you a.
36:41I'll give you an example.
36:43I came across this article
36:46in the in the early 2000s.
36:49It was basically an epidemiological model
36:52about cortisol variation in adolescent,
36:54white, black and Latina Latin X Kids.
36:58So basically,
36:59these researchers you may know
37:02Amy DeSantis and I'm blanking
37:04on her name Amy DeSantis and.
37:06And Adam.
37:07Did salivary cortisol levels on a
37:10large group of adolescents and what
37:13they found cutting to the chase is
37:16that compared to white adolescents.
37:18Black and Hispanic adolescents
37:20had blunted cortisol slopes.
37:21As you know,
37:22there's a diurnal variation in cortisol,
37:24and it appears as if black,
37:26an lat next individual teenagers had blunted,
37:29and usually their cortisol
37:30started lower in the morning or
37:33ended up higher in the evening,
37:34and this was basically an
37:36epidemiological study.
37:37They really insane much about the
37:39causes of it by the end of their
37:42discussion they talk about they maybe,
37:44maybe this might be a stress issue
37:46and difference in stress among the
37:48different racial ethnic groups.
37:50The light bulb went off in my head.
37:52Well yeah, stress racism.
37:53So when I got to send Chris,
37:56I got a little bit of money just
37:57to do a feasibility pilot study to
37:59actually look at cortisone levels and
38:01perceptions of racism in children.
38:03And this has never been published
38:04'cause we didn't get a lot of
38:07people is really just to see
38:08whether we are able to do it,
38:10whether we were able to go into the community
38:12and get salivary cortisol's from adolescence.
38:14So basically what we did is that we got a
38:16few samples from adolescent black males.
38:19And we also gave them the precis,
38:21the perceptions of racism
38:23in children and youth scale.
38:24And when I wanted to see, is that
38:27actually within a African American sample.
38:30Whether those individuals that
38:32had high perceptions of racism?
38:34May have different quarters or slopes
38:36compared to African Americans who
38:38had low perceptions of racism.
38:39Again, we never really went forward on this,
38:41but I'll give you an example
38:43of two of the kids.
38:44So this is one of the children again,
38:47African American teenager who had.
38:49Who scored low in the precis
38:51Hadlow perceptions of racism?
38:52Compare this variation,
38:53which is normal high at the morning,
38:56low in the evening to another adolescent
38:59African American who had scored
39:01like off the charts on the pricing.
39:04That's his cord so slow as you can see,
39:07it's blunted.
39:08Again, this is an end of two.
39:10I would never publish this,
39:11but hopefully someone will pick
39:13up on this and maybe we will also.
39:15But anyway,
39:16this just gives you an example of that.
39:18You know,
39:18perhaps that difference in corso
39:20slopes we're seeing among different
39:21racial ethnic groups may be due to
39:22a Psycho Psychosocial Stressor, I.e.
39:24Racism.
39:25Maybe it's one of the one of
39:27the psychosocial stress is it's
39:29not the be all and end all.
39:31So again,
39:32we're talking bout how these things
39:34occur through long periods of time,
39:35and when I want to end up in
39:37talking about is that the effects
39:39of racism certainly have health
39:41consequences during childhood,
39:42but also throughout the life
39:43course into adulthood.
39:44Which brings us to the adverse
39:46childhood experience literature.
39:47Again, I'm sure all of you know about aces,
39:50but just to review it a little bit.
39:53You know the original ace study
39:55was done in San Diego at Kaiser
39:58Kaiser Permanente back in the 1990s,
40:01actually.
40:02And what they did is that they
40:04interviewed 17,000 adults,
40:06typically between 40 and 70 years of age.
40:09And they asked us adults retrospectively,
40:11historically about the stresses
40:13they experienced in childhood.
40:15And the traditional ace study
40:17their tank questions having to
40:20do with too many physical,
40:22emotional and sexual abuse.
40:25Physical and emotional neglect.
40:28And family dysfunction as defined
40:30by parental mental illness.
40:33Interpersonal violence,
40:34substance use, divorce, separation,
40:36or having an incarcerated relative.
40:38So this is the traditional standard.
40:42Ace questions.
40:43There are 10 of them.
40:46And what they found,
40:47not surprisingly,
40:48is that aces are extremely common.
40:50OK,
40:50almost 2/3 of the adults surveyed
40:52reported at least one ace and most who
40:55reported one actually had more than one.
40:58OK,
40:58so the majority had aces and the
41:00majority of people at aces actually
41:03had to the four to six or whatever.
41:06Would they did then?
41:08Is that they tried to
41:10associate correlate ascore?
41:12With adult illnesses again.
41:13So looking at childhood experiences and
41:16how they relate to adult illnesses
41:18and what they found is that the
41:21more adverse childhood experiences,
41:23the more health problems these individuals
41:25as adults, mental health problems,
41:27risk taking behaviors, reproductive health.
41:29Victimization, suicide, and also physical
41:31health and chronic health issues.
41:33Again, using that allostatic load
41:35model the same things, heart disease,
41:38cancer, stroke, emphysema, you name it.
41:41The list has gotten gigantic even since then.
41:45So this happened in the 90s and it
41:48really just started taking hold
41:50in the medical kind of community,
41:53probably around 2000.
41:54And what they also found was that
41:57people with six or more aces.
41:59Died nearly 20 years earlier on
42:01average than those who had no aces.
42:03So 20 year difference in life expectancy.
42:05Sound familiar?
42:07Now, I'm not saying that the
42:09difference in life expectancy between
42:11strawberry mansions and Society Hill
42:12I do to ace exposure, but you know,
42:15think of base as a psychosocial stressor.
42:17Think of a psychosocial stressors
42:18part of those social determinants.
42:20It all fits.
42:21The model probably contributes to it.
42:24So the study was really,
42:25really important,
42:26but you know those 10 items weren't
42:28like the 10 Commandments of ace.
42:30You know they didn't come down
42:32from the mountain as you know,
42:33so written in stone,
42:35they are really important,
42:36but it's only a small proportion of the
42:38adversities and stresses that kids can
42:40experience having to do with the abuse,
42:42neglect, and family violence.
42:43How about community?
42:44How about you know,
42:46outside of the family,
42:47so there are a number of people
42:48that I work with in Philadelphia
42:50that we're really interested in.
42:52Kind of expanding the concept of
42:54adversity as it pertains to children.
42:56As well as it pertains to the
42:57adults that the children become.
42:59So we did an ace project where
43:01what we did was.
43:03We took the traditional aces,
43:06which were abuse,
43:08neglect and household dysfunction, and we.
43:12Added to that,
43:14additional aces mostly community level aces.
43:18When you were a child,
43:19did you witness violence in your community?
43:21Social capital,
43:22did you live in an unsafe neighborhood or
43:24neighbourhood without love connectedness?
43:26I was able to advocate for including
43:29racism and discrimination into this.
43:31Were you bullied and were you in foster care?
43:35So this,
43:36you know,
43:36we kind of expanded the questionnaire
43:39on aces and what we did was we
43:42gave it to about 1700 adults in the
43:45Philadelphia area and we kind of related
43:48our findings to the initial Kaiser study.
43:51So just to give you background,
43:53emotional abuse was extremely much higher
43:55in Philadelphia compared to Kaiser.
43:57Remember, we're talking bout
43:59San Diego versus Philadelphia.
44:01Substance using household Bender
44:04members were higher in Philadelphia.
44:07Mentally ill household member 20.
44:08About 25 versus 20% and having
44:10incarcerated household member much higher.
44:12Now when you look at the additional
44:15aces is what we found again,
44:17the Kaiser sample didn't have these,
44:19so we couldn't see.
44:21But as you can see.
44:2340% of our sample witness
44:26violence as children.
44:2735% experienced discrimination.
44:31They have to understand this.
44:33Philly sample was a multicultural,
44:35multiracial sample included whites everybody.
44:37If you look at just the minority
44:41subsample it was way over 50%.
44:44Experiencing discrimination,
44:44so I'm happy to say that most not most,
44:47but a lot of researchers now
44:49are using this expanded idea
44:50of aces when they do studies.
44:52And by the way,
44:53I don't think that these five additional
44:55cases are the be all and end all.
44:58Also, I really take a contextual
45:00approach to adversity ifeel that any
45:02researcher or any educator or any
45:04provider needs to look at what the
45:06adversities are in your own community
45:07or in the community of your clients.
45:09And really,
45:10you're able to modify and adapt accordingly.
45:13We could talk later on about
45:15a scores versus not ace,
45:17'cause I'm not big a score person,
45:19but that's really not part of this talk,
45:21but I'm happy to discuss later.
45:23So we also did some bivariate analysis
45:25of the associations between that racism
45:27question on the ace questionnaire
45:29and some adult health outcomes.
45:30And again, these are just by variant,
45:33so I'm not this is nothing to take home,
45:36but in general, if you,
45:38if you answered positively to
45:40this childhood racism exposure,
45:41you are more likely to have
45:43depression as an adult.
45:45Suicide.
45:46Tobacco use substance use,
45:49sexually transmitted illness,
45:51number of sexual partners.
45:53Unintended pregnancy fractures and emphysema.
45:58So we were hoping to do by Barry the analysis
46:00of multivariate analysis to really see.
46:02And the other thing that we're
46:03planning on doing is that I really
46:05don't like this idea of an ace score.
46:06So what we're planning on doing is
46:08a cluster analysis to see whether
46:09there are clusters of aces which
46:11are more predictive of outcomes,
46:12and just like a score of six or one or three,
46:15or whatever else.
46:16OK, I'd like to just summarize
46:18what we've talked about.
46:19First of all,
46:20racism is a stressor that's commonly
46:23experienced by minority children and youth.
46:25Yeah,
46:2560 years after Brown versus
46:26the Board of Education,
46:28it's still part of people's lives.
46:31Is a small book growing literature
46:34on the associations between
46:35racism and child health outcomes?
46:40Hopefully I've convinced that
46:41racism can be conceptualised as a
46:43toxic stressor that contributes
46:45to physiologic dysregulation.
46:47Allostatic load and subsequent
46:50chronic illness.
46:51The illnesses that are linked through
46:53this allostatic mechanism on the
46:54same illnesses that we see racial
46:56and ethnic health disparities.
47:00And that racism experienced in childhood
47:02should be thought of as an adverse
47:05childhood experience that affects
47:06health throughout the life course. Now.
47:09I often feel bad about giving this talk
47:12because it's it's such gloom and doom.
47:15You know, we talked all about how
47:17high loads of adversities, specially
47:19in racial and ethnic minority groups.
47:23Contribute to poor outcomes,
47:24but I've really only given you half of the
47:27equation you if you think about outcomes.
47:29Outcomes are a function not only
47:31of adversity, but the relationship
47:33between adversity and assets,
47:34so this is this is my new like mean,
47:37you know, assets over adversity,
47:38equal outcome.
47:39And although unfortunately,
47:40this adversity of racism is systemic
47:42and structural answer take a lot
47:44to read it out of our society,
47:46we need to work in that way.
47:48But as we're doing that,
47:50I think we need to work on
47:52the individual client level.
47:53To make sure that we increase
47:55the assets that are individuals
47:57has event so that they can.
47:59Can thrive despite being subject
48:02to this toxic stresser.
48:04His assets include include external assets.
48:06Obviously for children,
48:07family and parents and adults are the most
48:10important thing that peers and friends,
48:12coaches, mentors,
48:13an community.
48:14OK, these are assets that we need to build
48:17up in our clients as well as internal assets,
48:20coping style,
48:21locus of control,
48:22and epigenetics.
48:23So I'm hoping that as we weed out
48:26racism from our society were able
48:27to work on an individual level
48:29to make sure that we can pay
48:32the healing centered approach.
48:33These adversities.
48:34So thank you all for your listing.
48:37To me.
48:37I'd be happy to answer any questions
48:39that you have now an I appreciate
48:42the opportunity to thank you.
48:48Thank you so much for a wonderful talk.
48:50We're going to open it up for questions
48:53that you can also use the chat feature.
48:57Should I stop sharing? Sure,
48:59that'd be great, OK? Here we go. But
49:06see Carmen, Where are you?
49:11There you are. Hi, good morning.
49:13Carmen has a question.
49:15Hi, I'm sorry I'm using my phone today.
49:20I appreciate the efforts to
49:23quantify our racial trauma.
49:26It's bittersweet to a degree because I
49:28feel like so much of the presentation
49:31was what the black community,
49:34an black colleagues have been screaming at
49:36the top of our lungs for generations before
49:40an external source put a number to it.
49:43If that makes sense.
49:45I I'm very proud to come from Georgia,
49:48and I feel like when black communities
49:51try to advocate for ourselves of the
49:54disparities that you're able to quantify.
49:56It's met with societal resistance.
49:59In the South it was lynching historically.
50:01Now that's the black lives matter
50:04movement that's being misconstrued
50:05as terrorist organizations.
50:07And all these things from people who
50:10don't want to hear our racial story,
50:13but one of the things I in some
50:17other black colleagues were chatting
50:19about as we were listening is.
50:22There is concern that.
50:23As we try to quantify are my
50:27communities racial trauma?
50:29I want to caution against.
50:32Kind of typecasting it as if we don't
50:36express trauma in a certain way.
50:39That's quantified by XY zed measure.
50:41Then we're back to being.
50:44Silenced two degree.
50:45I really feel like our communities have
50:49been expressing this trauma for ages,
50:52but getting punished.
50:53And as you talk about assets,
50:56that one asset I didn't see was
51:00wage disparities in financial.
51:02I,
51:03as a black single mom I'm having
51:05to produce financial and physical
51:08and emotional assets to give my
51:11kids the same opportunities as the
51:14equivalent non black child and so.
51:17Money and targeted interventions
51:19is a huge part of that.
51:22I trained in Philadelphia,
51:24I lived in Claymont, Delaware,
51:26so you probably passed my former
51:29residents everyday on your way to work
51:32and I just want to put into this open
51:35space that as we're talking about things,
51:38black communities have
51:40been saying for centuries.
51:42And in the context of the pandemic
51:44where everyones publishing oh,
51:46black communities have more
51:47cardiovascular disease,
51:48well these are the reasons
51:49why personally speaking with
51:51my racial trauma and stress,
51:53I've gained 30 pounds and I am helpless
51:55to get rid of it because my stress
51:58level is always out of 10 and so just
52:01to my colleagues into this space.
52:03Thank you for the quantification,
52:05but I also want to make sure
52:08that we're being mindful that.
52:10We've been saying it all along.
52:15Alright, thank you I couldn't agree more.
52:19I'm just hoping maybe just bring to light
52:21in from it from a different perspective
52:23and you know all the perspectives being
52:26put together maybe will change something.
52:28How do you think that we as scientists and
52:31his researchers can help that perspective?
52:35What I think a lot of it is experiential,
52:40in addition to quantifying,
52:43I targeted interventions
52:44for wage disparities,
52:46targeted interventions like not just
52:49passively documenting my community's demise,
52:52'cause That's hurtful.
52:53I was sharing with my colleagues.
52:57Not that it's the same intentional
53:00harm is Tuskegee.
53:02But watching passively the natural
53:04progression of the disease course
53:06without intervention is what black
53:09communities have endured before.
53:11So I mindful of the history.
53:14Just documenting all the ways
53:17that racism is killing us.
53:19Without an intervention is not.
53:22It's not the step forward,
53:24not just documentation,
53:25but doing something 'cause as black
53:27faculty is getting increasingly
53:29harder to show up to these spaces.
53:31Well, I'm not even able to afford
53:33the resources for my kids.
53:35I need to afford because I have
53:37to overcome 400 years of all
53:39the things you just quantified
53:41and it's just frustrating.
53:42I would very much like to do something.
53:46Couldn't agree more.
53:47I if if I see one more epidemiologic
53:50studies telling me that poor people
53:52do worse or my noise it works,
53:55I'm going to blow my mind's going to blow.
53:58We don't need that anymore.
53:59What we need now, as you say,
54:02our interventions but also understanding
54:04the processes and mechanisms so
54:06that the interventions that we
54:08developed are based on some sort of.
54:10Evidence based approach.
54:11But I agree with you completely.
54:14An actually doesn't even
54:15need to be evidence based.
54:17It needs experience based
54:19right money. Isn't this just just paying
54:21us what we need to survive is a great
54:25the 400 years at you're describing has
54:28a price in emotional tag to it. You
54:32have no argument with me, thank you.
54:43Other questions comments.
54:49So I would like to to
54:52ask us something. Doctor
54:56Lim so sorry if my questions.
54:59It's very simple, but. And you were
55:02talking about the Philadelphia Studies an
55:05you bring this components of the community.
55:08I think that's so important. We have
55:12been studying listing an following
55:15research base in the first
55:18days and at the first time I'm
55:21seeing that you brought this
55:24component. I would like
55:26to know a little bit more because
55:30I strong believe that community
55:33is a huge company. Each of
55:36our lives and. The
55:39participatory resorts that bring the voice of
55:43the community. To say things,
55:46to show to us that there is options to
55:51develop interventions that's not necessary
55:54happening on the clinical setting,
55:56but community based settings
55:59where people has the freedom
56:02to talk about deep feelings.
56:04Special for African Americans in my
56:08team community from Brazil. Seems
56:11to me that the conversation the
56:15The Open is to bring matters for
56:19this specific two populations to
56:23be address in the sense that we can
56:28talk. You can express and the
56:31community has a responsibility
56:34for your health in your
56:37well being seems to be very important.
56:41So would like to know if you
56:44can talk a little bit more about that.
56:47You'll be great also if you have
56:50literature review, I'm looking
56:51forward for that. Thank you.
56:55Thank you, that's a big topic and yeah.
57:01We'll be obviously have medical centric
57:04view of both the research and interventions,
57:07and I think that that's changing a
57:10little bit, not enough obviously,
57:12to give you an example where
57:15I'm working in Delaware,
57:17we Delaware is a state that doesn't have
57:20large NIH funding, unlike New Haven.
57:23So we have opportunities for an H funding on
57:27a state level to help increase the crease.
57:31Research that's called.
57:33Idea State C TR.
57:36Where the central components of that
57:38clinical and translation are research
57:40grant is community engagement and outreach.
57:43So every grant that goes through
57:47the CTR needs to be.
57:50Needs to be assessed through
57:51community engagement outrage,
57:52and that's not just at the end point where,
57:56like you know,
57:57the researcher needs to bring the frame.
58:00You know the information
58:01back to the community.
58:03We require that any researcher actually at
58:05the time that they develop their proposal.
58:08Consulates with CEO or the
58:10community gagement outreach core
58:11because even bench researchers,
58:13there's a community that will eventually
58:15benefit from your work OK and we
58:18need to start thinking about that.
58:20From the beginning,
58:21and that's moving along is that
58:22that's the minimum.
58:23I mean,
58:24we also have community based,
58:25participatory research where you
58:27know between is actually an active
58:28participant from the beginning and
58:30actually has control and owns owns.
58:32The Dayton owns the research
58:33so we're making little steps.
58:34You know it's not as quick
58:36as I would like it to be,
58:38but that's one example.
58:40I see where we
58:41have two people have raised their hands,
58:43but I can't tell who they are.
58:46So if you just want to speak up,
58:48oh Charles, there you go. Ask
58:51Doctor Lee.
58:51I just said my name is Charles decay.
58:53I'm one of the faculty here.
58:55I'm also forensic psychiatrist and
58:57I want to thank you so much for
59:00bringing together some of this.
59:02Difficulties disparities I want to try
59:05and link it with forensic psychiatry.
59:09In the criminal justice system.
59:12We are expected to provide
59:16objective assessment.
59:17In a system that is patently unfair,
59:21unjust, discriminatory.
59:22And it's really hard to jump in
59:25with closed eyes to all of these
59:29difficulties that lead people to
59:31behave a certain way or that cause
59:33people to act out in a certain way
59:36that crosses the legal boundaries
59:38and to close our eyes to all of that
59:42and just provide a straightforward,
59:44objective assessment.
59:45And I know that a lot of my
59:48colleagues struggling with that and
59:50and one of the other areas that I
59:53think has become really important
59:55for us is the issue of mitigation.
59:58So you're doing an assessment to try
01:00:00to provide an explanation for why an
01:00:03individual could turn out this way,
01:00:05for why an individual could behave
01:00:08in something that you call whatever
01:00:10a criminal behavior or whatever,
01:00:12and to be able to sit down and craft
01:00:15all of what you've written down.
01:00:18Ask potential issues that when
01:00:20people react to them or respond
01:00:22to them in certain ways,
01:00:24they could come across as being criminal.
01:00:28And how can you craft on an explanation
01:00:31that shows people that this behaviors
01:00:34are actually not unexpected given all
01:00:37these adverse childhood experiences
01:00:38and the prices and all of that?
01:00:42And if you expose people to this
01:00:44level of dysfunction and crisis and
01:00:47structural racism and individual racism,
01:00:50or through their lives that
01:00:52they react in certain ways,
01:00:55and therefore they should
01:00:57be punished even more.
01:00:59And we're trying to find a way to
01:01:01change that narrative to say in
01:01:03fact they should be punished less
01:01:05because of all of these things
01:01:07that they're dealing with.
01:01:09Maybe if we can find a way
01:01:11to address these things,
01:01:12then maybe they can have a better
01:01:14outcome in along the lines of what
01:01:17doctor Carmen Barker was saying,
01:01:18where there's so much and you're
01:01:20trying to come to come at a certain
01:01:23level with your colleagues who are
01:01:25looking at you as if you haven't
01:01:27experienced all of these disparities.
01:01:29And all these difficulties.
01:01:30So I just want to thank you again
01:01:32and I wanted so use that as a
01:01:35point to say that it's more acute
01:01:38in the criminal justice system.
01:01:40The influence on the negative
01:01:42impact to black lives.
01:01:44Thanks.
01:01:46Thank you, I couldn't agree more.
01:01:50Need to look at behaviors in context.
01:01:52Anan I, I understand this completely.
01:01:54My Wi-Fi says the psychiatrist is
01:01:55in the criminal justice system,
01:01:57sees the psychiatrist for
01:01:58the Philadelphia jail system,
01:01:59so she lives every day and I see the
01:02:02wear and tear on her just being able
01:02:04to knock her head against the wall.
01:02:06Not being able to move anything.
01:02:08So I thank you for what you're doing,
01:02:10and I think your comments.
01:02:14Ishwara hit die pronounce your
01:02:17name incorrectly. I apologize.
01:02:20Hi, I'm a medical student that was
01:02:22watching the didactic session so
01:02:23something I'd like to say is that I
01:02:26think Yale and probably most medical
01:02:28schools at this point does a really
01:02:30good job of educating us on these
01:02:33types of topics and so coming into it.
01:02:35I was a little. I was surprised
01:02:37to hear you
01:02:38say that you were surprised by
01:02:40some of the findings that you
01:02:42saw because I think for
01:02:44us in our training these
01:02:45are things that
01:02:46were taught about every
01:02:48year, multiple times a month sometimes.
01:02:50Depending on our rotation and I think one
01:02:52of the things that I personally was hoping
01:02:55was that when I got to this level and
01:02:58I was watching you know resident
01:02:59rotation or resident didactics
01:03:01and attending didactics,
01:03:02it would be less about this problem
01:03:04exists because I feel like at this
01:03:06point it's really been established
01:03:08and more about. Here's what we
01:03:10can actually do about it.
01:03:11Here are interventions that we can have.
01:03:13'cause again I think.
01:03:15But no one's questioning that it exists.
01:03:18No ones questioning that it has bad effects,
01:03:22medically and sociologically
01:03:23or socially, but.
01:03:25No one's really giving an answer to what.
01:03:28What do we do?
01:03:30How does it change treatment?
01:03:32What should we be saying to
01:03:34patients to mitigate that?
01:03:35And so I'm a little frustrated
01:03:38by that lackof.
01:03:39Of. Education,
01:03:40because I feel like every
01:03:42time This has been presented,
01:03:45it's been presented as look at
01:03:46this new idea or look at this
01:03:48new topic and it's really not.
01:03:53Hello Cindy, do you wanna comment on that?
01:03:58I mean, it's great to hear that
01:04:01medical students are getting this,
01:04:03I can think 5 years ago,
01:04:05where they would say that they
01:04:07weren't at all in terms of
01:04:10social determinants of Health.
01:04:11So I guess efforts to change the
01:04:14curriculum have been successful.
01:04:16I had heard it that stated
01:04:19that strongly that.
01:04:20Change in progress has been made so,
01:04:22so that's great.
01:04:23I think for me I think there's still
01:04:26a gap in what people know about how
01:04:28this impacts children and their
01:04:30health and how it impacts behavior.
01:04:32So that was my goal for today that
01:04:35there's actually a way that you can
01:04:37measure this that you can study
01:04:39it more that you can understand
01:04:41the mechanisms at various levels
01:04:43and develop interventions.
01:04:44And I would say that there are.
01:04:47There are lots of interventions
01:04:49that are out there both for aces,
01:04:52so there's the Philadelphia based project,
01:04:54which doctor Pachter talked about that
01:04:57looks set this at multiple levels.
01:04:59So I mean, I'm great to hear that people.
01:05:04In the medical school, here are.
01:05:06You know?
01:05:07Have had this information now 'cause
01:05:10it hasn't always been that way.
01:05:13And I was wondering,
01:05:14doctor factor,
01:05:15if you could talk about recent
01:05:18editorial that you wrote about the
01:05:20role of the academic Journal in
01:05:23promoting racial equity in health.
01:05:26Sure. So in addition to
01:05:29my my my day job work,
01:05:32I'm a Journal editor and.
01:05:35I've been very perplexed.
01:05:39At the way that.
01:05:42Race and ethnicity as a
01:05:45social determine has been
01:05:46used in health research.
01:05:48I think that.
01:05:52We need to find a way to educate.
01:05:57Researchers as well as reviewers and Borhan.
01:06:00Journal Board members to understa
01:06:01really understand that when
01:06:03we talk about race ethnicity,
01:06:05what we're really talking,
01:06:06the operational term really is racism.
01:06:09And I'm really hoping to get past that.
01:06:11When I called the table,
01:06:13one use of race and ethnicity as
01:06:14just one of those other demographic
01:06:16variables that you enter into your
01:06:18regression model and you know.
01:06:19And that's the be all and end
01:06:22all we need to get past that.
01:06:24If in fact we do find in research
01:06:26that race ethnicity is an important
01:06:28component of whatever study we're doing,
01:06:30we need to dig down deeper and
01:06:33think about it in the lens of OK.
01:06:35If this is a social determinant,
01:06:37health, you know,
01:06:38is it racism and how that might,
01:06:40how that how we might be able to
01:06:42explain our results based on it as a
01:06:45social as opposed to a biological?
01:06:47Structure, so with with.
01:06:49I'm proposing for our Journal
01:06:52number one is is totally revamp
01:06:54our approach to peer review.
01:06:57I'm hoping that.
01:06:58We get peer reviewers who are.
01:07:01Knowledgeable and sensitive to the
01:07:04issues of race and racism in research,
01:07:07just as if I have a reviewer who is
01:07:10expert in structural equation modeling,
01:07:13I need to find reviewers that our
01:07:16expertise or expert in racism
01:07:18as a social determinant.
01:07:20So we're actually proposing to.
01:07:23Create a new position at the Journal.
01:07:25A associate editor for equity
01:07:27inclusion and diversity.
01:07:28Who will help me help us develop
01:07:30a systematic approach so that we
01:07:32can train researchers before they
01:07:34submit papers to us to think about
01:07:36race and ethnicity in a much more
01:07:38sophisticated way than it is now,
01:07:40and to also train peer review it now.
01:07:43Not every peer reviewer needs
01:07:45to become a social scientist,
01:07:46but again,
01:07:47when I when I have a paper and I
01:07:49sort of choose peer reviewers,
01:07:51I'll choose a content expert that.
01:07:53I statistical expert different types,
01:07:55so I need to get a cadre of
01:07:57social scientists or clinicians
01:07:58or whatever who really understand
01:08:00the importance of looking at race
01:08:03ethnicity as a social construct,
01:08:04not biological culture.
01:08:05So that's kind of like the call.
01:08:08I'm making the other journals to do the same.
01:08:11Can I see Pamela Pamela? Hi
01:08:17Hi. I I work in the
01:08:20intensive outpatient program.
01:08:22And I'm a social worker,
01:08:23have a Masters in public health,
01:08:25and have worked both in the
01:08:27adolescent and the adults.
01:08:28But I just want to say that I.
01:08:31Then I'm familiar with the research
01:08:34and that I what I found and what
01:08:39I've been doing is using brain
01:08:42based research an integrating that
01:08:46with dialectical behavior therapy,
01:08:49cognitive behavioral therapy.
01:08:51In in the track that I run,
01:08:54because I think that it helps people
01:08:57understand more concretely how behaviors,
01:08:59how lifestyle, how choices.
01:09:01I mean, we both talk about.
01:09:04Initially we talk about stressors
01:09:06an we talk about racism,
01:09:08as you know,
01:09:09as a major stressor and persistent,
01:09:12pervasive stressor.
01:09:13But we talk about all the isms
01:09:16upfront when we introduce each other.
01:09:18Every time we get a new member.
01:09:22And we talk about that so that
01:09:24we can put it out there an an we
01:09:26attribute that to the levels of
01:09:28stress and anxiety and depression
01:09:30psychosis and the other things that
01:09:33people bring to IO P you know and
01:09:36how it impacts their mental health.
01:09:38And so you know one of the things that
01:09:40I found is that incorporating you know.
01:09:44Not incredibly technical, I mean,
01:09:46I'm I'm not a neurologist
01:09:48or anything like that,
01:09:50but but using integrating brain,
01:09:52brain basics and understanding of
01:09:54the brain for people really helps.
01:09:57I think helps to motivate people
01:10:00to want to understand more.
01:10:06Do do deep breathing.
01:10:08You know what I mean?
01:10:10We do a lot of mindfulness.
01:10:13We do a lot of motivation.
01:10:15I mean, well, motivation yes,
01:10:17but I meant physical activation
01:10:19and things like that.
01:10:21But we also attribute that to the
01:10:24stressors and help people identify
01:10:26how those connections feed their
01:10:28stress and then how they can
01:10:31help to ameliorate it and help
01:10:33them develop stronger coping.
01:10:35You know, healthier coping.
01:10:37Skills so I only bring that out.
01:10:39Not that you know I'm doing not to
01:10:43count myself so much as just that.
01:10:45I think you know we're talking about this.
01:10:48I think the audience is predominantly,
01:10:51you know except for Doctor Childs
01:10:53who I I saw is here, you know,
01:10:56is predominantly researchers
01:10:57and professors etc.
01:10:58But I think you know taking this
01:11:01information and actually applying it in
01:11:04the therapy is the way or is one of the ways.
01:11:08Certainly that we're going to
01:11:10be able to have,
01:11:11you know,
01:11:12to make changes and to help people
01:11:14use this information and apply it
01:11:17to their daily lives in a way that
01:11:20can bring some meaningful personal
01:11:22change and hopefully change to
01:11:25families and ultimately communities.
01:11:27So.
01:11:29Thank thank you.
01:11:32I I agree and yeah. I think.
01:11:37I'm glad that trauma informed care
01:11:40has become very commonly used
01:11:43term and people are applying it.
01:11:47And like all good things,
01:11:49once it's used, we find what
01:11:52some of the deficiencies are and.
01:11:55In many ways I hear a lot of I don't
01:11:57want to be defined by my trauma,
01:12:00which I think is really true,
01:12:01so this isn't my idea,
01:12:03but but we need to move from a trauma
01:12:05informed perspective to healing
01:12:06centered perspective and those
01:12:08the Little Trope about that is,
01:12:09you know, trauma informed care
01:12:11is not what's wrong with you,
01:12:12but what happened to you?
01:12:14Well, in healing center care,
01:12:15the next step is what's right with you.
01:12:18Three people don't want to
01:12:19be defined by their traumas,
01:12:21they won't be defined by what's
01:12:23right with him.
01:12:24Absolutely,
01:12:25and you know. So dealing with
01:12:27the stigmatization of mental
01:12:28illness and mental health care
01:12:30in the 1st place is at the root.
01:12:32But also I I felt I feel like one of the
01:12:36one of the assets that I am repeatedly.
01:12:39Struck by that that.
01:12:41The communities of people of
01:12:44color have is resilience and I
01:12:47don't feel like that gets enough,
01:12:50you know, gets enough playtime
01:12:52because when you consider,
01:12:54I don't and I don't mean in any way
01:12:57to minimize the poor health outcomes
01:13:00and the negative the negative.
01:13:02The negative experiences or the negative?
01:13:05The negative outcomes that are
01:13:07caused by these stressors,
01:13:09but I think you know there is that people
01:13:12of color in African Americans in particular,
01:13:16that that they're resilience
01:13:17and their strength.
01:13:19You know,
01:13:20in the in the in the midst.
01:13:23This diversity is.
01:13:24Is not amazing,
01:13:26but it's so powerful and I feel
01:13:29like that's an asset that often gets
01:13:32overlooked an is understated so.
01:13:37So we're we're out of time.
01:13:39I appreciate everyone coming
01:13:41in all of your comments,
01:13:42and certainly there's lots more
01:13:44discussion to be had and grand rounds
01:13:47and other aspects of where we meet in
01:13:50come together and address these topics.
01:13:52So certainly to be continued,
01:13:54but I really want to thank doctor
01:13:57Pachter for being here and
01:13:59sharing a body of work with us.
01:14:02And I think it's really helpful
01:14:04and informative to all of us on
01:14:07personal and professional levels so.
01:14:09Thank you so much.
01:14:10Thank you, thanks for having me.