Transcripts For CSPAN3 Dr. 20240704

Equity in our Health Care System, dr. David ansell, soul of death gap, and equality, and dr. Thomas fischer, the emergency, the year of stealing and heartbreak in the chicago e. R. With kathryn davis. Dr. Ansell and fishers book will be available for signing at the book sale and signing tent, marked an and, for nasty nasty, on your map. David antel is the Senior Vice President , associate cohost for Community Health equity at University Medical Health Center in chicago. Hes the author of the death gap, how inequality kills and county, life, death and politics at chicagos Public Hospital. Thomas all fisher is aboard fide from chicago. Over his career he has worked to improve health care as an academic, Health Insurance executive, company creator and white house fellow in the first term of the obama administration. The emergency was published by Penguin Random house. Catherine is the health care and Life Sciences reporter at cranes chicago business, where she writes about hospitals, public health, pharmaceutical companies, and biotech startups. She graduated from Columbia College with a bachelor in journalism in 2016. I hope you grant them a warm welcome as they come before us today. Thank you so much for [applause] that warm introduction, hello everyone, thank you so much for being here today. I am kathryn, a reporter for chicago business, thank you to doctor ansell, doctor fisher for being here today. Were really excited to get the conversation underway. So, lets set the stage for our audience, you know, dr. Ansell, your book was published in 2017. Can you tell us a little bit about what was happening with your work, and with the health care mark it here in chicago at the time that made you want to write this book to begin with. Well, first, thanks everybody for coming. If i had known it had been such a big crowd i wouldve fired the back of my shirt. No, its just its a little bit about myself. Im a general intern, im a primary care doctor. I have worked in chicago now for as a doctor since 1970, eight first of the Public Hospital cook county, now at mount sinai, that i was recruited to medical center. You can walk here to rush. But all along on, street on the west side of chicago, in my patients came with me. I was really struck when i got to, rush where i was the inaugural treat medical officer for the hospital. When, street two worlds. Of living and health care that seem to be invisible. So i was motivated to write the death gap to point out that there are these large gaps of Life Expectancy, you can literally walk from one neighborhood to another and lose 30 years of Life Expectancy. Not only, that the root causes of these were not biological, they were not behaviors, but violated to the conditions under which people lived. And yet, it was largely invisible, driven by two things, inequality and inequity. I want to point out the far left corner is crystal pilot who helped write the book. She was premed and helped me publish the book, we wrote it together. Publish a book. We wrote it together perfect. And so dr. Fisher, sort of, you know, the same question so, dr. Fischer, your book published once the pandemic had started. What was going on in your personal work at that time where you what i am seeing in my experience and the thanks for the question. And its wonderful to be here, home, discussing and reflect on some of the challenges that we all face, whether we know it or not. I have been working on the south side of chicago in the same Side Community where i grew up for over 20 years. What i saw in the Emergency Department was overburdened waiting rooms, people with medical problems that couldnt solve and couldnt find the resources necessary, subsequent to their injury to repair. And after decades of training and experience and working on federal policy and in local solutions, precious little progress was made. The Emergency Department look the same in 2020 as it did in 2000, when i embarked on my medical career. And i was frustrated and challenged by the lack of progress. And so, in many ways, this book is a number of things. Number one, its a reflection on a society that pins black folks in place and rob some of their health care, shows them robs them of their health, and shows them no mercy. And then when they present to the Health Care System, the same structures add insult to injury. And i want to not only for me to better understand and create a compendium of the ways in which we have shaped a society towards won that but i also wanted to explain to my patients, why is this happening to you . What is it that brings you here and makes it difficult for you to receive the health care you deserve while, at the same time, you see others taking different pathways and living much longer, and having experiences absent the suffering that you think is normal. The pandemic was really just an accelerant to writing and not only did it give me plenty of time to write, but also reflected what his usually happens over decades, in creating health and equity occurred in a matter of months. You will find stories of humanity and challenge within the book. And so, i know that you all have been very aware of the Health Inequities in chicago and around the country, that have plagued the u. S. For many, many years. But im interested to know, what was laid bare for you during that first year of the pandemic. Were things surprising . Had theyve been worse than what you had already sort of envisioned . What was that first year like . Whoever wants to start so, i was on the front lines. And in the Emergency Department, one of the things we prepare for is pandemic. I generally follow international press, for when flus begin in china or hemorrhagic fevers begin in africa because, sooner or later with a global community, they come to chicago and walk into our Emergency Departments. I have seen covid coming for months before it did, and was quietly preparing, until march, when all of a sudden the closed and the society closed and very quickly there were no airplanes in the sky, and no television to watch. It was then that i sort of began to see the differences in who was effective in the patients that came to me in the Emergency Department. You expected people to be transformed by the virus, but they were but not all of our neighbors. Some folks were protected. They were sitting at home, having their food delivered to them, working in front of a screen, frustrated by the change, but safe. Other folks were forced into society, to deliver food, to stop shelves in warehouses, to slaughter meat and slaughterhouses, being essential but not so essential that they were protected with masks and plexus grass plexiglass screens in order to protect their health. And thats who flooded into the Emergency Department. In the first year before vaccine, i saw more people die than in the previous ten years of my clinical practice on the south side. Those lives deserve to be more than statistics. And so i tried to tell some of their stories in the book. I just want to say, dr. Fisher, its a great honor for me to read your book. And the stories of one thing that we have in common and we have a lot in common but one thing we have in common and share is that we see patients. And so, you hear words like oppression and suffering and things like that come home when you are face to face with a patient and it can be different. I wanted to tell you a little bit about my experience. So, i quit being chief medical officer of rush in 2016. My goal when i got to rush from sinai and cook county hospital, the goal was to be number one in quality. And so i did all my work with all my colleagues to actually move us to the pinnacle of quality hospital in the country. And yet, i am a social epidemiologist, and my patients had traveled with me and i could see that we could fix quality as much as we want, but if we didnt address the conditions, people would die unnecessarily, so, im saying, people are dying outside outdoors, weve got to think about this differently. And in my own hospital we named racism and economic deprivation as root causes of poor health, and something we should do something about. That was in 2016. So, when covid was coming, we prepared not only the hospital, but what our Community Response was going to be. We were thinking about it. So, i want you to imagine this. Covid, we were thinking about his being the great equalizer, because the whole World Population immunity, yet we knew, as it was coming, that it was going to disproportionately cause suffering in black and brown neighborhoods, poor neighborhoods in general, and black and brown neighborhoods in the city. And we began to prepare for that inevitability. It was as if one epidemic was crashing into this preexisting epidemic, which was largely invisible. And we did a lot of preparation for it. But i want to tell you a story of one of my patients. So, as the patient as the patients are beginning to come in, i in the beginning of the pandemic, i could read the charts of every patient coming into rush. That was impossible two weeks later. I see one of my patients. Sickle cell anemia, hospitalized multiple times for sickle cell anemia but this time it was covid, or presumed covid. It turned out to be covid. She worked at ohare, in Garfield Park, lowest Life Expectancy on the west side took the bus worked as a baggage handler. Because of her condition, after employer to wear a mask. Im going back to what you talked about in the working conditions. It was not allowed to wear a mask, caught covid somewhere along the way, her whole family got covid. And then we saw the disproportionate impact. And then, i will say, the first hundred deaths in chicago, 70 were in a black people. The mayor said it took my breath away. And then called and put together a Racial Equity Response Team that i had the honor to sit on, and actually address the Community Conditions and try to address them and that dr. Fisher talked about. So, dr. David ansell, could you actually expand on that and tell us about what came from that task force . What were the specific measurable metrics you knew you could go after and improve things . You know, a pandemic gives you an epidemic of any sort. It gives you no time. And youve got to charge into the problem. Let me say a couple of things that happened. Our medical students got pulled out of homeless shelters we had a meeting and say, what is going to happen in the shelters . They are going to move the beds. They are going to reduce the number of people in shelters by a third and separate the beds. And if you just a logical thinking well, a moving the beds a few feet apart in a room like this is not going to they whole department was very clear that the Health Department was overwhelmed, that they couldnt they didnt have problem so we actually came in and actually not just us. We pull together table Community Health providers, university of illinois, the city, to really think through, what could we do, to tamp down the impact of the pandemic and those experiencing homelessness. And we did. And we executed on it and made a giant difference in the city. So, when the first hundred deaths occurred, which was early april, the mayor of chicago, laurie lightfoot, asked her staff, what should we do about it . And they gave her some ideas and she said, that is not good enough. Call westside united. Westside united was an organization of hospitals and Community Leaders that was formed to address the death gap in chicago by addressing community in terms of health. And that group was asked which are the Racial Equity rapid Response Team, and suddenly, at the table, were not only the hospitals and clinics, but the city, and the Community Organizations. And the Community Organization says what do we need . They didnt say we need more health care. They say we need more masks in our neighborhood we need tests in the communities. Ultimately led to those strategies around vaccinations, was launched that early april. And i dont say, is it going to make a difference or . Not these things are hard to measure. But the high level measure, first year after the first year of the pandemic, in chicago, third in population, and seventh and mortality, was a good enough but i do think there were things that that brought the community to the table, to determine what did they need to survive the pandemic. And it wasnt more icu beds. That is not what they were asking for. It was for basics. And so you mentioned the Life Expectancy here in chicago. And as a result of the pandemic, we saw Life Expectancy for all chicagoans, but especially for black and brown chicagoans, drop to a very low level. The Life Expectancy for all chicagoans dropped two years on average to 75 years, with even steeper decline for black and latino residents. The Life Expectancy at the end of 2024 black chicagoans fell below 70 years for the first time, to 69 years. And the gap between black and white chicagoans is now a ten years. And so my question for you all is, where do our public and private Health Systems go from . Here what are the steps in turning these life expectancies around . And even improving them from where they were prepandemic . I think this is a question that is not really about our Health Care System, but really who we are a chicago winds and what we owe to one another. Our health is not really constructed by health care. It is created by where we live, work and play. One of the things we saw during the pandemic was not only the disproportionate impacts of covid that but dr. David ansell described, but it was also created a rash of violence in ways that we hadnt seen in years before. You have to keep in mind that our schools were closed. The Community Centers were closed many of the elders that temps down interpersonal violence were hiding out and people who had the most vulnerability that didnt provide were the ones who are most likely to fall ill. We and that led to ashes of violence across the city and the not only our death rates, but also our gun violence rate. When you think back to that time i took care of somebody who was an elder brought in from home. And they were in cardiac arrest. This is not an uncommon situation for us. And we took them into the room where we do our resuscitations. We intubated them, gave them medications, gave them chest compressions, and fleetingly got their heart rate back, but lost it again. And after a course of 20 minutes, we accepted the inevitable and, after a moment of silence, one of the things that i do as the attending is go and talked to the family. When i went in the room to talk to the family, the child of this elder was in his late 50s and i sat down. And theres a process by which i do this, which i have honed over 20 years where i sort of explain the circumstances, ask them their understanding, prepare them for what i am going to tell them, tell them that their loved one died. And in that moment, he stop me and said, dr. Fisher, dont you remember me . And i didnt. I didnt remember him and i felt humiliated and embarrassed. Because, here i am in a life and death situation, and dont remember the interlocutor that im speaking with. He said, last year we had this same talk when my other parent died. We have these social conditions that are running through our communities and these intergenerational homes and calling our elders, and there is by the time they come to me, it is too late. We, as a community, have to not only recognize that, in those moments, i feel very fortunate to see the depth of their humanity and recognize that these conversations, where we have the opportunity to be vulnerable and to clearly see one another as fully human as we see ourselves, which ought to be to the sort of policy solutions that would raise all of our health but theres a large voltage drop before we get there. And we have concentrated our shared tax dollars in the service of those on the north side of south and the west side. We end up with entrenched generationlong poverty as a result of desegregation. We have an absence of the social services and connection that lead to health and we are effectively creating jobs that would leave somebody out of these situations. There has been a ton of work done in the city. And that dr. David ansell has been a part of it the metropolitan Planning Board in the urban institute recently weve got chicago shag rug asian segregation that the services, goods and resources that protect our health from whiteness and distributed them more equally, not equally, but just as equally as our other segregated cities in the chicagoland in america are 30 . Our income would improve for everybody in the city. The question should be focused on, who do we as a society see ourselves as . And what is our commitment to one another . And are we willing to make the hard choices that are not lurching from emergency to emergency, but deciding to reorganize our society towards mom one that is more just and equitable in resources. And until, then we will continue to lurch from emergency to emergency. That was so really eloquent. And i want to just take the same response and then sort of a different take on it. Number one is, as a white physician, who has been a doctor since 1978, taking care of, largely, my whole career, an underserved patient population, black and brown, that it wasnt until a few years ago that i began to speak openly of racism. As a root cause to whiteness is probably even a better word day today so, like, we are all here downtown today, right . We dont look at what we are around here today is perhaps an active whiteness. But we are not. We are in a white neighborhood. The events like this are held and its not a bad thing. Except they are just not held in other neighborhoods. And so you dont spend your money there. But i want to take a step from the discussion about violence and reflect on something that is known as structural violence. So, as a doctor who took care of patients, i could not understand that how the degree of illness disproportionately the populations that i was compared to the people i knew. And so, this idea that we think of violence as being these barrage of bullets, but a structural designed into our laws, our policy, our procedures, our norms, our values how day to day life actually occurs. Oh we are, going to have a lets do it on lets not do it in on austin or the south side, right . Imagine if this capital was moved so that structural violence. Because people are put in harm s way as a result and then die early. But we think is that people have their lives really stolen from them. And the impact of it, the cost of this, and money, the cost of segregation, the report that you are talking about, is four billion dollars to the total, that we all suffer as a result of. And our demonstrated a very short period of time, which was something that we see in our patients occurring over many years. The structural nature of this inequality. So, if you look at covid, but this was before covid so you look at okay. In the United States, there 1. 3 Million People have died from covid. If we were canada, about half of that half that many people would have been but so, there were stupid deaths. They were unnecessary deaths. If we were australia, which had a conservative government, about 900 or 1 Million People of the United States would be alive but most Expensive Health care system and yet the worst outcomes, and maybe among the highest mortality in the world and so its a lot the way we structure things. You asked the questions of, what can hospitals do . We have to we cant do it alone. So i think what is doing on the southside, russia and other hospitals, westside united is a collaborative of hospitals and communities to address the death gap. But if you look at the actual causes of death postpandemic but, of course, covid was they are. But it wasnt number one. Except in a Latino Community the number one cause of death was cardiac disease. We saw a rise in diabetes deaths. We saw a rise in we saw a rise in overdose deaths. We saw our rise and diabetes deaths. We saw a rise in car crashes. And those increases, disproportionately, affected communities of color. But to think that the pandemic was the the pandemic on the preexisting faultline. But if you look at a city like chicago, this is actually true across the United States since 2012 Life Expectancy, which up to that time had been rising in every community, began to drop in chicago, most steeply for the latinx community, but for the black community, the Asian Community the only Booth Community before the pandemic that Life Expectancy rises in was the white community. So, these differences are just like we have to for malaria you have to go after the mosquito as the vector because you cant get rid of malaria. You can get rid of malaria in lots of way. But if you dont address the mosquito, you cant curate, we have to address the vector. And racism and other forms of systemic exclusion or the root cause and they are as violent as any other thing that we say. We just dont name it violence. And so in what i have said are the solutions. Can i just add to that . Because, we all are working on a daytoday basis. And one of the things i commonly here, when i described, as i you know, not usually as i would david these are bigger than an institution and even bigger than a city. This is as big as the United States. And what that often leads people to his a sense of despair. Okay, so, what does that mean . I dont do anything . Does that mean i just let it go . Because when you talk about decoupling a relationship to power from a relationship to whiteness, that is as though you are telling people to pretend as though as america has no gravity any longer, and we are just floating around. Its very hard for people to imagine that this construct of being white is no longer what defines whether or not you are living in a safe neighborhood or have Good Health Care or are linked to the certain jobs that gives you good insurance. And then we have institutions that have been created hundreds of years ago. I work at the university of chicago. And they are very proud that its founding was in 18 hundreds, back when black people could not get care there and women could not be doctors. And the linkage to those things are reproduced over years, and while the language may change, the culture is one that they are very proud of. And so what that leaves us with is, how do we tell the truth when we have a society that is invested in blinders . How do you acknowledge that, in fact, while we are all similarly human we do not have similar opportunities, and we do not have similar endowments of resources. And we cant, simply by working how do you do that in a setting where, in the middle of the pandemic response, instead of thinking about a collective solution, one of public health, it is turned into, what is your individual responsibility . Do it for mama, do it for pop pop, do it on your own. Do it for recognition, like i actually see we have to lean to invest in one another and we actually how do you do that when, what happens behind the locked doors of my Emergency Department is where the impact of these differential judgments impact the body of our patients . I was in the Emergency Department yesterday. And i took care of a woman who was young, and who had actually seen the day before, the same problem. She has a low level of schizophrenia and hearing voices and needed help. And the day before when i took care of her, i gave her medications, and we wanted to get her stabilized on those myths and get her hospitalized. And i came back the day later and she still, in the same room, is still waiting on a place to go. Like, that is something that our Health Care System can fix. If we, as people, decide to invest in those ways, and begin to open the locked doors where we hide our shame of what we are doing to one another, and start to use the data to tell the truth. We have Quality Metrics that we measure. We know our doctor for opening in the setting of a heart attack. We know the rate at which we use restraints in the mentally ill. We know wait times. We know less about being seen. Do we tell the truth about how that is stratified by race . Do institutions, particularly the Nonprofit Institutions whose existence is based on our taxpayer dollars that we all similarly pay into, share whether or not they are delivering this care equitably, given that these are Public Resources at the end of the day . Do they work as hard and incentivize their executives with bonuses and firings, if they are able to give equitable care . When we make it to that granular, we can recognize that we actually all have stakes, not only our financial stakes but, also in the stakes that we owe something to one another in these institutions are fundamentally hours. It is a big challenge, and one that is going to require a generation and when that people have been struggling with before i come from america descendants of slaves, folks who have been struggling to force america to live up to its Democratic Values for hundreds of years. This is not going to end in my lifetime. But we can at least tell the truth, not only animated by our humanity, but animated by the data. We know what is happened. And beyond telling the truth which is and that is why i think naming racism, but also as a white physician i need to look at my own institution, do the storytelling of that you know, my parents that were their whole families were exterminated in europe and were victims of antisemitism, white supremacism, our ianism, mass incarceration, and genocide. But in this country, despite that history, i was assigned to the favorite group. And while i worked hard, i had to come to the realization and to think about it that i have had an urn advantage. And then to understand the paradigms in which we both have been treated and taught were based on stereotypical ideas of gender and race, still deeply embedded into medical training. And that the paradigm that we are operating on is incorrect there and the whole set of implications for the next generation, and how our institutions are organized. So, at the institutional level, there are things that we can do. But at the societal level, there are things that we can do as well. And i want to just sort of theres an interesting sort of dynamic between those things. So we have a tale of two cities, of at least two countries. In terms of the opportunity of who gets to live and who gets to die. And then we have that sort of dynamic that whiteness, which is the dominant current in this country. And, of course, patriarchy is another dominant current. Women have done better in this country, but that is tenuous. Look at womens reproductive rights. It is tenuous in this country. But we have to understand how we act both within our institutions and civically can make a difference. But it is about rethinking the organizational paradigm of society and health. So, i just want to sort of think about this. If you are poor in the United States of america, the idea that this is a meritocracy is a lie, it is just not true. So, one out of 13 for people will make it out of poverty into the middle class. One out of 13. That sounds so good. You know, its not what we. Think and that number has been dropping over time. But the black experience is even much deeper. One out of 40 black people in the United States who is born in poverty as the opportunity can make it out. Those are exceptionalism. And that can be changed. And it can be changed by the way our institutions behave and our Public Policy. What happened in the pandemic, at the beginning of the pandemic i called up the chief medical officer of the city of chicago, who is now at cdc. And she is a wonderful person. And say, can you pulling institutions together so that we can fairly distribute icu resources such that people who need needed extreme icu care could be thoroughly distributed across the city. And the reason why i asked that question is, i knew that it was left to the usual, that people would be in Emergency Rooms that would not have access to it. And its never happened. But we could do it. And we could do it moving forward. And there are things that our institutions can do now and into the future that can make a big difference. And we are working on some of those things. I dont think that they are big enough. But they give their things that give me a lot of hope and the potential to change this. It turns out that, in United States, where you live when you make below the median income, your Life Expectancy its different if you are poor in new york city than if you are poor in detroit, adjusted for race. So, we know the Public Policy can make a difference, and Institutional Policy you just have to double down and do it. This sort of brings me to the next question. In my reporting on Health Equity in chicago, i have seen some of the newest initiatives coming from our Health Care Institutions that really Work Together some of these root causes, right . We have Health Systems that are funding and Building Public housing for people. Trying to interrupt cycles of Substance Use disorders. And so my question for you is, are there initiatives that you are personally involved in or that your institutions are involved in our close to your heart . And you see them making progress . What are they doing . Yeah. Do you want to well, i quit being a chief medical officer. So, its just you know, no one does that. I quit because i realized that just doing the work we would be doing would make a difference. And again, how would it make a difference . How do we won, we have to name we have to name the root causes of understand the differently about health and the and the rethinking had to do with, how do we use our size and power, and the leading private employer on the west side of chicago how do we take our community of employees, our first community, and understand what their lives are like when they were suffering . And how do we use our organizational power as a notforprofit organization to make a difference. And so we took on what is called an anchor mission. And there is about 90 Health Systems nationally that have done this, to hire locally, to have career paths into wealth, to support local businesses, to invest in Community Infrastructures and our neighborhoods. We took the west side and we said, this is our neighbors. We engaged other institutions to join us. And then we decided that equity has everything access to power, resources and money. How are decisions being made . You mentioned that about power, resources and money. Instead, a table that has a community and the institutions making decisions together. Because we realized we could not do it alone. Now, we would be the Largest Corporation in the city. Westside united, the entity was asked by the city to lead the Racial Equity responses to the city. Was it enough . But is it the right approach . Yes. And as work going on the lowest Life Expectancy on the west side. Led by the community to we are at the table to say they want to create a wellness village with food, with health care, but no, an exercise and they are just trying to facilitate that. They want to jobs, they want to support for local businesses. When we put russia employees and there are a lot of other people who are now under fuel park. When they go to lunch to drop their dime on the west side because most people avoid those neighborhoods. We have to get other businesses to do the same. I think what is critically important for everybody to understand is that covid was a Massive National failure and it wasnt about money. It was about how we organize ourselves as a country. And we tolerated to have a country in which white people in general had to do well and which and black people and people of color had suffered. And we can redesign that but we have to bring more of the hospitals along with this. And this is we are national Public Policy can make a giant difference moving forward. So, you have a lot of reason to be proud of westside united. Its one of the in the nation and im impressed by the way in which it has been vertically integrated to impact care. So, i want to thank you for that. The three areas that i am trying to assess, then, that give me encouragement about the future are, first of all, i continue to take care of sick people. I think, at the end of the day, there is honor and meaning in taking care of people who need help the most. It matters if you stop the bleeding. And i think that people can do that no matter where they are. Just stop the bleeding and relieve suffering. So, it is important for me to also share those moments of transcendence and grace that reminds me of my own humanity and touch other people in those moments, and informed that this is something bigger than all of us. And it is important for us to invest in taking care of each other. Part of that is also telling the truth around this, which was part of the genesis of this book. One of the things that happens when societies sort of fell apart was that it created these moments of and, i was forced into the position where it is not only that my patient might not do well, but i might not do well in the Emergency Department. Those moments of a challenge also create a clarity around what it is that matters and why it matters. Why does it matter that we push towards these intergenerational goals to perfect what we claim is a democracy towards one that we actually and centers are shared humanity . Why is it important to be honest about those things . And thats led to the book and it leads to me thinking with a full throat about these challenges. So, thats two things. The third thing is that i have been working on national policy. So, very i was the Health Equities cheer for the biden campaign, and a number of policy points that we are beginning to see turn into regulation and law. One of those that i believe most in is the important of capturing the reporting of quality data by race because downstream you can then link that to payments. You get what you pay for. Lets start paying for the things that we want in the setting of and then the last thing that i am doing that matters to me is, if we were to imagine a new america, one where the way we allocate our resources as a function of who we are and the way we vote, where every Single Person is similarly valued in resources, we would still need to build a brandnew system of care. We dont we have afraid a. Frayed safety net allows for us to bring together so Many Health Care handoffs. We dont have a focus on primary care over specialty care. We have so many things that we need to do that are challenged by these old Health Care Institutions that are doing just fine the way they are. Theres very little incentive for our incumbents to fundamentally transform the way they deliver care when, right now, they are fine. But they are trying to build new things you can embed in these legacy of 1892 but our legacy of 2022. And let our children in 50 years say, you guys still and lets still build new again. So, i work with a Company Creation enterprise that creates health care companies. And i am Billing Solutions for our elders who need behavioral im working on new ways to improve through the Emergency Department and place people home when they need to be and not in hospital. I am working on ways in which we can get people transplants for their kids who need it as opposed to ending up on dialysis for 30 years. I think there is a lot of merit in creating new things and being inspired by the arts as we do it because, what we are fundamentally talking about is creating something and bringing into being something that has never existed before. We have never had a just america. We have never had a society that reflects our humanity. We have never had a Health Care System that is equitable and equal. That is not going to come from walking away with incremental change. That is going to come from harnessing our imagination and building something that does not exist. And so that is the main thing that really inspires me and is really where i invest a lot of my energy in. So, something you mentioned, dr. Fisher, that i want to touch on is the labor shortage we are seeing in health care right now, which is something i have written a lot about this year i think even just before the panel you were saying, you know, chicago is still suffering some of those losses that we saw in the pandemic, as stress and burnout pushed Many Health Care workers out. So, how do we sort of rectify this issue . Either by bringing people back or encouraging the next generation to pursue medicine when we know it is a lot of sacrifice. Its a tough job, theres tough hours. And covid is likely not the last pandemic. I think the upside is, it is meaningful work, and people want that. So many people are tired of doing something that they do not believe in. They sit in front of a screen doing something incremental and they are like, what is the point . I hear that regularly from people of all ages. I think the challenge around American Health care particularly those of us who sit on the front line, is moral injury. I see it every time i come into the Emergency Department, and there are 45 people in the waiting room. Some have been waiting ten or 12 hours. And my job is to select who comes back next. Well, there are five people over 70. Three of them have abnormal vital signs. Many of them have been waiting for eight or nine hours, and yet im the one who says, that person, not that person. And i have to do that every day. We have been trained to, first, do no harm. We have been given all the skills and talents and experiences. And we want to take care of everybody. But we sit in a system that forces us to hurt people sometimes. When we alleviative those sorts of challenges, we wont need wellness endeavors to bring people back to work. We just need to make it so that people can do the job that they came to do, something meaningful, and relieve suffering and cure people. When we create that health care, System People will come back. Dr. Ansall . You, i think the pandemic shook a lot of things up, lets just say. And its not just health. Here you have medical School Applications which have at the same time. We have not been a generation of nurses and doctors coming in, and i think this will get resolved. I do think that the moral harm piece of it is critical. There are people who are facing problems that present themselves in human beings in front of them that are structural in nature, that the individual cannot resolve. And we face them all the time. I want to talk about hope a little bit. Because it is easy to feel discouraged in all of this, and people always say, how do you stay positive in well, one is, if you live long enough, you see change and things improve. And you see the incremental the most hopeful table i sat at during the pandemic was Racial Equity Rapid Response table which was Community Groups coming with solutions. Let me give you an example. When we have really few tests to give out, we put together a committee. And it was the providers in the community and we are going to open five testing sites around the city of chicago. Not enough but we insisted they be in black and brown neighborhoods. What should be the criteria for testing . At that point, the only way you could get tested is see if you had symptoms. So, we said, there should be people with symptoms, a community of folks said, no way, anyone who shows up to get a test. And thats what we did. That became the standard of care around the city. Anyone who wanted a test gets the test. And thats what we did. It was that Community Voice leading us that gives me a huge amount of hope. And there were other things in that period of time we realized very early in the pandemic there was Community Spread in the shelters and it was asymptomatic. We would furrow a test and we go to command Center Russian say we need test to go to and shelters. We found that 40 around one positive person was positive and i called together a meeting of texas these were what do we . Do the next weekend 25,000 were distributed across the shelters and before there were mask mandates the idea that people at the front lines can make a difference is a huge thing. Those are the in those moment things. But the most optimistic table i sat at was not the Racial Equity response, it was a group in Garfield Park when i saw the Life Expectancy in the neighborhood with the lowest on the west side, and there was a 30 year gap between the they want to do something about it. And before the pandemic an Informal Group began to make that formalizes self into the Garfield Park right to wellness collaborative. And this group meant every other week at town halls, did covid work, but plan for the future, plan for what this neighborhood should look like that has had no Capital Investment since Martin Luther king was assassinated, and the neighborhood went up in flames. No. And this table was so optimistic. Everyone lost people from covid. And yet, they had a vision for a neighborhood that gives me hope to carry on and so hope is a muscle. We have to focus not on some abstract idea and that you cant get hope hope is a muscle that gets exercised and it is pragmatic. I see there are Pragmatic Solutions that are going on thats ultimately find a way to Public Policy that we have sort of the Capital Investments that neighborhoods need to lift up the health of everybody. And at the end of the day that hope will be. Because i know that when we take the lives of those who have been most systemically marginalized and make them the center of Public Policy, everyone does better. Everyone does better. And you just have to look at the 1. 3 Million People who died unnecessarily from covid in the country to know that that is true. White people suffered. After black and brown people suffered. So, im hopeful, because i know the solutions are within reach for us. We just have to decide we are going to double down collectively to do this. We are getting close to wrapping up. So i wanted to leave some time and see if there is any questions from audience members for dr. Fisher or dr. Ansall . You have talked about reform a lot. And the whole time i am thinking about the Affordable Care act. Wasnt that our attempt to make Health Care Accessible . And did that stop Emergency Rooms from becoming the first place you went to to get health care . What about the Affordable Care act . The Affordable Care act was an amazing step forward in reshaping the Way Insurance works in the United States. It reduced folks being dropped in the middle of treatments. It allowed young people to stay on care until they were 26. It added regulations that made Insurance Companies better actors. But it didnt transform American Health care. In fact, the most impactful component was probably medicaid expansion. The challenge with the way we take our health care is, depending on who you are, you are the dollars you bring to a Health Care System are different. If you have one of these high paying job that offers insurance you get 50 or more you are able to bring 50 or more dollars to your doctor than if you are on mid medicare. Then dollars more than if you are on medicaid and so if you are a Hospital Administrator or a physician provider. And you love everybody, but you are just narrow minded lee making decisions based on finance, you are going to deferentially care for those who have insurance over those who do not, and even those who have medicare and medicaid. The challenge then becomes, we know there is plenty of good literature that describes the way you get those good jobs related to your race, is related to americas racial cast caste to these sorts of jobs and then a black man with a college degree. And so, race blind and disinterested from any sort of good people can reunify reify and deepen Health Inequities the Affordable Care act didnt do any of that. It wasnt designed to. We have to keep working. We have to continue our progress. And just to add to that, inherently, since the beginning of slavery in this country, we have had different Health Care Systems in general for white people and black people. And those who have been assigned white. And whiteness is an idea that its a social construct. And so, we have an inherently apartheid Health Care System. So, one of the things that is happening during covid, i called up the ceos of safety net hospitals and said, transfer your patience to us. We created a didnt happen at every hospital in the city, nor in the country. Many of these hospitals were swamped. They were overwhelmed. People died there. But they if you look at the care that anybody did no fault to themselves or clinics it is different than the care that you get at a northwestern or a usc or even a rush. And that differential is racialized for the reasons that were said. And so, you end up with bad outcomes. The good news is that, for the first time in this countrys history, both medicare, cms, and the joint commission have regulation that put out the that are going to make institutions look at their outcomes by race, ethnicity and language and other things, and then have some, hopefully, accountability but it has never happened before. And so just having a card itself is not the answer. And then you add the experience, the generational experience of mistrust and bad care. People are reluctant to come when they are so, its not just insurance helps. But it is not enough. Thank you both for being here. The its funny that you mentioned when if your statistics are that 2012 up until then we were going up inequality and we started going down from there. Because that was right around the time when chicago and decided to close down but start closing down the Mental Health care facilities. And i was wondering if you had anything to say about Mental Health care as far as that gap. You know, we shift down the Mental Health clinics in chicago at a time when psychic distrust was from all kinds of reasons, racial trauma and others was rising. So, i do think its a factor. If you look at the covid data i was talking about when you look at that but you look at but in a psychic to stress, huge levels across chicago, but double and triple the levels in the black and brown community. So, psychic distress is that you know, when you look at, if you see something has been going on. Its a secular trend. And its probably i wonder who is relate to the downturn of 2008 and 2009, when a lot of wealth was lost due to foreclosures, to explain something that began to show up in 2012. But the point is, nationally, prior to covid, we saw Life Expectancy drop in this country largely because of many factors. But white people without College Degrees began to experience drops. And weve not seen in any other developed country. So, there is something that has happened. It is not just local in chicago. It is a National Secular trend. And we are unique among the developed countries in having that. And that is the urgency to sort of get to the bottom that i think is tied to wealth inequality at the root, and then the social inequality, that racism. And its ongoing perpetuation and policies and things today have caused that is all the time that we have. So, thank you so much to them dr. Fisher and dr. Ansell. This has been truly enlightening and insightful. And im so happy we could talk today. So, thanks for being here. But [applause] in 1848, a husband and wife william and ellen craft embarked on a journey of self emancipation. Disguised as a wealthy disabled white man with a servant, the crafts left georgia slave traders, law enforcement, and even france, all while trying to conceal their author of master, slave, husband wife recount their harrowing journey north and the impact of the fugitive slave law passed two years earlier. Wu, sunday night on cspan app. A healthy democracy doesnt just look like this