[inaudible conversations] been that good evening, everyone. Good evening. I would like to start by thanking everybody for being here at our very first event at us poison pellets have been thinking collaboration of politics prose as we embark on our first in a series of many wonderful reading. At this time underminded attractors up on her and invite making devices before because there did. Thank you so much. Truth will not be dead and there will be a questionandanswer session. Raise your hand and i will come and give you a microphone. After the question will have to sign in right over here. My name is christopher and i welcome you here in a half for Bradley Graham and elizabeth magazine, coowners of politics prose bookstore and on behalf of our amazing staff. They do over 500 event year, split apart locations like this one, tacoma and our Flagship Store in connecticut avenue in different venues across the city. Classes, literary trips and childrens programming yearround. We have cspan tonight. If youd like to see events like these in the past and going forward, subscribe to our youtube channel. Id like to begin by saying i am pleased to welcome someone as she discusses her debut type, and care for racial inequality and American Health care. Someone is a professor at university of Colorado Law School in the Colorado School of Public Health issue served on the faculty at the university of colorados center for bioethics and humanities and is a cofounder of the Colorado Health equity project, a medical Bitter Partnership is Mission History bears that the good health to those who are their lowincome clients. Under Academic Experience and their expertise to illustrate the implicit race bias that is present in our Health System and result in a loss at 84th of them lives annually. The disparities entrenched in the Health Health care system ae premise of not these impassioned argument for a lawbased solutions, not just Training Programs and cultural sensitivity. They celebrate matthew for having presented a thorough picture of a problem facing minorities in the Health Care System and for proposing reform on specific sections of the Civil Rights Act of 1964 who she claimed to provide illegal and more basis to hold liable those who unconsciously discriminate and would help to establish a new standard of care and medicine. Michele goodwin, professor at the university of california irvine has just the racial inequality in American Health care is a massively written narrative that was once starving grizzly that claim washingtons page turning an awardwinning book medical apart site has there ever been a book that makes medical discourse so captivating. Please join me in welcoming dayna matthew. [applause] thank you, chris. I was an awesome introduction. I would like to package it and take it home to my kids. I want to get to the meat of the matter and talk about unconscious races that affect the health of the United States. I want to pick up on the member chris spoke about 184,000 people, the number of people the 16th Surgeon General of the United States estimates died annually because of Health Disparities in the United States. Thats a very big number. 84,000 people. Let that sink in and talk a little bit about why they died a minute. My objection on trent objective is to the view is some food for thought. Ive developed an acronym. I want to leave you with five and said he will. Unconscious racism and health care being morally untenable, medically untenable, monetarily untenable, manageable and just massively urgent. So those are what id like you to take away. I will trace them out for you in 20 minutes and take us to a conversation love boat. I had an experience when i was nine years old. I remember it clearly because it was my First Experience with explicit racism. The explicit expression that i was in area person to the speaker because of the color of my skin. I was on the playground. A 9yearold girl i was nine at the time also, made it or it clear by using the why she would not play with me on that playground. And she made it clear to everybody else who was on the monkey bar where they would not be playing with me either. I have no doubt about her motives. I have no doubt whatsoever about my relative position in her mind as to myself for it. That called explicit racism. I remember it well. It was my first time experience in it and that is not what this book is about. However, an unscientific study i have three kids in their 20s. I checked with them and i say do you guys remember your First Experience with explicit racism . Every single one of them does. They are in their 20s which tells us what . The generation between the two of us has not changed the existence and presence of explicit racism and the people of color in this nation today. I want to make that clear because thats not what im talking about. Im not talking about explicit racism. Im talking about implicit racism. Implicit bias, all three of those terms are used interchangeably. Let me start by defining them. Unconscious racism is what happens when your stored social knowledge, the information you take for the music you hear on the radio, the movie is presented to you commend the television stories, the discourse youve been watching the political debates and conversations, all of this is social knowledge and then current just part of your mind. It is triggered when you encounter a person of another race involuntarily. You call up that knowledge unintentionally and it informs your decisionmaking and your combat and interaction with people of different racial group unintentionally. Now lets be clear. The difference between explicit preferences and implicit preferences is very important because studies show us that most people in the United States today are not going to identify themselves as explicit race. That was before the president ial election cycle that we are in. Probably more than we thought would identify as explicit. But explicit racism is kind of out of style. Not how we identify ourselves. Its not who we are as a people. This is what the book is about. It is about finding out their dreams and dreams of data that even if youre explicit preference is our egalitarian, even if youre explicit preferences are to be a fair, nonprejudice, egalitarian person come your implicit biases trumpeter x posted preferences. Your implicit biases what is stored in your social knowledge will do more to inform and direct your conduct then will your explicit preferences. Why is this important . It is really important and health care and why i came to write this book was to get help disparity, but we politely call Health Disparities is killing people of color daily. It causes people of color in this country to live sicker and die quicker because of the color of their skin. So if i were so inclined i could than the rest of the evening running the data on just that fact. In 2003 the institute of medicine published an important seminal work called unequal treatment and a catalog 25 years of data. The fact that infant mortality in the africanamerican population is twice that of white population, and the fact that you are 75 more likely to die if youre diagnosed with coronary Artery Disease than if youre a person of color than if your way. These are the kinds of data, the kind of statistics replicated a matter what the cause of disease is true for stroke, diabetes. Im going to posit canned or because i want to make a point. With respect to cancer, whites and blacks diagnosed at the same time have a 33 different gap in their fiveyear survivability rate. This is not true, however if they receive similarly intend to treatment, education, screening. If these treatment disparities are eliminated, the difference in survival rate disappears. The fact that its true is morally untenable. Morally untenable in the United States in my view. It is medically untenable as the medical profession not only agrees to first do no harm, or that if you read closely the hippocratic oath talks about justice. It talks about being a provider and a traitor of an entire patient, a whole patient in context. And when that is not the case, implicit biases change the way people are treated. So let me turn now to the contents of the book, the institute of medicine study done in 2003 positive that it is possible that physician bias may have a causal relationship with help disparities that because physicians themselves as individuals were bias on race, ethnicity, socioeconomic, gender , orientation another grounds might actually influence their treatment decisions, but at the same time the institute of medicine said we dont know how the mechanisms work. The point of my book was to try and come up with an understanding of those mechanisms, to understand how it is that physician bias translated into Poor Health Outcomes for people of color as compared to white. So i looked at the empirical literature. I looked at the studies and they are copious. With respect to implicit bias in health care and i organize them into what i call six mechanisms, the bias care model. Im only going to talk about one tonight. I organize them in a way thats it just there or six different pathways are mechanisms by which physician bias translates in to help disparity. One of the most important contributions i hope my book will make us not only to organize work of mechanisms for others to discuss and research, but also the fact that one of those mechanisms become a dirty little secret, both biases that patients hold. If the fact of the matter is we get these biases by her social knowledge, all of a sudden in the United States would get a same social knowledge in the literature tells us that patients as well as providers will have implicit biases. One study in one mechanism for tonight and if youre interested in the other five we can talk about them some more during the q a. For one study was about mechanism number five comment implicit bias changes their treatment patterns. This is a very direct link where mechanism between bias and disparity, and between bias and Poor Health Outcomes. This study is better in the treatment space say this. And they give the fund by alexander green especially. They say that if a patient has a coronary Artery Disease and we present that Patient First as a black woman, then its a white woman, and next is a black man, then as a white man, but we use a script, we use it predetermined set of data that tells us about the medical indicators. He is a predetermined set of facts about their history and personal background. They are identical to the physician vouch for their race and gender. If we do that, we can see race and gender and form of the treatment decision. Second step of the study and probably the most troubling for my work and the reason i went to do this work, if we also measure the implicit bias of the physicians making the diagnostic decision, the inverse relationship between the level of implicit bias and the quality of the treatment decision. That is to say the more implicitly bias, the higher on the Implicit Association. I feel like i can talk about that as. The higher the Implicit Association test scores, the more likely they are to provide an inferior treatment fidelity to patients of color as compared to patients who are white. The reverse is true. The lower their implicit bias measures, the more likely they are. This is a study of coronary Artery Disease patients who needed the treatment of choice for their coronary Artery Disease. The more likely a physician scorer was to prescribe the treatment of choice. That tells us there is an empirically evidenced relationship between implicit bias in the quality of treatment that a patient will receive. That results in different Health Outcomes because different treatment will be afforded to people based on the color of their skin. The other mechanisms has to do with the conversation and communication between physician and patient. Im interested youve had this experience if you encounter someone and they are not looking you in the eye. The information if youre not a person of color. The interviewer sure. They are verbally dominant. Not asking our respect while crediting your opinion. These are and their implicit biases kick and also so they think i know what that is. Im no longer satisfied with a lot of data that tells us what Patient Satisfaction it was Poor Health Outcomes. What i found out in this book was a series of interviews with those kind of patients is not just low Patient Satisfaction. It is low Patient Satisfaction meaning im not coming back to you anymore. Thats an interruption in my continuity of care. It means if you tell me that i need to exercise, im not listening to you because youve insulted me. That means my adherence in compliance is so, which translate into low or relatively Poor Health Outcomes. All of these mechanisms work together. It is often the case that you read a book ive been told and you finish a book and you would write another book, a different at the conclusion of that conversation. That firm aegis to have a second project. To let me share with you a couple things. Im going to read one thing out of the book cannot close telling a little bit about what i would do to fix this and what my next book looks like. In the Empirical Data i set out to create a new data set to interview patients and physicians, Interview Health care providers and asked them about their lived experience, their own personal interaction with implicit bias or unconscious racism. But i found essentially as i was able to confirm all six of the mechanisms i describe in this book. I choose a different patient to read about and this time i want to choose a first generation chinese men who bears out mechanism number six says patient who feel and perceive themselves as being discriminated against drop out of the care system or at least interethnic care system in a way that impacts their help out and negatively. This is a story of a man who is an engineer by training and profession and the implicit bias that he experienced really is emblematic of what i heard for many patients. What i heard for many patients and you will hear it in his story is that his view was discredited, that perceptions about 10 is a foreigner meant that he was not believed or taken serious leg. His complaints were ignored and the treatment he received turned out to be inferior. Picking up the middle of the story since 198 i just found i got some clinical disease like reoccurring to me, which caused and came from the countryside back in china. It is mosquito, a very tiny. Its hidden in the liver and can one day show up and have a very high fever. And then you are dead and you go to sleep and he describes the scent is good you cant walk. You are lethargic. You cant work. I got that thing he said. It is an asian disease. When i came here, it came back. I went to dr. I knew everything about it for sure. When i got to the hospital, nobody believed me. And then they take my blood and they say you know i can find nothing. There is nothing wrong with you. But this thing is true. You cannot find it in the blood, but if you look carefully at them the. I dont didnt they bother to do that. Of course i cant really remember the name of the academic terminology. To the dictionary with me. Imagine this meant experience. He goes back and take the dictionary to explain to a stock or they can speak english. I took the dictionary and i found what to tell the doctor, but they say no way. I cannot give you any kind of treatment. You can show me what is making you feel bad. Come back. And this is done if you dont have symptoms, they only kill the symptoms. They dont treat you for whats really wrong. If you dont speak english very well come you have less of a chance of making them understand. This is not to say they hate chinese. They have some kind of prejudgment. They say youre wrong because youre not professional. Her whole life in the United States is you never met someone like me. It makes you so weak it can kill you. So after 15 years here i got this thing again but i decided im not going to the hospital again because it makes me feel worse to go to the hospital. I write to my friend and shanghai. I tell them i need the medicine and they bring it to me after a month. Im a professional in my area. Of these taken same welleducated. If i had a psychology degree i could take apart the sense of dignity this man lost in his encounter, defensive is both which he was quick to deny. Remember his comment. They are not racist. They dont hate chinese. But i am not going back there anymore he said. His Health Outcomes are at first sight did that in fact this has happened. I think this is medically untenable. Tom the bees to some of the foremost disparities scholars in this country tells us that it cost 1. 24 trillion with a t. Dollars m. Loss product to be, preventable hospitalization and increased health care costs. To treat Health Disparities over a course of his study of six years. It is morally, and medically and monetarily unsustainable not to address this problem of Health Disparities.