Cable provider. [inaudible conversations] good evening, everyone. I would like to start by thanking everybody for being here at our very first event at busboys and poet politician and pros as we embark on our first and this is a very wonderful readings. At this tile i would like to remind you to turn off your cell phones, any noisemaking devices. Thank you so much. Feel free to order food or drinks. As of tonights reading there will be question and answer. I will come and give you a microphone and after the question and answer session we will have a signing right over here. My name is christopher gregs and i welcome you on behalf of politics and prose bookstore and on behalf of our amazing staff. They do have 500 events a year spread aupon politics and prose like this one in our store in connecticut avenue and different venues across the city. We have cspan tonight, so if you would like to see events like these that we have done in the fast and going forward, feel free to subscribe to our youtube channel. I am pleased to welcome dana matthew, a cure for racial inequality in American Health care. Professor at the university of Colorado Law School and the Colorado School of public health, she serves on the faculty at the university of Colorado Center for bioethics and cofounder of the Colorado Health equity project, medical leadership chose mission to remove barrierses for those who have verylow income clients. Expertise to illustrate the race bias thats present in our Health Seasonal and results in loss of 84,000 lives annually. Disparities entrenched in the Health Care System are the premise of matthews em passion argument for lawbase solutions, not just Training Programs and cultural sensitive. Celebrates matthew for having presented thorough picture of a problems facing minority on specific sections of civil right acts of 1964 which she claims provide a legal and morale basis to hold liable those who unconsciously discriminate and would hope to establish a new care of medicine. And mitchell goodwin, medicine inequality asthmassively written captivating narrative. One cannot stop reading. Claiming that not since washingtons winning book, america apartheid has there ever been a book that makes medical discourse so captivating. Please join me in welcoming ms. Matthew. [cheers and applause] thank you, chris, that was an awesome introduction. I would like to package and take it home to my kids. [laughter] i want to get right into the meat of the matter and talk about unconscious racism as it affects the health of populations in the United States. I want to pick up on the number that chris spoke about, 84,000 people because thats the number of people that the 16th Surgeon General of the United States david estimates die annually because of Health Disparities in the United States. Thats a very big number. 84,000 people, let that sink in and we will talk about why they die in a minute. My objective tonight is to leave you with some food for thought and so ive developed a sort of acronym, i want to leave you with 5ms, if you will, i want to talk about unconscious racism in health care being morally unattainable, medically unattainable, monetarily unattainable, manageable and just massively urgent. So those are the ms i would like you to take away. Im going to try to trace them out for you in 20 minutes and then take this to a conversation level. I had an experience when i was 9 years old, i remember it clearly because it was my First Experience with explicit racism, the explicit that i was inferior to the speaker because of the color of my skin. I was on a playground, i was 9 also, made it clear why she would not play with me on that playground and she made it clear to everybody else who was on the monkey bars why they would not be playing with me either. I had no doubt about her motive, i had no doubt about my relative position in her mind as to myself worth. That is called explicit racism. I remember it well. That is not what this book is about. However, an unscientific study, i have kids all in their 20s, i check with them and ask do you guys remember with explicit racism, every single one of them does, the generation between the two of us has not changed the existence and presence of explicit racism. I want to make that clear because thats not what im talking about. Im talking about implicit racism. Let me start by defining. Unconscious racism is when you store social knowledge. The information that you take from the music that you hear on the radio, the movies that are presented to you, the television stories, if youve been watching political debate, all of this is social knowledge and stores in the unconscious part of your mind. It is triggered when you encounter a person of another race involuntarily. Involuntarily its triggered. You call up that knowledge unintentionally and informs your decision and conduct and interaction with people of a different racial group unintentionally. Now, lets be clear, the difference is very important because studies show us that most people in the United States today are not going to identify themselves as explicit racism, well, that was before the president ial elections cycle that we are in. [laughter] probably more than we thought would identify as explicit racism. But most people explicit racism is kind of out of style, right . Its not what we do, its not how we identify ourselves as a country and who we are as a people. Even if your explicit preferences are galitarian, are to be a nonprejudice, your implicit biases, will do more to inform and direct your conduct than will your explicit preferences. Why is this important . Its really important in health care and why it i came to write this book that Health Disparities is killing people of color daily. Its causing 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 spend 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 it cataloged 25 years of data, the fact that infant mortality in the africanamerican population is twice that of white population. The fact that you are 75 more likely to die if youre diagnosed with coronery Artery Disease than if you are white. These are the kinds of data that will be replicated no matter what the leading cause of disease. Its true for stroke. Im going the pause at cancer because i want to make a point. With respect to cancer whites and blacks diagnosed at the same time, 33 difference in the fiveyear survivability rate. This is not true, however, if they received similarly intensive treatment, education, screening, if these treatment disparities are eliminated, then the difference in survival disappears. The fact that that is true is morally untenable in the United States in my view. It is medically untenable because the medical profession not only agrees to first do no harm but if you read closely, the hippocratic talk about justice and when that is not the case, then implicit biases change the way that people are treated. So let me turn now to the content of the book that institute of medicine study that was done in 2003, positive that its possible that physician bias may have a causal relationship with Health Disparities, that because physicians themselves are individuals were bias on race, ethnicity, socioeconomic, gender, sexual whorntation and other grounds, that might actually influence their treatment decisions but at the same time, the institute of medicine said we dont know exactly how those mechanisms work. The point of my book was to try and come up with an understanding of those mechanisms, how to understand how physician bias translates into Poor Health Outcomes for people of color as compared to whites. I looked at the studies and they are copious, and i organize them to six mechanisms, the bias care model. Im only going to talk about one tonight but i organized them in a way that suggest there are six different pathways or mechanisms by which physician bias translates into Health Disparities. One of the most important contributions i hope that my book will make is not only the organized set of mechanisms for others to discuss and research but also the fact that one of those mechanisms, dirty little secret, involve implicit biases that patients hold. So if the fact of the matter is that we get the implicit biases by our social bias, all of us living in the United States are doing to get the same social knowledge and the literature tells us that patients as well as providers will have implicit bias, so one study and one mechanism for tonight and if youre interesting in the other five, we can talk about some more during the q action, but issue study is about mechanism number five that implicit bias changes their treatment pattern, right, this is a very direct link or mechanism between bias and disparities, between bias and Poor Health Outcomes. Why . Well, the studies that are in the treatment space say this, and im thinking of one by alexander green specially. They say that if a patient has coronary Artery Disease and we present that Patient First as a black woman, then as a white woman, next is a black man, then as a white man, but we use a script, we use a predetermined set of data that tells us about the medical indicatorses, we use a predetermined set of facts about their history and personal background and their family connections, so that all of these individuals are identical to the physician but for their race and their gender. If we do that, then we can see that race and gender informed the quality 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 and treatment decision, there was an inverse relationship between the level of implicit bias and the quality of the treatment decision. That is to say the more implicitly biased a physician is, the higher on the Implicit Association test, and if you would like i can talk about that test, the higher the Implicit Association scores, the most likely they are to provide an inferior treatment modality 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, a study of coronar Artery Disease patients which needed, a muchas gracias of a low implicit to prescribe treatment of choice. That tells us evidenced relationship between implicit bias and the quality of treatment that a patient will receive, that results in different, so the other mechanisms have to do with version and communication with patients. Maybe youve had the experience. You know that theyre not looking you in the eye. You know their interview is short that their body language puts zis tans between you and them. And so they say, i know what that is. Since i know what that is i no longer am satisfied with the experience and we have a lot of data lowpatient satisfaction equals poor outcome. What i found out in this book is a series of interviews of those kinds of patients that its not just lowpatient satisfaction equals Poor Health Outcomes. Its lawpatient satisfactions means im not coming back to you anymore. Its an interruption in care. That means if you tell me that i need to exercise, im not listening to you because youve insult today me, that means my adherence and compliance is low which translates into low or relatively Poor Health Outcomes. All the mechanisms work together. Its often the case that you write a book, ive been told, and you finish a book and you would write another book, a different book at the conclusion of that conversation, well, that for me just means i have a secondbook project to go on, right . [laughter] but let me share a couple of things. I am going to read one thing about the book and close a little bit about what i would do to fix this and what my next book looks like. When i finished categorizing the data, i set out to create a new data set qualitatively, interview patients, interviews physicians, Interview Health care providers and ask them about their lived experience, their own personal interaction with implicit bias and unconscious racism, what i found essentially that i was able to confirm all six of the mechanisms that i described in this book. I choose a different patient to read about and this time i want to choose a chinese man, bears out mechanism number six, patients that feel and perceive themselves as being discriminated against drop out of the care system or at least interrupt the care system in a way that impacts their Health Outcomes negatively and 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 from many patients. What i heard from many patients and youll hear it in his story is that his view was discredited. That perceptions about him as a quote, unquote foreigner meant that he was not believed or taken seriously. His complaints were ignored and the treatment that she received turned out to be inferior. So he picking up in the middle of the story he says, one night i just found i got clinical disease like recurring to me which caused and came from the country side back in china. Its a mosquito, a very tiny thing. I know that illness. Basely its hid nn the lover and can periodically one day show up and you have a very high fever. And then you are exhausted and then you go to sleep and he describes the symptoms. You cant walk, youre lethargic, you cant work, and i got that thing, he said. Its an asian disease. When i came here, it came back. I went to the doctor, 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, i cant find nothing, theres nothing wrong with you, but this thing is true. You cannot find it in the blood but if you look carefully, its in the liver. But i dont think that they bothered to do that and, of course, i cant really remember the name or the academic terminology so i took the dictionary with me, so imagine this mans experience, hes going back and taking the dictionary to explain to his doctor that he can speak english. So i took the dictionary and i found the word to tell the doctor but they just say, no way, i cannot give you any kind of treatment. When you get this kind of thing again and you can show me what is making you feel bad, come back. In this system if you dont have symptoms, they only kill the symptom, they dont treat you for whats really wrong and if you dont speak english really well, you have a less of a chance to making them understand. This is not to say they hate chinese but they have prejudgment, his words, not mine, they say youre wrong because youre not professional. Remember hes an engineer, ph. D, engineer, plus maybe in your whole life in the United States youve never met someone like me but this thing it makes you so weak, can can kill you, so after 15 years here i got this thing again but decided im not going to the hospital again because it really makes me feel worst to go to the hospital. I write to my friend in shanghai, i tell them i need this medicine and they bring it to me after a month. Im a professional in my area, at least i can say im well educated. Oh, my goodness, if i had a psychology degree i would take apart the sense of deg anity that this man lost in his encounter. The sense of of insult which he was quick to deny. Remember hisment, theyre not racist, they dont hate chinese but im not going back there anymore, he said, his outcomes are adversely affected by the fact that this is happened. I think this is medically untenable, tom who is one of the foremost disparities scholars in this country tells us that it caused 1. 24 trillion with a t dollars in loss productivity, preventible hospitalizations and increased healthcare costs to treat Health Disparities over a course of his study, was six years. It is morally, medically and monetarily unsustainable not to address this problem of Health Disparities and i think the most serious causal factor that we are not talking about is unconscious racism. So what do i want to do to fix it, i will do a lot of things that i want to talk in a q a. Why more law where medicine is concerned . Poor doctors, they are under so much law. I say that for my husband. The social no, maam needs to be changed in this country. The social norm right now tells us that it is okay because it is unintentional to discriminate. That is not true. My fourth m. Unconscious bias is malleable. Theres 25 years of data that tells us we can actually do something about unconscious bias. Some of the most interesting experiments are those in which people who are unconsciously bias as measured by the iat, the Implicit Association test and who are explicitly bias are told in an experimental condition and experimental situation that their biases are not shared by 86 of their peers and then there are subsequent parts of the experiment where theyre asked to sit down on a chair next to people of color, those who believe that their biases are affirmed by their peers sit further from the person of color then those who believe their biases are not the social norm. They sit closer. Thats just one example of social experience. Brown versus board of education. We changed the social norm of explicit prejudice racism. We have to do three things with respect to the Civil Rights Act of 1964, number one we have to make implicit or unconscious bias unintentional racism actionable under that statute. Number two, we have to reverse alexander