All right. Good afternoon. Thank you for staying until the very end. And I hope you'll have a safe flight when you get home. I will be talking and giving a sort of background on systemic sources of racial disparities in the ICU. I have no relevant financial relationships to disclose. And my goal is really to contextualize this whole idea of racial disparities in the ICU. What are the drivers? And how did this come about? So, first question is, are there racial disparities in ICU or in ICU outcomes? So, it's going to be difficult for me to answer. But just last year, a couple of years ago, this systematic review was published. So, about 750,000 patients, 25 studies. And bottom line, they found that on black patients relative to white patients or Hispanic patients had higher crude mortality rates, higher prevalence of sepsis, were more likely to be admitted to lower-performing hospitals. But when you adjusted for age, social, economic status, crude morbidity is that most of these differences disappeared. Now, we all know what the socioeconomic status factors are that we term under the bucket of social determinants of health. They're very, they've been well-documented. And their relationship to health disparities are well-documented as well. The question is, why do we have a disparity in terms of the prevalence when you compare black patients or minority patients to the rest of the population? And that's really what the whole idea of structural competency or structural determinism covers. The idea is that these factors emanate from systemic structures in society that are not under the control of an individual, but are rather driven by the structures. And so, the next question that comes in is where do these structures come from, right? And for us to answer that, there's no way we don't have to go back to the 246 years of slavery in the United States. That's really where all this started. And to illustrate that period, I want to show you a few quotes from Thomas Jefferson. I think you all know him. He was the third president of the United States, was one of the drafters of the Declaration of Independence. You can see that right there. And he thought slavery was abominable, right? And there was nothing he wouldn't sacrifice to find a plan to get rid of it. But he owned more than 600 slaves. He thought blacks were inferior to whites genetically, intellectually, and that you needed a vigor of discipline. These quotes they get from his book to make them do reasonable work. These are all quotes from his book. So, we know we have his own first-hand written thoughts. He made a lot of profit from slaves. So, he thought, you know, every slave woman who breeds twice or every other year is more profitable than the best worker on the farm. So, you can see the conflict and dissonance in his thoughts right there. And yes, he wanted the slaves to be freed. But he was also concerned about what happens after the slaves are freed. Do they get incorporated into society? And you can see these phrases again. These are phrases taken from his book. It was right about the deep-rooted prejudices entertained by the whites, 10,000 recollections, by the blacks of injuries they have sustained, and how this would impact society going forward. So, it's not a surprise to me. And then the reason I use him again, like I said, we have his first-hand written record. He was really emblematic of his society back then. And I came up with this term that the society definitely needed psychological permission for slavery to thrive. Excuse me. You know, you had to dehumanize the black people around so you could treat them unjustly and cruelly and take advantage of them economically. And whipping, subjugation by whipping, hard labor, state-sanctioned violence was how you kept these people in line. The picture of Peter here, which this man was named Peter, was taken after he escaped from the plantation where he was and escaped to the north. And actually, this picture helped galvanize public support against slavery during the Civil War. Unfortunately, physicians were also culpable, right? They profited from slavery. They were the ones that did the physical exams when slaves were being auctioned. If they got sick, they were the ones that were called to get them well so they could get back to work as quickly as possible. Some of them were paid in slaves, right? If they couldn't pay them cash, they were given slaves in return for their work. And of course, that gave them a substrate for their pseudoscience and the human research that many of them engaged in. I think about this example, Dr. Catwright. He even came up with diseases basically to pathologize the behavior of slaves. I think the one that struck me, dreptomania. I'm not sure if that's how it was pronounced. But basically, it was a disorder of the mind that caused the slaves to try and resist and try to escape. So just trying to run away was considered a disease. And, you know, the cure was more weeping. So there's so many examples like this in history that the physicians back in the day. Again, not all of them, but clearly they reflected the standards and the values of the society they lived in. And so what happened after emancipation? You would think this would get better. But we had 100 plus years of segregation and unjust policy. So blacks were basically excluded from full participation in community. And all of these policies you see listed here were things that were put in place by the government and society to basically continue to take advantage of black people or subjugate them. Again, basically continue to dehumanize them. And the impact of it, we continue to see today. And this is part of what we're talking about. We know that minorities and blacks are more likely to live in food desert areas. They're more likely to attend schools that are lower ranked. They have higher school student loan debt. They don't have as much household wealth. And even for those who are considered affluent by virtue of their education and training, they still are affected by inequities, right? They're more likely to live in poorer neighborhoods. The kids, the schools the kids go to are ranked lower. And these are people who, like I said, by virtue of their income and their status are not considered poor. These are people who are fairly affluent. And you see it demonstrated really sadly in the issue of methanol morbidity and mortality. Affluent, well-educated black women have the highest methanol morbidity and mortality in the country. Even college-educated women are more likely to die related to childbirth. And so the question is, why is it that education and income are not fully protected for these people? And it brings us to this concept of weathering, right? Early health degeneration due to accelerated biological aging. And the way I can demonstrate it or one of the best ways this has been demonstrated, again, is in maternal and child health. We know that low birth weight babies have higher infant mortality no matter your racial group. But even affluent, well-educated, highly-educated blacks are more likely to have low birth weight babies. And there was a study that was done that compared African-born blacks that had immigrated to America to U.S.-born black women and U.S.-born white women. And for that first generation of immigrants, they found that their babies had the same weight as the white women that were born in this country. But you fast-forward one generation later, their daughters were also having low birth weight babies. So there was something about living in this country and growing up in this country that affected their life. And something like that also was demonstrated in Iowa very recently, about eight years ago, 2018. There was a large immigration raid at a meat processing factory. Excuse me. I just finished the talk. And lots of hundreds of Hispanic women, both undocumented and native-born, were arrested. And after this raid, they took a look at birth weights of babies one year after the fact. And Hispanic women and the Hispanics that were arrested at this plant were both native-born and undocumented. They found that low birth weight babies born to these women rose, whereas in the white population in that state, there was no change over time. Similarly, after 9-11, they looked at some women in California, I believe it was, with Arabic-sounding names. And they found that they also had this sudden spike in low birth weight babies. So even an acute stressful event in the society can affect people. And so there is something going on, and it's really covered by this term weathering. And so how do you measure it? There are no easy measures, but people have looked at telomere length and DNA methylation and the concept of allostatic polluting. Basically, it's an index of physiologic dysregulation, thinking about the impact on you physiologically of chronic stress in your life and in society. The second is even, again, age, income, and educational status do not affect or do not protect you from this if you're black men or women. You begin to see the difference in allostatic weight scores begin to diverge around age 20, 25. And so the effect of this, when you look at some of these studies, is that you take the average person, their physiologic age is about 10, 15 years older than their chronologic age. And so when you're looking at, it begins to make sense why you look at some of these black women who have increased metamorbidity and mortality. They might be 25, but physiologically, they might be 30, 35, 40. And so the physiologic impact they're experiencing with pregnancy and childbirth is much more than they would have if they were at the same physiologic age. And so in general, this is one of the explanations that has been postulated as why you see higher proportions of chronic illnesses, morbidity, and chronic diseases showing up earlier and having an impact on survival for black people in the community. And then it brings us to the question of distrust. You look at what has happened over the years with this set of experiences that blacks have had in this country, and you begin to wonder why there's so much distrust in the black community health, healthcare industry, and the healthcare sector. There was a study that was done in 2015. 400 medical students and residents were surveyed and given a bunch of scenarios and testing their beliefs about black people and white people. More than 50% of them had at least one false belief, whether that blacks are insensitive to pain or that they had really thick skin and so they didn't feel pain, and all sorts of already discredited persistent false beliefs. And this was in 2015, nine years ago. These are people in medical school who are physicians who continue to have these false beliefs and myths about black people. So you can imagine how they manifest and how they treat their black patients, right? There'll be all sorts of stereotypes already going on in this place. Pain might be undertreated. Concerns might be dismissed, and patients might be seen as malingering or just being hypochondriacs when that might not be the case. And when you begin to have your concerns continuously dismissed and not getting the attention or care you need, well, why would you want to go back the next time, right? And it just begins to fit itself into this vicious cycle. And many of these patients also would then not want to volunteer for studies and research studies or may not even be invited to participate in studies. Obviously, when you think about a history of what we all know, some of the big ones that have made a lot of impact in society, Tuskegee Civilist Experiment, and some that are less well-known, the Cincinnati Radiation Trials, the World War II Mustard Gas Test, where government-sponsored and sanctioned research basically abused black patients. And so this, the history of all of this remains, and people are aware of this, and this information is passed down. And so when tomorrow you say, hey, sign up for a study, well, why would they? Why would they believe that you're telling the truth? And so it begins to perpetuate. And you see all these race-based algorithms that affect how equipment's calibrated or how severity of the illness is determined that end up being flawed. And the impact of that is either people have failed to be not as sick as they are or that they don't qualify for certain treatments or they're not sick enough to get whatever it is that they need, either a specialist referral, particular surgery, and things like that. And my colleagues are going to talk about that. So I'm not going to delve into details, more details about this. But the sad thing today, we're all talking about AI, is that these prejudices are being propagated even in the new AI models that are coming out today. If you just scan the literature over the last six months where people have looked, AI models are coming out with the same myths about blacks. And it's remarkable. How do we stop this so it doesn't continue to affect how our patients experience healthcare? And so you look at all of this, people just don't want to come. Even benign interactions in healthcare are treated with suspicion. They don't believe what people are telling them. So the next and then is, oh, they're labeled noncompliant. Well, they don't come back the next day. And you get this vicious cycle of presentation at later stages of illness or not at all. And so finally, it also supports why you see that black men would tend or black women would tend to trust doctors with the same skin color or the same race more than they do white doctors. And the sad thing is, this is not a solution. We can't say, well, just go see a black doctor or a white doctor because there's not enough of us black physicians and vice versa. So it's not a solution. I think we need to get to the root cause of the matter. And so finally, I'll close with expanding this. Again, why we have this drivers of poor health outcomes. The structures in place drive this social determinants of health. You layer on whether in a mistrust, no wonder we end up with health disparities. Thank you.

racial disparities

ICU outcomes

healthcare biases

socioeconomic status

historical injustices