Ladies and gentlemen, welcome to the 51st Critical Care Congress. The theme of the 2022 Congress focuses on intersectionality, diversity, and inclusiveness. Today, we will widen our horizon on intersectionality in healthcare. My name is Adeye Kadibara from the Brooklyn Hospital Medical Center. I have no financial disclosure. Let's start by defining what intersectionality is. The classic definition of intersectionality, according to the Oxford Language Dictionary, is the interconnected nature of social categorization such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent system of discrimination or disadvantage. This terminology was first coined by a renowned feminist and social activist, who I will be glad to introduce to you in the next couple of slides. The understanding of this context will help to bridge the gap and ground the differences amongst us. Please walk this path with me. Let's go back down memory lane so as to have a better idea of what this is all about. In 1976, in the case of the Graffiti versus General Motors, five African-American women sued General Motors for racial and gender discrimination. Surprisingly, the court found that the women in general weren't discriminated against when it comes to job as secretary. And the fact that General Motors employed African-American factory workers disproved racial discrimination. What the court failed to see then was that the overlap between race and gender, it ignored the fact that the shared majorities of secretaries were women and factory workers were all men. So the women lost. This landmark decision by the court shows that intersectionality cannot be overlooked from one prism alone, and that the system of discrimination is interwoven with a lot of factors interdependent on one another. This idea was first conceptualized by Kimberly William Crenshaw. As a young student studying to be a lawyer, she was able to prove through attitude research that gender and race were looked at as completely separate issues. To this straight blazer, studying them in isolation to each other made no sense. She saw that women of color, for example, are doubly discriminated against, particularly in the field of law. This is the landmark paper published in the University of Chicago Legal Forum by this erudite lawyer, Demarginalization, the Intersection of Race and Sex. A Black Feminist Critique of Anti-Discrimination Doctrine, Feminist Theory and Anti-Resistance Policy. This social critic and civil rights activist were able to prove how gender, inequality, race is all interwoven, and one facet cannot be looked at in total isolation. Gender is not separate from race, race is not separate from gender, and inequality is also part of the equation. Kimberly Crenshaw made a point by stating that if you see inequality as a them or a them or unfortunate other problem, that is a problem. Intersectionality is a form of analytical framework that helps with understanding how aspects of a person's social and political identity combine to create different modes of discrimination and privilege. In this analytical framework, we can see that how we are identified in the society by our gender, race, ethnicity, sexual orientation, combined with our political ideology and identity, can lead to a system problem. The end result of this is that some members of the society will be at the half of the totem pole through discrimination, while others will sit in the middle of the totem pole. How then can we as a society move forward with this dichotomy? In intersectionalism, we need to identify multiple factors of advantage and disadvantage. Kimberly Crenshaw, the progenitor of the term in her own words, stated that intersectionality as a method and a disposition, a heuristic and analytical tool in a 2013 article she quoted. Another Black female theorist, Patricia Hill Cullen, referred to as the interdependent phenomenon of oppression, whether based on race, gender, class, sexuality, disability, nationality, or other social categories. In a study conducted by Kimberly Crenshaw in 1991 on domestic violence against women of color, particularly among immigrant women in Los Angeles, she focused her analysis on the fraud provision of the 1990 Immigration and Nationality Act. Based on the fact that application for power and residence status could proceed only after two years of marriage and cohabitation, the law would require that the person who is of marriage and cohabitation and with the permission of this parties. This act effectively mandated immigrant women to stay married to and cohabit with their U.S. citizen of permanent residence regardless of any abuse suffered at the hands of the sponsors. Race, gender, caste, class, sexuality, religion, physical appearance, and age played one privileged group at an unnecessary disadvantage and give privilege and advantage to another group. The matrix of intersectionality is intertwined and linked together. Not one factor can be studied in isolation. This problem cannot and should not be studied in isolation, but all relevant factors should be combined to reduce disparity not only in health care, but in all spheres of life in a modern society. This report was first published in 1910. The report recommended closure of a large number of operating medical schools. The impact of this report was felt mostly in minority communities. The most gallant part of this report was the recommendation that Black physicians should serve as hygienists and sanitarians in villages and plantations. The impact was felt among Black minorities still struggling with access to medical care. Five out of seven predominantly Black medical schools were closed. Despite decades of advocacy, there is still a gross under-representation of minority in all aspects and all spheres of medical care. Let's start from Genesis. The percentages of applicants from the largest ethnic and racial applicant groups, Asian, African American, Latinx, and White, who were accepted and matriculated to medical school by race are as follows. Asians accepted, 44%, matriculated, 43%. African American accepted, 41%, matriculated, 40%. Latinx accepted, 47%, matriculated, 46%. White accepted, 45%, matriculated, 43%. This data shows that Asians, Latinx, and White applicants tend to get into medical school roughly at the same rate, whereas African American students have a markedly lower acceptance rate. If this data is called using African American and White for comparison, it is very obvious from the data that acceptance rate is lower in African American compared to White. 2018 to 2019, 36% of African American, White, 45%. 2019 to 2020, 38% African American, 45% White. 2020 to 2021, 41% African American, 45% White. 2021 to 2022, 36% African American, 39% White. This is another data that compares medical school application across all racial and ethnic groups. In circles are the major racial and ethnic groups. The next slide will show the percentage distribution of applicants to medical school based broadly on ethnicity and racial groups. Based on data published from AAMC from 2018 to 2019, 2019 to 2020, 2020 to 2021, 2021 to 2022 applications, there is a gross underrepresentation of minorities in U.S.-based medical school. Could intersectionality be a contributing factor? The data needs to be interpreted with caution as Asian Americans have a high rate of application to medical school relative to their representation in the overall U.S. population. The factors that might be related to low application among minorities, like access to good primary education, socioeconomic status, good mentorship, ETC is intertwined with intersectionalism. The American Association of Medical Colleges have separate positions on resisting and the mission to achieve gender equality. On June 1st, 2020, David J. Scrotton, MD, president and CEO of AAMC, Association of American Medical Colleges, and David A. Acosta, MD, AAMC chief diversity and inclusion officer, released the following statement. For too long, racism has been an ugly, destructive mark on American soul. Throughout our country's history, racism has affected every aspect of our collective national life, from education to opportunity, personal safety to community stability, to the health of people in our cities, large and small, and in rural America. This statement fails to address other issues pertaining to gender equality, religious, and cultural orientation, which are part of what the main issue is, intersectionalism. In Western settings, the downstream effect of medical education on doctors and patients are shaped by patriarchal and colonial histories and values. Most of the textbooks and research that are used and are currently being used in medicine is based on historical data and findings, which is key to a particular risk. Dominant education theory and methodologies are not neutral and may implicitly reproduce whiteness-based norm. That is a saying. Ethnic minority medical student and young minority specialist in training do not feel at home and perceive a systematic underestimation of their capacities. Patriarchal culture in medicine restrains women doctors' career choices and progression internationally. Most of the medical textbooks reinforce norms based on whiteness by under-representing other racial and ethnic minorities, e.g., different presentations and clinical signs for patients with darker skin tones. Another key point to emphasize is the dominant education theories, where all there is a tendency in medical research and education to gravitate to a particular race. Dominant education theories and methodologies are not neutral and may implicitly reproduce whiteness-based norm. Ethnic minority medical student and young minority specialist in training do not feel at home and perceive a systematic underestimation of their capabilities. The utilization of Western values and norms as it pertains to biomedical knowledge and exporting it to other global settings can have a dramatic impact on enhancing inequality. Our behavioral and social interactions all depend on the way we are raised and our religious views, cultures, and beliefs. The use of Western-valued Judeo-Christian principles in other countries, without taking into account their values and cultures, tends to further enhance inequality in a global setting. If we want to eliminate our taking-for-granted norms and reproduce processes of exclusion, we need to become more reflexive ourselves to engage in consciousness-raising and to strengthen the positions of those studies we study in line with Freer's work. This study was conducted in Israel using both quantitative and qualitative methodologies. The quantitative data were derived from the 2011 labor force survey conducted by the Israeli Central Bureau of Statistics, which encompasses some 24,000 households. The study found out that, with respect to physicians, the Arab minority in Israel is underrepresented in the medical field, and that this is due to Arab women's underrepresentation. Arab women's employment and educational patterns impact their underrepresentation in medicine. Women are expected to enter traditional gender roles and to conform to patriarchal and collectivist values, which make it difficult for them to study medicine. Ethnic diversity in healthcare workforce plays an important role in reducing health disparity among different ethnic populations. Underrepresentation in healthcare professions is one of the factors that influence health inequities. The term underrepresented in medicine is in reference to those racial and ethnic minority populations that are underrepresented in the medical profession, compared to their numbers in the general population. Based on the premise that ethnic minority populations are underrepresented among health professionals, it is imperative to broaden the ethnic diversity of the healthcare workforce. This will contribute to achieving high quality healthcare that is accessible, equitable, and addresses the cultural need of the population. In conclusion, the utilization of an intersectionality approach to study underrepresentation in medicine provides a basis for action aimed at improving public health and reducing health disparity. Further to our discussion on intersectionalism, one of the key factors that influences underrepresentation of minority medicine and science is sexual harassment. Although, over the last couple of decades, research activity and funding has been devoted to improving the recruitment, retention, and advancement of women in the field of science, medicine, and engineering. The participation of women in recent years with these activities has improved, and there are significantly more women entering careers and studying science, engineering, and medicine than ever before. Looking back, however, over a period of 30 years, the incidence of sexual harassment in different industries has remained steady because now there are more women in the workforce and in academia and in the field of science, engineering, and medicine as students and faculty, and so the number is more for women who are experiencing sexual harassment as they work and learn. Fifty percent of women faculty and staff reporting having sexual harassment at their academic institution. Here is where gender comes into play in intersectionalism. According to this paper published in 2018, Sexual Harassment of Women, Climate, Culture, Consequences in Academic Science, Engineering, Medicine, Washington, D.C. U.S. National Academic Press. In this study, female students, trainees, and faculty in medical centers have experienced sexual harassment not only by their peers and supervisors, but also by patients and patients' families. This study was published in 2017. Basically, it was an internet survey of workplace experiences of 474 astronomers and planetary scientists. Between 2011 and 2015, women in general, and specifically women of color, have reported postal working workplace experiences in astronomy and related fields for some time. About 40 percent of women of color reported feeling unsafe in their workplace because of their gender or sex, and 28 percent of women of color reported feeling unsafe because of their race. Finally, 18 percent of women of color and 12 percent of white women did not attend professional events because they did not feel safe attending or identify a significant loss of career opportunity due to a postal climate. In this study, early-stage investigators who received grant support through the NIH Research Supplement to promote diversity in health-related research programs were invited to a workshop in Maryland in June 2015 in order to assess the effectiveness of the current NHLBI diversity program, improve the strategy towards achieving its goal, provide guidance to assist the transition of diversity supplement recipients to independent NIH grant support, facilitating career development of diverse independent research scientists through NHLBI diversity programs, effectiveness of current NHLBI program for promoting diversity of the biomedical workforce. In this, there is a significant under-representation of women in the field of science and technology. Only 6 percent of advanced degrees in science and engineering were awarded to underrepresented minority women. From 2000 to 2010, Black comprises only 1.5 percent of the ROI applicant pool. Hispanics and Black remain underrepresented in academic medicine across more than 15 specialties. In a study published in 2017 in Academic Medicine, Hardin et al were able to demonstrate that the cumulative percentage of students in medical scientist training programs is less than 5 percent. Four percent Hispanic, three percent Black, 0.3 percent Native American, 0.2 percent Pacific Islanders. Folks, we are going to wrap up this discussion by talking about access to healthcare as it pertains to intersectionalism. In a book published in 2006, Moreland et al suggested that disparity in healthcare does not exist in isolation, but is interlocked with inequality and inequity in education, housing, employment. One entity is not separate from the other, and while it provides opportunities and advantage to one group, it puts other groups at an unnecessary disadvantage. Let's take a look at this flowchart, for example, as it relates to intersectionalism. This is just an example. A woman of color, because of disparity in education, employment opportunities, might undergo more stress during pregnancy that might predispose the individual to pregnancy-induced hypertension, diabetes, infection, et cetera. Because of limited access to healthcare and what have you, most of this program will remain undiagnosed or underdiagnosed, creating more problems for the mother and unborn child. Preeclampsia, eclampsia, low birth weight infant, infant of diabetic mother, neonatal sepsis, and the list goes on. In a report published by the World Health Organization on Social Determinants of Health, this report states thus, the poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services globally and internationally. The consequent unfairness in the immediate visible circumstances of people's lives, their access to healthcare, schools, and education, their condition of work and leisure, their homes, communities, towns, or cities, and their chances of leading a flourishing life. This unequal distribution of health, damaging experiences is not in any sense a natural phenomenon, but is the result of toxic combination of poor social policies and programs, unfair economic arrangement, and bad politics. In their work, Calling and Blight undiscuss disciplinary level as a domain of power that organizes and regulate the life of people in a way that echoes a distinct social position with regards to system of oppression. Who will get sent in a medical office based on ability to copay or not? Who will or will not be admitted to a domestic violence shelter based on their English proficiency or sexual orientation? In this context, underrepresented minorities are under the domain of power, and their social position and standing might make them afraid or apprehensive to seek medical help when necessary, either as a result of lack of funds, immigration status, exposure to violence, physical and verbal abuse. All the factors highlighted in the previous slides create a disparity in access to healthcare for the underrepresented minority. As the former President Obama said in the book, The Promised Land, what is the way moving forward? Where does our future stand with this hydra-headed problem called intersectionalism? How do we as a community, society, country, or the whole world move towards the ideal goal, which is the promised land? In a meta-analysis study published by Patrick Bennett and Gomez LE, the authors looked at diversity studies published since 1999. The study included medical and business research indexes. Only meta-analysis and large-scale studies pertaining to diversity and financial or quality outcomes were included. The research also had to include the healthcare industry and pertain to a related skill, such as communication, innovation, and risk assessment. The conclusion from this review is that healthcare studies show patients generally fare better when a more diverse team provides care. Professional skill-focused studies generally find improvement to innovation, improve risk assessment, and team communication. Increased diversity provides improved financial performance. Friction that comes with change is better enhanced in a diversity-friendly environment. In another study that explored the three Ds, social determinants, health disparity, and healthcare workforce diversity, there is currently an urgent need for healthcare professionals to adequately address social determinants of healthcare in their encounter with patients. During the next several decades in the United States, the ethnic demographic transition slated to occur will have numerous profound effects on the healthcare sector, particularly as it pertains to the need for a more diverse, inclusive, and culturally aware workforce. As mentioned earlier in 2004, the Sullivan Commission on Diversity in Healthcare Workforce, made up of a highly diverse and experienced body of commissioners, issued 37 landmark recommendations, widely supported by stakeholders to address the crisis of a lack of diversity in healthcare workforce in the United States. The commissioners put forward evidence that eliminating racial and ethnic inequalities in health and healthcare could be achieved by increasing the diversity of the healthcare workforce. For the past 20 years, the growing percentages of ethnic minorities in the United States have led scientists to pay increased attention to the issue of diversity. The result of these studies shows that ethnic diversity amongst street-level bureaucrats corresponds to low organizational performance. Meanwhile, ethnic representation amongst street-level bureaucrats correspond to higher organizational performance. In other words, the more ethnic variation amongst teachers, for example, the lower the performance in the school district. But if that variation matches the variation of students in their district, the school tends to perform better. In essence, to reach the promised land in school, the ethnic variation amongst teachers should be reflective of the ethnic variation in the student population. Here is an abstract on the preeminence of ethnic diversity in scientific collaboration. In this study, Al Shelby et al analyzed over 9 million papers and 6 million scientists to study the relationship between research impact and five classes of diversity, ethnicity, discipline, gender, affiliation, and academic age. The result of the study shows that ethnicity has the stronger correlation with the scientific impact of paper, regardless of year of publication, number of authors per paper, and number of collaboration per scientist. Ethnic diversity results in 10.63% impact gain for papers and 47.67% impact gain for scientists. Here are the listed references for this presentation. Thank you. Questions?

intersectionality

healthcare

discrimination

disadvantage

race

gender

disparities