Frontliners: Social Justice

Q: Why did you choose to present on human trafficking, and what did you hope to accomplish with your workshop, “Modern Slavery: Human Trafficking”?
A: Human trafficking is a topic that is often missed or forgotten in current medical training. As a medical student, I recognized the lack of training and hope that my presentation on human trafficking brings awareness to the lack of knowledge on this subject amongst other healthcare providers. Surprisingly, healthcare providers are often the first group of professionals to interact with victims of human trafficking with over 88% of victims seeking medical care in a variety of healthcare settings. For healthcare providers to fully assist victims of human trafficking, further awareness, knowledge, and training is needed to help identify and assess vulnerable patients.

Q: You included research in your presentation with some astonishing facts and figures surrounding human trafficking. What statistic in particular stood out to you when conducting your research?
A: In this widely distributed self-assessment survey, the majority of the over 6,600 participants from various levels of training believed that they would benefit from human trafficking training with less than 50% having previous training. It was also shocking to read the feedback that was provided in the survey and just how many healthcare providers expressed their interest in the topic. Many even went as far as to suggest how to best train others or how to go about raising awareness.

Q: You conducted a survey assessing self-reported knowledge on human trafficking by medical professionals and students. Less than half reported any formal training in human trafficking. Why do you believe human trafficking does not receive more attention in medical training?
A:I believe it is a topic that is very difficult and challenging to discuss. It is a topic that is often seen as one “that does not happen in my neighborhood or in my part of town” and is thus overlooked. Many do not realized just how prevalent this problem is and how it can be even happening right next door.

Q: For those who were unable to attend your workshop or who have not been properly trained in identifying victims of human trafficking, what are common signs to look for with patients?
A: Some of the common signs to look for in patients include: someone else is speaking for the patient and refuses to let the patient have privacy; patient exhibits fear, anxiety, or tension; patient is reluctant to explain his/her injuries or shared a scripted/inconsistent history; patient has tattoos or other forms of branding are visible; patient reports an unusually high number of sexual partners, STDs, pregnancies, miscarriages, or terminations.

Q: If attendees take just one thing away from your workshop, what do you hope that is?
A: I would hope that attendees would remember their most important resource: the National Human Trafficking Resource Center (NHTRC) hotline at 1-888-373-7888. The NHTRC can help assess the current level of danger, provide further recommendations, identify local resources, and potentially involve law enforcement. It is vital that you help the patient memorize the phone number, so they can call 1-888-373-7888 or text HELP or INFO to BeFree (233733) at a later time.

Q: How can SGIM members support your work or get more involved?
A: I would encourage SGIM members to continue their training in this topic and encourage others outside of their specialty to do the same. As a whole, we can continue to help those most vulnerable! 

You can access Dr. McAmis’s article, Assessing healthcare provider knowledge of human trafficking, here.

Q: Our members may be familiar with DEI efforts, but what are the DEIJ efforts at the center of your workshop?
A: Our workshop is designed to mirror the sequence often used in DEIJ work. We start with how to successfully structure and lead a DEIJ committee to ensure member engagement, obtain incremental victories, and maintain positive momentum. We then review the pitfalls to avoid and best practices to engage while crafting a mission statement to serve as a guiding light. Following this, we review our institution’s strategy and framework for advancing DEIJ efforts and then describe one specific strategy centered around how to create a DEIJ toolbox. We close with brainstorming on how to create a community within internal medicine to move this work forward.

Q: How was the Graduation Medical Education DEIJ Committee at Indiana University formed and why did you both choose to join?
A: George Floyd, Breonna Taylor, and Ahmaud Arbery. The Black Lives Matter movement. The inequities made more apparent by the COVID-19 pandemic. These moments heightened awareness of structural racism, race-related disparities in healthcare, and a need to diversify the healthcare workforce. Our institution responded. The Designated Institutional Officer called for the formation of a committee that is charged with developing programs and processes to address the DEIJ needs of our graduate medical education programs and fulfilling the ACGME core program requirements surrounding diversity and health care disparity teaching.

Curtis: I chose to join because I felt that we had reached a critical moment in time where we had the support (monetarily and philosophically) from key leadership and stakeholders to finally make substantive changes regarding DEIJ. Furthermore, I knew that I could not sit on the sidelines and not be a part of this important work.

Areeba: As an immigrant, female physician - I want to help create a better world for my own family and every other family out there. As representatives of a privileged set of professionals entrusted to protect health and lives- if not us, then who else is better positioned to make a difference? As my understanding of the problems has grown, so has my desire to be a part of the solution. So here I am!

Q: What is the GME Diversity Framework?
A:The GME diversity framework is a construct to conceptualize both the goals of our work and a longitudinal strategy for achieving them. Our School of Medicine has identified four key pillars of diversity which include representational diversity, inclusive environment, cultural humility, and anti-racism. The framework broadens these pillars to include evidence-based tactics to achieve these goals. We focus on pathway programs, holistic recruitment, retention planning, specific training, and development, (e.g., anti-bias, microaggressions), policy revisions, and evolving science. Further, the framework suggests how these core goals might develop over time.

Q: Why is the recruitment process of a DEIJ committee so important?
A: Holistic recruitment is essential to successfully matching with diverse applicants. GME programs and businesses in various fields have acknowledged that the way candidates are filtered out can be subject to bias, structural racism, and inequitable practices. To set diversity as a priority means concerted pipeline development outside of recruitment “season,” training of all faculty and staff involved in the process, holistic review of all applicants, structured interviews, and scoring, and continually studying the process to make improvements.

Q: You talk about the importance of making short, intermediate, and long-term goals. Can you give an example of each from your DEIJ committee?
A: In the short term, we refined an existing system for the reporting of mistreatment- we clarified definitions and created expectations for feedback. We reviewed surveys to ensure utilization of gender, race, and ethnicity inclusive language. For the intermediate term, we created a toolbox to help program directors with inclusive recruiting and created mechanisms to assess our GME recruiting practices. For the long-term, we are developing an infrastructure to track data longitudinally and create a shared understanding of priorities across learners, physician practices, health systems, patients, and our communities.

We do this work to realize our mission statement – to create an institution where everyone thrives and feels seen, where we are recognized leaders in diversity and equity in patient care, scholarship, education, and advocacy – and where we are proud of the role we all play in moving the world forward.

Q: How can SGIM members access your framework and toolkit for building their own institution’s DEIJ committees?
A: Our framework and toolkit can be accessed at: https://medicine.iu.edu/gme/why-iu/toolkit, Our work on GME DEIJ committees can be found here.

Q: Can you briefly describe your workshop, Contextualizing Care Plans Utilizing Docs for Health, at SGIM22?
A: At SGIM 2022, our clinical team at Brown University joined with a University of Chicago-based research team to provide a framework for addressing social and structural determinants of health in the context of a patient encounter.
Although physicians are increasingly aware of the impact of social and structural determinants of health on their patients’ well-being, they may feel under resourced and powerless to help, and constrained by the competing demands that arise during a typical medical encounter. And, if physicians were to elicit such a complex narrative from patients, would they know what actions to take to help get their patients back on track?

We answered this question in two steps for the audience.

First, we introduced an evidence-based strategy called Contextualizing Care for identifying challenges relevant to planning a patient's care during a routine medical encounter. This practical and common-sense approach to interacting with patients is associated with a range of improved health outcomes and, importantly, it does not lengthen the visit. An example of contextualizing care is learning during your visit with a patient that they are having difficulty keeping organized the many bottles of medications they are asked to take daily and, in response, transitioning the patient to a pharmacy that can organize the medications into convenient and easy-to-read packets by date and time (i.e., medpaks). A more challenging example is when the context that emerges is related to social and structural factors, which tend to leave the physician feeling helpless and resigned to focusing on the narrowly biomedical aspects of care. Failing to address these social contextual factors, however, can render strictly biomedical interventions ineffective.

Second, we introduced the Docs for Health website as an example of a practical tool to empower physicians to assist patients in addressing social contextual factors. On Docs for Health, we have curated prepared forms and letters intended to support patients in areas related to transportation, food insecurity, housing, immigration, income support, and miscellaneous.

After learning about the common impact of court debt on health, our team partnered with local lawyers to create a strengths-based letter template intended to educate judges about the medical impact of court debt. This customizable letter has been extremely successful for our patients and judges have indicated that learning the medical context of individuals for whom they are rendering decisions is immensely helpful. In fact, as this ground-level advocacy by individual physicians became more widespread, judges and individuals at our health system (Center for Health and Justice Transformation at Lifespan Office of Research) came together to organize large-scale court debt eradication events. At the first event, scores of individuals had their debt wiped away. This caught the legislature's attention and as of this year, Rhode Island no longer imposes court fines and fees on low-income individuals enmeshed in the criminal justice system. A heart-warming example of work at the physician-patient level inspiring high-level policy change!

Q: How did Docs for Health get started?
A: Docs for Health emerged from work between physicians, community health workers, peer recovery specialists, case managers, and social workers. Together, we recognized that our society has developed ways of restricting access to vital social resources like water, public transportation, and the requirement of a health care provider’s signature release from incarceration. We curated these resources into an open source platform called www.docsforhealth.org to make it easier for health systems to access them.

Q: Throughout your career, your work has focused on patients with histories of carceral exposure and substance use. Why did you decide to focus your career on these populations?
A: As an Indian American physician who grew up watching my immigrant father struggle, break rules out of necessity, and endure mistreatment to survive, I was drawn to texts and traditions that helped me understand why our country treats human beings so poorly. This has led me to center Bryan Stevenson's famous quote in my clinical work: "The true measure of our character is how we treat the poor, the disfavored, the accused, the incarcerated, and the condemned. We are all implicated when we allow other people to be mistreated."

Q: You have also created a Social Medicine elective at Brown. Can you tell me more about that?
A: I created the Social Medicine elective in 2021 with the assistance of Americorps VISTAs and Community Health Workers. The first goal of the elective is to immerse students in the day-to-day lives of patients. The hope is that by facilitating a month-long clinical elective that enables students to bear witness to most aspects of patients' lives, ranging from standing in line at the DHS office to assisting with securing a bus pass, students will spend time with and learn from patients and begin to develop an understanding of our bureaucratic social service system. When these students transition into physicians, they will have a greater understanding of how to serve their patients.
The second goal was to leverage the resources and human capital of academia to decompress and thereby support community-based organizations. We carried out the following aims: 1) to train medical students as case managers skilled in navigating housing, immigration and criminal legal issues; 2) to pair medical students with 3-5 patients who have needs in these domains; and 3) to ground this work in theory via a weekly social medicine reading group.

Q: How can SGIM members support your work or collaborate in the future?
A: I am always happy to collaborate and Iearn from others doing similar work. My e-mail is rahul_vanjani@brown.edu. In addition, in case the resources on it are helpful, our Social Medicine elective page is here.

Q: What are the Physicians for Human Rights group and how did you become the medical director?
A: Physicians for Human Rights (PHR) is an international health and human rights non-governmental organization that works at the intersection of medicine, science, and the law to secure human rights and justice for all. PHR leverages health professionals’ clinical skills and research expertise to investigate and document human rights violations and their health effects. Besides conducting rigorous research, PHR trains and strengthens the capacity of clinicians and legal partners throughout the world to provide medico-legal evidence of torture and ill treatment, including sexual violence and extra-carceral state violence and persecution against protesters and marginalized communities, to hold perpetrators accountable.

I first volunteered with PHR as a medical student in the 1990s. As I developed my research skills as a health services researcher, I continued to volunteer with PHR over the past few decades to help with their research investigations and joined their Board in 2010. In 2019 their long-term part-time medical director Vincent Iacopino, an important mentor to me, retired. My youngest child was about to go off to college, and I applied for the part-time position that requires I spend a week or so a month at the PHR offices in New York city. PHR contracts with the University of Michigan for my part-time effort (like a grant). This is a possible model for other SGIM members who are researchers and want to work with organizations that are addressing issues that the SGIM member cares about and can help support with their expertise and skills. It is exciting that more academic medical centers are making such partnerships possible—and University of Michigan gains as many UM medical students and residents have now worked with me on PHR projects.

Q: How did your previous experience working in human rights and poverty programs influence the way you approach medicine?
A: The work I did before medical training on issues of poverty and human rights in Latin America and the Caribbean with Catholic Relief Services and then with the Ford Foundation very much influenced my aims as a physician.
I had come to see how health professionals, with their specialized skills and credible voices, are uniquely positioned to help expose and prevent human rights violations and amplify the voices of people experiencing human rights violations. Health professionals like physicians have the incredible privilege of caring for individual patients while also leveraging our expertise and skills to promote human rights and social justice.

Q: What do you believe is the role of physicians in promoting human rights around the world?
A: Throughout the world physicians and other clinicians are at the front lines of caring for people who have experienced violence and other forms of persecution. With some additional training, we have all the skills and knowledge to systematically document individuals’ pain and suffering—physical and psychological sequelae—and correlate them with the abuses they experienced in investigations and individual medico-legal affidavits for accountability mechanisms. Those of us who are researchers can leverage our research skills—in conducting surveys, semi-structured interviews, gathering and analyzing population-based data—to help with human rights investigations. Also, health professionals make up a powerful constituency throughout the world to join to denounce human rights violations and advocate for remedies.

Q: How can SGIM members get involved your work?
A: Much of PHR’s work is in partnership with clinicians and researchers at universities who help on individual research projects and/or are part of PHR’s Asylum Network of clinicians who provide medico-legal affidavits for asylum cases in the United States. If you look at PHR’s reports and peer-reviewed papers, there is almost always one or more authors who are university-based researchers—and quite a few SGIM members have participated and are now participating on PHR research projects. In my own case, as a tenure-track academic, for the many years that I participated in PHR investigations, I explained that I did need to be able to write a peer-reviewed paper from the work I did with PHR. For those who want to contribute with their clinical expertise, PHR’s Asylum Network now consists of about 3,000 clinicians and has links with over 20 academic medical center-based programs in which Istanbul Protocol-trained clinicians work with pro bono lawyers to conduct medico-legal evaluations of individuals seeking political asylum. Several SGIM members started their collaboration with PHR by conducting asylum evaluations and then began to help with research with PHR’s asylum program. I would welcome SGIM members who are interested to reach out to me and explore ways they might become involved.

Q: Can you briefly explain the historical racialization of addiction and addiction treatment?
A: Helena Hansen and others have laid this out well, but there is a long history in the United States of racialization in the media and in politics of depictions of who uses substances. Whether stigmatizing opioid use in Chinese Americans, associating marijuana with Mexican Americans, or heroin use with Black Americans, these media and political tropes could then be leveraged into policies that marginalized communities of color (as with the Chinese Exclusion Act, for example, or the War on Drugs).

Nixon aide John Ehrlichman famously admitted that the War on Drugs was designed to devastate Black communities politically. Even effective treatment modalities for opioid addiction, like methadone, that emerged in that era are shaped in a heavily racialized and stigmatized way (hence the nickname liquid handcuffs, indicating the carceral-influenced requirements of methadone programs).

Q: Does the public policy response to the opioid epidemic differ from the “War on Drugs”, and, if so, why? How does this impact treatment among different communities?
A:As opposed to a punitive approach to addiction that conceptualizes substance use as willful criminal behavior requiring punishment, a public health approach recognizes that addiction is an illness requiring treatment.

Criminalizing possession of small amounts of drugs, and incarceration with high mandatory minimum sentences for drug-related crimes, did nothing to decrease overdose deaths. Rather, such policies devastated communities of color because they were typically implemented in a racist way (e.g., the 100:1 sentencing disparity for crack versus powder cocaine at a time when Black people were more likely to use crack cocaine).

A public health approach, in contrast, works to prevent the adverse effects of substance use—overdose, HIV, and hepatitis C, for example. A public health approach requires moving resources from the criminal-legal system to health care and adjacent systems—mental health, harm reduction, and housing supports, for example.

Unfortunately, given that many systems in the US are shaped by historical and structural racism, even implementation of a public health approach to addiction treatment can perpetuate inequitable outcomes. For example, studies have shown that Black patients are more likely to have access to methadone and less likely to have access to buprenorphine, compared to White patients. Without an equity focus, overdose prevention interventions that focus on buprenorphine alone are likely to disproportionately prevent overdose in White patients only.

Q: During your workshop, you had several case studies around OUD and treatment. Why is it important to reflect on the individual level, clinical level, and structural level of care for these scenarios?
A: The Social-Ecological model of health teaches us that ever-larger circles of influence—from the individual, to the interpersonal, to the community, to the societal—shape health behaviors and health outcomes. Furthermore, Camara Jones’s work on levels of racism tells is that racism works at the internalized, interpersonal, and institutional levels. Thus, interventions solely aimed at individuals, or even at the clinic level, could never successfully make outcomes for large numbers of people more equitable.

Q: How are minoritized women, specifically, affected by SUD treatment and outcomes?
A: One specific way is the way in which substance use and treatment are particularly stigmatized in people who are pregnant or caring for children. Health care providers are more likely to drug test pregnant patients of color. This leads to disproportionate involvement of child protective services in families of color, and subsequent trauma to children and caregivers. Furthermore, even in otherwise progressive states like Massachusetts, pregnant patients receiving prescribed medications for opioid use disorder are mandated to have a Department of Children and Families referral, regardless of how long they have been clinically stable on medications. This can actually serve as a deterrent to start medications, increasing risk of overdose and adverse pregnancy outcomes, particularly in mothers of color

Q: How can SGIM members get involved in combating racialized treatment of addiction?
A: First, get buprenorphine waivered so you can prescribe for all your patients, and if your practice is not already doing so, transform your practice so it offers buprenorphine.

Second, advocate in your community for expansion of access to MOUD under existing laws. For example, push for more methadone programs, mobile buprenorphine, and methadone programs, and MOUD programs in innovative settings such as shelters, correctional facilities, churches, and barber shops.

Finally, work to change existing laws to decrease the punitive approach to substance use in favor of a public health approach. Support efforts to decriminalize substance possession and use. Support efforts to expand harm reduction offerings, including syringe exchange programs in states that don’t have them, and safe consumption sites. Existing policies must change for our approach to substance use to become more equitable.

Q: Why did you choose to lead a workshop on climate change?
A: Over the past several years, I’ve become more aware of the current and future impacts of climate change on our environment, ecosystems and health. I live in Northern California, where drought is worsening and wildfires have become a regular threat, contributing to poor air quality, loss of homes and habitats, and general uncertainty and anxiety about the future for many, including myself. A September 2020 morning when I awoke to an apocalyptic dark orange sky due to wildfires will be forever etched in my memory.

Our workshop group is also comprised of clinician educators from Colorado, Nebraska, Illinois, and Georgia, where extreme weather events such as flooding, brush fires, and heat waves are affecting their patients and motivating them to educate others about the health harms of climate change.

I also care for many marginalized older Veterans, many of whom live in wildfire prone areas or are marginally housed and thus vulnerable to extreme heat and poor air quality. Currently our healthcare system does not have robust programming and systems to protect these patients from the effects of climate change.

As I’ve learned more, I’ve come to realize how pervasive and disruptive the impacts of climate change are to our institutions, economies, governments, societies, and our health. I’ve also come to better understand that although some might not feel the harms of climate change so acutely now, these threats continue to grow and will be a greater threat the longer we wait to address them. Because so many physicians and healthcare professionals are already so busy and have been particularly overwhelmed with meeting the needs of the COVID-19 pandemic, most do not seem to be aware of how large an impact climate change has and will have on their patients’ health, our clinical practices, our healthcare systems, and our public health support system. I wanted to lead a workshop that would not only raise awareness but help clinician educators find ways to show the relevance of climate and health in any clinical setting. We all need to be educated about and act on this issue as soon as possible.

Q: Your workshop focused primarily on heat-related illnesses. Why is that your highest concern?
A: Our group chose to focus on heat-related illness because this is a clinical syndrome that clinicians everywhere will encounter and need to treat. While climate change tends to have regional differences in impact, more flooding and storms in the Northeast and South and more drought and wildfire in the West, heat is universal. We felt that this also provided a good way to demonstrate how one could educate pre-clinical learners around basic processes such as physiology and how it is disrupted in extreme heat, as well as provide examples of heat-related clinical syndromes and how to address them acutely but also how to prepare vulnerable patients to try to avoid health harms from extreme heat.

Q: What is the climate risk assessment and how can it be implemented in patient care?
A: The climate risk assessment is a framework we developed to help both educators and learners see how climate change affects all aspects of health, identify real-time opportunities for teaching and learning in the clinical setting and be pro-active in supporting patients to be as resilient as possible in the face of health threats associated with climate change. It is flexible in that the entire rubric or just one portion could be applied in a given clinical teaching encounter, helping to ensure that it is time efficient. Because one of the foundational challenges right now is that many healthcare professionals do not see the connections between climate change and health, we hope that this will at a minimum increase the awareness necessary to help our workforce be prepared to skillfully navigate this crisis.

Q: How does climate change impact health systems and effect physicians?
A: Climate change increases the frequency and severity of extreme weather events, thus requiring that healthcare systems, including emergency management systems, be prepared for an increased volume of patients and be prepared to care for particular types of injuries or medical problems associated with different disasters. It is also associated with worsening of chronic conditions such as asthma and cardiovascular disease, and more insidious changes such as increased range of vector-borne illnesses such as Lyme disease and Zika. Physicians need to be equipped to educate patients about how to manage their chronic illnesses in the setting of climate change and to diagnose medical problems that were previously unusual in their region.

Climate change also requires that healthcare systems have physical plant and energy sources that can remain operational during these disasters. Additionally, since the US healthcare system emits 8.5% of total US greenhouse gas emissions, health systems have a responsibility to build more environmentally sustainable systems. Finally, we are responsible for educating patients and communities and partnering with them in building individual and community resilience and preparedness

Q: How can SGIM members get involved in climate health medical education?
A: You can read through our resource sheet to find out!

Q: You have mediated two discussions on “Anti-Racism in Medicine” at SGIM through the Health Equity Commission, with the most recent discussion on “Anti-Racism in Medicine” in January. What is this series and what do you hope to accomplish with these discussions?
A: I have been honored with the opportunity to mediate and speak for the SGIM Health Equity Commission “Anti-Racism in Medicine” webinar series. This series highlights approaches to delivering care to marginalized patient populations with a pro-equity, anti-racism lens. Given medicine is so multifaceted, each session has a focus: Immigration and Policy, Clinical Practice, Innovations in Education, and Advocacy through Research. We hope to bring more awareness and provide information on innovative ideas to create solutions for change to improve healthcare and systems. As physicians, we have great power in changing the narrative of medicine for marginalized, vulnerable, and uninsured patients and how the system treats these groups. If we share best practices, work together, and advocate locally to nationally as an individual and collectively with our professional organizations’ support, we can transform healthcare delivery to provide high quality, equitable and anti-racist care.

Q: You are the co-Chair of Diversity, Equity, and Inclusion for the Internal Medicine Division at the Allen Hospital at NYP/CUMC. Why did you choose to take this role and what do you hope to incorporate into your university through DEI efforts?
A: As a Latina and coming from an “economically disadvantaged” background, being considered “other” has always been a part of my life. My family and I experienced firsthand what it was to receive different care, being uninsured and not having access to medications or timely care, and implicit and explicit bias and racism from clinicians, who did not look or speak like us. From a perspective of obtaining my medical degree, I have personal experiences from the lens of being considered “other.” Given my resilience, I did not let it deter me from becoming a physician and found sponsors and mentors, who were instrumental in my success. After I attained my medical degree, completed my residency training, and started clinical practice, I know I had to do more for our patients, who were marginalized, vulnerable, and uninsured, and the healthcare workers, who care for them. As a physician, I use my voice to advocate with governmental officials and other organizations to improve access to high quality childcare and education as those are essential for success, health, and wellbeing for our communities of color and individuals from disadvantaged backgrounds. It includes supporting affordable, high quality Universal Childcare, Universal Pre-K, K-12 Education, and pipeline programs. This way, we can set up each child with the appropriate tools and skills to go to college and hopefully, later to medical school or whichever healthcare career track they are interested in.

In my role as co-Chair of Diversity, Equity, and Inclusion, Internal Medicine Division at the Allen Hospital, and committee member of the Columbia University Irving Medical Center Department of Medicine Diversity, Equity, and Inclusion Committee, I work with other leaders and colleagues to improve recruitment and retention of underrepresented minorities in medicine with the hopes of improving access and care for marginalized and uninsured patient populations. Having a diverse, equitable, inclusive healthcare workforce and leaders allows for everyone to lend their experience and expertise to the table in creating solutions to solve complex healthcare disparities and inequalities for marginalized communities of color, vulnerable, and uninsured patients and healthcare workers, who serve them.

Q: Why is improved healthcare delivery to underserved and vulnerable populations important for population health?
A: This pandemic has highlighted how greatly impacted communities of color and vulnerable patient populations are by health, systemic, and structural inequalities. We are all interconnected, even though some may not think so.  For example, migrant workers harvest our food. If they become ill, how will that impact individuals having food on their tables, in groceries, and/or at the restaurants? In the inner city, a healthier individual can provide food for their families, can work, can enjoy life…is there a reason we should prevent one group from having that? No, every individual has the right to access equitable, high-quality healthcare and improved well-being.

Q: How can SGIM members get involved in DEI efforts through our Health Equity Commission?
A: The Health Equity Commission has numerous opportunities to become actively involved, based on your interests and availability. It also allows for an opportunity to work with outstanding physician and physician leaders across the country and to be change agents in transforming healthcare. I am so grateful I learned about Health Equity Commission and was able to become actively involved in the committee. If you are interested in learning more about the initiatives of the Health Equity Commission or becoming involved by joining the Health Equity Commission, please reach out to Erika Baker at bakere@sgim.org.

The “Anti-Racism in Medicine” series currently has 4 webinars available free for members on GIMLearn.

Q: Why did your team choose to present a workshop on women Veterans?
A: As women’s health physicians within the VA, we work daily with women Veterans to advance their health. It is a privilege to serve these women who have made great contributions to our country and demonstrated such strength, heroism, and resilience. We also have firsthand experience addressing the challenges these women face that maybe the result of their service. Women Veterans have high rates of mental health issues such as post-traumatic stress disorder and may have experienced sexual assault and intimate partner violence. They also have high rates musculoskeletal injuries related to their service with subsequent chronic pain and have higher rates of cardiovascular and respiratory diseases. All these issues make women Veterans unique when compared to both their female, civilian and male, Veteran counterparts.

Q: What is trauma informed care and why is it important to apply when treating Veteran patients?
A: Trauma informed care is an approach to care that acknowledges the impact that prior trauma can have on patients’ interactions within the healthcare system. Unfortunately, we know that women Veterans are at increased risk for experiencing trauma both during their military service and in their civilian lives. We also know that interactions within a healthcare system, particularly during sensitive exams such as pelvic exams, can be triggering for patients. We universally use a trauma informed approach to ensure a positive interaction with the health care team.

Q: What separates women Veterans from their male counterparts in medical care?
A: Women Veterans are younger and more racially diverse than their male counterparts. Additionally, women Veterans have more complex care needs with both higher rates of chronic pain, medical co-morbidities, and psychosocial needs and have higher utilization of both primary care and mental health services. We also know that all women face barriers to care both within and outside of VA with gender disparities in diagnostic work ups, treatments, and outcomes across a variety of medical conditions.

Q: What role do primary care provider play in the provision of healthcare to women Veterans?
A: Primary care providers are critical to the care of women Veterans both within the VA and in the community. Primary care providers are often the first point of contact for women Veterans with the health care system and by asking about military service and screening for relevant physical and mental health conditions, they can ensure that women Veterans receive appropriate care including relevant referrals and both community and VA resources.

Q:How can SGIM members better understand and support women Veteran care?
A: There are more than 2 million women Veterans in the US and women Veterans represent the fastest growing group in the Veteran population. We know that many women Veterans access care outside of the VA system so it is critical for non-VA physicians to understand their unique health needs and to inquire about military service. A great resource to learn more about carrying for Veterans a 1-hour online CME course for community providers created by expert VA Women’s Health Clinicians. You can access the module for free here: Caring for Woman Veterans in the Community - VHA TRAIN - an affiliate of the TRAIN Learning Network powered by the Public Health Foundation

Q: In your workshop, you discussed the effects of mass incarceration at the family level as well as the community level. How does mass incarceration impact public health?
A: Mass incarceration affects public health on a personal, community and societal level. On a personal level, people who experience incarceration have more significant and higher rates of co-morbid health conditions and are more likely to experience death within the two weeks following incarceration. People who have been incarcerated often experience significant trauma related to incarceration which can have long-term psychological consequences on someone. On a community level, incarceration severely affects families- families are often left without a source of income and children are more likely to experience trauma. These communities also are often in places which lack resources to improve outcomes following incarceration including opportunities for employment, healthcare, and meaningful engagement within a community. On a societal level, public health suffers when large amounts of the population, especially minoritized groups, have been incarcerated. We see higher rates of recidivism and lower rates of employment.

Q: What was is the relationship between mass incarceration and COVID cases, and what is the COVID Prison Project?
A: In the setting of high rates of incarceration, COVID-19 was unfortunately able to spread rapidly and in a severely marginalized population. Isolation is harder in the carceral setting and often ended up in persons essentially being isolated to the degree of solitary confinement in multiple facilities. This led to significant psychological consequences within this population. Many carceral settings did not have access to the vaccine or released many people at once within a safety net to improve post-incarceration outcomes.

Q: You suggest we can protect public health through “decarceration”. What does this mean?
A: Decarceration is the concept of releasing persons from incarceration for multiple reasons. Jails often house persons who have not been convicted of a crime and are waiting for trial. Additionally, laws have changed such as marijuana laws, but people continue to be incarcerated for possession crimes. Decarceration would lead to the release of persons who do not actually need to be incarcerated such as those awaiting trial or those who no longer have crimes that would require incarceration. This would have a significant impact on public health and our society- this would enable more people to find meaningful work and support within their communities. Mass incarceration truly leads to more people experiencing healthcare inequities and can no longer access basic benefits within a society. Through mass decarceration, the only people who would be incarcerated would be those who have been convicted. Ideally, incarceration would not exist. We must question what incarceration achieves in a person’s life and for the welfare of society and remember that the initial purpose of incarceration no longer exists- it is not rehabilitative and instead leads to worse outcomes for a person and for society. If incarceration did need to exist, it would be truly rehabilitative- giving persons access to GED and college educations, job training, access to healthcare. Currently funding is being funneled to all the wrong things that makes incarceration in-humane.

Q:What are transitional clinics and how can they aid inmates after incarceration?
A: Transition clinics serve to improve outcomes of persons who have been incarcerated. The model acts as a quick transition from the carceral setting and into a setting with healthcare and access social resources. The CIH RIvER Clinic transitional clinic model acts as a funnel for people being released from our local jail- we receive referrals from the jail on a person’s release and immediately connect with people. We provide immediate access to medications for opioid use disorder and address any pending healthcare needs. We also connect persons to social services through a social worker and community health workers, who work to improve access to health insurance, housing, benefit management, employment and access to drug and alcohol rehabilitation as appropriate. Through this model, we have noted improvement in rates of recidivism within our population by advocating for meaningful diversion, reduced overdose deaths by providing low barrier medications for opioid use disorder, and decreased healthcare utilization by working quickly to re-active health insurance.

Q: How can SGIM members get involved in healthcare efforts related to mass incarceration?
A: On a basic level, it is important for all providers to question their biases. When someone comes into our care who is or has been incarcerated, remembering the humanity of patients is vital. If someone has experienced incarceration, make sure you screen them for trauma and ask about the effects of incarceration on their current life. It is important to understand that incarceration has lasting effects on an individual’s life and even more important to address these as they arise. From a policy standpoint, it is vital that we advocate for the end of mass incarceration and locally, to improve policies within jails and prisons that allow for a better quality of life, including rehabilitative programs, GED access, and life-saving healthcare such as medications for opioid use disorder.

 This workshop was done in collaboration with SGIM LEAHP and SGIM’s Global Health and Human-Rights Interest Group. To become a member, visit here. 

Q: What led to your research in Climate and Health Advocacy, and why did you choose to present on this topic at SGIM22?
A: Climate change is affecting every region across the globe (IPCC 6th Report). Manifested as weather disasters, heat waves, fires, flooding, and air pollution, climate change is affecting human health. While the effects will be felt by all, certain populations and communities are particularly vulnerable and will be disproportionately harmed. Scientific organizations frame climate change as the greatest threat to human health this century. However, they also describe it as one of the greatest opportunities for positive change (ACP, SGIM). These same organizations call on physicians to take action.

We chose to present on this topic to combat hopelessness, build connections, and empower physicians to become advocates for climate solutions. Being a part of a larger community of advocates amplifies individual effect and motivates sustained action .

Q: How does climate change impact public health and patient care?
A: The Lancet’s 2015 position paper, Figure 1, nicely illustrates the causal links between climate change and health. Green house gases, such as from the burning of fossil fuels, processing of natural gas, and car emissions, directly lead to (1) ocean acidification from the absorption of carbon dioxide, (2) climate change manifested as increased temperatures, altered rainfall patterns, sea-level rise, and extreme weather, as well as (3) air pollution in the form of particulate matter and ground ozone. Some of the downstream effects include reduced agricultural productivity, floods, heatwaves, drought, fire, and increased pollen burden.

Together, these conditions affect health: undernutrition, poor mental health, particularly related to extreme weather events and displacement, exacerbations in cardiovascular and respiratory disease, exposure to harmful algae blooms, shifts in vector-borne diseases, as well as increased waterborne illness – all of which are compounded by social mediating factors such as loss of habitation, poverty, mass migration, and violent conflict.

Physicians can raise public awareness through advocacy, as well as through patient education and counseling in clinical practice. Existing frameworks for social determinants of health and preventative care should be applied to environmental health. Subsequent physician counseling may help to engage patients, maintain health, and frame climate change as an issue of health rather than political debate.

Q: Why should physicians be concerned with political matters? Do you feel physicians have a responsibility to involve themselves in advocacy concerning public health?
A: Every citizen, physician or not, should be concerned with political matters; we are well-suited to engage in this space. Many of the tenets of our profession align well with those in public service. Politicians are tasked with upholding public interest while acting with selflessness, integrity, and leadership – expectations echoed in the Hippocratic oath. Physicians are also intimately connected to their communities. The stories of individual patients weave into a rich narrative of the strengths, weaknesses and needs of the communities we serve. Therefore, we have a unique ability to represent our patients and their communities to those in public service. Further, our voice carries weight. According to Gallup polls since 2001, nurses and physicians are ranked among the top-most trusted profession. And last, framing climate change as an issue of health makes it personally relatable and bipartisan.

Q: During your workshop, you asked attendees to answer the following question: “Why do you personally care about climate change’s impact on healthcare?” How would you answer this?
A: My family, my patients, and my community. I personally practice environmental stewardship out of concern for impacts on future generations and social justice. If I’m not willing to lead, who will? Further, the people impacted by our choices, our chosen advocacy or silence, are those we love the most: our children, our patients, and our communities. They also are often the least able to take action. Many of my patients, for example, live in areas historically oppressed, such as by government led redlining, and are disproportionately exposed to environmental hazards. The American Lung Association has found that more than 4 in 10 people (135 million) in the U.S. live with unhealthy levels of particulate matter and that people of color are 3 times as likely to live in the most polluted areas. Further, the American Heart Association reports an increased risk of myocardial infarction, stroke, arrhythmia, and heart failure exacerbations due to pollution exposure. Climate change is exacerbating health inequities. We as physicians are uniquely poised to bring these inequities to light, educate policymakers, and take a stand.

Q: You mention in your presentation SMART goals. This means doing something specific and measurable in a certain timeframe. What is your SMART goal for climate advocacy?
A: Short-term, my SMART goals include submitting an IRB with a medical student aimed towards studying heat- illness and adaptive capacity and lead the Wisconsin Health Professionals for Climate Action volunteer night on education. Near-term, I’m designing a medical school elective planned to launch in the Spring of 2023 and long-term goals include a longitudinal medical school curriculum, improving SGIM sustainability, and many more! I also have goals related to involving my daughters in my journey (ages 5 and 6). My six year-old recently joined me on a community garbage pick-up day, or in her eyes, an exciting hunt for “trash treasures."

Q: How can SGIM members get involved in climate and health advocacy?
A: Join the SGIM Environmental Interest Group! We are a diverse group of physicians with a shared concern for planetary health. Our views are influenced by each of our local, regional and global climate change experiences, and our aims are unified in education, research, and advocacy. The group’s goals align with the SGIM Position Statement and we are partnered with the Executive Committee in achieving them (SGIM Policy Statement on Climate and Health).

Outside of SGIM, members may consider joining other national or international groups including the Medical Society Consortium on Climate and Health (MSCCH), the Sierra Club, or the Global Consortium on Climate and Health Education. MSCCH and the Sierra Club have many state or regional branches for those interested in getting involved more locally. No matter which organization one chooses, finding allies in advocacy is key. Allies amplify our voice, inspire action, and ensure we’re connected and having fun in the process!

Materials from the presentation can be found here. 

References

Grande D, Asch DA, Armstrong K. Do doctors vote?. J Gen Intern Med. 2007;22(5):585-589. doi:10.1007/s11606-007-0105-8

MacMunn, A. More than 4 in 10 Americans Breathe Unhealthy Air, People of Color 3 Times as Likely to Live in Most Polluted Places. American Lung Association. c2021 April [cited 2021 July]. Available from: https://www.lung.org/media/press-releases/sota-2021

Brook R et al. Particulate Matter Air Pollution and Cardiovascular Disease:
An Update to the Scientific Statement From the American Heart Association. Circulation. 2010;121:2331–2378. doi.org/10.1161/CIR.0b013e3181dbece1

Watts N Adger WN Agnolucci P et al.. Health and climate change: policy responses to protect public health. Lancet. 2015;10006:1861-1914. doi:10.1016/S0140-6736(15)60854-62

Q: How are you involved in COVID-19 vaccination and testing in Chicago ?
A: On March 14^th 2020, the first patient to test positive for COVID at a long term care facility in Illinois was diagnosed. That night, the Illinois Department of Public Health reached out to Rush to help with testing, and I led a team the following day, a Sunday, that tested all 200 residents and staff. Forty six tested positive. At the same time, a coalition was forming out of concern for the impact of COVID on people experiencing homelessness in Chicago. This group, called the Chicago Homelessness and Health Response Group for Equity (CHHRGE), grew to over 40 organizations that met seven days a week developing systems to try to mitigate the effects of COVID. As the first few people in shelters started testing positive, I worked with CHHRGE members at the Chicago Department of Public Health and University of Illinois Health to pull together an emergency response testing team. The first shelter we tested had over 350 people and 43% tested positive for COVID. From that day forward, we have supported congregate settings full-time throughout the pandemic with testing, infection control support, education, and vaccination. Given that people experiencing homelessness are disproportionately Black, we see our work in congregate settings as part of the fight to reduce COVID racial disparities. Over time the team evolved from a volunteer-based team to a full time interprofessional team with College of Nursing faculty, community health workers, interprofessional students, residents, and attendings.

We partnered with the Chicago Department of Public Health again to do community testing in partnership with a FQHC, Esperanza Health Centers. Our goal has been to not just test, but also connect people to care and provide education about COVID. Most recently, this includes education about how to access treatment for COVID. In addition to on-site testing, we also have mail-in PCR testing so that anyone in Chicago can have easy access to PCR testing without having to travel anywhere.

With the Department of Preventive Medicine, we launched research studies about community testing and vaccination in partnership with the Alive Faith Network. This includes evaluating the effectiveness of on-site PCR testing in churches, distribution of at home tests by community members, and vaccination in churches. This work is funded by the NIH and Walder foundation.

We also have a community vaccination team that partners with local community based organizations on the West Side of Chicago to provide weekly vaccination events at the CBO sites.

Through all of this work, we have done over 76,000 COVID PCR tests and over 10,000 vaccinations in community based settings.

Q: You described your work as a “hyper-local approach” to vaccination and testing. Can you explain what this means?
A: This means we go to where people are. We remove barriers like transportation, IDs, insurance, English proficiency, requirements for online registration. We partner with community organizations and follow their lead. This philosophy is captured in my favorite video of our teams, which is an interview with church leadership about vaccination in which you can barely see our team in the background.

Q: You also lead Rush@Home. What is this program and why does it focus on Chicago’s West Side?
A: There is a 16-year life expectancy gap between the West Side and downtown Chicago. The top two causes of death on the West Side are cardiovascular diseases and cancer and the root cause of this life expectancy gap is systemic racism. Rush@Home is one of Rush’s community programs, which collectively have a goal of reducing the life expectancy gap. Rush@Home provides home based primary care for people whose chronic medical conditions have made it difficult for them to leave their homes. We are part of the health equity mission by providing the most comprehensive care to the people who need it the most. Given the low life expectancy on the West Side, our patients are sometimes in their 40s and 50s, yet have severe chronic diseases. We focus on what matters most to our patients, and our interprofessional team takes a holistic approach to help them meet their goals. Our patients have lower hospitalizations, ED visits, and costs compared to a control group.

Q: Last March, CNN ran a story on your home vaccination program. How many at-home vaccinations have been provided through your Rush@Home program, and how have your vaccination efforts changed in the last year in terms of scaling, and the Delta and now Omicron variant?
A: We were one of the first programs to do in home vaccinations and have completed over 200 home vaccinations. The City of Chicago scaled up its home vaccination program in the spring of 2021, which reduced the need for us to vaccinate people outside of our Rush@Home program. With the Omicron surge, demand for the City’s program also surged, so we did our own booster campaign with Rush@Home patients to make sure everyone got boosted quickly.

Q: How can SGIM members support your programs?
A: I would love to partner with others so that we can all learn from each other. You can contact me directly through GIM Connect!

Q: You’re an HIV primary care clinician, and your research also focuses on HIV treatment and prevention in the U.S. and sub-Saharan Africa. Why did you choose to focus your career on this issue?
A: I first became interested in HIV treatment and prevention twenty years ago as a Peace Corps Volunteer teaching high school science in Mozambique. Even though there has been so much progress in the field since then, many of the underlying issues driving the epidemic have not changed much. Here in the U.S., and globally, HIV disproportionately impacts communities that have less access to education, health, resources and power. Focusing on HIV, both as a clinician and investigator, allows me to think about and try to address some of the structural and individual factors contributing to these inequities

Q: What was the outcome of your research? Have you helped to implement change in HIV care practices in Sub-Saharan Africa based on your findings?
A: Together with a team of Rwandan investigators, we have been doing a number of projects in Rwanda focusing on the impact of their Treat All policy (antiretroviral therapy for all people living with HIV). The national Rwandan HIV program is extremely successful, but we’ve found that stigma, feeling overwhelmed, and structural barriers make initiating medication challenging for many patients. We're currently pilot testing a model of care that allows newly diagnosed patients to attend clinic appointments less frequently, which we think can reduce barriers without negatively impacting their health outcomes. I am also involved in similar efforts here in New York, including partnering with several community-based organizations to developing and testing telehealth-based strategies to increase access to HIV pre-exposure prophylaxis (PrEP) for Latinx immigrants at risk of HIV.

Q: Why do you feel a global health approach is necessary to medical care?
A: To me, a global health approach means maintaining a humility about our own individual approaches and cultivating an understanding of how our patients, communities and health systems are impacted by issues that transcend boundaries. We have so much to learn from how others approach their own health and need to remember that we as physicians by no means have all the answers. By having an awareness of our patients' values, beliefs and backgrounds, as well as the structural and global forces that shape their health, we will be better equipped to work with them on improving their health and partner with communities domestically and abroad to address disparities and work towards equity.

Q: You are also a member of SGIM’s Immigrant and Refugee Health Interest Group. How do you think this Interest Group can help to serve the immigrant and refugee communities?
A: Many SGIM members are working on issues related to immigrant and refugee health and immigration advocacy in their own communities and institutions. The Interest Group is a great space to bring interested folks together to share their experiences and collaborate on advocacy and research efforts.

Q: What advice would you give to fellow SGIM members who want to become more active in social justice issues, specifically around global health and immigrant care?
A: There are so many individuals in SGIM and in the larger medical community who are doing amazing work in this area, and it is easy to get involved. In addition to getting connected through the Immigrant and Refugee Health Interest Group, members can follow national organizations like Physicians for Human Rights, Doctors for America, Doctors for Camp Closure, and many others. Getting active in your own institution – by working to make the health center or hospital a more pro-immigrant space – is really important. Finally, we can use our voices as health care providers, through op-eds and petitions, to advocate for change, and this is a great way to expand your network too.

Q: You recently presented on “Combating Systemic Racism in Healthcare” at the SGIM 2021 Annual Meeting. Why did you decide to focus on this topic for your presentation, and why did you feel like SGIM was the right organization to present your research to?
A: With the death of George Floyd and the health disparities seen during COVID 19, we felt how racism affects medical care, was an important issue to discuss in the workshop presentations for the SGIM 2021 annual meeting. As our country takes a critical look at how racism affects the daily lives of Black Americans and minority groups, so too should the medical community examine the effects on health and healthcare. SGIM members are on the frontlines of healthcare and see the effects of racism on health daily. SGIM has been very vocal on these topics, and members have an invested interest in making our healthcare system equitable for all.

Q:You focused largely on implicit bias among healthcare providers. What makes it so important ?
A: You can become aware of issue of bias by educating yourself, reviewing the literature and attending workshops at SGIM! There are also online and in-person courses for the individual or larger institutions on how to be aware of and combat implicit bias. Upstander training is also available may places online or with groups that conduct in-person sessions. Implement implicit bias training to help empower learners (medical students and residents) and faculty to recognize and address bias and advocate for patients.

Q: How can scientific studies and algorithms produce misguided information in relation to race and health equity?
A: An alarming number of scientific studies used as the basis for clinical calculators have racist and pseudoscientific origins. Perhaps the most well-known example is the race modifier for estimated glomerular filtration (eGFR), but there are many others the span different medicine and surgical specialties. It is important to note that race is a social construct and should not be used as a proxy for genetic variation in medical decision making, as this can create bias and error. With regards to progress being made on eGFR, a joint task force created by the National Kidney Foundation and American Society of Nephrology has recommended against using a race modifier as of March 2021. Several major institutions had eliminated the eGFR race modifier prior to this recommendation, and we encourage others to approach their hospitals and institutions to do the same.

Q: You presented on the importance of differentiating race as a risk-factor verses a risk-marker. Can you explain this difference and how it can be important when treating patients?
A: Because of the impact of racism on our country, black and minority groups have been systematically disadvantaged in many sectors of society. It is very important that physicians do not attribute medical conditions or worsened medical outcomes as something inherent to an individual or group of people. The complete health of a person is affected only approximately 20% by actual health care, with social determinants of health having a much larger impact. There are studies to show that when members of different racial groups are placed under the same socioeconomic conditions, health disparities between the two groups largely resolve.

Q:How have you both been able to enact some of your solutions to combating implicit bias in your own practice and at your institutions?
A: In my daily interactions with students and residents, we discuss racism, how this affects the health of our patients, and strategies to move towards health equity. I hope by helping to educate doctors in training on these issues we can steer the medical profession in a more positive direction. Dr. Johnson has recently been asked by his hospital to implement a social determinants of health advocacy and policy curriculum.

Q:Why do you feel it is important as a general internist to also be conscious of, and an active participant in, causes related to social justice?
A: I think the goal of every general internist is to provide the best and most appropriate care for the patient sitting in front of them. Recognizing that outside the exam room patients have very different life experiences that affect their overall health, this is an important health equity issue. Because our country was founded with principles of racism, inequalities still exist in every aspect of our society: wealth, housing, law enforcement, workforce. General internists know the struggles of their patients very intimately and are the ideal advocate for change in healthcare and in society at large.

Q: You were a founding member of the founding member of the UCHealth Integrated Transgender Program. Can you explain what this program is and how it was started?
A: The UCHealth Integrated Transgender Program is a multi-disciplinary program primarily focused on culturally responsive, clinical care of gender diverse individuals. We began in September 2017 after several of us realized that we were independently providing care for gender diverse individuals in our own practices (Endocrinology, internal medicine, psychiatry, gynecology). We really wanted to focus on whole person care and wanted to facilitate safe clinical spaces for our patients (it is easier to train a smaller group of core staff on inclusive care than at multiple practices). In addition to providing comprehensive care to our patients (we have now expanded to include plastic surgery, urology, social work, voice therapy, and dermatology), we also have a community advisory board, a research program, and an educational arm that provides training nationally (via conferences, local programs, and a TransHealth ECHO).

Q:You are involved in multiple organizations related to LGBT health, what are these other organizations and what is their work?
A: I have primarily been working with One Colorado, which is a statewide advocacy organization. Their primary foci have been around anti-bullying in schools, equitable policies, and health. We’ve collaborated on several statewide surveys to better understand the overall health of LGBTIQ-identified Coloradans and their needs. Previously, I had also worked with The Center, which was working on creating a provider directory for the community and also running some health fairs. Those projects have been on hold for a few years due to budget issues. I also do a little bit of work with the National LGBTQIA+ Education Center—they do a lot of training with community-based clinics on LGBT health related issues.

Q: As the Director of Health Systems Science and Health Equity Education for the University of Colorado School of Medicine, how do you incorporate health equity into your curriculum planning?
A: We are working on health equity from 2 key aspects. The first is curriculum content. We will be including structural competency, which examines all the factors that influence health—from individual knowledge, behaviors, and attitudes to interpersonal relationships, and then community/structural factors such as the determinants of health, policy, the built environment, etc. We are integrating content on structural racism and bias, implicit bias, microaggressions, and strategies to mitigate/address these. In addition to what we are teaching, we are also looking at instructional materials (e.g. cases, slide decks, etc.) to do our best to remove biases/stereotypes that might exist in them AND ensure that different groups are adequately represented in curricular materials. The second aspect is examining our structures and processes. We are training all our faculty who interact with our learners on structural racism and implicit bias—in interactions, in grading, and in how they write evaluations. We are developing reporting mechanisms for both content issues that might arise, and for behaviors by individuals. We are integrating recruitment and hiring “best practices” as we hire faculty for educational roles.

Q: As a prominent faculty member at the University of Colorado, what are the other ways in which you are addressing health equity on campus?
A: We are collaborating with the other schools, programs, and centers across campus for health equity training, evaluating and creating inclusive policies, syllabi, equitable promotion criteria (women and minoritized folks have been demonstrated to have differential burden of work that is typically valued less in the promotion process—we are working to change that), creating structures and processes for each school/program/center to evaluate their own curricular materials for bias/stereotype/inclusion.

Q:Why do you feel it is important as a general internist to also be conscious of, and an active participant in, causes related to social justice?
A: Because we care about our patients and our colleagues. One of the things I love about my work is hearing my patients’ stories—their strengths, their successes, and the resilience they have in the face of adversity. And, when I hear those stories, it makes me want to advocate for the things that can improve their health and well-being. Most of those things are rooted in social justice—removing structures and barriers that impede health and well-being (e.g. racism, bias, discrimination)—building equitable access to opportunity and resources that promote their health and well-being.

Q: What is the Minnesota Immigrant Health Alliance (MIHA MN) and how did you get involved?
A: The Minnesota Immigrant Health Alliance (MIHA) is a collective of healthcare providers working for health justice for immigrants and refugees in Minnesota. Calla Brown, MD, and I formed this organization in the spring of 2019. We initially came together to respond to the growing crisis of family separation and reports of Immigration and Customs Enforcement (ICE) authorities detaining people from hospitals and clinics. We created tools and protocols for clinics and hospitals to use if ICE came to their facility and recruited many major hospital and clinic groups throughout the state to make public statements regarding the safety of immigrant patients in their facilities (i.e. sanctuary spaces).
Since then, we have been educating our community about the impacts of public charge laws and advocating for improved conditions for people held in ICE detention. Specifically, we partner with the Detainee Rights Legal Clinic at the University of Minnesota to eliminate the use of prolonged solitary confinement. Solitary confinement for more than 15 days is considered a form of torture by the United Nations and is currently not regulated in our state. Our aim is to end use of solitary confinement, especially for medically and mentally vulnerable individuals.

Q:How has the COVID pandemic uniquely impacted the immigrant population of Minnesota?
A: We have a robust immigrant population in Minnesota, with particularly large Latinx, Somali, Hmong, and Karen communities. Minnesota’s immigrant communities have been disproportionately affected by the COVID pandemic in various ways. Infection and mortality rates are higher in Black, Latinx, and Indigenous communities. Though we do not have data on immigrant communities specifically, people who identify as Latinx are 2.5 times more likely to be diagnosed with or die from COVID than white people in our state..

Q: Why are some immigrants detained by Customs Enforcement (ICE) and how does MIHA MN hope to support those currently held in the detention facility in Kandiyohi County?
A: People are detained by ICE for violating immigration rules or laws. ICE detainees are not held for committing a crime aside from lack of approved immigration documentation. In MN there are not dedicated ICE facilities. Instead, in five counties, the sheriff has a direct contract with ICE to hold ICE detainees within the county jail. Each county jail has its own plan for health care, often in the form of a contract with one of several for-profit correctional healthcare companies. There is no centralized oversight over the quality of the health care provided in MN jails or prisons and with current law, the Department of Corrections does not have the ability to intervene.
We are experiencing a devastating outbreak of COVID within our jails and prisons, with widespread illness in Kandiyohi County where many ICE detainees are held. Detainees and their lawyers have reported having limited access to medical care, inadequate monitoring of COVID symptoms, and unsafe housing practices including mixing the COVID positive and negative populations.
We are partnering with local immigration lawyers and activists to improve health conditions for people in detention. We are asking our state leadership for including incarcerated people in the next priority group for COVID vaccine. We are also asking for the creation of an independent medical oversight body for the healthcare provided in MN jails and prisons. (op-ed: https://minnesotareformer.com/2021/01/19/medical-ethics-require-improving-health-care-of-people-incarcerated-in-minnesota-prisons-and-county-jails/).

Q: How can SGIM members become involved in your organization or migrant and refugee health in general?
A: I encourage SGIM members to engage with their local immigrant advocacy community. Though ICE is a federal agency, there are many policies enacted on a local and state level that impact the quality of life of immigrants and refugees.

Q: Why do you feel it is important as a general internist to also be conscious of, and an active participant in, causes related to social justice?
A:As physicians we have a strong voice in advocating for the rights of our patients. If we ignore the conditions in which our patients live, we ignore one of the biggest contributors to their ability to live healthy lives. I think social justice advocacy is a natural extension of our role.

Q: As the co-director of the Immigrant & Refugee Health Center at Boston Medical Center, how do you advocate for immigrants and refugees both at your institution and within the health system at large?
A: We built the IRHC with the vision that your immigration history and status shouldn't affect how healthy you are. And yet, every day in my clinic, I see that the current political climate towards immigrants has dire health consequences. A large part of my day-to-day advocacy in our hospital is in building interventions that aim to reduce the disparities and barriers that our immigrant patients face in getting and staying healthy. For example, when we learned that many of our patients were struggling to secure affordable and trustworthy immigration legal representation, we built a program to have an immigration navigator in clinic (https://www.annfammed.org/content/17/2/177) and embedded legal clinics, to make representation more accessible for patients. On a societal level, I strongly believe in leveraging the privilege of being a healthcare provider to help advocate for state and federal policy changes that promote health equity. For example, I believe that advocacy from the medical community via press conferences and legislator meetings was part of the current administration's decision to reinstate Medical Deferred Action - an immigration status afforded to people with critical illness that protects them from deportation (https://commonwealthmagazine.org/immigration/trump-administration-ending-protected-medical-status-for-immigrants/). We have tremendous ability to push for change on the state and federal level when we show up and speak our truths in these spaces.

Q:You just published an article about what the Biden/Harris administration should do to protect immigrant rights. Can you summarize your ideas and explain what your hope is for the article?
A: Our goal in writing this piece (https://www.bmc.org/healthcity/policy-and-industry/immigrant-rights-5-executive-actions-biden-day-one) was to push for the new Biden-Harris administration to immediately demonstrate that they will stand up for immigrant rights, by using the power of Executive Orders to immediately end family separation, overturn the Muslim ban, reinstate Temporary Protected Status, welcome refugee and asylees, and stop use of the immigration wealth test (otherwise known as Public Charge). While true reform of our immigration system will take much more radical and longstanding change, these are important, and material steps the Biden administration could take immediately upon assuming power that would measurably improve matters for immigrants in the US.

Q: How has your work with refugees and immigrants been affected by the pandemic and has COVID-19 had a unique impact on these populations?
A: Coronavirus has reminded us that equity and justice needs to matter to all of us, because our interconnected community is only as strong as our most vulnerable members. We know that the COVID-19 pandemic has been especially economically devastating to our immigrant neighbors. Immigrants are more likely to be in front line essential jobs, putting themselves at immediate health risk, and are also more likely to have suffered from job losses, causing economic risk. Our team recently analyzed and published data from the CDC, which showed the disproportionate impact of COVID-19 on Hispanic groups within the US, with the most severe outcomes, including death and intensive care, among the Hispanic Black population, compared with Hispanic white and multiracial populations. (https://link.springer.com/article/10.1007/s10903-020-01111-5) We know that these disparities among racial groups aren’t biological but reflect the systemic impacts of racism and inequality that have long affected vulnerable populations.

Q: Why do you feel it’s important as a general internist to also be conscious of, and an active participant in, causes related to social justice?
A: My patients are living with the ramifications of our political decisions on their minds and bodies. If I ignore the deep and systemic effects that problems like xenophobia and racism have on all our lives, then I'm only focusing on the downstream effects that these problems have. As a primary care doctor, engaging in justice work is primary prevention for disparities, and is the only way to truly reverse the root causes of health disparities.

Q: What is your official title?
A: Assistant Professor of Medicine, Associate Program Director, and Director of the Global Health Pathway.

Q:You consider yourself a global health educator. Can you explain this role further and how it relates to social justice?
A: Global health has at its core a mission of equity in health for all people across our world. As such, my perspective is that to work in global health necessitates a social justice perspective - health equity is inextricably bound to equity of opportunity in a society.

Q: As Medical Director at an urban safety net hospital, how do you build partnerships with the population? What does it mean to be an urban safety net hospital?
A: Urban safety net hospitals to me means hospitals working with communities that are enriched with societal groups often deprived of resources, such as patients who are homeless, patients who have substance use disorders, patients who are immigrants, and patients who are Black or Latinx. As a hospitalist, my traditional focus is working within the hospital, and I think my group at BMC and the field of hospital medicine across the country are still at the early stages of working out how we can best build partnerships with our hospital's populations, bringing that community perspective back into the hospital. Invariably this work builds off the connections our colleagues in outpatient medicine have built with the communities and populations they serve, presently I am learning a lot from those GIM colleagues as to how we as an institution can partner effectively.

Q: As an educator, how do you educate your trainees to seek injustices in the medical system? And how do you encourage them to combat injustices on a systemic level within the healthcare system?
A: Health inequities come in many sizes, and one of the challenges we face with trainees is exposing them to that scope while not leaving them feeling overwhelmed or paralyzed. I like to remind trainees that there is work to be done on every level, and that our goal should be to push things forward steadily across all aspects of work. As an example, developing a process for compassionate release for end of life prisoners from prisons in Massachusetts was a health equity target of colleagues of mine several years ago - this is a big target that requires work with legislators, campaigning, and government action. In turn, as a healthcare provider, I might target one or two areas where I want to join campaigns on big topics, but likely I'll end up too diffuse and ultimately ineffective if I try to engage with three or four or five. As an example, we shifted the default time of methadone dosing in our hospital from 9am to 6am, which was a local health equity issue but one where we could have a quick impact. It was a change that just required us to listen to patients when they complained about getting medications later in the day than they are used to, and some brief meetings with health IT to shift methadone dosing to default to an earlier administration time. These smaller issues are the sort of system equity changes we can all make in our environments and should be looking for constantly.

Put another way, outrage at injustice is a fuel for change, but the engine for change is thorough knowledge of the injustice, the systems it appears in, and the people who have power over those systems. We need to be targeted and strategic to push forward agendas for change, otherwise we can end up in ineffectual social media activism that satisfies our egos but does not change our systems.

Q: Why do you feel it’s important as a general internist to also be conscious of, and an active participant in, causes related to social justice?
A: As general internists, we play an important role in the coordination of our patients' care - we and our colleagues in family medicine are the primary care providers or hospitalists who help our patient navigate their diagnostic and therapeutic processes. We already advocate for our patients to get the medical care they need, and help bridge the input of our medical system - scans, specialists - to the circumstances of our patient, to help our patients figure out what the best path is for them. As such, we are uniquely positioned among our MD, DO, PA, and NP colleagues across specialties to see the impact of the healthcare system and society as a whole on our patients. Inequity sometimes manifests via a single organ system, but more typically impacts the whole patient, and needs a whole patient perspective to be even partially appreciated. Seeing the impact that societal inequities have on the health of our patients should motivate us to join efforts to change them, and to help others across society realize that for many patients illness often stems not from poor personal choices, but from systematic deprivation of opportunities that those in more fortunate circumstances take for granted.

Q: You were recently named a Health Equity Scholar at the Center for Health Equity Education & Advocacy out of Cambridge Health Alliance. What is this program and what is your main focus as a scholar?
A: I was thrilled to be selected as one of 40 Health Equity Scholars from diverse professional, geographic, and personal backgrounds across the United States for this new program. This program is tailored towards busy healthcare professionals who have an interest in promoting health equity using the tools of education, community organizing, and peer support networks. Over the course of about nine months, we “meet” through Zoom, where a talented group of faculty members have designed a curriculum that addresses the structural and social determinants of health, the impact of systemic racism, and the art of advocacy. I will be applying the knowledge and skills from this curriculum to my scholar project, which focuses on harnessing the existing energy and networks at CHA to advance toward a more anti-racist future at our institution. While I am proud to work at an institution that promotes inclusive and comprehensive patient care, CHA is not immune to the historically racist tendencies of medical and academic institutions. For example, persons of color continue to be underrepresented in CHA’s clinician workforce, and even more so in leadership positions. This further exacerbates existing health disparities that exist in our patient communities.

Q: You are also a member of CHA’s Social Justice Coalition. What work are you involved in with that community?
A: I have been a member of the SJC since its inception in 2016, when it was started by a small group of resident trainees. Since then, SJC has grown into a 400+ member (and counting!) community of like-minded members at CHA and surrounding institutions/organizations who believe that our work in healthcare is intrinsically linked to the systems, institutions, and environment that we coexist in. Because our membership is truly interdisciplinary and interdepartmental (including but not limited to clinicians and trainees, department chiefs, medical interpreters, and social workers), SJC has broken down some of the hierarchies and siloes in which we work and operate in. In this way, we are more able to share resources, exchange ideas, and collaborate on projects. Using this wonderful network, I am able to focus on the three main goals of my Health Equity Scholars project. Firstly, to gain an understanding of the existing but often disjointed efforts of the various groups at CHA that are focusing on diversity and minority affairs. Secondly, to provide a safe forum for people to express their reflections, concerns, and experiences as a person of color or as an ally of people of color. Thirdly, to be able to identify concrete anti-racist action steps for CHA to take.

Q: Why do you feel it’s important as a general internist to also be conscious of, and an active participant in, causes related to social justice?
A: Over the last eleven years of my medical career, including medical school training, it has become more and more obvious to me that social justice causes and advocacy are an inherent part of being a general internist and not just an extracurricular activity. Unfortunately, the COVID-19 pandemic has shown the importance of having a strong social safety net and public health institution, both of which I am fortunate to have (to some degree) as a practicing physician at CHA in the state of Massachusetts. I was forced to make the drastic switch to outpatient telemedicine in March shortly before being deployed to the COVID floors of Cambridge Hospital, where I took care of a disproportionate number of patients from black and brown communities while having to keep my used masks in brown paper bags. Now back in my usual role as a PCP, I bear witness to the long term physical, mental, and social impact of this pandemic on my patient panel while facing the very real possibility of another surge in the fall/winter. Through these intense experiences of 2020, I have realized even more the importance of using my physician voice and perspective to advocate for issues such as increased access to testing and contact tracing, expanded protections and sick leave policies for essential workers and vulnerable communities, and having a system of health insurance that is not tied to employment status or income.

Q: What advice would you give to fellow SGIM members who want to become more active in social justice issues, specifically around voter registration?
A: I hope that SGIM members, whether in the early part of training or late in their careers, realize that it is never too late to become more active in social justice issues. Everyone has a powerful story to tell, and activism always starts with sharing your story. Before you know it, you will build a community of like-minded allies inspired by these stories, which then allows you to gain strength in numbers in order to build the change you want to see. I am fortunate to have found my community at CHA, where my fellow SJC members have really played a part in moving the needle towards an even more socially oriented institution. For example, back in July, an SJC member suggested organizing a voter registration drive at CHA, and within a week a working group was formed that included physicians and members of the marketing, IT, and community health improvement departments. This group has formed a coordinated effort that has included voter registration drives at each of the main hospital campuses as well as educating patients on safe ways to vote through various forms of communication that meet infection control standards during a pandemic (thanks in part to the resources provided by groups like the VotER program). While CHA held voter-registration drives during the last general election in 2016, the level of coordination of this year’s efforts are quite unprecedented.

Q: You recently coauthored a paper titled “Trends in Internal Medicine Faculty by Sex and Race/Ethnicity, 1980-2018". What inspired this paper and what were the findings?
A: I have always been passionate about increasing diversity in the medical workforce. In medical school I was a part of the admissions committee and advocated for a more inclusive admissions process. During my internal medicine residency, I realized how important it was for underrepresented groups to not only be recruited, but also be supported and have a sense of community, and as a result I founded the diversity committee for residents. My passion for diversity and inclusion led me to continue to search for other ways to engage in the space. Along the way I had the opportunity to do an internship at the Association of American Medical colleges (AAMC). During my internship, I split time between the workforce division and the health equity partnerships and programs division. I knew that the AAMC had published other reports on workforce diversity in different specialties: Ophthalmology, Family medicine etc. I was naturally curious about my own specialty of Internal Medicine and was fortunate that my proposal for evaluating workforce diversity among Internal Medicine faculty was accepted. It was not a fast process; this paper is three years in the making. But now I feel that the article could not have come out at a better time. In the article we found that the diversity of the IM workforce has improved over time, but still does not match the diversity of the population. The discussion of the paper focuses on barriers to recruiting and retaining a diverse workforce and makes suggestions about how to ameliorate those barriers.

As we grapple with the racial disparities in COVID-19 outcomes and think about the complex chronic diseases that may have contributed to those disparities, as well as the ones that will come as a result of the SARS-CoV2 virus, the role of a diverse internal medicine workforce will be an essential part of the conversation. This is something I brought up in another recently published article, “Historical Insights on Coronavirus Disease 2019 (COVID-19), the 1918 Influenza Pandemic, and Racial Disparities: Illuminating a Path Forward” (co-authored with fellow SGIM’ers Lakshmi Krishnan and Lisa Cooper).

Q: What advice would you give to fellow SGIM members looking to increase representation and diversity at their institutions?
A: Diversity isn’t just about recruitment – it is also about retention – people need to feel seen, valued, and respected in order to stay. A good starting point is to make workforce diversity and inclusion a part of the strategic plan. This work, like the work of improving health equity, is iterative. It requires reflection, humility, listening, and a commitment to act when change is necessary and an understanding that culture change and trust building does not happen overnight.

Q: Your institution also is also taking part in a voter registration project for the upcoming election. What is the project and why did your institution feel compelled to join the initiative?
A: Johns Hopkins Hospital joined the Vot-ER initiative, started at Massachusetts General Hospital by Dr. Alister Martin. The Vot-ER program uses QR codes that can be worn alongside your work badge. Patients can use their phone camara to capture the QR codes. They will be taken through steps to register to vote and gain access to information about voting dates and locations near them.

At Johns Hopkins Hospital, the trainees have led this work and have really been the champions for getting this initiative off the ground. I have always felt that voting is a part of a civic responsibility and a way to engage in health advocacy. But this year when the lines between health and policy became so blurred—when the handling of the pandemic was so deeply tied to our political leaders--I felt a heightened sense of urgency to do something. There are few things that impact our patient’s health more than the actions of our elected officials and in an equitable society all citizens can have a voice in choosing those officials. I learned that new voter registrations in Maryland, Virginia, Delaware, and the District of Columbia are all down more than 50% compared to 2016. This project felt like an important way to do something. It does not guarantee that people will vote, but it is a necessary step for political participation. It is also a way to use our platform as physicians and leaders in the hospital, to reinforce to our patients that their voices matter.

Q: You are also part of a new podcast about antiracism in medicine. How did you become a part of this series and what is its primary goal?
A: Antiracism in Medicine is a special series from the Clinical Problem Solvers. That the founders (Rabih Geha and Reza Manesh) thought this series was important enough to be included in their popular podcast really speaks volumes. It supports the notion that antiracism is a critical clinical skill and a powerful example of allyship. I was asked to be involved in the series by the co-directors Dereck Paul and Utibe Essien. We have a fantastic team (Naomi Fields, Rohan Khazanchi, LaShyra Nolen & Chioma Onuoha) and I think all of us feel that this a unique moment in history. It is difficult to deny structural inequity during this time, and people are more aware and receptive to authentic conversations about the role of racism in health. Our mission in this series is to equip our listeners, at all levels of training, with the consciousness and tools to practice antiracism in their clinical careers.