WEBVTT
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Rueben Warren: Good morning.
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Kevin Owens: Hey this is Kevin has everything
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Kevin Owens: going on over there.
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Rueben Warren: This is Reuben Warren and i'm i'm on
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Rueben Warren: And I see you in in Nima
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Rueben Warren: When I'm in
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Okay.
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Kevin Owens: Sounds good.
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Kevin Owens: I'm waiting for Captain Wilkinson.
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Rueben Warren: Seconds. Yes. Okay, great. We appreciate you, man.
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Alana Knudson: Doing well. Thank you. How are you
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Alana Knudson: And you are echo with
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Nma Ohiaeri: Me. Yeah, we're trying to bring out
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Alana Knudson: Is it a problem on my end.
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00:13:05.670 --> 00:13:06.630 Nma Ohiaeri: I got the audio.
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Rueben Warren: This is Reuben, Warren.
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Rueben Warren: Is my echoing. Am I coming
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Alana Knudson: You're clear Ruben
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Rueben Warren: Okay, how are you
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Alana Knudson: I'm doing well, how are you
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Rueben Warren: doing quite well like
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Alana Knudson: Happy Friday.
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Rueben Warren: Absolutely. Absolutely. Thank you for joining us.
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Alana Knudson: Oh, I'm delighted. Thank you for inviting me.
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Craig Wilkins: Yeah.
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Leandris Liburd: Good afternoon. This is dangerous, doing a sound check. Can you all hear me.
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Rueben Warren: Yes I can, through going one way. Thank you.
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Craig Wilkins: Hello everyone. Can you hear me.
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Alana Knudson: Yes, but you are echoing
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00:24:07.050 --> 00:24:12.390 Craig Wilkins: Okay, we're still working on the audio. So we'll start in just a few minutes. Thank you all for joining us today.
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Craig Wilkins: Good afternoon, everyone.
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Craig Wilkins: And greetings from Atlanta, Georgia.
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Craig Wilkins: We want to welcome you to our 2020 public health ethics form ethical dilemmas and rural health
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Craig Wilkins: Co sponsored by the Office of Minority Health and Health Equity and the National Center for bio ethics and research and healthcare at Tuskegee University in Alabama. I'm Craig welcome senior advisor within the office and I'll be serving as your master ceremonies.
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Craig Wilkins: As distinct honor to welcome each of our special guests. Our speakers and each of you for joining us today via zoom
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Craig Wilkins: I had the pleasure of being part of a small
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00:31:01.290 --> 00:31:11.790 Craig Wilkins: I had the pleasure of being part of a small planning committee that put this form together. My sincere appreciation and gratitude is extended
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Craig Wilkins: To them for all their heart efforts into planning of this year's event.
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Craig Wilkins: Their names are noted here. As you see, I don't have time to mention everyone's name. But again, we wouldn't be here today without all of their planning for this year's form. So, again, on behalf of this committee and our office at Tuskegee University. We appreciate your attendance and participation.
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Craig Wilkins: Today form before today's forum and with a couple of housekeeping updates on we know today is a very special day. And we want to pay homage on this special day of 911 and we'd like to have a few seconds of silence.
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Craig Wilkins: Thank you.
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Craig Wilkins: For those of you who want to send in questions for today's forum during the question and answer portions, please send those questions for our speakers via the zoom to amp a box.
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Craig Wilkins: If you're having any technical support related questions via the zoom via the zoom placing those also to the Q AMP a box or you can also email Kevin Owens, as noted at in 06 at cdc.gov
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Craig Wilkins: We also will have a form evaluation.
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Craig Wilkins: After the form the evaluation will be displayed when you exit the zoom webinar and I'll be half the planet committed. We really value your feedback.
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Craig Wilkins: To help us plan for future forums and your responses will be completely anonymous
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Craig Wilkins: We have a continuing education disclosure statement that I will not read, but we are asked
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Craig Wilkins: To share with you as part of architecture and education, our requirements.
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Craig Wilkins: You a note to receive continuing education. The instructions are will be available at this link. As noted the activity code for those who wants this event live stream you a note also the access code.
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Craig Wilkins: Also the activity code for those who watch the archive event recording on no ethics code will be needed.
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Craig Wilkins: And there will be no fees for CDC continuing education activities.
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Craig Wilkins: Now, it gives me a great honor and privilege to introduce our opening for opening welcome and opening remarks.
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Craig Wilkins: We first we have Dr. The antivirus live bird.
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Craig Wilkins: Talk a little bird currently serves as the associate director for minority health and health equity for CDC at SDR
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Craig Wilkins: In this capacity. She leaves and supports a wide range of critical function in the agencies work in minority health and health equity.
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Craig Wilkins: Women's Health and diversity and inclusion management. She also plays a critical leadership role in determining the agency's vision for health equity.
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Craig Wilkins: Ensuring a rigorous and evidence based approach to the practice of health equity and promoting it ethical practice of public health and vulnerable population.
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Craig Wilkins: Doing the
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Craig Wilkins: Pandemic and Casey's response. Dr. Live bird has been part of that response and serving as chief health equity officer.
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Craig Wilkins: Were in this role she has been working to advance health equity as a priority across the entire covert 19 response and lead a team responsible for developing a data driven strategy that will address all to persistence health disparities.
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Craig Wilkins: Our second presenter for opening remarks will be Dr. And circuit Dr circuit currently serves as the principal deputy director of CDC. She has been citizens Principal Deputy Director since September 2015
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Craig Wilkins: She served as acting CDC director from January through July 2017 in February, March 2018
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Craig Wilkins: She also served as director of CDC National Center for immigration and respiratory diseases from 2006 and 2015 and chief of the respiratory disease branch from 1998 to 2005 she first came on board and CDC as a he is officer.
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Craig Wilkins: After completing 30 years of service at
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Craig Wilkins: Dr circuit retired from the Commission core of the United States Postal Service with the rank of her Admiral
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Craig Wilkins: And our third speaker this morning. I'm sorry, this afternoon to provide welcome and opening remarks is Dr. Reuben morn
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Craig Wilkins: Dr. Reuben morn has a faculty appointment as a professor of by bioethics with joint appointments in The Graduate, public health program College of Veterinary Medicine.
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Craig Wilkins: And the vision of philosophic the College of Arts and Sciences at Tuskegee University.
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Craig Wilkins: He also currently serves as director of the NASA was center for our ethics and research and healthcare at the ski University. He also post adjunct
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Craig Wilkins: Academic appointments, including the following as a clinical professor within the Department of Community Health preventive medicine Morehouse School of Medicine.
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Craig Wilkins: And adjunct professor at the Department of dental public health School of Dentistry adjunct professor School graduate studies and research. The Military Medical College in Nashville, Tennessee.
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Craig Wilkins: And Dr. Warren also served as our first Associate Director for minority health here at CDC so can be a great person to introduce Dr. Lambert
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Leandris Liburd: Thank you, Craig and good afternoon everyone. And I bring you greetings today from the emergency operation center.
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Leandris Liburd: Here at the Centers for Disease Control and Prevention in Atlanta, and I want to welcome you to our sixth annual public health ethics forum that we are pleased and honored to co host with Tuskegee University.
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Leandris Liburd: We are so excited about today's forum about our speakers and the participation of so many people from all across the country.
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Leandris Liburd: This year's forum would not be possible, as you've already heard without the leadership of our planning committee and if we weren't together in person.
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00:38:40.290 --> 00:38:50.640 Leandris Liburd: I would have every member of the planning committee stand and receive a big round of applause. You saw the names of the planning committee members but
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Leandris Liburd: I do want to acknowledge the dedication and the leadership of Craig Wilkens who I call Captain Wilkens Dr. David Hodge, and Dr. Reuben, Warren.
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Leandris Liburd: This year we turn our attention to rural health and how we can achieve an ethical practice of public health in rural communities across the country.
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Leandris Liburd: Rural communities can represent the best of our nation in the beauty of the landscape, the social connectedness that characterizes many of these communities.
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Leandris Liburd: And the diversity of the people who live in rural and frontier areas from the standpoint of Health and Health Disparities in rural areas.
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Leandris Liburd: We are concerned about higher rates of mortality due to the leading causes of death lower insurance coverage rates higher poverty and increased age.
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Leandris Liburd: The worsening health providers shortages and the increased number of hospital closures in the era of covert 19 there is a dual disparity for people of color, living in rural and frontier areas.
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Leandris Liburd: As this audience as well knows, the population health impact of covert 19 has exposed in plain sight decades if not centuries of inequities.
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Leandris Liburd: That have systematically undermined the physical, social material and emotional health of communities, particularly some racial and ethnic minority populations and other groups.
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Leandris Liburd: Persistent health disparities, combined with historic housing patterns work circumstances and other factors have put members of some racial and ethnic minority populations at higher risk for covert 19 infection for severe illness and even death.
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Leandris Liburd: The covert 19 pandemic has caused a national awakening to both the root causes of health disparities and the fundamental changes that are necessary to achieve health equity.
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Leandris Liburd: While CDC and its sister federal agencies have long champion to efforts to advance health equity. There is a new focus on developing equitable recovery and resilience in communities across America.
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Leandris Liburd: Today I hope to gain new knowledge that we can use to inform the CDC covert 19 response and also specific strategies that can be deployed to improve health outcomes in rural in frontier areas.
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00:41:44.880 --> 00:41:56.910 Leandris Liburd: So thank you again to our speakers to the planning committee and to all of our participants for your presence today and let's move forward with today's agenda.
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Leandris Liburd: Thank you.
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Anne Schuchat: Well, thank you, Leandra Thank you Dr. Liberty. This is Dr. And shook it with us welcome from the CDC leadership team. I am so grateful to be part of today's
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Anne Schuchat: Session and I just want to emphasize how important a public health ethics forum is to our public health community and to us at CDC and how grateful we are for the partnership with Tuskegee University in hosting this annual Oram
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Anne Schuchat: public health ethics is always timely and perhaps never so much as today, while the entire world is facing the coven pandemic.
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Anne Schuchat: And the western coast of the United States is facing unprecedented fire forest fires, leaving many rural populations.
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Anne Schuchat: You know, requiring evacuation in the middle of the night. I think we've never perhaps been in is fragile state as we are. And as Dr. Liberty just reviewed the stakes are so high right now in rural communities around the country.
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Anne Schuchat: Scarcity or disproportionate resources as a theme throughout ethics and the pandemic highlights
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Anne Schuchat: Whether it's the testing capacity, the contact tracing capacity, the healthcare resources needed for treating urgent and severe illnesses or the future vaccines that we hope will become available.
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Anne Schuchat: We know that they're vulnerable communities around the country and that was living in rural areas have particular challenges.
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Anne Schuchat: The
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Anne Schuchat: ability for us to be connecting today through this zoom platform is
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Anne Schuchat: Precious something we wouldn't have been able to do 10 or 20 years ago and something that we hope.
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00:44:08.880 --> 00:44:18.480 Anne Schuchat: Will be available to rural populations and caregivers throughout the nation, but it's not year, yet there. And I know that many of our speakers today.
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Anne Schuchat: Are working in communities that don't have the same kind of communication or technology access that people have in or urban or suburban Peri urban settings so I'm looking forward to today's
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Anne Schuchat: Discussions to learning and to being able to apply at the National, state, local, and community level the the way forward for these public health ethical dilemmas that are never really as real as they are today. Thank you.
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Rueben Warren: Good morning.
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Rueben Warren: I'm ruling one and I to want to do a couple of things. First, to pause about 911
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Rueben Warren: And there's not remember but reflect and
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Rueben Warren: How to move forward collectively
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00:45:15.810 --> 00:45:33.030 Rueben Warren: Secondly, I want to highlight these what they're calling unprecedented times I would suggest their unusual times, which is a more normal ethical frame on which to you where we are, where we've been and where we're going.
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Rueben Warren: And
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Rueben Warren: The National Center for about ethics and research and health care at Tuskegee University joined in partnership
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Rueben Warren: With the Office of Minority Health and Health Disparities at CDC to really honor and recognize 100 year of the death of
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Rueben Warren: President Booker T. Washington, the first president of Tuskegee University. We did that to help the nation, understand that the whole issues around Minority Health install it in
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Rueben Warren: It started in
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Rueben Warren: 2020 note is started in 1915 with Booker T. Washington founded Negro Health Week. He recognized disproportionate burden of health disparities with now impacting on African Americans in particular.
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Craig Wilkins: Oh,
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Craig Wilkins: Reuben one. Are you still there, sir.
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Okay.
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Craig Wilkins: I think we lost
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Craig Wilkins: I think we lost. Dr. Warren and we apologize about that and hopefully he he can get back on. Um, I will give it a just a second. And if he's not able to then we will continue on with the form
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Craig Wilkins: Okay, hopefully he'll be able to join us here in a few minutes. So I want to thank Dr. Byrd again and and Dr.
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Craig Wilkins: Dr circuit for their opening remarks, so like to introduce our first presenter for this year the form
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Craig Wilkins: Is Dr. Alona condition daughter canoes and currently serves as a program area director and as the director of the walls Center for Rural Health analysis at North
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Craig Wilkins: Dakota condition has 20 years of experience leading health services and health policy research projects and implementing and evaluating the impact of public health programs.
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Craig Wilkins: She has conducted numerous health services and health policy studies and public health projects funded by the Agency for Healthcare Research and Quality, the CDC and the CDC and as soon as for Medicare and Medicaid Services.
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Craig Wilkins: Also includes the US A the US Agency for International Development and the Robert Wood Johnson Foundation her project findings have informed, state, tribal, and federal health policy. Please join me in welcoming Dr Knutson
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Alana Knudson: Thank you so much.
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Alana Knudson: Thank you. I'm absolutely delighted to be with you today as a person who grew up in a frontier County. I grew up in a county that had three people per square mile
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00:49:47.580 --> 00:49:58.770 Alana Knudson: So rural public health has been my passion from day one and I'm delighted to have this opportunity to share some insights with you and hopefully get some questions that can
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Alana Knudson: Be answered throughout my presentation at the end as well as later in the day to help advance your work in addressing rural health equity.
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Alana Knudson: I am the director of the wall Center for Rural Health analysis and we are soon to be celebrating our 25th anniversary
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Alana Knudson: On the wall center was brought to north in 2003 and by the way north is also a long history of Rural Health Research. Our first study was conducted 68 years ago so Rural Health has also been an important component of the work that we do.
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Alana Knudson: In looking at how to advance health and wellbeing in rural America as mentioned, we do a number of projects for federal agencies and foundations, as well as serving as one of the seven Rural Health Research Centers.
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Alana Knudson: Funded by the Federal Office of real health policy our center is housed at Northwestern University of Chicago. And we're a nonprofit research organization and we conduct research and evaluation that serves the public interest and improves the opportunities to make informed decisions.
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Alana Knudson: So with that, I just wanted to start with an overall discussion about what is we're all
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Alana Knudson: We're all means different things to different people. And I just want to remind you that every single day. You are touched by room America you eat food.
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Alana Knudson: You use energy you are in a building that often has some kind of materials that are
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Alana Knudson: Manufactured or produced in rural communities. And I think it's really important to think about rural as part of that interdependence that we have between rural and urban we have
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Alana Knudson: More success in our overall country when we have success in our rural communities. And when we have success in our urban communities and that success starts with helping populations.
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Alana Knudson: To provide a little bit of background on rural. There are many definitions of rural. In fact, it's a federal government has over 70 definitions and the four definitions that I have included on this slide are the most common definitions that you see.
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Alana Knudson: That are provided by the US Census Bureau by the Office of Management Budget by CDC National Center for Health Statistics and by the United States Department of Agriculture's Economic Research Service.
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Alana Knudson: These definitions are built on different types of geographic units, which then comprise a different percentage of the population or categorize a different percent of the population as being world and the most comprehensive
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Alana Knudson: World Population is the definition that is used by the US Census Bureau and that captures almost one out of every five Americans almost 20% are categorized and rural living in rural communities.
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Alana Knudson: The other populations that are included in world under OMB NCAA chess and USDA capture somewhere between 15 and 16% of the population.
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Alana Knudson: And these definitions are built on different types of geographic units. They can be zip codes. They can be counties and they can be census tracts. So when you're looking at one definition, you really need to know what underlies that
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Alana Knudson: Geographic unit to be able to make comparisons across time and across different populations.
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Alana Knudson: This particular slide shows OMB. And again, that is the definition that's most comprehensive and as you can see the orange. The orange darkens
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00:54:11.790 --> 00:54:19.770 Alana Knudson: Counties represent natural and the gray represent non metro and for those of us that has spent our careers working in world.
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Alana Knudson: We would much rather see natural versus rural then metro versus non natural
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Alana Knudson: But what this does depict is where we have concentrations of urban areas and as you can see the gray is most prominent in the Great Plains and in the West. However, there are still a number of rural areas that are interspersed in some of our most densely populated areas in the country.
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Alana Knudson: We also have differences with regard to the distribution of race and ethnicity in rural America.
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Alana Knudson: Race racial and ethnic minorities comprise about 22% of the rural population as compared to about 42% of the metro areas and the largest represented populations are lack in Hispanic
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Alana Knudson: There are also American Indian populations and Alaska Native as well as other population groups that represent a somewhat smaller demographic
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Alana Knudson: As was mentioned in the introduction to this forum.
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Alana Knudson: World, America has some health disparities and we have been working on these however
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Alana Knudson: Rural Americans continue to be at greater risk of death for the five leading causes of death.
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Alana Knudson: So no matter what you look out with regard to rural health outcomes, particularly in mortality, you will see higher mortality rates for rural residents than you see for urban and there are a number of contributing factors.
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Alana Knudson: CDC produced this information to share that only one in four adults practice at least four of the five health related behaviors that we know
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Alana Knudson: Will improve health outcomes and smoking and tobacco use has been a long standing challenge in many of our rural communities.
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Alana Knudson: Likewise, we have much higher BM eyes in our rural communities. And there are also some areas in rural America that have very high rates of binge drinking. In addition to not getting enough sleep.
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Alana Knudson: For a lot of rural communities. There's a lot of anxiety and a lot of challenge with regard to the economics that people are experiencing, particularly during these unusual times
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Alana Knudson: If we look at some of the underlying issues that contribute to those health disparities.
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Alana Knudson: On we always rely on our social determinants of health and this is particularly important when we look at our rural communities.
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Alana Knudson: By far economic stability is part and parcel to some of the health disparities that we see. And that also create barriers for us to be able to achieve health equity in rural communities.
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Alana Knudson: I'll share some additional information with regard to poverty, employment and unemployment in some subsequent slides.
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Alana Knudson: Row residence also do not achieve as high of educational attainment as their urban counterparts. And then this also contributes to long term earning capacity.
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Alana Knudson: Likewise, there is a difference in social and community contacts in terms of cohesion perceptions and discrimination and f we are
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Alana Knudson: Public health is not as prevalent in many of our rural communities and there is also less access to health care primary care and specialty care.
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Alana Knudson: There's also a number of areas that have no access to behavioral health and very limited access that best to oral health. So there are a number of challenges in accessing
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Alana Knudson: The health supports that also contribute to the overall health and well being. Lastly, there are some interesting challenges with regard to neighborhood and built environments.
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Alana Knudson: In including access to healthy foods. And in fact, as a person who grew up in a rural community. I had never been to a farmers market until I moved to a metropolitan area.
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Alana Knudson: And so even the concept of farmers markets has not been as prevalent in rural communities as it has been in urban likewise, there's also a challenge in many rural communities of quality of housing and affordable housing, even including in some of our research affordable.
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Alana Knudson: Utilities that can also be cost prohibitive. There's also a number of environmental concerns and I have been to world communities.
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Alana Knudson: In particular, a tribal community in my past or there have been some challenges, even in getting drinking water. When you turn on the faucet. The water is brown so we still have some way to go in even improving some of the drinking water that is available in our rural communities.
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Alana Knudson: But by far one of the most challenging issues that we've had in rural communities is access to employment and livable wages and as you can see from this particular slide.
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Alana Knudson: When we had that great recession from 2007 to 2009. This slide shows that we rural and urban we're pretty much on par with regard to where we were at the beginning of that time.
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Alana Knudson: If you look at where employment was on. As you can see over time. The Metropolitan or the urban areas have recovered from that time of the Great Recession but employment in our rural areas has never recovered. And in fact,
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Alana Knudson: We have continued to see that our rural areas have experienced higher unemployment rates than our urban areas consistently since 2007. The only difference was with
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Alana Knudson: This last coven 19 experience where we see our urban areas, having higher percentage of unemployment than our rural, but this is definitely an anomaly in the unemployment among rural and urban
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Alana Knudson: This also contributes to poverty and as you can see the blue represents rural and the yellow orange represents metropolitan or urban
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Alana Knudson: And there was a great disparity obviously in the late 50s between rural and urban but the challenges, even though we have seen improvements in decreases in the percent of people living in poverty.
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Alana Knudson: Rural has never been able to achieve the lower rates of poverty that we see in urban areas. So again, we continue to see that there is long standing differences in poverty between rural and urban
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Alana Knudson: This issue of poverty is further exacerbated when we look at areas that have had persistent poverty and these are areas that have had poverty for over 40 years. And if you look at the darkest red
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Alana Knudson: Counties. Those represent rural and you can see across the country. We also have dual disparities, although we have
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Alana Knudson: Poverty in Appalachia. As you can see in central Appalachia. You can see that the poverty in our southern states.
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01:02:42.120 --> 01:02:52.650 Alana Knudson: remains high and those are the counties that have the highest proportion of black residents living in rural in the rural South
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Alana Knudson: Likewise, if you look along the border in Texas and Arizona those counties also have the highest proportion of Hispanic residents living there.
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Alana Knudson: Likewise, when you move to the West and the northern plains those areas that are dark is our where American Indian Reservations are located.
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Alana Knudson: Likewise in Alaska, where Alaskan Native slip. So there is a great dual disparity. When you look at to where people of color with and when you overlay it with those rural communities where they reside.
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Alana Knudson: So that brings us then to health equity. Why, what are we talking about when we're talking about health equity.
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Alana Knudson: And I draw from our colleagues at the Robert Wood Johnson Foundation in sharing this definition. Everyone has a fair and just opportunity to be as healthy as possible.
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Alana Knudson: And in order to do so, we need to remove economic and social obstacles to health, particularly poverty and discrimination.
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Alana Knudson: And when we talk about health equity. What we also talk about is reducing and eliminating health disparities and sometimes the to get intermix but really health disparities serve as the metric
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Alana Knudson: for assessing our progress toward health equity and as I shared in my previous slides. You can see that we still have a long way to go to achieve health equity in our rural communities.
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Alana Knudson: I wanted to share with you some ethical considerations to achieving rural health equity that may be new to you and it may resonate with some of you who already practice in our rural communities.
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Alana Knudson: First of all, it's the value of place place is very important place to provide context of where you live, it is an issue of great pride for many
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Alana Knudson: Rural areas there are some very rich history and in some places. There's some very painful history. In some areas, we have
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Alana Knudson: families that have lived there for generations, and in other places. We have people who are just now moving there because Kobe has opened up the opportunity to work remotely.
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01:05:23.640 --> 01:05:39.870 Alana Knudson: And we are hearing more about rural communities welcoming people from urban areas who are looking for a different way of life during this coven and post hopefully post Kobe time
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Alana Knudson: We also have a value of community and community can mean so many different things on, you know, often we say you've been to one rural community. You have seen one rural community.
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Alana Knudson: And I think what's also important to understand is that there are networks within all communities. We have networks of churches. We have networks of senior citizens centers, for example.
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Alana Knudson: We have sport boosters in rural communities. We have civic organizations. We have other community organizations that are connecting. So you have all of these different networks.
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Alana Knudson: That contribute to the vibrancy of our rural communities, but that also contributes to many dual relationships and
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Alana Knudson: In doing so, that means that for those of us who work in public health. There's often a lot of overlap between our personal and our professional connections and that can create some challenges.
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Alana Knudson: There, there can be some ethical issues arising because a relationship with a stranger is very different than a relationship with somebody that you see in your workplace as in public health.
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Alana Knudson: Versus that person that you may see in the grocery store that you may see at your children's sporting events and then you may go to church with on Sunday.
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Alana Knudson: So there's a different sense of connectedness and sometimes it can be ethically challenging when you have information, particularly recognizing that stigma.
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Alana Knudson: Can still be a barrier to people getting the support that they need, in particular for substance use disorders as well as domestic violence.
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Alana Knudson: Those types of issues are sometimes very difficult to navigate in rural communities because there is the sense that people know your business.
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Alana Knudson: And when I used to work at the North Dakota, Department of Health. The number one question that was never answered in our Behavioral Risk Factor Surveillance System.
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Alana Knudson: Survey was a question on finances. So even that issue about finances can be seen as something very personal and it contributes to some of that.
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Alana Knudson: It also affects organizational level decision making as well as state and national level decision making.
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Alana Knudson: And one of the areas that I think that has been most challenging looking at rural public health.
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Alana Knudson: Is the allocation of resources. And this is something that we are always challenged with because oftentimes if we have a public health intervention, we want to reach as many people as possible.
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Alana Knudson: However, if we are really going to advance health equity we may need to reach to a smaller sub population that may have fewer people but have greater needs and sometimes it is difficult.
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Alana Knudson: To advocate for using those resources to reach smaller populations with policymakers or other decision makers, when the, the pressure or the accountability for that funding is to reach as many people as possible. So there's sometimes challenges in that arena as well.
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Alana Knudson: Um, and so when you're thinking about the ethics that really underlie what you're doing. I would really encourage you to think of a values approach because values are really central to what is framed as ethics.
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Alana Knudson: And really coming together and identifying what is the value of the community can also help provide some really important guiding principles.
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Alana Knudson: And frankly, there aren't that many rural emphasis out there, particularly rural public health emphasis
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Alana Knudson: And so I think this is also an opportunity through this forum to bring together people who are interested in this area and perhaps create a network of public health colleagues who can come together and talk about these very unique and very important issues that really have
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Alana Knudson: Consequences for the health and well being of rural communities and ultimately the opportunity for us to achieve real rural health equity.
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Alana Knudson: And in doing so, it is also very important to think about that real context, because again,
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Alana Knudson: Plugging in playing rural and urban does not work. We have seen that in many, many examples in the past, trying to transplant, a program that will work well in a resource rich urban environment does not necessarily work well in in
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Alana Knudson: In a rural environment. So I'm going to share a visual that we developed as part of a Robert Wood Johnson Foundation project.
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Alana Knudson: In which we look at the strengths and assets of rural communities. And I think, again, that is another really important
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Alana Knudson: Perspective, when you're thinking about achieving health equity, look at the different types of strengths and assets that come together.
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Alana Knudson: That create our world communities and our networks within rural communities because they're very important to the
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Alana Knudson: vitality of that community. And it also helps to bring people around a table to look at what is working well for any of you who have ever sat on the other side of the table and I have done that.
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Alana Knudson: It's really a challenge to have someone come and tell you all the things that are bad in your community.
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Alana Knudson: But when you can come around the table and say, look at all the positive things that we have going for us.
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Alana Knudson: And look at where we want to get to, to be able to achieve even more for our community members, having a context and having a way to talk about strengths and assets is a value add that
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Alana Knudson: Not only can improve health, but it can improve the entire community in terms of looking at economic development in improving education, improving health and safety, all these different areas can greatly benefit from looking at strengths and assets.
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Alana Knudson: One of the things that I think public health has a very unique and important role in doing and contributing to their real community is serving as a convener
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Alana Knudson: I cannot tell you how many times I have interviewed different types of successful networks Coalition's organizations that have said public health was really the catalyst that brought us all together.
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Alana Knudson: And if we are really going to be ethical in our work and advancing real health equity, we need to bring all stakeholders to the table.
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Alana Knudson: And that also include some of our communities that are marginalized and some residents that don't always have a voice and sometimes that means that we're going to have to nurture and grow and
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Alana Knudson: build trust relationships so that those community members can feel that they have a voice and that they are part of the decision making that goes into identifying
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Alana Knudson: How to address health disparities and how to look at improving on social determinants of health and ultimately how to achieve health access
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Alana Knudson: Health Equity
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Alana Knudson: And so whenever we talk in rural communities and I know the Surgeon General has had a
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Alana Knudson: Real focus on looking at how that link between health and wealth can improve health outcomes, not only at the individual and family level but at the community and at the state and national level.
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Alana Knudson: It's in it's important and foundational to improve the economic well being of people to be able to improve their overall health and to achieve health equity.
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Alana Knudson: And so I want to make sure that you have some tools that you can draw upon, especially if you are new to working in rural communities or if you have some interest in starting to address some social determinants to address health disparities to further your achievement of health equity.
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Alana Knudson: In partnership with the Rural Health Information home which is funded by the Federal Office of Mental Health Policy.
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Alana Knudson: Our north wall center in partnership, also with the University of Minnesota is real Health Research Center have developed over two dozen toolkits
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Alana Knudson: That address different issues that affect the health and well being a rural communities and all of these toolkits are developed in a modular format so that no matter where you are.
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Alana Knudson: Either at the very beginning and identifying an issue that you want to further pursue for addressing health and well being.
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Alana Knudson: Or if you are already in play and you want information on how you can evaluate a program that is part of your community. At this time there are different ways that you can just plug right into these toolkits to be able to get additional information.
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Alana Knudson: One of the things that we include in each of these toolkits our program models and these are models that have been tried, tested and successful
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Alana Knudson: In rural communities. And again, this is not about plugging in playing a role model.
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Alana Knudson: And trying to retrofit it into an urban area. It is really about looking at what is successful given rural contacts given girl resources.
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Alana Knudson: And also given real values. And we also have a program clearing house that has specific programs.
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Alana Knudson: That are successful with not only the overview of those programs, but also a contact, because we know world. People like to talk to other real people.
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Alana Knudson: So provides an opportunity to talk directly to that program implemented as well as finding out information, information pertaining to implementation.
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Alana Knudson: Evaluation evaluations sustainability and how to share the great good work that you're doing. There are also some really important considerations.
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Alana Knudson: For example, on how to create networks and Coalition's and you know how to engage your rural community in the particular issue that you are trying to address.
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Alana Knudson: In addition to the social determinants of health toolkit. We have a number of other toolkits that may be particularly helpful in addressing social determinants of health.
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Alana Knudson: I have never been to a meeting in a rural community where transportation was an identified as either the first or second challenge.
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Alana Knudson: That a real community has in being able to access health and other services and support health in wealthy, and again, all of these toolkits
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Alana Knudson: Are available on the Rural Health Information hub. The website is rural health info.org and this particular Hub has also access to information specialist
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Alana Knudson: Which you can contact by phone or by email, and usually within 24 hours, you will receive a response. So if you are interested in a specific topic.
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Alana Knudson: Or if you are interested in finding information about how to fund something or where there might be a program that you are interested in implementing and you can contact the Resource and Referral Center, and they will make that
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Alana Knudson: Provide that connection for you and please know all the services are free. Again, it is sponsored by the federal office of rural health policy, which is located in the health services and resources administration and
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Alana Knudson: They also work very closely with
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Alana Knudson: All of your colleagues at CDC and if you have information that you would like to share. There's also a section to share successes.
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Alana Knudson: So we are always looking for ways to help disseminate the incredible work and innovation that is occurring in our rural communities. So with that, if you have any questions, I'd be happy to take them. Now, or if you think of them at a later time, please contact me.
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Craig Wilkins: Okay, thank you so much darker conditions for that very informative presentation. We do have a time for just a few questions that have came in through the Q AMP a box.
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Alana Knudson: How about I just read
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Alana Knudson: How about I just read some questions. Would that be helpful. I can just take some questions from the Q AMP a
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Alana Knudson: I'm one of the questions is what to cope it rates look like in rural communities and is the coded mortality rate higher in rural communities. Well unfortunately my home state of North Dakota has the highest
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Alana Knudson: Rate at this point.
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Alana Knudson: Some of our rural communities have had
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Alana Knudson: A coded
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Alana Knudson: rates that are high mortality is
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Alana Knudson: No, similar to across the country. It is
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Alana Knudson: It is some way
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Alana Knudson: Higher for those with multiple chronic conditions or in nursing homes.
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Alana Knudson: That are challenged with health issues, but we're always not immune to cold it and we have seen some
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Alana Knudson: Some high rates of Kobe in areas where there have been large like manufacturing or production plants like important work plants or other types of value add a good culture and so
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Alana Knudson: Kobe is something to something that needs to be continually monitored in rural. I will say there are much fewer epidemiologists that are working in rural and oftentimes rural areas rely also on on the state and
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Alana Knudson: Having coverage for epidemiologists
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Alana Knudson: To help with the contact tracing and
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Alana Knudson: Follow up
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Alana Knudson: In those countries.
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Alana Knudson: There are a couple of questions. But are there any programs that are specifically addressing the persistent poverty in certain counties throughout the South Texas in the West.
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Alana Knudson: And as depicted in red and one of the slides and there are some programs that are targeted and if you recall in Appalachia.
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Alana Knudson: The Appalachian Regional Commission has had some success in reducing some of the persistent poverty counties, they have had funding to do so.
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Alana Knudson: The funding for example in the Delta region has not been robust. And so, there hasn't been quite as much investment in those counties. But clearly, there are a number of opportunities to make a difference.
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Okay.
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Craig Wilkins: Well, thank you again dr, dr conduction for all
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Craig Wilkins: Your participation in a form today and for your presentation. Okay. Right, we're going to turn it out. Now I want to reintroduce. I'm Dr. Warren
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Craig Wilkins: Warren apologize early I'm having some technical difficulties and so on. If you want, you would like for you to take a few seconds to finish your remarks and then you could go right into our panel discussion for today's
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Craig Wilkins: Age form. Thank you.
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RuebenWarren: Thank you again and and that I'm back on and we have to deal with this as we did with other kinds of adjustments.
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RuebenWarren: I won't take any more of your time in my introductory remarks, except simply to as I reflected on Dr. Newton's comments certain things came to mind. And the most important from my context is the
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RuebenWarren: rural populations moving to urban areas and that that that adjustment. You mentioned people and places. And what we found is that people bring their culture to the new place. And so in Chicago.
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01:24:36.570 --> 01:24:46.080 RuebenWarren: In Washington, DC in Los Angeles, California. They are rural populations African Americans in particular that brought that culture right to the city.
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RuebenWarren: And we have to recognize that that people bring their culture to the new place.
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RuebenWarren: And I close it out with with my my reflections on the Great Migration 1920 to the 1950s when African Americans moved from the rural south into
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RuebenWarren: The North looking for new and and different opportunities to really respond to what we now recognize clearly institutional racism.
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RuebenWarren: Let me close reminds them move on to what I think is a very exciting panel of speakers that want to talk about
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RuebenWarren: Rule health and the perspective on public of ethics and what I won't do is the labor, the time by introducing all of them have given you their backgrounds, they, they, you can read them.
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RuebenWarren: And what I want to do is follow the line as as they're listed and have them answer a couple of questions.
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RuebenWarren: And we want to at least leave some time for hopefully with some question and answers as we end this panel that we also say this panels over the years have had been exciting. Our, our first one
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RuebenWarren: Dealt with a women's health and then we moved on to talk about
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RuebenWarren: The elderly and I last and most exciting for me was the one dealing with youth and so we're really having some exciting times. Talking about the opportunities from a four pound discussion.
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RuebenWarren: So I'll start with just a calling the names of our panelists and then we'll move on to the questions actually do i do haha I hope I'm pronouncing it correctly Skylar part
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RuebenWarren: Deal Melvin Daniel Miller Maria put upsell
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RuebenWarren: Michael Michelle. I'm sorry, Mr. Brown and Andrew security. Let me start with with and we'll go down the line as I asked the questions and please give a little bit about your sales as we open up our panel.
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01:26:53.820 --> 01:27:13.980 RuebenWarren: The first question and our introductory context is what is your past and current work and public health ethics and how has that been influenced by public ethics in your work, what your past and present, and your current work and how is public of ethics influenced your work.
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RuebenWarren: Actually
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Ashley Andujar: Everyone, I hope, I hope you can hear me.
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We can
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Ashley Andujar: Yes, so I have a background in management.
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RuebenWarren: Kind of losing you
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Ashley Andujar: Is that better now.
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RuebenWarren: It's much better.
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Ashley Andujar: Some technical issues.
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RuebenWarren: Can we go describe come back to you.
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Ashley Andujar: Yes, let's try that.
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RuebenWarren: Let's try that live
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Scott Lockard: Okay. Good afternoon. My name is Scott lockard on the public health director for the Kentucky river District Health Department. I have spent 30 years in public health.
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Scott Lockard: Working primarily in rural areas of have worked in Kentucky river district and also for a time in a more macro politician area and
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Scott Lockard: Clark County, Kentucky, which is adjacent to the Lexington Fayette County urban area, but I have lived my life here in Eastern Kentucky ethics has played a big role in my practice, I am a social worker by training and so always strived and looked at the
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Scott Lockard: What we call social justice, you know, in public health, health equity we really working towards that. And now my practice in Eastern Kentucky, an area where there is great health disparities, where we have some of the poorest health outcomes forest health factors in the nation.
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Scott Lockard: One in three people live in poverty and just ethics really God's
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Scott Lockard: So much of what we do in this area just from the basics of looking at how we fund public health in the Commonwealth of Kentucky with a heavy reliance on property taxes.
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Scott Lockard: Were individuals who need public health services. The most have the least local funding due to low property values and low income to provide those services. So again, always taking a big look at ethics and how that impacts our practice every day.
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RuebenWarren: Fantastic HD, can we get you now.
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Ashley Andujar: Yes.
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01:29:54.990 --> 01:29:55.650 RuebenWarren: Fantastic.
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Ashley Andujar: Sure. What's going on with the video. But we get started. Um, so yeah. My name is Ashley, I'm to her. I am currently a health promotion communications leave at CDC in the waterborne disease prevention branch.
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Ashley Andujar: But a lot of my background has been an emergency response in emergency management communications so
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Ashley Andujar: Like during CDC. I've done you know responses with Sega with Hurricane Maria now coven and port the legal and I feel like every decision that I've made, you know, in my career, you know, ethics, has played a huge role in
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Ashley Andujar: And just making sure that I influence and that I you know that lead voice so that minority populations. And specifically, you know, for the people that information gets across to not only rural communities. But yeah, you know, pregnant women during
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Ashley Andujar: You know, during the hurricane. We had a lot of people with chronic illnesses that needed life saving information so that has been always
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Ashley Andujar: Sort of like a driver for me and during my time. You know, when I worked for FEMA I deployed to around 10 disaster areas in the States.
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Ashley Andujar: And I would always you know gravitates toward making sure that Hispanic communities, you know, again, in rural populations, had you know
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Ashley Andujar: And, you know, emergency response information that they knew how to apply for systems and all that. So I think, you know, it has always been sort of like a driving force for me personally.
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RuebenWarren: Fantastic. Let's go on to Darryl now we want to try to focus in on the public health ethics because we know perfect God infuses how's the ethical context influence what you do. And in fact, what do you do, Darrell.
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Daryl Melvin: The methylation, but now it's up to you. In Matthew hospital.
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Daryl Melvin: My name is Darrell mouth, and I'm a member of the Hopi and Navajo TRIED TO ARIZONA AND MY PEOPLE ARE from the mustard seed clan and Roadrunner clan and I'm born for the coyote past climb.
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Daryl Melvin: And what I want to share is that my life experiences that inform my work and it's the personal decisions I made
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Daryl Melvin: That I serve to serve my community, along with other rural tribal communities and that these choices include being
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Daryl Melvin: An engineer and providing safe drinking water to communities and families that didn't have any and also leading critical access hospitals and health centers as a CEO to address the health disparities and deliver healthcare services to the underserved populations.
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Daryl Melvin: The experience of those experiences really brought me to my current role and working with tribes and tribal live led organizations on different initiatives that further.
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Daryl Melvin: Native asset control and asset management and the work really includes addressing in equities experienced by indigenous people.
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Daryl Melvin: Through perpetuation of myths and stereotypes and in visibility issues and really to further work on what we now see as reclaiming needed truth.
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Daryl Melvin: And that would be include changing existing deficit narratives that surround indigenous people and promoting the sharing of strength based narratives
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01:33:31.440 --> 01:33:42.600 Daryl Melvin: And so that's the work that I do in that informs my public health lens that I used to work and to share with the panel today. So thank you.
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RuebenWarren: Fantastic that that is beginning to to open up the window of ethics. And that's exciting.
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RuebenWarren: Daniel, give us your context and within the framework of what you do.
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Daniel Miller: Sure. Thank you, Dr. Warren and first just thank you to the Tuskegee Center for Bioethics and CDC for gathering us together to talk about all of this.
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Daniel Miller: So my name is Dan Miller. I'm a practicing family physician and I'm the chief of graduate medical education and behavioral health integration for Hudson River healthcare in New York State.
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Daniel Miller: We are a large federally qualified health center. And so I think I'm here to represent the community health center movement in this discussion.
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Daniel Miller: To get some to this ethical perspective, like all federally qualified health centers, we are nonprofits governed by a board of director and
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Daniel Miller: In by law and admission more than 50% of our board or actual patients of our health center. And so, you know, we're in a somewhat unusual privilege of actually working for our patients.
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Daniel Miller: All community health centers provide primary medical care dental care behavioral health care to everyone, regardless of insurance or ability to pay. We start with this fundamental understanding that healthcare is a right and is accessible to everyone.
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Daniel Miller: Let me say that that our own health center was founded in 1975 by our four founding mothers for African American women in the city of Peekskill
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Daniel Miller: Who recognize that there was nowhere in that community for them or their families to access competent or dignified healthcare and so they did what they were told they couldn't do which was make it happen.
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Daniel Miller: We are now you know 50 odd years later 43 practices serving 200,000 people in rural and urban environments and with a particular focus on migrant and seasonal farm workers.
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Daniel Miller: Let me just say briefly, I also serve on the board of the National Association of community health centers community health centers in this country serve 30 million people, one in 12 Americans get their health care in a community health center.
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01:35:54.090 --> 01:35:59.850 Daniel Miller: Of the about two and a half to 3 million agricultural workers we serve about a million of them.
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Daniel Miller: And enclosing about ethics. Here I let's just say that we cannot talk about rural health without talking about poverty and about racism and I know we will get to that and I'm looking forward to it. Thank you.
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RuebenWarren: Thank you so much. You, you hit the money on. Right on the money. So thank you will open up the really powerful conversations as we proceed. I'm Maria
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RuebenWarren: Your context and the context so public of ethics.
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Maria Poepsel: Are good afternoon, everyone, and thank you for having me on this panel. Um, I go by Sally for short and Lance capsule.
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Maria Poepsel: I have been in healthcare for 40 to 4647 years and in spanning clinical research and my background is primarily critical care.
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Maria Poepsel: And in the last 27 years been practicing as a nurse anesthetist specializing in anesthesiology and providing services to critical access hospitals in Missouri.
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Maria Poepsel: As well as surgery centers and tertiary centers, primarily, I'm doing, you know, obvious based surgery centers and covering for critical access hospitals. My philosophy is that as a professional life. My ethics has always been to
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Maria Poepsel: A gear my efforts to be the best person possible in my work life and in
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Maria Poepsel: Rural critical access hospitals. I'm always confronted with many making ethical decisions on a daily basis, simply because we have a power over a patient's well being, which creates a mandatory need for me to be
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Maria Poepsel: Ethical and to practice Integrity, so I practice within that culture of ethics and integrity in all of my aspects of professional life, including. Personal life
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Maria Poepsel: Um, my experience in the last 27 years in critical access hospital are the challenges that I've confronted with
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Maria Poepsel: In making decisions, life and death decisions whether we should do a certain procedure, whether we should not do any of certain procedure and do we have the resources.
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01:38:12.090 --> 01:38:28.020 Maria Poepsel: For this patient to be able to do that particular service or the question also is if in fact this patients are the benefits outweigh the risk for this patient to have to undergo this procedure. So that's where I'm coming from.
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Maria Poepsel: Thank you.
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RuebenWarren: Fantastic, we're really getting down to peeling the onion and get down to some really critical questions I'm
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RuebenWarren: Michael
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Michal Rhymer-Browne: Good afternoon. It's Macau.
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Michal Rhymer-Browne: Macau brown
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Michal Rhymer-Browne: No problem. Common mistake I've been Michael for all my life. My other name. Yes, but it is a pleasure for me to be here today.
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01:38:57.420 --> 01:39:11.910 Michal Rhymer-Browne: Representing the beautiful US Virgin Islands. We are proud people here in the territory and we are US citizens in the United States umbrella territories, and I believe that
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Michal Rhymer-Browne: My position here today is to really highlights the need for us as US territories to have equitable access to public health.
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Michal Rhymer-Browne: Especially in our areas in our territories which are so far removed from the US mainland my background has been social services for about 28 years now, in the last, I would say 10 years I became involved, specifically in the area of Medicaid management and here is where the ethical
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Michal Rhymer-Browne: experiences have been many, I was reminded so much about the ethical decisions that we have to make and very coincidentally this morning about 630 I heard my WhatsApp text ring.
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Michal Rhymer-Browne: And it was a mother who asked if I remembered her and she said seven years ago, you helped to save my baby's life. And I remembered that this child who they told us with
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Michal Rhymer-Browne: And not to send him to Florida for assistance because it really he would die in a matter of a couple days.
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Michal Rhymer-Browne: Well, I believe, because of my training because of my spiritual background. I'm also a pastor that whether his life there's hope. And with our Medicaid funding limited as it was, and still is, at the time.
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Michal Rhymer-Browne: We were able to send this young this young infant to the state of Florida and today I was able to see the seven year old young man who at that point they did not even think he would survive seven days.
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Michal Rhymer-Browne: I chair that account because I believe it's ethical decisions like those that come up for an agency like ours as we administer Medicaid with some of the lowest funding that we have in the United States there continues to be
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Michal Rhymer-Browne: In equitable allocations to the territory in the area of Medicaid, which is so critical for the health care access for a low income our elderly our children are disabled.
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Michal Rhymer-Browne: And so it is a passion of mine professionally and personally to be the voice for those who are voiceless and to stand up for those who may not be able to stand up for themselves.
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Michal Rhymer-Browne: In the last year I had the opportunity to go to the US House of Representatives twice to represent the US Virgin Islands and the territories.
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Michal Rhymer-Browne: To speak up about the inequity of the treatment of territories when it comes to Medicaid and Public Health Access. So I really believe and I'm very
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Michal Rhymer-Browne: Proud to be able to sit in this seat and to be able to not only administer the Medicaid program, but look at that program as a way that we can help our citizens and we are citizens of the United States. Unfortunately, many of the practices and the
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Michal Rhymer-Browne: Federal funding is not equitable and so my time here today. I just want to be able to share some of the challenges that we face here in the United States territory, but it's not all bleak. We are pushing forward.
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Michal Rhymer-Browne: With using the funding that we have been allocated and I believe we if we get the support of our federal government will be able to do some really great things in the next five years.
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RuebenWarren: Thank thank you for sharing that.
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RuebenWarren: Really ethical decision making and how this had a very positive outcome as you saw that young child come back to tell you. Hello. Thank you so very much. And just to carry
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RuebenWarren: Yes, of what you do, what as public health ethics and how's it influenced IT YOU WHAT DID YOU DO
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01:43:25.590 --> 01:43:27.510 Andrew Zekeri: I'm Eros. The show August
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Andrew Zekeri: I don't Pennsylvania Penn State.
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Andrew Zekeri: And I have been studying the rap like belt for the past 2526 years
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Andrew Zekeri: I studied poverty rural poverty among black people in this area. And as we all know, Black Belt counties are one of the forgotten or left
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Andrew Zekeri: Forgotten counties in America.
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Andrew Zekeri: When I studied poverty in this area, what guided me or what is always on my mind is social justice.
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Andrew Zekeri: Participation
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Andrew Zekeri: Effectiveness.
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Andrew Zekeri: affordability and accessibility to do people have access
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Andrew Zekeri: Can they participate in things are mainly I like meaningful.
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Andrew Zekeri: You know, equity, has to do with everyone's you have a stake in the things that make life meaningful. The people in black belt counties don't have the resources.
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Andrew Zekeri: They don't have
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Andrew Zekeri: The manpower, they don't have the
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Andrew Zekeri: For example, they don't have hospitals.
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Andrew Zekeri: They travel up to 70 miles for our healthcare.
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Andrew Zekeri: Okay. All these things are very, very important.
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Andrew Zekeri: Consequences of things that affect their life that they have no control over, and yet they are part of Americans or the Americans or the Americans, but yet.
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Andrew Zekeri: You have problem.
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RuebenWarren: unsecured to just touch the screen down below so we can see your face.
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RuebenWarren: There we go.
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Andrew Zekeri: Can you see me now.
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RuebenWarren: Yes, perfectly
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01:45:14.310 --> 01:45:23.940 Andrew Zekeri: Yeah. Yes. So I started is communities and societies and the family that I raised in these societies that are very poor.
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Andrew Zekeri: They have no say in what is happening to their communities have no seen what is happening to the allies.
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Andrew Zekeri: And you all know as you deal with ethics and
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Andrew Zekeri: Public health you deal with social justice.
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Andrew Zekeri: Participation
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Andrew Zekeri: Okay effectiveness of what is happening in these places.
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Andrew Zekeri: And try
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01:45:55.680 --> 01:46:02.760 Andrew Zekeri: To look at that and bring the applied to the public perspective. But then in national conferences. I've been to Washington DC.
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Andrew Zekeri: To talk on behalf of black belt people and the county as a whole, and there are black belt South
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Andrew Zekeri: In addition to study in Alabama. I've looked at some black belt counties in Georgia to Dr. Warren and I have looked at that together some black belt counties in Georgia.
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Andrew Zekeri: And what I found that is that they are similar. There's no distinction when I look at their rural schools in Georgia in black belt counties. They have the same problem that the ones in Alabama have so
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Andrew Zekeri: Ethic framework public health ethics. I use that to Korea. What is happening in these communities.
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RuebenWarren: You all can see we have a very powerful panel and I'm not going to waste time by going through the order. I'll raise a question and have the pounders respond as they see fit.
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RuebenWarren: Or you've heard about some some challenges that dilemma. The Urban rule the ethnic, racial geography differences.
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RuebenWarren: Give us some suggestions on how do we deal with them. What do we do besides define the problem. What did we do to resolve it. So, any other panelists that you'd feel free to chime in.
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Daryl Melvin: Dr. Warren to sterile Melvin. I just want to share a little bit information with the participants on this here in this form. And one of the things that we do and Native communities that has been really a
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Daryl Melvin: Game changer. It's been information that's just come out in the last few years, but
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Daryl Melvin: First Nations Development Institute has conducted a study which is called reclaiming naked truth and it's a national nationwide study that looked at
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Daryl Melvin: Surveys interviews and analyzing social media posts and what it did is it help uncover some of the deep rooted biases and toxic assumptions that
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Daryl Melvin: People held about American Indians and really, these are the same individuals that
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Daryl Melvin: Are leaders and say our court systems and our legal systems, our law enforcement government, etc. And some of the findings were that
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Daryl Melvin: Most Americans learn about American, Native American or American Indian history from elementary school and high school or maybe through pop culture.
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Daryl Melvin: movies, TV, etc. And what the findings showed was that only about a third of Americans believe that Native Americans face discrimination.
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Daryl Melvin: And what this really shows is that discrimination for our population is underreported and of course that leads to the biases that we're talking about today and the biases can be introduced them into the policies for the institutions and the programs and health care.
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Daryl Melvin: That
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Daryl Melvin: That we're talking about additionally 40% of Americans believe that Native Americans actually don't exist in our community today.
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Daryl Melvin: And part of that is because the Native American narrative is actually dominated by narratives of non natives.
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Daryl Melvin: Individuals talking about our communities. And so really this issue of invisibility is destructive to the Native community population and youth and it underpins some of the in
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Daryl Melvin: Non access to the health care services. It's a driver for the need to really have conversations, which we are in currently in America about race. And so in visibility for Native American really is the modern form of racism.
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RuebenWarren: ABSOLUTELY. ABSOLUTELY, OTHER PANELISTS sure he's opening it up.
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Andrew Zekeri: I think, I think we need to give them the resources.
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Andrew Zekeri: Okay, yeah.
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Andrew Zekeri: Public
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Andrew Zekeri: Coming out in public and saying that Black Lives Matters is a good idea but Black Lives Matters, but they needed the media resources they need the power
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Andrew Zekeri: We need to put them in control of their own communities. We have to make them effective they are the one to change their communities. Give them the resources, give them the power put them in the driver's seat. Let them drive the car, but the guy right or wrong, without the petrol
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RuebenWarren: Absolutely. Okay, another timeless, we didn't. We get warm. Come on.
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Maria Poepsel: Yeah.
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Michal Rhymer-Browne: I was about to say that for the US Virgin Islands and other territories, I really agree with Mr. Melvin we we need to bring knowledge to those who may not be very knowledgeable about who we are.
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Michal Rhymer-Browne: Here in the territory. Yes, we are US citizens. Yes, we have strong cultural and strong sense of community.
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Michal Rhymer-Browne: But I believe that it's important for us to raise our voices and that's why I took it so seriously to go to Washington DC last year.
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Michal Rhymer-Browne: To raise the voices and let them know that the territories. We do matter. We have serious health issues and as you as citizens, we should not be neglected. I remember one of the
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Michal Rhymer-Browne: One of the representatives said, and in your country. And I said, Yes, my country.
469
01:51:45.330 --> 01:51:46.860
RuebenWarren: Of the United States of
470
01:51:46.860 --> 01:51:47.550
Michal Rhymer-Browne: America.
471
01:51:47.910 --> 01:51:49.530
Michal Rhymer-Browne: And it was so important.
472
01:51:49.830 --> 01:51:51.000
Michal Rhymer-Browne: And he
473
01:51:51.420 --> 01:51:55.170
Michal Rhymer-Browne: knew he wanted to fall down behind the desk when he said that
474
01:51:55.470 --> 01:51:56.700
Michal Rhymer-Browne: But I said yes.
475 01:51:56.790 --> 01:52:01.860
Michal Rhymer-Browne: My country of the United States of America who I'm so proud to be an American
476
01:52:02.190 --> 01:52:16.020
Michal Rhymer-Browne: Needs to be aware of the plight of the territories. We're not asking for a handout. We are asking to be treated like any other US citizen that is in on the mainland. If I go to the United States.
477
01:52:16.470 --> 01:52:28.980
Michal Rhymer-Browne: I am a US citizen, I'm able to get the health care that I need here if I live in the territory, I cannot get the services that I need. I am not able to access
478
01:52:29.640 --> 01:52:54.180
Michal Rhymer-Browne: Much needed Medicaid or sometimes Medicare benefits. I don't have SSI. All of these are benefits and opportunities that are available on the US mainland to citizens and should be available to our US citizens in our US territory. So my advice is, we must raise our voices, we cannot be silent.
479
01:52:55.080 --> 01:53:03.870
RuebenWarren: Is a rule problem is it's it's a problem for the Virgin Islands. Some panelists is this. Who is this she all she, along with this challenge.
480
01:53:04.920 --> 01:53:16.800
Scott Lockard: I don't think so at all. I'm in Rule Appalachia, and we are a area that has often had our resources extracted and the people forgotten about.
481
01:53:17.220 --> 01:53:25.230
Scott Lockard: And we see that frequently you. So we spend a lot of time educating policymakers about what our needs are.
482
01:53:25.920 --> 01:53:33.810
Scott Lockard: Spend a lot of time trying to work and bring together our community partners in public health departments were really convenient years now.
483
01:53:34.050 --> 01:53:47.190
Scott Lockard: And we bring together our FTC partners, our health care partners, our government partners and we remind them of the ethical issues that we deal with, with health disparities and inequities in our communities.
484
01:53:47.580 --> 01:53:58.950
Scott Lockard: And we also to sometimes have to remind our residents themselves who now have developed a very fatalistic outlook because of living in poverty for so long.
485
01:53:59.460 --> 01:54:08.790
Scott Lockard: One of the groups we partner with is sore shaping our Appalachian region. And they did a public relations campaign targeted at the people of Appalachia.
486
01:54:09.180 --> 01:54:11.850
Scott Lockard: Which said Appalachia, there is a future.
487
01:54:12.330 --> 01:54:25.320
Scott Lockard: So really trying to educate the people themselves and to improve their mental health and well being, that they should feel good about themselves and the area in which they're from. So it is a constant never ending struggle.
488 01:54:25.740 --> 01:54:36.120
Scott Lockard: For us to make those empower aware of what we're facing every day and giving them solutions as to how they can support us to improve the situations we face.
489
01:54:36.480 --> 01:54:49.140
RuebenWarren: And touch. Thank you heard the word SQL sees and and optimal. Let's talk about rule fairly find a community health centers, what, what has been your experience and
490
01:54:49.410 --> 01:54:57.420
Daniel Miller: Thank you, Dr. Warren, you know. So I think we're, you know, as you've been saying we're getting into, into the meat of this now and
491
01:54:58.230 --> 01:55:13.380
Daniel Miller: You know, as a clinician and as providers of healthcare. One of the things I think we all recognize is the importance and the power of properly understanding and naming what it is we're trying to improve and help and work on
492
01:55:13.860 --> 01:55:20.160
Daniel Miller: And and i think words here and definitions are really important in in our work and and all of our work and so
493
01:55:20.520 --> 01:55:26.220
Daniel Miller: For a minute. I'd like to come back to this concept of the social determinants of health that we've been talking about.
494
01:55:26.760 --> 01:55:35.310 Daniel Miller: And I think we all recognize that probably about roughly 50% of the factors that affect our health are not just the health care, we
495
01:55:35.640 --> 01:55:45.510
Daniel Miller: We provide but really kind of what's in our zip code and whether that's rural or urban and these are issues of education and housing and employment income.
496
01:55:46.170 --> 01:55:56.820
Daniel Miller: And I think when we go a little bit deeper into that concept of these social determinants and when we do it looking, you know, with an understanding of institutional and systemic racism.
497
01:55:57.360 --> 01:56:07.290
Daniel Miller: We recognize that those social determinants of health are the same systems that we found that mediate the effects of institutional and systemic racism.
498
01:56:07.800 --> 01:56:18.180
Daniel Miller: And and as we look even closer at them at banking and housing and mortgage systems and education and healthcare. You know, when we look at our history, which isn't so old.
499
01:56:18.660 --> 01:56:27.030
Daniel Miller: We recognize that when these systems and institutions were created. They were created with the intent and purpose to be in equitable
500
01:56:28.020 --> 01:56:34.620
Daniel Miller: And and that's that's they were meant to be an equitable and so you know you challenge list of what do we do
501
01:56:35.160 --> 01:56:42.360
Daniel Miller: I think this is crucial because when we, you know, as all good people are going to work hard within the systems.
502
01:56:42.750 --> 01:56:50.730
Daniel Miller: Are outcomes are still in equitable and fair and equitable. I think because this is how these systems were designed and they were designed really well.
503
01:56:51.210 --> 01:56:55.200
Daniel Miller: And and so just to close this piece I think naming is important.
504
01:56:55.650 --> 01:57:05.580
Daniel Miller: And coming back to the social determinants of health, I've really come to believe this term itself is a euphemism. It's a euphemism for poverty and it's a euphemism for racism.
505
01:57:05.940 --> 01:57:11.820
Daniel Miller: And and it makes us realize that when we do what we do in our world, when we
506
01:57:12.450 --> 01:57:28.740
Daniel Miller: Treat the illnesses, we treat when we see the people we see and the interventions we make are enormously powerful, but at the end of those days what our patients are actually dying of is racism and poverty and once we understand that, then I think we can get to work.
507
01:57:29.940 --> 01:57:30.180
Daniel Miller: Thank
508
01:57:30.900 --> 01:57:36.660
RuebenWarren: powerful statement. I heard Martin talk about discrimination and I heard you talk about racism.
509
01:57:37.530 --> 01:57:45.420
RuebenWarren: Are they the same or are they different I do just impact upon certain populations, whatever the powerful panelists, try to unpack that for us.
510
01:57:47.400 --> 01:57:48.420
Daniel Miller: How much time do you have
511
01:57:49.230 --> 01:57:49.740
RuebenWarren: A
512
01:57:50.040 --> 01:57:51.660
RuebenWarren: Good job, you get to go too far.
513
01:57:54.270 --> 01:57:57.090
RuebenWarren: But I know it's hot. So somehow, Dallas. Let's go.
514
01:57:59.220 --> 01:58:00.120
RuebenWarren: This is the time
515 01:58:01.020 --> 01:58:02.610
Daryl Melvin: That I'd like to comment on the
516
01:58:02.610 --> 01:58:09.180
Daryl Melvin: Questions about this institutional systems that we currently have, and
517
01:58:10.440 --> 01:58:17.190
Daryl Melvin: In Indian country, you're going to see things about the institutional inequities and, you know,
518
01:58:18.420 --> 01:58:26.340
Daryl Melvin: What we see for our communities of Indian Health Service and the Bureau of Indian Affairs actually are the education. Traditionally, the
519
01:58:26.760 --> 01:58:42.150
Daryl Melvin: Education and the health systems for Native Americans. And I think it was previously said is that they're perfectly designed for the results that we get, and their national and focus. And so with over 600 tribes across America.
520
01:58:42.840 --> 01:58:49.380
Daryl Melvin: Both federally recognized and state recognized the solutions really for creating that
521
01:58:49.980 --> 01:59:00.210
Daryl Melvin: education and health care systems are local their place base. So within I just as an example to have transformation occur.
522 01:59:00.510 --> 01:59:17.010
Daryl Melvin: Is to ask the question about what their mission is and what it could change to to focus on the place based solution or mandating that say local tribal solutions are inherent in the fabric of local health care systems so
523
01:59:18.120 --> 01:59:34.770
Daryl Melvin: The other way, if you look at the pathways to addressing some of the inequities would be as an example for public health surveillance. When you talk about Kobe is why our native people misclassified or listed in as other category, you know, and
524
01:59:36.000 --> 01:59:48.870
Daryl Melvin: Creating systems should be the response to more accurate reporting, you know, to create opportunities that will allow for addressing these
525
01:59:49.440 --> 02:00:05.190
Daryl Melvin: Systems that create the inequity, you know, and really question systems that are self reinforcing so that we can include different criteria that can help address those structural and institutional inequities that we see.
526
02:00:07.230 --> 02:00:26.760
RuebenWarren: Now I'm challenged to because I'm, what I'm hearing sounds urban and rule or there's some uniqueness about rule that that impact in greater ways than they do in other areas. And maybe that i i am i grew up in urban cities. So somebody share their that their perspective about that.
527
02:00:29.250 --> 02:00:33.600
Andrew Zekeri: Yeah. Difference is a big differences in rural areas.
528
02:00:34.770 --> 02:00:44.700 Andrew Zekeri: You know, the population as scattered all over the area. Yes, past so that K bringing services.
529
02:00:45.780 --> 02:00:48.000
Andrew Zekeri: To this area becomes difficult
530
02:00:49.110 --> 02:00:52.560
Andrew Zekeri: And the services available. They have to travel far and wide.
531
02:00:53.730 --> 02:01:04.290
Andrew Zekeri: To have access to the services that is so great a boredom, or our families, some of them don't have the transportation
532
02:01:06.270 --> 02:01:13.200
Andrew Zekeri: They don't have the financial resources. We don't have the human resources, compared to urban areas.
533
02:01:15.120 --> 02:01:25.410
Andrew Zekeri: So there's a big distinction between rural and urban when it comes to hospital services. Another economic services that are available to make life million for
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RuebenWarren: OTHER PANELISTS
535
02:01:28.920 --> 02:01:29.970 Ashley Andujar: And this is Ashley.
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02:01:30.330 --> 02:01:37.830
Ashley Andujar: To that to that, for example, work of ego. You know, it's an island, and I'm sure USB, I can relate to what I'm about to say but
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02:01:38.490 --> 02:01:45.570
Ashley Andujar: For example, during Hurricane Maria, where you have, you know, not only metropolitan areas are heavily affected.
538
02:01:46.470 --> 02:02:02.250
Ashley Andujar: In the rural communities is more so, you know, the situation was more so dire in terms of access to just basic things like food and water, like, um, you know, electricity and healthcare access
539
02:02:04.170 --> 02:02:13.470
Ashley Andujar: You know, going back to the idea of racism, I think can call any colonialism, you know, as a whole for us in the territory.
540
02:02:14.580 --> 02:02:28.260
Ashley Andujar: Is is a big factor that plays into you know why we're under funded or why you know our rates in chronic diseases are much higher. So yeah, I think for
541
02:02:29.160 --> 02:02:48.690
Ashley Andujar: Like if you compare the territories with the states and the rural areas in the States. It's a little bit more so dire. And you know the poverty rates are more extreme. So I think, at least from the perspective of the islands. That's something that also need to take into consideration.
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Ashley Andujar: And
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Michal Rhymer-Browne: I
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Maria Poepsel: Would say that
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Maria Poepsel: Okay.
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02:02:52.980 --> 02:03:08.640
Michal Rhymer-Browne: I was gonna say I do agree Ashley being here and and from the territories. I think back historically many territories. We were taken into the umbrella of the United States because of military
547
02:03:10.290 --> 02:03:17.850
Michal Rhymer-Browne: Distinctions and where we were located geographically and I believe we were adopted into the
548
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Michal Rhymer-Browne: Family of the United States. However, I do not believe there was at the time. Any anticipation that we would get equal rights and so we worry
549
02:03:31.320 --> 02:03:46.920
Michal Rhymer-Browne: That up with certain laws, rules and regulations that have marginalized us as US citizens here in the US territories and so I believe in the Public Health Act on our aspect. This is glaringly so
550
02:03:47.760 --> 02:03:58.080
Michal Rhymer-Browne: As a matter of fact, our delegates to Congress delegate plaskitt has introduced and she introduced this in February 25 2019
551
02:03:58.470 --> 02:04:08.910
Michal Rhymer-Browne: An act calling for equity in public health access all the territories health equity app. And that has yet to move, but
552
02:04:09.450 --> 02:04:20.190
Michal Rhymer-Browne: Eventually, that's what we as the territories need to gain equity, we will have to challenge the preconceptions. We will have to help to
553
02:04:20.700 --> 02:04:37.980
Michal Rhymer-Browne: Inform that know we our country is the United States. So we can remove these barriers that have been been put up for us and that have marginalized us and given us less than stellar services and resources for our territories.
554
02:04:38.640 --> 02:04:39.840
RuebenWarren: Please keep reminding
555
02:04:39.840 --> 02:04:40.200 Michal Rhymer-Browne: Us.
556
02:04:40.320 --> 02:04:43.620
RuebenWarren: Like a some seem to forget maybe unintentionally, but they seem to forget.
557
02:04:44.610 --> 02:04:45.120
RuebenWarren: Maria
558
02:04:45.420 --> 02:04:53.790
Maria Poepsel: You were ready to say something. Yeah, I was gonna say that many of these challenges that you find in rural areas are more magnified compared to the urban
559
02:04:54.360 --> 02:05:04.560
Maria Poepsel: The dimension of transportation lack of access, lack of health education educational on health issues, inadequate health coverage. That's nobody has mentioned yet.
560
02:05:04.890 --> 02:05:17.310
Maria Poepsel: Many of these challenges our mods are magnified in rural areas and when we go back to the solutions. I might say that I've had an opportunity to work in the last four years.
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02:05:17.700 --> 02:05:23.580
Maria Poepsel: With the Secretary of Health and Human Services, as a member of the National Advisory Committee for Rural Health and Human Services.
562
02:05:23.850 --> 02:05:39.210 Maria Poepsel: And that's exactly what we looked at from a policy standpoint, we look at all the social determinants of health as the main framework. When we look at the rural issues and challenges, whether it's the maternal or obstetric care. There are so many
563
02:05:39.870 --> 02:05:49.350
Maria Poepsel: obstetric deserts. Now, there's so many healthcare deserts. Now, because many of the house rural hospitals have closed. We have also addressed.
564
02:05:50.040 --> 02:06:08.970
Maria Poepsel: opioid abuse. We have also addressed adverse child childhood experiences the ACE experiences. Many, many, many of these issues are very complex and can be resolved or can be addressed to a national policy. And so that's what we did.
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02:06:09.210 --> 02:06:12.450
Maria Poepsel: With the National Advisory Committee for rural health in the last four years.
566
02:06:12.720 --> 02:06:27.360
Maria Poepsel: And many of these recommendations have been implemented. Not all of it because many of them many of them will be our had to be within the purview of the Secretary of Health and Human Services, but I would say maybe 50 60% of them have been implemented.
567
02:06:28.830 --> 02:06:39.900
RuebenWarren: We were intentional about trying to get some geographical diversity and rule panel, are we finding anything different or unique
568
02:06:41.070 --> 02:06:55.440 RuebenWarren: About these rural areas or there's some conclusion that we can draw about rural areas, Northern rural areas, Southern rural areas, very an island Puerto Rico are some common lessons, a message that we should be should carry
569
02:06:56.190 --> 02:06:56.940
Maria Poepsel: Yeah, come on.
570
02:06:59.040 --> 02:06:59.700
RuebenWarren: Let's hear
571
02:07:00.210 --> 02:07:04.020
Andrew Zekeri: It raise composition of these rural areas, makes a big difference.
572
02:07:05.100 --> 02:07:07.080
RuebenWarren: Okay, so
573
02:07:07.110 --> 02:07:08.760
Daryl Melvin: I'd like to just comment that
574
02:07:10.020 --> 02:07:18.240
Daryl Melvin: You know, when he started talking about how to address some of these issues and the ideas or concerns that are raised.
575
02:07:19.500 --> 02:07:38.940 Daryl Melvin: Some of it, but really looking at the systems that we currently have in place and those systems that are important into the rural communities. So for example, when we're living in a rural community and we have an institution, not unlike what you know we represent here today.
576
02:07:40.260 --> 02:07:48.510
Daryl Melvin: Asking the question of, if we are going to put positions, whether they are board positions of professional positions.
577
02:07:48.960 --> 02:07:57.630
Daryl Melvin: As part of changing that system. Can we ask questions are, are there a central experiences, should that should be required.
578
02:07:58.560 --> 02:08:06.300
Daryl Melvin: That challenge requirements, say, for having certain degrees that might exclude participation.
579
02:08:07.200 --> 02:08:19.350
Daryl Melvin: For for rural community. So having that representation is important. And as I mentioned, as a former CEO and healthcare and critical access hospitals. I know the question came up with.
580
02:08:20.130 --> 02:08:26.610
Daryl Melvin: Medical students and residents ease and how can we get residents to really look at
581
02:08:27.150 --> 02:08:36.900
Daryl Melvin: Rural communities as opposed to some of the other opportunities that have an urban settings to come out and what are some of those experiences and working with Indian communities.
582
02:08:37.260 --> 02:08:48.090
Daryl Melvin: The values, the culture, the language and the history is important. And if you can get a medical student to come to a rural community and experience what that's like.
583
02:08:48.390 --> 02:09:04.050
Daryl Melvin: The likelihood and the probability that they'll practice medicine in rural communities as much greater than if they take a residency in another location. So those are some of the solutions that I think can be looked at, to change some of the systems that we currently have.
584
02:09:06.480 --> 02:09:14.130
Scott Lockard: I want to go back to, to the the logistics here and was was brought up earlier. I think it's a commonality among a lot of our rural areas.
585
02:09:14.670 --> 02:09:27.240
Scott Lockard: That we have basic infrastructure challenges here and they the Calvin 19 pandemic, as we've shifted a lot to virtual meetings Tele health, things of that nature.
586
02:09:27.540 --> 02:09:39.000
Scott Lockard: Our rural communities are the ones that have the least capacity to do these things because of poor bandwidth for Internet in my area, we still have three g's sales service.
587
02:09:39.270 --> 02:09:44.340
Scott Lockard: And because of these beautiful mountains in Appalachia. We have great
588
02:09:44.400 --> 02:09:46.170 Scott Lockard: Areas with no cell service.
589
02:09:46.680 --> 02:09:58.590
Scott Lockard: So we've seen a huge push to upgrade services as schools have gone to a virtual format. And I think right now we have a tremendous opportunity.
590
02:09:59.280 --> 02:10:11.520
Scott Lockard: You know, I have a mentor who always said never let a big crisis, go to waste capitalize upon it and and the coven 19 pandemic has shown us and really
591
02:10:11.970 --> 02:10:15.240
Scott Lockard: brought to the forefront, some of these challenges we face.
592
02:10:15.510 --> 02:10:23.910
Scott Lockard: And we need to utilize any funding, we can access right now to build our infrastructure, not just to respond to this coronavirus pandemic.
593
02:10:24.120 --> 02:10:32.190
Scott Lockard: But, but to really position us better for whatever else comes down the way to build up our, our IT infrastructure in our schools.
594
02:10:32.700 --> 02:10:37.500
Scott Lockard: We're lot of areas here in Eastern Kentucky. They're actually putting internet in
595
02:10:38.100 --> 02:10:54.060 Scott Lockard: Children's and residences for homes and so there's just lots of opportunities and we have to be prepared to capitalize work together to make sure that we can take advantage of the opportunities were given now to use that to benefit our populations.
596
02:11:04.500 --> 02:11:08.340
Daniel Miller: Folks, it appears to me that maybe we lost. Dr. Warren's can
597
02:11:08.940 --> 02:11:10.830
Craig Wilkins: Warn are you back on Dr. Warren
598
02:11:14.790 --> 02:11:15.360
Craig Wilkins: Okay.
599
02:11:16.710 --> 02:11:32.850
Craig Wilkins: Well, hopefully. Hopefully he will be able to come back on in a few minutes on what while we're waiting him on. We've received on several questions very good questions that I'd like to go ahead and and and ask the panel.
600
02:11:34.380 --> 02:11:45.720
Craig Wilkins: One of the questions we receive and again this is open to any one of you who would like to respond. Is that one of the questions was, we appear to be kind of focusing on on health equity.
601
02:11:46.410 --> 02:12:02.550
Craig Wilkins: And could someone talk about addressing the parallels between health equity and ethics, looking at it. Are they are they one in the same. If not, are they similar and what what are the what are the differences
602
02:12:09.600 --> 02:12:11.400
Daniel Miller: Craig me if I might say,
603
02:12:11.520 --> 02:12:18.540
Daryl Melvin: Maybe I could respond to that. Just in talking about, for example, the pandemic and Kobe.
604
02:12:19.380 --> 02:12:36.510
Daryl Melvin: And talking more about not just the health equities, but the inequities and how it relates to the ethics. So I was a provided a tour of time as the public health official for the Hopi tribe my tribe and Hopi and Navajo were severely affected by
605
02:12:37.680 --> 02:12:49.200
Daryl Melvin: We had a higher new incident rate than the state of Arizona and the nation, a month or two back and have recently been able to get it under control, but
606
02:12:50.940 --> 02:13:00.990
Daryl Melvin: Inexperienced that for native and communities. We experienced a huge loss of our elders, you know, our cultural thought leaders language holders matriarch and patriarch for the communities.
607
02:13:01.350 --> 02:13:07.620
Daryl Melvin: And additionally, the isolation of elders and our families and communities had a significant toll.
608
02:13:08.070 --> 02:13:28.830 Daryl Melvin: And you look at our fragile economies and the loss of income exasperate exacerbates the hardships that you have in these food desert areas of food deserts and so when you talk about the inequities and ethical dilemmas. How do you respond to can whole communities that have these
609
02:13:30.480 --> 02:13:49.500
Daryl Melvin: lack of resources or awareness. When we talk about in visibility, the awareness to be able to address even address questions on how do you solve these inequities. If you can't address that that ethical dilemmas that we have that underpin the issues that we see.
610
02:13:52.830 --> 02:13:53.550
Craig Wilkins: Thank you. During
611
02:13:54.930 --> 02:14:02.220
Daniel Miller: That if I might, Craig. You know, I think, you know, as you're saying into your question into the the questioners question.
612
02:14:02.610 --> 02:14:15.750
Daniel Miller: You know, it seems to me, when we talk about inequities. Again, it's, it's a word. We've gotten used to that, you know, we're really talking about people dying more than others. People being hurt more than others.
613
02:14:16.920 --> 02:14:31.230
Daniel Miller: And there's a fundamental ethical question here for for us as as a society and for us and what we do, which is how many of those people dying. How many family members and
614
02:14:32.490 --> 02:14:40.170
Daniel Miller: You know, etc. Is is acceptable to us. I think we often in this world, end up managing inequity.
615
02:14:41.850 --> 02:14:57.810
Daniel Miller: And it's and it's fundamentally I think unethical and unacceptable for us to look at this to say, you know, these, these inequities. You know, on a basic level are somehow okay they represent a deeply
616
02:14:58.950 --> 02:15:04.500
Daniel Miller: Unethical aspect of our culture that that needs that needs to be addressed.
617
02:15:05.820 --> 02:15:10.260
Daniel Miller: So that they're not just numbers, obviously, you know, we're talking about people in people's lives.
618
02:15:11.820 --> 02:15:12.180
Daniel Miller: Thanks.
619
02:15:13.290 --> 02:15:26.910
Craig Wilkins: Thank you, darling. Thank you, Dr. Miller. Okay. Another question we received was we spent, we spent annually around three to $3 trillion on health care services which could have been prevented.
620
02:15:27.600 --> 02:15:40.320
Craig Wilkins: How do you address preventive services in rural invisible areas where early access is a challenge. And again, this is questions open to any panel member who like to respond.
621
02:15:43.050 --> 02:15:53.700 Scott Lockard: Getting funding for prevention is always one of the biggest challenges I've done a lot of work and advocacy with our state legislature with our federal legislature of federal policy makers.
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Scott Lockard: And it's one of those things when prevention works at its finest. You don't know it's there, the majority of people do not and whatever prevention is not working. Just like right now.
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Scott Lockard: We have a pandemic and people are like, Well, why didn't you do something about this. And now we're trying to make
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Scott Lockard: Very political something as basic is wearing a mask is became coming to political statement in our country.
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Scott Lockard: So again, I think we go back to really haven't to educate and we're constantly
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Scott Lockard: Advocating for resources for prevention, first we have to educate with policymakers, that there's a difference between preventive health and health care. They all try to lump us together and and focusing on prevention.
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Scott Lockard: It's just, it's such a challenge because so many people just
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Scott Lockard: Haven't struggled to see that and they think, because we're putting money into health care that we've taken care of all the preventive health needs. So it's a constant ongoing battle where we're educating we're trying to inform policymakers and then it gets back to that ethical
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Scott Lockard: discussion we're having here is what is the acceptable level of death. I had a policymaker when I was doing testimony, one day.
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Scott Lockard: Just point blank said to me, Why should my constituents in my urban area be worried that people in your rural area that teen years sooner than they do and have a 10 year shorter life expectancy
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Scott Lockard: And so it's just like, Okay, well you know there's basic
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Scott Lockard: Ethics involved here and we should all. Some of us take for granted. We should all have those concerns and and care about our fellow citizens and and non citizens and just fellow human beings as such, but it's a constant battle to educate all the time about that.
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I'm back.
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02:17:50.310 --> 02:17:50.820 Maria Poepsel: I'm back.
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RuebenWarren: Okay.
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RuebenWarren: I see like we talked about rural
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RuebenWarren: Rural America. I feel like I'm in rural America.
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Craig Wilkins: Yeah.
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RuebenWarren: Miss some powerful conversation. But where are we
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Craig Wilkins: Not one on since you are
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Maria Poepsel: Wisconsin.
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Craig Wilkins: We started with killing the questions that we had been that we had received
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Craig Wilkins: And great. Yeah. And if the sea, looking at time, we can continue with those questions, or did you want to ask another
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Craig Wilkins: question for the panel from, you know,
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Craig Wilkins: That you are going to that you were going to bring up
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RuebenWarren: I guess what, what, what we want to leave some some time for questions that if there is a closing thought from the panelists. Let's hear that and then we can continue with the question from the others on the on the audience.
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Craig Wilkins: OK.
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RuebenWarren: OK.
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RuebenWarren: The store with with our panelists as they just what what are your concluding thoughts that we can go forth because I definitely do this into the taste. I can pick up without Miss but give me your thoughts.
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RuebenWarren: In terms of what's the take home message you want the audience to hear from your from this panel.
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Michal Rhymer-Browne: I believe that it's very important for us to realize that public health and access to public health and having it be so on equally distributed, especially in light of our rural and our
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Michal Rhymer-Browne: Our territories. The Commonwealth of Puerto Rico is really creating a lot of ethical dilemmas we have to on a regular basis, decide on which resources to place where
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Michal Rhymer-Browne: And these bring us into some very large ethical decisions and I know here in the territory. The prevention aspect is a is a really big part of what we believe we need to do.
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Michal Rhymer-Browne: The form of our society that if we invest in things like dental health and prevention for children that we don't have to invest in 25,000 50,000 in serious surgeries and dental surgeries.
655
02:20:01.380 --> 02:20:16.800 Michal Rhymer-Browne: If we promote mental health and good mental health and prevention in that area that we don't have to spend the excessive dollars sending some of our people out into institutions outside
656
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Michal Rhymer-Browne: Of the territory to the mainland. So I believe that if we as a people, United States citizens really realize that all people deserve to have
657
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Michal Rhymer-Browne: Health care all people deserve to be healthy and have a good sense of well being, that we will invest what it takes to ensure that all of our communities are treated equally.
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Michal Rhymer-Browne: And I really just appreciate the opportunity to share some of these thoughts today on behalf of the US Virgin Islands.
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RuebenWarren: Let me push the envelope, because what I'm, what I'm hearing sounds like classical public health and how, how are you distinguish it is you are from public of ethics.
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RuebenWarren: I've been in public health for too long to even recount but that sound in the traditional public health, I was at public of ethics different if it is it is it may be a also saw the public out the public that
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RuebenWarren: I'd want them to distinguish it from previous sessions. People were asking, well where's the pub public of ethics in this conversation because it sounds like public health and maybe there's no difference.
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RuebenWarren: Endless
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Scott Lockard: Ethics should got our public health practice and if we are going to be
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Scott Lockard: True public health practitioners are there is always an ethical consideration and it is incumbent upon us, as practitioners and working with agencies.
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Scott Lockard: There's a question about cross jurisdictional sharing
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Scott Lockard: Resources are so scarce. Now is the time for competing with each other is over.
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Scott Lockard: If we are truly practicing ethically, we should be working together, we should be collaborating, we should be partnering if my F2 HC partner can provide a clinical service.
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Scott Lockard: Better than I can. I need to get out of the way and let him do it. And let me focus on the communicable disease, the epidemiology and convening partners.
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Scott Lockard: Our academic partners needs. The key question needs to be fundamental to every piece of research is that is done is, how can this translate to improving public health practice so it can improve the lives of the people we serve.
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Scott Lockard: You know, I would say, ethically, we need to do research that improve the lives of people. I'm a big practice advocate. So to me, you cannot practice public health with our practice in it ethically and do it the way it should be done.
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RuebenWarren: Fantastic night. Okay, now the panelists and your closing remarks, if you can make that distinction as a last colleague just been
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Daryl Melvin: I'd like to comment that and just closing that
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Daryl Melvin: Some of the ethical dilemma that I've been trying to, to, to bring to the forefront about the issues of invisibility and in our case my case it's about Native communities, but really it's about rural communities as well.
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Daryl Melvin: Rural communities, not being represented. And so for me, part of it. And you talked about addressing the ethical dilemmas. It would be when you see a chart of
675 02:23:23.010 --> 02:23:42.480
Daryl Melvin: Some state health department or national health data set and Native people are not included. I think you have to ask the Department organization, why it's that way and our communities and small populations lumped into some other category we shouldn't have to have that
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Daryl Melvin: If there are panels and and I appreciate the fact I was invited to today's panel. But if a native perspective isn't included. I think it's incumbent to ask the question.
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Daryl Melvin: And suggest that someone being included, and I would offer. If you don't know somebody, you can contact me or really any
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Daryl Melvin: Nonprofit and get referrals. And then finally, if you sit on a board or advisory panel and there's not a native voice at the table and ask why, you know, there's this
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Daryl Melvin: A tired and a false narrative out there that there isn't, there's a lack of talent and expertise in public health and medical fields. And that's just simply not the case. There are lots of Native American professionals carrying out the public health and the health care work every day.
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Daryl Melvin: And so the health care community those folks out there listening. You know, I just want to leave with with the with something that I just read recently read
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02:24:38.640 --> 02:24:54.750 Daryl Melvin: From Wilma Mankiller from the Cherokee Nation. She and she said, you know, as we do our work here. The secret to our success is that we never ever give up. And I think that's the important message for addressing these
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Daryl Melvin: ethical dilemmas that would that we face as public health officials, so thank you.
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RuebenWarren: Fantastic I when I was working at CDC, I spent some time with the American Indian physicians Association and David. David veins. So I hear you. Were there other panelists concluding remarks. Yeah.
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Ashley Andujar: I wanted to piggyback a little bit of what Darrell said I think representation is key to, you know, bringing minorities like us to the decision making table. I think that's one of the areas that
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Ashley Andujar: A lot of times it's lacking. And it's why you know we don't see you know data being captured in terms of surveillance or
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Ashley Andujar: Just, you know, the train of thought, you know, for people to think about the invisible community's needs to be at the table.
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Ashley Andujar: And needs to be part of that wider conversation so that we can put, you know, solutions and have strategies in place to reach you know minorities to reach rural communities. I think it's all intertwined. And it's also
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Ashley Andujar: Speaks to, you know, the need for, you know, universities and contingencies and health departments and local health departments to have, you know, a pipeline in place to bring those minorities and to build that capacity.
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Ashley Andujar: You know, to increase just for presentation and public health. So I think that's my main takeaway is to, you know,
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Ashley Andujar: Have have a pipeline and place, you know, universities that are out there listening on I think it's super important to bring minorities into public health so they can you know be the workforce of the future that can really shape shape up on these ethical issues so
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RuebenWarren: Thank you. Thank you know the panelists.
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Andrew Zekeri: Along with that, what you just said is we need to bring them in, by providing them telemarketing and in providing them. I mean, tell a
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Andrew Zekeri: Little medicine telemedicine. They don't have internet access. So there's another resources that we need to give them. You have to have access to internet broadband services. A lot of these places are not why they are not connected to the mainstream America that is affecting them a lot.
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RuebenWarren: Testing other panelists, we get some good take on this just a whole bag.
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Maria Poepsel: I think that
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Maria Poepsel: Public health and ethics are not mutually exclusive, because you'd have to have ethics as your foundational requirement to practice public health.
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Maria Poepsel: Everybody has already mentioned that many factors such as economic infrastructure, cultural and social differences educational shortcoming, and the very lack of recognition by our legislators.
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Maria Poepsel: Contribute to create this health care or public health disparities and that impedes our rural Americans to struggle to, you know,
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Maria Poepsel: To lead a normal, healthy life. They have every right to lead a normal, healthy life. And if we can address all these multiple factors and we can help minimize those Public Health Disparities or inequities.
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RuebenWarren: Thank you, other panelists.
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Daniel Miller: Dr. Warren, if I might.
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RuebenWarren: You know, use
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Daniel Miller: Your asked us in a few different ways of
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Daniel Miller: How ethics here applies to rural communities as opposed to urban and what our closing thoughts are and and and for me, a lot of this comes to kind of reframing our perspectives. Here we've talked about inequities and outcomes. And I think one place to start is
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Daniel Miller: What do we do when we look at the graphs, you know, we all see the data of the discrepancies in
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Daniel Miller: In life expectancy by race, by poverty by income, you know, we've seen them for years and. And the question I think becomes, what do we do with that and what's acceptable.
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Daniel Miller: You know, if we if we took an analogy to the airline industry and looked at, you know, lives lost in crashes between one airline and another
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Daniel Miller: If there was
709
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Daniel Miller: A huge discrepancy. We wouldn't accept it, we would just say either. You can't fly or we got to fix it. Period somehow come to accept this.
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Daniel Miller: So, you know, beginning with rural communities. I think there are differences in rural communities. We've talked about transportation. We've talked about access
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Daniel Miller: I think there are times we need to just recognize that the ways we do things often don't work in rural communities. So we need to do them differently. And, you know, for us, that means
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Daniel Miller: You know, recognizing that rather than expecting people to get transportation and come to our offices. We need to get a mobile van and go out to the farms and partner with the farmers and the farm workers and say, you know, we're coming to you because we know you can't get to us.
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Daniel Miller: A colleague of mine, put it to me, of saying, perhaps we need to reframe that this is not about a hard to reach population, but maybe it's about how we're creating a hard to reach services.
714
02:30:15.780 --> 02:30:25.170 Daniel Miller: We need to, you know, we need to switch our mindset for me. In closing, you know, I want to kind of come back to some concepts I think doctors to carry that you were bringing up
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Daniel Miller: Which, to me, is to recognize that our patients and our communities that they're the experts of their lives, not us. And certainly if we're talking about communities of color, certainly not people who look like me.
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Daniel Miller: So we need to ask and we need to listen.
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Daniel Miller: In closing, you know, I've been struck for years by a statement from Ron Chisholm, who's one of the founders of the People's Institute for survival and beyond, who
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Daniel Miller: Teach and organize an anti racism and Mr Chisholm for years has said we're not suffering from a lack of programs or a lack of services, we're suffering from a lack of power.
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Daniel Miller: In, you know, a fundamental difference here of where interventions need to be made.
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RuebenWarren: And said, thank you so much. Now we as every panelists had something to close on
721 02:31:19.200 --> 02:31:19.410
Daniel Miller: Yeah.
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RuebenWarren: Okay, well, we've been we've been fairly close with with a couple of thoughts. One is that I
723
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RuebenWarren: Have been honored to listen, even when I was cut off to this panel. You all have been very powerful. I think we've seen some distinct rule.
724
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RuebenWarren: Circumstances that ought to be recorded and shared on nationally and we intend to do that every year when we conclude this Public Health Forum. We have the proceedings published
725
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RuebenWarren: In the Journal of healthcare science and the humanities. So we're going to reach out to you and hopefully we can get you to put your thoughts to paper and we can then publish it.
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RuebenWarren: This has been a great, fantastic panel an experience has been a challenge, but it's been a great one. And I will turn the the session back over to Captain Wilkins, so we can close and a half hour break. Great.
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Craig Wilkins: Okay, thank you very much. Warren and I like to take my head off to this great panel.
728 02:32:28.200 --> 02:32:30.240
Craig Wilkins: Thank you for your time today.
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Craig Wilkins: And response to so many very deep.
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Craig Wilkins: Thought questions that that was brought up by Dr. Warren. We appreciate your participation in today's forum. Thank you. Okay. Um, I think we will take a
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Craig Wilkins: Very kind of we could take a three minute not five minute a kind of a three minute stretch break so grab some coffee or some water or whatever. And then we'll start back with our second
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Craig Wilkins: Plenary presentation of the day here. We're going to take just a quick three minute kind of stretch break. Thank you.
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RuebenWarren: I'm going to take that dog. I'm gonna get them to you. You'll still work off the chain.
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Craig Wilkins: Okay.
735 02:36:28.380 --> 02:36:29.250
Craig Wilkins: We are back.
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Craig Wilkins: For our second presentation today.
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Craig Wilkins: The topic is looking at ethical considerations regarding the barriers and solutions to accessing healthcare services and rural areas and populations. We have a two presenters on with us who are going to
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Craig Wilkins: Who are going to talk about this topic on our first speaker is Dr. Diane Hall. Dr. Diane Hall currently serves as a senior scientist for policy and strategy.
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Craig Wilkins: In the policy research analysis and development office here at here at CDC that's within the Office of the associate director for policy and strategy.
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Craig Wilkins: Dr. Hall leaves the office work on translating science for policy use policy research and analysis and developing policy relevant trainings.
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Craig Wilkins: Dr. Hall also serves at CDC coordinator and point of contact for rural health work. Dr. Hall led the development of the offices policy portal.
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Craig Wilkins: The policy analysis and research information system and following her presentation will be Miss Cathy Kim law misc is kilo currently serves as the associate director
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Craig Wilkins: Of the associate director for the Center for ethics, Assistant Professor of Pediatrics at Emory University and Director of the Health Care at this consortium.
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Craig Wilkins: She serves as chair at Emory University Hospital ethics committee, Assistant Professor of Pediatrics Emory School of Medicine and director of the healthcare ethics consortium a network of healthcare systems in the south east
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Craig Wilkins: Please join me in welcoming Dr. Hall and the Kimmel Dr. Hall Thank you.
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Diane Hall: Thank you, Craig. And thanks to the committee for the invitation to present today as Craig mentioned, my name is Diane Hall and I'm a senior scientist working in CDC policy and strategy office.
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Diane Hall: But it is also my privilege to serve as CDC point of contact and lead for coordinating our rural health work today I'll be talking with you about rural access to health care services and it will be focusing on rural in the US, not global rural
748
02:39:01.500 --> 02:39:03.750 Diane Hall: So, next slide please.
749
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Diane Hall: Next slide.
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Diane Hall: Okay, so I'd like to talk about rural populations. Next slide.
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Craig Wilkins: Diane, you have control of the screen so you can move it is really, yes.
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Except control and you can move it forward.
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Hmm.
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Diane Hall: So there we go. Excellent. Thank you. So I'd like to start with a definition of rural as dr Knutson said at the top of the session. There isn't one definition. As a matter of fact, there are over 70 that the US government uses
755
02:39:55.110 --> 02:40:04.860 Diane Hall: But I'll be using the 2013 National Center for Health Statistics urban, rural classification scheme for counties, which is based on the Office of Management and budgets.
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Diane Hall: County based classification system. If you look at the bottom right hand corner of this map, you'll see a legend.
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Diane Hall: non-metropolitan is often considered a proxy for rural areas and those would be the green areas and those represent micro politician and non core so micro politician.
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Diane Hall: Is an area that has a population between 10,050 thousand residents and non core or counties that lie outside metropolitan statistical areas.
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Diane Hall: I'm going to talk about rural and nonverbal, for the most part, mostly because definitions of rural are usually whatever's left over after you've defined your metropolitan and your urban areas.
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Diane Hall: So as you can see by all the green on this map, there are 46 million individuals or about 15% of the population distributed across a very large geographic area and pretty much every state.
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Diane Hall: The metropolitan areas or the urban areas are designated by the form REMAINING COLORS.
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Diane Hall: Okay, so in 2017 CDC published a rural health series of morbidity and mortality weekly reports or MW ours.
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Diane Hall: The first report in that series show that the percentage of people dying was higher and rural counties than a non rural counties across the five leading causes of death.
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Diane Hall: In November 2019 CDC published an M WR on causes of death by morality breaking out the counties using those six levels in that NCAA chess classification. So as you can see from this graph, if you focus on the two darker brown colors, we see that rates are higher in the most rural areas.
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Diane Hall: That 2019 November 2019 mmm WR also showed trends over time. And as you can see here
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Diane Hall: The percentages of potentially excess deaths from the five leading causes or higher in the most rural counties compared to the most urban and I've indicated, those with those red arrows.
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Diane Hall: This MW our update also included comparisons by different levels of morality by region and by state. So I encourage you to take a look at it.
768
02:42:24.210 --> 02:42:30.810 Diane Hall: You can also see that there are gaps between the most rural to the most urban counties and you can see them over time.
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Diane Hall: So the gap increased between the most rural and the most urban for cancer, heart disease and chronic lower respiratory disease, stroke remained relatively stable.
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Diane Hall: The Gap decreased for unintentional injury, which includes poisonings or overdoses falls and motor vehicle collisions because non-rural is getting worse. And that's not the way you want to close the gap.
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Diane Hall: So thinking a little bit about populations and the folks that live in rural areas. A lot of times people say that rural populations are older poor and sicker.
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Diane Hall: This graph shows the continuing gap in the poverty rate, looking at Metro and non metro areas. Well, things have improved since 1959 the gap has been persistent for decades.
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02:43:20.550 --> 02:43:31.890
Diane Hall: In addition, when we look at different geographic regions race ethnicity family household type or age groupings. The rural poverty rate is consistently higher than the non-rural rate.
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02:43:32.730 --> 02:43:39.360
Diane Hall: And when we look at geographic region. This probably won't be surprising, but the rural non-rural gap is largest in the South.
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02:43:39.900 --> 02:43:46.140
Diane Hall: When we look at race, ethnicity, the gap is largest for American Indian Native Alaskan and black African American
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02:43:46.860 --> 02:43:58.560
Diane Hall: Family household type, the largest gaps are female headed households. And finally, when we look my age group, the largest rural non-rural gap is for children under five years of age.
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Diane Hall: I'd also like to point out to reports that examine what might be behind the mortality rate differences we see
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02:44:11.010 --> 02:44:17.280
Diane Hall: This first article was published in Health Affairs in December 2019 in a special issue focused on rural health
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02:44:17.790 --> 02:44:23.250
Diane Hall: The researchers specific specifically looked at poverty access physicians and health insurance.
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02:44:23.880 --> 02:44:35.820
Diane Hall: Looking at state level data. The researchers found that rural mortality was higher than non-rural mortality in all states, except for three Colorado, Montana and Wyoming.
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02:44:36.480 --> 02:44:41.580
Diane Hall: Largest differences between rural and non more rural we're in Virginia Florida and California
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02:44:42.330 --> 02:44:48.540
Diane Hall: But there was quite a bit of variation with rates different cross states by as much as 69%
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02:44:49.140 --> 02:44:57.570
Diane Hall: The authors looked at five explanatory variables rural non rural residents well being index primary care physician access
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02:44:58.230 --> 02:45:04.230
Diane Hall: The percentage of uninsured residents and percent of racial and ethnic minority groups in that area.
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02:45:05.070 --> 02:45:14.280
Diane Hall: They found that larger rural mortality rates could be largely explained by three factors socio economic deprivation, which came from the wellness index.
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02:45:14.610 --> 02:45:23.130
Diane Hall: Business position shortages and lack of health insurance and have those three socio economic deprivation was most closely closely linked.
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02:45:23.430 --> 02:45:30.450
Diane Hall: To higher mortality in rural areas. So it's not just living in a rural area in and of itself that affects mortality.
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02:45:31.350 --> 02:45:43.470 Diane Hall: The second report is an MSW are published in February of 2017 as part of that series and it looked at health behaviors as reported in the behavioral risk factors surveillance system or br br FSS
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02:45:44.280 --> 02:45:57.240
Diane Hall: The researchers looked at five health behaviors getting sufficient sleep non smoking non drinking or moderate drinking maintaining a normal body weight and meeting a robot leisure time physical activity recommendations.
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02:45:57.870 --> 02:46:10.140
Diane Hall: And adults living in the rural areas non metro did not differ in terms of sufficient sleep are non drinking or moderate drinking, but
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02:46:10.650 --> 02:46:23.400
Diane Hall: They had lower prevalence of non smoking, meaning there were smoking more lower prevalence of maintaining a normal body weight and lower prevalence of meeting aerobics leisure time physical activity recommendations.
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02:46:28.350 --> 02:46:36.450
Diane Hall: Now that I provided a brief overview of the health of rural populations. I'd like to talk more specifically about health services and access issues.
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02:46:37.020 --> 02:46:45.690
Diane Hall: I'm going to call these services, health services. I'm borrowing language directly from healthy people, but I will use health services and healthcare services interchangeably.
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02:46:48.750 --> 02:46:55.650
Diane Hall: So this was mentioned previously, and hopefully this graphic or something similar is familiar to many, if not most of you.
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02:46:56.220 --> 02:47:03.360
Diane Hall: It is important to keep in mind that what makes and keeps us healthy is about many factors. It is not just about seeing a physician.
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02:47:04.110 --> 02:47:10.260
Diane Hall: Health care services provide treatment to address illness and injury. A lot of times when we talk about health in this country.
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02:47:10.500 --> 02:47:20.100
Diane Hall: We shift almost immediately to talking about health care and as was previously noted, those are not the same things, both are important, but they are not the same.
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02:47:22.650 --> 02:47:29.610
Diane Hall: Today I'm talking about health care and access and rural communities. So let's start with why access to health services is so important.
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02:47:30.030 --> 02:47:35.250
Diane Hall: Some of the reasons are listed on the slide. And I'm not going to read them to you, but none of them should be surprising.
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02:47:35.670 --> 02:47:46.980
Diane Hall: A person's ability to access health services can affect every aspect of his or her health, yet many people do not have a primary care provider or even a center where they can receive regular medical services.
801 02:47:50.430 --> 02:47:59.040
Diane Hall: In many rural communities, there are barriers to being able to access health services. There are several listed here, but I will go into detail for only a couple of them.
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02:48:02.130 --> 02:48:18.000
Diane Hall: The first is distances. So in 2018 Pew Research published a policy brief that showed that rural residents live an average of 10.5 miles from the nearest hospital compared to 5.64 suburban and 4.4 for urban
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02:48:18.960 --> 02:48:27.720
Diane Hall: Again, this is an average. This map shows the average car travel time to the nearest hospital. However, it's important to note that the ranges in time vary greatly
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02:48:28.200 --> 02:48:40.950
Diane Hall: For rural residents Pew found that the range was 5.8 to 34 minutes for suburban it was 5.2 to 21 minutes and for urban. It was 4.5 to 18.7 minutes
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02:48:41.400 --> 02:48:55.380
Diane Hall: This might not seem like a significant amount of time. But imagine if there is an emergency or imagine that you need to have some sort of routine screening and you have to take time out of your day to go and get that screening
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02:49:01.770 --> 02:49:15.990
Diane Hall: Since 2005 there has been 174 rural hospital closures over 132 of these have been since 2010. In fact, as I was putting together the slides for this talk another hospital closed and I had to update the map.
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02:49:17.010 --> 02:49:25.740 Diane Hall: This map shows the hospitals that have closed. However, the national rural health Association estimates that another 700 are at risk of closing
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02:49:26.490 --> 02:49:38.190
Diane Hall: Most of the closures are in the south 60% and in the South, we see that poverty rates are higher, and people are generally less healthy and less likely to have insurance either public or private insurance.
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02:49:39.000 --> 02:49:48.030
Diane Hall: Most of these hospitals close because of financial problems and according to the shop Center, which does this research 38% of rural hospitals are not profitable.
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02:49:48.720 --> 02:50:00.540
Diane Hall: However, it is important to note that we're all hospitals in addition to providing health care are also one of the largest if not the largest employer in a community, the typical rural hospital employs about 300 people
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02:50:01.290 --> 02:50:12.000
Diane Hall: Research out of the University of Minnesota shows that between 2004 and 2014 179 rural counties lost all hospital based obstetric services.
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02:50:17.040 --> 02:50:25.110
Diane Hall: The person doesn't have health insurance, they're less likely to have a regular source of medical medical care and a more likely to skip routine care because of costs.
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02:50:25.590 --> 02:50:34.620
Diane Hall: This can increase the person's risk for serious health conditions. We often hear about people waiting to seek care because of cost which can mean that their condition can worsen.
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02:50:35.190 --> 02:50:41.130
Diane Hall: We also know that delays and seeking care for serious illness or injury can have serious and even tragic consequences.
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02:50:42.300 --> 02:50:44.400
Diane Hall: According to a report by the US Census Bureau and
816
02:50:45.840 --> 02:51:00.030
Diane Hall: 9.1% of people living in rural areas, did not have any health insurance compared to 8.4% for non rural areas and if people in rural areas did have insurance, it was much more likely to be public insurance, such as Medicaid
817
02:51:00.720 --> 02:51:07.530
Diane Hall: And there is a challenge because there is a limited supply of rural healthcare providers who offer low cost care or except Medicaid
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02:51:09.570 --> 02:51:17.040
Diane Hall: 2018 policy brief by the rupee Center for Rural Health Policy Analysis reported that insurance premiums are higher in rural areas.
819
02:51:17.400 --> 02:51:25.050
Diane Hall: And rural counties are more likely to only have one insurance issue or participating in the Health Insurance Marketplace in that area.
820 02:51:25.920 --> 02:51:34.500
Diane Hall: This issue of insurance market challenge is a topic of 2018 policy brief that was issued by the National Advisory Committee on Rural Health and Human Services.
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02:51:35.250 --> 02:51:49.830
Diane Hall: A 2016 report from HHS found that 26.5% of rural residents delayed or did not receive care due to costs in the previous 12 months this rate was also similar to non rural residents who are not insured.
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02:51:53.130 --> 02:51:59.310
Diane Hall: This map shows areas that have been designated health professional shortage areas or hips and this is for 2019
823
02:51:59.790 --> 02:52:06.930
Diane Hall: The darkest blue indicates that the entire county has been designated or shortage area and look where the darkest blue counties are
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02:52:07.590 --> 02:52:21.270
Diane Hall: I also want to note that this map is only for primary care. It is much worse for obstetrical care oral care mental health care substance abuse treatment Hospice and Palliative care.
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02:52:27.270 --> 02:52:35.220
Diane Hall: federally qualified health centers FQ agencies were mentioned in the previous panel. And so I do want to point out that there are safety net clinics that serve rural areas.
826
02:52:35.580 --> 02:52:48.750 Diane Hall: FQ agencies are part of the rural health care safety net. Note that FQ agencies also serve non rural communities rural communities also have access to Indian Health Service and tribal clinics that are part of that rural safety net.
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02:52:53.670 --> 02:53:01.260
Diane Hall: And rural health clinics are another part of the safety net. They serve rural areas and. This map shows where those rural health clinics are located.
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02:53:05.490 --> 02:53:12.360
Diane Hall: So that was a lot of doom and gloom. So what are the programs and activities are attempting to address some of these issues.
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02:53:17.670 --> 02:53:27.810
Diane Hall: Okay, so this is actually a picture of Tinker mountain in southwestern Virginia where I went to college and it's one of my favorite areas, my son took that photo. A couple of years ago.
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02:53:29.070 --> 02:53:36.180
Diane Hall: So this slide show some of the programs and activities that are working to address health care issues in rural communities.
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02:53:36.570 --> 02:53:42.000
Diane Hall: The first is the National Health Service Corps and I saw something in the previous session in the chat with some information about it.
832
02:53:42.690 --> 02:53:53.940
Diane Hall: The National Health Service Corps award scholarships and loan repayment to students and qualified primary healthcare professionals who agreed to work in areas that have limited access to health care those hips areas.
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02:53:55.380 --> 02:54:01.740
Diane Hall: Recruitment and retention of physicians in rural areas can be challenging. It was also mentioned in the previous discussion.
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02:54:02.580 --> 02:54:11.730
Diane Hall: Many communities recruit non US citizen international medical graduates who have trained on a j one visa essentially international medical graduates.
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02:54:12.060 --> 02:54:16.500
Diane Hall: Have up to seven years to complete their medical training before returning to their home country.
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02:54:17.220 --> 02:54:23.760
Diane Hall: They are required to spend two years in their home country before they can apply, apply for permanent residents or an H1 visa.
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02:54:24.270 --> 02:54:34.470
Diane Hall: This waiver waves. The to your home country residency requirement, allowing the physician to stay in the US to practice in a healthcare professional shortage area.
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02:54:35.370 --> 02:54:42.180
Diane Hall: There are also medical schools that specifically trained students to become rural providers Mercer University in Georgia is one example.
839
02:54:42.630 --> 02:54:53.190 Diane Hall: Their website states the School of Medicine educates physicians and health professionals to meet the primary care and health care needs of rural and medically underserved areas of Georgia.
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02:54:53.970 --> 02:55:01.020
Diane Hall: In addition, in 2019 the American Academy of Family Physicians AFP launched their rural health initiative.
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02:55:01.440 --> 02:55:08.820
Diane Hall: This not coincidentally was when dr john colon was president Dr colon is a family physician practicing in Alaska.
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02:55:09.720 --> 02:55:16.350
Diane Hall: There are also efforts to assist facilities. The first is critical access hospital designation also previously mentioned,
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02:55:16.740 --> 02:55:28.740
Diane Hall: Essentially this designation is designed to reduce the financial vulnerability of rural hospitals and improve access to care in rural areas, essentially, keeping those critical services available in the community.
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02:55:29.310 --> 02:55:40.950
Diane Hall: Ch designation carries benefits such as cost based reimbursement for Medicare Services. There are specify specific requirements and facilities need to apply and be approved for that designation.
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02:55:42.450 --> 02:55:55.860
Diane Hall: During the coven 19 pandemic, the paycheck protection program and healthcare Enhancement Act of April 2020 provided $225 million to rural health clinics for code 19 testing.
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02:55:56.490 --> 02:56:02.640
Diane Hall: The sponsor managed through herself and funding went to 4549 rural health clinics.
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02:56:03.450 --> 02:56:16.200
Diane Hall: Finally, tele health is a way to increase access to services, I will not say a lot about it because it's covered in so many areas, and it is a complex issue and I don't have the time to cover all of those issues.
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02:56:16.620 --> 02:56:28.710
Diane Hall: But I do want to note the tele health is a tool. It's not a cure for access issues. There are many barriers to telehealth, such as broadband access reimbursement issues and licensure challenges.
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02:56:29.400 --> 02:56:35.700
Diane Hall: The pandemic has called increased attention to the issue of tele health. So maybe some of these barriers will be addressed sooner rather than later.
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02:56:41.340 --> 02:56:53.730
Diane Hall: CDC has two different websites that put together a lot of our rural health information the URLs else are listed there. You can also email rural [email protected]. If you have any question about the rural work that we do.
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02:56:54.330 --> 02:57:05.370
Diane Hall: With that, I'd like to thank you for your time today and I would like to turn it over to Kathy kin law Associate Director of Emory center for ethics and program director ethical engagement and Health and Science
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02:57:13.830 --> 02:57:15.510 Kathy Kinlaw: Thank you very much.
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02:57:19.980 --> 02:57:25.110
Kathy Kinlaw: Not sure why you're not seeing me, but I will proceed with my slides. If I can be put up please
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02:57:31.830 --> 02:57:32.520
Kathy Kinlaw: Can you hear me.
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02:57:35.790 --> 02:57:41.040
Diane Hall: Yes, we can hear you. Okay, you might have control of the slides like I didn't, didn't realize it.
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02:57:45.690 --> 02:57:46.920
Kathy Kinlaw: Haha. Thank you very much.
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02:57:48.750 --> 02:58:06.630
Kathy Kinlaw: So as I've been introduced diamond emphasis working at Emory University. And that's sort of the perspective. I want to start bringing in here. And because I know we have limited time I will probably stay close to that and flipped by a few of the slides that
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02:58:07.800 --> 02:58:23.160
Kathy Kinlaw: May affirm, some of the things that Dr. Hall just indicated and then want to get some some opportunities for for discussion with you. So first of all, again, thank you to CDC and the National Center for Bioethics at Tuskegee University for the opportunity to participate.
859
02:58:25.170 --> 02:58:35.160 Kathy Kinlaw: So I want to make sure we've at least sort of pause long enough to think about what we mean by access to care and so I still go back to the Institute of Medicine 1993 definition.
860
02:58:35.580 --> 02:58:44.700
Kathy Kinlaw: Having timely use of personal health services to achieve the best possible health outcome. I think it's still stands the test of the fun if you will.
861
02:58:45.960 --> 02:58:49.140
Kathy Kinlaw: Do it for one to me maybe
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02:58:53.070 --> 02:58:59.430
Kathy Kinlaw: Okay, there are components to access to health care services that I think are important and hope that we can talk about
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02:58:59.910 --> 02:59:10.200
Kathy Kinlaw: Certainly insurance coverage in general makes entry into healthcare systems easier. And without it, people are less likely to seek care that's true of course
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02:59:10.560 --> 02:59:18.960
Kathy Kinlaw: As Dr. Warren said in an urban as well as non urban areas, but insurance coverages diminished in many rural areas.
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02:59:19.530 --> 02:59:34.470
Kathy Kinlaw: But also requires in health care services be available. Hopefully were a provider relationship is established, and so one can, you know, regularly receive care and receive importantly primary and preventive services, not just treatment for
866
02:59:35.670 --> 02:59:43.590
Kathy Kinlaw: Tertiary services care needs to be timely so readily accessible after, you know, a need is recognized by the individual
867
02:59:44.520 --> 02:59:53.790
Kathy Kinlaw: And really importantly, it requires that there be in a qualified culturally thoughtful and let your competence competencies really up the right term but culturally
868
02:59:54.540 --> 03:00:06.600
Kathy Kinlaw: Humble and listening members of health care teams so cultural humility, where we can develop some aspect of trust in working with our providers.
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03:00:09.240 --> 03:00:21.630
Kathy Kinlaw: To public health ethics as a discipline is really a systematic process that tries to clarify and prioritize and justify what are the courses of public health action.
870
03:00:21.960 --> 03:00:34.770
Kathy Kinlaw: And that we should be moving forward and they're based on ethical principles and values and beliefs of stakeholders scientifically available evidence and other information and this is the CDC definition that you see.
871
03:00:35.910 --> 03:00:47.730
Kathy Kinlaw: So I want to focus for a moment on the power of what it means to be attentive to public health and the ways that you all are and that isn't safeguarding the public's help
872
03:00:48.540 --> 03:00:59.400 Kathy Kinlaw: So that's a core commitment, of course, and in saying this each person's welfare and and the whole community as a whole, really.
873
03:00:59.970 --> 03:01:12.510
Kathy Kinlaw: Are important so they they mad matters to support each person and to support them in what I would call they're flourishing or their well being. So what opportunities exist.
874
03:01:12.960 --> 03:01:20.430
Kathy Kinlaw: And we are do individuals have capabilities that are supported capabilities for making your own decision.
875
03:01:20.850 --> 03:01:32.340
Kathy Kinlaw: For being creative for having enough information and understanding to to participate fully in decision making, essentially for loving ones potential you know fully
876
03:01:33.150 --> 03:01:40.800
Kathy Kinlaw: I think that's a powerful part of what we should be thinking about in terms of values and principles and public health ethics.
877
03:01:42.060 --> 03:01:47.580
Kathy Kinlaw: So there are a number of principles. If you guys have been working in the discipline knows that are important.
878
03:01:48.390 --> 03:02:02.400
Kathy Kinlaw: Certainly we talk a lot about maximizing benefit and minimizing harms and we're thinking about that, not just a first for individual patients, but for communities as a whole, I will say that that
879
03:02:03.300 --> 03:02:12.390
Kathy Kinlaw: articulation of a principle is sometimes called utilitarian ethics are the greatest good for the greatest number. So I think we have to
880
03:02:13.410 --> 03:02:16.710
Kathy Kinlaw: constrain that understanding of that by thinking about
881
03:02:18.120 --> 03:02:19.020
Kathy Kinlaw: Who else
882
03:02:20.130 --> 03:02:30.480
Kathy Kinlaw: Israel is going to be cared for, as we make this decision, so it's not a matter of just the good of the whole being maximized because that community about segments of our population.
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03:02:30.930 --> 03:02:38.670
Kathy Kinlaw: So there are some constraints on the idea of greatest good for the greatest number. We really need to think about fear distribution which we've already begun talking about
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03:02:39.360 --> 03:02:50.490
Kathy Kinlaw: And then and understanding the values of the communities affected. We have a lot of obligations by following the public health ethics analysis framework so
885
03:02:51.510 --> 03:02:57.990
Kathy Kinlaw: We need to do. I mentioned before that we need to do asset assessments. So who is already available in the community.
886
03:02:58.410 --> 03:03:07.320
Kathy Kinlaw: And one of our chat numbers Juliana mentioned how resourceful members of your community communities can be so recognizing that
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03:03:08.040 --> 03:03:17.880
Kathy Kinlaw: fully supporting the concept of interdependence and engaging and public participation engagement and involving sort of throughout the process.
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03:03:18.360 --> 03:03:24.750
Kathy Kinlaw: And of course respecting individuals along the way, even as you're caring for the community as a whole.
889
03:03:25.410 --> 03:03:33.690
Kathy Kinlaw: Another principle that's really powerful is the concept of transparency and that's come up in some of our, the former panels conversation.
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03:03:34.110 --> 03:03:46.440
Kathy Kinlaw: I'd say it's really based on a very deep respect for all persons and communities supporting values and principles and processes for allocation decisions to them be made very clear.
891
03:03:47.010 --> 03:03:51.870
Kathy Kinlaw: They should be understandable and they should be open for review along the way.
892
03:03:52.500 --> 03:04:05.610 Kathy Kinlaw: So these are powerful. And then we move to two of the principles that I think has tremendous bearing on our conversation today. And that, again, we have again talking about together and that is social justice and fairness.
893
03:04:06.420 --> 03:04:11.730
Kathy Kinlaw: As well as equity and I think equity must you know be named must be critically named
894
03:04:13.290 --> 03:04:18.750
Kathy Kinlaw: So when we talk about health justice and equity. We're talking about
895
03:04:19.830 --> 03:04:27.060
Kathy Kinlaw: Any steps that we can take to make sure that individuals and communities have equal opportunities to be healthy.
896
03:04:27.570 --> 03:04:39.540
Kathy Kinlaw: With an equitable distribution of benefits burns and opportunities for help to try to move toward equality so equity is really a primary concept here.
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03:04:40.350 --> 03:04:48.240
Kathy Kinlaw: So we need to be asking what are the causes of existing disparities and inequity in power we addressing what is needed in light of this,
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03:04:50.070 --> 03:04:58.410
Kathy Kinlaw: And so we've already talked about this with Dr. Hall. So I'm going to fairly quickly move through a few slides that simply emphasize the shortage of healthcare professionals.
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03:04:58.830 --> 03:05:06.780
Kathy Kinlaw: In order for us to look at disparities, we have to look at the lack of resources available as we think about access
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03:05:07.410 --> 03:05:22.020
Kathy Kinlaw: Number of patients per physicians in the rural areas, about two times that for the number of patients per physician in urban areas are fewer primary care physicians and then there's fewer pediatricians in the rural health, environment.
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03:05:23.580 --> 03:05:32.460
Kathy Kinlaw: More rural health providers, by the way, are nearing retirement. So we need to have a plan for attracting new health care providers to rural areas.
902
03:05:32.910 --> 03:05:40.230
Kathy Kinlaw: And of course the shortages, have an impact on health, such as indicated here. The, the team birth rate.
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03:05:41.130 --> 03:05:59.190
Kathy Kinlaw: Changes. We've talked a little bit about how far people have to travel in rural areas to to actually access a primary care provider and in Georgia. I'm constantly surprised at how many counties have one primary care provider in their, in their community.
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Kathy Kinlaw: Dr. Hall showed this slide. I think it's powerful to know that 174 world hospital close between
905
03:06:08.610 --> 03:06:27.270 Kathy Kinlaw: And now with a greater increase over the last decade. And this just highlights that in 2019 alone, we had 19 additional hospitals close to the there seems to be an increasing percentage or amount of hospitals that are closing
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03:06:28.500 --> 03:06:37.440
Kathy Kinlaw: There has been an assessment. This one is by the terrorists Rural Health Center that indicated, and this was back in January of this year pre
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03:06:39.420 --> 03:06:48.180
Kathy Kinlaw: In a sobering way that 454 hospitals were vulnerable to disclose to closure on that had not already
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03:06:48.600 --> 03:06:56.850
Kathy Kinlaw: Closed and again with much vulnerability in the southeast and in the lower Great Plains, so two regions that have already been hard hit.
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Kathy Kinlaw: And then looked at a number of variables and we can talk about that later if you're interested. And of course, in addition to
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Kathy Kinlaw: Whole hospital closures, there are particular services like obstetric services that have dropped drastically over the last decade and a half and are causing additional scarcity of resources in those counties and really in those regions as well.
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03:07:25.230 --> 03:07:27.090
Kathy Kinlaw: So, importantly,
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03:07:28.200 --> 03:07:30.570
Kathy Kinlaw: I want to focus for just a moment on
913
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Kathy Kinlaw: So back in April, we saw increasing warnings of financial concerns for already fragile rural hospitals, such as in this this article.
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Kathy Kinlaw: And then in August and continuing today this story continues. So the President of the Alabama Hospital Association indicated that nearly 80% of Alabama rural hospitals started out 2020 with negative balance sheets and just a week or two of cash on hand and then with Kevin
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03:08:06.540 --> 03:08:20.220
Kathy Kinlaw: A large percentage of their income drop as patients avoided coming in going to the emergency room or going going to doctors appointments or doing elective surgeries. So the financial situation if you will worsen further
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Kathy Kinlaw: So I think it's important that we recognize. We've talked a little bit about this today that there has been an exacerbation
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Kathy Kinlaw: As well as a light kind of shown making increasingly visible. The pre existing rural health disparities.
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03:08:35.430 --> 03:08:44.790 Kathy Kinlaw: So we know that in general, rural and urban that coke permitted co-morbidities certain ones place. Individuals more at risk for poor outcome with Kevin 19
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Kathy Kinlaw: And often there's an overlap with some of the most prevalent health conditions that Dr. Hall mentioned and causes of death enroll communities.
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03:08:54.360 --> 03:09:07.110
Kathy Kinlaw: Also associated with socioeconomic factors, poverty, lack of access and systemic racism. So we need to be able to address. Of course, these causes of inequity.
921
03:09:08.130 --> 03:09:08.820
Kathy Kinlaw: I will
922
03:09:10.020 --> 03:09:20.070
Kathy Kinlaw: Show you a couple of resources in case you're not familiar with them. I hope most of you are that there is a poet 19 health equity dashboard.
923
03:09:20.790 --> 03:09:25.890
Kathy Kinlaw: That has was funded by the Robert Wood Johnson Foundation and is
924
03:09:26.430 --> 03:09:39.630
Kathy Kinlaw: A partial partially run by colleagues at Emory that begins to look specifically at every county in the United States and gathers a number of the factors.
925 03:09:40.080 --> 03:09:48.540
Kathy Kinlaw: That impact, including comorbidities socio economic level housing, etc. So that's a powerful tool.
926
03:09:49.290 --> 03:09:59.310
Kathy Kinlaw: That you might be interested in and ask accessing also because of the racial data tracker. This is a joint project of
927
03:10:00.030 --> 03:10:11.700
Kathy Kinlaw: University Center for anti racism and in the cupboard tracker program which is interestingly was started by two journalists associated with the Atlantic in a volunteer basis.
928
03:10:12.360 --> 03:10:31.530
Kathy Kinlaw: This tracking system also shows you, for example by state, the percentage of the population that fall within various racial or ethnic groups and then the amount the percentage of individuals in that state that actually guide from
929
03:10:32.610 --> 03:10:49.890
Kathy Kinlaw: So you began to see the inequities and the disparities very clearly demonstrated and the last one that I'm sure most of you know certainly see the see folks do is the social vulnerability index, which takes into account about 15 different
930
03:10:51.510 --> 03:11:04.500
Kathy Kinlaw: Indicators or factors that lead to social vulnerability. So all of these are excellent tools as we think about further assessment assessments of our community and what we do so.
931
03:11:04.980 --> 03:11:19.440 Kathy Kinlaw: With my last couple of slides here next steps. I think that continued assessment of again an asset assessment things we have, but also where, where do we need to make a difference in particular communities.
932
03:11:19.950 --> 03:11:23.610
Kathy Kinlaw: As well as an emphasis on transparency about that. It's important.
933
03:11:24.180 --> 03:11:33.750
Kathy Kinlaw: That we do look for opportunities to be inclusive of all parts of our communities and public engagement and public involvement people at the table.
934
03:11:34.170 --> 03:11:40.470
Kathy Kinlaw: And there's an interesting initiative in Georgia that's been funded by the health care Georgia foundation called the to George's initiative.
935
03:11:40.740 --> 03:11:50.910
Kathy Kinlaw: That is working really closely with I think 11 different communities listening, they built their own Coalition's to to bring to the table to decide which way to go.
936
03:11:51.720 --> 03:12:06.600
Kathy Kinlaw: Gap identification of next steps valued by the community members themselves. We've talked a little bit about payment issues. And certainly, there were congressional congressional federal relief funds that were
937
03:12:07.740 --> 03:12:09.210
Kathy Kinlaw: Given an April.
938
03:12:10.290 --> 03:12:23.340
Kathy Kinlaw: So that would reimburse hospitals related to their Medicare payments, but there was finally a recognition that there needed to carve out funds for rural hospitals and covet 19 hotspots that made a difference.
939
03:12:23.910 --> 03:12:31.350
Kathy Kinlaw: We need continued and enhanced funding for Medicaid and Medicare Services workforce training.
940
03:12:31.980 --> 03:12:48.810
Kathy Kinlaw: Clinician placements. We there were some discussion of recruitment and retaining of clinicians in rural areas and how would we go about doing that, that, that is a powerful commitment and we may want to talk further about that. Sorry, moved on to quickly.
941
03:12:51.390 --> 03:12:53.970
Kathy Kinlaw: Okay, and then public education.
942
03:12:55.560 --> 03:13:01.710
Kathy Kinlaw: Invest investments in Telehealth and Telehealth. It's an interesting question. We see the pros and cons sometimes of Telehealth.
943
03:13:02.070 --> 03:13:14.130
Kathy Kinlaw: But being able to have that as a potential venue for accessing care. I think it can be powerful and I would ask us to be doing ethics assessments for all of the programs that we are
944
03:13:14.550 --> 03:13:16.170 Kathy Kinlaw: Considering as we move forward.
945
03:13:16.830 --> 03:13:30.240
Kathy Kinlaw: There are a number of projects or models and Lana when our earliest speaker talked about the Rural Health Information hub. There are number of projects there that might be interesting to you as you look for models moving forward.
946
03:13:30.930 --> 03:13:40.140
Kathy Kinlaw: So with that, again, giving our time, I'm going to stop and say thank you and would be happy to. If we have any time to answer questions or
947
03:13:41.940 --> 03:13:43.080
Kathy Kinlaw: Make further comments.
948
03:13:43.830 --> 03:13:57.960
Craig Wilkins: Good with Thank you Dr. Ho and this kilo. We do have time for one question, and it would be for each of you, um, the first question is for you. Specifically, Dr. Dr. Hall, um,
949
03:13:58.770 --> 03:14:12.630
Craig Wilkins: As as hospitals continue to close across the country. Can you talk about any innovations in the rural health care delivery system to continue insert ensuring access
950
03:14:13.890 --> 03:14:19.680
Craig Wilkins: Or other organizations filling gaps or new models of care emerging
951 03:14:21.240 --> 03:14:22.500
Diane Hall: That's a great question. Thanks.
952
03:14:23.700 --> 03:14:33.210
Diane Hall: So I did post in the Q AMP a there's a link CMS just announced their chart model which is specifically focused on rural hospitals. It's just announced last month.
953
03:14:33.690 --> 03:14:44.700
Diane Hall: And they've had a couple of different strategies that they've been employing. The other thing to notice the federal office of rural health policy that Dr Knutson mentioned
954
03:14:45.180 --> 03:14:56.730
Diane Hall: They have a lot of different grant programs where they are working to try to help rural hospitals, they they've got TA centers and different models that they're also trying
955
03:14:58.680 --> 03:15:19.560
Craig Wilkins: Okay. Thank you, Dr. Mo Mo, mo have a question for you. How can the feel of public health address the issue of access to care and rural areas when even the definition of concept of access to care is unclear and complex.
956
03:15:22.830 --> 03:15:33.300
Kathy Kinlaw: That's a great question. I mean, I really do feel that there are opportunities for us to start with where we are might start with our own communities.
957
03:15:33.630 --> 03:15:45.900
Kathy Kinlaw: Start with the kind of asset assessment that was discussed earlier to say, are there some beginning points that we can we can recognize that we can name.
958
03:15:46.560 --> 03:15:59.490
Kathy Kinlaw: And begin there. Now having said that, I really appreciate a Dr. Daniel Miller's comment about managing inequities is not enough. So in addition to moving from our local area.
959
03:15:59.910 --> 03:16:10.530
Kathy Kinlaw: And on specific issues that we can we can examine. I think we also have to be advocates in this area, and particularly advocates for understanding
960
03:16:11.850 --> 03:16:28.140
Kathy Kinlaw: The sources of inequities in our areas and cross states and actually now finally doing something about them. They're so long standing that there's a visibility, now that I think we might we could build on.
961
03:16:30.990 --> 03:16:42.090
Craig Wilkins: Okay. Okay. Thank you. Miss can law. So again, thank you, Dr. Hall MS kilo for your, for your presentation on this very important topic.
962
03:16:42.780 --> 03:16:53.130
Craig Wilkins: Before we move on to our next plenary session on on one leg. I want to know if you know that we are running a few minutes behind schedule but
963
03:16:53.730 --> 03:17:16.410
Craig Wilkins: We do have two very exciting remaining plenary sessions that will also include a student poster award session. So, um, so please stay around for this next to next two sessions and our student award system as well and we appreciate your patience. Okay. Our next plenary session.
964 03:17:18.120 --> 03:17:37.050
Craig Wilkins: will focus on looking at the physical determinants of rural health addressing the natural and built environment and environmental justice and humanities our two presenters today for this very important topic is Dr. Kristin a bill so
965
03:17:38.190 --> 03:17:46.680
Craig Wilkins: Dr. Bill. So currently serves as the Associate Professor within the department of social behavior health sciences program.
966
03:17:47.520 --> 03:17:55.980
Craig Wilkins: He's also the Program Director of Research and Evaluation Health Research Center, West Virginia University School of Public Health.
967
03:17:56.670 --> 03:18:07.950
Craig Wilkins: His research interests include Health Promotion Program evaluation and socio associate ecological determinants of physical activity, including policy and the built environment.
968
03:18:08.850 --> 03:18:21.690
Craig Wilkins: Dr. Bill, so has multiple peer reviewed publications about Morgantown area real trails health impact assessment physical activity. Planning and Evaluation of state level health
969
03:18:22.140 --> 03:18:33.420
Craig Wilkins: Promotion programming I primary focus of his recent research has been understanding that social ecological determinants of physical activity in rural areas of the United States.
970
03:18:35.310 --> 03:18:47.610 Craig Wilkins: Following him will be Dr. Leonard Altman, Dr. Leonard Altman currently serves as senior ethics consultant with citizens public health ethics and strategy unit.
971
03:18:48.630 --> 03:18:57.390
Craig Wilkins: Dr oatman provides ethics training and consults for CDC staff and programs including emergency response partner CDC.
972
03:18:58.110 --> 03:19:17.850
Craig Wilkins: Dr Orton been taught ethics and other topics at the college level, most recently he was senior associate for programs at the Tuskegee University National Center for ethics. So please welcome and welcome me in joining Dr abusive and Dr food for the presentations.
973
03:19:19.650 --> 03:19:25.110
Christiaan Abildso: All right, thank you Craig. It's a treat a real honor and a privilege to be here. Hopefully everybody can hear me all right.
974
03:19:27.000 --> 03:19:34.140
Christiaan Abildso: And with that, I'm going to try to catch us up on time a little bit. So we'll dive right in. I appreciate the introduction and everything.
975
03:19:34.680 --> 03:19:45.540
Christiaan Abildso: That is going on here. There we go, got control. So I'm going to talk specifically about physical activity as it relates to the determinants of rural health and the natural built environment.
976
03:19:46.920 --> 03:19:51.960
Christiaan Abildso: Along with just on behalf of colleagues that I've worked with on multiple projects about this.
977
03:19:52.800 --> 03:20:02.520
Christiaan Abildso: Nice colleagues are scattered throughout the US and do a lot of rural physical activity work. So I'll talk a little try to catch yourself a little bit talk for about 15 minutes or so and then turn it over to Dr. Workman
978
03:20:04.710 --> 03:20:12.750
Christiaan Abildso: So few of the things just to give you an outline of what all talk about all frame it right from the get go on the ethical issues.
979
03:20:13.350 --> 03:20:26.580
Christiaan Abildso: Talk a little bit about our approach in this work on positive deviance and and then talk about a couple of very briefly talk about some work we've done to understand what some of the natural and built environmental
980
03:20:27.630 --> 03:20:35.250
Christiaan Abildso: factors are that are associated with physical activity in rural places kick back for a few minutes here and and enjoy.
981
03:20:36.960 --> 03:20:44.370
Christiaan Abildso: So we saw we saw some of the public health ethics definitions and information on the last plenary I'm specifically going to be talking about
982
03:20:45.000 --> 03:20:56.070
Christiaan Abildso: How we work in rural areas to clarify prioritize and justify potential courses of public health action specifically as it relates to physical activity in this case.
983 03:20:57.060 --> 03:21:09.210
Christiaan Abildso: And and and working from a place where it is based on the ethical principles, listening to stakeholders in the values and beliefs of those stakeholders and building a good scientific evidence based
984
03:21:12.000 --> 03:21:27.300
Christiaan Abildso: Little more information about framing up the ethical issue, as we saw, thank you, Dr. Hall for saying it's not all doom and gloom in rural areas, but we do have health disparities in rural areas, as we all know, including, as we've mentioned a lower prevalence of physical activity.
985
03:21:30.090 --> 03:21:32.010
Christiaan Abildso: Now, what we know though on
986
03:21:33.390 --> 03:21:50.880
Christiaan Abildso: It from the scientific evidence is changing the natural or changing the built environment, those interventions are largely based on a very urban centric evidence base and my colleagues Renee, and Cindy from Baylor and Oregon Health Sciences university that
987
03:21:52.140 --> 03:21:59.160
Christiaan Abildso: We've written a few times over the last decade, basically, to look with work on expanding and learning from rural places so
988
03:22:00.660 --> 03:22:09.990
Christiaan Abildso: One of the ethical issues to consider today is whether it is actually ethical to recommend these rural built environment interventions that are largely focused on
989
03:22:11.400 --> 03:22:16.890
Christiaan Abildso: Planning and Zoning policy and heavily built on policy changes.
990
03:22:18.090 --> 03:22:26.550
Christiaan Abildso: Is it is it ethical to recommend those in rural areas in those based on a very proven centric evidence base so further we saw this in the last presentation.
991
03:22:27.900 --> 03:22:37.830
Christiaan Abildso: You know, there are many challenges that exist in rural places. We all know that. But there are also opportunities and we want to work from that public health ethical and
992
03:22:39.300 --> 03:22:49.200
Christiaan Abildso: One of the as dr Orban, and I were talking in preparing this one of the challenges for sure in the research enterprise is bringing in enough
993
03:22:49.710 --> 03:23:03.690
Christiaan Abildso: Resources to develop those long term relationships in these places that have been victims of extraction for generations of natural resources of people of health information and knowledge.
994
03:23:05.520 --> 03:23:16.020
Christiaan Abildso: You know, based on the doom and gloom. However, there is a powerful opportunity and we talked about this call the and colleagues wrote about the rural mortality penalty.
995
03:23:16.830 --> 03:23:27.810
Christiaan Abildso: With you know we can see the gap that has been created the rural areas are experiencing you know roughly 150 to 200 more deaths per hundred thousand people.
996 03:23:29.250 --> 03:23:31.200
Christiaan Abildso: And the trends are not good. So
997
03:23:32.310 --> 03:23:41.160
Christiaan Abildso: In the physical activity literature, however, we know that like globally, the lack of physical activity is the fourth leading cause of death so
998
03:23:41.520 --> 03:23:52.890
Christiaan Abildso: In these areas that are the least active, there is a tremendous opportunity if we can get people moving those that are least active, we can see the most benefits and health outcomes.
999
03:23:54.810 --> 03:24:09.180
Christiaan Abildso: So quickly shipping to our group. And what we've been doing thanks to the CDC, some of the French research center support to the physical activity Policy Research and Evaluation network peppering you can look them [email protected]
1000
03:24:10.950 --> 03:24:19.260
Christiaan Abildso: You know, in this iteration, the previous generations. We've had a rural act of living workers and we really have a chip on our shoulders to to build this world evidence base.
1001
03:24:20.550 --> 03:24:30.510
Christiaan Abildso: We have worked to identify some of the most active most rural places. Those are physical physical activity positive deviance. We'll talk about that a moment.
1002
03:24:31.290 --> 03:24:38.880
Christiaan Abildso: And then from there, we really are in our second purpose is to identify these environmental factors that are associated with physical activity.
1003
03:24:39.450 --> 03:24:51.240
Christiaan Abildso: Using national data sets at the county level. And then also, by going and listening going and doing in depth comparative case studies qualitative work in three counties and you can see
1004
03:24:52.500 --> 03:24:59.640
Christiaan Abildso: Our rural poverty deviant subgroup. We are from all over the country. And there are there are more that helped advise us as well.
1005
03:25:02.010 --> 03:25:13.230
Christiaan Abildso: So of course, for those that haven't worked and and haven't really read up on positive deviance. You know, one of the first things to better understand what it is. And it's a real positive spin on our philosophy to research.
1006
03:25:14.490 --> 03:25:20.610
Christiaan Abildso: This is largely done in very resource poor communities, mostly in developing nations.
1007
03:25:22.170 --> 03:25:27.240
Christiaan Abildso: Where you go and you find on through on the ground work a few individuals or families.
1008
03:25:28.080 --> 03:25:45.930
Christiaan Abildso: That are employing sort of uncommon beneficial practices that allow them in spite of their lack of resources to have better outcomes compared to their peers and their similarly impoverished neighborhood. So you can see actually back in 2002 there was a food and nutrition Bolton supplement
1009 03:25:46.980 --> 03:25:52.860
Christiaan Abildso: That looked at places all over the world and largely rural places in developing countries.
1010
03:25:54.090 --> 03:25:57.300
Christiaan Abildso: And trying to identify those beneficial practices.
1011
03:25:58.380 --> 03:26:04.740
Christiaan Abildso: I guess in common, common parlance, some of the Blue Zones work is is very much a positive approach.
1012
03:26:06.450 --> 03:26:07.110
Christiaan Abildso: So using
1013
03:26:09.390 --> 03:26:21.390
Christiaan Abildso: Work by Laura wire lingering and colleagues out of University of Washington. Please county level physical activity prevalence of meeting. Physical Activity Guidelines for the women and men with females and males.
1014
03:26:23.790 --> 03:26:24.630
Christiaan Abildso: You're back on.
1015
03:26:27.840 --> 03:26:46.890
Christiaan Abildso: And we identified essentially the positive deviance in the most from among the most rural places and not surprisingly, those are out west and in New England, whereas Appalachia in Morgantown, West Virginia, so it didn't surprise me that Appalachia and areas down in Texas.
1016
03:26:47.910 --> 03:26:49.650
Christiaan Abildso: Were some of the non positive
1017
03:26:50.730 --> 03:26:55.260
Christiaan Abildso: Sometimes I might shift calling and negative places that are not doing as well.
1018
03:26:57.540 --> 03:27:06.990
Christiaan Abildso: So quickly. I understand there are much greater details to this, but we use those. He was like 26 county level environment measures.
1019
03:27:07.500 --> 03:27:22.290
Christiaan Abildso: Social transportation and built and natural environment measures and and ran some exploratory factor analysis to clump them together and see work out of a parsimonious model we we could create
1020
03:27:22.830 --> 03:27:36.360
Christiaan Abildso: And then multiple linear regression to identify the association from those factors with the prevalence of mean physical activity guidelines separately for males and females, obviously there's much greater detail to that.
1021
03:27:37.680 --> 03:27:47.610
Christiaan Abildso: But we could we could get into it a little bit, but we defined morality as, as always, we talked about this in every presentation. We actually use 2010 census data.
1022
03:27:48.900 --> 03:27:56.010 Christiaan Abildso: The percentage of the population in rural areas in accounting or measures or county level. We actually started with core tiles.
1023
03:27:56.670 --> 03:28:07.710
Christiaan Abildso: But we found that those counties and you can see on the slide or 389 of them were 100% of the population is defined is living in a rural area, those were really dominating that
1024
03:28:08.310 --> 03:28:18.900
Christiaan Abildso: Top poor child morality. So we separated them. They were very different to separate them out and then decor tiles from there from rural a down to our least rural
1025
03:28:20.070 --> 03:28:20.850
Christiaan Abildso: Urban areas.
1026
03:28:24.600 --> 03:28:27.060
Christiaan Abildso: Sony oriented to the slide a little bit
1027
03:28:29.580 --> 03:28:31.590
Christiaan Abildso: On the left side here, receive
1028
03:28:33.690 --> 03:28:41.490
Christiaan Abildso: The regression coefficients for all the counties in the study. So all the counties around us, blue and are the
1029
03:28:42.540 --> 03:28:59.400 Christiaan Abildso: Are the regression coefficient for our natural environment factors, read our social environment green or built environment and the purple is or transportation environment factor. I'm going to focus only on the natural and built environment.
1030
03:29:00.480 --> 03:29:14.520
Christiaan Abildso: And what we can see in this pattern holds true for males that the natural environment factors stand out as being significant in every quarter or every, every quarter. I'll accept
1031
03:29:15.540 --> 03:29:18.150
Christiaan Abildso: Our least rural and most urban counties.
1032
03:29:19.470 --> 03:29:27.570
Christiaan Abildso: We also see in the green that the built environment measures are significant.
1033
03:29:28.650 --> 03:29:36.090
Christiaan Abildso: significantly associated with female Physical Activity Guidelines prevalent in our two most rural counties on the far right.
1034
03:29:37.830 --> 03:29:41.640
Christiaan Abildso: And our next word or most urban on the left.
1035
03:29:43.170 --> 03:29:44.970
Christiaan Abildso: Now what's interesting is that
1036
03:29:46.470 --> 03:29:54.840 Christiaan Abildso: The natural environment measures are driven by air temperature heat index and percent exposure to some we have some
1037
03:29:57.420 --> 03:30:07.170
Christiaan Abildso: You know we have some charts and data from many different data sets. So that's what really drove the natural environment. But that's not significant in those counties.
1038
03:30:08.220 --> 03:30:13.110
Christiaan Abildso: If we combine that with a look within the factors for the built environment.
1039
03:30:14.490 --> 03:30:32.730
Christiaan Abildso: the built environment in the rural be in the rural seed and most rural areas, the factors that loaded most heavily were access approximate access to elementary schools and parks, but in the urban area is generally just access to exercise opportunities.
1040
03:30:33.780 --> 03:30:51.180
Christiaan Abildso: And we think if we combine these are very preliminary analysis if we combine the natural and built measures, we see that in the urban areas, there is more protection probably an indoor facilities to be active and that negates the natural environment important
1041
03:30:52.410 --> 03:30:54.450
Christiaan Abildso: Like I said these are preliminary analyses.
1042
03:30:55.980 --> 03:30:58.530
Christiaan Abildso: And we're going to talk more about these
1043
03:31:02.160 --> 03:31:03.810
Christiaan Abildso: newly appointed in a second.
1044
03:31:05.190 --> 03:31:10.560
Christiaan Abildso: So like I said that the pattern holds true in the physical activity guidelines for me.
1045
03:31:11.670 --> 03:31:21.930
Christiaan Abildso: But from a, you know, national data set that only tells us from a big picture something you know if something's going on at the different world. And so actually went to Texas.
1046
03:31:23.010 --> 03:31:29.550
Christiaan Abildso: To visit the first time in Texas and did some more in depth case study compared a case that we work
1047
03:31:31.230 --> 03:31:40.740
Christiaan Abildso: And I went to two counties. You can see some details about those and green that were positive deviance and one in read the data from that county or in the red
1048
03:31:41.850 --> 03:31:50.400
Christiaan Abildso: That is not a positive deviance and basically we looked at to kind of distinct positive evening counties as far as you know what they look like.
1049
03:31:52.230 --> 03:31:55.020
Christiaan Abildso: Compared to the negative one. And you can see, I'm not going to
1050
03:31:56.490 --> 03:32:02.820
Christiaan Abildso: spend too much time on this, but you can see there's a definite difference in a physical activity guidelines for females and males.
1051
03:32:03.750 --> 03:32:15.150
Christiaan Abildso: And actually, some associations that are contrary. These are, you can see the proximity to elementary school, which is, as expected, but some contrary evidence about population density and access to exercise.
1052
03:32:16.800 --> 03:32:22.620
Christiaan Abildso: Which is why you can see why it's so complicated. Those are things from the urban evidence that would suggest
1053
03:32:23.640 --> 03:32:28.170
Christiaan Abildso: These. I'm sorry, the rural reversing and here is contrary to what we see in urban areas.
1054
03:32:29.190 --> 03:32:35.580
Christiaan Abildso: So the qualitative work comparative case study of those two positive deviant counties one non positive
1055
03:32:36.990 --> 03:32:43.710
Christiaan Abildso: Went to the largest municipality in the county and the next largest we definitely make sure that if the county seat.
1056
03:32:44.820 --> 03:32:51.090 Christiaan Abildso: Collected stakeholder interviews key stakeholder interviews snowball sampling, our primary contact with the Cooperative Extension agent.
1057
03:32:52.560 --> 03:33:01.380
Christiaan Abildso: And they introduced us to people from their work pretty nicely. We also did kind of person on the street interviews intercepting people
1058
03:33:02.550 --> 03:33:16.890
Christiaan Abildso: And talking to them about physical activity and the people and the places and the policies that really influenced them and also those of us that went just did experience experiential observations, walking, running, biking, whatever they've been just to get a feel for the place.
1059
03:33:20.280 --> 03:33:24.420
Christiaan Abildso: Well present person is kind of universal findings across all three counties.
1060
03:33:25.860 --> 03:33:33.420
Christiaan Abildso: And I think those that have been the Texas, it is no surprise that culturally sports are very important. So scholastic sports really matter.
1061
03:33:34.980 --> 03:33:46.230
Christiaan Abildso: What was interesting. Under this leisure activity. Of course, we measure when you hear time physical activity is our primary measure to the VR FSF but that concept may be difficult.
1062
03:33:47.340 --> 03:33:56.460
Christiaan Abildso: I heard essentially in all three counties variations of the quote that if it ain't working worth doing for literally two men and two different counties said
1063
03:33:57.090 --> 03:34:12.390
Christiaan Abildso: Boy, if I'm running, you better run to because somebody's chasing me. So this idea. And of course, I took it to heart. This idea very purposeful activity for work maybe easier to accept them for leisure activities or doing activity for my own health sake.
1064
03:34:15.180 --> 03:34:30.090
Christiaan Abildso: Universal was that legislative policies capital P policies do not matter as much as organizational policies and we'll see more about that in a moment. The little key policies mattered. And as we all know, human resources for physical activity are very limited.
1065
03:34:31.530 --> 03:34:43.410
Christiaan Abildso: So, what, what, and I'll, I'll conclude with this, but essentially when we compared what the themes to what we heard themes of what we heard positive EV accounting against the non positive
1066
03:34:44.490 --> 03:34:50.130
Christiaan Abildso: They tended to form for those that have worked in the community capitals framework, the tendency to fall in that capital.
1067
03:34:51.990 --> 03:35:01.650
Christiaan Abildso: So first social capital social harmony matters, the one non positivity county had a it was about a 30% population.
1068
03:35:03.000 --> 03:35:09.330
Christiaan Abildso: 30% of the population in their county seat was African American and I literally heard, quote unquote, those people
1069 03:35:10.530 --> 03:35:15.090
Christiaan Abildso: So social harmony definitely matters, and I did not hear that in the other counties that were
1070
03:35:16.830 --> 03:35:17.970
Christiaan Abildso: predominantly white though.
1071
03:35:19.920 --> 03:35:28.410
Christiaan Abildso: Social norms about lifetime physical activity are critical. So in the non positive EV accounting. It was very much about sports and nothing else.
1072
03:35:29.550 --> 03:35:44.520
Christiaan Abildso: But in the others. They were they did have like walking groups and other things to get people out doing leisure time activity. They had a Parks and Rec department in the to positive easy accounting and not in the one that was not applied.
1073
03:35:46.380 --> 03:35:52.590
Christiaan Abildso: So there was some interesting stuff going on their social capital human capital, obviously, limited, like I said,
1074
03:35:53.580 --> 03:36:03.330
Christiaan Abildso: But in that non positive Union County, the leadership of the county was not representative of that population was old and white and that was about it.
1075
03:36:04.080 --> 03:36:12.900
Christiaan Abildso: So the voice be heard, giving people the power very early on, there really was very limited power with people of color in that now and positivity.
1076
03:36:14.790 --> 03:36:21.840
Christiaan Abildso: Similarly, the amount of focus of the human capital on physical activity by those key leaders mattered.
1077
03:36:23.610 --> 03:36:28.620
Christiaan Abildso: In a non positive even a county. They were very much focused on substance use disorder.
1078
03:36:29.670 --> 03:36:31.740
Christiaan Abildso: Issues that we would probably associate
1079
03:36:33.360 --> 03:36:39.540
Christiaan Abildso: Just a child welfare issues and other things like that and not physical activity, though. I could hear sprinkling of
1080
03:36:40.080 --> 03:36:45.990
Christiaan Abildso: Intersection ality of those things to get people active to prevent such countries like that. They just weren't there yet.
1081
03:36:46.890 --> 03:36:52.650
Christiaan Abildso: Organizational capital matter to talk about little p policies before access to facilities.
1082
03:36:53.220 --> 03:36:59.160
Christiaan Abildso: Literally in the non positive Eaton County. They have beautiful new school facilities that were locked. They didn't let people in
1083
03:36:59.970 --> 03:37:10.050
Christiaan Abildso: Their schools will be on dates and barbed wire their playground in the positive even counting it with wide open actually invited people to use it pretty much at all times, other than when there is a football game.
1084
03:37:12.420 --> 03:37:17.790
Christiaan Abildso: Even the rodeos which are very, you know, popular very important to touch with those were locked
1085
03:37:18.900 --> 03:37:21.570
Christiaan Abildso: In the nonprofit world wide open in the positive one.
1086
03:37:24.960 --> 03:37:30.900
Christiaan Abildso: Lastly, in the financial capital piece. It was interesting to see the positive evening Academy is we're
1087
03:37:32.160 --> 03:37:46.590
Christiaan Abildso: pretty stable as far as appointment goes in one of them. They actually had a private prison that are just closed so the men actually we're starting to leave to do work remotely and send money back at work in shifts for weeks at a time back
1088
03:37:47.910 --> 03:37:55.050
Christiaan Abildso: But in a non positive even the county. They were dominated by shift work and nursing home some overnight healthcare kind of work.
1089 03:37:55.740 --> 03:38:07.410
Christiaan Abildso: So we surmise that that impacts things in a couple different ways. First is funding for public facilities for Parks and Rec, like I mentioned, there was no Parks and Rec department in the non Union County.
1090
03:38:08.430 --> 03:38:13.500
Christiaan Abildso: So budgeting was very tough when obviously family incomes increase and decrease
1091
03:38:14.730 --> 03:38:31.230
Christiaan Abildso: But also get impacted the human aspect because people would oftentimes picked up ships as much as they could, they were working in nonprofit been counting TV. They're working kind of the night shift so they can't really volunteer and be around for physical activity programming.
1092
03:38:32.370 --> 03:38:40.320
Christiaan Abildso: Schools just said, we take care of the children as much as we can. And they come to our house and they really care about these children because apparently
1093
03:38:42.510 --> 03:38:46.560
Christiaan Abildso: Um, so there's a lot of really complex stuff, try to summarize it here.
1094
03:38:47.730 --> 03:38:58.140
Christiaan Abildso: I'd be happy to take questions later. But I think I'm going to turn it over a call this interrogation time and I'm going to turn it over to Dr. Here, so I appreciate. I really do appreciate the time
1095
03:38:59.730 --> 03:39:01.440
Christiaan Abildso: And before to hear from y'all.
1096
03:39:03.990 --> 03:39:07.680
LeonardOrtmann: Thank you, Dr built. So, and before I turn to your
1097
03:39:08.790 --> 03:39:15.480
LeonardOrtmann: Discussion of your paper. I wanted to give a shout out from all the golden tigers. I saw on the chat session.
1098
03:39:16.830 --> 03:39:19.230
LeonardOrtmann: And as I mentioned, I have rest.
1099
03:39:20.280 --> 03:39:30.360
LeonardOrtmann: The introduce her mentioned I taught for a number of years at Tuskegee University National Center for bio ethics and I lived in city of Tuskegee for a number of years.
1100
03:39:31.230 --> 03:39:41.610
LeonardOrtmann: And so tell a little story about that, that when I live there, you know, had some neighbors one neighbor, in particular, used to use this saying. I think it's a
1101
03:39:42.330 --> 03:39:54.570
LeonardOrtmann: Provides a subtext for all I'm gonna say, and when he'd be describing the city of Tuskegee, he'd some times conclude by saying it ain't much but it's ours.
1102
03:39:55.560 --> 03:40:05.310
LeonardOrtmann: And I think that saying sort of is is is very interesting. The first part in a much sort of reflects what people from the outside.
1103
03:40:05.790 --> 03:40:11.640
LeonardOrtmann: Might think of it, you know, you know, compared to Atlanta or Auburn or or Montgomery.
1104
03:40:12.510 --> 03:40:30.480
LeonardOrtmann: Maybe Tuskegee doesn't seem like much, but it's their home and by saying it's ours. They own it, they affirm it and they recognize it that you know it's it's their place. So I think that's very important. And I think it's very relevant also to to you're talking into your approach.
1105
03:40:34.980 --> 03:40:38.880
LeonardOrtmann: Okay, monitoring advancing or
1106
03:40:40.140 --> 03:40:40.920
LeonardOrtmann: How to do that.
1107
03:40:45.030 --> 03:40:45.450
Christiaan Abildso: You should
1108
03:40:47.280 --> 03:40:47.970
Christiaan Abildso: Know, there we go.
1109
03:40:49.230 --> 03:40:54.570
LeonardOrtmann: Oops. So there's a disclaimer. These are my views and not the views of the CDC.
1110
03:40:57.270 --> 03:41:05.880
LeonardOrtmann: So what I'm going to do is distinguish complementary approaches to public health interventions. And those are what I'm calling a top down, public health.
1111
03:41:07.110 --> 03:41:19.020
LeonardOrtmann: Perspective versus a bottom up public health perspective and I'm going to interpret Professor a bill toes approach to positive deviance in terms of this top down. Bottom up distinction
1112
03:41:22.020 --> 03:41:25.200
LeonardOrtmann: So the top down, public health interventions.
1113
03:41:26.430 --> 03:41:33.930
LeonardOrtmann: To describe that I'm going to use former director of CDC director Tom Frieden notion of winnable battle criteria.
1114
03:41:34.980 --> 03:41:39.990
LeonardOrtmann: And those were that you know you have data on the burden or impact of a certain condition.
1115
03:41:41.220 --> 03:41:49.230
LeonardOrtmann: You have evidence based solutions that address that burden and that that you have the ability to scale up
1116
03:41:49.920 --> 03:41:58.350
LeonardOrtmann: Your intervention. So the size of the burden and tools to evaluate the success of your interventions. And if you have all those
1117
03:41:58.890 --> 03:42:11.910
LeonardOrtmann: Criteria, and according to Dr. Freedom. You had a winnable public health battle and it you know this is more or less as a condensed version of what you might say the traditional public health science approach.
1118
03:42:15.390 --> 03:42:26.400
LeonardOrtmann: Now, this whole approach the efficiency of and the scalability of this top down approach depends on these interventions being replicable in a variety of settings.
1119
03:42:27.450 --> 03:42:44.010
LeonardOrtmann: However, you cannot always assume they are and the picture there illustrates that when they aren't you can make the mistake of trying to shove a round intervention into a square hole. It just might not fit the particular community in question.
1120
03:42:46.560 --> 03:42:52.140
LeonardOrtmann: So that's when this notion of a bottom up public health intervention arises.
1121
03:42:53.160 --> 03:43:07.170
LeonardOrtmann: And it's really the idea of finding the best fit for the community. So we not only need evidence based practice, we need practice based evidence. First, you know, that's based on working with communities and seeing what works.
1122
03:43:09.720 --> 03:43:10.200
LeonardOrtmann: And so
1123 03:43:11.430 --> 03:43:18.900
LeonardOrtmann: I, you know, it mentions that I'm in the Office of Science, or I am in the Office of Science at CDC and one of our
1124
03:43:19.590 --> 03:43:27.600
LeonardOrtmann: Other offices or divisions. There is the Office of tech innovation and they've been pushing this idea of human centered design and public health.
1125
03:43:28.200 --> 03:43:45.900
LeonardOrtmann: And its really represents sort of almost the essence of what you you get when you're you emphasize community engagement stakeholder analysis or community based participatory approach and it begins with an empathic listening to your end users.
1126
03:43:46.950 --> 03:43:57.450
LeonardOrtmann: Excuse me, to the community and I noticed that in several of his slides. Dr built so talks about all the discussions, he had with
1127
03:43:57.840 --> 03:44:07.140
LeonardOrtmann: With people in the communities that he researched. So you really have to get out there and see what that community is like and you need to translate
1128
03:44:07.890 --> 03:44:17.100
LeonardOrtmann: This community input into intervention design. You can't simply take something that was developed and works in an urban setting and believe
1129
03:44:18.060 --> 03:44:27.270 LeonardOrtmann: That it's necessarily going to work in some other setting. So even if you do begin with something from elsewhere. You always have to run it by the Community.
1130
03:44:27.900 --> 03:44:38.850
LeonardOrtmann: And so the the end goal you want is something which you might call user friendly design something that has been designed for the end user, not something that oh
1131
03:44:39.420 --> 03:44:45.960
LeonardOrtmann: You know, I want to do this research. I'm going to fly in here conduct this research because you know this worked in Detroit or this
1132
03:44:46.260 --> 03:44:55.560
LeonardOrtmann: This worked in some other cities and I'm, you know, and I'm just going to sort of treat the the population here. As you know, the next sort of installment of this
1133
03:44:56.160 --> 03:45:04.650
LeonardOrtmann: Model to be replicated. Instead, which have to do is, you know, even if you do have some preconceived notions. You want to talk to the community.
1134
03:45:05.100 --> 03:45:16.620
LeonardOrtmann: And you want to get their input. You want to have several iterative loops of discussion with them to make sure that the product that you get is going to resonate with that community.
1135
03:45:19.050 --> 03:45:21.120
LeonardOrtmann: Okay, so looking now at with
1136
03:45:22.140 --> 03:45:25.500
LeonardOrtmann: Dr. Bill to is done with his notion of positive deviance.
1137
03:45:25.980 --> 03:45:32.940
LeonardOrtmann: He avoids attempting to replicate what works in urban settings to rural settings and I know several speakers have mentioned this idea that
1138
03:45:33.210 --> 03:45:39.090
LeonardOrtmann: You know, you can't just take stuff that worked in an urban environment and assume it's going to work somewhere else.
1139
03:45:39.600 --> 03:45:52.710
LeonardOrtmann: Rather you want to find indigenous solutions that taps into community resilience, you know, and a lot of times we hear when we're talking about rural health or minority health
1140
03:45:53.760 --> 03:46:13.530
LeonardOrtmann: We always hear the bad side that these communities have, you know, have all these terrible health measures that they're full of health disparities compared to, you know, white populations, but I think that's, you know, you have to look at the glass half full, sometimes and see that
1141
03:46:14.670 --> 03:46:26.640
LeonardOrtmann: You know, these, these folks in these areas have survived. Despite all these disparities, despite the fact that on measures of social determinants of health. They lack resources.
1142
03:46:27.030 --> 03:46:42.780 LeonardOrtmann: They lack hospitals education level is low, and yet you know they have survived and like my friend and neighbor and Husky. He says, you know, it may not be much but it's ours, and they are affirming that life so
1143
03:46:43.980 --> 03:46:50.250
LeonardOrtmann: So if you're looking for solutions that might work. It's going to be more likely that such solutions will be appropriate.
1144
03:46:50.700 --> 03:47:01.470
LeonardOrtmann: In other similar counties. And so this is what I liked about Dr. A bill toes approach that he went and talked to folks in rural communities that
1145
03:47:01.920 --> 03:47:18.600
LeonardOrtmann: Manifested these positive deviance and if you're going to begin a discussion with other rural communities, you're going to take a solution that I think is, you know, halfway there towards this notion of a bottom up approach.
1146
03:47:19.800 --> 03:47:26.790
LeonardOrtmann: Where you're going to discuss it with the communities. But you know what you're going to take as your
1147
03:47:27.240 --> 03:47:35.910
LeonardOrtmann: Preliminary model is one that stands a much, much better chance of working in those communities because it's from a community.
1148
03:47:36.630 --> 03:47:41.340
LeonardOrtmann: That is similar to theirs. So you'd still need to engage with these communities.
1149
03:47:42.000 --> 03:47:49.200
LeonardOrtmann: Even if you, you know, you couldn't just assume that something that worked in one rural area is going to work and another
1150
03:47:49.740 --> 03:48:02.730
LeonardOrtmann: But it's more likely, and it's more likely that you will achieve this end goal a user friendly intervention and one that resonates with other rural communities. So I applaud.
1151
03:48:03.360 --> 03:48:23.190
LeonardOrtmann: Dr built so far for his work. I think it's cutting edge. I think it is really listening and engaging with communities. And I think he's going to have a lot of success with that. So on that note, I'm going to stop and be willing to entertain any questions. Thank you.
1152
03:48:40.230 --> 03:48:43.440
Craig Wilkins: Okay, thank you very much Dr Hartman and Dr.
1153
03:48:44.640 --> 03:48:45.060
Craig Wilkins: O B.
1154
03:48:46.710 --> 03:48:47.280
Christiaan Abildso: Worry about it.
1155
03:48:50.520 --> 03:48:50.940
Craig Wilkins: Okay.
1156
03:48:52.560 --> 03:48:54.300
Craig Wilkins: So we have one question that
1157
03:48:55.380 --> 03:48:57.450
Craig Wilkins: That came in wanted to ask
1158
03:48:58.650 --> 03:49:03.330
Craig Wilkins: The question is, um, I think this is particularly for you, Dr. Ray.
1159
03:49:04.440 --> 03:49:05.940
Craig Wilkins: Have you done any work.
1160
03:49:07.230 --> 03:49:08.820
Craig Wilkins: To examine the role
1161
03:49:11.100 --> 03:49:14.940
Craig Wilkins: The role inter generational poverty plays within rural communities.
1162
03:49:16.920 --> 03:49:17.760
Christiaan Abildso: No, I haven't.
1163 03:49:19.290 --> 03:49:25.950
Christiaan Abildso: I can almost guarantee if we're I haven't with regard to physical activity. Specifically, and that's that's primarily my focus
1164
03:49:27.360 --> 03:49:34.110
Christiaan Abildso: I can almost guarantee that folks have I've never really looked into that data that literature.
1165
03:49:35.280 --> 03:49:43.650
Christiaan Abildso: But I can almost guarantee people have different health outcomes, rather than the behavior of physical activity. I appreciate that question.
1166
03:49:50.670 --> 03:49:59.100
Craig Wilkins: Okay, um, again, we want to thank both of you very much for your participation in today's forum and addressing
1167
03:50:00.180 --> 03:50:11.730
Craig Wilkins: A very important topic, looking at addressing the natural built environments environmental justice and communities. So thank thank you both for your participation based form.
1168
03:50:13.110 --> 03:50:13.470
Christiaan Abildso: Thank you.
1169
03:50:14.430 --> 03:50:15.390
LeonardOrtmann: My pleasure. Thank you.
1170 03:50:17.160 --> 03:50:18.510
Craig Wilkins: And now I would like to
1171
03:50:20.610 --> 03:50:32.400
Craig Wilkins: Turn it over to my colleague, Dr. Karen boy. Yay. Dr. Boyce day is a Senior Advisor for research and have scientists here within our office and Cs go to be
1172
03:50:33.930 --> 03:50:41.880
Craig Wilkins: This is going to be talking and presenting on our student poster award system. So Dr. Bohr. Yay. The floor is yours.
1173
03:50:52.380 --> 03:50:53.310
Craig Wilkins: We can't hear you.
1174
03:51:10.050 --> 03:51:13.080
Craig Wilkins: Oh yeah. Are you are you by chance from mute.
1175
03:51:30.780 --> 03:51:31.260
Craig Wilkins: Okay.
1176
03:51:33.240 --> 03:51:39.360
Craig Wilkins: Okay. All right. We're good. We're gonna stop the presses here and see if we could find out, find out
1177 03:51:41.340 --> 03:51:41.580
Craig Wilkins: Why
1178
03:51:42.630 --> 03:51:42.990
Craig Wilkins: Okay.
1179
03:51:44.250 --> 03:51:44.700
Craig Wilkins: Yes.
1180
03:51:44.880 --> 03:51:47.970
Karen Bouye: I don't know what was wrong with the computer, but we were unmuted.
1181
03:51:48.510 --> 03:51:56.010
Karen Bouye: Okay, I'm Dr. Boy Yeah and minority health and health equity. I'm going to be very brief because we are running behind time
1182
03:51:56.700 --> 03:52:04.380
Karen Bouye: So, therefore I'm going to do is only introduce you to the students. We had a student poster presentation.
1183
03:52:05.130 --> 03:52:22.620
Karen Bouye: And it consisted of eight students out of the eight students. We had three students that were awarded third second and first place those students will be speaking today. And they're also going to receive awards and they will be eligible to publish their work.
1184 03:52:23.700 --> 03:52:32.280
Karen Bouye: In the Journal of healthcare science and humanities published by the National Center for Healthcare and research at Tuskegee University.
1185
03:52:32.940 --> 03:52:42.150
Karen Bouye: The first place winner is Mr. Christopher Lawrence, who is a doctor for your post doctoral scholars at Northwestern University.
1186
03:52:43.110 --> 03:53:01.380
Karen Bouye: Institute for sexual and gender minority health and will be the second place winner is Miss Kellen banks from more veal Alabama Monroeville. I'm sorry, Alabama. Recent who recently graduated from Tuskegee, Alabama.
1187
03:53:02.730 --> 03:53:28.380
Karen Bouye: The first place winners are Miss Katherine Gonzales was currently a doctoral student in the community. Research and Action Program at Vanderbilt University and Miss Lee random was currently pursuing pursuing a PhD or community Research and Action at Peabody college at Vanderbilt University.
1188
03:53:29.550 --> 03:53:35.010
Karen Bouye: I'm going to ask Mr Christopher Owens to please give us a brief.
1189
03:53:36.420 --> 03:53:37.620
Karen Bouye: Overview of his work.
1190
03:53:40.800 --> 03:53:42.120
Chris Owens: Hello. Can everybody hear me.
1191
03:53:43.080 --> 03:53:44.730
Karen Bouye: Yes, perfect.
1192
03:53:45.360 --> 03:53:56.220
Chris Owens: Hello, everyone. I'm very excited to be here. So my project was based on my dissertation, which is a community based project where a local aid service organization who serves a rural
1193
03:53:56.820 --> 03:54:08.370
Chris Owens: Area in a Midwestern state and I collaboratively interviewed gay and bisexual men who live in rural areas in that state and who are living with HIV.
1194
03:54:08.940 --> 03:54:14.490
Chris Owens: About their lived experiences of being in and going through the world HIV care continuum.
1195
03:54:15.210 --> 03:54:30.960
Chris Owens: And our results really show and speak to three ethical considerations and the first is the ethics of measurement. So how do we measure the success of the world HIV care continuum, rather than just measuring blood tests.
1196
03:54:31.590 --> 03:54:37.380
Chris Owens: Our participants face social determinants of health. So how else can we measure social determinants of health and
1197
03:54:38.100 --> 03:54:47.490 Chris Owens: Successes within that. The second is the ethics of practice. So how can we incorporate HIV care into primary care services.
1198
03:54:47.970 --> 03:54:57.300
Chris Owens: Which we know that HIV care services, are lacking in rural areas. So how can we incorporate these into primary care settings. And the third is the ethics of decision making.
1199
03:54:57.930 --> 03:55:05.130
Chris Owens: Social workers and public health practitioners, as we know, are quite embedded and thinking about social determinants of health.
1200
03:55:05.790 --> 03:55:16.920
Chris Owens: So how can we elevate them to be policy decision makers, not only on a national level, but also state and regional levels and we think about world. Each of each her policies. So thank you.
1201
03:55:24.570 --> 03:55:31.980
Karen Bouye: Chris is the third place winner. Now we're going to the second place winner who is Miss Kelly. Thanks for 50
1202
03:55:35.550 --> 03:55:36.450
Kellon Banks: I can you all hear me.
1203
03:55:40.290 --> 03:55:41.700
Karen Bouye: Okay, now we can see you.
1204 03:55:42.870 --> 03:55:51.720
Kellon Banks: Good evening, everyone. My name is Carolyn banks as she stated, I am a recent graduate from Tuskegee University his master's in public health program.
1205
03:55:52.170 --> 03:56:04.890
Kellon Banks: I'm extremely grateful, just to be able to have the opportunity to briefly present my research to you all, which was on the knowledge and awareness about cervical cancer and human papillomavirus among women living in Macon County, Alabama.
1206
03:56:06.240 --> 03:56:17.730
Kellon Banks: So cervical cancer is a malignant tumor that grows in the lower area of a woman cervix. It's typically caused by different strains of human papillomavirus, which is also commonly known as HPV.
1207
03:56:18.690 --> 03:56:28.680
Kellon Banks: Album actually possesses the highest death rate for cervical cancer in the country. And most of those deaths take place in underserved populations that are similar to the County, Alabama.
1208
03:56:29.790 --> 03:56:39.480
Kellon Banks: Many people like the knowledge about HPV vaccinations and its ability to prevent cervical cancer if paired with the proper screenings. So the purpose of this
1209
03:56:40.260 --> 03:56:45.510
Kellon Banks: Study was to simply increase knowledge and the intention to have cervical cancer screenings.
1210
03:56:45.900 --> 03:56:56.280
Kellon Banks: By administering pre and post questionnaires pertaining to cervical cancer and HIV AWARENESS before and after a short term educational based intervention.
1211
03:56:57.180 --> 03:57:02.100
Kellon Banks: So I began campaigns around making county to sort of introduce the nature of the study to the community.
1212
03:57:02.910 --> 03:57:08.490
Kellon Banks: Pre and post questionnaires we utilized for the collection of data before and after the intervention.
1213
03:57:08.880 --> 03:57:15.840
Kellon Banks: And then descriptive statistics using chi square and frequency test work performed for analysis using SAS software.
1214
03:57:16.380 --> 03:57:28.200
Kellon Banks: So we had a total of 100 women participants 85% of which self identified as black 65% were over the age of 30 and making List of $50,000 a year.
1215
03:57:28.620 --> 03:57:42.780
Kellon Banks: 62% live in the Tuskegee community 73% were either single without or divorced and more than 80% were in between their first year of college and graduate school and 40% we're currently working for pay
1216
03:57:43.920 --> 03:57:51.390
Kellon Banks: So I'm based on the stars, the finding show increase in the participants knowledge, following the intervention.
1217 03:57:51.840 --> 03:57:58.020
Kellon Banks: There was also a level of significance between the participant education level. And if they knew what cervical cancer was
1218
03:57:58.380 --> 03:58:10.740
Kellon Banks: So I'm finding suggests that cervical cancer interventions and treatment patterns targeted and disadvantaged women, particularly those living in black communities and rural communities such as Macon County.
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Kellon Banks: Could have the potential to dramatically reduce high rates of cervical cancer with hopes of eventually eradicating this disease. Um, so that concludes my brief overview of my research, I would like to thank the organizers and judges for granted me with this opportunity.
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Karen Bouye: Thank you. Carolyn. Okay, now we have the first place mentors who are Catherine Gonzales and Miss Lee Brennan.
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Catherine Gonzalez: Good afternoon everyone can hear me.
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Catherine Gonzalez: Our poster was on addressing rural health
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Catherine Gonzalez: Equity and access in rural Tennessee. So rural populations in the US are experiencing a decline in access to health care as rural hospitals are closing rapid rates.
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Catherine Gonzalez: Since 2010 131 hospitals have closed across the US with the majority occurring in the southeast Tennessee holds the second highest rate with about 14 hospital closures and the highest rate possible closures per capita.
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Leah Branam: To further understand the impact of hospital closures three focus groups were conducted in five rural communities in Tennessee in partnership with the Tennessee healthcare campaign.
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Leah Branam: Focus groups and questions centered on who is impacted the most by closure how closure decisions were made and communicated
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Leah Branam: Know could have helped prevent a closure within the community. And then what helped mitigate the effects of a closure on the Community.
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Leah Branam: And focus group sessions were held in Clay County Carroll County and a virtual session with Campbell Scott and fentress counties. Overall, there were 40 participants in the focus groups.
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Leah Branam: And then Kathryn and I independently review transcripts and coded them for themes and then these reviewed by the team at th DC
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Catherine Gonzalez: Several things evolved around the significance of structure on contextual factors in shaping the differential experiences of community residents.
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Catherine Gonzalez: The first being the level of awareness of key community stakeholders enclosure decisions.
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Catherine Gonzalez: And our focus groups, there are patterns of board members, not being don't notified about the decision until immediately before the closure.
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Catherine Gonzalez: Or misinformed about the financial stability of the hospital, leaving them very blindsided
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Catherine Gonzalez: The second being concerns and dissatisfactions on the process of informing residents about the closure.
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Catherine Gonzalez: This include a hospital staff who were told that as long as they admitted one patient, they wouldn't have to worry or doubt their job stability, many of them came to find out that that was important.
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Catherine Gonzalez: And how doctors brought in more patients that would have made a difference to the closer decision.
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Catherine Gonzalez: The third being about the disparate impact of eliminated services on everyday life experiences. This includes a loss of Obstetrics care emergency and specialty services, as well as dramatic increases in travel time to hospital.
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Leah Branam: The fourth being focused on the varying sense of responsibility that a hospital can have towards the community.
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Leah Branam: Many participants identified that corporate hospitals do not seem to feel that they owe the community any input in the closure process. Well, that would not have been the case for the public on hospital.
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Leah Branam: The 15 demonstrated the residents concern about the long term impact of the hospital closure on the communities economic well being, including
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Leah Branam: Real Estate tourism and other industries, moreover, without a local hospital employees and patients were spending less money at local businesses.
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Leah Branam: And the 16 highlighted the ways in which other organizations or services have had to compensate for the lack of a local hospital.
1243
04:01:13.410 --> 04:01:23.190 Leah Branam: So police officers are responding more to mental health issues than they did previously and Ms personnel are also having to provide more emergency care as the distance to hospital as much farther
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Leah Branam: So in conclusion, multiple public health ethical concerns were identified through our analysis, including how hospital closure decisions are made.
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Leah Branam: Which stakeholders are involved in who justifies these decisions addressing addressing these questions is critical in terms of ethical responsibility of ensuring access to healthcare and rural hospitals and rural communities with competing private and public interest.
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Catherine Gonzalez: The current findings will be utilized to inform future policy recommendations at the federal, state, and local levels.
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Catherine Gonzalez: And company to compile it's okay with community strategies to prevent or mitigate the effects of hospital closure. Finally, we want to thank THC see for all their hard work in developing this project and allowing us to be a part of it. Thank you, everyone.
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Karen Bouye: For your point, like to thank each of you for presenting today and for participating in the holster process.
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Karen Bouye: And I'm not sure if we have any time for questions and answers.
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Karen Bouye: Do we correct
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Craig Wilkins: No, we didn't have any
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Craig Wilkins: Questions that came through.
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Craig Wilkins: Tony. Thank you, Dr. Boy, yay. And then, particularly each of you for your, for your presentations, your poster presentations and congratulations to the winners, but you so much.
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Karen Bouye: Thank you. And I think these were excellent presentations.
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Craig Wilkins: Yes, they were. Thank you.
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Craig Wilkins: Okay. Um, so we're up to our final presentation for today's um form. Um, I'm Dr. Car James I'm closing forum is working to achieve have equity in your community.
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Craig Wilkins: Dr. James currently serves as President and CEO at grantmakers in health. Prior to joining GH
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Craig Wilkins: Dr. James served as Director of the Office of Minority Health at the Center for Medicare and Medicaid Services.
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Craig Wilkins: Where she provided leadership vision and direction to advance the United States Department of Health and Human Services.
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Craig Wilkins: And CMS goals related to reducing disparities and achieving health equity for vulnerable populations, including racial and ethnic
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Craig Wilkins: Populations persons with disabilities sexual and gender minorities and persons living in rural communities.
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Craig Wilkins: Under her guidance CMS developed its first CMS equity plan to improve quality in Medicare its first rural health strategy.
1263
04:03:59.970 --> 04:04:19.740 Craig Wilkins: Created an ongoing initiative to help individuals understand their coverage and connect to care increase the collection and reporting of demographic data and developed numerous resources to help stakeholders in efforts to reduce disparities. Please join me in welcoming Dr. James
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Cara James: Good afternoon and thank you so much credit for that warm introduction and congratulations as well to our students literacy just about it. It's really exciting to see the future of our workforce researchers
1265
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Cara James: So here I am going to move us quite quickly here, so I know I am holding you up between whatever activities, you have to celebrate the end of the week. And as we are moving forward. So trying to just figure out
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Cara James: And maybe not so the control panel here for. There we go. Okay, so today let's talk a little bit about achieving how faculty and rural
1267
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Cara James: America, and you've already heard me to where I am now at grant makers and health and we are an organization that's working with over 240 health
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Cara James: Centers or lack of the organization's with the serving organizations to improve health outcomes through better philanthropy and you can see the number of the areas in which we are engaged and including
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04:05:28.560 --> 04:05:40.530
Cara James: Rural Health you've already heard about the disparities that we see in rural communities compared to urban areas as well as a number of the challenges that they face.
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Cara James: I was asked to talk a little bit about going to come up with disparities that I think that there's also been something we have covered in the afternoon, but just want to highlight that.
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Cara James: It is something that is affecting nearly overall calories and has been touched by so many of them have a number of
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Cara James: Deaths and even see the real case rate is lower, but does not know that it is not have a strong impact on those health systems which tend to be smaller.
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Cara James: The other thing is learning look at song the data of where it's happening locally. You can see that the incidence rates in the cases that are popping up or in some cases very comparable to some of the top
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04:06:22.620 --> 04:06:34.620
Cara James: Urban Counties that we have. But in terms of what we were talking about, really, that was asked to focus on today. Just want to provide a little bit of a snapshot of some of the racial ethnic disparities that we see in rural communities.
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Cara James: And much of what I'm going to present it worked out. We were doing when I was at CES with our colleagues here at the Office of Minority Health and Health Equity, including carefully as you just saw, so
1276 04:06:47.340 --> 04:06:52.980
Cara James: Are the great opportunity for us to work together to look up and showed light on some of the disparities that we see.
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04:06:53.850 --> 04:07:01.410
Cara James: And one of the reasons that it's important as we think about rural communities, our friends lives there. I think these are some of the images that people really
1278
04:07:01.770 --> 04:07:07.350
Cara James: Kind of come to mind and left. So do we think about the diversity of our community.
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04:07:08.040 --> 04:07:14.700
Cara James: Clearly, in our urban areas. They are more diverse and rich farming goods and number of racial and ethnic minorities, but it's just not
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Cara James: That there isn't diversity within rural communities by race, ethnicity,
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Cara James: So this is the data from the last sentence in terms of what the distribution of population look like and you can see that in Metropolitan Council that
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Cara James: About 60% of the population identified as non Hispanic white, whereas the whole communities. It was closer to 80%. We'll see what the change is and who's next census, as we move forward.
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Cara James: The other thing or diversity is represented by just by reflectivity by the number of other communities that we have several million individual to our
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Cara James: LGBT and rural communities as well as a number of individuals with disabilities.
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04:08:00.180 --> 04:08:10.140
Cara James: Who are living in these communities. So there's a lot of diversity that we see. I'm going to focus project my comments today and discussion on racial and ethnic disparities within
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Cara James: A session to look at some of those challenges and as a highlight few there's not going much as we would like to kind of make sure we pick pretty close to time.
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Cara James: So as we look at their core help you can see overall about one in five adults in all communities identifies our health Israel poor but hi Rita.
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Cara James: Found for those who are African American or black, it's going to come next, as well as those who are American leaders and Alaska Native
1289
04:08:39.210 --> 04:08:54.810 Cara James: When we look at obesity rates in rural community, we see that there as in other communities higher rates of obesity. For those who are African American really concerning is like a bar of the 12 Christianity have a BMI over 40
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Cara James: As well as high res and recommend meals at Alaska Native
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Cara James: We also see in terms of the access to coverage earlier about some of the challenges that rural communities have in general, but within those rural communities to see that.
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Cara James: Hispanics African Americans also have more challenges associated with activity because she was reporting that they didn't have a doctor's visit do to coverage will help coverage. Sorry. And similarly fitness we that
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Cara James: We started at CMS putting out a little disparities report, similar to what the national health care disparities, the national health care quality reported within that size. The heat is all caps measures and Medicare Advantage and fee for service.
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Cara James: And this shows including look at those that he has clinical quality measures in Medicare Advantage, but within the planets that are in contract in rural area.
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Cara James: Fisheries, you can see that a number of them that African American or Hispanic beneficiaries have worse quality of care of don't care to those who are
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Cara James: non Hispanic white and there are some letters for which we already groups are receiving better care. Those are the ones in yellow at the top of that.
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Cara James: But overall, we can see that disparity. One other thing to note is that not always do we see that the disparities.
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Cara James: Are worse for our communities of color will shows you with depression that while we do have higher rates for those who are like me and and Alaska Native
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Cara James: next highest ratings actually experienced by those who are not a fan of light in rural communities and lower rates experienced by other populations.
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Cara James: We also know that where you live ladders. And when we look at disparities. I just pull up within
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Cara James: The State of Georgia and there's there's are grappling or they're having Medicare disparities tool that was developed by the Centers for Medicare, Medicaid Services, Office of Minority Health
1302
04:10:53.220 --> 04:11:00.660 Cara James: And here I just highlight, do we carry as one example. Each of the county have set is solid represents a rural county
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04:11:01.140 --> 04:11:12.660
Cara James: And this is the black light disparity in the diabetes hospitalization rates and you can see and do the county for African Americans, which is reference here is the primary group.
1304
04:11:13.140 --> 04:11:26.370
Cara James: The rate of 24 per thousand beneficiaries compared to two for non Hispanic white beneficiaries so significant of disparities and those that are darker blue representative higher disparity.
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Cara James: drill down and look and see what's happening as well within 20 to 30 policy things just wanted to share cases some interesting correlations of what we're seeing which
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Cara James: Given what we know about the disparities and focusing on all that the price of these challenges represents the rural counties with the highest total
1307
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Cara James: Reported code cases, at least as of two days ago, I think it's still the same sort of a few days.
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Cara James: Ago, but as you can see what I circled in red, going back to that demographic that I showed you earlier about 80% of
1309
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Cara James: Individuals a girlfriend, they've identified as long as it's going to quite, you can see that for many of these calories. The representation for undergrad, like a significantly lower
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Cara James: I like little there in the channeling number to Mexico. It's only 8% of the population or elaborate Texas and start down towards the bottom where you see at three parts.
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Cara James: We also look at the broadband subscription rates that you're talking about, about half for less than 60% of the population with access to broadband.
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Cara James: And similarly, when we think about those who speak the language other than English at home, they have some communities like traffic experts.
1313
04:12:45.420 --> 04:12:50.460
Cara James: Will 93% of those individuals, especially the, the language other than English at home.
1314
04:12:51.120 --> 04:13:02.220
Cara James: In the future as well. So what that means when we think about information distribution how people are getting access to that information access to care. Other means that can help them to
1315
04:13:02.670 --> 04:13:11.250 Cara James: Protect themselves and their families. These can be things that we need to take into consideration as we are thinking about our messaging and looking at how we're supporting
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Cara James: One other thing is we think about the demographics of who lives in our community that we often think about those individuals as being older
1317
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Cara James: Or and, in general, that is the case, I would say rural or urban counterparts. But we also see that there's variability within that
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Cara James: So here, just kind of playing out that for Hispanic adults and those who are Asia and Native Hawaiian over Pacific Islander 60% or 60% of them.
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04:13:42.930 --> 04:13:52.650
Cara James: are between the ages of 18 and 44 so they're going to the terms of the healthcare systems are going to be a little different than those who are at the 65 and older stage.
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04:13:52.980 --> 04:14:04.620
Cara James: On that 1844 still within that childbearing age to accept my total health as part of the halls and coaching based on just the challenges associated with that NGO community is something that
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Cara James: may be needed work there. And as long as the other community somewhere. We will, we think about those with your calm, you can see that for African Americans.
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Cara James: As well as regularly as a lot of haters and Hispanics and rural areas that 60% 60% or so have an income of less than $25,000
1323
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Cara James: And again, what about implications related to prove it, and other access to care issues, the ability to buy personal protective equipment for transportation to pay out of pocket costs, all of those going to support and stay healthy are going to be much harder for some of those community.
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Cara James: Violence, as we all know where you live matters and out. As you can see, the distribution of the community looks pretty different where you who you are.
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Cara James: So 94% of rural African Americans living without and 60% of Hispanics are in the south as well with
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Cara James: When we look at marketers and loss leaders as well as Asian and Pacific Islander higher percentages despise them in the West in Scala percentages in the South.
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Cara James: And why this matters. You have seen this figure, a couple of times is a slightly different take on this maker, which is the rural hospital closure so
1328
04:15:32.610 --> 04:15:38.280 Cara James: Each of the previous presenter shared with you. The hospital closures portrayal of decades or a quarter of what happened before.
1329
04:15:40.590 --> 04:15:50.370
Cara James: These are the hospitals that are closed effort to compare it to their to the perverted to talk about. So the dark blue. The blue dots are the ones that are completed.
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Cara James: So again for rid of that happening, and in the South. And again, just the figure I just shared in terms of the distributions. Those closures are evident that is disproportionately affecting some of those communities of color who are there.
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Cara James: And Dr. Hall also mentioned the financial distress that we see with the hospitals and number rural hospitals. These are those critical access hospitals that are at high risk of financial distress, so
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Cara James: Accesses is really something that needs to be thinking about as we're looking at head to thinking about how we can achieve health equity in rural communities.
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Cara James: I share that, you know, just so we're all in the same mindset of what we mean.
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Cara James: When we talk about health equity is giving people what they need to achieve their highest level of health. It doesn't give you every month, the same thing.
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Cara James: And as we think about what it takes to achieve that and focusing on those faith based strategies to help people design solutions that
1336
04:16:53.850 --> 04:16:58.260
Cara James: address the problems that are specific to the communities and to give resources that we need
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Cara James: Exactly whole mentioned the chart model that just came out that there's been other models with them with ours for Medicare and Medicaid Innovation that has been supporting
1338
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Cara James: Rural communities that have had a number of participation. So chart was just released last month. And there's a lot of interest on that. We'll see what happens with that.
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Cara James: Similarly, the maternal opioid misuse model is one and the integrated care for kids, focusing on some of the challenges related to ovulate behavioral health
1340
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Cara James: The new emerging retreats triage street for transport and the chronic health issues as well as for Medicare Diabetes Prevention Program, which has the opportunity to
1341
04:17:40.950 --> 04:17:49.830 Cara James: Leverage a number of resources within the community I highlight all of these because one of the challenges associated with some of the
1342
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Cara James: Innovation opportunities is that, and we heard this in our previous because not all communities have also fairly the resources when were with all that it needed to be able to replicate it.
1343
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Cara James: And if we look at charts. This is going to be a model that is going to find it only a certain number of entities.
1344
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Cara James: There are other programs like the technical assistance offered through the federal office of rural health policies, but there are also our number of communities that
1345
04:18:18.030 --> 04:18:22.980
Cara James: really struggling to kind of pull together the resources. There's been research that has talked about
1346
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Cara James: sense of community and some of those communities that don't have that sense of community are less likely to be able to engage in for the development of some of these curriculums.
1347
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Cara James: So, as I think about one of the challenges associated with the place based strategies and that consideration with
1348
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Cara James: This approach can leave some community for high and one or just kind of looking. There's really valid within that is this is the map of innovation that's kind of happening in Georgia.
1349
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Cara James: And some of the health care facility to participating in
1350
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Cara James: CMS models and this could be a model, model that is currently in existence or one that had already subsequently close and you can see where those areas are that are participating. And if you look at the catchment areas.
1351
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Cara James: We go to that map you can look at the catchment areas that are covered by this there are large parts of the states that are not covered by innovation.
1352
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Cara James: Models. So how do we help to make sure that everyone has an opportunity to benefit and to maximize their ability to achieve their highest level of health.
1353
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Cara James: And not necessarily have a place where we could exacerbate disparities by only supporting for working with. There's certainly communities.
1354
04:19:39.300 --> 04:19:46.770 Cara James: Like building that capacity in some of the other communities that may be a little harder. It's something that is important. And finally,
1355
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Cara James: As we kind of close out and forth about what we need to do to achieve health equity.
1356
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Cara James: We really are at an all time in our country where a lot of people are talking about health equity, they're interested in understanding number of resources that are being devoted to this.
1357
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Cara James: I think that there's a potential that we may actually not get significant progress is need a lot more to get to where we need to be in chief of our goal is to talk about number five, which is really tackling those top issues.
1358
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Cara James: Or previous speaker separation structural racism and discrimination in our systems and some of those inherent any activities that are built in.
1359
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Cara James: Thinking about how do we work towards tackling him. I think the other piece is making sure that we are sustaining a focus on health equity.
1360
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Cara James: These are not problems that arose overnight. We've had over 400 years as an expertise in our health and our country and it's going to take us a while.
1361
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Cara James: To address these things about things that we're going to be able to get rid of in 30 6090 days or even in a year. So having that focus sustain focus engagement from leadership and the resources that are needed to
1362
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Cara James: continue the work. I think the other thing we talked about as well. We heard in the beginning of a poet, really, the lack of data and the ability to monitor what's happening in our already community.
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Cara James: Community community itself or something that's very slowly shared with our rural communities were not always do we have the data to be able to understand what's happening there.
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Cara James: And supporting our data infrastructure analysis and reporting to be able to not only identify where we have problems, but to be able to track and monitor progress working in state and local areas to increase enhance that data capacity so that we can know what's going on.
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Cara James: And then to other favorite valuable kind of invoices ensure that we are building has health equity into our standard operating procedures and making
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Cara James: Progress past for sustainability. This really is something that everyone should be working on and we shouldn't have these special initiatives that we're thinking about are really
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Cara James: Part of our standard operating procedure. So it's second nature reports that come out desegregate data concert possible
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Cara James: Programs. Look at what the impact of that a reply that equity lives to programs and policies to develop them with considerations for how
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Cara James: proportionately impact certain communities at the beginning so that we can mitigate those impacts to the extent possible for provide additional support where we cannot
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Cara James: And finally, developing a robust pipeline from the increase that we've seen in attention on health equity has been great, but it's also going to taxing
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Cara James: Or any number of folks who've been in the space because this is not a well funded and well staffed area for a long time. So,
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Cara James: Those are the idea that you've been pulled in multiple directions, which is great and also something that we need. But if people are looking for diverse leadership across
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Cara James: Every factor every level of our associates are thinking about how do we get diversity policy at the Public Health at the community in
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Cara James: All of the areas of clinical and others, we need to increase the pipeline so that we have more graduation.
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Cara James: rates higher graduation rates for municipalities to be able to be in a position to serve in these in these places. So with that kind of quick but want to be respectful of people's time but I want to thank you again for the opportunity.
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Cara James: Look forward to questions when we have
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Craig Wilkins: Rumors very much, Dr. James proper presentation. So we've had a few questions that have came in that we would like to
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Craig Wilkins: That we'd like to ask
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Craig Wilkins: First question is, are there particular states that have developed rule initiatives that have been effective. And what had these initiatives being able to accomplish.
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04:24:09.150 --> 04:24:21.150 Cara James: Yeah. So in terms of, I guess the question is related to equity or others. I think that there's a lot of innovation that's been out in space. If you look at some of the innovation models where we've had success.
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Cara James: With row participants in a number of those spaces that have been able to do that we've seen quality of care.
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Cara James: The rural a CEOs who have been to Spain, even those accountable care organizations have seen
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Cara James: Savings and improve health outcomes. So I think that there are a number of them working collectively and collaboratively some of their tendency
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Cara James: Towards the Midwest and civic northwest. We also have people who are successfully implementing other models like the accountable care.
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Cara James: Organizations who are working in some rural areas and working on equity to link up social determinants of health utilities food insecurity to address some of those issues and I think
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Cara James: You know the other bottle that I would lift that that is a success and it's having some challenges, but it is one is obviously build off of the CC CDC National Diabetes Prevention Program.
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Cara James: But that Medicare diabetes prevention program is effective in the communities that it has been able to be implemented and when things were
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Cara James: Of the providers to be participating in that so we can reach more of the rural communities and other communities of color who are disproportionately affected by diabetes. But those are a couple that I wish I could say
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Craig Wilkins: Okay.
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Craig Wilkins: We got a we got to cover it 19 question and
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Craig Wilkins: Wanted to see if you could provide any comments or give your thoughts on the intersection of race, class, ethnicity, poverty in the face of covert
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Craig Wilkins: Specifically, and health disparities in general.
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Cara James: So that's, that's a lot. I mean, I think that these intersections with every single one of those areas has played out in the unfortunate outcomes that we have seen
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Cara James: So we're seeing the intersection of class and race as well as morality in terms of the workers who have been essential and the lower wage workers who are still having to
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Cara James: Provide transportation if they work in transit or if they're in some of the fleet process will cancel, some of those other places, has led to them being at higher risk for exposure as well as not having the resources and wherewithal to be able to
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Cara James: Take care of themselves and their family. You think the other thing that really weighs on my mind at this point. When we look at the intersection of a number of those areas is we have just started a new school year, or some people are going to be delayed started pretty soon we have a
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Cara James: Huge. I have a huge concern in terms of what this means for those families. We already know in rural areas that broadband is an issue.
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Cara James: We also in families in which the parent has a high school education or less. They are significantly less likely to have progress so their ability to participate or virtual education.
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Cara James: Is going to be limited, and even if you have broadband. And for those of you who don't have kids, you are working on things like technical
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Cara James: Issues resolving those are the kids if those are happening during the class if those parents are social workers. Is there someone there to help them resolve those issues or are they just disconnected.
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Cara James: We also think about either whether or not the family's house multiple laptops or computers or tablets or whatever the case may be, if they have multiple children.
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Cara James: Or if that parent is also working from home or doesn't have that computer. So I think there is a potential that we will have huge
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Cara James: Disparities, and I'm really concerned about those students who may get disenchanted, particularly those in high school who do not graduate and just drop out.
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Cara James: So that is one way in which the intersection of all of this comes together. And of course that has huge implications for their future earnings potential future jobs future health outcomes. So
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Cara James: I think we really need to focus a lot more attention on that and helping to lift that up and that will lead to better health as well.
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04:28:44.730 --> 04:28:45.240 Craig Wilkins: Thank you.
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Craig Wilkins: Again, thank you, Dr. James for taking time out of a very busy schedule to join us today for our political ethics forum. Thank you.
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Craig Wilkins: And now as we get ready to close out this year's public health ethics forum on, on behalf of the planning committee, I would like to thank everybody who has participated in the form today.
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Craig Wilkins: And to provide closure remarks are like to ask Dr. Bring back. Dr. Light bird and also Dr. Warren for their closing remarks.
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Leandris Liburd: Thank you, Craig in
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Leandris Liburd: Today has just been really an extraordinary day for us for this public health.
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Leandris Liburd: Ethics forum and I noticed as I was observing the screen and listening to the presenters that we we've had over 800 participants.
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04:29:46.920 --> 04:30:11.520 Leandris Liburd: Join us today for this critical examination of ethical dilemmas in rural health and many of these dilemmas em have has been repeated over and over our historical they're structural and they are complex, but there is a way forward, as described by so many of our speakers.
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Leandris Liburd: To borrow from Dr. Hall, there may not be curious, it's needed, but there are tools. So ultimately, though we seeks solutions solutions that are ethical that are equitable and then our people centered
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Leandris Liburd: There's much work still to do it goes without saying. And I appreciate and thank all of you for your contributions and your willingness to share your expertise.
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Leandris Liburd: And passion and replacing dilemmas with solutions. I also want to congratulate the students on their submissions and for all of their accomplishments to date.
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Leandris Liburd: No matter how your poster fared you have a bright and promising future and we are all looking forward to how you were bold shape.
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Leandris Liburd: And steer public health and ethics in the years ahead. And so I would just like to close by saying let's all stay the course and let's all stay will thank you again for your time today.
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Leandris Liburd: Dr. Warren
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RuebenWarren: This has been an exciting day for me and a challenging day both professionally and personally, as you all watched. I look at blacked out a couple of times.
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RuebenWarren: That's why I'm anxious to get all the details. We have an opportunity for that to happen. I want to express my appreciation for the planning committee and the leadership of CDC and these times are so many things going on to stay focused on something that's important is not easy to do.
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RuebenWarren: Roll America is new to some but older others. And I think that to focus on what's happening in rural America as the rest of the country is focusing on what's happening in the airport of the other country.
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RuebenWarren: We had a lot. They got a lot of data we've a lot of presentations pounds of data and I would leave you with the thought.
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RuebenWarren: Not what does the data say because we all can get can really read it and do the kind of analysis that needs to be done, but what did today to me.
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RuebenWarren: In my view, that's the ethical question. That's the construct of ethics, that's the the context of ethics and that's really my commitment.
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04:32:47.190 --> 04:32:59.160 RuebenWarren: We're in transition to really look at the right part of doing what is public health and that's sometimes in conflict with what we think we ought to be doing. This is an exciting time.
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Leandris Liburd: Dr. Warren has been victim to the technology again.
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Leandris Liburd: And hope, hopefully he'll be able to come back. But I just like to say certainly
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Leandris Liburd: And share as he is. I know it's thanking everyone for all of your efforts today.
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Leandris Liburd: For acknowledging that you know the future that we can create for ourselves moving forward.
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Leandris Liburd: And the leadership and the perseverance that we're going to need in order to realize the kind of rural communities where we can see health equity and we can experience social justice in all of the other areas that were raised today.
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Leandris Liburd: Captain Wilkins.
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04:34:07.260 --> 04:34:12.600 Craig Wilkins: Live bird, and thank you, Dr. Warren, we're sorry you had done technical difficulties and had to
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Craig Wilkins: To get off again on on again on behalf of Planet committee.
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Craig Wilkins: We thank everybody for your partition participation today. Um, and looking at these very vital critical issues in rural health
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Craig Wilkins: As Dr. Library said we would with everybody. Well, and continue to be safe. Have a wonderful weekend and thank you again for attending our 2020 political ethics forum. Thank you.