I'm Vivian Pender, President of the American Psychiatric Association, and I welcome you to this special session on the impact of racism within large organizations. The need for diversity, equity, and inclusiveness in mental health care has never been greater, and the time to act is now. The APA is firmly committed to embracing the diversity of our members, staff, organization, profession, and ultimately the patient communities we serve. Words are not enough. This session will explore how the APA and the AMA are putting their vision and mission into action to address structural racism. We are delighted to have a distinguished and highly accomplished panel with us today. I will briefly introduce them now. They will each speak for approximately 10 minutes, and that will be followed by a question and answer session, which I will start off for the panel to answer questions. And then we will have the at least remaining 30 minutes or so to turn to questions asked by the audience. And now I would like to introduce Dr. Michelle Reed, who received her undergraduate and medical degrees at Fisk University and Meharry Medical College, two HBCUs in Nashville, Tennessee. She completed her psychiatric residency at Wayne State University in Detroit, Michigan, where she serves as a clinical assistant professor in the Department of Psychiatry and Behavioral Neurosciences. Currently, she is the chief medical officer at CNS Healthcare, a certified community behavioral health clinic providing services in Wayne, Oakland, and Macomb counties in Michigan. Dr. Reed also serves as the trustee-at-large on the APA Board of Trustees. Next we have Dr. Dilip Jesti, who is a distinguished professor of psychiatry and neurosciences at University of California, San Diego. He is a geriatric neuropsychiatrist. He is a former president of the APA and chair of the current APA Presidential Task Force on Social Determinants of Mental Health. He has recently published books titled, Wiser and Positive Psychiatry, and is editing one on loneliness. Dr. Regina James is deputy medical director and chief of the Division of Diversity and Health Equity at the American Psychiatric Association. Dr. James is a child and adolescent psychiatrist with over 25 years of experience providing leadership and direction in the planning, policy development, and implementation of national and international health disparity programs and initiatives for children and families. She received the NIH Director's Award for exceptional leadership in the promotion and development of scientific programs addressing gaps in minority health and healthcare disparities. And Dr. Karthik Sivashankar is the vice president of equitable health systems in the Center for Health Equity at the American Medical Association, and a medical director in quality safety and equity at Brigham and Women's Hospital. He's a psychiatrist at Justice Resource Institute in Massachusetts. His work has focused on driving racial justice and equity in the healthcare arena by leveraging high performance quality and safety practices to systematically make inequities visible and to address and resolve them as an integral part of healthcare delivery. So I will turn the floor over to Dr. Reed, who is our first speaker. Welcome all. Thank you, Dr. Pinder. Thank you so much. I'm so pleased to be at the Mental Health Services Conference virtually this year and talk with you about the impact of racism within large organizations. As Dr. Pinder told you, I'm the chief medical officer at CNS Healthcare, that's a certified community behavioral health clinic in Michigan, and I'm also the APA trustee at large and on the Budget and Finance Committee of the APA. What has been the APA's response to structural racism? I had the privilege of serving on the Presidential Structural Racism Task Force last year, and Dr. Cheryl Wills was our chair. And there were a number of board members and past presidents who also served on the committee. And that would be Dr. Renee Bender, Dr. Frank Clark, Dr. Charles Dike, Mary Jo Fitzgerald, our speaker, Dr. Fitzgerald, Dr. Daniel Hairston, Dr. Hunter McQuiston, myself, Dr. Stephen Starks, Dr. Richard Summers, and Dr. Sonia Varani. So I was so happy to serve with them. And most notably, we had fantastic administrative support from central office of APA, Colleen Coyle, Camille Bryant, Sharetta Clerkley, Allison Crane, Michelle Durst, Gabriel Escontrias, Debbie Gibson, Patrick Hansard, and our own Regina James. Dr. James is with us today on the call, Ricardo Suarez, Ashley Mild, Monique Moorman, Jenny Titterton, Ryan Vandervoort, Ashley Wittner, and Nadia Woods. So we're really excited that they were there to help and support us. Initially, you know, we were charged with providing education and resources on the APA and psychiatry's history about structural racism, and that was a big task. We also had to explain the impact of structural racism on the mental health of our patients and the colleagues, and most notably, we were to achieve actionable recommendations for change to eliminate structural racism in the APA and psychiatry from now during the future, and made several reports to the board of trustees, and also we were to be monitoring the task. The workforce structure was established, and we started off with a group, and you wouldn't believe how long it took us for everybody to come up with definitions. So that was accomplished. And also we had a resource workgroup that helped us work on communications about the clearinghouse and about a hub for our website and also our various advisory partners. There were workgroups looking at the board of trustees, looking at the components, looking at the assembly, one for a clearinghouse, also for town halls, and also working with the APA foundation fellowship. At the end of the day, what did we accomplish? There were 27 action items that were put together, 26 of which were accepted by the board of trustees, so that was just a monumental task. We have consultants now working with the board and with the CEO looking at the items that were positively accepted by the board and continue to work with us on our goals relative to improved diversity, equity, and inclusion and connecting with our memberships and being more transparent. Also our president and CEO report are always going to have a section looking at diversity, equity, and inclusion and anti-racism initiatives. And also we now start our board of trustees meeting reviewing our strategic initiative and the pillar that has to do with diversity, equity, and inclusion. We successfully completed five continuing education programs, town halls on various topics from children's issues to education and residency and fellowship. And there were numerous reports from the various workgroups, including all of the components and assembly who participated in that, and also working with the American Board of Psychiatry and Neurology to be adding content for inclusion in maintenance of certifications readings. As a result of the many 26 recommendations that were approved, clearly all of those things could not be accomplished in a year. And so the executive committee of the board recommended and the board of trustees approved putting together a board of trustees structural racism accountability committee. That is chaired by Dr. Mary Roussel and Dr. Felix Torres as co-chairs. Dr. Elia Ayum, Dr. Kenneth Serta is also on that, as well as Dr. Jeffrey Geller, our immediate past president, Dr. Glenn Martin, Dr. Alpha Stewart is serving as our consultant, and Dr. Yazdani is a member as well as Dr. Melinda Young. So they're all charged with looking at the 26 recommendations and make sure they get implemented. And we have two staff members working with us to support us in this activity at the board level, Sheretta Kirkley and Ms. Yang. So we're very excited about that. The committee is going to have some ongoing responsibilities. And number one, they have to ensure that the 26 recommendations of the APA presidential task force to address racism throughout psychiatry are carried out. They will be evaluating the success of those 26 recommendations. They also will have the ability to make improvements in the recommendations. And also any other objectives that were in the final task report are available for them. Thank you so much. I want to turn it over now to Dr. Dilip Jesty, who will talk with us about the social determinants of mental health. Thank you, Dr. Reed, for a wonderful presentation. First of all, I want to thank Dr. Pender for inviting me to this wonderful session. I'm going to talk on structural racism as a social determinant of mental health. As most of you know, Dr. Pender appointed the Presidential Task Force on Social Determinants of Mental Health earlier this year, in May 2021. And I was honored to be appointed as its chair. The task for the task force was to build upon the outcomes of the 2018 APA position statement on social determinants of health and the 2021 APA Presidential Task Force on Structural Racism that Dr. Reed just talked about. That task force did an amazing job, and it's a great role model for our task force to follow. Our goal is to develop evidence-based pragmatic strategies to improve individual and community well-being by optimizing social determinants of mental health. And I want to stress both these things, evidence-based and pragmatic. Our task force has four workgroups. Clinical workgroup is chaired by Dr. Francis Lu and includes Dr. Steve Koh and Dr. Tricia Gibbs. The research and education workgroup is chaired by Dr. Dolores Malaspina and includes Dr. Ailey Aoun and Dr. Kimberly Gordon-Achebe. The public health workgroup is chaired by Dr. Kenneth Thompson and includes Dr. Michael Compton and Dr. Saniya Virani. And the policy workgroup is chaired by Dr. Alan Tasman and includes Dr. Gary Belkin and Dr. Lisa Fortuna. So, as you can see, we have an amazing group of leaders in the field in our task force. We also have a great group of staff members, including Ricardo Juarez, Yoshi Davison, Dr. Regina James, and Dr. Saul Levine. The staff has already created a wonderful webpage that will keep the readers posted of the developments in our task force's work. So what are social determinants of health? Actually, there was not much interest in social determinants of health until about 2002, when the World Health Organization published a report for the first time on this topic. The CDC, Centers for Disease Control and Prevention, followed suit soon after that. The social determinants include early childhood development, education, job opportunities and income, social inclusion, racial and other discrimination. In 2002, this was ranked number three, but we know that during the last year, because of the major changes that occur in terms of attention and focus on the racial discrimination, this determinant has really risen to prominence. Other social determinants include safe housing, transportation and neighborhoods, air pollution, water pollution, access to nutritious foods and physical activity opportunities, and access to decent quality, affordable health services. All these social determinants are, of course, important for all the people, including people with psychiatric disorders. However, they don't really focus on psychiatric disorders. And one of the first tasks for our task force was to broaden his list of social determinants to include those that are especially relevant for psychiatry and for our patients. These include stigmas, stigma against mental illness, stigma against marginalized groups, stigma against migrants, stigma against older adults, the ageism. It is worth remembering that we are the only field in medicine where more patients are in prisons and jails than in hospitals. It is an embarrassing, I would say, shameful fact for the society as a whole and reflects on the stigma against mental illnesses. One social determinant that has acquired a lot of interest in recent years is loneliness. And this interest in loneliness increased during the last year of COVID pandemic. Not all social determinants are negative or adverse. There are also some that are positive. These include things like community level resilience, compassion, social support, wisdom. So what we need to do is try to prevent or minimize influence of adverse social determinants, but promote and enhance positive determinants. As I mentioned, our task force has four work groups, and each has somewhat related but distinct targets. The clinical work group focuses on clinical competency and practice guidelines. What can we do in our practice today? Then comes research and training. We need to decide what kind of biopsychosocial investigations are necessary to develop a better understanding of the mechanism by which these social determinants impact health. Importantly, we also need to develop interventions that will optimize the impact of social determinants. And then comes training, training of medical students, residents, fellows, and practicing psychiatrists in social determinants of mental health. The public health work group focuses on public education because training is not restricted to students and residents. It really should include the public at large if we are going to have an impact on diseases, including prevention of diseases. And finally, the APA needs to advocate for optimizing the impact of social determinants and improving healthcare access, something which is particularly important for people with mental illnesses. As a researcher, I feel that it is important that we collect empirical data on these social determinants because that will impact the policies. As this slide shows, racism is indeed a pandemic, and that's how it affects health in a major way. I just want to show you a couple of studies that looked at empirical data on racism and health. The first was a systematic review of 138 quantitative population-based studies that was published several years ago. The conclusion was that self-reported racism is associated with poor physical and mental health in oppressed racial groups. And this, even after we adjust for various socio-demographic confounders. And then comes a study which I just published a couple of months ago. It was a study of levels of measures of county level residential segregation and racial disparities as well as incarceration rates. And the study showed that these measures were associated with higher rates of COVID-19 cases and COVID-19 mortality. And once again, even after we adjust for the relevant socio-demographic confounders. So you can see how racism impacts not just health, but mortality, and it gets even worse during a pandemic like COVID. One social determinant, as I mentioned, that is receiving increasing attention in recent years is loneliness. You know, we talk about COVID-19 as the pandemic. But we don't realize that there has been a pandemic, behavioral pandemic going on for the last 20 years. That's a pandemic of loneliness. It is called a silent killer. It increases the odds of mortality by 30%. It is as dangerous to health as smoking 15 cigarettes a day, and more dangerous than mild to moderate obesity. And mind you, this is based on hardcore studies and meta-analysis of large number of investigations across the world. Why is loneliness so bad? Because it increases the risk of heart disease, Alzheimer's disease, and other dementia, major depression, suicides, obesity, substance use, and related deaths. And that's why the mortality is so high with conditions associated with loneliness. And who are the people at a risk of loneliness? People with serious mental illnesses, people with schizophrenia, major depression, bipolar. Similarly, racial ethnic minorities and other marginalized groups are at a greater risk of loneliness and social isolation than others. And this is not because of any biological differences among these groups, but it is because of the social exclusion that occurs because of the stigma, like stigma against mental illness and racism. The good news is that loneliness is modifiable. We can reduce it. We can prevent it. And I think loneliness becomes a good example of how we can train people and improve the practice in trying to reduce loneliness and even preventing it. So what should we do? The first thing is we must evaluate loneliness routinely in our practice. There are standardized, validated ways in which we can do that with just two or three questions. That needs to be done. Secondly, we need to encourage people to engage in physical, cognitive and social activities because they help reduce loneliness and social isolation. There is something called social prescribing. You know, the prescription don't stop with antipsychotics and antidepressants. We also have to prescribe social connections. And then there are interventions, again, some exciting research that is going on in recent times that suggests that interventions focused on compassion and social connection can reduce and prevent loneliness. Our own research group at UCSD, as well as several other groups, have shown that these are evidence-based interventions that can reduce loneliness in various groups, including people with mental illnesses and racial and ethnic minorities. The question is this, how can we then promote training and implementation of such strategies to reduce health inequity in mentally ill persons and in marginalized groups? If we reduce loneliness in our patients, their mental and physical health will improve, their well-being will improve, and they will have a longer lifespan. And this is a model for what we can do with other social determinants too. Let me stop here. I want to thank you for your attention. And I want to turn the podium over to Dr. Regina James. Thank you, Dr. Jessie. So yes, so thank you again, Dr. Pinder, for the invitation to participate in this fabulous panel talking about something very important and timely, the impact of racism within large organizations. Many of us know that there were two major events that I think that really sparked the conversation and really raised the awareness around structural racism and structural barriers that certain groups feel within the United States. Of course, I Can't Breathe and COVID-19. I think those were two episodes that really brought to the forefront what we are talking about and dealing with today, which is a good thing in that we are beginning to have these conversations and we are beginning to talk about what do we need to do to resolve and address these issues. So it's an unfortunate issue for George Floyd and his family and those who have been impacted by COVID, but it has brought us to a point of a conversation that I think we really need to have. Thinking about creating an anti-racist organization, there should be meaningful and long-lasting actions to create an anti-racist organization. Of course, this requires strategic vision and intent. Today, I'm going to briefly talk about the strategic approach from the American Psychiatric Association to address racism by supporting equity, inclusion, and diversity, and then I'll segue into specifically some examples that are being supported within the Division of Diversity and Health Equity that are addressing racism within the organization. As mentioned earlier, there are four pillars to the APA's strategic plan, and the piece that I have highlighted in yellow specifically focuses on the diversity, equity, and inclusion piece, which is increasing diversity within the organization, serving needs of diverse populations and underserved patient populations, and essentially, overall, working to end disparities in mental health care. With the premise, our division developed a strategic plan with these five tenets, promoting awareness, developing strategic partners so that we can address mental health disparities together, fostering an inclusive professional development pathway, and supporting and expanding member diversity and strengthening the division's management by demonstrating impact of these programs. I'm not going to talk about all five of these tenets, but what I'd really like to focus on is three areas. I'd like to talk about some of our initiatives around awareness, education, and some of the policy issues, which I think are three really key areas that can begin to turn the wheel and make changes around how an organization deals with racism within its structure. So, the first is a series that we developed within the organization to really bring awareness to the inequities that are facing marginalized populations. So, this is just one example. This is how we opened up what we call a fireside chat. Our first one was in April, and it really talked about bringing awareness about mental health substance use disorder inequities, particularly around African American communities and the impact of COVID-19. Again, one of the two sort of incidences that really raised our antennas about why this is important to discuss. We had a wonderful panel, distinguished panel. Of course, Dr. Cynthia Turner-Graham, who's President-Elect of the Black Psychiatrists of America. We had Dr. Kizmikia Corbett, who at the time was at the National Institutes of Health, and now I believe is in Boston, and I was able to fortunately moderate this session with these two wonderful ladies, and it was a great session. We not only had a session for psychiatrists focus, but also for the community, and there were a number of great questions, and people were really asking sort of, you know, deep questions that probably would not be asked in the typical academic arena, but I think is really important because as an organization, it not only serves, as Dr. Pender mentioned earlier, the psychiatrists who are members, but also has an impact on the patients that they serve, and so with this fireside chat, that's exactly what we're trying to do. Not only impact the psychiatrists of the members, but also the patients that they serve. So this fireside chat was really opening the conversations around COVID-19 and the impact on the mental health of African Americans. We followed up on that with a second fireside chat that really focused on building coalitions and supporting the Asian American and Pacific Islander community, particularly around not only COVID-19, but a lot of the xenophobia that was going on, and that particular panel, we had the opportunity to work with Congresswoman Grace Ming from New York, as well as a representative from Stop AAPI Hate, a non-profit organization, Mr. Russell or Dr. Russell Jung, a member of the APA, Dr. Dora Wang, as well as another APA member, Dr. U.K. Quang Dang, and so again, a great conversation that engaged communities as well as psychiatrists to really talk about not only what the issues are, but how might we tackle these issues moving forward. In terms of policy, our division works very closely with our government relations division to really bring, again, not only more awareness, but to advocate for health equity. So one of the conferences that we were involved in was the APA Federal Advocacy Conference this past summer around addressing mental health, which involved Dr. Dion Hart, myself, and Michelle Greenhalgh, and it was an opportunity, again, to really bring to the forefront why we need to have these conversations and what actually can we do about them. We are currently working to address mental health equity, again, in a Hill briefing, and so we have two confirmed speakers so far. First, we'd like to provide an overview of what health equity is, and Dr. Lisa Cooper, who is here at Johns Hopkins, will provide that, then talking about mental health equities and health services and Dr. Bernardo Ng from California, and then finally closing out with some of the policy solutions that we can do to address this, and Dr. Glenda Wren at Morehouse School of Medicine. So we're definitely looking forward to that, again, really taking awareness, education, and policy, and really trying to move the needle in addressing structural racism and racism within organizations. Another way is through education, right? So we work with a, so we call it a trajectory or the pipeline of students, so we start our programs that really touch pre-medical students, medical students, as well as our fellows. So our pre-medical program essentially focuses on really engaging those racial and ethnic groups that are underrepresented in medicine, so primarily with Black, Indigenous, and Latino, and Asian populations, and we do things like provide preparation for the MCAD and connect them with mentors within the APA organizations, really provide them with guidance and understanding of what it is to be a psychiatrist, what are the different sub-specialties that one can enter into, and really just try to make that connection to keep them engaged in what's going on in the mental health arena. Our second part of the pipeline is with medical students, and actually we are revamping our program, so let me just share with you now. Currently, the program, and of note, this program is supported by a grant by SAMHSA, Substance Abuse and Mental Health Services Administration. The medical student program initially had sort of pockets of sub-specialty areas that students could engage in individually, so if they were interested, let's say in HIV psychiatry, they would spend four weeks in that area. What we wanted to do really, because they are at the medical student level and it is for a short time period in the summer, is really give them a breadth of the various opportunities and sub-specialties within psychiatry to see which one of them may pique their interest, so in the first week they'll be exposed to child and adolescent and geriatric psychiatry, second week community consultation liaison, etc. We'll be starting this pilot program of June of 2022, and not only will they be have an opportunity to get exposure to these various areas of sub-specialties, but it's opportunity to take online courses and they'll get a book scholarship, again really looking at the training trajectory pipeline and really trying to impact diversity of not only the workforce in psychiatry, but hopefully the membership within the APA, and this is actually another new initiative that we have established within the division. We're calling it the LEAD Institute, Leadership and Equity and Diversity, and what we wanted to do here is really push the envelope around not only what mentorship is, but really moving past mentorship and really moving toward some call sponsorship, others call advocates, really forming that stronger bond and connection so that the fellows could actually network with leaders within the organization. So the institute will provide sort of this advocate-protege program as well as courses, and we wanted the courses to be specifically focused on these issues around diversity, equity, and inclusion. So we're very proud to say that we have four new courses. One is focused on the social determinants of mental health with Dr. Frances Liu, Dr. Dolores Malaspina, and Dr. Robert Trestman. We also have a program that's or a course that's going to focus on structural and institutional racism and mental health with Dr. Emmanuel and Dr. Trinh, and we'll also have three more courses, one in applying racial equity lens from Dr. Jessica Isom, cultural competence from Dr. Neil Agarwal, and mentorship and networking from Dr. Hector Colon Rivera. So again, really putting some meat on the bones when it comes to exposing and teaching and educating our early career psychiatrists about the importance of diversity, equity, inclusion, so hopefully these upstream interventions can have an impact downstream when they become practicing psychiatrists in the field and members of the organization. And the last piece that I'd like to talk about is our advocate protege program. So people say, well, what's an advocate, which is sometimes confused with a mentor. So an advocate is really someone who will use their social capital, their stance, their leadership to advance the career of another person, commonly referred to as a protege. So they will provide exposure, experience, visibility, and essentially vouch for the merit of the legitimacy of the protege that they're working with. So we really thought that this really takes it the next step past the mentorship piece and really forming a bond or a relationship that can really help leverage those who are underrepresented within psychiatry to really move them into more leadership position. So within the program, we hope to not only refine leadership skills, but really allow them to grow, develop, and become new leaders by pairing them with leaders within the organization. And so we're proud to say that I think we have about 14 or 15 of the APA members who are leaders who will be serving as advocates within the program. And so we're looking for a few more volunteers, but again, this is something I really think will have a significant impact on the lives of young psychiatrists coming into the field. And so I'd like to close with this final thought. Organizations must take seriously their role in educating members about the realities and the inequities of our society, increasing awareness and offering strategies for individual accountability and structural changes. Thank you. Thank you for the opportunity to share my thoughts. And I'd now like to pass the baton to my colleague, Dr. Siva Shankar from the American Medical Association. Thanks so much. And I will be speaking to you without slides today, if that's okay. And really great to hear about all the work that's being done. So I'm coming to you as a psychiatrist, as a medical director in quality, safety, equity, and also through my role at the Center for Health Equity in the AMA. So I'll be speaking to you through each of these lenses. And maybe a good place to begin is really truth, reconciliation, healing. That's the fifth pillar of our AMA's health equity strategic plan. So really beginning the conversation from a point of humility and acknowledgement of past harm. So for example, the AMA's support of the Flexner Report, a landmark study with the Carnegie Foundation in the early 1900s that led to the closure of all but two black US medical schools. And we're still seeing the effects of that today in terms of how we've really failed to adequately diversify our physician workforce. And there's many, many other examples. And I'll highlight just a few. The history of claiming that segregation was medically necessary in organized medicine and in psychiatry. And the effect of Samuel Cartwright. So he was a highly influential physician that some of us may know about. Pro-slavery, argued that slavery was a natural state that actually benefited black people through hard work. And invented psychiatric disorders like drapetomania to explain the behavior of enslaved people and running away or quote unquote resisting hard work as a form of mental illness. Claiming that enslaved people had this sort of childlike simplicity. And then tying that to this idea of race as a biologic construct or biologic racial feature. And that has actually been perpetuated to the present day in the form of quasi-scientific racist medical theories grounded in this idea of a genetic or biologic essence that defines all members of a racial category or racial essentialism. And that has been used to justify a lack of any real therapeutic treatments for African-American patients and other groups for a long time. And really a dual system of care that was formally kept in place since the 1960s but then has persisted to the present day in terms of racial inequities in mental health and in medicine more broadly. And we see that in terms of just the segregated access to health care even today across our health system. So I'm beginning there because I wanted to provide that context for how we've gotten to this moment. And at RAMA we've been on a journey for 20 plus years. I only joined in the last year but it's been a journey for the last 20 plus years. And the mission of the AMA is really to promote the art and science of medicine and the betterment of public health. And more recently equity is across enterprise accelerators. That means it's a part of everything that we do. It's embedded in everything from our chronic disease work to our professional development to removing obstacles to care. And very recently our strategic plan was released. And there's five key arcs to that strategic plan. So embedding equity and practices, processes, action, innovation, organizational performance and outcomes, building alliances and sharing power by meaningful engagement, ensuring equity and innovation for marginalized people and communities, for pushing upstream to address all determinants of health, and then finally as we talked about fostering truth, reconciliation, healing and transformation. And really the goal of our work is to envision a nation in which all people live in thriving communities where resources actually work well, where systems are equitable and create no harm nor exacerbate existing harm, where everyone has the power, the conditions, the resources and opportunities to actually achieve optimal health, and where physicians are equipped with the consciousness, the tools, the resources to confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression, as well as to actually effectively embed racial justice and equity within their work, their organizations, and across health care. And so I mentioned this has been a journey, and so in 2019 the Center for Health Equity was formed under the leadership of Dr. Lita Maybank, and we recently passed three resolutions through the House of Delegates on racial essentialism in medicine, laminating the use of race as a proxy for ancestry, genetics, and biology in medical research, education, clinical practice, racism as a public health threat, and really our strategic plan is a very bold, ambitious vision for what the work should look like moving forward. My work has specifically been focused on operationalizing equity to quality and safety, and this gets to the IOM, the Institute of Medicine definition for quality as safe, timely, equitable, efficient, effective, patient-centered, but equity has really been that forgotten dimension for far too long, and so I and others are really focused on trying to understand and address root causes in health care for inequity, so really driving toward equitable, high-quality care, because there is no such thing as high-quality, yet inequitable care, and that's mostly what we deliver in this country. Improving efficiencies around access and coordination, awareness and understanding of structural racism plus, so leading with racism, never to the exclusion of other isms, thinking about health system accountability, tracking, monitoring, reporting, including things like quality dashboards and performance metrics, and developing a pipeline of leaders who can do this work, and then finally really thinking about cross-sector collaboration, so within those five pillars, my work is really the equitable health systems or pushing upstream approach, and we break that out into three key areas, really four. There's public health and cross-sector engagement, health care institutions, providers, and then internal AMA work that we're doing, so in the public health and cross-sector engagement, we're really thinking about how can we coordinate our efforts across sectors so that we're not so siloed and fragmented, including public health, social care, health care, and beyond to really promote people- and community-centered collective action that addresses social and structural drivers of health, and ultimately to try and dismantle intersecting systems of oppression, and so within that bucket are large bodies of work that are either ongoing or that we're designing and launching, including an equity campaign that'll be launching in 2022 with IHI and a third partner, which should end up being raced forward, and many, many other organizations across five pillars, so individuals, health systems, payers, biotech, pharma, and finally professional societies, including hopefully societies like the APA, and this is really about that longitudinal collective action to drive national efforts. In the health care institution pillar, we have a real focus on eliminating harmful variation in health care delivery, access, and outcomes, and really embedding equity in the DNA of our operations, so quality, safety, data, education, with a real focus on place-based, equity-focused, anchor mission strategies, so what's our responsibility as an organization to our communities around us, and so, for example, there we're going to be launching a peer network later this year. This is a quality, safety, equity peer network with up to 15 health systems to really take some of the approaches that we've been designing for the last two plus years and really tested with a lot of power at Brigham and Women's Hospital, now trying to spread that to other systems, and then finally, in the provider bucket, we have developing a pipeline of health care leaders who actually have that racial justice praxis who are capable of redesigning health care for social care, and so we're thinking about how we can develop that in terms of education for individuals, but also developing the next generation of leaders who are operational leaders in quality, safety, equity, and so on. Beyond that, we have a lot of other efforts that fall into these buckets, so, for example, we spend millions of dollars every year across this country in DE&I, racial justice education, and programs, and we really don't know if it works because there are no validated instruments out there, so we've been designing what should be the first of its kind validated instrument to tell us whether our efforts are making an impact, not just on intentions, awareness, knowledge, but also on behavior, and we'll also be launching a Grand Rounds series next year with ACGME, which will also combine lab spaces for early adopters, so it's not just about a passive learning experience, but really translating that learning into practice and into individuals work. Finally, we have a lot of work that we're doing internally in terms of education and with a lot of partner organizations, and that's all available on our education hub as we start to post content, so maybe with that, I'll really close and mention, you know, I think the topic of COVID-19, we can't avoid it, and it's an important one. It's been a magnifying glass around long-standing injustices in healthcare and beyond, and so when we think about what needs to change, to me, the answer is really everything needs to change. I think what is being elevated for some folks today is the fact that these are structural issues that are embedded in our policies and our practices and our laws and our media and our culture and our organization, so we literally need to re-examine everything that we're doing if we're going to solve for a problem as big as this, and so that's my invitation to everyone here is to really examine deeply, starting with oneself, but then also with your teams and your organizations. How is this showing up, and how can we do this differently and better moving forward? With that, I'll turn it back over to Dr. Pender. Thank you so much, Dr. Sivashankar, and thank you to all of the panelists for just outstanding presentations of a kind of vast array of perspectives and terrific programs and actions that are taking place, and these, as Dr. Sivashankar just said, are bold and ambitious plans that I think all of us are embarking on, and they're enlightening and hopeful, so I will start the Q&A segment and ask that each panelist will take a stab at each question.

racism

diversity

equity

inclusiveness

mental health care

structural racism

APA

social determinants