Thank you. Can everyone hear me okay? Awesome. I'm just going to try to make sure I have everything muted right. Sorry, I didn't have any time to test this out technically. I'm not hearing any feedback anymore, so I think it's okay. I'll just share my slides and we'll get cooking. Hopefully we'll have some time for questions as well. The one thing I'm wondering is I have a video I'm going to want to show, but we'll see if it works. Alright, can everybody see that okay? I'll assume you can. Alright, so as you guys know, my name is Zeke McKinney. I'm the program director for Health Partners Occupational Environmental Medicine residency here in Minnesota. The only residency program in Minnesota. Good, everyone on the virtual saying they can hear me. I'm also an affiliate assistant professor for the University of Minnesota School of Public Health, Division of Environmental Health Sciences, a clinical investigator for the Health Partners Institute, immediate president of Central States component, as well as the Twin Cities Medical Society president. Alright, we're going to rock and roll. The beginning is going to be me just telling some stories. To start with, I don't have any disclosures. Thank you. My story is this. I want to talk about these two issues of pandemics going on here in the Twin Cities and in this country globally. We have COVID-19, which had greater impacts in Black, Indigenous and communities of color, as well as George Floyd's murder locally here in Minnesota, which really raises this huge focus on systemic racism. And this little map here, which is, by the way, from August 2020, so from a while ago, but not too far after George Floyd's murder, just showing that these orange areas were having disproportionately high percentages of COVID-19 deaths in Black people compared to White people. So interestingly about Minneapolis, which you guys probably don't know, is back when I was a teenager, they used to call this Murderapolis, specifically talking about the north and south side of the city, where there was tons and tons of gun violence and primarily in Black neighborhoods, such as where I grew up. And in case you're not clear on it, I am Black. So another issue we know in medicine is we're really lacking Black physicians in general, and specifically Black male physicians. So back in 2017, the AAMC had information saying that of all the Black people applying to medical school, only 37.8% of those people are men. And so there's clearly a disproportionate percentage of women greater than men of the Black population in medicine. And we know that concordance of physicians and patients can help reducing some of the inequities and disparities we see in terms of systemic bias. Well, how does this look in Minnesota? So on the left, you see this graph of census data from Minnesota, where in Minnesota, we have about 76% white people, about 7% Black people, 6% Latino, Latina people, 5% Asian, etc. So pretty white state, but a little bit of diversity, especially in the Twin Cities metropolitan area. If you look at that table up in the top right, that's data from the Minnesota Department of Health showing that Black physicians make up about 2.5% of the state, and that's about the same in the metro area. So really, a discrepancy there. If you have 7% Black people in the state, and by the way, it's probably more like 20 or 25% in the Twin Cities, and only 2.5% of physicians, again, there's going to be a discrepancy in who's being represented. So we saw in 2020, again, May 20, 2020, George Floyd was murdered here in South Minneapolis, and this led to huge national and international unrest in terms of, you know, you see this George Floyd mural on the right, as well as down on the bottom right, this picture of this Ferris wheel. This was a protest in Brussels, Belgium, which is kind of crazy if you think about it. I didn't really imagine that anybody outside of the U.S., and certainly Belgium of all places, would care about what was going on here in the Twin Cities. It's kind of crazy when you think about it. And so then, on June 6, 2020, here at the state capitol in Minnesota, we had a protest, or I guess an organized gathering, organized by this organization White Coats for Black Lives, which was a medical student organization of which we had a chapter here. And so you can see some black physicians in this middle picture, I'm in that picture, but as well, just lots of people there in general, some of whom who were clinicians. So again, this was something that was really right at the fore here in Minnesota that we were thinking about a ton. Don't worry, this whole thing isn't going to be about me and my story, but it's giving you context. And so then in June of 2020, this was when I was still editor of our state medical journal, Minnesota Medicine, I started telling this story about how I went to this new barber shop, well, new to me, in north Minneapolis, a neighborhood I grew up in, because I couldn't get to my old barber and I hadn't been during the whole pandemic, and I walk in there and I'm the only person wearing a mask. And I'm like, oh my goodness, I need to get out of here. I was really freaked out. But then I said, wait a second, if I really want to try to help people and explain what's going on with COVID and engage people in a really nice and good way, I need to stay here and talk to them. So I did, and they were kind of freaked out that I was asking all these questions about COVID and what was going on, and I was the only person wearing a mask. They said I was like some kind of narc or something. But I was also genuinely concerned, because at that time we had laws that would allow people to get fined, businesses to get fined if they weren't wearing masks. So anyway, I wrote this article about engaging people, you know, in the community, even when you're putting yourself at your own risk, because that's what our job is as clinicians, to really do our best to make sure people are educated. So then it got even more interesting for me in 2020 when I became a research investigator on the AstraZeneca COVID-19 vaccine trial here in Minnesota. My colleague Charlie McEvoy was a PI, and I was her either co-PI or co-I or whatever. It didn't really matter, but the point was, this was the only vaccine trial at the time in Minnesota, and we started recruiting people pretty heavily and really wanted to talk about high-risk people, especially people in high-risk occupations, or of course communities of color who are generally underrepresented in research and have a lot of concerns. So this gave me a really close look into what was going on with vaccines, and I had to keep my eyes on the data pretty closely at that point, too. So then, moving forward, I started continuing to talk to my barber more, continuing to work on the vaccine trial more. I wrote an article for our local Black newspaper talking about research protections and why communities of color maybe shouldn't be as concerned as they once were. So in the Black community, they talk a lot about Tuskegee and the syphilis study, but what people don't know is that led to the National Research Act in 1978 or 1980, which really was the establishment of Belmont Principles, research is voluntary the whole nine yards. And at the same time, because people were really interested in vaccine trials and everything going on, I kept getting interviewed for the news. My PI, Dr. McEvoy, was not available, so I just kept being on the news over and over and over again, and that one on the right is just one example of that. So then in January of 2021, that's a picture of me getting my second vaccine actually, because of our work in the study, we were vaccinated the same day as Joe Biden, so we were vaccinated like super early at the end of December. And then again, I was doing more and more stuff like these panels, this was with a couple other Black doctors, one's an infectious disease doctor, one's actually a doctor who's a pediatrician, but also our state director of Medicaid. And we were talking about what was going on with COVID-19, and again, the benefits of people getting it greatly outweighing the risk. And so this is like more and more work we were doing. And so then, it was funny, because right after that in January, as soon as I went into my barber, who by the way had been a little bit hesitant, I come in and he's like, hey, where can I get a vaccine? And I was like, what? I was really surprised, I didn't think he was like that into it. So then him and I were talking about more ways to engage people, and he wanted to hold this little town hall in his barber shop that ended up being streamed live on Facebook. Coincidentally, this documentarian who was doing a lot of work on community-based COVID work was there filming too, and you can see him and his camera there as well. But anyway, this was streamed live, you can still go watch it. And we had a really open discussion. People were against it, people were for it, people were in the middle. And again, just really getting out there and trying to get information in front of people. So if this works, and I'm going to trust people on the virtual comments here to tell me if they can hear this. This was a commercial. I've been dealing with so many different people. I decided it was best that I go ahead and take a chance and have a vaccine. And then on top of that, I wanted to visit with my mother, be around her. I know you're not in the job of convincing, but you stayed on top of it. Every time you come here, you talk about it, you talk about it, you talk about it. You provided adequate information for me to go ahead and feel comfortable and make a decision and get it. You're an essential worker, man, and I need my haircut. Were you guys able to hear that? Or see it? Can anybody hear me or see me? Yeah, we were able to, it was very, the sound volume on that was pretty low. I don't know if we... Well, sorry about that. You guys can watch it on YouTube. But suffice it to say, because of all this work Barbara and I were doing, thank you for that, Dr. Santino, they ended up engaging us, the Minnesota Department of Health, to have ads that were playing on TV and the radio. Those ads actually played during the NBA finals last year, during the Olympics, and that was one of many. But I thought it was funny, and you guys would like that because I was talking about him being an essential worker. And not only because I wanted to get my haircut selfishly, but also because he was going to be highly exposed in that environment. So then they took those ads and even made a billboard, which I've never seen this, because it's an hour north of my house, and I don't really go anywhere. But somebody finally sent me a picture, and it says, the vaccine greatly reduces the risk of hospitalizations, death, or severe illness. Which, thank goodness, it's still there, and still that's a good message, so I'm not mad about that. And so then in June of 2021, we saw this article in the Washington Post talking about the Biden administration and the University of Maryland School of Public Health partnering on this Shots at the Shop initiative, which was essentially to give grants to barbershops, salons, whatever, to host one or two day vaccine events, which is really cool. Well, we found out it was like $1,000, so that's like one or two day events. And so my barber was like, yeah, let's do that. We totally want to do that. That's what we've been trying to do. Let's go for it. The issue was that we talked to MDH, and they said, well, hey, the Minnesota Department of Health, and they said, well, we got more money if you guys want to do something bigger. And I said, yes, I do. Because I'd been volunteering at vaccine events around town. Somebody gets a gym rented out for the YMCA or whatever, and you have tons of tables, not just for COVID, but other types of screening stuff. And you have 50 or 100 people volunteering, and over the course of a whole day, eight hours, you get like 50 or 100 people vaccinated. Now, I'm not knocking vaccinating low numbers of people, but what I am saying is that that sounds like a lot of resources for not a lot of return. And so I said, well, if we can do this thing at the barbershop, but maybe do it longitudinally, more than a one or two day event, but like maybe once a week, I think we'd do a lot better. Because for the people you're trying to reach, let's say somebody's hesitant. Well, they walk by and they say, oh, this vaccine event's going on right here, right now. I want to go get a vaccine, but I'm not sure I'm ready. Maybe I'll come tomorrow. Well, there is no tomorrow. That's a problem. Or what if they're like, well, gee, I'd like to go there, but I don't have childcare. I can't miss work. By the way, I can't get sick and miss work tomorrow if I have side effects from this. So again, having something in the long term where people can plan and really work around some of those social determinants that are affecting them in terms of their ability to get a vaccine, whether it's access or interest, is a huge deal. So we did engage them, and ultimately, we set up this vaccine barbershop clinic. It started July 9th of last year, 2021, and right now we're slated to go through June 30th, just because they're worried about federal funding running out at that point. And honestly, I'm not always in the barbershop chair every time they take pictures. It just happens to be coincidentally for a lot of them I am. And so we've had Black doctors, Black nurses. It turns out there was a local organization that works on issues with the Black community that gave community coordinators and resources. So what we had planned is maybe just have a couple nurses, and maybe I'll be hanging out there and give some shots. It ended up being a lot bigger of a thing. And thankfully, my barber there, Tito Wilson, had space to do this. So the real point I'm trying to make is if you want to help people, show up and go where they are and do the best for them. And by the way, it's not like this is a novel idea, and I'm not some kind of genius or something. It's been shown throughout the preventative medicine literature that if you show up to community places, barbershops, salons, churches, community centers, whatever, laundromats, you name it, you can engage people for preventative screening and preventative services in a way that really is effective compared to trying to get them to come to clinic. And so again, here's more examples of us being there. And again, I'm sitting in this stupid barbershop chair. But you see us out on the street talking to people. Even this guy on the right, he was actually running for city council at the time. He's sitting there waving signs for us and stuff, which is really cool. And so again, we were just really there all the time. It turned out we were there every Friday, every Saturday for four hours per day. It eventually extended to five hours Friday and Saturday. We're about to scale back because right now, across the country and in this community location, there's not a lot of vaccinations happening, but it's still pretty cool that it's been going on this long. And so the documentary that I talked about finally did come out in September. This is on Twin Cities Public Television, which is like our local PBS. And you can see this for free online. But it didn't just feature my barber and I, but also a bunch of other local doctors and community members who were really working on these issues of vaccine hesitancy and trying to get right to the community. And actually, I think it's really good. I've seen this like five times. And every time I watch it, I keep thinking like, oh, this is going to be really boring because I've seen it already. But it's not. Some of it's kind of like quaint, like, oh, look at me getting my first vaccine dose. That's like a million years ago. But then there's another messaging that's still really relevant and still really important, despite the people think the pandemic's over. And by the way, if it's not clear from all this, I'm pretty draconian other than going to this vaccine clinic where, at the barber shop as well as working on the vaccine trial, I got young kids who are still not vaccinated. I take this very, very seriously. And so I couldn't come to HCD. But I'm happy you guys are sitting in there for me. So thank you for that. And so then, you know, after all this, ACOM was really cool and actually featured me in ACOM Quarterly in the summer. You know, I posted this picture on Twitter. So I don't normally give shots at the vaccine clinic, but like if it's really, really busy, I will. And so one day I was and I took this picture of like a Pfizer, you know, 0.3 milligram dose. And like this picture got like 9000 likes on Twitter, which I'm not that prolific on Twitter, but that was like a lot. It was like the most popular thing I ever posted. And so, you know, Charlie Peck and ACOM Communications, they found her like, hey, can we write an article? I was like, great. Thanks. Whatever. Yes, do it. Because I want to get the information out there. More and more people need to do stuff like this. And so then this is even in December of 2021. That's my little sister and my little brother. They don't mind that I shared their pictures. But, you know, they themselves were both, you know, in the Marines and were definitely hesitant, as you sometimes see service members are who get a lot of vaccines and they're black. And so, you know, but they were comfortable coming in and having their older brother give them some doses. So, you know, that was a good thing for me. And then, you know, in December also, you know, I got to go speak at Century Colleges, a local school here where they were talking a lot about issues with COVID. And that guy on the right wearing the beige jacket, that's the governor of Minnesota who I'd never met before. But through this work, he was there speaking and I was there speaking. And again, bring this to the community and trying to make sure that we're giving good information to people so that they can make decisions about why this is helpful and important. And so then even more recently, let's just say April 2022, I actually did a webinar for Medscape about vaccine preventable disease in general. And I think this came from all this prior work. So I don't know, maybe if I didn't feel like I made it before, I did now once Medscape asked me to do like a CME event. Holy smokes. So it's cool. And you guys can watch that. It's fine. I think it wasn't my best one, but it was okay. I'm glad I did it though. All right. So that's enough talking about me. You guys are probably sick of that. So now let's get down to brass tacks. So first of all, let's talk about the basics of medical ethics. You know, number one is patient autonomy. Patients get to choose for themselves. Our job is to give people good information. So some would argue, and I want to write a paper about this I haven't gotten to yet, that patient autonomy is more than autonomy because people can't really be autonomous about medicine and their body and these things they don't understand in that way. So it's really us empowering them to make good decisions in a partnership. Whereas beneficence and non-maleficence is a balance of doing good and doing bad. Everyone talks about do no harm and that's what we hear about. But most importantly, I like to talk about justice. Now people think about, hey, we got to provide the same care to everyone. You know, it may not have been cool that our last president when he got COVID was in the hospital and got the most experimental treatment and whatever ever and that's not available to everybody. Yeah, maybe that's not justice. But I'm also talking about outside the exam room. How do we seek justice for people? Because we know that what affects people outside of the exam room has much more impact than how we can affect them in the exam room. And I'll talk more about that in a second. I've seen hesitancy as an issue certainly in my lifetime starting in the late 90s after the Wakefield study came out about MMR, associating thimerosal and autism. And you know, partially I think we're spoiled because we don't see a lot of post-infectious disease consequences. So I have this picture of President Roosevelt who had polio and then as a function of that had problems walking for the rest of his life. We don't see that. I joke around and ask people all the time, hey, have you ever met somebody who can't walk because of polio? And they're like, what? And I'm like, yeah, that's because disease has been basically eradicated in the United States. And we should take that very seriously. But to be honest, vaccine hesitancy has existed for the history of time, you know, so this started back with smallpox, you know, and people are like, wait a second, so you want to inject me with cowpox so I don't get smallpox? That sounds crazy. But anyway, so people have been thinking about this for a long time. And so when the communities of color, Tuskegee's a big one, I talked about that, but you know, Henrietta Lacks and you know, the cervical cancer cells that were, you know, basically replicating indefinitely and have been used for research all over the world without her, because she was dead, or her family's consent, that's a huge deal. Marion Sims, who's considered the father of OBGYN because of like a lot of modern surgical techniques, that guy basically had experimented on slaves to develop those techniques for vesicle vaginal fistules and stuff. In terms of systemic racism more broadly, we know that communities of color always are walking around anxious, whether it's interacting with doctors, banks, schools, you name it, because these are systems that were never designed to and haven't historically really had our best interest at heart and aren't looking out for us. And then there's all these issues of peripheral trauma like law enforcement violence, you know, me as a black man watching George Floyd get murdered over and over and over again on TV, like a thousand times in a row, was not good for my mental health. I'm just gonna be honest, and I basically didn't watch it that many times because I couldn't, it was really hard. Okay, more broadly, we see these issues manifest in terms of life expectancy. So this is looking at like 2006, 2009 data, but again, over time, you see life expectancy creeping up, but in general, we know that for women, it's better than men. And for white women, it's better than communities of color. And so again, non-Hispanic black males, that's my group mostly, are not doing so great. You can even look at it more longitudinally from 1970 up to about 2010, where again, you see everybody's life expectancy going up, but you don't see those gaps narrowing dramatically. And even though black females are almost at parity with white males, black males are way, way, way down there. And so that's not reassuring to me. We see this manifest in terms of chronic disease rates, you know, high blood pressure, diabetes, stroke, with the CDC data, but again, even across all age groups, continuing from young to old, the rates are much higher of chronic disease. And this is not just true for the black community. I'm just speaking to that because that's what I know very well and from even personal experience, but this is true for all communities of color in general. And overall, African-Americans or black people are more likely to die from all causes. Again, in every age group. There was a study published in JAMA in January of 2021 that showed a relative risk of like 1.27. So that means like, you know what? I'm just 27% more likely to die for whatever reason. That does not make me feel great, but here we are. Okay, so now you guys are probably asking yourself, okay, wait a second, Z. Why is race such a big deal? Well, I don't like to read a lot of quotes, but I'm gonna probably read this one just to make a point. And so structural racism is defined as the totality of ways in which societies foster racial discrimination through mutually reinforcing systems. If you haven't learned anything from me today, I just remember those three words, mutually reinforcing systems, because these things don't exist on an island of housing, education, employment, earnings, benefit, credit, media, healthcare, and criminal justice. Wait a second, those sound familiar. Are those perhaps social determinants of health? The answer is yes, they are. And so, you know, social determinants of health are delineated in these five categories, education, economic stability, the neighborhood and built environment, health and healthcare, and social and community context. And on the right, I just show this web of causation just to make a point that if you see the outcome of increased maternal and infant mortality in the middle, well, that's affected by income and local safety and access to care and rates of incarceration. And that stuff all extrapolates out far back to things like slavery and Jim Crow and the GI Bill. And so the point is, these are mutually reinforcing. And it's not like, oh, well, you're just poor or you're just black, or you just don't have access to a car or a job. Those things are all making each other worse. They are synergistic. And so some people would argue, and I would too, racism is its own social determinant of health, and it is. And that will be part of social and community context. If you wanna be more new school, though this isn't really that new of an idea, but nobody's talking about it yet too much, colorism is a social determinant too. The darker your skin is, the worse off things are for you, regardless of race, ethnicity, whatever. We know that systemic racism has serious impacts on mental health. It impacts how people communicate about it and about things in general and with their doctors, how people are seeking help, what stigma looks like, which, because by the way, a stigma about mental illness or mental behavior health in communities of color is much, much, much, much worse, what type of support you have and how you even manifest symptoms in addition to the overrelying stress of systemic racism in general. But the point is, it's yet one more layer to all of this. We know we as clinicians are not immune to this. So there's been a million, billion studies, it's not a million or a billion, but many, many, many, many, many thousands of studies showing that implicit bias exists for clinicians. It impacts how we make decisions. It impacts how we communicate with patients. I like this picture from this Hagiwara study here because it says, okay, like, hey, physicians have implicit racial bias. And then it jumps to this affects immediate patient outcomes in terms of dissatisfaction or mistrust. And then in the longterm, that affects adherence and healthcare utilization. We know that. And what's missing in that gap? How we communicate with people during our medical interactions. Dun, dun, dun, no surprise. Now, the problem is people get trained on cultural sensitivity or cultural competence, but that doesn't address the how and the why of how communities of color may have mistrust or distrust of healthcare and research. And so again, these peripheral traumas are one variation of this. And we've seen this as I've talked about like a bunch of times already through research and through law enforcement violence. And I can give you a thousand other examples, but those are probably really big ones that are right at the fore of everyone's mind right now. Now, as I was pointing out earlier, social determinants have a greater impact on health outcomes than what we can do in clinic. This diagram here suggests that bottom 20% healthcare has a 20% impact on outcomes versus, you know, the other rest of the 80% is really social determinants. And, you know, the literature overall says it's 50 to 90%. My point to you is what we do in the clinic has the minority of impact on people's outcomes. Therefore, we should have the responsibility through the auspices of the medical ethical principle of justice to do things outside of the exam room, to advocate for our patients. The stories I was telling already so far. We see these types of disparities show up in occupations. Now, this is, you know, speaking to what you guys know. So this study for Stanbury and Rosenman looked at Michigan workers in the year 2011. And as you can see, the point I'm just trying to make by this slide is, oops, that black and Latino, Latino workers generally, so you're black and brown people, are generally in lower blue collar occupations where hazards are gonna be potentially greater. They're gonna be more likely to be essential workers versus your white or to some degree Asian population are in more white collar or jobs that may have more access to work remotely. We, in that same study, they looked at, you know, again, how does this distribute across race? And again, just making simple points here that you look at tractor truck trailer drivers or, you know, food servers or whatever, and you see greater proportions of black and brown people across those by that race versus in the white population. So again, more essential workers are black and brown. We know that that plays into COVID risk amongst other things. It's not surprising, but I'm just showing you data that supports that, old data even. And so then you look at actual occupational illness and injury, silicosis, deaths, pesticide injuries, work-related burns, work-related asthma or occupational asthma. And in black people, you see a 5.5 rate ratio for silicosis, ouch, 1.25 rate ratio for work-related burn, about a two times rate ratio for occupational asthma, scary. For pesticide injuries, that's four times for Latino, Latino workers. And for deaths, it's 1.5 times, ah, that's messed up. And so we know these disparities exist and we need to do stuff about it. Sears et al in 2015 looked at 90,000 workers across six years, across five states of Arizona, California, Florida, New Jersey, and New York. And so interestingly, again, telling the same story, you see that Latino, Latina in this study primarily had a lot of increased rates of all types of injuries, fall, machinery, motor vehicle crashes. But then interestingly, assaults and homicides were super high in the black population for reasons I don't know. And so we still have plenty of work to dive into this type of data to figure out the why and the how. But again, identifying these inequities is maybe the first step. Steege et al in 2014 looked at US private sector workers, this is about 1.7 million people, a little more than 200,000 non-fatal injuries and illnesses, comprising also 27,000 deaths. And maybe unsurprisingly, your Latino, Latina population had a greater than two times higher rate of injuries, indigenous 1.7, Asian actually was about two thirds, so lower, whereas multiple races was like a little bit higher, 1.2. And again, what does that really mean? Nobody can parse that out very well. Having a less than high school education increased your risk pretty highly. Being from outside the United States increased your risk pretty highly. Being out from off of the continental United States increased your risk. And probably super unsurprisingly, lower wage jobs were more at risk of injury. We know that. So why does this happen? Well, we know people have precarious work environments, seasonal jobs, they're contract workers rather than being full employees. They don't have unions. They may not have like correct documentation status, so they can't be protected by the same legal protections as everybody else. They might have multiple types of work to put together to make like their normal paycheck. A lot of people don't have health insurance. Maybe people aren't covered by work comp, which sounds crazy, but it happens. Some people have actually health insurance, but can't afford their copay or their deductible. So really it's not accessible anyway. We know safety training and availability is messed up for people. Their trainings aren't offered. People are migrating, you know, like migrant workers and can't get there in time. It's not offered in their language. People have low education or health literacy anyway and can't take it. Personal protective equipment may not be given to people or not fit for people or the person doesn't use it. And by the way, at the beginning of the pandemic, doctors couldn't even get N95s. How bad do you think it is for other people? And to be honest, I'm not, again, limiting this to just black and brown people. Any disenfranchised or underrepresented group has these same types of problems in lots of dimensions. And so we see problems in identifying this stuff because we don't know even how to slice up the demographics. So like in our electronic health record, at least as of three years ago, it's gotten a little bit better. Back then you could only pick one race and it had to be white, black, Asian, other or multiple or native. And ethnicity was Hispanic or non-Hispanic. Okay, now in the current era, you can pick more than one race, but that still doesn't solve this problem because if race is a social construct, well, then we can also think about like, what is nationality? Well, in nationality, people ask, well, what's your country of origin? That's hard here in Minnesota. Here in Minneapolis, we have the largest Somali population outside of Mogadishu. You ask a Somali guy, hey, where are you from? And he's like, I'm from here in Minneapolis, I'm a US citizen. And they're like, no, no, no, where are you from? And by the way, me, Zeke McKinney, born here in the United States, I was actually born in Maryland, and living in Minnesota most of my life, people ask me all the time, where am I from? Because I'm like indiscriminately brown. But the question people are really getting at is, for me, is ethnicity, but for everybody else in this scenario is, what is your country of birth? Which we know is a social determinant. We know gender matters a lot in terms of discrimination, harassment, bullying, but biological sex is also important from a medical perspective. We see data gaps in looking at race and ethnicity in the electronic health record. The left is a study from the VA, the right is a study in some primary care clinics. But the point that's being shown here is, there's not always concordance between what you see in the electronic health record for somebody's race and ethnicity, and what they themselves will report. And I'll tell you one easy reason for that. Think about that. Patients aren't ever touching that electronic health record. So a guy walks in who looks like he's white and maybe doesn't identify as white, but somebody just sees him and says, oh, this guy's white, so I'll put on white. Or somebody walks in and maybe they look like they're black and they're identified as black, and somebody just puts that information in. So my point is, it's never the patient doing it themselves. They might be asked, but they're not the ones actually reporting on the data. And so when we ask people directly, we get better information. Our group, my clinic did that, and we just published this data in 2022, showing that race and ethnicity in our electronic health record against a gold standard form, because I assume patient reported information will be the gold standard, had really high specificity, but really low sensitivity. And generally speaking, it was not concordant. Now people say, wait, wait, wait, wait, wait, wait, now you're confusing me. What is specificity? What is sensitivity? Well, I'll make it easy for you. Specificity says that if the electronic health record says you're black, you probably are black. Sensitivity being low says, if the electronic health record doesn't say you're black, you don't really know, scary, but true. And so this is just reproducing data that's already been shown. This was probably the biggest of its kind so far. And we wanna expand on this more. The reason we did that work was from an earlier study, looking at two years of our occupational health clinic data, that showed Hispanic workers had three times higher rates of low back injuries and two times higher rates of upper extremity injuries. But the big question was, well, wait a second, are we talking about people from Mexico or Spain or Dominican? Are we talking about Spanish speaking people, undocumented people? We don't know. And that's why it's crazy just to use these really broad levels. Similarly, in our case, we didn't know how these distributed across industry and occupation. So there's like lots more data to do. And our next plan is to really submit an R1 grant to really synthesize all of this data into sort of an occupational health surveillance system where we can look more closely at race and ethnicity. Because when we've collected this data, we actually asked people very specifically, like within black, be considered as a Somali or black or African-American or Nigerian or whatever. And the same thing for Asian because of our Southeast Asian populations, particularly Hmong here in Minnesota, as well as for Latino, Latina, or you can choose a Puerto Rican, et cetera, things like that. So we saw COVID inequities broadly across our black and brown or communities of color. So these are chloropleth maps, otherwise known as heat maps. On the left, we're looking at incidence. On the right, we're looking at mortality. A is white, B is black, C is Latino, Latina, D is Asian, E is indigenous, F is native Hawaiian. And again, no surprise that incidence in black and brown populations was greater. Mortality in those same populations is greater. This isn't a surprise at all. Yet again, don't wanna read quotes, but I particularly like this one. I'm gonna make a point out of this. So to look at COVID as a case study of occupational health disparities, they said, as with all diseases for which workplace environment is a root cause, the most marginalized workers with the least power and resources, such as people who are undocumented residents, incarcerated people of color, women, lesbian, gay, bisexual, transgender, queer, okay, we've talked about that, are the least likely to have access to testing for infectious diseases and the most likely to be missed in cohort enumeration. Wait, wait, wait, wait, wait, wait, wait, wait, wait, wait. So you're telling me the people who are the most at risk for getting sick and having problems are the ones who aren't getting tested and we're not finding them either? Scary and bad and yet true and representative of what we already know. So again, making the point that we gotta start to find the gaps and go after them. Just again, sticking on this point of mutually reinforcing risks. So you look at the middle here, environmental lung disease burden. And again, this risk extends all the way out to what's happening at a global level in terms of the climate and resource allocation and the economy. Also looking at the level of your community, what type of employments are available? What type of cultural beliefs do you have? What's your built environment like at your individual level, thinking about what's your job? How do you sleep? Do you smoke? What other stresses do you have? And then even individually, people have their own intrinsic factors. What is your genetic risks? What's your health literacy, et cetera. All these things stack on top of each other. And that's why I like this concentric circle showing that sort of stacking effect. Another instance where this came up in the workplace, I like this study talking about discordance between people reporting occupational injury themselves and otherwise it being reported administratively. So in this graph, the dark bars are the person did not report it and occupational health did not report it. And the light part is both people reported, occupational health and safety reported and the person reported it. And the two in the middle are divergences between two people, whether or not it was reported by occupational health and safety or whether it was reported by the person. And unsurprisingly for Hispanic or Latino Latina and non-Hispanic blacks, you have this greater discordance of it being reported by them, but not by occupational health or vice versa, more by them. There's not a lot of research on workplace vaccine hesitancy. To be honest, I did this PubMed search a little while ago, like a few months ago, and there's been some more since then, but there's still not a lot there to be honest, especially if you, and you can search for better terms than this, but I'm just making the point that overall it's a limited field of study and there's a lot of areas for work to be done because the workplace we know is a good place to intervene on stuff. So we know that mistrust comes from these peripheral traumas. I talked about Tuskegee. I talked about Marion Sims. We've seen infectious disease stigmatization be an issue. The AIDS epidemic when I was a kid or in the eighties and nineties, really focused on certain groups of people. COVID-19, we talked about the China virus and that led to a lot of Asian American hate and still is leading to that, which is kind of messed up. We know in clinical settings, people of color are less commonly believed, including for pain, including when they're pregnant, including when they're severely injured. They're often thought to be drug seeking or malingering or whatever, called difficult patients sometimes because of communication styles. We know redlining has been an issue. That's what that's in that white box talking about. You can't buy property in certain areas if you aren't of a certain race, particularly white usually. We know cultural appropriation has been an issue. That's why I show the Redskins logo there. And by the way, thank goodness they got rid of that. And then we know immigration law and stigmatization around that has been a huge issue too. Okay, now switching gears a little bit, we know we're facing issues of information here right now. The WHO calls this an infodemic. And really they're talking about the fact there's too much information, whether it's good, bad, or misinformation, disinformation. They define this as during a disease outbreak. But I would argue this has been a problem prior to COVID-19. People have had access to the 24-hour news cycle, social media, whatever for several years now or a long time now. And there's increased access to this sort of echo chambers, people getting opinions that mimic theirs. And they consequently have difficulty accessing or assessing rather accurate sources. So I always like to joke about this one, paging Dr. Google. And I'm just pausing for a second just so you can read that. And the good news is this isn't what my Google search looks like, but Google does show you things that reflect what you're looking for. So if you're somebody who's looking for this type of information, it's going to find it. Some people talk about searching Google in incognito mode. So you get like quote neutral results and don't see this stuff. I would argue Google should have like a couple of like sets of search results. Here's things consistent with what you want. Here's things inconsistent with what you want. So then you're seeing a diversity of opinions. You can like find different stuff, maybe divergent from what you're normally looking for. So we know employees are getting information from a lot of different places. At the work site, it's formal or informal types of safety training. When I say informal, like, you know, from their supervisor or from their colleagues talking to them. Out in the community, you know, maybe the union's giving them information. Maybe they're getting information from the news, social media, friends and family. The point is there are a lot of sources, but, you know, probably community sources are going to be more trusted than what they get at work. So again, we have to watch out for this echo chamber effect. Academically, that's called cognitive conservatism. That's a tendency to resist changing your self-concept while also seeking information that reinforces that self-concept. And as our country has become more polarized in the last 20 years, we've seen a lot, lot, lot, lot more of this. We know in certain groups, this is worse. You know, some groups have mistrust in systems, you know, because of systemic racism, for example. And so even though some, you know, the public health department or your doctor is giving you good information, you're just like, I'm just not trusting them because I don't trust anybody like that. And so I would call that a type two error, you know, a false negative. You believe something's negative, even though in fact it's true. And similarly, this mistrust may lead to people accepting misinformation from sources that they trust more even though it's an accurate source. And so that would be a type one error, a false positive. And you think something's true, even though it's not. And so there's this attraction of what we would call conspiracy theories because underrepresented groups experience chronic social devaluation, like my life sucks worse than other people's and why is that? And so people are trying to manage that and figure out ways to explain it. And so they're looking for potentially alternative explanations other than things are just worse for you than other people because of systemic factors you can't do anything about. That's not reassuring to people. And unfortunately for us as, you know, educated people or health professionals calling these things conspiracy theories, unfortunately reinforces that devaluation of perspective. So that's not great and we need to be careful with that. So we have to first start by identifying the populations at risk and that's addressing those issues of data gaps I was talking about. We have to address these issues of information overload and we have to specifically listen so we can address this and make sure that information becomes accessible to people all the time and in the workplace, make sure that people trust not only us and occupational health, but also their safety leadership by starting to show, hey, we know these problems exist and we are ready to hear your individual concerns because, you know, at the ground level, employees often know about stuff better than we do and ensuring that adequate resources are out there so people can get them all the time when they need them and then making sure that we're giving people information at their own level. So everyone's favorite picture of all, we got to just get to this end point of removing the barrier. So in reality, people want to all watch this baseball game and there's a fence in the way and some people have better resources than others to actually do that. And in fact, some people have negative resources. They're in a hole. Equality says gives everybody the same resources regardless of what happens to them. Equity is more outcomes based, thankfully, and this is where we are today. People are saying, okay, give differential degrees of resources to make people, you know, get the same outcome seeing the game. But in reality, we want to get to the end point of liberation where, you know, there aren't any barriers. So it doesn't matter what resources we give people because everyone, regardless of where they start, can actually achieve the same outcome anyway. That's where we need to go. So inclusion starts with trust. So I interviewed the CEO of Medtronic for this magazine and he was saying it's not just about diversity. You can't just put bodies in there, but you also have to have inclusion and making sure that people know their voices are heard. And so that means in safety leadership and throughout your institution, you have to have representation of people of different jobs, different races, different ethnicities, different backgrounds, so that people know their voices are heard or if their individual voice isn't heard, there's someone throughout the organization who might be able to represent their perspective accurately. And so again, don't make assumptions about anybody. You know, look, a lot of people have different degrees of knowledge or expertise and you have no idea what that is. A lot of people have different lived experience and you don't know what that is. Just because somebody looks a certain way doesn't mean they think a certain way. Not all black people think like this. Not all Spanish speaking people think like this. Not all white people think like this or that, you know? And so we have to listen and understand that there are people who may be aware of problems that we may have never heard of. And when we start to hear about those, that's when we can dig in on it. And by the way, there's divergences between what people want, you know, between when we're treating them at the doctor and what our goal is versus their goal or what the employer wants versus what the employee wants. And you can also, you know, ask community organizations, maybe labor unions, maybe, you know, community groups, how do we develop resources to help bridge those divergences? And again, ask yourself this, are there competing interests for people? You know, like, gee, I want people to get a vaccine and I'm mandating it, but I'm also going to write them up when they're sick the next day when they can't get it. I mean, maybe the situations aren't that bad, but that is a concern that people have, that they're going to get sick and they, you know, they're going to lose their job, even though, you know, maybe they in fact do want to get vaccinated. And of course we have to empower people to know they have some decision-making capacity for themselves. They can take care of themselves to some degree. So we have to keep on building or maybe rebuilding trust. And we know that in the workplace, we have to have representation again of different groups of people throughout the organization. Now I talk about this point of restorative versus retributive justice to make the point that, you know, we know some of the barriers between employers and employees are this issue of, you know, punishment, you know, oh, you're late to work. So now you're going to get written up. You missed work. You're going to get written up. Oh, you did this. You're going to get fired. I would argue in general, both in the workplace and as well as American criminal justice, we need to have more retributive justice because like, let's say somebody shows up to work five minutes late a lot of the time. And finally, the boss is like, dude, you're going to get fired. And the guy's like, look, man, I'm just trying to get my kid to school and to get my kid to school on time. You know, there's always a train that comes across the path I take to get to work. And unfortunately, I have to wait for that. And that always makes you five minutes late. And they're like, well, it's not our problem. You know, it's our business. You're just out of here. Well, what about a better solution of saying, you know, gee, I understand that, you know, maybe we have problems with our quota or morale or whatever, if you're late all the time, but why don't we just start your shift 15 minutes later and you'll leave 15 minutes later. And then maybe that solves everybody's problem. And I don't have to fire and retrain a new worker and you don't have to lose your job and find a new job. And everybody's happy. Now for major infractions, you know, somebody's embezzling millions of dollars from a company. Yes, fire them. Retributive justice is needed. But I'm just saying in general, we don't approach restorative justice enough. And our criminal justice system, think about it. I mean, it's really retributive all the time because people are always punished even after they get out of jail and have quote, paid off, you know, their debt to society. And so, again, you know, ask yourself, do we need to translate things in people's language? And, you know, tell people why it's important to you that, you know, safety matters because if people get hurt and they miss time, my insurance modifier goes up and I got to pay more money. And oh, by the way, I'm not going to get contracts as much. And, you know, whatever, all these different reasons, employees can understand that and then just hear what they have. They have to say about it. And I'm sure everyone can sometimes find a happy medium that gets everybody what they want. So we see sometimes in health care, people talk about, well, I don't trust doctors. Well, look, you can validate people and say health care is not always protected communities of color or not always have their best interests at heart. You can ask people, well, if not me, who do you trust? Or throw it back at them and say, look, you came to see me in the office. What kind of help can I give you? Or you can reassure them, say, look, I get that things have been bad before, but I'm doing my best for you today. Or really just ask them, fine, if not me, who would make you more comfortable? You hear people say, well, I don't want to be a guinea pig. Well, look, here in clinic or here in my occupational health setting, you can choose whatever you want. I can't force you to do anything. Similarly, what I'm doing here is not research. This is the standard of care. And then, you know, also educate people like a lot of people can talk about Tuskegee in this guinea pig context. Again, even though Tuskegee was horrible and an atrocity, it resulted in a lot of research protections. You know, I also like to say this about George Floyd. You know, I wish it didn't take George Floyd getting murdered. But now people are talking about systemic racism. And I'd like to think George Floyd, wherever he is, if he can hear us, would be happy to know that his death actually had some positive impact. Again, I wish it didn't have to come down to that. A lot of people say I don't trust the government. I'll just leave this there for a couple of laughs. But you do hear that a lot. And again, I know the government's harmed communities of color. I know the government has always had communities of color, best interest at heart. Look, as your doctor, your nurse, your social worker, your whoever, the government does not control what I'm doing right here right now. As it pertains to medications, the government approves medications, I prescribe them. At the end of the day, I'm not asking you to trust the government, I'm asking you to trust me. People say, well, my body can heal itself or I don't want to take medication. Great. I don't want people to take medication either. Medication, surgery, our last resort. You know, look, I think your body can do its job to heal itself. But for some diseases, that may not be enough. Or if you waited like 50 years to treat your hypertension, it definitely isn't going to be enough. And at the end of the day, I'm trying to give you better choices, better education so you can do whatever you need to do to prevent taking medication. And again, you're here to see me. I'm a doctor, I have medications or I have other stuff too. But if you don't want a medication, what do you want? And so then a lot of people say, well, I do my own research. Oh my gosh, this has been like my favorite, least favorite thing to hear during the pandemic. But I think it's important to gauge people. So you say, okay, can we look at some of the stuff you've researched, talk about what you've learned? Or like, hey, I'm really glad that you're passionate enough and interested enough to learn more. And then you can take it a step further and say, but by the way, there's a lot of bad information sources out there. Do you know how to check a source? Or you know what? Fine. You don't trust the government, you don't trust whoever. Check out a lot of local organizations that have good information. In this case, I'm talking about Minnesota stuff, the Minnesota Association of Black Physicians, the Minnesota Medical Association, the Minnesota Nursing Association, the Minnesota Association of Family Physicians, whatever, Central States Occupational Environmental Medicine Association. There are groups that are, you know, government neutral and have good information. And you don't have to believe, you know, you can't disbelieve everybody, I think, I hope not. So we know the workplace is a huge venue in which we can support health promotion. That's the spirit of total worker health. And this is the CDC's workplace health model, which, you know, starts with, again, assessment. What's really going on? This is what I've been talking about this whole time. But then you plan it out and get support from leadership and engage management and set up resources and set up communications. You implement it and you start doing it on site and making sure you have the right access points and the right opportunities for people to engage or involve them through insurance or incentives. Again, providing education and counseling as part of this. And then you evaluate what you did. Did worker productivity get better? Did healthcare costs get better? Did outcomes get better? Did it just change the culture of health that you have there or how people feel about, you know, engaging safety and health in the workplace? And so this is just a publication that had the same workplace health model and more in a different layout and detail, which I liked. So I wanted to show it to you. But with that being said, you know, I finished with probably about eight minutes left, but we started a few minutes early. And that's all I got for you for now. And I just got to say, you know, first of all, thank you all for being here. I presented this at Central States meeting in fall, and Mark Roberts was insistent I submitted to AOHC. So that's the reason you guys had to put up with me today. I'm looking at the chat over here. Does anybody have any questions or concerns? Again, thank you for attending. Sorry, I'm remote here. Yeah, Dr. McKinney, thank you so much. That was wonderful. Great job. Thank you. And I do see that we've had some communication in the chat, and I'll also invite folks who are here, if you have a question, please don't hesitate to walk up to a microphone and ask a question. And while folks are doing that, I'm wondering if there's anything in the chat, Dr. McKinney, that caught your eye that you want to discuss or respond to. Mostly in the chat, I just heard people saying, you know, yes, they can see and hear me. Thank you for presenting. I didn't see any questions or comments yet. Okay. Any questions? Actually, I had a question. I very much appreciated your approach to go out into the community to address some vaccine hesitancy. And I was wondering if there was any content in the message that you thought was particularly influential. So beyond just the location and trying to find a trusted source, was there any information that you felt that you gave or some exchange that you thought was particularly influential to address vaccine hesitancy? Yeah, that's a good question. Interestingly, it's really different for each person. And that's why it's important to start by just listening and saying, okay, well, what's your concern? And, you know, even in clinic like my med clinic, I ask everybody I see whether they've been vaccinated. And people often tell me they aren't. And I ask them why. And for the most part, people are open to talking about it. A lot of people say, you know, gee, no doctor's ever talked to me about this. So, I mean, I'll just tell you right now, one of the most important things is just bring it up. Bring it up. But then, of course, in a community setting, I think it is important to think about what community you're talking to and understand what types of barriers exist. You know, for the black community, I've talked a lot about those and I have a sense of those. For other communities, it's going to be different. And of course, if you are concordant with that community in terms of, you know, similar background in any number of ways, that helps too. So I don't think that answers your question directly, Dr. Vincitino. But the point is, it really varies. And that's why I'm trying to give people a lot of different strategies to approach this because everybody's concerns are different and it's not going to be even the same at the level of community. You'll see trends. And so I showed like some of those at the end, you know, I don't trust the government. I don't trust doctors. I do my own research. You know, I do my own research is probably the most interesting one. And that's where you can engage people because that's where you can actually challenge people and say, okay, well, let's look at the stuff you saw and, you know, really back to them. You know, here's why some of this may or may not be true. Yeah. Okay, great. Thank you. I think we have a couple of questions, Dr. Fagan. Thank you so much. Kathy Fagan was a wonderful presentation. Do you have any others? So you talked a little about this, but do you have any other suggestions for OCDOCs out in practice to try to also address the social determinants of health in their practice? Oh, good question. You know, some of the things I'd like to do, and I don't know that I've done this as much as I would like to yet is, you know, try to engage the local insurers. I mean, I think we especially, you know, knowing that work is a social determinant and that's our area of expertise can show data to insurers that look, I know it's hard to, you know, lose money quarter after quarter for a few quarters, but investing in prevention is really your best way to save money and showing them data that shows that, you know, addressing social determinants is going to be more impactful than what we can do in clinics. So that means, you know, gee, make sure people have transportation to get to work. You know, maybe if somebody's, you know, ask your patients why, I mean, you or even insurer, ask a patient why, you know, they can't come to their appointments or why they don't want to take their blood pressure medication. You might be super surprised by the reasons you find out that people aren't engaging in the same way you'd expect, but I really do think emphasizing this issue of prevention and showing everybody that that's where we can save the most money does the best. One thing I want to do is actually put a lot of preventive services out in the community, you know, screening people for blood pressure or, you know, doing A1C checks and things like that, cholesterol screenings, because again, getting people engaged, you know, easier than making them come to the clinic on our time. You know, look, you see patients get fired from clinics for being late. I would argue that's a big mistake because if those are the people we need to help the most, then we just did them a disservice by firing them. So I guess all I'm saying is let's make things more patient focused and patient oriented rather than what's convenient for us as the doctors and what's convenient for us as insurers. A couple of people just said, thank you. Once somebody said, may we have access to your slides? Yes, you can. I didn't post them yet. I'll have to figure out how and where to do that, but I will. And then somebody else can tell us, somebody else can tell us, ask me to tell about these musical instruments. Look, at the end of the day, I'm just a basement DJ. I like music for fun. I'm really not a great musician, but I like to play a lot of different stuff just for kicks. Yeah, thanks, Dr. McKinney. I'm Dr. Michael Caldwell. I'm Associate Vice President for Vaccine Research and Education at Meharry Medical College. I work with Dr. James Hildreth. So of course I did see all the

Zeke McKinney

COVID-19 pandemic

George Floyd

systemic racism

Black physicians

barbershop vaccine clinic

occupational health disparities

implicit biases

community health initiatives