So, well, thank you all for joining. Good morning, if you're on my side of town, or, you know, good afternoon if you're on the East Coast. So today's webinar, we'll be talking, a really important webinar. The title is Celebrating the Journey to Inclusive Healthcare for Black Patients and Physicians. I'm Chimobi Anugom. I'm a hepatologist with Health Partners in Minnesota, and also an assistant professor of medicine at University of Minnesota. Today, we're honored to have two expert speakers. We have Dr. Julius Wilder, who is an associate professor of medicine at the Duke University Department of Medicine. And we also have Dr. Lorna Dove, who is a professor of medicine and director of clinical hepatology at Columbia University. Today, our speakers will be talking about care of liver patients as it relates to racial inequities, hopefully also highlights the challenges and roles of black physicians in medicine in the United States. So I will hand it over to Dr. Wilder to go ahead. I think I'm starting, no? Yeah. Good morning. Dr. Dove first? Okay. Yeah, a little bit of a pivot. So good morning, everyone. And thank you to the organizers for inviting us for this very important topic to be discussed. And apropos, it is Black History Month, so happy Black History Month to everyone who's celebrating. Today, we want to talk about the journey in liver disease, but as all of us know, disparity in healthcare is not organ specific. And the topics and ideas that we're gonna mention today are going to refer to healthcare in general, and we'll also refer to populations outside of the African American population that we're gonna talk to today. And I think if I could get across one message, it is that promoting healthcare equity is not just a benefit to the group in question. Promoting healthcare equity doesn't just help African Americans, it helps the entire community as we decrease the overall cost of care, we get rid of catastrophe care, we just increase the overall care, health and wellbeing of our general population. So in my mind, healthcare equity is a conversation and a topic that should be of interest to all healthcare providers. And because it's History Month, I'm gonna start off with a little bit of history. I'm gonna try to share my screen now and hopefully won't have a problem. Do you see my larger screen now? Yes, we can see it. Yes, we can see it. Okay, great. I was having some technical difficulties. So overall, I'm gonna start talking in my talk today is about building trust and creating access. And I think that this building trust issue is not one to be minimized because I think one of the first issues that we encounter when we talk about healthcare equity is both the attitude of the healthcare provider and the attitudes of the healthcare recipients. And I want to start off by sharing with you a little bit of what I think colors the attitudes of the healthcare system and of the providers. So I'm gonna go through our history. I'm gonna talk a little bit about inequities in healthcare in regards to liver transplant. Because that's what I do most days. Try to discuss some solutions because I think that it's always important to not just identify problems, but talk about solutions. And then hopefully end a little bit with my story and my journey in healthcare and how hopefully my journey in healthcare helps address healthcare equity. So how we see the world and the story of the Tuskegee story is an old one. And most people, and I'm sure most people listening to this webinar know the history of a more than 30 year history of not treating syphilis in African-American men in the South, sort of watching the natural history of that disease even after therapy became available. And the discovery of that and its impact on how African-Americans and people of color see their interaction with the healthcare system and with research is not to be minimized. And as I'll go through in my first few slides today, it is not an isolated example, but I show you these next two slides not to discuss sort of what I consider to be the atrocities of the situation of the history, but to give you a moment to reflect on the attitudes and how these attitudes are deep within the community. So hopefully these two videos, and what you're gonna be hearing is the voice of a gentleman who was actually a part of the study and then the voice of his daughter and what advice she gives to her kids. So now we have three generations of people who have been affected by this study. It was pretty rough, though, that they just involved themselves just among the black, you know. Anything like that around, and they never met a black, it must be something wrong. It was pretty rough, though. Now his daughter. And I told him I couldn't participate in it. So I don't know what was gonna happen, but I was afraid the same thing was gonna happen to my daughters that happened to my family. When somebody call in the law, we should try to know what's it all about. But a lot of times they come and tell you it's a good thing, you know, and you just fall for it, and then it's bad, but you don't know it till it's all in, you know. So we didn't know. We thought it was a good thing going on. So that is the voice of people who have been harmed by the healthcare system. And as you hear from him, we thought it was a good thing. People came as healthcare providers to provide what was a good thing. And he sort of expresses how he should have been suspicious because everyone who was involved was black. And so that gives you just a comment on how people are thinking about the healthcare. And then now when healthcare providers approach this woman's daughter, she is advising them to think about it with suspicion. And that's how I think communities look at us. And I think that we have to consider that when we meet people and we have to bring, we have knowledge of their experience to our encounters. Now, I want to look at how the healthcare system looks at that. And I want to bring to your attention a study that was done, ended in 1972, where 82 charity patients in Ohio were exposed to powerful full dose impartial body radiation that was 10 times higher than radiation that had been used in the past. And the purpose of the study was to see what radiation exposure would do to soldiers. Specifically, they were discussing soldiers and what had happened in Vietnam. But the radiation was being provided to charity patients who had cancer. But their wellbeing was not the goal of the study. Their, the goal of the study was to look at effects of radiation. Well, in any case, they signed up these patients and 61 of the 82 were black men and women. Many of them who definitely had the diagnosis of cancer but were very functional when the study started. And then within two months of starting the study, 25 of the 61 had died. And this of course caused outrage and an investigation. And I don't, again, want to focus on the atrocity. I want to focus on the attitude of the scientists who conducted the study and what their concerns were and how they looked at the patients they had included in the study. Extremely interesting thing. But what happened was that we had had a contract with the Department of Defense because I was very much interested in what happened to individuals who would get single doses of uniform whole body radiation. And at the same time, I was very much interested in whether these patients who had disseminated cancers would respond to whole body radiation as well with radiation as they were with chemotherapy, which was in its infancy at that time. We set up a protocol which had been approved by all the committees as Dr. Barrett indicated. And we had treated approximately 120 people. The attack came really from people who were unilateral disarmament people and so on. And it gradually kept on increasing in magnitude until Senator Kennedy picked this up to make a few points at a time when he felt he needed a little bit of ammunition to attract the public to his deal to see that he was a defender of the poor and the weak and downtrodden. He sent out two men to investigate this question. And what they were interested in doing was getting a patient to say in front of television that his rights had been violated and that he really had been pushed around. And so this of course required the signed consent of the patients. And we would not release the patient's name because this would have been a violation of privacy without their express consent. So we went through a lot of negotiation and had a very shrewd attorney advising us at the time. And we wrote letters to each of the patients to request to see whether they would help Senator Kennedy and his crew. Well, unfortunately, the patients were so very well treated by our nurse and our staff and physicians and so on that they wouldn't have any part of this. In fact, they said, well, if they thought this was for the benefit of the boys in the service, they'd be happy to participate in these studies. But the other thing that was interesting was I said to this one. So I think what I wanna highlight here is, you know, that he thought his concern was to the benefit of the soldiers. And certainly the soldiers deserve research and they deserve knowing their exposure. I don't minimize that. But I don't think that the thought was really to what happened to these 82 patients who were being experimented on for the benefit of the Department of Defense. But I think, again, I wanna just emphasize the interaction between the medical system and African-Americans is a long one. And you can bring out individual people and identify them as individual people who have committed things that were wrong, but it's more of a systemic effect. And if you look at African-Americans originally, this goes back to even as early as slavery where Southern physicians were involved in the daily evaluation of slavery, of slaves to determine their soundness. Because you realize that slaves were like cattle. They were to be used for work. And if they had lost an arm or had injuries that prevented them to work or they had underlying diseases, that definitely decreased their soundness and would affect your ability to sell them. And then what's actually quite a few legal cases that doctors were called in to determine that someone had been taken advantage of by being sold a slave that was not of top condition. So the physicians at that time who were supposed to be providing healthcare were very much a part of the whole slavery system, just like masters and overseers. And so we can't forget that that is the history that comes with African-Americans when they come to the medical system. It continues. Female slaves were basically primary job was to produce more slaves. And so it was very early in our knowledge of gynecology. Childbirth was often fraught with problems. Women develop fistulas. And in fact, one of the most famous gynecologists started a women's hospital in New York, perfected fistula surgery using slave women with no anesthesia in the mid 1850s. And interestingly enough, to control the pain, he gave them morphine, which then addicted them to opiates. And the only relief out of the pain was to have more surgery. So, and this statue was just taken down in the last decade. It continues. We all consider anatomy a great art in medicine. Where did their original cadavers come from? Many of them came from the poor, the downtrodden and slaves. And then after slavery, many of them came from cemeteries. And many of the cemeteries that were of choice were the ones that had primarily African-American bodies as the cemeteries and everything else were segregated. So, this is a cemetery in Philadelphia, Lebanon Cemetery, where the quote was, it was almost empty as bodies were being taken to Jefferson Medical College. And this was discovered. These grave robbers who would bring the bodies were convicted and actually sent to jail. But the doctor who was affected, who was receiving the bodies, claimed no knowledge of where the bodies came from and he was acquitted. And so, this was not an uncommon practice. Most of the cadavers in Medical College of Georgia or also came from graveyards, many from people who were poor or African-American. And this went on from 1835 to 1923. Now, experiments keep going on throughout the decade. Retin-A was developed using experimentation on prisoners. And this is now two vulnerable populations. Many of them were people of color and now they were also prisoners. And the experimental drugs used, 75% of the population received powders, shampoos, cosmetics, some of it causing permanent scarring, all in the population who in theory gave consent, but consent was often given in exchange for more time outside, more food, obviously fraught with problems. And again, where the medical care system is not being held at high regard when these things are discovered. And it feels very remote until you realize this most recent case was a study between 1992 and 1997, right in New York, where 126 boys were subjected to fenfluramine infusions in order to measure their prolactin levels because the theory was that this was linked to violence. And they chose these boys based on them having an older brother in the juvenile court system. And when you interview or when you read about the interviews of the mothers who allowed this, they somehow connected the medical system. If they allowed this, it would help their other children. So we don't have the greatest history with populations of color. And that loss of trust is something that we must work on every day. So when you talk about healthcare equity, it means, you know, everyone has a fair and just opportunity to be as healthy as possible. And there's many, many obstacles. And we all know that there's poverty, there's discrimination at the societal level. There's powerlessness linked to anxiety and depression. There's lack of access to jobs, lack of housing, lack of safety environments and healthcare. And all of that is a part of health equity. And the question is, where do we as individual providers fit in? We recognize that there are barriers at this society and structural level. We recognize the healthcare system itself as a provider. And then we sometimes feel so small. So at the society level, when we look at first insurance, 21% of blacks compared to 9% of non-Hispanic whites live below the federal poverty level. And race is strongly correlated with socioeconomic status in the US. And so therefore socioeconomic status is probably the most critical factor. And that's gonna come out on another slide I'm gonna show later on. 11% of blacks were uninsured compared to 6%. This is a little bit of old data, 2017. And when you look at insured blacks, 57% of them only have private insurance versus public insurance. So public insurance has definitely improved. And in my mind, any insurance is good insurance as of right now. At the societal level, we're talking about food deserts. You need a good healthy environment in order to be healthy. You need access to green spaces to be able to move, to be able to breathe. All of those things are at the societal level. Now, how about within the healthcare system? And I'm gonna talk a little bit about my personal experience here, because I work in transplant. And transplant is a sort of, at the very end of the tertiary system where a patient has to be identified as actually having liver disease first. So that's the first barrier, getting access to someone who tells you you have liver disease. And then you have to have someone who follows you and discovers that your liver disease has progressed and you need to be referred to a transplant center and to be referred. So that's now your second barrier. Is someone gonna recognize and refer you to a liver transplant center? Then when you're at the liver transplant center and you're being evaluated, are the people who are evaluating you biased? Are they bringing their opinions about you to this evaluation? And are you bringing, as a patient, your opinions about the healthcare system to these visits? And are you trusting what they're saying? And this goes all the way back to the beginning. Did you go to the doctor in the very beginning? And then once you get through that process and you get transplanted, do you have the environment and the support needed for you to have a good outcome? Do you have someone to bring you to your appointments? Do you have someone to help you pick up your medicines? Is your insurance secure so your medicines are all paid for? So disparities across the board affect my daily life in liver transplant. And so though the problem feels large to me, it feels very large at a societal level. It feels very large within the healthcare system. It also feels very large for me as an individual provider, but this is where I see as a place where I can make changes each step of the way. There are critical interactions between race and the environment. And a study that was published just this last year looked at patients who were referred for liver transplant and found that patients in this environment, if they came from a low socioeconomic neighborhood, they were more likely to be black. They were more likely to be on Medicaid, more likely to have cancer, which had not been discovered. And higher risk of not being listed for liver transplant because of all of the societal things that came with that, higher risk of not initiating evaluation and higher risk of dying without actually ever being transplanted. So take this to a personal level. And if you say, what helps with overcoming trust? And I think that one of the things that helps with overcoming trust for patients is seeing themselves in the healthcare system. And as of 2018, only 11% of gastroenterologists, which is often the entryway for liver transplant, were 11% underrepresented minorities and only 4.4% were African-Americans. So to me, that is one of the very first places that we start because representation does matter. This is another study that looks at concordance and racial concordance and what patients like. And what you found was, if you looked at patients who were black, Latino, in the red, and Asian, blacks were four times as likely to choose a provider who was of the same race as were Latins and Asians. And there's obviously a language component here, but African-Americans by far choose if they have the option. And I think it's very much rooted in that history lesson that I started out with. And when you look at concordance, overall racial concordance decreases cost. It doesn't decrease everything, but there seems to be less emergency department use, lower rates of hospitalization, lower total healthcare expenditures. When I think patients develop a healthy, trusting, therapeutic relationship, and I'm not saying they can't develop that relationship with a provider who is not concordant, I'm saying that that is one of the first steps. So one of my recommendations now in this history lesson is that I think that we have to continue to work towards improving health insurance coverage. We have to continue to improve health education of our community. We have to talk to teach our colleagues about the history of people of color and the healthcare system and help them understand that, help them understand how that affects the patient's perception, and help them with their communication and bias. I gave this similar presentation two years ago, and I had many more historical signs. And then at the end of the presentation, I have to say many of the people who listened were a bit traumatized. And I didn't mean to traumatize them, but history is important. And if you don't understand history, I don't think you understand now. We need more physicians and leaders from underrepresented groups. And we need to work really hard to build the trust we need to bring people to healthcare and to bring them to research for the right reasons so that they are included in the stories that we tell. So the history of medicine in blacks is checkered with neglect and abuse, but that doesn't mean we can't move forward. And fear and mistrust of the medical system impacts healthcare. Patient and provider attitudes affect healthcare. And as of right now, blacks have a disproportionate morbidity and mortality for many GI and liver diseases, including liver cancer and end-stage liver disease. And addressing these healthcare disparities requires commitment. So where does that leave me as an individual? So every day I think when I leave this world, will I leave it better than when I arrived? And I questioned that, I questioned my role. I grew up in a heavily civil rights family with my father was the president of the NAACP, my sister integrated the schools. I definitely think my father left the world better than when he arrived. And so at my individual level, I try every day to think about the different places in my day-to-day job where I can help with healthcare equity, whether it's educating my colleagues, approaching my patients with respect, understanding their positions, making sure at committee meetings we are discussing the socioeconomic disadvantages they have and not letting that impair them from receiving the care that they deserve if we can help with fixing that. And so with that, I will stop in the interest of time. Thank you. Thank you, Dr. Dove. That was a very interesting talk. I think we'll just go to Dr. Wilder and then hopefully at the end of it, we'll kind of talk about or we'll run through questions. Sounds good. I'm gonna share my screen. You all see that okay? Yep, we can. Great, I just wanna make sure you got the right screen as well. Hope you're all doing well. Honored to be here. Here are my disclosures. I'm gonna just kind of get to it. This is a quote here. It's Black History Month. I'm kind of doing a smorgasbord of talks I've given in the past on this topic of Hep C and health equity because I believe it's a great example of how we begin to understand the role of things like structural racism and health inequities and how they've driven what we've seen to the health outcomes, particularly in the African-American community. And I think no one has historically been so eloquent at describing the roles of these fundamental issues that drive disparate health outcomes and MLK himself. And you can see here, this is a quote that I'm sure many of us are very, very familiar with. But what I wanna do is draw your attention to the full quote where he says, we are concerned about the constant use of federal funds to support this most notorious expression of segregation of all the forms of inequality and justice and health is the most shocking and the most inhumane because it often results in physical death. I've seen an alternative to direct action and creative nonviolence to raise the conscience of the nation. So what he's speaking to here is not just talking about the idea of these health inequities, but he begins to touch on these fundamental issues, right? These fundamental causes of disease, these social terms of health that we know are quite prominent and important in terms of understanding why we see the disparate health outcomes that we see today, particularly in GI and in hepatology. There are a number of ways that we can begin to sort of think about this and how we begin to study it, how do we begin to create interventions to address these issues? My PhD is in medical sociology and so I often like to show these conceptual models because I find them very helpful. And what this model is doing in some respects is speaking to exactly what Dr. King was talking about. It speaks to the role of things like the political economy. It speaks to the importance of class and injustice of racism, gender and sexuality and justice. And recognizes the importance of not only putting into perspective where you fall within society today, but a life course perspective. What it means to me be a black man being educated growing up in the 1980s and 1990s, being very different from what it meant for my father being a black man growing up in the 1930s and 40s and how that clearly impacted not only my opportunities, my transitions, but my life trajectories as well. Not only in terms of my job, but also in terms of my health. Obviously, when we think about broadly speaking, liver disease and in this case hepatitis C, we understand the importance of recognizing a disease, understanding the risk factors for that disease, how time along with a number of other factors can drive what we see in terms of progression of disease and fibrosis and ultimately cirrhosis and unfortunately death with HCC or it's just liver disease. But we know that it is important that we begin to understand, screen and treat these diseases before they become a problem. So let's just take a step back now and look a little more closely at hepatitis C and why it's an important disease to think about right now. We're not done with it and why it is such a good example of health inequities, but also an example of what we can do to address health inequities. Many of you are very familiar with the fact that there is tremendous disparities with respect to hepatitis C here looking at overall prevalence. And this has pretty much been the case for a while now. And along with that prevalence in terms of the disproportionate burden of hepatitis C in communities of color, we can see here that similarly there are similar death rate issues as well in terms of among American Indian, Alaska native populations and black populations you see much more deaths from hepatitis C. I think there is a separate conversation that needs to be had about the acute hepatitis C cases in the various unique populations being addressed by that including a lot of white, particularly white rural populations. But when you think about the prevalence in this racial ethnic disparity in terms of overall prevalence of hepatitis C, this is prevalent. It's been prevalent for a while and it's prevalent everywhere. And we're looking at various jurisdictions where we can see that prevalence being higher. In fact, in many of them three times as high as white populations. And so it's pretty clear that hepatitis C is disproportionately impacting communities of color. We've all known that for a while. There are a number of reasons and mechanisms that come into play. This is why hepatitis C is so interesting because it is a disease that is really the model for understanding how, who you are, where you're from, where you live, how you live. All of these factors come together to drive a health disparity. There are genetic issues that contribute to the overall burden with respect to prevalence. We know IL-28B impacts not only natural clearance of disease, but in the old school treatment options of, you know, Feron and Rapavirin, we know there were differences in terms of response to treatment in SVR. And so we acknowledge that. I will also say as a soapbox that we may have arrived at some of these differences sooner if we appropriately engaged African-American populations within those hepatitis C clinical trials to begin with. Particularly bothersome in that the populations that have historically been most affected by hepatitis C have been populations consistently underrepresented in terms of hepatitis C clinical trials. And I will add that while this analysis we're looking at right here, or this slide is focusing on U.S. studies, we found a similar pattern for studies outside of the U.S. as well. And I also say that if you look at the timing of these slides, the lack of representation of people of color in hepatitis C clinical trials existed before we knew about L2AB, but sadly and frustratingly, it also existed after. So even after we knew that there were genetic differences in terms of response to hepatitis C treatment, we were still not appropriately engaging in ensuring diversity in our clinical trials, including the population most impacted by the actual disease. And so if we put the genetics aside, which we know explains a smaller proportion of what we see, but what's really driving what we see in terms of hepatitis C. And then what we'll get to later on is a conversation about an opportunity for us to really, through a very equitable approach, address the disparities that exist in hepatitis C. One of the things we'll talk about, I'll begin with, is to talk about segregation, and we'll talk about incarceration inequality. The reason why I want to focus on these two things is because it's Black History Month. These are two things that there are very clear mechanisms of what we may call social drivers of health, fundamental cause of disease, that have clear links to health outcomes, particularly among people of color, and can be linked to our understandings of what we see in terms of the patterns of hepatitis C, but also inform us about how we need to move forward to address disparities that we know exist in hepatitis C as well. This is Black History Month, I'm going to show a couple of pictures here. This is Lincoln Hospital, which is a hospital that when black folks couldn't come to Duke, this is where they went. And when black folks were allowed to begin to come to Duke, here you're kind of seeing a picture of one that's sort of the plan that they were using for Duke Hospital. And you can see in the middle there, the colored woman's ward, where they were clearly separating out where patients stayed. And if you were to come to the ER back in the 1930s, 1940s, this is what it would have looked like at that time. You can see the black folks back there being seen, while the black folks kind of wait for their turn in a segregated manner in a separate section. And sadly enough, back then, they even felt the need to segregate babies. You're looking at a well baby clinic. Surrogation is very real. And in fact, if you look at different parts of the United States today, there are certain neighborhoods and spaces that are more segregated today than they were in the 1960s. But surrogation is not something that was, a lot of folks say this is all about choice. And today, actually, there is a considerable amount of choice that leads to residential segregation that we see. But what the surrogation that was originally developed in this country, that did have health consequences, including hepatitis C, was actually born out of policy. All right, going back to that quote from Dr. King. There were policies, government public housing policies, as well as discrimination and redlining, that drove the resident segregation that we see today, that's how it's had such really significant health consequences in almost any way you want to measure it. If you were to go back in time to the early 1930s, a lot of these spaces that we are familiar with, Chicago, New York, Detroit, D.C., you know, these were cities that were actually quite integrated. And the reason that is, is because you had influx of white, largely immigrant populations from Europe. And post-Reconstruction, you had a lot of black families, right, moving into these cities. They both came there, right, post-Reconstruction slavery, immigrants, because those two populations were fairly, relatively uneducated, right? But the jobs in those cities were jobs that were relatively low-skilled, but high-paying jobs. And so that created a sort of the perfect opportunity for these populations to come together. And they lived together in these integrated cities for a while. In the setting of the World War I and II, there was a need to sort of focus those factories now on war, ammunitions, and weapons, and so forth, development. And when Congress decided to do so, they wanted to prioritize white people for those jobs. And so public housing was created in the vicinity of these cities where these jobs were and prioritized for white families. And it was that public policy around housing that initially drove a lot of the segregation that we see now. And what happened is that when those jobs went away or moved out of the city, those issues were in way, those resources went away, and you began to see the deprivation develop in many of the spaces. Another piece to this in terms of original segregation and why we have it quite relevant to black history is something that, unfortunately, many of us still do with today. And this is the idea of homeowner loans or corporation and redlining, which impacted the opportunities for folks to own houses. Now, historically, and quite frankly, still relevant today, the main means to which an individual can have wealth in the United States is through homeownership. And coming out of the World War and the single depression, one of the ways that the federal government decided to help people in the United States was to provide these very favorable mortgages for families, right, particularly those that were in default, providing them with better refinancing deals. But they were, again, very selective in terms of where they decided to do this and who they decided to make these mortgages available to. In that setting, they literally would sit down, look at maps, look in spaces where there were or were non-black folks. And the red areas were where the black folks were and were the areas where they did not invest in those communities. And so, we take a step back outside of the context of health and think about, you know, the idea of government housing and jobs and opportunities in these spaces that went away and what that meant to those communities. And then, out of that, a lack of investment at this point post-depression in communities of color provides a lot of context, right, which is understanding what we see today in terms of the manifestations of these policies long-term in communities of color and why it drove such significant residential segregation. And what that has meant is that it has significant health consequences in those spaces, okay. So, there's a reason why where you live matters and why we see black folks living where they do, okay. And when we actually look at the impact of segregation long-term, we're talking 80 years later, number one, is what you would have guessed. You'd probably see it today if you go to D.C. or you go to Chicago. You see that segregation still exists. In those spaces, there are decreased earnings, even among children generations later. Worse health outcomes persist because the health infrastructure and resources are poor in these spaces. There's lower tree canopy, increased environmental toxins, obviously violent crime and police use of force. And we'll get to that here in a second about what it meant to segregate residentially and have had a lot of targeting about other policies. And actually, they've actually done studies to look at various outcomes. This is health outcomes in these spaces. And when they look at hepatitis C, they see significantly higher rates of hepatitis C in those spaces where you have higher residential segregation. And what's interesting is that this is part of what's driven what we see in black communities and urban spaces, but likely segregation playing a factor, I would argue, in what we see in a lot of other spaces, including rural spaces and other populations because of the meaning of segregation, what it means to be segregated as a community, how it impacts your resources, quality of health care, risk of exposure to various toxins and risk factors that can contribute to a number of communicable diseases like hepatitis C. Let's move on to incarceration inequality now. Another policy that has ramifications with respect to race and ethnicity and drives disparities that we see in terms of hepatitis C. We're all aware of the disproportionate burden of policing in communities of color, a lot of that driven by segregation in that red space of redlining and targeting those communities with police force. And that over-policing, at least that correlates with redlining, led to more arrests. And then, of course, inequitable prosecutions for low-level drug offenses, things like that. And then inequity in terms of sentencing for these minor crimes as well. And what that's led to is, regardless of gender, a tremendous disproportionate burden of people of color within the penal system. Looking in that space now, we know hepatitis C is the most frequently reported level of infection among both general and incarcerated populations, prevalence much higher than the general population. And there's a number of factors in that space that contribute to it. But we know that people of color appear to comprise the majority of that burden in these U.S. correctional settings. And so not only do we see more hep C, so we're putting more people of color in these spaces. In these spaces, there's more hep C. And in the setting of having these people in this sort of confined space, we still are not necessarily to the extent that we should, we're not screening and treating for hepatitis C. And here you're looking at how that can vary quite a bit statewide depending upon where you are. And now what happens is this idea of recidivism, right, and exposure to communities. Because now these folks, because most people in prison, actually do leave eventually. And when they leave, they go back to communities that they came from, which in this setting, of course, are currently segregated communities of color. So you're creating this vicious cycle where individuals are exposed to hepatitis C and return to communities. And that can obviously contribute to this significant burden of hepatitis C within these settings. And it's a shame that we are where we are, right? Because we are at a point now where we actually not only have a cure for hepatitis C, but it works, you know, really in people of color. Our prior treatment options were not very good. And so in the setting of this, you know, this is further exacerbated by the fact that, that, you know, we know the burden of this disease, we know these medications work, but we see these disparities. But the burden, even if you know a person has hepatitis C, is that if you look at depending upon their type of insurance, there's quite variability in terms of their access. There are all these issues following diagnosis in terms of treatment, in terms of like, you know, requirements for fibrosis, liver specialists having to be the person who can write the script or sobriety, all these factors that still exist as barriers, you know, once we know folks have hepatitis C and we're prepared to treat them. But we're at a point now where there's some hope, you know, because we know we have a good treatment. We know the populations we need to target. It's simply a matter of us, you know, going back to, you know, Amal K's quote, you know, as fundamentally as a nation decided to do the right thing and create policies to address this issue. And we have an opportunity to do that. And it looks like now that that funding is going to be much related to the cancer being shot. And this is part of the plan that President Joe Biden has developed and worked with Francis Collins, as well as Rachel Florence, the sort of first national plan to limit hepatitis C. And I love this because it's actually is an example of how you think about addressing health inequities. And I think if we're able to do it will be a great model for how we look at addressing other health inequities moving forward. This was first involved at a White House summit back in August, 2022 with input from various healthcare agencies, state leaders, patients, advocacy groups, insurers, drug manufacturers, to think about what it would look like to do this. And the idea being that, you know, how do we think about the diagnostic testing there? Do we leverage a national subscription model, almost like a Netflix when we provide these resources? And it looks like that's where we're headed. So number one, clinical diagnostic tests. And those clinical trials for the US are actually beginning right now. We'll be looking at point-of-care diagnostic testing that allows quick, easy, efficient, safe, and accurate, immediate sort of diagnosis of hepatitis C, no matter where you are. And then how are we going to pay for it? Well, again, the Netflix model and sort of a fixed drug, some for the drug across the board. And then of course, providing a free to Medicaid, uninsured, incarcerated opioid treatment programs, our Native American populations reservations as well. And then as we do this, thinking about engaging communities, because we need to make sure we have those community partnerships to ensure that we're actually able to get the sort of screening in the actual medication and treatment to those populations at greatest risk. And that's going to involve community health centers and our community partners in terms of doing this. Another piece of this is going to be the idea of re-energizing our vaccine research. And it's actually been some exciting work here recently done around the development of a hepatitis C vaccine, similar to the MRNA technology leveraged for the COVID vaccination. We know this is worth it. Here, you're looking at numbers that describe what would happen within 10 and 20 years with respect to complications averted from hepatitis C. You see quite significant numbers here and it's cost-effective. Here, you're looking at by subpopulation in terms of, you know, justice involved, Medicaid, uninsured, so forth, Medicare. And as well on the right, you're looking at what's attributed to it in terms of funds, federal versus non-federal, the significant cost savings once we are able to move this legislation forward and create a successful hepatitis C eradication plan. And so I think this is the perfect example of health equity. We have a disease whose disparity is rooted in things like structural racism through a number of mechanisms highlighted here. We spoke to regimen segregation, incarceration inequality, but we have a cure. It's a matter of us actually leveraging our resources and our policies in an equitable way and with community partnership to address it. And I think if we do that, we can successfully eradicate hepatitis C in the United States and obviously have a tremendous positive health impact on communities of color who are disparately impacted by this disease. I'll stop there and take any questions that you all may have. Thank you. Thank you both. I wish we had more time to talk. And I really enjoyed discussion about, especially with looking at those pictures that Dr. Dove put up, actually put a couple heartstrings there. But a couple of questions, I don't see any questions now, but I do have a question. And it was just, I was thinking about myself and how far I've come and I'm thinking about you guys and your career as well. And when you think about it and you think about challenges that you encountered being a black physician, if you could think about or pick one thing that you would change, something systematic that you would change, what would that be? Well, it's tough to think about one thing. I will say that for me and my success, academically and professionally, I've benefited from family, particularly when I was very young. My mom, a teacher who was willing to speak up and fight for me because she saw how smart I was, even when my teachers refused to acknowledge it. I would say that I've benefited particularly in my undergrad experience, being a Meyerhoff Scholar at UMBC, University of Northern Baltimore County, where I was in an environment where there are a number of other, quite frankly, black students who had the same sort of goals in school that I could sort of have that lived experience with studying together, growing together and learning about science together. That was my first experience and was extremely helpful, particularly during the tough times in college, when you're struggling with all the work and so forth and so on. And they're my best friends today still. And I would say that I finally, I've benefited. One thing I would change is mentorship and sponsorship for people who are of color in medicine. And that needs to be mentorship and sponsorship, not only by black people, it needs to be white people too, because they are, you are also accountable for addressing these, not just us making this lift and ensuring, you know, I've had some great mentors who are black and I've had some great mentors and sponsors who are not black and ensuring that as people who are now more senior, so to speak, in our training and matriculation of our careers, you know, serving those roles for people of color and women for that matter as well. It's going to be really important. I think I would echo the mentorship, even starting at a younger age. I'm from rural North Carolina, a town with 20,000 people. What town are you from? Princeton. Oh, okay. Yeah, that's not far. So when I entered college, I didn't even know what I didn't know. I didn't even know what I hadn't been exposed to that other people had been exposed to that gave them an advantage. You know, I just, I was happy in my environment. I had a very politically active family, but they weren't a medical family. And so they gave me nourishment support in my day-to-day life, but I didn't have, just didn't have that exposure. In fact, only now, sometimes as I expose my own kids, do I recognize what I didn't have and how hard I must have been working to get to where I needed to be. So I think that the programs don't start early enough for some kids. I mean, I think that we need to be in the neighborhoods earlier and, you know, junior high school, high school, helping kids get access to what they need to prepare them for whatever they want to do. And then for us as medicine, expose them to medicine, talk to them about SAT training classes or whatever it is they need to do. Talk to them about what the first semester of college is and how you don't need to take five, you know, you need to just sort of get a hold of the system, talk to them about it. And I think that that has great impact. And only as I've become an old lady do I realize that. So mentorship, mentorship starting as early as you can do it. Thank you. That's very good to hear. I'm just going to look and see if there are any questions in here. I don't see any. Okay, I think there's a question. Okay, so a couple questions. So one question is, what can the ASLD do to advance these missions? Well, I think there's multiple different places that it, first off, you have to identify that there is an issue and you have to identify that there is a benefit to the general community and get buy in. So I think that that's step one, right? And so I think in many ways, even having this webinar is acknowledging that this is an important issue and it's to start. But I think it has to be an ongoing, not just education, but ongoing perhaps putting funding and grant support to young investigators who want to investigate equity and how to achieve equity. Politics is a difficult issue and the ASLD is a diverse group and many different political beliefs. But I think identifying what you think is important and how individuals, you know, support that politically, I mean supporting the Hep C and Moonshot is an important step. You can't, that's just acknowledge regardless of what your politics are. So I think the acknowledgement is good, but I think ongoing support with education and grant support for people who are looking at equity is step two. Yeah, I would agree with that sentiment. And even speaking to some of the other questions related to that, I was going to speak to that. We need to embed this kind of conversation into everything that ASLD does. We have a diversity committee and that committee is fantastic and probably a model for how these committees should behave or work, you know, at these kind of national level organizations. But they should not be the only committee where this is a priority. I can tell you, it is a priority for a policy committee. It needs to be a priority for the education committee, i.e. Lorna was speaking to the importance of things like pathway programs. It needs to be a priority for every SIG, you know, because of the importance of disparities and inequities in terms of the outcomes around Hepatitis C, HCC, transplantation, yada, yada, yada. And so, I think what we need to do is as an organization, really, you know, begin to think about how we truly embed this work, these issues into everything being done to ensure that we're able to, you know, fundamentally begin to have a significant impact on these outcomes. Yeah, and I think you kind of touched on, you know, the other questions that we have there. But I think one other question that someone asked was, you know, if you, like, in your case, what would you think will be, what was your best form of mentorship for you? Because I know I've had, you know, you have people who prefer a more, like, really hands-on, you know, approach, and somebody who you, like, hang out with, like, really often. And so, just in your experience, what would you think, you know, worked best? And if you're going to instill or, like, provide a kind of mentorship for trainees, what would you recommend? Sure. For me, there are a number of examples, I think, I feel that where I've had great mentorship. You know, my main mentor here at Duke, Andrew Muir, at every step has, including as a fellow, engaged me directly as a person who was a participant in clinical trials and clinical studies. So, he was very intentional about bringing me to the table and teaching me about these issues and letting me be a part of this process. And I remember my first talk ever at ASLD was in the setting of presenting the study on the big Harvoni studies, showing that data was so good and safe and efficacious in the Black population. And that was an article that I got first author on with people who I had no reason even being in the same room with people, you know, who were on that study. And, you know, and the impact they and who they've done and what they've done, but they saw me as a person who they thought could do it. They gave me an opportunity to do it. They were supportive of me doing it. And so, you know, those are small examples in my life where folks, you know, took a chance on me and really focused on being great mentors and sponsors for me in that setting. And I think we all need to think about how we can do similar things like that, you know, for our trainees, particularly, I would say, though, our trainees of color and our and our trainees who are who are female. Need more than one mentor. I think that for me, there's a mentor who may help you with content and research and your topic of interest. And then there may be another mentor who helps you navigate the politics of the health care system you're working in, where there is an academic one on one. And maybe even a third and maybe there's a combo, who is a special mentor for helping you navigate the challenges that come from being a person of color, being a woman of being whatever your what makes you an other. I don't think you can minimize those things. And I think hearing even at your same academic level, even bouncing it off someone else, even hearing someone else hear your struggle helps you say, am I seeing this right? Am I interpreting this right? Am I being sensitive today or am I ignoring what actually is happening? And I think that that's validation. And I think you need validation to help you fight challenges. You have to know that you're that you're standing on firm ground. I'm right here. I'm not being what's the term now the gaslighting. I'm not. And, you know, and they may not have a solution of exactly how to fix it. But even the validation of helping you fix it is, I think, important. So I think sometimes mentors come mentorship comes in different forms and you may need more than one person. I can still remember from literally over 20 years ago, and I don't even know if this black woman surgeon remembers that she said this to me, but she said something to me that has impacted me my whole life. She was like, don't try to be them. Be confident in you and know that you're just as good. You don't have to be in the country club. You don't have to that. That's not your goal. Even though that's where everyone on the top is. Acknowledge that, but be happy with who you are. And I think that that was in my early, early career. That was very important to hear the validation of my role as not that, but that being still as good. I want to echo that, so I totally agree. I think what I, you know, through like, you know, medical residency fellowship, I think what I found most important to me was actually someone helping me navigate life rather than like research and all that, which I, you know, again, like you said, I think it helps to get like multiple mentors. I know we're kind of out of time. There's one more question here that I find really interesting. I think this might actually be a very long one, but advancing these goals in this current political climate. Any takers? I mean, I, honestly, I think it's a pretty quick answer. I, you know, the political climate has nothing to do with what's right or wrong. And so as an organization or individuals, we shouldn't allow politics to dictate our willingness to do what is fundamentally the right thing to do or the wrong thing to do. And so this conversation we're having about, you know, for example, ASLD and its need to be very intentional and thoughtful in how we embed this work right into everything that we do is not a matter of, you know, making some, you know, sort of political affiliation uncomfortable. If a person is uncomfortable with that, that's their problem, because we know fundamentally what is the right thing to do. And so we can't ever allow politics to influence what we know to be fundamentally is the right thing to do. So, I mean, I would say we don't need to take that. Well said. And we shouldn't allow our leaders to. At an individual level, I know that some days are challenging when you see the world around you some days feels like it's on fire. You have to pause and realize that you're strong. We are strong people, and there's perseverance and patience and sometimes I look and I say, okay, Lorna, your father was sitting at the back of the bus. If he can do it. You got to do it. So you got to reach in and from your personal strength and do what's right. So I completely agree with Julius and not let the chaos, make you forget what's right. And also discourage you from fighting from what's right, you got to keep the hope to know you got. Because that's what they want to do. Please recognize that. That's part of the plan. Okay, I'm just gonna check and see if any additional questions. Yeah. I guess that's all for questions. I just want to say thank you to you both for being available and talking with us today. I'm sure everybody who listened and who are going to listen and would definitely learn a lot from you guys so thank you very much. Thanks. That concludes our webinar for today.

webinar

Dr. Chimobi Anugom

Dr. Julius Wilder

Dr. Lorna Dove

inclusive healthcare

racial inequities

healthcare equity

medical field representation

healthcare disparities

equitable healthcare