We would like to welcome you to the 2021 Diversity Workshop entitled Promoting Diversity Within Hepatology Practice and Research, Domestic and International Considerations. It is essential to foster health disparities research to reduce disparity and improve outcomes among ethnic and racial groups with liver disease. There is also a critical need to expand the pool of persons underrepresented in medicine within hepatology. This diversity workshops goals are to educate practitioners on barriers to care for immigrant populations within the US, provide tools to develop diverse clinical and research programs, and promote cultural competency within hepatology. We're excited to present this wonderful agenda with a fantastic group of speakers. Dr. Andrea Reid will lead us off with a talk entitled Cultural Competency and Unconscious Bias in Patient Care and Research. This will be followed by a lecture entitled Caring for Immigrant Populations in the United States by Dr. Nizar Mukhtar. Dr. Mohammad Hassan will then review barriers to healthcare and the burden of liver diseases in immigrant communities from Africa and the United States. Lastly, Dr. Jorge Moreira will present how to increase diversity, inclusion, and equity within the hepatology workforce. Upon the conclusion of the workshop, please join us for a breakout session where our faculty will be available for a Q&A session via Zoom. Thank you for asking me to speak to you today about cultural competency and unconscious bias in patient care and research. I have no disclosures. Over the last 18 months, we've had lots of new conversations about long-standing problems. The COVID-19 pandemic laid bare before the nation, the long-standing racial and ethnic disparities in healthcare outcomes with increased morbidity, mortality, and economic fallout from the COVID-19 pandemic amongst black and brown individuals in the United States. At the same time as the global pandemic was reaching its peak, we watched in horror as George Floyd was murdered on video. That led to a call for justice for all with a wide demographic of individuals coming together to call for an end to police brutality. The juxtaposition of the COVID-19 pandemic and the call for social and racial justice led the student group White Coats for Black Lives to call for individuals who wear white coats to kneel down together for eight minutes and 46 seconds to declare that black lives matter, that there's no room for hatred in medicine, and that racial bias impacts the healthcare system. My question for you today, many of whom may have knelt down, is what did that kneeling represent? I suspect that it represented horror at what we saw and discomfort with what we heard on that video. It may have represented sympathy for George Floyd's family and other families who have lost individuals to the COVID-19 pandemic or to police violence. It likely represented solidarity with other white coats who finally called out that enough is enough. It may have meant outrage at systems, including the healthcare system, that has perpetuated racism. But my question for you today is what changed when we stood up? If nothing changed, then it was a performance. One of the things that I hope changed is the dialogue about the cause of medical mistreatment and medical mistrust. One of the most infamous examples of medical mistreatment was officially called the Tuskegee Study of Untreated Syphilis in the Negro Male. This study was sponsored by the federal government, and it was an experiment in which over 400 black men with syphilis were deliberately left untreated even after appropriate treatment had been discovered so that doctors could study the natural history of the disease. This study, which ran from 1932 to 1972, had dramatic impacts not only on these 400 men and their families, and continues to have impact today, but has led to a lot of medical mistrust in the black community. But it's not the only example of medical mistreatment. We can talk about J. Marion Sims, the father of modern gynecology, who perfected his gynecological techniques on black women slaves. They did not give their permission, nor did they receive anesthesia. He got permission from the people who owned them. We can talk about eugenics, forced sterilization of individuals who were deemed inappropriate to continue to procreate. Those who were of different racial backgrounds, those with mental disabilities, and others. We can talk about HeLa cells, which came from the cervix of Henrietta Lacks, a poor black woman whose cells were removed from her without her permission. HeLa cells transformed by medical research, while her family, who had no knowledge of this, was still in poverty in the Baltimore area. These are just some of the many examples of medical mistreatment that's led to medical mistrust amongst black and brown communities. If you want to know more, I suggest that you read Medical Apartheid, The Dark History of Medical Experimentation of Black Americans from Colonial Times to the Present, written by Harriet Washington. I hope that kneeling down also led us to begin to have different conversations about bias. Unconscious and implicit biases, are unconscious attitudes or stereotypes about things, people, or groups. There's been a lot of conversation about racial bias. However, bias can exist across any number of identifiers, whether that be gender, age, sexual orientation, sexual identity, or geography. These unconscious biases are pervasive. Everyone has them. They are based on learned stereotypes just from growing up in the world. We pick up stereotypes and integrate them into the way that we think. They do not necessarily align with our stated beliefs. And the most important thing that I can say today is that our implicit biases are malleable. If we know what they are, we can change them. Doctors are as susceptible to implicit bias as everyone else. And in our case, they can impact patient care. The medical literature is replete with examples of bias impacting the things that are recommended for and to patients. From racial bias amongst medical students in pain assessment, which impacts their treatment recommendations, to unconscious bias in peer review, in how we treat colorectal cancer, and even how we train women in gastroenterology. But it's not just limited to impact on patients and patient care. Implicit bias impacts science in other ways as well. There is implicit bias in racism in science. And their recent editorial by the editors of Cell said that science has a racism problem. They stated that it is easy to divert blame, to point out that the journal is a reflection of the scientific establishment, to quote statistics. But it is this epidemic of denial of the integral role that each and every member of our society plays in supporting the status quo by failing to actively fight it that has allowed overt and systemic racism to flourish, crippling the lives and livelihoods of black Americans, including black scientists. And the editorial board of Cell has committed to making a change and other journals have followed. I wanna tell you how implicit bias contributes to healthcare disparities using one example that is relevant to our field. There are many who state that Latinx patients overstate pain. This is a provider implicit bias that can have devastating consequences through two different pathways. One is that it influences the judgments and decisions about patient care. If the doctor believes that Latinx patients overstate pain, that provider may undertreat or underevaluate that abdominal pain and leading to disparities in pain treatments. But then the personal becomes structural. There's another pathway that also impacts healthcare disparities. If the provider believes that Latinx patients overstate pain, it may influence their communication with the patient. The provider may spend less time with the patient and the patient may leave feeling unheard and undervalued. This affects the communication and trust with patients, which directly impacts patient adherence and engagement with the medical establishment. This may increase patient no-show rates and low adherence to provider recommendations continuing to lead to disparities in healthcare outcomes. Implicit bias is a problem in healthcare. The interpersonal becomes structural. I think that the kneeling down has also led to conversations about cultural competence and improving cultural competence. But I'd like to suggest that we change the language and change our focus from cultural competence to cultural humility. Cultural competence is that which is said to enhance providers' knowledge about cultures of different social groups with the hope that familiarity with these cultures might improve provider and patient communication and help to establish effective patient-doctor relationships. Cultural competence is largely content-focused, giving content to the provider so that they might be aware of what may influence the patient and how the patient believes. But I would suggest that we focus on cultural humility and respect. This understands that culture is not stagnant. That it is a changing system or systems of beliefs and values. And it also recognizes that there's tremendous intersectionality of identities, cultures, and belief systems. That individuals that may share the same race have completely different relationships with culture and that their belief systems may be very different. This intersectionality is critically important. And the cultural humility and respect is process-focused so that we're asking the patient, what matters to you? What influences the decisions that you make and how you engage with your providers and the decisions you make about your medical care? Cultural humility and respect is the goal, not cultural competence. So that brings me to my first question. Is after the NEO, what changed? How do we move forward? The first thing that we have to do is educate ourselves. And my hope is that this conversation and those that will follow it will begin to help us to educate ourselves more about the importance of understanding culture, medical mistreatment, racism, and its impact on patient care. We also need to acknowledge we also need to investigate our own biases. And I've suggested here that every individual take at least one implicit association test. You can look at this website and do a variety of different kinds of tests that allow you to see where your biases lie. It is really important that we understand though that identifying our biases does not change them. It's the first step. It's also important to resist defensiveness when those biases are identified, either through testing or in your engagements with others who are different light than you, who might tell you some biases that they're beginning to see. We have to lean into cultural humility. We have to ask patients, what is it that they value? And what do I need to know to be able to treat you most effectively? We need to ask our trainees those same questions. How can I be the best educator for you based on what you value? We need to commit to being anti-racist. And it is very important to recognize that racism is built into the fabric of our country, into the laws, into the processes and procedures. And being anti-racist means that we are actively engaged in dismantling those systems that allow preference to be given to one group over another. It is not passive and it is not celebration of diversity or cultural competence. It is an active process. How do we optimize patient experience? Well, the first thing we have to do is we have to ask them the questions. What do you experience here at our institutions? What do we need to change? We need to listen to them without defensiveness and respond to what they raise as concerns. And then we need to repeat that process. It is not a stagnant process and it is something that we will have to commit ourselves to doing forever. If you wanna know more about everyday bias, I suggest that you read the book by Howard J. Ross called Everyday Bias, Identifying and Navigating Unconscious Judgments in Our Lives. We also have to focus on cultural humility in research. We need to understand the roots of medical mistrust in certain communities and recognize that medical mistrust is earned. Therefore, we have to commit ourselves to building connection and trust with communities long before we want to do any research with them. We need to diversify our research teams. The research teams need to reflect the communities that we're trying to engage with. We need to bring the investigation to the communities rather than expecting those individuals to come into our Ivy Towers, into our academic centers, into our settings. We need to go to them, build those bridges and build trust. We also need to create and support pipeline programs to diversify the individuals in science, in medicine, reach back farther than college, invite those individuals that are interested in science into your laboratories, give them opportunities to shadow so that they can see that the opportunities are before them to transform medicine and science. We need to focus on mentorship and sponsorship. Sponsorship means that we are using our reputations and our perspective and our positions to elevate others who might not have access, sponsoring individuals, giving them opportunity to give talks, to sit on leadership boards and to be a part of our leadership in our institutions. There's a well-worn adage, which I'll bring up here now so that to really look at the difference between diversity, equity, inclusion, and belonging, we really wanna focus on belonging in our institutions, in our research. Diversity is like a dance, bringing individuals into the dance, not caring if they have any role, it's numbers. They're in the room. They could be around the walls, not participating. Inclusion is inviting them onto the dance floor, allowing them to be a part of the central part of the process. But belonging is actually giving them control of the playlist, inviting them not just to be a part, but giving them the ability to change what is actually done. We wanna focus in our institutions with our patients on belonging, where they feel that they're a part of the institution and that their needs are really very important to us. So our key takeaways here are that racism and implicit bias have led to medical mistrust, which is earned, and it's led to longstanding health inequities and disparities. Cultural humility and respect is the goal, and that requires an ongoing active process. We need to build bridges to communities to enhance trust, as well as engagement in medical care and research. It is only with this perspective that that kneeling that we all did actually leads to change. I will finish up with a quote from one of my favorite authors, James Baldwin, who said, not everything that is faced can be changed, but nothing can be changed until it is faced. Thank you so much for your attention. Hi, everyone. My name is Nizar Mukhtar. I'm a transplant hepatologist at the Kaiser Permanente San Francisco Medical Center and member of the Kaiser Permanente Hepatology Research Network. Thank you to the course organizers for inviting me to be a part of this wonderful workshop. I'll be discussing a topic that is near and dear to me on a personal and professional level as an immigrant and a provider who's privileged to be practicing in one of the most culturally rich and diverse parts of the country, and that topic is caring for immigrant populations in the US. I have no relevant disclosures. My hope is that through this talk, you'll walk away with an understanding of immigrant demographics and population trends, as well as available immigrant health statistics. I want you to be able to recognize the impact that immigration and legal status has on the health of individuals and gain an understanding of the social determinants of health shaping the health of immigrant communities. And lastly, I hope that you're able to draw some inspiration for ways of advancing immigrant health through changes in your clinical approach, research, or advocacy efforts. Before delving into the demographics of this population, I think it's very helpful to review some basic definitions pertaining to this population. These were obtained from the International Organization for Migration. Firstly, immigrant is from the perspective of the country of arrival, a person who moves into a country other than that of his or her nationality, such that it becomes his or her new country of usual residence. A migrant is more of an umbrella term that essentially describes a person who moves away from their usual residence, whether within a country or across international borders, temporarily or permanently, and for a variety of reasons. A migrant worker, of which there are many in the U.S., is a person who engages in paid work in another country. The terms refugee and asylee can be somewhat confusing. A refugee is a person who leaves their country or is unwilling to return to their country due to fear of persecution, and this is a status that is generally granted before an individual arrives at the port of entry. An asylum seeker is an individual who has applied for protection from a country but is still awaiting a verdict. These individuals generally apply for asylum after already arriving at the country from which they're seeking protection. So not every asylum seeker will ultimately be recognized as a refugee, but every recognized refugee is initially an asylum seeker. So why do people immigrate to the U.S.? For most, it's in search of the opportunity to become part of a society that has a more level playing field with respect to social, economic, and political opportunities, and to escape significant disadvantages across these arenas in their country of origin. There are several broad classes of admission for foreign nationals in the U.S., and as providers, we should be aware of these different groups as the immigration policies enforced in the U.S. can impact immigrants within each of these categories differently. For most immigrants, the most highly desired immigration status is to become a U.S. citizen, and naturalization is the process by which a lawful permanent resident or green card holder becomes a U.S. citizen, usually after three to five years of holding that status. For the most part, green card holders qualify for many of the same benefits as U.S. citizens but are still at risk of being deported for committing certain crimes and do not have certain privileges such as the right to vote or easily sponsor family members to enter the U.S. And then, once you go further down this list, you see increasingly less privileges and much greater susceptibility to changing immigration policies that can impact access to benefits, employment, and travel really in the blink of an eye. Immigrant legal status is quite fluid and oftentimes changes over the course of an individual's lifetime owing to personal circumstances such as marriage and shifting policy environments. Some examples of immigration policies that change legal status for individuals virtually overnight include the Immigration Reform and Control Act of 1986, which allowed some 2.7 million migrants to gain legal status, and more recently the Deferred Action for Childhood Arrivals or DACA program announced in 2012 that granted semi-legal status to more than a half million undocumented youth for a renewable period of two years. And while legal status can change swiftly, the life experiences encountered along the way can leave a long-standing impression on the health of an individual and we'll talk more about that. So now I'd like to transition to sharing some of the most recent statistics regarding the immigrant population in the U.S. For anyone who hasn't already, I highly encourage you to visit the Pew Research Center's website for a ton of super interesting statistics about the immigrant population in the U.S. Since 1965 when the U.S. immigration laws replaced the national quota system, the number of immigrants living in the U.S. has more than quadrupled. Immigrants today account for 13% of the U.S. population, nearly triple the share seen in 1970 when it was around 5%. At 45 million, the U.S. has more immigrants than any other country and this number is expected to almost double over our lifetimes. Looking forward, immigrants and their descendants are projected to account for 88% of U.S. population growth through 2065, assuming these current immigration trends continue. More than one million immigrants arrive in the U.S. each year and Mexico is by far the top country of origin, accounting for 25% of the immigrant population in the U.S. to date. However, as shown in the line graphs on the right, in more recent years, more Asian immigrants than Hispanic immigrants are arriving in the U.S. with the top country of origin being China. Indeed, Asians are projected to surpass Hispanics to become the largest immigrant group in the U.S. by 2055. The vast majority of immigrants in the country are here legally, but almost a quarter are unauthorized immigrants. In 2017, among lawful immigrants, 45% were naturalized U.S. citizens, 27% were permanent residents, and 5% were temporary residents. It is notable to highlight that since the creation of the federal refugee resettlement program in 1980, about 3 million refugees have been resettled in the U.S., which is also more than any other country, and you can see the breakdown of countries of origin for refugees in 2019 in this figure on the right. In 2018, most immigrants lived in just 20 major metropolitan areas with the largest populations in the New York, Los Angeles, and Miami metro areas, but immigrants are increasingly settling in the Midwest and South. Immigrants have long been recognized as a vulnerable population at risk for poor physical, psychological, and social health outcomes with inadequate access to high quality health care. Despite accounting for a large proportion of the population, systematic monitoring of health outcomes among U.S. immigrant populations remains poor, and most national data systems do not routinely report on health statistics based on immigrant status. Moreover, ethnic, cultural, and linguistic diversity of the U.S. immigrant population adds to the difficulty of establishing reliable metrics. That said, there are some population-level data that provide useful information about immigrant health. This data shown in the figure above are based on the CDC's National Vital Statistics System, which has long been the cornerstone of health monitoring in the U.S. for over a century and represents a vital registration system of all births and deaths occurring in the U.S. Based on this registry, immigrants as a whole have a greater life expectancy than U.S.-born populations, living up to three and a half years longer, with foreign-born Asian and Pacific Islander immigrants living the longest, followed by Hispanics, Blacks, and then Whites. Infants born to immigrant mothers also appear to do better than those of U.S.-born mothers, with significantly lower risks of mortality, low birth weight, and preterm birth. This observation that immigrants as a group are healthier than U.S.-born populations has come to be termed the healthy immigrant or healthy migrant effect. It's thought that this is because people who are able to immigrate to the U.S. may be healthier than those who remain in their countries of origin or that they have lower rates of health risk behaviors such as smoking and alcohol consumption than U.S.-born individuals. As a group, they tend to have less chronic health problems when compared to Native residents upon arrival from their home countries. Unfortunately, this health advantage tends to diminish over time, such that immigrants who have lived more than 10 years in the U.S. end up having similar health problems as the Native population, and you don't observe as large a difference in life expectancy with subsequent generations. And this is important to appreciate given that about half of the immigrant population are second-generation immigrants as shown in this figure. And despite the healthy migrant effect, several important health disparities have been identified. From a GI or hepatology standpoint, it's important to know that Asian and Pacific Islanders, Hispanics, and Black immigrants have substantially higher rates of stomach and liver cancer, likely owing to higher rates of H. pylori and hepatitis B infection, respectively. Some groups do, in fact, have higher rates of infant mortality and low birth weight, particularly Black immigrants and island-born Puerto Rican mothers. Several groups, as highlighted here, have higher risk of gestational diabetes, including Asian Indians, Chinese, Filipino, Black, and island-born Puerto Rican mothers. And immigrants as a whole are disproportionately affected by HIV, with foreign-born individuals accounting for 16% of HIV cases between 2007 and 2010, while only representing, as we highlighted previously, 13% of the total population. And as you can see here in this figure, foreign-born Blacks, Hispanics, and Native Hawaiians or other Pacific Islanders have the highest rates of HIV. Based on the National Survey of Children's Health and National Health Interview surveys, a very large proportion of some immigrant communities, particularly Pacific Islander, Mexican, and Puerto Ricans are overweight or obese, and up to a quarter of immigrant children are obese and less likely to be engaged in sports and physical activity. And consistent with the acculturation hypothesis, the risks of chronic disease morbidity among immigrants and their children was found to increase with increasing length of residence in the United States, as did their self-perceived state of health. Barriers to health care access certainly represent the major health issue facing immigrant populations, many of whom have a legal status that makes them ineligible for public insurance programs and or who fear enrolling in public programs due to concerns that it will limit their chances of getting permanent health insurance. Limit their chances of getting permanent residency or citizenship in the future. Indeed, among the non-elderly population, 25% of lawfully present immigrants and about 45% of undocumented immigrants were uninsured compared to only 10% of citizens. And unfortunately, as highlighted by the Kaiser Family Foundation in this figure, many lawfully present immigrants who are eligible for coverage options under the Affordable Care Act remain uninsured. In fact, with the recently enacted American Rescue Plan Act, access to health coverage through temporary increases and expansions in eligibility for subsidies to buy health insurance through the health insurance marketplaces, 79% of the uninsured lawfully present immigrants would be eligible for ACA coverage. This lack of enrollment is likely because of a host of barriers, including fear of immigration enforcement, mistrust of health services, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. And unfortunately, as shown in the last bar there, uninsured undocumented immigrants are ineligible for ACA coverage options due to their immigration status. And in the absence of this coverage, they remain reliant on emergency departments, safety net clinics, and hospitals for care, and very often just go without greatly needed care. Indeed, as a whole, immigrants are more likely to rely on the ED for their care and are less likely to have an outpatient doctor's visit. Some immigrants avoid going to doctors for preventive care, including pregnant women, in large part due to fear of immigration enforcement or mistrust of health services. And unfortunately, when immigrants do access health care services, they've been shown to receive suboptimal preventive health care services, with disproportionately low screening rates for breast, cervical, and colorectal cancer, as well as for cardiovascular risk factors such as hypertension and dyslipidemia compared to the U.S.-born population. Immigrant children have also been shown to have a lower likelihood of receiving preventive care services, including immunization and maintenance medications for conditions such as asthma. From a political standpoint, there's no doubt that laws and policies that restrict immigrants' rights can have negative effects on the health of immigrant communities. In recent years, there's been a substantial rise in anti-immigrant legislation that carries significant implications that are experienced not only by the individuals immediately involved, but also their friends, children, and extended family members. Such restrictive immigration policies have been found to contribute towards an increased likelihood of U.S.-born children living without a parent, having increased household poverty, lower educational attainment among individuals and their children, heightened fear, distrust of authorities, and increased stress. And beyond policy changes, a complex host of non-medical factors, including behavioral and cultural factors, as well as inequalities in social and economic systems, can impact immigrant health. And as such, there's perhaps no greater context in which to incorporate a social determinants of health framework in our efforts to provide better care for immigrant populations. Indeed, some experts argue that immigration in and of itself should be regarded as a social determinant of health, and by doing so, we'll be able to advance scientific and public health progress in this field. And as we think about areas for intervention, it's also helpful to think about these social determinants of health along the various stages of migration, as highlighted here. Using this framework, you can see that many immigrants face pre-migration economic stress, extended periods of poverty, political instability, and violence, endure hazardous conditions during their migration, including starvation, dehydration, and physical, verbal, psychological, or sexual abuse, and then face a variety of political and social factors once they settle in the U.S., including limited access to health care and restrictive immigration policies that promote fear, social isolation, and discrimination. Indeed, these exposures prior to, during, and after migration can all impact their health, and this is most greatly observed in our undocumented immigrant community. As such, some of the major health issues we see in caring for immigrant populations include high rates of mood disorders, such as depression, anxiety, and post-traumatic stress disorder, poor perceptions of their own health, decreased use of preventive services, including testing for sexually transmitted diseases, difficulty adhering to treatment plans, and oftentimes crippling social isolation. I am certain that most of you hepatology providers in the audience see a large volume of first or second generation immigrants in your practice, and I hope that some of the information I shared today will help you inform the way you practice. I encourage all of you to do some degree of screening, or at least thinking about social determinants of health among the patients you see. Try to get a sense for how they're doing beyond just a specific disease or complication you're treating. Try to understand what other struggles they're facing day to day, including poverty, food and housing insecurity, poor literacy, and difficulties navigating the health care system. Direct your patients towards resources that promote health literacy and English proficiency, as low levels of both are associated with poorer health outcomes. Get to know your patients, learn about their culture, learn a phrase or two in their language, they'll appreciate it. And of course, also make sure to have professional interpreters readily available for your visit to make sure they fully understand their condition and your treatment plan, and invest in establishing a strong sense of trust between you and the patient. This will inevitably go a long way towards promoting their health. We need to be knowledgeable about immigrant rights and the services they're entitled to receive so that we can empower them to utilize any and all available resources, and that includes legal representation when needed. We should promote and encourage participation in programs that validate their shared life experiences, process migration-related trauma, and celebrate their culture. We should advocate for changes in immigration policies that alleviate fear of deportation and increase access to affordable health care. And we should engage and support our local community health centers and form partnerships with their teams as they're truly the cornerstone of health care services for many immigrants, particularly those who are undocumented. And lastly, to truly advance our understanding of immigrant health, we need to have greater inclusion of immigrants in research studies and public health surveillance programs. And the more details we can gather with respect to legal status, countries of origin, mode of entry, and health status changes over time, the more thorough and meaningful our understanding of the factors influencing immigrant health will be. In order to fully and accurately apply complex behavioral and structural health frameworks to studying immigrant health, we need to rely on input from our colleagues across disciplines, particularly psychology, sociology, history, political science, and law. We will indeed take a village, as they say, and we need to learn from each other as we address immigrant health challenges. In summary, the U.S. has the largest immigrant population in the world, and their proportion of the total population will only continue to grow. As such, improving the health of immigrants is critical to ensuring the health of our nation. Various social determinants of health encountered prior to, during, and after migration impact immigrant health, and providers are uniquely positioned to advance immigrant health by considering these social determinants of health in our delivery of patient care, advocacy for favorable immigration policies, and public health research. Thank you so much for your attention, and thank you again to the course organizers for inviting me to speak today. Please don't hesitate to reach out to me at the email shown here. Take care, everyone. This is Dr. Mohamed Hassan from the University of Minnesota. I will be talking about today barriers to health care and the burden of liver diseases in the immigrant communities from Africa into the United States. I have nothing to disclose. So as most of you already know, there are around 300 million people who have chronic hepatitis B virus worldwide. The top 20 countries for hepatitis B are shown on this graphic and map. And as you can see, nine of them are from Africa, Nigeria being the most populous country in Africa. Another important fact in hepatitis B is that it causes around 800,000 deaths globally each year. Globally each year compared that to hepatitis C, which causes around one third of that each year globally. And if you look the cause of death altogether, hepatitis B causes 5% of deaths from infections, parasitic diseases, digestive diseases, and cancer. Another important factor is that hepatitis B virus in 2018 caused 360,000 cancer deaths. This is more common, as you see in general, in men compared to women. And you can look this graphic and you can see that. Compare that with hepatitis C, as I have said before, which is mostly half of it. Another important factor is the high incidence of HCC in Africa. You can see it's more common, mostly in West Africa and also in Egypt. In general, this graphic shows the global progress towards 2030 for viral hepatitis in this sustainable development goals, targets. And you can see the blue line, the green line and the red line. The blue line shows how many infections were due to hepatitis B, which were around 3 million new infections. In 2019, death was around 1.1 million. And the prevalence in children under five in 2019 was less than 1%. The WHO Africa region had 2.3 of the new HPV infections in 2019, as shown in this map. One thing I will tell you now is that Africa lies or belongs to two groups in the WHO classification of regions. The Eastern Mediterranean, as you can see that in that light green on the right side, and then the red. So the Africa region, which excluded here, the Eastern Mediterranean, new infections, it was number one. And for deaths, it was number three in the world. Hep C was number five or the fifth new infections and the third in deaths. Africa also, as I have shown there, ranked third in HPV deaths in 2019. You can see that it was around 80,000. Compare that with hepatitis C, which was half of that. Another important factor in Africa about viral hepatitis B is Africa lags behind in HPV per dose vaccination. This map shows estimates from the end of 2019. And you can see Africa mostly happens to be in the zone of hepatitis B in childhood schedule, but not universal HPV birth dose. So there are a few unique features of hepatitis B in Africa, which you need to know. Number one is most transmissions in Africa is early horizontal transmission before the age of 10. That is in contrast to the vertical transmission where you have it in Southeast Asia and East Asia. The mode of transmission usually is associated with some interventions, which are done in children. Female genital mutilation, for example. Mass circumcision of boys where a local healer is doing it and does it in a non-sterile equipment. Another thing is the genotypes, which are different between East Africa and West Africa. In West Africa, it is genotype E. In East Africa, it's A1. And then later on, I will tell you what is the importance of that. Another thing is HPV DNA usually is lower than what you will find in Asia. And as you know, HPV is more oncogenic than will be expected on a low HPV DNA. HPV-induced HCC occurs also in Africa at a younger age. Only a small minorities are aware also in Africa of their HPV infection. And most HPV-induced HCC is diagnosed at a later stage compared to other continents, including Asia and also Europe and the Americas. HPV also compared to other causes of HCC usually happens at an earlier age in Africa, as you can see from this slide. HCC, and I will show that later on, happiness at an older age. Also, the other thing is Africa has the youngest age at HCC diagnosis. And in that, it has the largest years of potential life lost. You can see from this graphic, between Japan and Africa, you see the life expectancy differences there. So younger age of onset for HPV-induced HCC in Africa, what can you say about that? First of all, the population is younger. So there is a lot of young people. The second thing is the host genetics, strong familial association. Viral genetics, low replication, high oncogenicity. And then environmental factors, such as aflatoxins or co-infection with HPV. You know, the aflatoxins, most of you know that in Africa, grains are stored underground. And that causes, you know, the aspergillus flavus to produce this aflatoxins, which are carcinogenic. So in the United States, this is a little bit old statistics, but there is close to 40 million, 40 million born people in the United States might be higher now. And 1.6, which is also higher now, came from Africa, or they were born in Africa. One third of them from East Africa. And this is recent arrivals, usually as they came, most of them after 1999, 1990. And this is because of the civil wars, which happened both in East and West Africa. I did, together with other hepatologists from other universities, looking into the U.S. Hepatitis B research network data, you know, differences between genotypes born in East and West Africa. And we look at this information. And this is what we have at that time. And the countries which we recruited people from, you know, they are in the United States, but this is where they originally were born or came from. We did East and West because of the fact that this was used before, and people travel along the coastal lines, which is Atlantic in the West and the Indian Ocean in the East, because going through the continent is very difficult because of diseases, rivers, and sometimes unfriendly people. We found that, you know, as I have alluded earlier, that East Africans are mostly A1 genotype, and West Africans are 67% genotype E. And then we did another study, which we look at all our hepatocellular cancer patients, and then identified what was the etiology of their underlying liver disease. In fact, we found that the majority of them were men. We have that the majority of them have Hep B or Hep C. Some had both. And there were few who did not have Hepatitis B or Hepatitis C. And this is what we found. In East Africa, the majority of those patients have HCV as their underlying liver disease, 73.9% compared to 17.4% with Hep B and 5.8% with B and D. In West Africa, instead, it was the Hepatitis B that predominated. And if you add with the D, that's almost over 70%, and only 23.1% was due to Hepatitis C. This had some interesting factors. First of all, the patients from East Africa were older. Remember that it was HCV that caused it. The West Africans were younger, and there were more men than women. This is the map of where these patients mostly came from. And when you look, if they were treated or not treated, you can see that for Hep B, the majority of them were treated. For Hep C, they were untreated. Please remember that the data collected, some of them were from the direct-acting antiviral therapy. And even with the direct-acting antiviral therapy, they were reluctant to undergo treatment. Another thing is that group of patients, which we collected, when we look at if they were still around, a good number of them were lost to follow up. Some of them declined treatment. And in a good number of them, HCC was the first presentation of the viral hepatitis infection. Another area which I want to address is barriers to healthcare. We look at into that also, and we divided it into three groups, financial and insurance issues, cultural, like trust, compliance with visitors and medications, gender concordance between the doctor and the patient. What about the religious beliefs of the patients? These have all significant role. The language also. If you have a doctor who speaks the local language about, you know, with the immigrant patients, then that increases compliance with visitors and also with medications. So, for example, financial issues. The number of uninsured immigrants has increased significantly also, since the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Another point is legal immigrants who came to the United States after August of 2006 were not eligible for the health insurance. They were not eligible for Medicaid until they had been in the US for more than five years. But if you came as a refugee, you will lose your insurance after five years you are here in the US. Foreign-born adults are nearly now three times as likely than native-born adults to be uninsured. And these differences in coverage remains even after you statistically control for income, education, employment, and health status. Another point which I wanted to use at the end of my talk is there is these things which are practiced in Africa, especially in younger people, which you would call harmful traditional practices. And these are, for example, the group male circumcision, ovulectomy, female circumcision, brain molar, teeth extraction, tattooing, cauterizations, and cupping. All of these are associated with high risk for parenterally transmitted diseases, including viral hepatitis. So I will stop there, and thank you. I want just to acknowledge Dr. Robert Robertis, who gave me some opinions and also provided me with some of the slides. Thank you. The title of my presentation is How to Increase Diversity, Inclusion, and Equity Within the Hepatology Workforce. My name is Dr. Jorge Marrero. I'm the Chief of the Division of Gastroenterology and Hepatology at the Perelman School of Medicine at the University of Pennsylvania. These are my disclosures. So in 2020, the U.S. Census was quite interesting. It showed that white alone, non-Hispanic patients is the largest racial and ethnic group in the United States at 57.8%. This is a slight decrease from the 2010 census and it has continued to decrease over the last 20 to 30 years. Hispanics comprise the second most common racial ethnic group in the United States, and it's estimated the prevalence 18.7%. Black or African American non-Hispanics are the third most common racial ethnic group at 12.9%. As I said previously, the number of white alone non-Hispanic people are decreasing while the Hispanic and other groups such as Asians tend to be rising in the United States. So overall, this data from the census shows that we're overall a pretty diverse country. This is also from the census and it measures the diversity index in the United States. To the left is the 2010 census, and on the right, the 2020. In the left, the 2010 census showed a diversity index of 54.9%. And in terms of how this is evaluated, the map shows the percent of diversity according to each state. The greener, the higher the diversity. So California in 2010 was the country or the state with a diversity index, which was above 66%. There are other countries along the Mexican border, Florida, New York, that appear to also be quite diverse but not as diverse as California based on this diversity index from the 2010 census. To the right is the current 2020 census that shows that diversity index has increased to 61.1%. And now you see more darker green states like Nevada, California, Texas, New York, Maryland. And there's an increasing trend for other states to be also more diverse like Illinois compared to the previous census. So overall the message is that there's to be increasing diversity in terms of the racial and ethnic composition of the United States population. This is also data from the census, that it's at the county level. And on the left, we're going to discuss the most prevalent race or ethnic group at the county level. In orange are whites, in green are Hispanics, in blue are black or African Americans, and in purple, these are Native American or Alaskan Natives. What this shows is that obviously the predominant, as we discussed earlier, the predominant racial or ethnic group is Caucasian throughout the United States. Hispanics tend to be concentrated more along the states along the Mexican border. In the southeast, you see more of the Asian American, black or African Americans, in terms of the most prevalent race in the different counties, and then you have Native Americans more towards the west and Alaska. And then on the right is the second most common race or ethnic group, according to the counties. And this is you hear that in terms of the second most common group along the Mexican border are whites. And then of course the west is, you see more of the Hispanics. In the southeast, you see more African American and then you see an other group of other which may be a mixture of Asians and Pacific Islanders and other racial or ethnic groups. So overall, this is just to show that we are diverse. And over time, the diversity is increasing. So now, how does that compare to physicians in general. So this is the gender according to applicants to medical school. So, traditionally, the females have been underrepresented in in the physician workforce in the 90s in the 80s and 90s, the it peaked actually to be in slightly over males in 2004 and five, then it dipped, and they're now in based on the last data from 2019, it appears to be increasing in or at least being slightly over males. So, so, but in the last several years we have been an improvement in in the access in the equity to applicants to medical school from females. Now, what about matriculants to medical school and what is the racial and ethnic composition. You see, the whites had decreased, but have plateaued since the 1990s, more or less, you see in green the Asian population has been slightly increasing from night in the 1980s. And then it has plateaued in the, in the last few years. And then you see the black and Hispanic population that appears steady. For the last 30 to 40 years, and then the American Indian and Alaska natives is barely detectable from zero. So definitely this is just to show that there is a significant difference in the, in the racial ethnic compositions of those who go into medical school. These are the accepted medical students in 2018 and 19 in purple are female in green are males, and then the different every row it's a different ethnic group. One of the interesting tidbits is the black or African American group is mostly composed of female, as well as the native Hawaiian or Pacific Islanders. And Asian appears to be more female predominant as well, compared to males. The other groups like Hispanic white multiple ethnicity or appear to be more male predominant so it's it. There has been improvement I take it, but still does not mimic the entire United States. Now at active physicians and 2018 the latest data from the double a MC. You see here that most of the active physicians 56% appear to be white 17.1% Asian 13.7 unknown. And then you see a significant decrease compared to the general population as we discussed with a census with 5.8 Hispanics and 5% black or African Americans, and then a significant decrease in the native Hawaiian Pacific Islanders Alaskan natives and So definitely there's a gap between the population of the United States and the active physicians in, in terms of reaching that the same level as the general population. This is a United States medical school faculty in 2018 in terms of the racial and ethnic composition. So here, there is mostly predominant 6.3% 6.63 point 9% Caucasian 19% appear to have multiple or Asian sorry 2.3 is multiple 3.6 appears to be black or or African American 3.2 appears to be Hispanic. And 4.8 unknown so definitely this is just another way to show that at the medical school level which is critical, where, where a lot of the young on underrepresented minorities are are developing the, the, this type of medical school faculty definitely does not mimic what's happening in the United States. And now let's look at GI gastroenterologist in 2010 that are active in 2018 that are active again 50% Caucasian 23% Asian 4% black or African American Hispanic 6% and then barely noticeable 0% American Indian Alaska native native Hawaiian or Pacific and other so. So again, this is just to show in getting closer to our specialty, that is a pretty small percent that in GI that that are of Hispanic black American Indian native Hawaiian and other races. And again, at the SLD membership level, the regular membership which is any scientist scientist physician or allied health professional who works in North America, which is 38% of the membership at ASL the only 9% appear to be underrepresented minorities in medicine, and at least in this membership category. Significant percent are unknown. But again, this highlights that the gap. So, even at the SLD. So there is a significant gap gap in gender and racial and ethnic diversity between the general diverse population in the United States, and physicians in general, but also specifically pertaining to hepatologists. So we need to bridge that gap. And what I tried to show with this figure is that that gap will be bridge. If we work together as a team, that's and working together towards achieving this trying to eliminate this gap or inequality that that will, we are going to be better for. Why, so this is one of the reasons that that we need this kind of trying to bridge that gap in racial and ethnic disparities as well as gender disparities. So this is one study that show highlighted the disparities in access to liver transplantation. These are donor service areas across the United States in the left is is adjusted for for blacks and African Americans. So what they did at each service donor service area, they tried to calculate it. The expected number of serotics based on the specific populations as the denominator and then on the numerator, it was the, the actual number of blacks, that, that were actually wait listed. According to the local demographics. As you see here, the ratio is under one, showing that there's a significant disparity between the expected number of wait listed, and the actual on the right is the same graph, but is showing Hispanic data for Hispanics, specifically those that are wait listed for transplant in terms of the expected to observe ratio. So it's a little bit better than African Americans but it's still it's under one, especially compared to Caucasians so this is just an example of significant disparities. When such in someone this type of inequality exists, and having physicians that look like patients may improve that inequality. As we're going to discuss here in the next in this next slide. This is one of the famous studies that showed the importance of diversity in medicine. This is a randomized trial of Africa, of black patients that were seen in a, in a primary care clinic setting this, it's in California. They randomized the blacks to an, a black doctor and doctors of other races that included Asian, and, and, and others. And the patients were given a photograph of the physician and answered questions before they actually were seen. And they were good and the same thing happened, and they feel the question. Pre consultation, and then they fill the question or post consultation. And this is what they found in terms of blood pressure BMI cholesterol diabetes management of all these aspects as well as getting a flu shot, either with or without an incentive. And this is an increase. When the black patients identify with a doctor so in blue are the black the black physicians pre consultation and post consultation so you'll see post consultation that there was a higher degree of of education, access, and access for all these factors blood pressure BMI cholesterol diabetes, and the flu shot. After they saw the doctor and talk to the doctor about all these issues so having I see have patients seeing someone that looks like them will improve care. And that's one of the problem one of the important aspects of trying to improve outcomes overall in healthcare. So, why is diversity medicine important as I show you improve outcomes. It informs public policy. We're living through this with a vaccination for covert and and misinformation and, and, and there are significant barriers to healthcare and education on all of this, according to racial and ethnic differences so it can inform public policy and focusing on diversity equity and inclusion will allow to problem solve will maximize engagement and innovation in healthcare and providing increased access so so that's why it's important to do. I think, to, to bridge that gap. I reach and engage the pipeline. So students I've given lectures to high school students in a predominant Hispanic neighborhoods given my heritage. And we have a grant for basic and another grant for clinical sciences, led, led by Dr. Katz and booter respectively. And we've been with historical black colleges and universities to try to bring their best candidates to our summer program undergraduate summer program so they can be taught about research and he has led to an increase of these candidates to an increase of these underrepresented minorities from HBC use. So this is a great thing and there are many programs like that the AGA the SLD have, and these are critical to engage the pipeline and get them engaged into medicine research education, etc. Confront implicit bias we all have implicit biases. And I think now more universities hospitals, different institutions are engaging more implicit implicit biases, as that will lead to better care, engage the gatekeepers at the medical school level residency fellowships, and not to undergo by that traditional training or by testing scores. Look at other aspects like what other skills, where did they come from what did they have to overcome any person to get where they are trying to get to medical residency, etc. So that's important. Make diversity a priority and visible, perhaps with social media and other aspects. This is important. The SLD has had a call to action with increased mentorship and sponsorship and, and they're at the forefront so I applaud the SLD for that. In my experience I grew up in Puerto Rico went to medical school. I went to Medical College of Pennsylvania, UIC and very supportive environment, learning environment, they recognize my potential, the gatekeepers. Everyone seemed happy and was infectious. When I went to faculty at the University of Michigan. I had a female mentor Dr. Locke, that really was created a great academic environment. Chong Ouyang also did the same allowed me to grow. So, at UT Southwestern they saw my potential as well. I had a very supportive environment. So these were important and now I'm at chief of GI and hepatology at Penn and they've allowed me to grow as a leader throughout all the institutions that I've been at. So what have I learned. I think the culture that values professionalism, respect and mentorship, regardless of how someone look, it's important. And that culture builds trust and confidence. The gatekeeper they took a chance on me and, and, and they saw my potential and that's what is clear I don't have the traditional pedigree. We need more mentors John Del Valle gave a lecture when I was a fellow he's Puerto Rican like me, and that ignited my interest in academia, and a diverse environment that we can learn from different cultures is so important. There is religious gender issues, etc. That's important so we can be provide better care and better doctors. So to conclude, there's a gender, racial, ethnic diversity gap. It is important to address this gap to do to existing inequalities that lead to poor outcomes. We need to engage the pipeline early work with gatekeepers make a priority, and just do it. Thank you very much. We'd like to thank you all again for attending the diversity workshop, and we'd like to send a special heartfelt thank you to our speakers who were able to give us such wonderful talks on these topics. We hope that you will continue to attend diversity workshops in the future and support as all these mission. And again, on behalf of Dr killer room, and myself, we thank you for attending.

Diversity Workshop

Promoting Diversity

Hepatology Practice

Health Disparities

Cultural Competency

Immigrant Populations

Clinical Programs

Research Programs

Cultural Competency in Hepatology

Diversity in Healthcare Workforce

Implicit Bias