Health Care Manifesto

H E A LT H C A R E M A N I F E S T O Actions towards holistic and equitable community health

Katie Gourley & Kristin Sukys SES 5374: Community Development: Past, Present, and Future Spring 2017

VISION

Hospitals are increasingly embracing the need to address social determinants of health and recognizing the inequities that our present health care system perpetuates. Yet, the United States continues to have the highest per-capita health care spending in the world, relatively poor health outcomes overall, and significant racial, ethnic, and socioeconomic disparities.1 We have examined hospitals’ current community benefit practices and believe that they must expand and deepen their understanding of community development. We encourage hospitals to break stagnant cycles of charity, extraction, and disproportionate investments in their communities that have been the status quo.

We call upon hospitals to leverage their significant financial power and political voice as anchor institutions to eliminate the values and practices of capitalism, patriarchy, neoliberal individualism, colonialism and white supremacy embedded in the health care industry. With the shifts in investment strategies and corporate values presented here, hospitals can center the needs of, elevate the voices of, and correct for the historical injustices and neglect imposed upon society’s most vulnerable and marginalized groups, including persons of color, women, queer, trans, femmes, gender nonconforming, formerly and currently incarcerated, non-western religions, cash poor and working class, differently abled, mentally ill, undocumented, and immigrants.

Primum non nocere

RECOGNITION OF PA S T

Today’s widespread disparities in health outcomes and accessibility to care can largely be traced to medicine’s long and silenced history of racial and gender discrimination, exclusion, and gross exploitation. Legacies of slavery’s commodification of black bodies, and Jim Crow era laws are still plaguing the American health care system, though these histories are rarely acknowledged.

Medicine owes much of what it knows about cancer to the cells of Henrietta Lacks, which were used without consent given or compensation received. Though the medical industry has acknowledged the importance of her cells and the mishandling of her rights, her surviving family has still never received a penny for the decades of medical advancements that have been built upon Lack’s genetic contribution to science.1 The horrific realities of Tuskegee Syphilis Experiment, where, between 1932 and 1972, nearly 400 poor and mostly illiterate black sharecroppers were subjected to the longest human study in medicine’s history without informed consent nor treatment when penicillin became the drug of choice for syphilis in 1947.2 The study has long been seen as symbolic of the mistrust and fear felt by communities of color towards the health care industry and has often been cited as a reason for African Americans not participating in clinical trials or agree to donate organs.3

The LGBTQ community has been subjected to grossly manipulative pathologizing of sexuality. Until 1973, homosexuality was listed as a disorder in the Diagnostic and Statistical Manual of Mental Disorders and individuals have been the victims of conversion therapies which have gone as far as electroshock treatments and castration.4 Hospitals have been major players in urban displacement and gentrification. For example, in Portland, Oregon the Legacy Emanuel Hospital expansion plans in the 1960s and 1970s leveraged urban renewal mechanisms that resulted in the razing of over 300 homes and in the heart of the city’s black business district.5 Today, the neighborhood is one of the most gentrified and is representative of the widespread whitewashing of the city.

INJUSTICES Birth control, often placed on a pedestal as landmark victory of early feminism, is deeply linked to a history of violent exploitation of black bodies, including the forced sterilization of poor black women and experimental hysterectomies performed on black women without consent – a practice that in the was so prevalent in the American South that it garnered the nickname “Mississippi appendectomy.”6 Acknowledgment of some of these past harms has occurred.

Emanuel Hospital opened a permanent exhibition in its atrium detailing the neighborhood’s history and the hospital’s role in devastating it.7 In 1997 President BIll Clinton, in the presence of five living survivors of the Tuskegee experiments issued a nationally broadcast apology stating “What was done cannot be undone.

But we can end the silence. We can stop turning our heads away... what the United States government did was shameful, and I am sorry.”8 However, for every injustice that has been acknowledged, hundreds go unremembered, and for every apology issues, millions of Americans still live in a world where they are denied equal care or shoulder the disproportionate effects of chronic illnesses that are more the result of their zip code than their genetic code.

Discussions of reparations must go beyond apologies for these past injustices, including but not limited to inhumane medical experimentations, forced sterilization campaigns on poor women and black women, exclusion from medical schools and professional appointments, denial of care for people of color, colonization of tribal groups, conversion therapies conducted on LGBTQ individuals, and mass displacement at the hands of institutional expansion efforts. These injustices are the very things that have produced the widespread disparities in health outcomes and accessibility to care for that hospitals are now attempting to address through their community investment strategies. Hospitals must acknowledge and reconcile the fact that they played a major role in created these conditions from the onset and must account for the health care industry’s roots in white supremacy, colonialism, and misogyny.

RACIAL JUSTICE + CULTURAL COMPETENCY Fifteen years since the Institute of Medicine’s landmark report, Unequal Treatment, racial and ethnic disparities continue to riddle the American health care system. The difference in access to and utilization of health services between racial and ethnic populations have been accepted as the status quo for far too long. The disparities in health outcomes between white and nonwhite patients are at essentially the same levels as 50 years ago even thoough overall American health has improved.1 Well-documented disparities persist in quality of care.

Studies have shown that even when they have the same type of insurance and the ability to pay, minority patients receive a lower quality of care than non-minorities.2 People of color receive unequal treatment for pain, asthma, heart disease, kidney disease, cancer, transplants, amputations and childbirth. African-American men are up to 30% less likely to receive diagnostic tests such as cardiac monitoring and chest x-rays than white men.3 Black mothers in the U.S. die at three to four times the rate of white mothers.4 Two-thirds of medical professionals display unconscious racial bias.5 Hospitals must go beyond token diversity trainings and actively address and manage prejudices.

• End racial disparities in quality of care received by patients of color.

Comprehensively educate medical students about racial biases in care engendered in medical school and persisting throughout the industry.

• Ensure culturally appropriate healthcare. Acknowledge every person’s agency to determine what level and type of care their body needs. Validate concerns of individuals used to nonwestern medical traditions.

• Enhance equity in physical access to and utilization of care. Provide access to comprehensive health centers in all neighborhoods of color. Provide free transportation services to hospitals through partnerships with rideshare companies.

• Acknowledge and improve the diversity of staff and significantly increase the number of medical and public health professionals of color.

• Publically stand against the substandard treatment allowed under the Federal Health Program for American Indians and Alaskan Natives. Campaign for a better nominee to run the program, which has been without a permanent director for three years. Donald Trump’s nominee withdrew in February 2018.

• Hospitals must immediately act to end the gender pay gap in the medical industry. The pay gap between female and male doctors has only been growing wider. Women doctors earned an average of 27.7% less than their male counterparts in 2017.

GENDER EQUITY + REPRODUCTIVE RIGHTS Gender disparities are glaring in every aspect of the health care industry. The pay gap for females working in the hospital industry is persistent and has been tolerated for far too. Female physicians and surgeons earn 62¢ for every $1 earned by a man.1 While 86.9% of the health care support workforce (many of the lowest wage positions within hospitals, from home health aides to dining services staff) the average female salary for these jobs is $24,300 compared to $31,406 for men.2 In an industry where 8 out of 10 workers are women, nearly 9 out of 10 CEOs are men.3 As patients, women face unequal insurance costs, discriminatory coverage of medicine, and gender bias in clinical pain management. Though women report more severe levels of pain, more frequent incidences of pain, and pain of longer duration than men, they are treated for pain less aggressively until they “prove that they are as sick as male patients.”4 Men wait an average of 49 minutes before receiving an analgesic for acute abdominal pain. The wait time for women is 65 minutes or more. One in 10 women suffer from endometriosis, but it takes an average of eight years to be diagnosed.5 The gender inequity inherent in health care is manifest in the decades-long war waged on women’s reproductive rights at the local, state, and federal levels. The current political administration has made it apparent that women’s bodies are under attack.

• Listen to the voices of the #MeToo In Medicine movement. Declare zero tolerance for sexual harassment in the workplace. Institute firm and transparent policies that elevate the voices of victims and create traceable records of assault that follow offendors.

• Treat female pain seriously. Gender bias in healthcare is an epidemic. Refuse to support medical studies and drug trials that only test on male-identified subjects.

Ensure doctors treat female reported pain as they would male reported pain.

• Create programs to provide equal menstrual care for homeless and incarcerated women .

• Demand reform on unjust reproductive health policies, including but not limited to the Global Gag Rule, H.R. 7, the Life at Conception Act of 2017 the fetal heartbeat.

• Openly discuss and address media attention to the disparities in black infant and maternal mortality in America, such as the New York Times’ recent, “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.”

IMMIGRANT & REFUGEE RIGHTS Though hospitals are by law required to treat any patient regardless of immigration status, and are prohibited from requiring a social security card for care or from sharing patient information with enforcement officers, hospitals can be a place of extreme fear for those living in America undocumented. Health care is a human right, yet people are forced to choose between the treatment they need or being deported. Since the Trump administration rolled back Obama-era protections prohibiting arrests in sensitive locations, ICE officers have turned up to arrested people at hospitals and health clinics. The risks of these tactics go beyond morals. If undocumented immigrants are not seeking preventative care and the emergency care they need, this could mount a serious public health threat and could take a significant toll on taxpayers.1 Further, most large hospitals are staffed by immigrant medical professionals from around the world. Trump’s 2017 travel ban poses a grave danger to medical profession in practice and research. About a 25% of all physicians in the U.S. have medical degrees from abroad and 18% of academic physicians were born abroad. Foreign born physicians are also more likely to practice in rural areas and serve as geriatricians.2 Refugees, like immigrants may feel unsure of their protections and rights within the walls of a hospital. The bureaucratic nature of the American health system and the type of care provided can be culturally jarring. Hospitals should be community anchors for refugees and asylum seekers to find care and support, yet often lack cultural sensitivity, language services, and adequate understanding of different cultural traditions that may require specialized medical care (for example, female circumcision).3

• Ensure culturally and linguistically appropriate medical care for recently resettled refugees with particular care for the needs of refugee women fleeing sexual violence.

• Refuse to stand for ICE raids within hospitals, and on or near hospital property. All hospital staff should be trained to refuse to provide any patient information or grant access to any non-public areas of a hospital to agents.

• Publicly denounce immigration restrictions and travel bans that limit the ability of hospitals to staff international medical professionals and researchers.

• Keep all staff and patients informed on all current rights and legislation regarding immigration control and enforcement in the face of rapid new cycles and destabilizing political tactics from the current administration.

• Design public awareness campaigns to demonstrate that patient information will be protected and to assure undocumented individuals that they are safe seeking care or visiting loved ones at the hospital.

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Bias against LGBTQ+ individuals in the health care system continue to affect health-seeking behavior and access to care, causing multiple health disparities for LGBTQ+ populations and exacerbating stigmas already felt by LGBTQ populations. Currently, LGTBQ+ community members suffer from higher rates of depression, suicide, substance abuse, depression, anxiety, homelessness, HIV and other STDs, hepatitis B, and lower rates of mammography and Pap smear screening than heterosexual populations.1 Expected and experienced discrimination deter LGBTQ+ persons from seeking routine care and care refusals leave individuals vulnerable to serious emotional, physical, and financial consequences. The U.S. Transgender Survey reported that 1 in 4 transgender people avoided seeking needed medical care in 2014 due to fear of discrimination or mistreatment due to their gender identity.2 In 2017, the Center for American Progress reported that 8% of 857 LGBTQ+ respondents experienced care refusals from medical professionals due to their actual perceived or perceived sexual orientation and 29% of transgender respondents reported this type of refusal.3 Ignorance of specific health issues and a lack of LGBTQ+ cultural competency within the health care settings also impact patient-provider relationships and access to care. A JAMA study on 137 medical schools found that, on average, doctors only receive five hours of LGBTQ+ specific training throughout their four years in medical school.4 It is imperative that hospitals enhance their support of the LGBTQ+ community inside hospital walls by standardizing culturally-affirming and informed health care while standing in defiance to threats to federal protections for LGTBQ+ persons in the United States.

• Demand the Accreditation Council for Graduate Medical Education to require all medical schools to formals incorporate LGBTQ+ and sexual minority specific health issues and cultural competency into their curricula.

• Create safe environments for LGBTQ+ populations that are culturally-affirming. Demand the Joint Commission to require hospitals to have a written patient and employment non-discrimination policy outlining their non-discrimination standards that include both sexual orientation and gender identity.

• Provide access and assistance with social services that mitigate mental health and homelessness for LGBTQ+ populations with special attention to youth vulnerability.

• Provide inclusive care that address behavioral health, HIV prevention and transgender care. Collect more SOGI data within hospital settings and require the inclusion of SOGI-targeted questions on national surveys to increase nationally represented data on LGBTQ+ community members.

• Advocate for federal funding to support the Human Rights Campaign’s Healthcare Equality Index, a benchmarking tool that evaluate healthcare facilities’ policies and practices related to the equity and inclusion of their LGBTQ+ patients, visitors and employees.

• Publicly denounce the Trump administration’s lawsuit against the U. S. Department of Health and Human Services challenging the 1557 rule prohibiting discrimination on the basis of gender identity.

LGBTQ+ INCLUSION AND PROTECTIONS

• Stand against the creation of the Conscience and Religious Freedom Division within the Department of Health and Human Services that imposes broad religious refusal policy that protects medical professionals who refuse to provide services that violate their moral or religious beliefs.5

WORKFORCE DEVELOPMENT Nationally, hospitals directly employ more than 5.7 million and indirectly support 16 million jobs.1 Though hospitals contribute significantly to the U.S. economy and workforce, labor shortages are decreasing access to medical services and threatening quality of care. Supply issues stemming from institutional barriers and retiring medical professionals cannot keep up with the demand for medical services from our growing nation and aging population. The American Medical Association warns of a nation-wide shortage that could range from 48,000 to 104,900 physicians by 2030.2 Reliance on traditional state-based regulatory systems and process-driven approaches inhibit innovative solutions to improve education, licensing, training, and certification of high-quality medical professionals.3 Aside from improving options within the professional educational pipeline, hospitals need to address local employment concerns and capitalize on community assets. Hospital workforce development programs need to be improved to retain existing workers by providing robust support and tools their employees need to fulfill their personal, professional, and educational potential. Promotion within need to be revisited within the industry, prioritizing low-wage support staff training and continuing education. Workforce retention requires monitoring and evaluation that includes external stressors like housing and food insecurity as well as broad policy reforms that enhance financial security. Diversity in hospitals need to be prioritized. Out of the total active physicians in the United States in 2013, only 4.1% were black and African American, 4.4% were Hispanic or Latino, 0.4% were American Indian or Alaska Native, 11.7% were Asian and 48.9% were white.4 Racial, age, gender, and ethnic diversity of health care providers is a vital step in creating a healthy workplace.

• Improve the current pathways into medical professions. Explore competencybased assessments that embrace new opportunities to certify and train competent incumbent workers, specifically entry level and middle-skilled staff members.

Increase youth exposure to careers in healthcare • Refuse to accept housing and food insecurity within hospital support staff. Proactively monitor these barriers and provide layered social services for employees within standard care benefits packages.

• Target and prioritize community workers with attention to worker-owned cooperatives. Partner with community organizations to develop learning and employment opportunities that are aligned with ongoing recruitment needs.

• Build cultures of health within the walls of the institution by reducing exposure to toxins disproportionately affecting lowwage support staff, insisting on humane hours and suitable working conditions.

• Enhance diversity across all salary levels and striver towards creating more diversity in leadership roles and boards.

URBAN PLANNING Housing instability, food insecurity, public safety, environmental exposure, climate disaster risk, violence, lack of transportation and other urban planning issues have a direct impact on health outcomes an abilities to access adequate care. (quick fact) While it is common for academic institutions to be involved in community planning, it is still rare for hospitals.

Hospitals’ are major holders of land and capital. Constant expansion plans have a huge economic and physical ramifications. The Buffalo Niagara Medical Campus expansion has led to such rapid growth and land speculation that residents are crying out to the city to force the hospital to mitigate massive displacement. The Cleveland Clinic, held up as one of the greatest hospitals in the world, has eaten up a 17-block stretch of its surrounding area while its neighbors experience some of the worst living conditions and economic outcomes of the city.1 Gentrification is a public health issue. It resdults in increased hospitalization for mental health related illnesses.2 Hospital themselve are often major drivers of gentrification, meaning they are undermining their very mission to protect community health.

Even when health care is available, low income urban residents or people living in rural places do not receive the care they need due to lack of transportation. Investments and policies that privilege majority white, affluent communities leave society’s marginalized groups vulnerable to negative externalities of infrastructure. The neighborhood of East Boston, for example, is forced to bare the burden of the city’s most noxious transportation infrastructure and their bodies are suffering for it.

Housing is a fundamental human right, yet about 11 million families spend more than half of their incomes on housing.3 Lack of affordable housing forces families to cut spending on healthy food, child care, transportation, and medical care and exacerbates risks of eviction and cycles of homelessness. shelterless individuals often have nowhere to turn for a place to sleep other than emergency rooms.Hospitals often spend much more on hospitals stays for patients without homes than they would if they simply provided them with free rent.

• Where you live should not determine how long you live. Create infrastructure projects that improve green spaces, safe streets, culturally relevant bike infrastructure, and better bus routes in all neighborhoods.

• Housing is healthcare. Fund building and managing affordable housing and adopting innovative models to combat homelessness.

• Create, support, and fund community land trusts for housing and agriculture to prevent displacement and other negative impacts of development, particularly development created by hospital expansion projects.

• Embrace values-based food procurement for hospital dining services and create direct opportunities for communities to own their own food systems.

• Cut ties with corporate food management services and refuse to allow fast-food establishments on hospital property.

• Create healthier environments within hospitals, ensure workers and patients have adequate access to safe outdoor spaces, courtyards, light and air quality.

• Provide direct and free transportation services to care, including routine check ups. Partner with rideshare companies to provide free rides. Invest in mobile care.

ENVIRONMENTAL JUSTICE

Climate change is one of the most pertinent public health concerns of the 21st century. It’s estimated that the U.S. health care system was responsible for one tenth of all national greenhouse gas emissions in 2013.1 As temperatures warm and climate patterns shift from rising CO2 levels in the atmosphere, the healthcare sector is bracing for inevitable health consequences from temperature related deaths, air quality impacts, extreme weather, vector-borne disease, water-related illness, food safety and nutrition, and mental health and well-being.2 These negative health impacts will disproportionately affect low-income populations, those already burdened the most by health disparities. One study in the American Journal of Public Health estimated that the greenhouse emissions from the healthcare industry would be responsible for 123,000 to 381,000 years of healthy life in the future.3 Health care‘s contribution to carbon emissions and waste is not only driven by powering and sustaining services at their individual facilities but by additional industries they choose to support like medical supply producers, pharmaceutical manufacturers, industrial agricultural operations, and laundry facilities. Hospitals have a moral and medical obligation to decrease their carbon emissions and reduce waste.

• Reduce greenhouse gas emissions in hospitals. Develop and commit to facilityspecific sustainability goals and publicize emissions.

• Investigate equivalent alternatives to desflurane, an expensive anesthetic gas that has 5-18 times the global warming potential than other anesthetic gases.4 • Limit waste in hospitals. Utilize Practice Greenheath’s Greenhealth’s Tracker, a tool that audits and tracks waste spending and volume by individual waste streams.5 Stand against the standard practice of incineration technologies for medical waste management.

• Decrease the external environmental footprint of hospitals. Evaluate emissions along the supply chain and prioritize supporting products and companies that value safe substances, minimal pollution, energy efficiency, reusable materials, and limited packaging material.6 • Create safer working environments.

Transition to safer cleaning supplies and toxic waste removal practices. Provide healthy, sustainably grown food and adopt procurement practices that emphasize low-carbon footprint transportation. Follow Health Care Without Harm’s furnishings criteria. Limit use of toxic chemicals that may be carcinogenic and transition to using green chemicals that reduce disposal costs, reduce liability, and improve the health of workers.7 • Publicly support a global carbon pricing scheme.

• Adopt institutional implementation plans to acheive the Paris Agreement Goal of limiting warming to 2 degrees Celsius.

INVESTMENT REFORM

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As economic engines in both urban and rural communities, hospitals have collective investment portfolios estimated at $400 billion.1 They purchase over $850 billion in goods and services from other businesses and support over $2.8 trillion in economic activity and hospital spending supports one in nine U.S jobs.2 As anchor institutions they sit on a wellspring of untapped assets in the form of investment portfolios that should be leveraged to address the social determinants of community health at significantly higher levels than present.

Through values- and place-based investments, hospitals have a moral, medical, and financial obligation to invest in community wealth building and to divest from extractive and toxic industries that are contributing to today’s most pressing public health crises.. Hospitals must invest upstream to address community health, rather than providing financial assistance to patients in the E.R., the point of highest healthcare costs. The health care industry has proven that it has the power to create culture shifts through divestment as it did in the 1990s by taking a public stance and divesting from the tobacco industry.3 Hospitals are often one of the largest landowners in a given community. Yet the 58% of all hospitals are not-for-profit institutions meaning they do not pay property taxes.2 In order to claim tax-exempt status, non-profit hospitals are mandated by the IRS to provide a “community benefit.”

This loosely defined requirement has historically been met through charity care for uninsured patients who lack the ability to pay out of pocket. With the passage of the The Affordable Care Act, additional community benefitrelated requirements were placed on tax-exempt hospitals encouraging they dedicate more funds to directly to the community, yet no state has a minimum requirement for this (source). Currently, this type of spending amounts to barely a drop in the bucket of a typical hospital’s community benefits allocation, let alone in relation to their extensive assets and investment portfolio holdings. For example, in 2014 the Cleveland Clinic had reported expenses of $6,036,534,021 and $6,956,278,537 in revenue. The clinic claimed to dedicate 11% of spending, or to activities they qualified as “community benefits.” Looking closer, the largest category of this spending, 4% of total expenses, went to professional education and research, while a less than 0.01% went to “community building.”4

Divest • Divest from all fossil fuel holdings • Divest from portfolio holdings with ties to the gun industry • Divest from companies that participate in advertising added sugar products to children

Invest • Invest in companies that comply with the UN global compact • Invest in clean energy sources and renewables • Finance affordable housing development and community land trusts • Help seed and scale local womenand minority-owned businesses through private equity and venture capital investments.5 • Provide micro grants and loans for community led projects that create community wealth.

• Place cash and cash equivalent holdings to community banks, blackowned banks, credit unions.

VIOLENCE REDUCTION Hospitals must stand against all forms of violence that plague our nation inside and outside hospital walls. Healthcare workers currently endure the highest rates of assaults in U.S. workplaces every year, and the rates continue to rise.

Between 2012 and 2014, workplace violence injuries rose 65% for all health care staff with a 55% increase among nurses.1 Externally, the CDC reports that 55,000 people are killed and 2.5 million are injured from violent incidents each year.2 These direct assaults and indirect behavioral and emotional consequences of community violence cost the hospitals $2.6 billion in 2016.3 Sources of community violence and aggression must be addressed with special attention to youth and vulnerable populations that are susceptible to gang pressures and activities, street violence, human trafficking, and unsafe gun behavior. The severity of human trafficking in the United States continues to warrent more attention. Reports of human trafficking increased 35.7% between 2015 and 2016.4 It’s been reported that over half of labor and sex trafficking survivors had interacted with healthcare workers at least once while being trafficked.5 As health care staff represent some of the few professionals to interact with victims of human trafficking, it is essential to ensure providers have the support, tools and training to identify and care for these individuals. Hospitals must stand collectively in favor of strict gun control. Loose gun restrictions allow for 13,000 firearm homicides each year in the United States and roughly twice as many injuries.6 Two-thirds off all gun-related deaths in the United States are suicides.7 The healthcare industry must not only recognize gun violence as a national epidemic that requires public health interventions and strategies, but be clear about the policies, regulations and institutional failure that has allowed such an epidemic to occur, haunting our communities and public spaces.8

• Reject workplace violence through internal reporting and managing processes and external policy demands.

Like the American Nurses Association, petition OSHA to require mandatory comprehensive programs to prevent workplace violence, (source). Stand up for zero-tolerance reporting in the workplace that does not disregard verbal abuse or low-battery and create early warning systems that alert medical professionals of patient experiences.

• Expand the hospital interventionist movement to create opportunities for those affected by gang and street violence, building paths to conflict resolution and re-engagement in the community. Advocate for insurance companies to include hospital-based violence prevention programs.

• Train staff and provide screening to detect gang involvement and partner with community organizations to continue prevention strategies through behavioral health and social support outside hospital walls with mentorship programs, guaranteed housing and food insecurity assistance.

• Improve measures and processes to identify victims human trafficking that flow through health care settings. Educate health care providers of the warning signs and train staff members in sensitive protocols involving victims.

• Declare gun violence a public health epidemic and be transparent about the institutional failures that have led to its creation. Commit to correcting the over 20 year lack of research on gun violence in the United States by funding research and publicshing data on gun injuries.

CRIMINAL JUSTICE * work in progress

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• The US must reframe the conversation from one that places punishment before treatment. Hospitals must commit to replacing jail with treatment.

• Refuse to stand for inadequate training on drug and mental health in police force • Demand an increase of federal funding for mental health care.

• Become the leaders in ending the War on Drugs.

• Homelessness is not a crime, commit to proving homes rather than ER beds or jail beds to persons without shelter.

• Fund gun violence research; demand stricter gun laws, publish data on gunrelated deaths and injuries that go beyond mass shooting reports in the media.

• Commit to open access medical research.

Universal access to information representative of the wide spectrum of American peoples is essential for improving health care and health outcomes. Persistent calls for reforms and improvements in medical education and training programs have been left reforms have been left unanswered. Yesterday’s stagnant systems of medical training does not prepare physicians for today’s public health needs. Regulatory framework makes innovation and reform nearly impossible and must be contemporized and the legacy of financial and structural barriers to the medical field, though improving, still contribute to inadequate representation of minority physicians. Hospitals are just beginning to breakdown the professional silos in their own facilities by creating integrated care models or “clinical microsystems,” that provide interdisciplinary, patientcentered care.1 Currently, the fact that access to medical research prioritizes elite professionals is a direct threat to education, patient care, innovation, patients’ rights, and global health equity.2 Increasing the diversity of subjects in clinical trails has been on the National Institute of Health’s priority list for almost 30 years, yet women and people of color continue to be underrepresented.3 Though AfricanAmerican and Black men’s death rates from prostate cancer are double that of Whites’, they comprise only 5% of participants in prostate cancer clinical trials.4 Clinical trial participants that do not accurately represent the populations that the findings are used on can impact health outcomes from inappropriate diagnosis and treatment of disease.

Critical public infrastructure is also needed to guarantee information democracy. Almost 23 million rural Americans lack access to high-speed broadband.5 Early childhood education is the single most important determinant of health over a person’s lifetime.6 In 2017, more than 60% of toddlers in the United States didn’t have access to publicly funded preschool programs.7

• Publish research and journal articles by minority authors.

• The gun control debate is a public health issue. Fund research on gun violence in the United States.

• Reform medical research design to be more inclusive. Clinical and drug trials need to include people of all races, genders and ages.

• Create educational pipelines and financial relief for people of color and minorities into the medical field.

• Advocate for policy on universal internet access.

• Demand universal preschool and increased funding towards public schools.

INFORMATION DEMOCRACY

Sources Recognition of past injustices 1.https://www.theguardian.com/world/2010/apr/04/henriettalacks-cancer-cells 2. https://www.cdc.gov/tuskegee/timeline.htm 3.https://www.npr.org/programs/morning/features/2002/jul/ tuskegee/commentary.html 4.http://www.lgbthealthzducation.org/wp-content/uploads/ LGBTHealthDisparitiesMar2016.pdf 5. http://www.oregonlive.com/portland/index.ssf/2012/11/legacy_ emanuel_medical_center_2.html 6. Kelley, R. (2002). “The Battlefield Called Life: Black Feminist Dreams,” Freedom Dreams—pg.135-156.

7.http://www.oregonlive.com/portland/index.ssf/2012/11/legacy_ emanuel_medical_center_2.html 8. https://www.cdc.gov/tuskegee/clintonp.htm Racial justice and cultural competency 1.https://www.npr.org/sections/healthshots/2015/08/20/432872330/can-health-care-be-cured-of-racialbias 2.https://www.vox.com/health-care/2017/12/7/16746790/ health-care-black-history-inequality 3. Pezzin, Liliana E. and Keyl, Penelope M. and Green, Gary B. (2007) Disparities in the Emergency Department Evaluation of Chest Pain Patients. ACADEMIC EMERGENCY MEDICINE, 14 (2). pp. 149-156.

4. https://www.vox.com/health-care/2017/12/7/16746790/ health-care-black-history-inequality 5 https://www.medicalnewstoday.com/releases/242975.php Gender Equity 1. https://www.todayshospitalist.com/gender-gap-in-hospital-medicine-do-women-have-the-same-opportunities/ 2 data.usa 3. http://www.modernhealthcare.com/article/20160730/MAGAZINE/307309980 4. “The Girl Who Cried Pain” https://www.theguardian.com/lifeandstyle/2017/nov/20/healthcare-gender-bias-women-pain Immigration rights 1.(http://www.wbur.org/cognoscenti/2017/06/22/undocumented-immigrants-medical-care-leila-haghighat 2. (http://www.wbur.org/cognoscenti/2017/12/28/foreign-born-physicians-katherine-mckenzie 3. refugeehealthta.org/physical-mental-health/health-conditions/womens-health/tips-and-strategies-for-culturally-sensitive-care/#_edn1 LGBTQ 1. (Healthy People 2020) 2., (National Center for Transgender Equality, 2015).

3.(Center for American Progress, 2017).

4.(Obedin-Maliver, 2011) Workforce 1. (https://www.aha.org/system/files/content/17/17econcontribution.pdf ).

2. AMA).

3., (Mercatus) 4. AMA 5. https://www.aha.org/news/insights-and-analysis/2018-02-28-imperative-strategic-workforce-planning-and-development

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2 (CDC) ,3(American Hospital Association) 4According to the National Human Trafficking Hotline, r 5(Coalition to Abolish Slavery and Trafficking (CAST)) 6.(EveryTown) 7 (EveryTown) 8. The Atlantic