Practice English Speaking&Listening with: Public Health Ethics Forum 2020 Part 2

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RuebenWarren: Ashley Andujar I hope I'm pronouncing it correctly Scott Lockard,

RuebenWarren: Daryl Melvin, Daniel Miller, Maria Poepsel,

RuebenWarren: Michal Rhymer- Browne and Andrew Zekeri. Let me start with with and we'll go down the line as I asked the questions and please give a little bit about your sales as we open up our panel.

RuebenWarren: The first question and our introductory context is what is your past and current work and public health ethics and how has that been influenced by public ethics in your work, what your past and present, and your current work and how is public of ethics influenced your work. 5 00:00:56,240 --> 00:00:55,800 RuebenWarren: Ashley

Ashley Andujar: Everyone, I hope, I hope you can hear me.

We can

Ashley Andujar: Yes, so I have a background in emergency management.

RuebenWarren: Kind of losing you

Ashley Andujar: Is that better now. 11 00:01:23,800 --> 00:01:23,720 RuebenWarren: It's much better.

Ashley Andujar: Some technical issues.

RuebenWarren: Can we go describe come back to you.

Ashley Andujar: Yes, let's try that.

RuebenWarren: Let's try Scott Lockard

Scott Lockard: Okay. Good afternoon. My name is Scott Lockard on the public health director for the Kentucky river District Health Department. I have spent 30 years in public health.

Scott Lockard: Working primarily in rural areas of have worked in Kentucky river district and also for a time in a more macro politan area and

Scott Lockard: Clark County, Kentucky, which is adjacent to the Lexington Fayette County urban area, but I have lived my life here in Eastern Kentucky ethics has played a big role in my practice, I am a social worker by training and so always strived and looked at the

Scott Lockard: What we call social justice, you know, in public health, health equity we really working towards that. And now my practice in Eastern Kentucky, an area where there is great health disparities, where we have some of the poorest health outcomes forest health factors in the nation.

Scott Lockard: One in three people live in poverty and just ethics really God's

Scott Lockard: So much of what we do in this area just from the basics of looking at how we fund public health in the Commonwealth of Kentucky with a heavy reliance on property taxes.

Scott Lockard: Were individuals who need public health services. The most have the least local funding due to low property values and low income to provide those services. So again, always taking a big look at ethics and how that impacts our practice every day.

RuebenWarren: Fantastic HD, can we get you now.

Ashley Andujar: Yes.

RuebenWarren: Fantastic.

Ashley Andujar: Sure. What's going on with the video. But we get started. Um, so yeah. My name is Ashley, I'm to her. I am currently a health promotion communications leave at CDC in the waterborne disease prevention branch.

Ashley Andujar: But a lot of my background has been an emergency response in emergency management communications so

Ashley Andujar: Like during CDC. I've done you know responses with Sega with Hurricane Maria now coven and port the legal and I feel like every decision that I've made, you know, in my career, you know, ethics, has played a huge role in

Ashley Andujar: And just making sure that I influence and that I you know that lead voice so that minority populations. And specifically, you know, for the people that information gets across to not only rural communities. But yeah, you know, pregnant women during

Ashley Andujar: You know, during the hurricane. We had a lot of people with chronic illnesses that needed life saving information so that has been always

Ashley Andujar: Sort of like a driver for me and during my time. You know, when I worked for FEMA I deployed to around 10 disaster areas in the States.

Ashley Andujar: And I would always you know gravitates toward making sure that Hispanic communities, you know, again, in rural populations, had you know

Ashley Andujar: And, you know, emergency response information that they knew how to apply for systems and all that. So I think, you know, it has always been sort of like a driving force for me personally.

RuebenWarren: Fantastic. Let's go on to Darryl now we want to try to focus in on the public health ethics because we know perfect God infuses how's the ethical context influence what you do. And in fact, what do you do, Darrell.

Daryl Melvin: The methylation, but now it's up to you. In Matthew hospital.

Daryl Melvin: My name is Darrell mouth, and I'm a member of the Hopi and Navajo TRIED TO ARIZONA AND MY PEOPLE ARE from the mustard seed clan and Roadrunner clan and I'm born for the coyote past climb.

Daryl Melvin: And what I want to share is that my life experiences that inform my work and it's the personal decisions I made

Daryl Melvin: That I serve to serve my community, along with other rural tribal communities and that these choices include being

Daryl Melvin: An engineer and providing safe drinking water to communities and families that didn't have any and also leading critical access hospitals and health centers as a CEO to address the health disparities and deliver healthcare services to the underserved populations.

Daryl Melvin: The experience of those experiences really brought me to my current role and working with tribes and tribal live led organizations on different initiatives that further.

Daryl Melvin: Native asset control and asset management and the work really includes addressing in equities experienced by indigenous people.

Daryl Melvin: Through perpetuation of myths and stereotypes and in visibility issues and really to further work on what we now see as reclaiming needed truth.

Daryl Melvin: And that would be include changing existing deficit narratives that surround indigenous people and promoting the sharing of strength based narratives

Daryl Melvin: And so that's the work that I do in that informs my public health lens that I used to work and to share with the panel today. So thank you.

RuebenWarren: Fantastic that that is beginning to to open up the window of ethics. And that's exciting.

RuebenWarren: Daniel, give us your context and within the framework of what you do.

Daniel Miller: Sure. Thank you, Dr. Warren and first just thank you to the Tuskegee Center for Bioethics and CDC for gathering us together to talk about all of this.

Daniel Miller: So my name is Dan Miller. I'm a practicing family physician and I'm the chief of graduate medical education and behavioral health integration for Hudson River healthcare in New York State.

Daniel Miller: We are a large federally qualified health center. And so I think I'm here to represent the community health center movement in this discussion.

Daniel Miller: To get some to this ethical perspective, like all federally qualified health centers, we are nonprofits governed by a board of director and

Daniel Miller: In by law and admission more than 50% of our board or actual patients of our health center. And so, you know, we're in a somewhat unusual privilege of actually working for our patients.

Daniel Miller: All community health centers provide primary medical care dental care behavioral health care to everyone, regardless of insurance or ability to pay. We start with this fundamental understanding that healthcare is a right and is accessible to everyone.

Daniel Miller: Let me say that that our own health center was founded in 1975 by our four founding mothers for African American women in the city of Peekskill

Daniel Miller: Who recognize that there was nowhere in that community for them or their families to access competent or dignified healthcare and so they did what they were told they couldn't do which was make it happen.

Daniel Miller: We are now you know 50 odd years later 43 practices serving 200,000 people in rural and urban environments and with a particular focus on migrant and seasonal farm workers.

Daniel Miller: Let me just say briefly, I also serve on the board of the National Association of community health centers community health centers in this country serve 30 million people, one in 12 Americans get their health care in a community health center.

Daniel Miller: Of the about two and a half to 3 million agricultural workers we serve about a million of them.

Daniel Miller: And enclosing about ethics. Here I let's just say that we cannot talk about rural health without talking about poverty and about racism and I know we will get to that and I'm looking forward to it. Thank you.

RuebenWarren: Thank you so much. You, you hit the money on. Right on the money. So thank you will open up the really powerful conversations as we proceed. I'm Maria

RuebenWarren: Your context and the context so public of ethics.

Maria Poepsel: Are good afternoon, everyone, and thank you for having me on this panel. Um, I go by Sally for short and Lance capsule.

Maria Poepsel: I have been in healthcare for 40 to 4647 years and in spanning clinical research and my background is primarily critical care.

Maria Poepsel: And in the last 27 years been practicing as a nurse anesthetist specializing in anesthesiology and providing services to critical access hospitals in Missouri.

Maria Poepsel: As well as surgery centers and tertiary centers, primarily, I'm doing, you know, obvious based surgery centers and covering for critical access hospitals. My philosophy is that as a professional life. My ethics has always been to

Maria Poepsel: A gear my efforts to be the best person possible in my work life and in

Maria Poepsel: Rural critical access hospitals. I'm always confronted with many making ethical decisions on a daily basis, simply because we have a power over a patient's well being, which creates a mandatory need for me to be

Maria Poepsel: Ethical and to practice Integrity, so I practice within that culture of ethics and integrity in all of my aspects of professional life, including. Personal life

Maria Poepsel: Um, my experience in the last 27 years in critical access hospital are the challenges that I've confronted with

Maria Poepsel: In making decisions, life and death decisions whether we should do a certain procedure, whether we should not do any of certain procedure and do we have the resources.

Maria Poepsel: For this patient to be able to do that particular service or the question also is if in fact this patients are the benefits outweigh the risk for this patient to have to undergo this procedure. So that's where I'm coming from.

Maria Poepsel: Thank you.

RuebenWarren: Fantastic, we're really getting down to peeling the onion and get down to some really critical questions I'm

RuebenWarren: Michael

Michal Rhymer-Browne: Good afternoon. It's Macau.

Michal Rhymer-Browne: Macau brown

Michal Rhymer-Browne: No problem. Common mistake I've been Michael for all my life. My other name. Yes, but it is a pleasure for me to be here today.

Michal Rhymer-Browne: Representing the beautiful US Virgin Islands. We are proud people here in the territory and we are US citizens in the United States umbrella territories, and I believe that

Michal Rhymer-Browne: My position here today is to really highlights the need for us as US territories to have equitable access to public health.

Michal Rhymer-Browne: Especially in our areas in our territories which are so far removed from the US mainland my background has been social services for about 28 years now, in the last, I would say 10 years I became involved, specifically in the area of Medicaid management and here is where the ethical

Michal Rhymer-Browne: experiences have been many, I was reminded so much about the ethical decisions that we have to make and very coincidentally this morning about 630 I heard my WhatsApp text ring.

Michal Rhymer-Browne: And it was a mother who asked if I remembered her and she said seven years ago, you helped to save my baby's life. And I remembered that this child who they told us with

Michal Rhymer-Browne: And not to send him to Florida for assistance because it really he would die in a matter of a couple days.

Michal Rhymer-Browne: Well, I believe, because of my training because of my spiritual background. I'm also a pastor that whether his life there's hope. And with our Medicaid funding limited as it was, and still is, at the time.

Michal Rhymer-Browne: We were able to send this young this young infant to the state of Florida and today I was able to see the seven year old young man who at that point they did not even think he would survive seven days.

Michal Rhymer-Browne: I chair that account because I believe it's ethical decisions like those that come up for an agency like ours as we administer Medicaid with some of the lowest funding that we have in the United States there continues to be

Michal Rhymer-Browne: In equitable allocations to the territory in the area of Medicaid, which is so critical for the health care access for a low income our elderly our children are disabled.

Michal Rhymer-Browne: And so it is a passion of mine professionally and personally to be the voice for those who are voiceless and to stand up for those who may not be able to stand up for themselves.

Michal Rhymer-Browne: In the last year I had the opportunity to go to the US House of Representatives twice to represent the US Virgin Islands and the territories.

Michal Rhymer-Browne: To speak up about the inequity of the treatment of territories when it comes to Medicaid and Public Health Access. So I really believe and I'm very

Michal Rhymer-Browne: Proud to be able to sit in this seat and to be able to not only administer the Medicaid program, but look at that program as a way that we can help our citizens and we are citizens of the United States. Unfortunately, many of the practices and the

Michal Rhymer-Browne: Federal funding is not equitable and so my time here today. I just want to be able to share some of the challenges that we face here in the United States territory, but it's not all bleak. We are pushing forward.

Michal Rhymer-Browne: With using the funding that we have been allocated and I believe we if we get the support of our federal government will be able to do some really great things in the next five years.

RuebenWarren: Thank thank you for sharing that.

RuebenWarren: Really ethical decision making and how this had a very positive outcome as you saw that young child come back to tell you. Hello. Thank you so very much. And just to carry

RuebenWarren: Yes, of what you do, what as public health ethics and how's it influenced IT YOU WHAT DID YOU DO

Andrew Zekeri: I'm Eros. The show August

Andrew Zekeri: I don't Pennsylvania Penn State.

Andrew Zekeri: And I have been studying the rap like belt for the past 2526 years

Andrew Zekeri: I studied poverty rural poverty among black people in this area. And as we all know, Black Belt counties are one of the forgotten or left

Andrew Zekeri: Forgotten counties in America.

Andrew Zekeri: When I studied poverty in this area, what guided me or what is always on my mind is social justice.

Andrew Zekeri: Participation

Andrew Zekeri: Effectiveness.

Andrew Zekeri: affordability and accessibility to do people have access

Andrew Zekeri: Can they participate in things are mainly I like meaningful.

Andrew Zekeri: You know, equity, has to do with everyone's you have a stake in the things that make life meaningful. The people in black belt counties don't have the resources.

Andrew Zekeri: They don't have

Andrew Zekeri: The manpower, they don't have the

Andrew Zekeri: For example, they don't have hospitals.

Andrew Zekeri: They travel up to 70 miles for our healthcare.

Andrew Zekeri: Okay. All these things are very, very important.

Andrew Zekeri: Consequences of things that affect their life that they have no control over, and yet they are part of Americans or the Americans or the Americans, but yet.

Andrew Zekeri: You have problem.

RuebenWarren: unsecured to just touch the screen down below so we can see your face.

RuebenWarren: There we go.

Andrew Zekeri: Can you see me now.

RuebenWarren: Yes, perfectly

Andrew Zekeri: Yeah. Yes. So I started is communities and societies and the family that I raised in these societies that are very poor.

Andrew Zekeri: They have no say in what is happening to their communities have no seen what is happening to the allies.

Andrew Zekeri: And you all know as you deal with ethics and

Andrew Zekeri: Public health you deal with social justice.

Andrew Zekeri: Participation

Andrew Zekeri: Okay effectiveness of what is happening in these places.

Andrew Zekeri: And try

Andrew Zekeri: To look at that and bring the applied to the public perspective. But then in national conferences. I've been to Washington DC.

Andrew Zekeri: To talk on behalf of black belt people and the county as a whole, and there are black belt South

Andrew Zekeri: In addition to study in Alabama. I've looked at some black belt counties in Georgia to Dr. Warren and I have looked at that together some black belt counties in Georgia.

Andrew Zekeri: And what I found that is that they are similar. There's no distinction when I look at their rural schools in Georgia in black belt counties. They have the same problem that the ones in Alabama have so

Andrew Zekeri: Ethic framework public health ethics. I use that to Korea. What is happening in these communities.

RuebenWarren: You all can see we have a very powerful panel and I'm not going to waste time by going through the order. I'll raise a question and have the pounders respond as they see fit.

RuebenWarren: Or you've heard about some some challenges that dilemma. The Urban rule the ethnic, racial geography differences.

RuebenWarren: Give us some suggestions on how do we deal with them. What do we do besides define the problem. What did we do to resolve it. So, any other panelists that you'd feel free to chime in.

Daryl Melvin: Dr. Warren to sterile Melvin. I just want to share a little bit information with the participants on this here in this form. And one of the things that we do and Native communities that has been really a

Daryl Melvin: Game changer. It's been information that's just come out in the last few years, but

Daryl Melvin: First Nations Development Institute has conducted a study which is called reclaiming naked truth and it's a national nationwide study that looked at

Daryl Melvin: Surveys interviews and analyzing social media posts and what it did is it help uncover some of the deep rooted biases and toxic assumptions that

Daryl Melvin: People held about American Indians and really, these are the same individuals that

Daryl Melvin: Are leaders and say our court systems and our legal systems, our law enforcement government, etc. And some of the findings were that

Daryl Melvin: Most Americans learn about American, Native American or American Indian history from elementary school and high school or maybe through pop culture.

Daryl Melvin: movies, TV, etc. And what the findings showed was that only about a third of Americans believe that Native Americans face discrimination.

Daryl Melvin: And what this really shows is that discrimination for our population is underreported and of course that leads to the biases that we're talking about today and the biases can be introduced them into the policies for the institutions and the programs and health care.

Daryl Melvin: That

Daryl Melvin: That we're talking about additionally 40% of Americans believe that Native Americans actually don't exist in our community today.

Daryl Melvin: And part of that is because the Native American narrative is actually dominated by narratives of non natives.

Daryl Melvin: Individuals talking about our communities. And so really this issue of invisibility is destructive to the Native community population and youth and it underpins some of the in

Daryl Melvin: Non access to the health care services. It's a driver for the need to really have conversations, which we are in currently in America about race. And so in visibility for Native American really is the modern form of racism.

RuebenWarren: ABSOLUTELY. ABSOLUTELY, OTHER PANELISTS sure he's opening it up.

Andrew Zekeri: I think, I think we need to give them the resources.

Andrew Zekeri: Okay, yeah.

Andrew Zekeri: Public

Andrew Zekeri: Coming out in public and saying that Black Lives Matters is a good idea but Black Lives Matters, but they needed the media resources they need the power

Andrew Zekeri: We need to put them in control of their own communities. We have to make them effective they are the one to change their communities. Give them the resources, give them the power put them in the driver's seat. Let them drive the car, but the guy right or wrong, without the petrol

RuebenWarren: Absolutely. Okay, another timeless, we didn't. We get warm. Come on.

Maria Poepsel: Yeah.

Michal Rhymer-Browne: I was about to say that for the US Virgin Islands and other territories, I really agree with Mr. Melvin we we need to bring knowledge to those who may not be very knowledgeable about who we are.

Michal Rhymer-Browne: Here in the territory. Yes, we are US citizens. Yes, we have strong cultural and strong sense of community.

Michal Rhymer-Browne: But I believe that it's important for us to raise our voices and that's why I took it so seriously to go to Washington DC last year.

Michal Rhymer-Browne: To raise the voices and let them know that the territories. We do matter. We have serious health issues and as you as citizens, we should not be neglected. I remember one of the

Michal Rhymer-Browne: One of the representatives said, and in your country. And I said, Yes, my country.

RuebenWarren: Of the United States of

Michal Rhymer-Browne: America.

Michal Rhymer-Browne: And it was so important.

Michal Rhymer-Browne: And he

Michal Rhymer-Browne: knew he wanted to fall down behind the desk when he said that

Michal Rhymer-Browne: But I said yes.

Michal Rhymer-Browne: My country of the United States of America who I'm so proud to be an American

Michal Rhymer-Browne: Needs to be aware of the plight of the territories. We're not asking for a handout. We are asking to be treated like any other US citizen that is in on the mainland. If I go to the United States.

Michal Rhymer-Browne: I am a US citizen, I'm able to get the health care that I need here if I live in the territory, I cannot get the services that I need. I am not able to access

Michal Rhymer-Browne: Much needed Medicaid or sometimes Medicare benefits. I don't have SSI. All of these are benefits and opportunities that are available on the US mainland to citizens and should be available to our US citizens in our US territory. So my advice is, we must raise our voices, we cannot be silent.

RuebenWarren: Is a rule problem is it's it's a problem for the Virgin Islands. Some panelists is this. Who is this she all she, along with this challenge.

Scott Lockard: I don't think so at all. I'm in Rule Appalachia, and we are a area that has often had our resources extracted and the people forgotten about.

Scott Lockard: And we see that frequently you. So we spend a lot of time educating policymakers about what our needs are.

Scott Lockard: Spend a lot of time trying to work and bring together our community partners in public health departments were really convenient years now.

Scott Lockard: And we bring together our FTC partners, our health care partners, our government partners and we remind them of the ethical issues that we deal with, with health disparities and inequities in our communities.

Scott Lockard: And we also to sometimes have to remind our residents themselves who now have developed a very fatalistic outlook because of living in poverty for so long.

Scott Lockard: One of the groups we partner with is sore shaping our Appalachian region. And they did a public relations campaign targeted at the people of Appalachia.

Scott Lockard: Which said Appalachia, there is a future.

Scott Lockard: So really trying to educate the people themselves and to improve their mental health and well being, that they should feel good about themselves and the area in which they're from. So it is a constant never ending struggle.

Scott Lockard: For us to make those empower aware of what we're facing every day and giving them solutions as to how they can support us to improve the situations we face.

RuebenWarren: And touch. Thank you heard the word SQL sees and and optimal. Let's talk about rule fairly find a community health centers, what, what has been your experience and

Daniel Miller: Thank you, Dr. Warren, you know. So I think we're, you know, as you've been saying we're getting into, into the meat of this now and

Daniel Miller: You know, as a clinician and as providers of healthcare. One of the things I think we all recognize is the importance and the power of properly understanding and naming what it is we're trying to improve and help and work on

Daniel Miller: And and i think words here and definitions are really important in in our work and and all of our work and so

Daniel Miller: For a minute. I'd like to come back to this concept of the social determinants of health that we've been talking about.

Daniel Miller: And I think we all recognize that probably about roughly 50% of the factors that affect our health are not just the health care, we

Daniel Miller: We provide but really kind of what's in our zip code and whether that's rural or urban and these are issues of education and housing and employment income.

Daniel Miller: And I think when we go a little bit deeper into that concept of these social determinants and when we do it looking, you know, with an understanding of institutional and systemic racism.

Daniel Miller: We recognize that those social determinants of health are the same systems that we found that mediate the effects of institutional and systemic racism.

Daniel Miller: And and as we look even closer at them at banking and housing and mortgage systems and education and healthcare. You know, when we look at our history, which isn't so old.

Daniel Miller: We recognize that when these systems and institutions were created. They were created with the intent and purpose to be in equitable

Daniel Miller: And and that's that's they were meant to be an equitable and so you know you challenge list of what do we do

Daniel Miller: I think this is crucial because when we, you know, as all good people are going to work hard within the systems.

Daniel Miller: Are outcomes are still in equitable and fair and equitable. I think because this is how these systems were designed and they were designed really well.

Daniel Miller: And and so just to close this piece I think naming is important.

Daniel Miller: And coming back to the social determinants of health, I've really come to believe this term itself is a euphemism. It's a euphemism for poverty and it's a euphemism for racism.

Daniel Miller: And and it makes us realize that when we do what we do in our world, when we

Daniel Miller: Treat the illnesses, we treat when we see the people we see and the interventions we make are enormously powerful, but at the end of those days what our patients are actually dying of is racism and poverty and once we understand that, then I think we can get to work.

Daniel Miller: Thank

RuebenWarren: powerful statement. I heard Martin talk about discrimination and I heard you talk about racism.

RuebenWarren: Are they the same or are they different I do just impact upon certain populations, whatever the powerful panelists, try to unpack that for us.

Daniel Miller: How much time do you have

RuebenWarren: A

RuebenWarren: Good job, you get to go too far.

RuebenWarren: But I know it's hot. So somehow, Dallas. Let's go.

RuebenWarren: This is the time

Daryl Melvin: That I'd like to comment on the

Daryl Melvin: Questions about this institutional systems that we currently have, and

Daryl Melvin: In Indian country, you're going to see things about the institutional inequities and, you know,

Daryl Melvin: What we see for our communities of Indian Health Service and the Bureau of Indian Affairs actually are the education. Traditionally, the

Daryl Melvin: Education and the health systems for Native Americans. And I think it was previously said is that they're perfectly designed for the results that we get, and their national and focus. And so with over 600 tribes across America.

Daryl Melvin: Both federally recognized and state recognized the solutions really for creating that

Daryl Melvin: education and health care systems are local their place base. So within I just as an example to have transformation occur.

Daryl Melvin: Is to ask the question about what their mission is and what it could change to to focus on the place based solution or mandating that say local tribal solutions are inherent in the fabric of local health care systems so

Daryl Melvin: The other way, if you look at the pathways to addressing some of the inequities would be as an example for public health surveillance. When you talk about Kobe is why our native people misclassified or listed in as other category, you know, and

Daryl Melvin: Creating systems should be the response to more accurate reporting, you know, to create opportunities that will allow for addressing these

Daryl Melvin: Systems that create the inequity, you know, and really question systems that are self reinforcing so that we can include different criteria that can help address those structural and institutional inequities that we see.

RuebenWarren: Now I'm challenged to because I'm, what I'm hearing sounds urban and rule or there's some uniqueness about rule that that impact in greater ways than they do in other areas. And maybe that i i am i grew up in urban cities. So somebody share their that their perspective about that.

Andrew Zekeri: Yeah. Difference is a big differences in rural areas.

Andrew Zekeri: You know, the population as scattered all over the area. Yes, past so that K bringing services.

Andrew Zekeri: To this area becomes difficult

Andrew Zekeri: And the services available. They have to travel far and wide.

Andrew Zekeri: To have access to the services that is so great a boredom, or our families, some of them don't have the transportation

Andrew Zekeri: They don't have the financial resources. We don't have the human resources, compared to urban areas.

Andrew Zekeri: So there's a big distinction between rural and urban when it comes to hospital services. Another economic services that are available to make life million for

RuebenWarren: OTHER PANELISTS

Ashley Andujar: And this is Ashley.

Ashley Andujar: To that to that, for example, work of ego. You know, it's an island, and I'm sure USB, I can relate to what I'm about to say but

Ashley Andujar: For example, during Hurricane Maria, where you have, you know, not only metropolitan areas are heavily affected.

Ashley Andujar: In the rural communities is more so, you know, the situation was more so dire in terms of access to just basic things like food and water, like, um, you know, electricity and healthcare access

Ashley Andujar: You know, going back to the idea of racism, I think can call any colonialism, you know, as a whole for us in the territory.

Ashley Andujar: Is is a big factor that plays into you know why we're under funded or why you know our rates in chronic diseases are much higher. So yeah, I think for

Ashley Andujar: Like if you compare the territories with the states and the rural areas in the States. It's a little bit more so dire. And you know the poverty rates are more extreme. So I think, at least from the perspective of the islands. That's something that also need to take into consideration. 233 00:36:30,520 --> 00:36:29,840 Ashley Andujar: And

Michal Rhymer-Browne: I

Maria Poepsel: Would say that

Maria Poepsel: Okay.

Michal Rhymer-Browne: I was gonna say I do agree Ashley being here and and from the territories. I think back historically many territories. We were taken into the umbrella of the United States because of military

Michal Rhymer-Browne: Distinctions and where we were located geographically and I believe we were adopted into the

Michal Rhymer-Browne: Family of the United States. However, I do not believe there was at the time. Any anticipation that we would get equal rights and so we worry

Michal Rhymer-Browne: That up with certain laws, rules and regulations that have marginalized us as US citizens here in the US territories and so I believe in the Public Health Act on our aspect. This is glaringly so

Michal Rhymer-Browne: As a matter of fact, our delegates to Congress delegate plaskitt has introduced and she introduced this in February 25 2019

Michal Rhymer-Browne: An act calling for equity in public health access all the territories health equity app. And that has yet to move, but

Michal Rhymer-Browne: Eventually, that's what we as the territories need to gain equity, we will have to challenge the preconceptions. We will have to help to

Michal Rhymer-Browne: Inform that know we our country is the United States. So we can remove these barriers that have been been put up for us and that have marginalized us and given us less than stellar services and resources for our territories.

RuebenWarren: Please keep reminding

Michal Rhymer-Browne: Us.

RuebenWarren: Like a some seem to forget maybe unintentionally, but they seem to forget. 248 00:38:25,160 --> 00:38:24,760 RuebenWarren: Maria

Maria Poepsel: You were ready to say something. Yeah, I was gonna say that many of these challenges that you find in rural areas are more magnified compared to the urban

Maria Poepsel: The dimension of transportation lack of access, lack of health education educational on health issues, inadequate health coverage. That's nobody has mentioned yet.

Maria Poepsel: Many of these challenges our mods are magnified in rural areas and when we go back to the solutions. I might say that I've had an opportunity to work in the last four years.

Maria Poepsel: With the Secretary of Health and Human Services, as a member of the National Advisory Committee for Rural Health and Human Services.

Maria Poepsel: And that's exactly what we looked at from a policy standpoint, we look at all the social determinants of health as the main framework. When we look at the rural issues and challenges, whether it's the maternal or obstetric care. There are so many

Maria Poepsel: obstetric deserts. Now, there's so many healthcare deserts. Now, because many of the house rural hospitals have closed. We have also addressed.

Maria Poepsel: opioid abuse. We have also addressed adverse child childhood experiences the ACE experiences. Many, many, many of these issues are very complex and can be resolved or can be addressed to a national policy. And so that's what we did.

Maria Poepsel: With the National Advisory Committee for rural health in the last four years.

Maria Poepsel: And many of these recommendations have been implemented. Not all of it because many of them many of them will be our had to be within the purview of the Secretary of Health and Human Services, but I would say maybe 50 60% of them have been implemented.

RuebenWarren: We were intentional about trying to get some geographical diversity and rule panel, are we finding anything different or unique

RuebenWarren: About these rural areas or there's some conclusion that we can draw about rural areas, Northern rural areas, Southern rural areas, very an island Puerto Rico are some common lessons, a message that we should be should carry

Maria Poepsel: Yeah, come on.

RuebenWarren: Let's hear

Andrew Zekeri: It raise composition of these rural areas, makes a big difference.

RuebenWarren: Okay, so

Daryl Melvin: I'd like to just comment that

Daryl Melvin: You know, when he started talking about how to address some of these issues and the ideas or concerns that are raised.

Daryl Melvin: Some of it, but really looking at the systems that we currently have in place and those systems that are important into the rural communities. So for example, when we're living in a rural community and we have an institution, not unlike what you know we represent here today.

Daryl Melvin: Asking the question of, if we are going to put positions, whether they are board positions of professional positions.

Daryl Melvin: As part of changing that system. Can we ask questions are, are there a central experiences, should that should be required.

Daryl Melvin: That challenge requirements, say, for having certain degrees that might exclude participation.

Daryl Melvin: For for rural community. So having that representation is important. And as I mentioned, as a former CEO and healthcare and critical access hospitals. I know the question came up with.

Daryl Melvin: Medical students and residents ease and how can we get residents to really look at

Daryl Melvin: Rural communities as opposed to some of the other opportunities that have an urban settings to come out and what are some of those experiences and working with Indian communities.

Daryl Melvin: The values, the culture, the language and the history is important. And if you can get a medical student to come to a rural community and experience what that's like.

Daryl Melvin: The likelihood and the probability that they'll practice medicine in rural communities as much greater than if they take a residency in another location. So those are some of the solutions that I think can be looked at, to change some of the systems that we currently have.

Scott Lockard: I want to go back to, to the the logistics here and was was brought up earlier. I think it's a commonality among a lot of our rural areas.

Scott Lockard: That we have basic infrastructure challenges here and they the Calvin 19 pandemic, as we've shifted a lot to virtual meetings Tele health, things of that nature.

Scott Lockard: Our rural communities are the ones that have the least capacity to do these things because of poor bandwidth for Internet in my area, we still have three g's sales service.

Scott Lockard: And because of these beautiful mountains in Appalachia. We have great

Scott Lockard: Areas with no cell service.

Scott Lockard: So we've seen a huge push to upgrade services as schools have gone to a virtual format. And I think right now we have a tremendous opportunity.

Scott Lockard: You know, I have a mentor who always said never let a big crisis, go to waste capitalize upon it and and the coven 19 pandemic has shown us and really

Scott Lockard: brought to the forefront, some of these challenges we face.

Scott Lockard: And we need to utilize any funding, we can access right now to build our infrastructure, not just to respond to this coronavirus pandemic.

Scott Lockard: But, but to really position us better for whatever else comes down the way to build up our, our IT infrastructure in our schools.

Scott Lockard: We're lot of areas here in Eastern Kentucky. They're actually putting internet in

Scott Lockard: Children's and residences for homes and so there's just lots of opportunities and we have to be prepared to capitalize work together to make sure that we can take advantage of the opportunities were given now to use that to benefit our populations.

Daniel Miller: Folks, it appears to me that maybe we lost. Dr. Warren's can

Craig Wilkins: Warn are you back on Dr. Warren

Craig Wilkins: Okay.

Craig Wilkins: Well, hopefully. Hopefully he will be able to come back on in a few minutes on what while we're waiting him on. We've received on several questions very good questions that I'd like to go ahead and and and ask the panel.

Craig Wilkins: One of the questions we receive and again this is open to any one of you who would like to respond. Is that one of the questions was, we appear to be kind of focusing on on health equity.

Craig Wilkins: And could someone talk about addressing the parallels between health equity and ethics, looking at it. Are they are they one in the same. If not, are they similar and what what are the what are the differences

Daniel Miller: Craig me if I might say,

Daryl Melvin: Maybe I could respond to that. Just in talking about, for example, the pandemic and Kobe.

Daryl Melvin: And talking more about not just the health equities, but the inequities and how it relates to the ethics. So I was a provided a tour of time as the public health official for the Hopi tribe my tribe and Hopi and Navajo were severely affected by

Daryl Melvin: We had a higher new incident rate than the state of Arizona and the nation, a month or two back and have recently been able to get it under control, but

Daryl Melvin: Inexperienced that for native and communities. We experienced a huge loss of our elders, you know, our cultural thought leaders language holders matriarch and patriarch for the communities.

Daryl Melvin: And additionally, the isolation of elders and our families and communities had a significant toll.

Daryl Melvin: And you look at our fragile economies and the loss of income exasperate exacerbates the hardships that you have in these food desert areas of food deserts and so when you talk about the inequities and ethical dilemmas. How do you respond to can whole communities that have these

Daryl Melvin: lack of resources or awareness. When we talk about in visibility, the awareness to be able to address even address questions on how do you solve these inequities. If you can't address that that ethical dilemmas that we have that underpin the issues that we see.

Craig Wilkins: Thank you. During

Daniel Miller: That if I might, Craig. You know, I think, you know, as you're saying into your question into the the questioners question.

Daniel Miller: You know, it seems to me, when we talk about inequities. Again, it's, it's a word. We've gotten used to that, you know, we're really talking about people dying more than others. People being hurt more than others.

Daniel Miller: And there's a fundamental ethical question here for for us as as a society and for us and what we do, which is how many of those people dying. How many family members and

Daniel Miller: You know, etc. Is is acceptable to us. I think we often in this world, end up managing inequity.

Daniel Miller: And it's and it's fundamentally I think unethical and unacceptable for us to look at this to say, you know, these, these inequities. You know, on a basic level are somehow okay they represent a deeply

Daniel Miller: Unethical aspect of our culture that that needs that needs to be addressed.

Daniel Miller: So that they're not just numbers, obviously, you know, we're talking about people in people's lives.

Daniel Miller: Thanks.

Craig Wilkins: Thank you, darling. Thank you, Dr. Miller. Okay. Another question we received was we spent, we spent annually around three to $3 trillion on health care services which could have been prevented.

Craig Wilkins: How do you address preventive services in rural invisible areas where early access is a challenge. And again, this is questions open to any panel member who like to respond.

Scott Lockard: Getting funding for prevention is always one of the biggest challenges I've done a lot of work and advocacy with our state legislature with our federal legislature of federal policy makers.

Scott Lockard: And it's one of those things when prevention works at its finest. You don't know it's there, the majority of people do not and whatever prevention is not working. Just like right now.

Scott Lockard: We have a pandemic and people are like, Well, why didn't you do something about this. And now we're trying to make

Scott Lockard: Very political something as basic is wearing a mask is became coming to political statement in our country.

Scott Lockard: So again, I think we go back to really haven't to educate and we're constantly

Scott Lockard: Advocating for resources for prevention, first we have to educate with policymakers, that there's a difference between preventive health and health care. They all try to lump us together and and focusing on prevention.

Scott Lockard: It's just, it's such a challenge because so many people just

Scott Lockard: Haven't struggled to see that and they think, because we're putting money into health care that we've taken care of all the preventive health needs. So it's a constant ongoing battle where we're educating we're trying to inform policymakers and then it gets back to that ethical

Scott Lockard: discussion we're having here is what is the acceptable level of death. I had a policymaker when I was doing testimony, one day.

Scott Lockard: Just point blank said to me, Why should my constituents in my urban area be worried that people in your rural area that teen years sooner than they do and have a 10 year shorter life expectancy

Scott Lockard: And so it's just like, Okay, well you know there's basic

Scott Lockard: Ethics involved here and we should all. Some of us take for granted. We should all have those concerns and and care about our fellow citizens and and non citizens and just fellow human beings as such, but it's a constant battle to educate all the time about that.

I'm back.

Maria Poepsel: I'm back.

RuebenWarren: Okay.

RuebenWarren: I see like we talked about rural

RuebenWarren: Rural America. I feel like I'm in rural America.

Craig Wilkins: Yeah.

RuebenWarren: Miss some powerful conversation. But where are we

Craig Wilkins: Not one on since you are

Maria Poepsel: Wisconsin.

Craig Wilkins: We started with killing the questions that we had been that we had received

Craig Wilkins: And great. Yeah. And if the sea, looking at time, we can continue with those questions, or did you want to ask another

Craig Wilkins: question for the panel from, you know,

Craig Wilkins: That you are going to that you were going to bring up

RuebenWarren: I guess what, what, what we want to leave some some time for questions that if there is a closing thought from the panelists. Let's hear that and then we can continue with the question from the others on the on the audience.

Craig Wilkins: OK.

RuebenWarren: OK.

RuebenWarren: To start with our panelists as they just what what are your concluding thoughts that we can go forth because I definitely do this into the taste. I can pick up without Miss but give me your thoughts.

RuebenWarren: In terms of what's the take home message you want the audience to hear from your from this panel.

Michal Rhymer-Browne: I believe that it's very important for us to realize that public health and access to public health and having it be so on equally distributed, especially in light of our rural and our

Michal Rhymer-Browne: Our territories. The Commonwealth of Puerto Rico is really creating a lot of ethical dilemmas we have to on a regular basis, decide on which resources to place where

Michal Rhymer-Browne: And these bring us into some very large ethical decisions and I know here in the territory. The prevention aspect is a is a really big part of what we believe we need to do.

Michal Rhymer-Browne: The form of our society that if we invest in things like dental health and prevention for children that we don't have to invest in 25,000 50,000 in serious surgeries and dental surgeries.

Michal Rhymer-Browne: If we promote mental health and good mental health and prevention in that area that we don't have to spend the excessive dollars sending some of our people out into institutions outside

Michal Rhymer-Browne: Of the territory to the mainland. So I believe that if we as a people, United States citizens really realize that all people deserve to have

Michal Rhymer-Browne: Health care all people deserve to be healthy and have a good sense of well being, that we will invest what it takes to ensure that all of our communities are treated equally.

Michal Rhymer-Browne: And I really just appreciate the opportunity to share some of these thoughts today on behalf of the US Virgin Islands.

RuebenWarren: Let me push the envelope, because what I'm, what I'm hearing sounds like classical public health and how, how are you distinguish it is you are from public of ethics.

RuebenWarren: I've been in public health for too long to even recount but that sound in the traditional public health, I was at public of ethics different if it is it is it may be a also saw the public out the public that

RuebenWarren: I'd want them to distinguish it from previous sessions. People were asking, well where's the pub public of ethics in this conversation because it sounds like public health and maybe there's no difference.

RuebenWarren: Endless

Scott Lockard: Ethics should got our public health practice and if we are going to be

Scott Lockard: True public health practitioners are there is always an ethical consideration and it is incumbent upon us, as practitioners and working with agencies.

Scott Lockard: There's a question about cross jurisdictional sharing

Scott Lockard: Resources are so scarce. Now is the time for competing with each other is over.

Scott Lockard: If we are truly practicing ethically, we should be working together, we should be collaborating, we should be partnering if my F2 HC partner can provide a clinical service.

Scott Lockard: Better than I can. I need to get out of the way and let him do it. And let me focus on the communicable disease, the epidemiology and convening partners.

Scott Lockard: Our academic partners needs. The key question needs to be fundamental to every piece of research is that is done is, how can this translate to improving public health practice so it can improve the lives of the people we serve.

Scott Lockard: You know, I would say, ethically, we need to do research that improve the lives of people. I'm a big practice advocate. So to me, you cannot practice public health with our practice in it ethically and do it the way it should be done.

RuebenWarren: Fantastic night. Okay, now the panelists and your closing remarks, if you can make that distinction as a last colleague just been

Daryl Melvin: I'd like to comment that and just closing that

Daryl Melvin: Some of the ethical dilemma that I've been trying to, to, to bring to the forefront about the issues of invisibility and in our case my case it's about Native communities, but really it's about rural communities as well.

Daryl Melvin: Rural communities, not being represented. And so for me, part of it. And you talked about addressing the ethical dilemmas. It would be when you see a chart of

Daryl Melvin: Some state health department or national health data set and Native people are not included. I think you have to ask the Department organization, why it's that way and our communities and small populations lumped into some other category we shouldn't have to have that

Daryl Melvin: If there are panels and and I appreciate the fact I was invited to today's panel. But if a native perspective isn't included. I think it's incumbent to ask the question.

Daryl Melvin: And suggest that someone being included, and I would offer. If you don't know somebody, you can contact me or really any

Daryl Melvin: Nonprofit and get referrals. And then finally, if you sit on a board or advisory panel and there's not a native voice at the table and ask why, you know, there's this

Daryl Melvin: A tired and a false narrative out there that there isn't, there's a lack of talent and expertise in public health and medical fields. And that's just simply not the case. There are lots of Native American professionals carrying out the public health and the health care work every day.

Daryl Melvin: And so the health care community those folks out there listening. You know, I just want to leave with with the with something that I just read recently read

Daryl Melvin: From Wilma Mankiller from the Cherokee Nation. She and she said, you know, as we do our work here. The secret to our success is that we never ever give up. And I think that's the important message for addressing these

Daryl Melvin: ethical dilemmas that would that we face as public health officials, so thank you.

RuebenWarren: Fantastic I when I was working at CDC, I spent some time with the American Indian physicians Association and David. David veins. So I hear you. Were there other panelists concluding remarks. Yeah.

Ashley Andujar: I wanted to piggyback a little bit of what Darrell said I think representation is key to, you know, bringing minorities like us to the decision making table. I think that's one of the areas that

Ashley Andujar: A lot of times it's lacking. And it's why you know we don't see you know data being captured in terms of surveillance or

Ashley Andujar: Just, you know, the train of thought, you know, for people to think about the invisible community's needs to be at the table.

Ashley Andujar: And needs to be part of that wider conversation so that we can put, you know, solutions and have strategies in place to reach you know minorities to reach rural communities. I think it's all intertwined. And it's also

Ashley Andujar: Speaks to, you know, the need for, you know, universities and contingencies and health departments and local health departments to have, you know, a pipeline in place to bring those minorities and to build that capacity.

Ashley Andujar: You know, to increase just for presentation and public health. So I think that's my main takeaway is to, you know,

Ashley Andujar: Have have a pipeline and place, you know, universities that are out there listening on I think it's super important to bring minorities into public health so they can you know be the workforce of the future that can really shape shape up on these ethical issues so

RuebenWarren: Thank you. Thank you know the panelists.

Andrew Zekeri: Along with that, what you just said is we need to bring them in, by providing them telemarketing and in providing them. I mean, tell a

Andrew Zekeri: Little medicine telemedicine. They don't have internet access. So there's another resources that we need to give them. You have to have access to internet broadband services. A lot of these places are not why they are not connected to the mainstream America that is affecting them a lot.

RuebenWarren: Testing other panelists, we get some good take on this just a whole bag.

Maria Poepsel: I think that

Maria Poepsel: Public health and ethics are not mutually exclusive, because you'd have to have ethics as your foundational requirement to practice public health.

Maria Poepsel: Everybody has already mentioned that many factors such as economic infrastructure, cultural and social differences educational shortcoming, and the very lack of recognition by our legislators.

Maria Poepsel: Contribute to create this health care or public health disparities and that impedes our rural Americans to struggle to, you know,

Maria Poepsel: To lead a normal, healthy life. They have every right to lead a normal, healthy life. And if we can address all these multiple factors and we can help minimize those Public Health Disparities or inequities.

RuebenWarren: Thank you, other panelists.

Daniel Miller: Dr. Warren, if I might.

RuebenWarren: You know, use

Daniel Miller: Your asked us in a few different ways of

Daniel Miller: How ethics here applies to rural communities as opposed to urban and what our closing thoughts are and and and for me, a lot of this comes to kind of reframing our perspectives. Here we've talked about inequities and outcomes. And I think one place to start is

Daniel Miller: What do we do when we look at the graphs, you know, we all see the data of the discrepancies in

Daniel Miller: In life expectancy by race, by poverty by income, you know, we've seen them for years and. And the question I think becomes, what do we do with that and what's acceptable.

Daniel Miller: You know, if we if we took an analogy to the airline industry and looked at, you know, lives lost in crashes between one airline and another

Daniel Miller: If there was

Daniel Miller: A huge discrepancy. We wouldn't accept it, we would just say either. You can't fly or we got to fix it. Period somehow come to accept this.

Daniel Miller: So, you know, beginning with rural communities. I think there are differences in rural communities. We've talked about transportation. We've talked about access

Daniel Miller: I think there are times we need to just recognize that the ways we do things often don't work in rural communities. So we need to do them differently. And, you know, for us, that means

Daniel Miller: You know, recognizing that rather than expecting people to get transportation and come to our offices. We need to get a mobile van and go out to the farms and partner with the farmers and the farm workers and say, you know, we're coming to you because we know you can't get to us.

Daniel Miller: A colleague of mine, put it to me, of saying, perhaps we need to reframe that this is not about a hard to reach population, but maybe it's about how we're creating a hard to reach services.

Daniel Miller: We need to, you know, we need to switch our mindset for me. In closing, you know, I want to kind of come back to some concepts I think doctors to carry that you were bringing up

Daniel Miller: Which, to me, is to recognize that our patients and our communities that they're the experts of their lives, not us. And certainly if we're talking about communities of color, certainly not people who look like me.

Daniel Miller: So we need to ask and we need to listen.

Daniel Miller: In closing, you know, I've been struck for years by a statement from Ron Chisholm, who's one of the founders of the People's Institute for survival and beyond, who

Daniel Miller: Teach and organize an anti racism and Mr Chisholm for years has said we're not suffering from a lack of programs or a lack of services, we're suffering from a lack of power.

Daniel Miller: In, you know, a fundamental difference here of where interventions need to be made.

RuebenWarren: And said, thank you so much. Now we as every panelists had something to close on

Daniel Miller: Yeah.

RuebenWarren: Okay, well, we've been we've been fairly close with with a couple of thoughts. One is that I

RuebenWarren: Have been honored to listen, even when I was cut off to this panel. You all have been very powerful. I think we've seen some distinct rule.

RuebenWarren: Circumstances that ought to be recorded and shared on nationally and we intend to do that every year when we conclude this Public Health Forum. We have the proceedings published

RuebenWarren: In the Journal of healthcare science and the humanities. So we're going to reach out to you and hopefully we can get you to put your thoughts to paper and we can then publish it.

RuebenWarren: This has been a great, fantastic panel an experience has been a challenge, but it's been a great one. And I will turn the the session back over to Captain Wilkins, so we can close and a half hour break. Craig.

Craig Wilkins: Okay, thank you very much. Warren and I like to take my head off to this great panel.

Craig Wilkins: Thank you for your time today.

Craig Wilkins: And response to so many very deep.

Craig Wilkins: Thought questions that that was brought up by Dr. Warren. We appreciate your participation in today's forum. Thank you.

The Description of Public Health Ethics Forum 2020 Part 2