Dr. Keith Newby is the Medical Director for Health Equity at Sentara Healthcare. He defines the importance of healthy equity, the social determinants and offers solutions to health inequities
on behalf of the Sentara Heart Hospital and the VMS. I'd like to welcome dr keith Newby today to present grand rounds entitled Health equity, What does it mean and how do we make the most of the most impact. After graduating from Norfolk State University, then Eastern Virginia Medical School, keith went onto an internal medicine residency at Emory, followed by cardiology fellowship at Duke before returning to Hampton Roads. Ultimately established cardiology and arrhythmia consultants and then Fort Norfolk Medical group. Dr Newby has authored an impressive the number of articles on atrial and ventricular dysrhythmia as therapy and CinCO P. But even more impressive is Doctor Newby's extensive involvement in our community, working to build a better community for all of us, Keith created the James E. Newby Foundation in 2009 in honor of his late father. This foundation's mission is to improve the health care, financial stability and educational inequality for people living in under resourced communities in our area. Dr Newby is a member of the VMS board of Visitors. He serves as an insistent professor of medicine at the University of Virginia School of Medicine and he's also famous on the airwaves, having been a co host of health segments on public radio, including W. H. R. V. Another View co produced Hampton University Medical minute with Dr keith Newby and keith hosts the monthly podcast, crucial conversations with keith Newby. That address issues important Well to all of us, but targeting people of color uh and continuing his mission keith was named medical director for health Health equity uh by Sentara health systems last july and it is in this capacity that he joins us today. He thank you for joining us and we're looking forward to your talk. Thank you very much, Robin, I appreciate the wonderful introduction and good morning to everyone and we'll go ahead and get started. So I'm gonna try to warn you, I get along with this, I gotta put myself on a timer to make sure I stay on time. So I'm starting that now. So what we're gonna talk about today is health equity. What does it mean? And how do we make the most impact? So see this thing gonna let's now let me forward my slides here, hold up. Okay, run into a problem here, let me see. Never had this happen for his working earlier today because I have to do it this way. That's fine. So what we're gonna talk about today is definitions of health equity, its importance, social determinants of health, some examples of health inequities solutions or how do we address it? And then we'll conclude out. So let's talk first about what is the definition of health equity? Well, health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location or other social constructs have fair and just access opportunity and resources to achieve their highest potential of health. Unfortunately, we know that social and political determines of health negatively affect many communities their people and their ability to lead healthy lives. So let's talk about another term because you hear these terms all the time. But let's make sure we all understand what they mean. You hear the term health disparity. Well that is the difference that affects a person's ability to achieve their best health. And those examples of disparities include differences in race, gender, education, income, disability, geographic location and sexual orientation. So again, we're talking about differences. Now. You may have heard the term health equality versus health equity. So health equality means that everyone has the same opportunities such as the community center offering free or low cost checkups to everyone. Health equity means that people have opportunities based on their needs. So as an example that same health center we talked about a second ago charging people based on their ability to pay a person who cannot afford care may receive it for free while another person may pay for the same care. So in short health equality means everyone receive the same standard while health equity means everyone receives individualized care to bring them to the next level of health. So I want to use this slide to kind of give you a better sense of what I mean with that. If you look at this slide, the first slide talks about equality. So you look at those carts that these individuals are standing on. You see the first individuals tall is look at that fence is like just attaining good health. So you have the cards are the same size. So everybody has equal cart numbers of carts, but you can see there are disadvantages of the third person over the first person meaning there's a height difference really between all three. But you see they have the same number of cards. One each but one is taller, which means he has an advantage. That fence being your health shows that that person in the first position has a much better access to be able to see that game. That equity is when you raise the number of carts to the person with the most disadvantaged situation so that all three can see over that fence, then you look at liberation as you take away the fence, you take away the carts and everybody has free access to live work and play as they would like to. So the term health disparities do create health inequities. So I want to talk about social determinants of health and mention that in the earlier slide. So what are social determinants of health, but they are the conditions in which the environment in which people are born live, learn work, play and worship that affect a wide range of health. They're functioning, quality of life, outcomes risks and have a major impact on persons health well being and quality of life. So when we talk about social determinants of health, what do we mean? Well, we talked about safe housing, safe transportation, safe neighborhoods. Those that where racism may impact discrimination and violence where one neighborhood versus another racial group may have uh a aspect of racism they have to deal with versus others. Education. Do every does everyone have the same opportunity to have the same level of education? Job opportunities and income access to nutritious foods? Physical activity opportunities. Those who had to live in areas where there's polluted air and war to compared to other areas and language and literacy skills, does everyone have the same level of access? And you know, the answer is really no. So um social determinants of health contribute to the wide range of health disparities and inequities, for example, people who don't have access to grocery stores with healthy foods are less likely to have good nutrition. That raises their risk of health conditions like heart disease, diabetes and obesity and lowers their life expectancy relative to people who do have access to healthy foods. So just promoting these healthy choices won't eliminate these other health disparities. Instead, public health organizations and their partners in sectors such as education, transport and housing need to take action to improve the conditions in people's environment. So groups who do not help have health equity are those judicially disenfranchised and discriminate against through no fault of their own racial and ethnic minorities. People living in low income households, members of the L. G. B. T. Q. Community members of these communities are more likely likely to experience barriers to care and health such as violence, low income and poor living conditions. So what are some examples of steps to help achieve this? Health equity? Well, you have to first identify how health disparities in the community affects specific groups. You have to recognize that each person has their own racial and ethnic biases and learn how to recognize when a policy or environment may exclude sometimes unintentionally a personal group. We must show respect to people of all groups and make efforts to involve all groups in enacting change. This means that if someone is going to start a policy or program that addresses addresses health disparities, they should ask those individuals they are trying to reach. If the program will help them frequently evaluate how well policies aimed at health equity are working. It's one of the things I live by is that issue of you. If you're going to institute a change, you have to first develop what that change will be, institute that change. And then you have to have follow up to make sure that change Acts is working and you have to encourage people to contribute using their talents times and gifts. Example could be include tutoring students to help them obtain the high school diploma or health care professional volunteering their time to help at the clinic. Now I want to go into a case study of health equity and obesity and you'll see why I'm bringing this up as a relevant topic. So we look at the definition of obesity. It really is if your B. M. I. is 30 or greater. So that's just to have that definition in place. So it obesity represents a significant health risk in the U. S. And it's considered a health epidemic. Well, why is it so problematic? But first, let's talk about its prevalence in the United States in 2018. Obesity rates were approximately 42% nationwide, representing almost half the us population Fully 1.5 billion people worldwide are considered overweight or obese and it carries additional complications of significant emotional disorders as many individuals feel victimized by discriminatory practices. Second, obesity leads to increased morbidity due to development of chronic medical conditions such as hypertension, diabetes, heart disease, stroke, various forms of cancers, sleep disorders and severe arthritis, which have led to decreased life expectancy. 3rd is the financial burden on the healthcare system Because obesity rates in the us have more than tripled over the past three decades, there's been a continual increase in medical costs, both direct and indirect on a level of $147 billion 2008. So you can imagine 2,023 where those numbers will potentially be direct costs include money spent on labs, medications, increased hospitalizations, durable medical goods and both inpatient and outpatient procedures, indirect costs often related to disability workers compensation, absenteeism, additional sick leave and reduction in work productivity and recent estimates suggest that if obese state trends continue down the current path, Annual medical cost of tribunal could rise by an additional 48 66 billion per year. by 2030 fourth. Obesity does not affect all people equally. There's a growing disparity among specific populations, especially african american and latino groups. According to the CDC data in 2000 and 18, non hispanic blacks carry almost 50% age adjusted prevalence of obesity followed by Hispanics of 44% The non hispanic whites of 42% with asians being the lowest prevalence at 17%. So why does this disparity exist? Well, we know that types of unhealthy food consumed are equally as crucial in developing this health concern as the amount consumed. Why people eat in excess become obese is not always straightforward for some, especially in the african american latino populations, anxiety and stress remain an issue as many eating excess out of financial hardship, other reasons for weight gain or lack of exercise or the ability to do so, look at if you look at certain neighborhoods, how many of those neighborhoods have access to gyms or places they can go to exercise compared to to other neighborhoods, whether, you know, people in certain neighborhoods have greater access to unhealthy food choices based on where they live and finally the cost of food, which is a problem. So it's interesting and the reason I brought this up as a topic of interest is although obesity remains a medical, a major medical issue. Prevention has only received significant intention recently. Two major groups who seemed the most interested in keeping the obesity epidemic ongoing are the food industry and interestingly the US government. Well, why? Well the cost of per calorie of healthy foods far exceeds the cost of energy dense or other nutrient poor foods creating an access problem. Between 1985 and 2000 healthy foods like fruits, vegetables, dairy, fish products increased by more than twice the prices of sugar and sweets, fats and oils and carbonated beverages. The advantage to the food industry is by acquiring this nutrient poor food items inexpensively. They can prepare and sell to the consumer at higher prices, thereby maximizing profits to provide greater context. Fast food restaurants in the us earn $278 billion 2021. So let's talk about geography and access well and I'm sure I can some may be able to relate to this particular side. Low income neighborhoods with a large proportion of african american latino, residents have higher access to unhealthy foods such as fast food restaurants and convenience stores compared to white neighborhoods. So that would challenge everyone to ride through the city of Norfolk, ride through Chesapeake Virginia beach. Look at areas that have lower socioeconomic or higher incidence of african american or latino. Um, people that live there and look at the surrounding area look at the types of choices of restaurants and grocery stores that are there compared to other neighborhoods. And you'll see why this is an issue aggressive marketing strategies by companies who sell unhealthy food options are then used to target these predominantly black and brown communities, focusing on Children and adults. And studies have shown that lifestyle and eating habits impact obesity rates in Children. It is estimated that Children view over 5000 food advertisements per year with 95% of those advertising restaurants serving fast food, the sale of sugary sugared cereals, sugary drinks and other unhealthy foods and other studies have shown that the average preschool child sees greater than 1000 advertisements per year for fast food alone. These advertisements effectively guide Children's preferences and requests to parents for these types of unhealthy food choices. So those of you who are parents remember when your kids, you're, you're tired, you're trying to get home and your kids are whining about one Mcdonald's or one some other fast food joint. You're like fine, anything to keep you quiet and think about how many times you've actually done that and how this is impacting on their life as time goes on by no means, can we blame the food industry alone for fostering the problem of the obesity epidemic. For years now the US government has remained in the way of global progress on the issue of addressing obesity, focusing only on individual education and supporting and protecting food industry interests at the behest of high paying lobbyist groups to further illustrate their lack of commitment to the problem. In contrast to the amount of money spent by the food industry on advertising. Unhealthy foods targeting black and brown communities. In 2010 coca cola spent $758 million in U. S. Advertising. Mcdonald's 1.3 billion And Burger King. $392 million. Look at the Mcdonald's commercials and see who they put on those things. You'll be able to see what I'm talking about. They have a target and they've gone after that target. Look at what the federal government does. In contrast, 2011, the federal government's budget for the USDA My Plate plan, which is a program designed to teach food group and physical activity targets to be reached, was a mere $2,002,002 million per year. So you look at $1.3 billion Advertisement vs two million per year set on targeting good food group habits and physical activity habits. So you can see why there's a clear discrepancy. So let's talk about this health equity and obesity a little bit more. Until recently. The use of legislation to change the food environment was seen as a radical and unrealistic proposal In 1990 for an opinion editorial about the obesity epidemic hit the New York Times. This piece recommended changes in the food environment by decreasing children's exposure to food advertising and if needed, taxing unhealthy foods higher than nutrient dense or good foods for them to eat. The response at that time was negative and blistering, especially from the political right and from groups funded by the food industry and attempts to protect profits. So let's talk a little bit about what are the causes of of some of these health inequities. And as you can imagine, we have an issue of structural racism which we have to all agree that is present. Look at the tuskegee experiment, what happened then? George Floyd incidents of what's happened going on with that which has created this lack of trust issue and that lack of trust is key. And those of you who take care of patients know that trust is everything. If you're trying to get a patient to follow your lead and your instructions and that's really the center of my life trying to gain their trust in the patients I take care of so that they know that my role is to help them. But it's difficult when you look at different cultural groups and how you may be perceived no matter how well you may be trying to help. But if there's no trust involved, that there has not been achieved the ability for you to convey a plan of action that people are going to follow can be affected if that trust factor is not present. So I cannot emphasize that enough. So what are other things that create this? Health inequity, Well, lack of access, lack of opportunities and lack of engagement to take it one step further. Let's talk about those solutions that we need to discuss and that is what are the three keys to health equity? Well, essentially, those three things we talked about in the last slide, access opportunity and engagement and you will find that trust kind of rears its ugly head through all three of these aspects. So let's talk a little bit about access. Well access is being able to access the tools and resources people need to be healthy and successful, which is key. That means not only to health care and services but also to food, education, housing and decent jobs. Because if you don't have the money to pay for the the prescription drugs, you don't have money to pay for your services you receive. It's gonna be difficult for you to get the type of health care that you need. So all these impact. And that goes back to that slide earlier about social determinants of health. If you're if you're working at a place that doesn't pay you enough to take care of yourself and your family, how can you provide the necessary resources to have the kind of health care you need buying graining access within communities, we can reduce the gaps and disparities in terms of life expectancy, infant mortality, maternal health outcomes, finding disease prevalence, educational attainment and household incomes, access and opportunity, which is our next topic go hand in hand from a healthcare perspective, meeting the demands for practitioners and having providers who represent the communities they serve is extremely important. People oftentimes want to see folks that look like them in order to gain that trust factor. Now, it's not to say that people cannot overcome that, but you will find that you have a better potential for getting that trust factor addressed earlier and having individuals follow a guideline and a plan that's gonna help them live their best life if they see people that look like them and have the ability to convey that plan of action in a way that they understand and they feel that trust is there to move forward in a positive way? So, building that pipeline of young people of color to engage in health care careers is vital. So we must provide those opportunities for higher education training and better jobs outside of just health careers by itself. So the opportunity is gonna be key. Um, no, the engagement is the next thing we have to talk about. Um, neither access nor opportunity happens without a grassroots focus on engagement. Civic League's churches and local businesses must know our name and our voice. That's how we generate the buy in and the trust we need to deliver on the access strategies and opportunities we're working to build. So what are some other ways or how do we make health equity? A core strategy of of our organizations specifically? Well, you have to make health equity a leader driven priority that the developed structures and processes that support equity specific actions that have to occur that address social determinants of health. We must confront institutional racism within an organization and partner with community organizations to continue to build that trust and that's what we're doing with Sentara right now. So let's talk about some examples that promote health equity while providing health seminars and courses that are specific to the needs of certain ethnic communities and racial groups, providing low cost services to those living in a low income household using mobile health screenings to help those who may not have access to transportation. So mobile vehicles that can actually go into neighborhoods and to provide services that are needed is what needs to take place. Think about those who may work long hours and unable to really get the care because you know, most of our offices close at four or five o'clock. So if they don't get off till six or seven, you know, then how can they get the access they need? We're offering evening or late night health appointments is one factor that could be helpful providing better education testing and treatment access to communities particularly impacted by certain conditions or diseases. So this issue of how Sentara has helped and how we continue to help with promoting health equity. Well this COVID-19 pandemic and vaccine. Hesitancy is key. And even in my practice um for north and we were the first practice in the Hampton roads to get access to the vaccine. Had to make a lot of phone calls to the governor's office at the time fussing about this issue of of access and I knew that we were running to an issue where people being hesitant to be to get this vaccine and unfortunate. So there was a poor rollout in the government which creates this distrust issue. So I had a lot of people, a lot of patients of mine of color who refused to get the vaccine because of mistrust. So having that consistent presence has helps in terror. Individual practices understand these community needs from the ground up. And we actually took the time myself and my practice and as a member of the terror system to really assist with vaccine clinics where we administered tens of thousands of shots in arms activated mobile clinics to serve large communities. And actually we have programs that going door to door in neighborhoods that reach the most vulnerable and most reluctant among us. And typically those are in certain neighborhoods where you have the highest vaccine Hesitancy are the individuals who if they are infected have the highest risk of dying That obesity. We brought earlier chronic medical conditions. You know, it's clear if you look at any of the data that people of color have a higher instance of dying of COVID-19 than people who are not of color and why is that living conditions, work conditions, exposure aspects, lack of lack of vaccine acceptance all play a factor. And our role is to try to improve that by constant messaging. I'm out there in the airways all the time promoting vaccine um acceptance, trying to help people understand that the vaccine is not the enemy of the people, but it really is an effective way of prevention. And I think all of us on this in this webinar know that we've seen the case numbers dropped once the vaccine became prevalent. So that is a big factor and that's one that we're constantly pushing to try to make sure we we bring to the forefront. So we have to also build up a stronger pipeline of african american providers. So centuries rally educational partners with O. D. U. North State. The VMS to attract some of these gaps in service and outcomes. They created the one school of public health to focus on education, research and services. I my fight and I myself um enrolled in the public health program. I'm getting a master's in Public health at UNC Chapel Hill currently and part of that I wanted to make sure I had enough education and understanding as to how I could assist in making sure that I address some of these these disparity issues and find out how to really focus on things that I thought were important. And I felt that I needed that extra education to make that happen. So we have to ensure connections to care, reducing those access barriers and which is a big issue. Um we have to make sure we increase those points of contact and providing navigational services for needy individuals as health care professionals privileged to serve diverse communities. We know the term access can mean different things depending on the neighborhood. Increased presence and personalized support are key to ensure all have equitable access to care and services. Example that I have been working with with Sentara as a Berkeley clinic, which is going to be opening sometime in the next couple of months, which was designed to not only provide general medical care, but also behavioral health services on site, we're going to hire social services navigator and provide program coordination and support with other area organizations offering dental services, health literacy education, medical assistance, and healthy cooking classes. So if you look at the end, Berkeley was a target area because of the high incidence of emergency room visits and lack of care in that area. And what we're trying to do is create a different type of clinic environment because all of us know when you when we're rolling through patients every day, what time do we really have to really sit down and go through with a patient, you know, when they're £100 overweight or the you know, what's the importance of them taking their medication. We can address it, we can touch on it, but we really need that extra help to say how do we get them to that next level, understanding what their shortfalls are to get that access. As example, if they live in neighborhoods or their jobs only allow them to get a dollar value meal at Mcdonald's, you know, it's gonna be difficult for them to lose weight if their ability to obtain food is is compromised. So are being able to get into the homes, understand the problems that people are going through, understand where the shortfalls are and how do we provide those educational support services of what we're trying to do, starting in that Berkeley Clinic. So we also know that behavioral health needs have been an issue. It's important to provide those accelerated access to behavior behavioral health professionals and resources. Virginia Healthcare Foundation's conquering the consequences of COVID-19 initiative worked to increase availability of mental health service providers. We developed a psychological nurse practitioner of scholarship program which supported 39 individuals with full scholarships Who commit to serving two years and areas with significant storages of behaviour professions and more than half the recipients have been people of color. A critical factor in building that trust. I mentioned earlier with individuals and underrepresented communities. We have to support our youth of Hampton roads. We see this gun violence issue as a major problem that has to be addressed. More than 15% of Virginia use have experienced a major depressive episode within the past year. So terra supports those programs that strive to help make a difference. There's the Empowerment Center for Children Youth and Families, which provides out of school programming for Norfolk's park place community, which includes the Sentara scholars daily after school program, saturday academy, weekend themed recreation themed, early career exposure, sunday, fun day cultural field trips, mentoring, athletics, faith training and family enrichment South Side Boys and Girls Club focuses on youth in the Berkeley campus, stellar communities of Norfolk features the emotional wellness program to build the social emotional skills necessary for academic, professional and personal success. I personally have been involved in meetings with the president of old Dominion who has some concerns because the surrounding neighborhood is plagued with gun violence. Uh, you know, we've partnered with a lot of pastors in the area who have programs and a lot of people have programs, but there's no real way that we're bringing them together and that's what we're trying to do is figure out how do we attacks with the schools systems, find out those at risk youth and find out which programs are available may be better suited for that individual to get them in a better place in their life. New vision, Youth services helps young adults and chest speak who are transitioning into adulthood through life skills and case management services, education advancement opportunities, housing and employment assistance. So currently we're really trying to make sure we make a difference with our youth. We have to reduce those gaps in maternal health and early childhood outcomes. Like much of the U. S. Mortality rates for black mothers in Virginia and north Carolina are more than double that of white mothers. Systemic barriers to maternity care persists inequitable access to health insurance, maternity care. Deserts reluctance of expecting mothers to seek care or report problems for fear of law enforcement involvement. Mom's Matters. A Children's Health investment program initiative extends postpartum care at home to reduce the risk of for women with hypertension when discharged for Norfolk, general or centering overseas. So too many of our newborns have lost their mothers to uncontrolled hypertension, particularly in women of color with this program, nurses make weekly business to ensure moms are taking their medications and receiving that follow up care, providing health education and screen for postpartum depression, observed for other factors that complicate life after childbirth, including food and housing insecurity and transportation barriers. We have scholarships that help provide freedom to pursue passion. Now more than ever, it is essential to recruit and support future health care professionals. Sentara works extensively with universities and community colleges across Virginia and north Carolina. Examples include work with the piedmont Virginia, Community College to provide scholarships through the right diagnostic sonography scholarship and direct support to students pursuing health careers, offer scholarships to employees, community members and high school seniors pursuing healthcare careers at Longwood University average University, Liberty University and more. We have to eliminate those barriers to healthy, locally sourced food in Charlottesville cetera has partnered with local food hub to expand his farm program to deliver locally sourced food options to the community, including to pay what you can farmers markets in the local school parking lot in Hampton roads. We've partnered with Hampton roads Urban agriculture to serve residents with diabetes or at risk of developing the disease. Through vouchers they can use to shop for fresh organic locally grown produce and mobile markets. They also receive instructional, healthy cooking techniques, meal prep strategies and even how to grow food. We're talking a little bit about that in a minute. So there there now this is just one example of what we're trying to do to make sure we provide those healthy foods to individuals because it takes a lot of work because we have to change the dynamic of how people think and it used to eat in a certain way. It is difficult to really institute that change. But through constant messaging we found out and that's why I do the things I do on Hampton University radio with um Barbara hamli show is my effort to try to constantly through messaging, deliver a message that we can live better and healthier lives if we take the time to learn what's needed to do. So. So um so in in our final finality, I haven't touched on one thing, a couple of things we're doing with my Foundation in the James Newby jr Foundation two programs were doing currently. We are having a Sentara scholars program where we've identified some students within Norfolk public school system, partnered with secure college to provide scholarships to those Children who may not necessarily be college bound kids, but have clearly have the intelligence and have the will to be better in their life. And we're developing these scholarship programs uh to help them become better uh individuals meaning they have access to jobs through some of these credential um certification programs To to actually and some of these programs have actually provided extensive job opportunities, making uh you know, up to 50,000 and up to 80 and 90,000 depending on what they're doing per year uh coming out of these programs. So we're trying to promote that. And we started off, this is the first year we've really done it. We have a pre program that we've developed. That pre program is to make sure because what I don't want to do is just feel like we're just giving scholarship money away. We want to identify those individuals who are motivated and want to be successful. So we're doing a pre program we started and we started our first class last weekend and we have identified some students at Booker T uh and we're, what we're doing is we're giving them those those those those individual tools they have to show up every saturday for six weeks for a program where we're teaching them how to measure, you know, banking skills things, they need to know about their financial support, things, they need to know about different areas that may help them for for the future. And if they're successful through that program, then they get scholarship monies that will help them debt free to get through the program and to have their start in life. So that's one thing we're doing with centering and James, Newby Foundation. Second thing we're doing is we're trying to teach kids about AARP onyx. So we're put Tower gardens in two schools right now where there um see these Tower gardens of structures that give them the opportunity to grow different vegetables and different fruits and they can actually see how things grow, how they develop. And these Tower gardens are put in these schools and it's part of their curriculum. So they're actually, we have a person come there to help them show how these Tower gardens can help them to understand the importance of nutrition and how these food, these positive food groups can help them grow to be healthier individuals, so they get a chance to taste the food they grow because these individuals, we have to go into the schools actually have cooking demonstrations, picking the vegetables off of the tower Garden that they grow themselves and they were going to create a dish for them to be able to taste so they can see that healthy food is not necessarily bad and we know they all think it it is and they'd rather have the Mcdonald's and burger king and these other Wendy's and what have you. But we're trying to give them engage them to see that they can live better lives if they take the time to learn what's necessary. And we want to give these young kids the tools to do. So we're starting with two schools this year. Hopefully that will extend to four and six schools throughout at least Norfolk, starting and then to take to other cities as we go along based on the success of the program. So those are two things we're doing with the new B foundation, amongst other things that that we do. But I wanted to bring those two issues up. So in finality, what we talked about today, we talked about definitions of health equity, we talked about health equity, health equality, uh, disparities, how they're different. We're looking at the importance of this. How does this make an impact where it makes an impact? Because if people have equity, they live better lives. And even look at Brass taxes the amount of money spent on health care, if we can change people's lives in a positive way that health care cost goes down if we can find out attacking that obesity problem with that comes better blood pressure's better diabetes scenarios, less heart disease. You know, we we don't want to have, I mean, you know, we want to have people live better healthier lives not be an emergency room with heart failure all the time because they really don't understand what's necessary in order to live their best life. We talked a little bit about social determinants of health, those factors that do impact, you know, job opportunities, things, how they live, how they work, how they play, how they worship all impact the ability to have good health. We look at some examples, we talked about this health inequities and the aspects of obesity and how different organizations can actually make a negative impact as much as other organizations making a positive impact. And we talked a little about about solutions and the key thing to solutions, we have to grow trust. We have to be able to demonstrate that we do care. So each of us has to understand the culture of the patient in which we're dealing with that understanding of that culture helps build that trust factor, which helps us deliver the care necessary. And I know it gets frustrating sometimes when you try to have these conversations and you're feeling you're not getting anywhere, but please take that time to understand different cultures have different backgrounds and the ability to understand what we're trying to convey can be difficult. So we have to find ways of constant messaging, but constant ways of producing that trust value that will help. So that in conclusion is a health equity talk, and I thank you for your time and I hope that I was able to at least give you a perspective. That perspective I want to do is not necessarily do anything, but have you look at the world from a different lens. How we interact, how we interplay with our patients impacts how they receive that information we're given. And I think that if we can take into account some of these things I talked about today, we will see a difference in our delivery of care, that acceptance of care and our ability to help patients live their best lives. Thank you very much.
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