Institutional Racism in Healthcare

0:00:01 - Announcer

You are listening to the National University Podcast. 

0:00:10 - Kimberly King

Hello, I'm Kimberly King. Welcome to the National University Podcast, where we offer a holistic approach to student support, well-being and success- the whole human education. We put passion into practice by offering accessible, achievable higher education to lifelong learners. Today, we're talking about whether or not there's racism in healthcare and what that may look like. It might be easy to take for granted, but we talk to the experts to get their opinion. On today's episode, we're discussing racism in healthcare and we are fortunate enough to have two guests with us. 

Dr. Gloria McNeal is an Associate Vice President for Community Affairs in Health at National University and over the course of her academic career she has served as a program director and an assistant associate founding dean for public, private and Ivy League institutions of higher education. She's continuously funded for the past 23 years and currently serves as the PI for the HRSA Simultation Education Training Grant and the HRSA Mobile Health Training Program. Together with a team of clinicians, she has launched the National University Nurse Managed Clinic in 2015, which provides primary care services for low income residents in Los Angeles and San Diego counties. She has authored over 170 articles, abstracts, books, book chapters and editorials and has served as editor or associate editor for peer reviewed nursing journals, and that is just a few of her accomplishments. Plus, we are fortunate enough to also have Dr Ricardo Parker over for over 11 years at National University. 

Dr. Parker serves as a professor and academic program director for the Bachelor of Science in Allied Health Program in the Department of Health Services School of Health Professions. He also serves on the department and school level committees and actively supports health science students professional development. He was co-investigator of two National University Innovation Grants for a pilot project titled Interactive Health Career Pathway Tools, journeys, an interactive degree and career planning tool designed to assist students navigating the complexity of health professions and to improve retention and graduation rates. Dr. Parker served as a faculty mentor for two HRSA Grants funded projects National University's Nurse Managed Clinic Initiative Program and their simulated virtual healthcare system model project. He is also a member of the Planetree Higher Education Certification Pilot Group Council, and if we listed any more of his accomplishments, that would take up the entire podcast. Impressive, my goodness, did I get through everything okay? We welcome both of you to this podcast. How are you? 

0:03:05 - Doctor Gloria McNeal

Thank you. Doing well, thanks. 

0:03:07 - Doctor Ricardo Parker

Good. Doing well, thanks.

0:03:09 - Kimberly King

Yes, so interesting and what a mouthful, but what an accomplishment on both of your behalves. Thank you so much for being here. I'm going to start with you, Dr. McNeal. Why don't you fill our audience a little bit in on your mission and your work before we get to today's show topic? 

0:03:23 - Doctor Gloria McNeal

Okay, thank you so much. So I think I became interested in the discipline of nursing because my mother served as a nurse and she instilled in me the importance of giving back to our community. So we grew up in underserved communities ourselves, but we're able to achieve quite a bit because I think my mother was just so visionary and so when I had the opportunity to actually give back to those communities I did so. So I was born and raised in public housing and understand very well what the needs of that community can be and in my ability to become better educated, it allowed me then to serve in that role. 

0:04:14 - Kimberly King

So first hand knowledge was your key, and then, of course, your mentor as your mother. That's great. And then what about you, Dr. Parker? 

0:04:22 - Doctor Ricardo Parker

Well, I have some similar beginnings. I recall as a young kid being raised in projects in Washington DC called Kenworth, and what was kind of exciting about that was there was a pond nearby it was called the lily pond and as a young kid I used to go down and collect pond water and one day I caught some tadpoles and it was watching tadpoles turn into frogs. That just was like a spark that ignited a huge flame in my interest in biology, if you will. And then later on I recall my elementary school teachers. One in particular had a microscope and I happened to get some pond water and look under the microscope at pond water and there's a whole new world that opened up to me. 

And it was then that later on the excitement grew and I had a personal issue with the family, with my grandfather was diagnosed with cancer and eventually had surgery. He became invalid and eventually died. But it was that interest in cancer. And again going back to school, my high school instructor gave me a science project called DNA topology of the molecule of life. All of that culminated into a keen interest in looking at cancer and then developing an undergrad. Grad school was fortunate to participate in certain programs that gave me my bachelor's degree, master's degree then, went off to Oregon State University where I got my PhD. 

By the way, my undergrad and master's were at historic black institutions, Shaw University and Tennessee State University. Postdoc was at the National Cancer Institute, which was another incredible, eye-opening experience, where I worked in first laboratory of tumor immunology and biology and then in clinical oncology section looking at drug resistance as a mechanism of why patients fail treatment, and that was another actually open up the whole new world of cancer research to me, and I've been in that field for over 35 years. 

0:06:59 - Kimberly King

Wow, impressive and inspirational both of you, your stories and your journey to where you are today. So thank you for inspiring all of us. I am looking forward to hearing more. I wanted to find out. We're talking really about institutional racism in healthcare, and so, Dr. McNeal, I'm going to start with you. What are some of the causes and examples of institutional racism in healthcare today? 

0:07:25 - Doctor Gloria McNeal

Yeah, I think COVID-19 really opened up everyone's eyes to the disparities and inequities of healthcare that are out there. The United States is a very well-developed nation in terms of medical science. However, our healthcare outcomes are the worst of any industrialized nation. The one that really strikes me is the maternal infant death rate in the United States, and we have arguably the highest standards of medical practice. So why is that occurring? And when we look at the history of our nation, it has been one that well, it's available for everyone to achieve and become accomplished. I mean, I'm an example of that. However, that's not open to everyone, and so, for the few of us we're able to achieve, we're not enough in numbers to really make a difference and improve, for example, maternal infant death rates. 

0:08:41 - Kimberly King

That is fascinating, and I saw that you nodded your head. Let me hear what you have to say. 

0:08:45 - Doctor Ricardo Parker

And there are other aspects if you actually look at the historic and contemporary issues associated with racism in healthcare. 

There's a foundational factor associated with that. 

Let me just speak to the historical aspect. 

When you talk about segregation here in the United States, where people have been divided, if you will, based on color, and it's this whole concept of what a person looks like, when you also consider the government and, for that matter, laws being incorporated, particularly during segregation, where this concept of separate but equal comes into play there, that has caused and instituted a lot of inequities, and I think, if you continue to kind of look more granularly at this, what you actually see is that there is indeed some discriminatory practices, beliefs and, I'll call values that have been associated with the challenges that we see in the healthcare system, for that matter, in the community. Historically again, if you consider how, I'll say, medicine or healthcare system evolved initially, it started off as a you had charities I mean well, sanitariums and places where people that did not have the wealth of wherewithal, where they would go to probably be isolated and not become, let's say, a burden, but really to contain disease and if you didn't follow it through these charitable organizations and turned into these volunteer organizations, moved that further along. 

Now you start developing a public health system where people that were either indigent or just didn't have all the wealth and ability to take care of themselves. 

They had those facilities available and when the business of medicine started to come into play, you had this whole idea of now kind of better organize how to administer healthcare for the community and for people at large. 

One of the biggest challenges with that is you had organizations that actually come in to actually buy up hospitals, buy up clinics and then start institutionalizing how medicine and healthcare is being doled out In the, I'll say in the late 60s, somewhere in the 60s, when the Hill Burton Act came into play and it's a very important act that the government provided tens of millions of dollars for hospitals to upgrade and to become more modernized. 

One of the what was going on there when you already had this segregation or separation of public hospitals, public and charitable hospitals versus those that were considered non-profit and private the dollars that were being doled out to those different areas were going more towards the more wealthier facilities, particularly those facilities that had patients, that had private health insurance and were able to afford the type of healthcare that these more I'll call them elite hospitals provided. When you look on the other side, the public community health had gotten less, and if you also throw in this whole idea of segregation again, where blacks were delegated or relegated to more inferior facilities, that also exacerbated the challenges of this health and equity between folk in the community. So it's an interesting history and considering the factors that play into that, we'll maybe talk about that later on the structural factors that actually cause this, they are still in play. 

0:13:15 - Kimberly King

After all these years. 

0:13:17 - Doctor Gloria McNeal

And I'll just piggyback on to that, you know. I grew up in the zip code and I've often indicated this in my publications 19122. It's a zip code in Philadelphia, Pennsylvania.p It's one of the worst in terms of health outcomes in the nation. 

And so when I was in the eighth grade now, mind you, I had gone through eight years of education I had the opportunity, because my GPA was so high, to be admitted to the Philadelphia High School for Girls, which was at that time a public, elitist high school, and there were only one such high schools in the country like that or 100 such high schools like that in the country. 

That's where I learned that I could not read and I could not write, and so the deficit was profound. Right, and I came to understand that when you are in these underserved communities, so many, so much of the resources are not available to you, what can you do? When you graduate from high school and you can't read or write, right, you have no opportunity for collegiate education or anything else beyond that. Well, fortunately for me, my mother understood the problem, and she went out and worked three jobs to provide me private tutors so that I could be brought up to the level of my classmates. But that opportunity is not for everyone, and so a large segment of that group is left out of the educational foray. 

0:14:57 - Kimberly King

Wow. This history needs to be heard and needs to be told, so thank you for sharing, and this is what this is all about so that we make changes for the future. What are some and either one of you can answer this what are some of the effects and that impact of this history of racism in healthcare? 

0:15:19 - Doctor Gloria McNeal

I'll start with life expectancy. So the average longevity of an American white male is like 72, 74 and for a female 82, something like that. When you look at the life expectancy of a black male in lower income communities, it's 45 years of age and so that disparity really is significant. Higher rates of diabetes and high blood pressure and mental illness. Higher maternal infant mortality rates, as I indicated earlier, and the eligibility of health insurance. So if you are an African American male and you are 21 years of age, you're no longer considered a pediatric case. There is no health insurance for you and you will have no health insurance until you're a 65 and maybe you'll qualify for Medicare. Now a woman who is childbearing age will be covered with some program or other until maybe 50 years of age, but then she's left uncovered between 50 and 65. And so all your, if you are not insured, you cannot access healthcare. That's not there One. 

You know I do a lot with mobile health clinics and I put nurse practitioners aboard those clinics. When I initially started out, I made it clear to the people that we serve was that this was really for individuals who did not have health insurance at all, and I had a patient come aboard the vehicle. She had four children and she said to me I have health insurance, however, my physician has indicated to me that he does not accept Medicaid insurance and so he will not see me or my children. So that caused me to understand and recognize that just because you have health insurance, that does not guarantee access, Probing that next question right and it's. 

0:17:53 - Kimberly King

And again, treating everybody. Everybody has a different story, but really asking the full line of questioning, you were going to say something. 

0:18:03 - Doctor Ricardo Parker

Let's speak back on what Dr. McNeal spoke to. 

If you also look at, say, the effects of racism, if you will, you also have to look at, in certain communities, certain distrust and lack of involvement or engagement in the health care system could be because of either being uninsured or underinsured and in those situations when a health crisis occurs, they may not have the right insurance to cover what's needed and therefore have to go into the emergency room as a means to gain access to health care. Looking at that distrust concept, I am mindful of at least there are several, I mean historically. There are several studies or several events that have occurred historically. Two that come to mind. 

Of course, people are very familiar. Most people are familiar with the Tuskegee studies and just a very quickly through 1999, African American sharecroppers out of Tuskegee, Alabama, were actually being studied or a research was being done on them without their consent by the way, it's not even knowing about it and looking at syphilis, and looking at the pathohistology, or the pathohistology of syphilis, looking at it from when they get it all the way to when they die, and this is from the government, the public health system that actually did this and it went on for nearly 40 years and it wasn't found out until a reporter that happened to be one of the annual meetings that these guys came to compare notes. 

He became what you call a whistleblower and made the statement and brought it to the fore, and it started in 1932. And in 1972, I believe, when it was discovered, this actually brought about the Belmont report that provided certain safety nets. And the Belmont report instituted anyone that is undergoing any type of research. First it has to get their consent. Now there was Nuremberg and then there was Helsinki that also brought that in, but with the Belmont report it says that a person not only have to be told what this research is about, but the person have to get consent to participate or not. 

Now, the other study that comes to mind that a lot of folks aren't familiar with is a gentleman by the name of J Marion Sims, who they called the father of gynecology, at least gynecological surgery, and what he did was perform surgery on enslaved women and at first they did not give their consent. And what was so horrendous about it is that he performed surgery without anesthesia. And though you look at this double edged sword, same thing with the Nuremberg trials, that science that came out of that while advanced science per se, but it was under the guise of a very horrendous racial, racist mindset. And again, to this day, these effects, or what we know can affect, at least for African-Americans, fear or distrust of the health of doctors and, for that matter, the health care system. So there in lies another underlying issue where we might also tie in some of the disparities and some of the inequities that we see, because we trust the system, because it's failed us. 

0:22:34 - Kimberly King

And it's so important to know that history, and so thank you for bringing that forward again. And the key word is the education and really talking about this, what is the ethnic composition of the current health care workforce? I? 

0:22:51 - Doctor Gloria McNeal

can speak for the discipline of nursing, and it continues to be not very diverse at all. Now it is attempting to rectify that. Most recently, I'm going to say within the past year, they brought together groups of individuals to study the problem and to encourage more grant funding opportunities for individuals of lower income and socioeconomic status. But it will be years before we're able to really realize that there are about 26 historically black colleges that have schools of nursing, and that's where a predominant number of African-American students go to be educated as nurses. I was fortunate to attend Villanova University and the University of Pennsylvania and at least in the years that I was at Villanova, I was the only African-American female on campus of 5,000 students, and so it's difficult to raise this bar and to encourage minority students to go into the discipline of nursing. Many minority students feel that they'd rather go into medicine or engineering or other more high profile disciplines to overcome some of the stigma attached to them. So it's a double-edged sword. 

0:24:27 - Doctor Ricardo Parker

Indeed, indeed. You know, when you can actually consider the stats. You can't give solid numbers, but we do know I mean, along with Dr McNeal said that there's predominantly white. Roughly. If you actually look at the breakdown 85% to 90% and you look at African-Americans and Pacific Islanders in Asia, we probably make up somewhere between 12% and 13%. And overall, and then other if you will that category others falls under that 2%, 3%. So yeah, it's across the spectrum. It's still that huge separate disparities between, I'll say, non-whites and minority, if you will in those various health fields. 

0:25:17 - Kimberly King

And to what you were saying, Dr McNeal, that it's still going to take years from even making these adjustments and making these changes. What are some policy decisions to address health inequities? 

0:25:32 - Doctor Gloria McNeal

I think we need to lift the cap that we have on grant funding for schools of nursing, schools of medicine, schools of physical therapy, and on and on and on. 

Allow these schools to have opportunities to provide scholarships, stipends or things like that to encourage more minority students to apply, I think also boosting the support for schools of nursing and faculty. The Department of Labor just put out a call for a proposal that we did submit a grant opportunity to increase the number of nurse faculty in our schools of nursing. So we have 1,500 schools of nursing but we turn away every year 80,000 plus qualified student nurses because we don't have the faculty to teach the courses, we don't have the clinical placements to put the students in, et cetera. And in addition, most nursing faculty are 60 plus years of age, they're about to retire and there is no one in the pipeline to bring up the rear. So we need to and the faculty salaries need to be addressed Because nurse faculty make far less than others on the academic campus and you could do so much better in the service sector. So individuals are just not interested. It's really dedicated folks who take on the faculty role. 

0:27:14 - Kimberly King

Those numbers are disparaging, aren't they? Wow, Dr. Parker, did you want to say anything about that, Dr.? 

0:27:23 - Doctor Ricardo Parker

McNeal with nursing and in general health care in general. I mean, of course, I agree wholeheartedly about that. There are also issues with regards to looking at the pipeline of doctors, nurses here, in the United States. We're finding that more and more doctors that have looked at how managed care has kind of caused a rift with what they can make versus how they can provide the best quality care for their patients. That pipeline is kind of trickling in because many of the doctors are moving into. 

I call it boutique medicine and working these private groups, whereas the hospitals or clinics that help people with either uninsured, uninsured or not the right insurance having challenges and we are looking to bring in and we have to address that bring in more foreign doctors nurses and health care professionals. There should be have to be some means by which more equitable I'll say access and equitable pathways, if you will, for, I'll say, more representative populations, to have folks that look like them in their communities and also that have the resources available. 

Again, we'll go back to how the policies governance is in place and what we put value on with regards to health care. 

It goes back to the built structures, the structural factors associated with how this health care system works, how it operates. 

There are challenges If the government and those that are making decisions locally nationally, for that matter, even internationally are making decisions on where the dollars are going, who gets the health care, what the insurance policies are, practices are. There are big challenges, big challenges with that are looking at, again, policies, they tend to be more selective on what they call the majority benefit versus the minority, all these terms where we've been able to separate people based on these classifications, definitions, minority, ethnic minorities and nonwhite majority, the practices and policies and more or less, what we value, what has been placed on the value of health care. Put it that way, if you can put a value on it, it has a measurement If people that have less access to health care don't get involved into the practice of health care versus those that gain access, have access, have the great insurance policies. That separation still causes these policy makers, law makers, to look at what's important for the majority and residual for the minority, if at all. It causes a chasm between a have and a have not and has done so historically. We still have a ways to go, but what we put value on, I think is an important aspect for the health care, those that provide health care, the systems that actually make up the health care system. 

I'm talking about anywhere from the hospitals to the insurance companies, to all the other players and community health facilities and whatnot. 

Take a close, close look at what's needed to have some type of equitable access practice, and the business of medicine has to somehow take really look at this and take I want to call it a back seat, but allow doctors to be doctors and allow them to really interact more intimately with their patients so we can increase the trust and, as importantly have doctors, nurses and all the support staff develop these very essential teams where they can communicate, where they can collaborate and truly, truly, truly work on providing not only the best health care provide at least people can have better access to quality care and also have better outcomes. 

The business of medicine has to provide the resources and the space for doctors to be doctors and all the health care support staff to do what we've been trained to do. And I get caught up in to being more, not more concerned, but being concerned about the dollar. The dollar has taken center stage in what medicine has been about, and in order for us to save ourselves, because we're all in the same boat, whether you like it or not we're all in the same boat to save ourselves. 

We've got to take a look at this and really start changing course, because if we don't and continue down the course we're headed, we're in for a lot of hurt. 

0:33:31 - Doctor Gloria McNeal

Yeah, the disaster is there, that's clear. I want to get back to you. So the emergency room because of primary care service. So when you go into underserved environments, you will find no clinics, no physician offices, none of that. And so when they become ill, they have to travel sometimes two, three buses or at least great distance, to be seen in a tertiary care facility. When you walk into an emergency room because you have the flu or symptoms of the flu and you want to be careful, in about two hours that bill is $5,000. You can see a physician or a nurse practitioner for maybe a hundred, right, something much more reasonable. And because the hospital has to pick up that bill, because you cannot. 

I've watched 11 hospitals over the course of 10 years close. They simply had to close. Now there are no resources for anyone, right? And the other thing regarding where our professionals are these regulatory conditions that prevent the nurse practitioner, for example, from hanging a shingle and delivering services in many states is incredibly, prohibitive, incredibly. So we have to look at those regulations. We have to look at how we can put more primary care services in the communities where they are so that we can prevent this use, overuse, of the ER for primary care conditions. 

0:35:18 - Kimberly King

It's insane the amount of money that is being spent, and especially when you do the history in the backup as to why they're walking into emergency care rather than the clinics. We have to take a quick break, but thank you so much. This information is so inspiring, but it's also we need to make changes. So thank you for all of your time. Don't go away. We will be right back. And now back to our interview with Dr Gloria McNeal and Dr Ricardo Parker, and today we're discussing the examples of institutional racism in healthcare, and it's been a fascinating conversation. I wanted to ask you both what historical practices continue to contribute to structural racism in the United States. 

0:36:06 - Doctor Ricardo Parker

Well, I think I can start. I mentioned previously about certain socioeconomic and political aspects of the healthcare system and where we find ourselves. It goes back, I mean, if you have to look at socioeconomic and political aspects again, difference policies and what we value and all of those structural aspects tie into some of these socioeconomic activities and practices that individuals, families and communities practice. When we speak to this whole concept of structural racism, what are we actually talking about? We're talking about built environments. We're talking about the structures that actually are put in place legally, historically over time, that have impacted the differences that we see in various communities Now divide a line between them those communities that have and those communities that don't have. 

The concept of structural racism is founded on it and we don't talk about this too much. You really have to kind of look at what this whole idea of race is about. And it's just. Racism is not real. It's a social construct that has been historically used and exploited. It's a means of separating people about what they look like, and it is the foundation under which racism stands, sits and has evolved historically over time and continues to this day. 

When you consider a concept of structural racism, we have to look at the social determinants of health, and I think Dr. Mielano will talk more expansively about that. But we have to actually consider what are actually those factors, what are those differences that we see with regards to where a person lives, or first, where they're born, where they live, where they go to school, where they die? That whole environment, I mean that whole environments and conditions set the stage for their health, what they do, who they are, and when you consider one environment I'll say a wealthy environment versus underserved, empowered environment who people are, what they do, where they live and those conditions under which they live, the schools in which they go to and, for that matter, the jobs that they have, all of those factors play into health. And, by the way, health is outside the hospital, it occurs outside the hospital. 

0:39:14 - Kimberly King

That's a headline right there. Yep, I love it. 

0:39:17 - Doctor Ricardo Parker

And so when you actually look at what these conditions lead to, I mean it's obvious that you see in underserved, empowered environments that they do use the emergency room as primary care. Go in that way because being underinsured or uninsured, you know. Thank God Medicare did come along in the late 60s when LBJ instituted it. What that did, if you go, I mean looking back at it you got to still remember, while segregation was outlawed, if you will on the books, it was still practiced extensively. I remember as a kid having to sit in the back of the bus in Washington DC. Anyway, that's another story. But with all of that going on, you have these separations, you have these differences. And when you consider the dollars that go into, again going to quality care, I'll say access to quality care, what that care is about and the cost associated with it, again there is that demarcation, that separation, again based on communities. But we have a ways to go when it comes to equity, along those lines. 

0:40:34 - Doctor Gloria McNeal

So yeah, I want to speak to the cost. So when I first came to California I did not have health insurance, I wasn't employed yet, and I went to see internist just for physical exam and so she spent about 45 minutes or so doing an examination, taking my blood pressure, drawing some blood, doing some tests, and then she presented me with the bill. It was $650. Now if I had given her a Medicare card or a Medicaid card, she would have been reimbursed in the state of California $25. In the state of I mean, new Jersey sorry, state of New Jersey about $25, state of California maybe 125, because you have more people in this state, right. And then the lab results came back and the bill for the labs, the whole thing was $1,100 for a 45-minute visit, and so that is what the system cannot maintain at that level. 

So I also want to speak to how can we make a difference? So my mobile projects I've tried to ensure that we are in the community in which the individual lives to address their health care needs. So we have set up in churches, in drug rehabilitation centers, in Salvation Army locations, in school districts. If you have space that you are not using for anything else, can we turn that room into a clinic and can we see the clients that you serve. And so now what we've done is we've cut away the distrust because we're inside of a facility that the community knows, recognizes, believes in, right. And we've cut away the transportation issue. Right, that's a big part, and because we are grant funded, it's free, so you don't have to worry about, you know, out-of-pocket expenses, and that's the model that needs to be replicated across the country. 

0:43:08 - Kimberly King

You're a pioneer. And you're seeing that that's working. How many spots are you or are your mobile? Right now? We're in six. 

0:43:15 - Doctor Gloria McNeal

We have about 600 patients in our caseload right and we're building it as we go. 

0:43:22 - Kimberly King

And so, just on that, when you build it, how is it a lot of word of mouth? Is it because of this distrust in the community, people, family members, friends, are they talking to each other to get the word out as it grows? 

0:43:36 - Doctor Gloria McNeal

So that's a great question. So we utilize the pastors of the churches, the organizers of whatever facility we're in to put the word out, to let them know that we are here. We leaflet the neighborhood with flyers. You know that kind of thing. 

0:43:54 - Kimberly King

Good, I love hearing that, and good luck to you. I'll be keeping you in my prayers for that. That's how it works. What steps can be taken to address racism and I know we've been talking about this and it's been so interesting because of the history but what other steps I should ask? 

0:44:13 - Doctor Gloria McNeal

Yeah, I think we need to sit down at a table and have conversations. You know, some of that scientific research, quote unquote that was conducted in the 30s 30s that indicated that African Americans had lower, smaller brain pans and so therefore intellectually inferior. That was published in peer review journals. People believed it for a long time and other kinds of you know belief systems like that. If we can sit next to one another, and have a conversation. 

People who were part of World War II tell me you know. So we're going back to the 40s now. Tell me that when they were in a foxhole together and there were minorities and there were non minorities, all fighting an enemy, they trusted each other. They had to right. You couldn't look at a person's skin and determine that that's not someone you want to work with, and then they would come back to the United States and you know, the segregation and discrimination would rear its ugly head. We did it in the war, we did it in the foxholes. Why can't we do it in our communities? 

0:45:38 - Kimberly King

It's a great example, a sad example. 

0:45:42 - Doctor Ricardo Parker

Yeah. 

0:45:44 - Kimberly King

And. 

0:45:45 - Doctor Ricardo Parker

I think it reflects again the idea of, I guess, the misconception, the myth of race that we are different based on what we look like and the science, by the way, proves that wrong but the beliefs and who's talking the loudest seems to be what people hear. As Dr. McNeal said, we need to have a conversation. I think it started. We have to broaden that conversation, actually start taking measures to make some changes. And it goes back to some of the areas that we encounter as human beings where, because of where we live, because of where we go to school, it's kind of interesting that, for when you actually look at medicine in general and how it's practiced, you have both well, actually all ethnicities going through the same universities. 

And I see, in some aspects, some of the myths, ideas and ideologies that are racist in nature tend to be incorporated in how many doctors, regardless of ethnicity, practice it. And we kind of have to take a step back and start looking at what truly are the issues associated with the myth, this ideology, that we're racially different and race makes a different, and it truly doesn't. Again, science has already shown. I mean, if you look at human beings, actually the human genome project showed that we're 99.9% the same, and what that.1% is, that difference is, has nothing to do with skin color. 

0:47:52 - Kimberly King

Right. 

0:47:54 - Doctor Ricardo Parker

So I think again the conversation and truly looking at ourselves in the mirror and seeing that who we are. 

Now, unfortunately, when we look in the mirror, we see who we are, and I think when it comes to racism, one really has to name it, truly name it, and speak to it, and that's the only way. Latest stuff on the table and try to make amends and try to get this issue off the table, both from the higher executive level all the way down to the children, Because unfortunately the grandparents teach, the children teach the grandchildren. 

0:48:43 - Kimberly King

Right, it goes through. 

0:48:46 - Doctor Ricardo Parker

And it perpetuates. So we do need to start looking at that. And also some of a lot of this begins upstream. We've got to go back and see what again it goes back to structures, the structural racism that's in place, and again name it what it is and start making some changes. If we want to move forward, we have to start with our kids. 

0:49:16 - Kimberly King

You know, and I think, as you're both talking and hearing the stories and the history, and it is. It's about sitting down and having a conversation and maybe that racism has been implemented without the next generation even realizing is what you're talking about. It's opening your eyes. 

It's normal, it's been normalized Right and, as, Dr. McNeal, you mentioned, how you know, we're talking about it now. Things are implemented or starting, but it still takes a long time. It's not going to happen tomorrow, or you haven't seen that happen just yet, but the conversation is definitely the impetus to making something happen. 

0:49:57 - Doctor Gloria McNeal

And when. When Dr. Parker mentioned, you have to name it. I remember being seven years old and asking my mother what are we? And she said well, we are Negroes. And so I knew what that word meant, that it was negative, negative connotation. But as I grew up, suddenly I wasn't a Negro anymore. Suddenly I was an African American, and then then, after maybe 15 more years or so, I was black, and then and now I'm a person of color. These are socio-political designations that have no basis in scientific fact, and that is what we have to overcome as a country. 

0:50:53 - Kimberly King

And to be heard and not being told by the political, by the ideology, whatever. 

0:51:00 - Doctor Ricardo Parker

whatever that headline is, it's whatever is speaking the loudest, right as you mentioned. 

0:51:04 - Kimberly King

Right, yeah, okay, okay, wow. What are some of the statistics associated with racial disparities? 

0:51:15 - Doctor Ricardo Parker

Okay, the stats I think are numerous, some of them are factual, some of them are contrived. You might have heard, I know, for when I was in college and my professors were talking about statistics, we know there are statistics and damn statistics, because I actually had a professor that showed us how you could how a flea could weigh as much as an elephant, so you can manipulate the numbers. But when you actually kind of look at stats, I tend to. I will refer to at least several, at least two studies that speak to the evidence, the scientific evidence, of when we look at health disparities, look at how racism has played a role in health disparities. One study was a 2019 science study. It's October 2019 science study that addressed that issue. 

Another one was even earlier, 2003, and this was a I call it probably groundbreaking, or at least really opened up people's eyes as to what, how racism played into the inequities in health. And one of the at least the first author of that study, his name was Brian Smedley and it was a 2000 study, a 2000 study, and it was called Unequal Treatment Constructing Racial and Ethnic Disparities in Healthcare. If one looks, looks, look up those two articles or the Smedley book, that's actually almost a book. But if you look at those two studies, it will break down and give you a huge number of other references that speak specifically to statistics on how and why studies, historically, have shown that these disparities or these differences in health outcomes occur. It has nothing to do with the person's genetics, it has nothing to do with what they look like. It primarily has to do with the environments in which they live. 

I'm going to tell you, health occurs outside the hospital and where you live, where you're born, live, go, go to school. All those factors tie into your behavior, who you are, your diet. All that ties into your health condition, if you will. So when you consider those issues, those doctors that made up the Smedley study, when that study came out, many of the doctors, either high class folk, a couple of them on the panel did not realize or recognize the disparities based on this racial issue and they actually denied it until the results of the study came out and one of the most, those that were denying it eventually became starch advocates that we must. We must change the way we do medicine or again, we're going to be in a world of hurt if we don't. 

And that was in 2003. 

0:54:48 - Kimberly King

Wow, it seems like just yesterday, doesn't it right, after all of that. 

0:54:51 - Doctor Ricardo Parker

But there are indeed a lot more discussions that are going on at tables within professional organizations and specifically in healthcare organizations to really start looking at what we truly need to do to make things work. And I mentioned it previously that the business of medicine we call it healthcare Inc, medicine Inc have to kind of get out of the way. Let doctors be doctors and have that doctor-patient relationship to build the trust and the doctor teams, nurses and other healthcare support staff really work together as a unit to really work on the best, providing the best quality care they can for their patients. So the business of health what they can do is provide the resources and the space to let them do what they do. 

We well yeah. 

0:55:57 - Kimberly King

Do you have anything to say about? 

0:55:59 - Doctor Gloria McNeal

That I think you covered it. 

0:56:05 - Kimberly King

So, while oh, mobile healthcare, I wanted to talk to you about that as one way what are other ways that we can get better healthcare outcomes? 

0:56:13 - Doctor Gloria McNeal

We need to standardize our healthcare delivery system and our practices across the board, so it should not matter your income level or who you are, and that with the kind of care that you receive. And we need to start looking at lowering healthcare costs. Why does an MRI in one community cost $1,500 and in another community it's $300? Right, what is causing that difference? And then we need to use more mid-level practitioners. That's a term that Congress understands. So we're talking about physician's assistants, midwives, nurse practitioners, clinical nurse specialists people like that. They can help, but if you're going to put regulatory barriers on them so that they can't practice this, is a problem, so that needs to be addressed and whatever the sociopolitical reasons are for keeping those regulations in place, they need to be lifted. 

0:57:19 - Doctor Ricardo Parker

Go ahead. Well said stated. When you actually look at the strategies, they're multi-level. It's just hugely complex and multi-level. 

I'll outline a couple, at least three or four the healthcare stakeholders. They have to be aware of the healthcare gaps between racial and ethnic minority groups in the United States. The healthcare system itself should base decisions about the resources and allocation of material resources. Dollars have to be based on I'll call it published vetted scientific data, what the data show and guidelines, and try to avoid this disproportionate allocation of restricting dollars to minority patients and provide more improved access to care. 

Thirdly, I think, as I mentioned earlier, you have to improve that doctor-patient relationship. It's critically important for trust and also for those doctors that actually engaged in that. Already, reward them, Reward them with their appropriate dollars. In fact, when you talk about us moving from a fee-for-service. Many insurance companies and other third-party carriers are actually looking at how can we transition from a fee-for-service into a value-based healthcare service. 

While we're trying to move towards that, you still have a huge body of professionals that have been indoctrinated and used to fee-for-service and again trying to get as much medical dollars out of the practice, and that's fine. But when the dollar becomes a central focus as opposed to quality patient care, we have an issue. But still try to improve that in such a way to reward doctors that are actually doing these screening, preventive care and preventive care-based care so that at least we're focused on keeping people on the hospital, improving their quality care and, for that matter, educating them, so that not only the individual but the family and the community can then really start supporting individuals so they don't have to go back to the hospital. In fact, this is what Value-Based Care is about. I think many of healthcare providers not healthcare providers, but many third-party carriers, insurance companies are looking at this value-based model and are incentivizing docs that if they can keep that pay and I say, leave the primary care setting if they can keep them from coming back to the hospital in 30 days, they can get rewarded for that financially and they're looking at that model, how we can incentivize and expand that. And fourthly, it's important that doctors and healthcare providers, for that matter, the system itself have to avoid fragmentation of healthcare plans along socioeconomic lines. It has to be more standardized. It has to look at the healthcare needs of the community, the individuals within that community, and not look at bottom-line dollars. 

And this also ties into what has been happening historically. It's when doctors and hospitals have used algorithms to assess how to treat a patient once they're in the system. If you will, many of the algorithms have been based on costs and how efficiently they can bring in more people to get more dollars, as opposed to providing quality care. So the algorithms themselves have created this inequity in the outcome, because if you look at folk that are in, say, underserved environments, they very seldom come to the hospital. 

This whole concept of not following up and they call not being compliant and compliance or not being compliance, has been a- it's played a role in these algorithms saying okay, how can we most effectively and efficiently save our medical dollars If these underrepresented folk aren't coming in? Then let's load up trying to get as many people in who can pay for it as possible. And it goes again, goes back to the have and have nots those that have the insurance and have the dollars that can pay for certain services versus those that can't. So it's a double edged sword. But again, conversation talking about it, and now healthcare providers and systems, if you will, in this case the business of healthcare really have to look at these and address them and make some changes. 

1:02:41 - Kimberly King

And I like what you're saying and what you're seeing of what the incentivizing for those rewards. And this all leads me to my next question, which this has had to have made a huge impact the impact of COVID-19 on our current mental health of healthcare providers and beyond. This is the world has changed, but what do you see? 

1:03:02 - Doctor Gloria McNeal

Yeah, it's, it's horrific. We're seeing high rates of suicide among doctors and nurses. They're just overwhelmed by the system. The loss of employment for large segments of the population you know, when you lose the primary breadwinner, the family is really in tough straits. High retirement rates people who maybe weren't thinking about retiring, you know, suddenly are going to like leave. The system increases suspicion of the treatment modality and this vaccine was experimental for a very long period of time and people were very much stressful of that. We've talked about misinformation and disinformation that's out there. And then the higher death rates among minority populations due to COVID. Huge and then desperate distribution of the COVID vaccines, available in some communities but not in others. 

1:04:11 - Doctor Ricardo Parker

And to piggyback on what Dr Neil spoke about, when you talk about the higher rates of death among minority populations, when you guys can recall, when COVID hit, and in a very short period of time, when we looked at the rate of death within the populations, you saw a huge impact on the elderly and those with comorbidities. When you put that group as a lump sum, it's now breaking it down to ethnic differences. The underserved minority populations got the biggest brunt hit, the biggest brunt of it, and COVID revealed what has historically been in place in this country for a very long time, and it is this realization of the condition under which our healthcare system operates. 

We really have to look at what needs to be done, moving forward historically. If I keep saying, when we don't, if we don't, we're in a world of hurt and boy. 

I could, we could have another whole session. But with all that being said, while COVID has exposed the chinks in our armor in fact, there are a lot of chinks in the armor and I believe when discussing these things with Dr. McNeal in the past, she's always made a comment that when you actually look at the chain, we're as strong as the weakest link in our chain, and COVID revealed an important weak links in the chain, so we had to address that. 

1:06:16 - Kimberly King

So with that revelation, again on the timing. So now it's out there in the open. There's no, that's not lying to anybody, there's no mis. You know naming what has happened. Where are we at with what happens next? 

1:06:37 - Doctor Ricardo Parker

We're talking about that, isn't it? 

1:06:39 - Kimberly King

I mean, it's kind of in that same so, with this reveal, though specifically with everything I mean we have, this has been our conversation, but has it accelerated now? Just because now there's no denying this is. 

1:06:54 - Doctor Ricardo Parker

I think what the aftermath of COVID when we look at our healthcare provider and Dr. McNeal indicated that people have dropped out either suicide burnout, if that matter a lot of folks not wanting to go into a healthcare system because of seeing the challenges and problems that we actually have. So therefore, the pipeline in which we try to recruit and bring others in becomes depleted. Now we already had a problem. Obviously we continually have a problem with the. 

If you look at the pipeline of people that are retiring, in healthcare and those that are actually coming in replacement retirement is at a much more higher rate than the influx of folk coming into the system. 

And even just before, prior to COVID, the baby boomers, for example. This next, what five plus years? If you look at the baby boomers, the largest portion of that bubble is actually coming to retirement right now. And throw COVID on top of that, with all the other challenges we had there, that pipeline is dwindled and I am for myself, personally, what I really want to try to focus my efforts at National University on is what can we do to incentivize students, at least let them see the need. Of course, in our School of Health Professions all the programs that we have in that school, we're trying really working hard to really get students incentivized to say that look, guys, we see these problems, we can see them nationally, locally, but look in your community. What can you do in your community to start? And it starts there. You've heard that expression think globally but act locally. It's what a rubber meets the road, and when I'm talking to my students other than going through the lectures or whatever, I'm always trying to integrate. 

1:09:03 - Kimberly King

We are both direct reflection of starting from your community and look at where you started and look at where you are now, and that is such a key. You're right think globally but act locally. 

1:09:15 - Doctor Gloria McNeal

So when I spoke about the 80,000 students who return away, we need to have a better way of educating students using the technology available to us. So we are beginning now to use virtual reality, augmented reality, those kinds of technologies into the classroom, where the students can immerse themselves in this environment, be well trained and able to hit the ground running when they graduate. And I borrowed that scenario from the aviation industry. 

So a pilot has to sit in a simulated cockpit for thousands of hours before he or she has even left to be in a real plane. And you can't expect that the experience of a vertical nose dive is gonna happen often enough that you're gonna know what to do about it. Right, it's too expensive at risk to take. So nursing is moving forward. With VR technology, we're putting our students into immersive situations. We're having the patient deteriorate before your eyes. We're having the student have to think quickly on his or her feet to turn that situation around, and we can practice again and again and again. You can't do that in the real world. 

1:10:44 - Kimberly King

You can't do that in the real world, you don't get that second chance, right. I can have a whole show on just this, because this is something new, as you're talking about, with this immersive virtual reality, and I think it's fascinating and I love your, you know, talking about the pilots doing a nose dive. I mean, it's true, when you think about it, it's about scenarios that we're not. I lost both of my parents to cancer and to Alzheimer's, but it's, you know, we don't. We learn the facts of life, but we don't always learn the facts of death, and that's just a reality, right. So just to go along with what there's realities every day and scenarios that we just don't talk about in anything and everything, but especially as we're talking today about racism in healthcare, but with that VR, I think it's fascinating that we're here now. 

1:11:37 - Doctor Ricardo Parker

You know, I really admire this lady here. 

1:11:40 - Kimberly King

Oh, I do too. I mean, why are both of you? 

1:11:43 - Doctor Ricardo Parker

And she's very soft spoken and she's a powerhouse. 

1:11:48 - Kimberly King

Yeah. 

1:11:49 - Doctor Ricardo Parker

I think she mentioned earlier in her introduction that she has been involved in directing at least two programs sister nurse manage, National University nurse management program, and one that we're currently engaged in where she got a hercogram for over a million bucks I believe. That involves simulated virtual reality and we have this workshop that these students can go into as an eight week program that they're learning again this engagement, this hands-on virtual reality and really speaking to where the rubber meets the road and some of these healthcare issues, particularly in underserved community. What can we do? 

to improve that. We're actually teaching students how to develop research grant proposals. Great that are. I'm talking about those that can hit the ground running, and we've had several students that have put together proposals that a couple of them have actually submitted for funding. 

1:12:52 - Kimberly King

And that's a part that's the business side of it, but that's something that probably hasn't happened. 

1:12:58 - Doctor Ricardo Parker

It's a skill set. It is, and that's something that we rarely get in an academic institution. 

1:13:03 - Kimberly King

I love hearing that. 

1:13:04 - Doctor Ricardo Parker

And Dr. McNeal and her vision and what she really has put together an incredible program and again looking at where the future is using virtual reality as a means to teach students that you can make a mistake over and over and over again until you get it right so that when you're in a real world situation you know automatically what to do, right. It's critically important in the healthcare environment. 

1:13:33 - Kimberly King

It's saving lives. Yeah, and again, it's interesting to me that it's taken this point. I literally could talk to you about this all the time, because it is. It's a shocking when your first was you're a new nurse or a new doctor and you come upon something you've never heard about or talked about, and it is shocking, and it's that split second. That's what it takes. So I go kudos to you. I'm among greatness here on both their behalf. What percent of US citizens continue to be uninsured? I know we've been talking about this, but is there a percentage, a number on this? 

1:14:09 - Doctor Gloria McNeal

Well, it keeps going up and down, but it's about 10% now. It was 40% just before the Affordable Care Act was passed, so that did cover some people, but remember that the states had to buy in to the Affordable Care Act and 26 states did not, and so in those states those individuals did not have the luxury of being able to be insured. So we have to rethink how we're going to utilize state mandates and how we're gonna cover care expenses. 

1:14:47 - Doctor Ricardo Parker

And if you look at that, look at that in the advent and aftermath of COVID. Because these states didn't buy into expanded Medicare and already deprived environments or communities, it impacted them more significantly with regards to the COVID incident. But it mattered the death associated with COVID. It's a double edged sword and. I think we really ought to lay all this on the table name of what it is and make some real inroads to change this. 

1:15:27 - Kimberly King

This conversation today. We need to get this global. Everybody needs to sit down and listen to what you're having to say, because, again, eyes have been opened, and especially right after COVID. What are the social determinants of health? Okay, that's a loaded question, isn't it? 

1:15:48 - Doctor Ricardo Parker

When you look at a person's health, it's influenced by a range of factors called the social determinants of health. It includes who they are. That means their gender, their age, what they do, their lifestyle habits that be, the smoking, alcohol and their diet. Now you also have to look at the conditions in which people are born, where they grow up, where they live and where they age. This also includes people's social and community networks and socioeconomic, cultural and environmental conditions, and also the healthcare system in which these people live. Now, these factors are highly variable and collectively, are called social determinants of health. Now, social determinants of health are ultimately saved by money, power and resources, and also whether they're available locally, nationally or internationally. Now, again, social determinants of health are very variable and complex because they all interact, and now that interaction has to deal with both the conditions and the structured systems in which they interact. 

And that also determines, or has determined, what we call health inequities. Now health inequities by a functioning definition is an unfair and avoidable health differences between groups of people. That's broadly. However, and if you actually look at the national dialogue of when we talk about health inequities, interestingly enough nowhere in that national conversation when we talk about social determinants of health, do you hear any discussion about the five ton gorilla that's in the room and that's the role of racism in this country on health and health outcomes the World Health Organization has framed probably provided two broad frames of determinants, and I mentioned them earlier one was socioeconomic and political. The other has pertained to the actual self-determinants of health. 

The socioeconomic political identified three areas. We said governance policies and values. What we value and defining those can translate into the community in which we live, because policies, laws and policies and practices have kind of established these structures, if you will, and living environments in which we live. That includes people living close to industries where there's polluting of the air, polluting of the water, polluting of the land. You find that those that are under rep well minority generally are in those types, are close to those type of environments, versus the other side where the wealthy date. They have the money and wherewithal, political power to avoid those areas. 

The other component that World Health Organization speaks to is actual social determinants of health and those are ones I've indicated about where a person is born, grow up, live and where they age, and all of those again are highly complex, interactive, and the outcome of that is what we have to deal with, and that's where the inequities come into play. 

1:19:37 - Doctor Gloria McNeal

And I would add, education access. Under no circumstances should children be graduating from our high schools unable to read or write, and if we continue down that path, we will lose our status as a world-class nation. 

1:20:00 - Kimberly King

Amazing. I could talk to you both all day and I really appreciate the time that we've had today to have this conversation. Absolutely go ahead. 

1:20:09 - Doctor Ricardo Parker

I can make one statement just to add to that and probably tie it up in a nutshell these challenges that we spoke to and are speaking to, as I indicated I actually mentioned it prior that we have to look upstream, look at all those factors, those structures that are already in place causing the challenges that we see right, now. 

And it will continue to cause the challenges in the future. Looking upstream, start actually making certain policy changes and our leaders will really have to be put to tax for that. And here is where those of us that went to rubber meets the road, Joe Blow Citizen we engage ourselves and just necessarily have to get totally immersed. But, if you like that, get totally immersed in your local activities. What's going on? The PTA community, start becoming community activists and, most importantly, this is for everyone. Okay, what your political persuasion is, vote. 

1:21:07 - Kimberly King

Right, ooh. Participate in the process. 

1:21:12 - Doctor Ricardo Parker

I think that's where we have to make the greatest impact and make our voices known and name things what they are, move them forward. 

1:21:25 - Kimberly King

Amazing, thank you. Thank you both for your time and for what you've accomplished and where you are now and where you're going in the future. I'm just, it's such an inspiration. If you want more information, you can visit National University's website, nu.edu, and you can find Dr. Gloria McNeal and Dr. Ricardo Parker there today. Thank you again for your time and we look forward to your next visit. 

1:21:49 - Doctor Ricardo Parker

Thank you, it's a pleasure, thank you. 

1:21:54 - Kimberly King

You've been listening to the National University podcast. For updates on future or past guests, visit us at nu.edu. You can also follow us on social media. Thanks for listening.