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Dr. Ruth Shim – Achieving Equity in Mental Health Services Research (Mental Health Services Research Conference Day 2 Keynote Address)


Hi. Welcome to the MHRS, the second keynote. We're honored to host Dr. Ruth Shim for this keynote presentation on Achieving Equity in Mental Health Services Research. Dr. Shim is the Luke and Grace Kim Professor in Cultural Psychiatry, a professor of Clinical Psychiatry in the Department of Psychiatry and Behavioral Sciences at the University of California Davis, an Associate Dean of Diverse and Inclusive Education at the UC Davis School of Medicine. She is an expert on mental health equity, structural racism in medicine, and diversity equity and inclusion in academic medicine. After Dr. Shim's talk, we'll have a few minutes for discussion. Please feel free to submit questions using the Q&A button. As a reminder, when you click on the question mark box, if the pop-up box appears low in the bottom left of the screen, you can click and drag it elsewhere on your screen to make it easier to type. So with that, I'll turn it over to Dr. Shim.

Thank you, Jennifer. And I'm really so pleased to be here with all of you virtually. And as I was mentioning before, I always try to pack way too much information into one talk. And so I'm going to jump right in so that we can hopefully have some time for discussion. So we are going to talk about how to achieve equity in mental health services research. And we can't really talk about achieving equity without talking about structural racism and how to address social structural racism. And before we can even talk about structural racism, I have to offer up a couple of disclaimers because it's very, very hard to talk about these topics. And one of the reasons why it's so hard is because we've been socialized to believe that it is not polite to have these types of discussions. So it's difficult for us to talk about racism, injustice, and oppression without thinking that we're being rude or we're being inappropriate. But also, I think it's very difficult because mental health services researchers do not have kind of a fundamental understanding of the connection between oppression, injustice, and health.

These things are not typically or traditionally taught in the training that the standard mental health service researcher might get. And then another reason why it's so hard to talk about structural racism relates to the fact that there's a lot of retrenchment whenever we try to make progress, whenever we try to move forward addressing issues of race. And as an example of that, this is some data from The New York Times that talks about levels of support of the Black Lives Matter movement over time. And what you can see here is looking at different racial and ethnic groups of people that white people are currently in current times less supportive of Black Lives Matter than they were prior to the murder of George Floyd. And so you see a huge peak in the support for Black Lives Matter after the murder of George Floyd. But then there was almost a massive regression after that and really almost kind of a backsliding in terms of level of support. And it's that kind of challenge that makes it so difficult to really move forward and make progress in these areas.

And then I think that when we talk about structural racism, there's a lot of politics involved. And so you can see that The Wall Street Journal keeps a lot of discussion open. Much of this discussion comes from a former associate dean of curriculum at the University of Pennsylvania, Stanley Goldfarb, who has made kind of a career in his retirement from really lamenting the ways in which talks about racism, talks about equity, talks about oppression, has kind of made it into medical education and really maybe infected the ways that we think about health and health care. And so some of these articles you see here have been widely published and with a lot of response. But what I think is most concerning about that is that The Wall Street Journal editorial board also expressed a lot of concern about this direction that medical education is going in and thinking about systems of oppression. I do want to point out that the Association of American Medical Colleges did respond specifically to these (UNKNOWN) by pointing out that there is ample evidence that historically marginalized people who live in poverty, as well as members of the LGBTQ communities disproportionately experience poor health and inadequate access to quality care.

These inequities are often rooted in systemic discrimination, including racism. And so I bring all of this up to kind of set the stage for our discussion today and just say that I have to acknowledge that these are difficult topics, but also that we are smart and intelligent people and we should be able to grapple with some of these difficult topics and be able to move past kind of the basic limitations that prevent us from really making important progress in this area. So one of the reasons why it is difficult to think about race and to think about structural racism in mental health services research has to do with the fact that race is a social and political construct. And I know that people have heard that concept over and over and over again and I will just say it is challenging sometimes for people to understand what the meaning of race is a social and political construct actually means. And what it actually means is that there is not any sort of accurate biological or genetic categorization of race that can be made.

I can't draw somebody's blood and determine what their race is and I cannot run any genetic test on someone and determine what their race is, because the categories that make up race and ethnicity are categories that we have created as a society. We have created to advance certain objectives. And we've created those categories, quite frankly, to ensure that one group of people can oppress and marginalize other groups of people. So we created those categories in order to confirm and to perpetuate hierarchies of power. And so what we do know about race is that it is a rough and imprecise proxy for a number of other things, including culture, genetics, and socioeconomic status. And we also use race to confirm a number of assumptions and prejudices and biases about our patients, about the participants in the studies that we run and we really kind of run with those assumptions and prejudices and biases, and it sometimes infects the work that we do. And so it is kind of important to get back to this concept of the social and political construct of race.

There is no genetic basis for race, despite again many genetic programming and testing and many thoughtful geneticists having some belief that there is. But what we do know from sequencing the human genome is that 99.9% of all genes are shared by all humans and that variation exists only in about 0.01% of the human genome. And in that 0.01% of that variation, the proportion of total diversity in the human genome is actually about 87% within populations, so not across racial groups. So in that tiny little variation, the variation that you see in that variation is within populations, and then a small percentage and even smaller percentages between populations within regions and then between regions. So what we know really about race is that it really codes for very small, subtle differences in kind of outward appearance like skin tone, hair texture, but it doesn't really code that effectively or helpfully for kind of the internal things that we think about. Now, of course, we then think about genetic ancestry and we say, well, that's not true.

There are certain conditions or certain illnesses that are passed on. And in mental health services research, we look a lot at family history, and that becomes a very important and significant role. So genetic ancestry is (UNKNOWN) but it is not the same thing as looking at race and ethnicity. So genetic ancestry involves sharing a genetic line of descent. And it is important because some population groups are more likely to carry certain alleles because of a shared ancestry. But what's really key here is that that shared ancestry may or may not be mapped onto regions within the world. So we're thinking more regionally when we talk about genetic ancestry and much less from a racial categorization. And just to kind of really hammer that point home when we think about the countries, because one of the illnesses we talk about a lot when we think about genetic ancestry around race is sickle cell disease. And so when we think about sickle cell disease, we think that particularly in the United States that sickle cell disease is a disease, a racial disease, a disease that only impacts black people.

But actually, we know that that is not correct, that there is genetic ancestry associated with sickle cell disease, but it is not a racial disease. And so we know that the three countries with the highest rates of newborns with sickle cell disease in the world are Nigeria, Congo, and India. And so what happens if we're only looking for a disease around a racial group or organization we are going to miss people and not and not be able to treat them effectively. So a mini history lesson of how we got to this point. I want us to ponder this particular quotation. It says that African-Americans have higher incarceration rates, higher unemployment, lower incomes, lower home and business ownership, less education, less health care, more disease, and lower life expectancy than whites. If you believe blacks are naturally dumb, sick, criminal, you have your answer for these discrepancies. If, however, you resist using stereotypes to make sense of your world, institutional racism provides a very practical and very traceable explanation for the inferior societal position of African-Americans.

And I find this quote to be so important because I think that we don't disagree with the things that are said here. I think the data does reflect that, particularly in the United States, black people do have these poor outcomes consistently across the board and we see these poor outcomes consistently as it relates to mental health conditions as well and access to health care, access to more diseases, these types of things. But I do think that we have not always resisted using stereotypes to make sense of why we see these differences and outcomes. And many times we have kind of reverted back to thinking that maybe there is some sort of natural intrinsic difference in these particular populations. Maybe there is some sort of biological inferiority or some sort of genetic inferiority that's really driving these differences that we see. And then if we're going to go all the way back in history to the founding of this country, we can talk about this painting, this famous painting, the signers of the Declaration of Independence.

And, of course, the ideals on which this country was founded, which is, of course, that really powerful statement in the declaration. We hold these truths to be self-evident that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness. And that's such a powerful statement. And it is, again, the ideals on which this country was founded. But I think that not enough people acknowledge or not enough people understand the history of this country to recognize that this ideal was not a universally held ideal, that when the men that gathered in this room gathered to sign the declaration, they gathered specifically to say that all men were created equal. And also they were very particular about making sure they meant the men that looked like them, because certainly they were not talking about indigenous people and they were not talking about black people, and they were also not talking about women.

And so there was at the founding of this country, a very clear idea that only certain people in this country should be granted unalienable rights like life, liberty, and the pursuit of happiness. And then if we fast forward a little bit in history, we get to a physician by the name of Samuel Cartwright, and he really kind of advanced this idea of psychiatric pseudoscience. He describe conditions like drapetomania, which was the disease that he said, the mental illness that he said was of enslaved black people wanting to run away from captivity and described that as a mental illness. And he also talked about another condition called Dysaesthesia, Aethiopica. He said this was a disease of rascality or the enslaved black person's tendency to be lazy and to not want to work hard. And this description of these conditions, which were, you know, not universally accepted and a lot of people kind of laughed at Cartwright and thought he really didn't know what he was talking about, even at the time in the 1850s.

But even at that time, his thoughts had some remarkable persistence in modern-day times because I do think that there is a tendency to have that some people do believe that black people may be not wanting to work hard or may be naturally more likely not to be lazy. And so there is a certain persistence, even when an idea can be fully debunked, the stereotypes can really perpetuate over time. That gets me to this definition that I think is so important and something that I kind of harp on because I want us to be really precise in the way that we define things. And it is the difference between health disparities and health inequities. So health disparities are described as differences in health status among distinct segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, or where you live. And I contrast that with this definition of health inequities, which are disparities in health that are the result of systemic, avoidable, and unjust social and economic policies and practices that create barriers to opportunity.

So it's so important to contrast these things because health disparities, which is what we all talk about when we talk about differences in health between different groups in the United States in particular. Health disparities does not give any sort of explanation for why we see those differences in health. So it's a definition but it's not as precise as it could be. Because what we really see in this country, when we look at differences in health, and particularly when we look at differences in mental health, that those differences that we see in mental health outcomes across population groups are specifically the result of systemic, avoidable and unjust social and economic policies and practices. And I would say probably about 99% of the differences that we see among populations has to do with or are driven by systemic, avoidable, and unjust social, economic policies and practices. When we talk about health disparities and we don't name that up front, I think sometimes people have the tendency to sit the problem in the individual or in that group, in that population.

So they might say maybe that particular population has some sort of biological explanation for why we see these differences. A clear example of this often is when we think about women and rates of depression, and we know that women have higher rates of depression in our country and in our society across the world than men. And I think that if you take a health inequities approach, you would think very deeply about the fact that we live in patriarchal societies, the fact that women are much more likely to be victims of trauma and abuse than men are. And they're also more likely to be victims of policies that are oppressive and create unfair social and economic conditions for women, including, you know, very recent Supreme Court decision in the Dobbs case. But if you focus on a disparities approach in approaching these things, you might be more likely to think, oh, this must be, the explanation has to be a hormonal one. It has to be that testosterone has some sort of protection and that estrogen does not around depression and you can go down that path.

And it's not to say that it's not important to study these things, but studying those things without focusing on really these systemic, avoidable, and unjust policies and practices being kind of the primary drivers of those differences, I think is a really important thing that we often tend to miss. So we're really here talking about the social determinants of mental health. And these are the societal, environmental, and economic conditions that impact and affect mental health outcomes across various populations. These conditions are shaped by the distribution of money, power, and resources at global, national, and local levels which are themselves influenced by policy choices. And the social determinants of health are prominently responsible for both the disparities and the inequities that we see within and among populations. So here is a conceptualization of the social determinants of mental health by myself and Michael Compton. And you see at the very top of this figure, you see adverse mental health outcomes and mental health inequities.

And as you move down the figure, you're moving further upstream. So the next step below adverse mental health outcomes are a number of risk factors. And we know that risk factors precede an illness and lead to the development of that illness. And so all of these risk factors here, these reduced options, these behavioral risk factors, these physiologic stress responses, they come together to create this outcome. But what we know is that when we try to intervene at the level of the risk factor we're often intervening too late because there is a lot of context that is set that leads to the development of that risk factor. So if you move further upstream, you get to these boxes in the center, these are the social determinants of health or what Sir Michael Marmot and Jeffrey (UNKNOWN) call the causes of the cause. What Bruce (UNKNOWN) and Joe (UNKNOWN) call the fundamental causes of the disease. So those are the social determinants of health. These things like adverse early life experiences and low education and housing and food insecurity and poor access to health care and climate change and neighborhood disorder.

So all of those things are the social determinants of health, incredibly important. But we have come to understand that if you're intervening at the level of the social determinant, you're still intervening too late because there is further, there is even more context that is set prior to the development of that social determinant. And that context is social injustice. It's unfair distribution of opportunity that really drives the creation of the social determinants of mental health. And underlying all of that are public policies and social norms that really interact with each other, social norms being our ideas that we have in society about who is valuable and who is less able, and (UNKNOWN) policies are the laws that we pass that reflect those ideals. So as an example, we can talk about crack cocaine. We can think a little bit about our perceptions, our social norms about people. And particularly in the 80s crack cocaine was a highly racialized condition in which we thought that men who use crack cocaine, black men who use crack cocaine were dangerous criminals and that black women who use crack cocaine were crack mamas that were not interested in taking care of their children.

Those were our social norms and as a result of that, we passed a number of policies in the eighties that were incredibly punitive based on our beliefs about the types of people who use this drug. And so one of the most important things that we passed was the Anti-Drug Abuse Act of 1986. And that was the law that created a 100 to 1 jail sentencing disparity between crack cocaine and powder cocaine. So the same chemical compound of drug but if you were caught with one gram of crack cocaine in your possession, you would get the very same jail sentence as somebody with 100 grams of powder cocaine in their possession even though these drugs are the same drug and that even though 100 grams is clearly someone who is planning on distributing and selling that drug, whereas one gram is somebody who's using for their for their own substance. And so that law created a number of negative social determinants of health that impacted people. So those social norms and public policies created an unfair distribution of opportunity that led to a number of social determinants of health, mass incarceration which led to people leaving when they left jail after being incarcerated for long periods of time for substance use disorder, those people would have difficulty finally finding a job because they had to state that they were felons on employment.

And when you don't have a job, you don't have money. When you don't have money, it's hard to find a place to live. It's hard to access healthy foods. When you don't have a job you don't have health care. So all of these social determinants of health are activated by these laws and by these social norms. And also, it's important to know that there are multigenerational effects here because one of the adverse childhood experiences that we know is having a parent that's incarcerated. So we have kind of a number of effects that take place. And then also, I want to point out that these policies were not focused at all about making sure that people got treatment for mental health conditions. These policies, as stated by Ernest Drucker, the fundamental ability of drug treatment professionals to individual patients has been subordinated to the goals of the criminal justice system. And I think it's important to contrast the ways that we think about that (UNKNOWN) the opioid epidemic, where we do think of opioid use disorder as a public health crisis.

And we don't think about people who use opioids as criminals, and we don't create policies that directly work to incarcerate people or marginalize people from society. So a couple of concepts that I really want to run through very quickly. The first is to kind of define structural racism, which is something that is a bit challenging to define. But I really like the definition from the Aspen Institute, which says a system in which public policies, institutional practices, cultural representations, and other norms work in various often reinforcing ways to perpetuate racial group inequity. This system identifies dimensions of our history and culture that have allowed privileges associated with whiteness and disadvantages associated with color to endure and adapt over time. It is not something that a few institutions or people choose to practice. Instead, it's been a feature of the social, economic, and political systems in which we all exist, and it does not require the actions or the intentions of others.

So if we got rid of all of the interpersonal discrimination that exists in society today, we would still see racial and ethnic inequities due to the persistence of structural racism. (UNKNOWN) about some other important concepts, some ways of which we see errors in thinking that we see show up when we talk about structural racism. And the first is essentialism. And this is the belief that there are distinct, unchanging, and natural characteristics that define social groups. Things like race, ethnicity, gender or sexuality that facilitate their categorization. Sadly, and I think this is really important to think about when we're doing mental health service research. Sadly, human beings do not categorize as well as we believe that they should. And so across these ideas, like race and ethnicity and gender and sexuality, (UNKNOWN) discretely fall into any of these categories. And so when we try to categorize people and put them into these categories, we are going to make errors much of the time.

And then erasure of context is when we fail to consider the socio-historical context we're seeking to understand the ideology of inequities, that really speaks to it for itself. But really thinking about Cartwright and assumptions that he made is an example of how badly it can go when you don't have an understanding of the social, historical context. Biological determinism, it's the false belief that racial groups are biologically and genetically different. I say the false belief and interestingly enough, there are still people that do believe that there are biological differences between races. There was that Hoffman study in 2016 in which medical students, high proportions of medical students believe things like black people have thicker skin than white people. Black people have fewer nerve endings than white people. And then cultural determinism is kind of like biological determinism's cousin. It's the false belief that the differences that we see in racial groups are primarily the result of cultural factors.

It's really pushing an idea that some cultures are just better at thinking about their health, and other cultures are less thoughtful about health decisions and mental health decisions. Cultural determinism shows up a lot in our mental health research around thinking that certain communities of color have more stigma about accessing mental health services without really understanding the socio-historical context behind why that might be the case. I want to talk briefly about oppression because I mentioned there is this connection between oppression and marginalization and poor outcomes and health. These are the five faces of oppression as described by Iris Marion Young. They include exploitation, which is the unequal exchange of one group's labor and energies for another group's advantage and advancement. For example, that is, of course, the practice of chattel slavery in this country. But also current-day exploitation includes human trafficking, treatment of migrant farm workers, treatment of warehouse workers even are clear examples of exploitation.

Cultural imperialism is establishing the ruling class culture as the norm and othering those groups that is not part of the dominant culture. Where I see this show up in mental health research all the time is when we are looking at odds ratios and we're comparing race and ethnicity and looking at differences. And I think every study that I've ever looked at, whenever the study is being done, white people are always the reference group and there's not really a question about that. There's not really kind of why are we choosing white people as the reference group. It's just this understood thing, this idea that this is the normal group and so we must compare all of the other groups to this normal group. Powerlessness is when oppressed groups lack power and are blocked from routes to gaining power. We see this very clearly with current attempts to suppress votes and prevent people from proper representation. Marginalization is when we expel specific groups from meaningful participation in society.

So mass incarceration and generally the treatment of indigenous people in this country. And then violence is just, as it says, threats and experiences of physical and structural violence. So in the time that I have left, I want to talk about possible solutions. And here, you know, where we're currently in the state of inequality where we have unequal access to opportunities, a lot of people when we talk about solutions will say, oh, we need to move towards equality. Whatever we do, we need to make sure we're being fair. And so we don't want to single out any populations. We don't want to give more to one particular population, that would be dangerous. But you can see from this figure that if you're trying to address structural racism and mental health inequities and you're taking an equality approach, an approach of fairness, you will not solve the problem. So to solve the problem, we have to take an equity approach. And that's when you customize the tools and give the particular population what they need to be successful.

But it cannot be equity alone. It has to be partnered with justice. And justice is when you fix the system to offer equal access to both tools and opportunities. So we have to think about how are we going to combine equity and justice and coming up with solutions. And this is a really important paper that was published (UNKNOWN) that talks about in the NIH how there's a massive funding disparity that I myself have personally experienced. And this article is such a great article. It's called Fund Black Scientists, and it really just highlights how many possibilities, how many opportunities for achieving equity are not reached in the process, and the current policies and processes we have in the NIH and our review process. And so there are opportunities to push innovation and creativity if we were thinking from a more equitable mindset and thinking about how to fund people of color in their research. And so if we're going to eliminate structural racism, there are a number of things that we should be doing.

First, we need a lot of context, we need a lot of education. We need to be able to be educated and we need to self-reflect. And these are things that we're not traditionally taught in any of our training programs, in any of our places. So I have listed a number of books here to help you begin your journey to self-education on these topics. And I want to highlight one book in particular because Medical Apartheid really highlights and talks about how few people of color and how few black people engage in medical research. And I'm not going to read this quote right now but really we need to think through why we have not considered the context of why black people and other people of color are resisting research in a really thoughtful way. There are, I think, even more books and so I've added an additional list of books here. I find these books to be more accessible. And then there are a number of podcasts that are also accessible. And then we need to practice this concept of cultural humility which was created by Melanie Tervalon and my colleague Jann Murray-Garcia.

And cultural humility is about three important concepts first, committing to a lifelong practice of self-evaluation and self-critique, and then a desire to fix power imbalances between providers and clients. And then most important is developing these community partnerships to advocate within the organizations in which we participate. I really want to emphasize that lifelong process of self-evaluation and self-critique because you can't go to one lecture, you can't take one class and kind of be done. This is a journey that you're on and you commit to for basically the rest of your life. And then I think we also need to be much more thoughtful about taking a structural competence approach. And this is work by two wonderful psychiatrists, Jonathan Metzl and Helena Hansen, who talk about the trained ability to discern how a host of issues defined as symptoms, clinical problems, attitudes, or diseases are influenced by upstream social determinants of health. So we should be kind of thinking more in that vein about how can we look at the systems that we're evaluating, the services that we're evaluating, and think about how to incorporate the social determinants of health into those thoughts.

And then I think we also have to focus on being anti-racist. And these are the words of Ibram Kendi. He said The opposite of racist isn't not racist, it's anti-racist. What's the difference? One either endorses the idea of a racial hierarchy as a racist to equality as an anti-racist. One either believes problems are rooted in groups of people as a racist or locates the roots of problems in power and policies as an anti-racist. One either allows racial inequities to persevere as a racist or confronts racial inequities as an anti-racist. There is no in-between safe space of not racist. And then he concludes by saying, the good news is that racist and anti-racist are not fixed identities. We can be racist one minute and anti-racist the next. What we say about race, what we do about race, and each moment determines who, determines what, not who we are. And then I think that we need to think about the ways in which we're measuring structural racism from a mental health services perspective.

Single domain measures are not appropriate because structural racism is multifactorial, it is complex, it is interactive. And so it's best to consider a multitude of index measures that cover a variety of domains and relevance should be assessed over historical eras and across the entire life span. And so then we have to address public policies and social norms. And so if we're going to promote social norms of inclusion and equity, we need to enforce them. We need to either educate or legislate to change social norms. We need to observe and challenge our own implicit biases and evaluate and break down unnecessary hierarchies. If we're going to advocate for equitable public policies, the work involves taking action beyond the walls of our research institutions, moving into those community spaces, advocating for social determinants of mental health and policies that dismantle structural racism, communicating with elected officials to promote equitable representation, and using the research that we do to advance that equitable representation and legislation and forming cross-sector collaborations and conducting racial equity assessments.

And so I will wrap it up with just a couple of final concepts. The first is that political stances and policy interventions are required. Because to remain apolitical or neutral is in fact a political stance because it is a tacit acceptance of the status quo. And then one of the other things that we need to do is become much braver. We need to be able to speak out when we see injustice and when we see it within our own institutions and among our own communities. And so these are the words of Audre Lorde. She said, When we speak, we are afraid our words will not be heard nor welcomed. But when we are silent, we are still afraid. So it is better to speak. And then to end, I brought this up at the beginning. I said that, you know, we're in a time of progress, which is made through the passage of legislation, court rulings, and other formal mechanisms that aim to promote racial equity. But also, I think it's important to remember that always with progress comes retrenchment. And these are the ways in which progress is very often challenged, neutralized, or undermined in key policy arenas.

And so as an antidote to that retrenchment and to the undermining of progress I often look to the words of Congressperson John Lewis, who said, Do not get lost in the sea of despair. Be hopeful, be optimistic. Our struggle is not the struggle of a day, a week, a month or a year. It is a struggle of a lifetime. Never, ever be afraid to make some noise and get in good trouble, necessary trouble. So thank you so much. I think we have some time for questions.

Yes. Thank you so much, Dr. Shim, for this presentation. And before we get to the questions, I'm going to remind the audience that these slides will be available once closed captioning is completed. So it might take a little bit of time for all of the slides to be ready, but they will be available and also in perpetuity on the NIH YouTube channel. So if audience members want to go back, especially to get the books that you've recommended that these resources will be available. We've also obviously had a number of questions that have come in. We won't be able to get to all of them. But clearly, this discussion's sparked a great deal of interest. And I'll just briefly mentioned that someone's nominating you for a Nobel Prize, much deserved. So I'll start with one question thanking you for a wonderful presentation, it makes it very clear as to why we need to focus on health inequities. How can this awareness be disseminated to the average person?

I mean, I think that's a great question about dissemination, I think is really key. The average person, that's a struggle for me because what I found in thinking about these concepts and how important these concepts are, is there is so much resistance in our society to talking about, to learning about, to being really kind of honest and straightforward around these concepts. If you compare the traumas of slavery, marginalization of indigenous people, the things that we did at the founding of our country. If you compare those to other atrocities that have happened across the world, in almost every other instance, those countries in which those atrocities occurred have been much more thoughtful about how they approach the healing process around acknowledging and moving forward and moving forward together as a society. And for a number of reasons that we could spend a lot of time talking about here, we have not gotten to that place in our society where we're able to just really have some honest conversations about what happened.

And so as a result of that, because there is so much retrenchment because so many people are so resistant to this idea, and because I think so many people still kind of harbor really entrenched beliefs that there are inferior races of people in this country, I have chosen not to think about disseminating this information to everybody. I think that the work is really disseminating the information to those people who just haven't been educated enough. So they haven't had enough knowledge to be able to make up their own minds about what is happening and what's going on. And so I think that our work is about making sure that people who haven't ever really thought about this information gets accurate, straightforward information about these things. And I feel like there's a number of really effective strategies happening kind of in society in this country to do that. One of the most effective ways I think that has communicated this is the 1619 Project and the 1619 podcast, which has really kind of had an incredible power at disseminating this information.

Thank you. I think we have time for about one more question. We have a couple of minutes, and I don't think any of these questions could be answered in a couple of minutes So we'll do our best here. But given that race is a social and political construct that cannot be accurately biologically or genetically categorized, what are your thoughts on researchers measuring race in a productive way?

Measuring race in what kind of way, sorry.

Yes, sorry. In a productive way.

Yes. I think that's a great question. I think that and maybe I didn't emphasize this as well as I would have liked. But when we talk about race being a social and political construct, we don't always talk about how it has massive implications though. Just because it is a social and political construct doesn't mean that it doesn't have like massive impacts, because really the impacts are racism. So the structural racism is the thing that creates these differences in outcomes. And so we have to study and we have to think about and we have to consider race and we have to incorporate race into our design of studies in order to try to better capture the structural racism. And that's why when we talked about those index measures, those index measures are used to measure across different racial groups. But I think because it is a social construct, what we have to keep in mind is that when we're looking at racial groups, we have to be very thoughtful about how we're measuring those groups, and we have to be incredibly thoughtful about making sure that we're capturing people's self-identification as to what their race is.

Because I think sometimes we look at people and we make assumptions and sometimes race is assigned to people instead of people kind of identifying. And because it's such a messy construct, when we get to people who are biracial or multiracial, based on their appearance they may identify with a certain race or racial group. They may identify as multiracial but they may not. And so it really depends on kind of creating important measures that could really better categorize the experience of the individual and how to do that in a way that is incredibly thoughtful and really kind of gets to the complexity. I think that one of the important things we have to do is really make sure that we're thinking through how we write and how we create context around these things when we present this data and when we look at the data. So I often ask people to just kind of create the context before presenting any data on race, around talking about race being a social construct and how it's inaccurately addressed.

However, these are the ways that we categorized it for this particular study.

Thank you so much. Really appreciate it. And thank you to everybody who submitted questions. And as you said, you can't get to all of them today. (UNKNOWN) the presentation will continue to be available on the NIH YouTube channel once it's ready. And we do invite you now to go into the next concurrent session. If you exit out of here and go back into the auditorium you can select the concurrent session of your choice. But again, thank you so much, Dr. Shim, for taking the time to speak with us and for creating these resources that will continue to be available. Thank you.