The title of this talk actually comes from thinking about the Death and Grandfather's group and the fact that that helper has been around for 11 years or something like that. I think I'm going to wait a couple of minutes until I get people a little bit longer and trickle them because I do have as many people here as possible just to, you know, with doctor names or votes and so on and so forth. This one I'm going to talk about is changes that have been made to Def Conk over the past about a year and a half. In terms of all of this, sort of unexpectedly, we started making some larger changes to that helper that have happened in the past seven or eight years of its existence. And one other thing, if I say Def Conk accidentally during this talk, I mean Def Helper and just for other people's information, when I referred to Def Recade, Def Helper yesterday I was referring to Def Conk. I do tend to get confused. I have no plans to Def Recade Def Helper at this time. So you should all be familiar with this, I hope. This is pretty much how your W to this file has looked for 10 years or so. Now, what happened to me last year as I was looking at this and I realized, hey, there's some code duplication here. So it's re-factoring. And so the idea here is that DH, Binary Arch, just runs everything that your Binary Arch company will do. So that's simple enough to write. And that's DH. You went into Def Helper 7.0 back in last year. And when you use DH for an entire rules volume, come up with something like this. So for every target, for every standard target, you run DH. And you just give it the name of the target. Now you might ask, what about dependencies between targets? What happens if I run the Binary Arch target and I haven't run build yet? And the answer to that is that DH is intelligent and tries to figure out behind your back basically what you've already done and what it needs to do next, even without targets in there. Now if you want to, the targets in there, you could stamp files and all that kind of thing like you've had before. But the fact is you don't need any of them. And the nice thing about that is that we can notice, hey, there's code duplication that's fine. Let's refactor it. And so if you're not familiar with make pattern rules, what this does is the percent up here stands for any of the rules in that file. The fluctuation here stands for the name of the rule. So basically if we run the variables build, it's going to run DH build. And run the variables binary, run the DH binary, et cetera. So with that change, some interesting changes began to happen to the length of the rule styles of Debbie. And unfortunately, I didn't collect historical data here. So it's just the current data. And to understand this graph, going up, we have the percentage of rule styles given length. But along the side, we have the length of the rule styles starting at five over here, which you can't read. And going up to a hundred and more lines. Now the red line here is CDVS, which as you can see is really good at making the rule style the under five lines, maybe ten lines, something like that, and the trailer's off. Down. And if you look at traditional death helper, which is the black line here, we see that it's really good at optimizing rule styles around 40 lines, 55 lines, something like that. And then sort of trails down and it almost parallels the length of other, which is the smaller set of packages that don't use death helper or anything else than just going all by hand. And those tend to be longer to the long end. Interesting that it can be shorter for the short end. And there's that interesting little thump over here, which I suspect is things that use Yawter or something like that. And I didn't bother to fill those out. So there might be some interesting, weird short rule styles out there that I didn't grab for properly. So of course DH is the remainder of the graph. There's a really tall hump there. 45%, almost 50%, for those files that use DH, walk in somewhere between 15 and 20 lines. And then there's a previous hump, 15%, or so, actually, you know, somewhere in that area, or two lines to five to 10 lines. Now there's a reason for the two pumps. And that is that if you go back, you've got two different variants of the rule style that can use DH. So that's simple enough to understand. Okay. This is market share of various tools, after DH's been around for a year or so. As you can see, it's gotten almost 10% of use. CVS, I forget what it was at last year, it was somewhere around 25%. I think I probably eroded it a small amount, but it's probably also gained some more followers. And that helped, of course, since most of the rest, there is that 3% of weirdos. So what does DH can do? It's really easy to figure out what DH is going to do, exactly which commands it's going to run, and the exact order that it's going to run them in, just tell it to run the command to do no act. You have to run the system inside a actual source package, or it's going to go clean out of you. But it's useful to see what it actually does. And when we look at what it does, we see these DH auto commands, which you might not be familiar with, or you might be. These have the added to depth helper to support DH. So what do these things do? Well, they basically figure out what they need to do to build the given source package, and magically do it. This is a short answer. So if we have an auto prompt using source package, they'll run the figure, and then they'll run the name. And then when they want to test it, well, some of these packages may test, some of these may check, and they magically somehow figure out which target to run, and run it. And if there's an error, or an error, which is sort of tricky to make, actually, it's impossible, but we did figure out what to do. Now, if you have a pipeline package, they'll do something completely different like this. And there is currently, I think, no generalized test suite for pipeline. So they don't run the test set. There's no configuration. They just want to set it up high, and they pass it various things. And I think I'm going to see my cleaner. I think that's an open office, but it's actually in the source. Okay, so for PURL, they might do something like this, or they might do something completely different. And PURL has lots of different ways to build.  But they'll do something that is probably the right thing that it might not be. So the interesting thing about DH Auto is it's designed to work for a common case, a case like this. You need to build a package by running the figure and running the name. It's been like that forever. These tools can handle that pretty well. What about something like this? You need to build the package, pass it, arbitrary arguments to configure. When you're a mate, you have to do some other weird thing. You obviously can't use DH Builder. This is a good new idea how to do it. So how do we handle this case? Here's one way. You can say, let's override the DH Auto Configure. And when we do, we'll pass in this without pushing the same parameter. Let's override the DH Auto Build. And when we do, we won't even run the DH Auto Build command. We'll just run whatever name commands we want. And the thing you need to realize about this is these override targets are run by DH Build, and it sort of figures out behind your back, hey, your rule spot has these override targets in it. I'll run them. And that's the right targets when in February of this year. Here's some more examples of it. So there's, you know, these handle, you can handle lots of the standard cases that you may be familiar with, like needing to make a file, set UID, DH fix firms, of course, clears all the accept-by-dits, just to make sure when you're treated by accident. So you can override that, run DH fix firms as normal, and then go back in and make something safe that you need to make to. If you need, you know, there's other examples. Passing various options for commands is fairly common. The under the bottom, I put one in. I remember that at one point we would see something like this because it was going to not work on some architectures. And they wanted to see the test suite results even though they knew it was going to fail. So you can basically, I think these overrides are pretty powerful. They let you do all kinds of configuration and customization in your rules file and still use DH. Here's a completely variable example for the 80-week package. This is the complete rules file. And you can see that there's really not too much customization needed here. There's a little bit of weirdness around how to clean up. I don't want to compress files in the HTML directory because it's breaking some links. And I've passed some weirdness from the group. But the thing that I like about this is when you look at the rules file, you see exactly how this thing is different from every other package out there really quickly. There's nothing in the rules file except for the differences, which I think is really handy to just say, oh, three differences. Okay, I know what they are. And this is a graph of the frequency that various commands are overridden currently in the archive. So I'm happy about this graph because all of these down here are the DH auto commands, which are basically designed from beginning to be overridden because I know that I obviously can't figure out how to handle these cases in all cases. So they're frequently overridden. And then, you know, there's things like DH install change logs that people frequently need to pass parameters to. So it's pretty common to overwrite that. I'm not really sure why so many people overwrite DH install. Maybe they want to pass to the weird parameters it has. So that's a pretty, one other thing I like about this is I can now graph the archive and figure out when the developer isn't working for people, when they have to pass in weird parameters and things like that and just get some easy idea of it just by looking at the overrides. So that's helpful for me to make the developer better later. So when I was making this DH thing, I did run into a whole problem, which is that we have three programs that handle Python. Now, one of them is actually that developer is completely, you know, obsolete. But there are the other two, DH Plastic Board and DH Placentral. And there's window consensus, which one we use, but I did need to make one be used by default because otherwise I wouldn't store Python packages, which would seem like a really good design choice. And I arbitrarily chose the DH Plastic Board, but that also didn't seem like a really good design choice. So, here's a way to, here's my question. Now, you could do a video provide, and I think that's perfectly valid way to do it. The overrides actually were developed after the second system, which is just saying, run the build, but run it with Python Central. And how does that work? It's called a sequence add-on. And it, I would develop a pretty soon after I developed the original DH before I did overrides. So, here's some of the sequence add-ons that are available now. I don't even know what some of these do. For example, root bash completion. I'm not really sure I can answer some developer command to your command sequence that installs bash completion files. The Haskell desk description is very complicated. The most interesting one there is probably with bolt. And I think there probably were in the archive. I didn't believe it was a good graph. The key point, though, is that all of these, with the exception of with Python Central, are add-ons. They're not even included in developer. Somebody's gone off and written them. And that's encouraged. And it's as easy as writing a very short plural module. Something like this. What this does is this is the actual implementation of with Python Central and that helper. And all it says is on where DH plural is, and the sequence that you're going to run. And it's in there, put in DH PyCentral, and then just paint out DH PySupport. And this makes sure that DH PyCentral is in a reasonable place. It also makes sure that even if DH PySupport isn't available for some reason, we still get PyCentral. Here's a really complicated example from Haskell Demscripts, which adds all kinds of weird commands to various points in the sequence that DH Auto runs. And what I really like is they go before DH Compress, they add DH Compress dash X dot Haddock, and then they remove DH Compress, which apparently works, but that's the kind of thing that I think might break. And though I guess I'll have to keep it working now, I know about it. So here's the usage pattern for DH sequence add-ons. And I thought this was really interesting, especially since the Quilt one has only been around for like two months or something like that. There's obviously a lot of demand out there from people in Debian to be able to use Quilt in their packages easily. And the nice thing about the Quilt one is you just say with Quilt, and you automatically get patching and un-patching of using Quilt, no other modification of the whole style necessary. And again, that's implemented completely without any changes to depth helper. So the next interesting thing, yeah, they just keep coming, was uploaded during depth comp after significant testing, and it's called Build System Classes. And this is actually interesting to me because it's an enormous modification of that helper that I didn't write. It was written by the store called Modestus Vinius, who may be in the audience, but I doubt it. And I don't know how to pronounce his name. Does anyone know how to pronounce his name? Because when I see that name, I can't help but think of Modify. Anyway, the Build System Classes are basically what you get from CDDS, except they're now in Dev Helper, right? So you can ask the DH Auto commands to list which Build Systems they know about. And this is the current complete list. You know, Autocon, various cool things, make files, Python, CMake, Ant, maybe Scon, Smorrow. No? And okay, the interesting thing about this list is it has to be in this order where things break horribly. And the way this works is when any of the Autocon commands go to build a package now, they say, well, which Build System do I use? They figure it out by looking at which files you have in your source package, and those are all the files that are listed in parentheses. So if there's a configure script, it's probably an Autocon package. If there's a Build.xml, it's probably an Ant package. If there's both, well, we'll assume it's an Autocon package, because otherwise you might break some unknown number of packages when we add Ant support, which was done in an afternoon about a week ago. Now the problem, of course, with just guessing, is that you sometimes guess wrong. So this does let you override it, which can be really helpful for things like Perl Build, where there can be a Build.xml file, there can also be a Make.xml file that will guess that it's a Maker package, and possibly do the wrong thing. So the Perl Group, I hope, will start using this whenever they know it's a Perl Build, or a Module Build package. The other nice thing about Build System support is Modesta's went in and taught all the DH Auto commands how to build from a different source directory in the top level directory, and how to build into a different build directory, assuming that the Build System supports it. Of course, Autocon does things like Perl Build, and that kind of thing don't. But if it is supported, you can build in a different directory and just nuke it easily at the end, like you might be familiar with doing without using Dev Helper. So third-party Build Systems can be added by writing another Perl Module, and I'm happy with people doing that, especially if it's something really weird that I don't want to maintain. That would be great. The only problem is that Dev Helper will not automatically go off and use your Build System unless you do pass this Build System switch. Otherwise, somebody could upload a Build System that just broke everything, and I really don't want that to happen. So if you want it to be enabled by default, you do have to contribute it to me, and I'll figure out which order to check for it and things like that. Here's an example of a made-up Build System, FooConfig. It works something like Autocon, and this would be the complete implementation of that Build System. So all we have to do is the CheckAutoBillableSubroutine, or actually Method, this is object-oriented code, goes in and checks to see if there's a FooConfig file that's executable. And if so, when we're configuring in DH Autoconfigure, it just runs it, passes it parameters, and that's it. Now you might ask what happens for actually building the package? What happens for cleaning the package or testing? The answer for that is, this is inheriting from the make-file class. This is object-oriented, blah, blah, blah. So it works, apparently. You can just inherit the make-file, and then when you run Build, it will run, it will build using the make-file that FooConfig presumably creates. So you put all this together and you get something that is not entirely like DevAlper used to be, with all these weird switches and overrides and stuff like that. And it might look something like this as I really hope not, because this is pretty over-the-top amount of stuff being used. But I do hope that these things will make DevAlper easier for people to use and result in shorter and easier to understand rules, files, and et cetera. And with that, I'll thank you for using DevAlper and open it up for questions. Enrico. One thing that I find quite interesting is that in the end, DevAlper is doing most of the work, but it gets invoked a lot of time during the build process, and it always has to figure out where is stuff, what can it do, what it shouldn't, and so on. So I wonder, I mean, it feels like to me, we are pretty near the point where you can do, like, instead of a hash bank make, do hash bank developer, and then it figures out what's in Debian slash at the beginning, and then just do that little bit, which would make it insanely faster in theory, but I don't know if that's any sane thing. I think that you're right that we're pretty near the point that it would be a pretty easy modification to do that. Of course, policy wouldn't allow you to do that, because Debian rules does have to be a make file, no matter how perverted and short it is, apparently. I don't know if it would really make it significantly faster, because DevAlper was, after all, written 11 years ago for machines that were a lot slower and does have a lot of wacky little optimizations in it to make it start up quickly and figure out where it's at fairly quickly. So you might save a couple of seconds, and it might be a shorter and more comprehensible rules file, but then again, I think that the way that we have overrides in here does sort of use make in a fairly sane way. It's a useful use of make. If DevAlper were up at the top, we'd have to have some other way of doing these overrides, and that would involve re-implementing make, so. Any others? A DevAlper 7 module for doing Java some Java packaging stuff. And a couple of questions about it. With these overrides, can you override things which have been added through sequence add-ons? Okay, yes, you can. Using the overrides here, any command that DH happens to run, it will first go off and look to see if there's an override, and if so, it'll run the override instead. So yes, you can do that. Okay, so when you're adding things into the sequence, you say add after DH file, and then you say remove DH Python support. So other part of my question is, can you do double dash with, quilt double dash with, and so on and so on, and include several different third-party add-ons? Okay, so you're, oh yes, yes, of course you can. You can use with as many times as you can. What if you, the person writing the second one that gets included is trying to put something after DH Perl, and for whatever reason, the first one you include has removed DH Perl? Well, then obviously you have a problem, and those two people need to sort that out. I can't really fix that problem without coming up with some much smarter way of figuring out where things go in the sequence, you know, dependency-based or something like that. Hopefully that won't come up that often. I think that the need to actually remove a command should be pretty rare, unless two packages are conflicting like these two aren't. In that case, I think they have a problem of their own making. And the last thing was, I've got a sort of absolutely minimal Java build system as part of the tools for this, which basically says I've got a bunch of Java files, please put them in a jar, and I just call that, I've added it insert after DH Auto build, and a file, it'll do something otherwise it won't. And is there any reason why I should write it as a build system class, and which then people have to explicitly use, rather than just saying with Java helper, and then it just does it? Well, I think it's up to you which one makes the most sense to use in a given case. The build system classes are useful in that you can use them even if someone isn't using DH. It's possible if you don't like DH, you obviously don't have to use it, but you still might want to use DH Auto build in your rules file just to let it take care of building for you, and so it's clear what's happening. And in that case, if you have a build system, then DH Auto build will actually know how to handle it. If you're using with to add something to the DH command sequence, then that won't happen. So that might be one reason, but it really is up to you which one makes sense, and there is a bit of overlap, clearly. All right. I see here that in Lenny, we currently have DevHelper 7015. So during the squeeze release cycle and development cycle, should we avoid using Overrise because they're not in Lenny, or is this going to be added to a point released to Lenny or something like that? Well, I have given all the versions that you need, and of course you do need to make sure you build dependent on those versions if you use one of these new features. As always, one of the new features added to DevHelper, people do wonder about this, and I generally hope that someone will backport it, but I can't really do anything more than hope or possibly backport it myself, but I'm not going to try to get it into stable at this point. So it's sort of up to you whether you want to use these new features or way to release cycle to do so. I'm personally using them in my packages because I think the minor pain of having a backport DevHelper more than makes up for, I mean it's more than made up for by actually being able to use new features when they come out. Well, already we can at least use the... You can already use the DH stuff. The DH stuff and the sequence add-ons at least, right? The sequence add-ons, of course you can't use sequence add-ons that have been added to unstable in another package. You also have to when you use a sequence add-on figure out what package is providing that and depend on that package. The make file overwrite thing is parsed by Perl, I guess. So that would mean that you have to be a bit careful about how to specify them? No. It turns out the way we figure out that there are overrides in the make file is by asking make to list all the targets that are provided by the make file. Now, make doesn't have a really elegant way to do this. It's possible that its output might change, but any valid make file will work. You could even... I'm not sure if you could include another file and use overrides in that one if make would tell that those targets are available or not, I'd have to check. But you can use all kinds of make constructs in here. There's no parsing of the skilling one that is fragile or anything like that. That actually surprises me because I was told for a very long time that the reason we don't have binary arcs is that was it possible to do? Yeah, well, it's apparently not. It's not pretty to do. It'd be nice if make just had a really easy way to test if a rule was in a file, but it's not there. I can show you the code if you're interested. It involves running make in debug mode and parsing its debug mode output. Right. Anybody else? Is it possible to use DH for packages that built multiple binary packages with different configure options? That's a good question. Currently, if you want to do that you have to manually override DH configure and DH auto build and run those yourself and DH auto install and install it in yourself probably. There was a bug report filed yesterday with some suggestions in this here. I don't think it actually completely covers that case though. So if you're doing something really out of the ordinary like that, well, potentially a little bit out of the ordinary like that, you do have to override it and do it by hand. But I think that's really okay because you'll end up with a rules file that will pretty clearly show what you've had to do and it's probably not any worse than beforehand, I hope.  Good question. Don't know. Well, I guess I'll look at the graph in a year or so and see if people are just switching from Dev Helper to CDBS or if they're switching from CDBS to DH or what. Personally, I would prefer that when I edit a rules file, it use Dev Helper or DH or something like this and not CDBS or IATA or something like that, but I'm not going to try to dictate to the project what they should do. I'm just going to provide the tool and if you want to use it, there it is. My question to CDBS one too. No, no, go ahead. The abstract specifically says how it can be better than CDBS. I haven't really addressed that, have I? Exactly what you think the differences are and why you don't like CDBS, etc. So, this is one way of looking at Dev Helper and DH and CDBS and comparing them and what I like to do is just look at what I think of as the visible surface area of a command. Now, I realize this slide is really scary, especially if you're in the back of the room and it's sort of meant to be. This is all the things that you might need to know if you're using Dev Helper in a rules file. You have to know all these strings, what they do, when to use them, etc. Now, of course, we have some long options, we have some short options, we have some environment variables, we have some package control files in the Debian directory, and then we have some commands. And that's the interface to Dev Helper, right? Here's the interface to CDBS. Now you have to be about here to see it, right? We have some make files, fragments that you need to include. You might not need to include all of these, but most of them are things you might need. We have some options, about 150, I don't know, a lot that you might want to use at some point if you can figure out what they do, if they're documented, if they don't change what they do tomorrow. Some of these are semi-internal-ish, a few of them are probably completely wrong and you would never want to use them, but it's really hard to tell. And some of them are very well documented in the manual. And then down here at the bottom you have a couple of minor changes that you might want to make to your rules file to run other commands and things like that. So when we look at DH, this is a visible surface area. Of course this is added on top of Dev Helper, but then so again so is CDBS. It's 153 items plus the 100 odd items from Dev Helper that you might want to need to know because you can mix and match. Now in DH we're adding 12 items. We have overrides, we have a few commands, we have a few options. So I think it's really elegant that I was able to do it with this little, if I say so myself, but I was able to do it with this few addition to the visible surface area. So that's personally why I think the DH is better than CDBS. It's up to you to decide. I think Jonas is going to have a comment now. I must say we looked a bit on that specific one together. Yeah, I did a few events. And actually I must say, could you switch back to the ugly one? How completely wrong is this? I did spot one of them in the middle, around the middle somewhere. I don't remember which one it was. That Dev Helper does not support. Well, yeah, that's true. Yeah, yeah, CDBS has an option that Dev Helper does not support. They're okay? Yes. Yeah. There are options in here. Yeah, that's right. That's the auto update. There are options. The one that is illegal to use. Right. I wonder why Dev Helper doesn't support that. Is that really the only thing that CDBS does that Dev Helper doesn't support? Because if so, gosh, you've got a big interface for that one thing. It takes time. So, you know, when I think about this, I like to think of this. Now, when you're building a ship in a bottle, you need all kinds of specialized little tools to reach in through the neck of the bottle and lift the sails up and then attach the rigging. And, you know, you need a little tool to adjust that cannon just right and all these things. And there they are, right? Now, granted, we are building, we could say, well, there's lots of tools here, but the fact is, this is a whole workshop of tools that's out there for you to do whatever you want to mash around with. These things are all reaching in through the neck of the bottle of environment variables, settings, and making changes to that ship in there. And sure, it looks really pretty when you're done with it, but, gosh, it's really complicated to get there. So, Colin. So, you've just checked. You've been working in Dev Helper for about 12 years now, I think. And, you know, free software development is always kind of incremental and you do what's needed at the time. But I'm interested to know if you have a sort of end goal and slice. Are you ever going to stop and work in something else? Or are you going to declare Dev Helper done, or is it something that you see as always evolving to make the needs of Dev in? You know, the end goal for Dev Helper was actually accomplished like seven years ago. The end goal was, let's make the rules files a little bit prettier and easier to understand, hopefully, and, you know, easier to make broad changes to large swaths of packages by changing one thing instead of having to modify a lot of rules files. And that was accomplished, and I thought I was done. And then in the past year and a half, I thought, well, gosh, there's a CDBS thing and it's really showing that there's a need to do something else. So thank you, Jonas, for that. Thank you very much for showing that there's a need and demonstrating it in a way that made me actually have to do something. Am I going to continue to be interested in this? I don't know. Somehow it has remained interesting. I think it's because working with Dev Helper is a great way to completely destroy Debian by accident. And that's the kind of thing that can be interesting. I actually had to do full distribution regression testing to test the build systems option, which I've never done when I've added something to Dev Helper before, believe it or not. And I did find one or two packages that were broken by the new system, but I actually thought it was worth putting it in and just filing a couple of bugs. And unfortunately, one problem with the new build systems and with DH is that they have a lot of very specific things encoded in them, like the order in which you run commands. And if you change that order, you can break untold numbers of packages now. So I have all kinds of ways to break Debian by accident now. So maybe I'll be interested in it for another 10 years. Who knows? Well, I think the decision what will be used, Dev Helper or the CDBS will be done by the documentation. And it is not really hard to have a better documentation than CDBS. I was always fighting with it. And I'm really, really happy that I see now these very easy rules files. Well, as far as the documentation goes, there is a man page for DH. Can you see that in the back? I'm going to get a bit bigger. There is a man page and it has some little examples at the bottom, which I basically just reused in this talk. And I think that if you read that, you pretty much understand enough of it to use it. Or if you just read a couple of rules files, you probably understand it. So I hope that that's enough. If not, maybe I should turn this talk into a bit more documentation. Just a small comment about documentation. When I read about your new DH work last year, I said, oh, cool. I tried to actually migrate my small, really small package to it. And I couldn't find anything similar to how to, really, really simple. You have to do this. This is the equivalent of this. For example, patching. I'm still trying to find out how to do the patching. Are you talking about quilt patching or just generic patching? I'm applying patches to the source of the... By hand in the rules file, basically. Yeah.  Or you could override DH Auto Build and DH Auto Clean and put the patching in before that, but it's a little... I don't know if you'd want to do that. You'd probably just go back to the older style rules file that has all the targets explicitly in there and then do the patching by hand that way. I think that would be the way to go. I think it's okay to not use this really short stuff if your rules file is doing something a little bit out of the ordinary, which patching sort of is because there's no established way to do it except for using quilt. Of course, if you switch to using quilt, it's very easy. You say with quilt and then you put your patches in the right place and it all works. Now, as far as your broader point about the documentation, yeah, I think it'd be great if somebody wrote a little tutorial. Here's your typical rules file and some things in it, and here's how it looks when you convert it over to DebHolper V7 and DH and all the other new things. Yeah, or just a wiki page with a list of packages using DebHolper. Yeah, sure. Yeah, that's a good idea. That will be great. I have a list right here, so yeah. Thanks. Well, now that we seem to be converging a bit on quilt for patching, wouldn't it be possible to just check for a Debian Patches series file and then assume it's quilt and then try to do that? Because otherwise, that seemed to be the most overridden thing. Right. Is there any plans for that? Well, it is the most used with flag. On the other hand, I like the fact that there were no changes made to DebHolper to implement that, and I'm hoping that we get a source format that actually natively supports quilt that's actually supported in the archive. So I'm sort of reluctant to make DebHolper have some kind of special quilt feature in it at this point because it'll be temporary and it'll be more cruft. Speaking of cruft, there are a few false steps that I made when I was implementing DH. There are some flags before and after and things like that. You can pass a DH to control which part of the sequence it runs, and those are all basically cruft at this point because they try not to work very well. So I really need to stress that this is an evolving thing. I've been talking with, for example, Sam Hartman's, and he's pointed out a couple of cases where the emulation of make, the DH does, isn't exactly right, and you might run a target and DH just says, oh, we've already done that, just like as if there's a stamp file for every target, which can be really annoying if you want to run Debian Rules binary twice in a row to see if your change has made the change that you want to make. And so I really think this is still evolving. There'll probably be some minor tweaks or might be a new compatibility level that changes some things. Who knows? I just want to stress that because it's obviously... Thank you. This is obviously still a work in progress. Anybody else? Hello. This is all very good, aren't it? Have you noticed that the dPackage now supports dPackage of Endor, which is a mechanism for building all sorts of derivatives? Haven't noticed that. And having done a lot of rules file patching over the last few years, we've found that by far the easiest way to make things work is if the meta-build systems actually support the changes you want to make rather than changing a million rules files in the same way. And I'm just wondering whether you've looked at or thought about how this stuff might use effectively a dPackage of Endor override like dPackage architecture to say, we're building this flavor and automatically do the right stuff. I have to admit, I haven't even heard about the DH of right Endor or whatever it's called. I think it was mentioned to me earlier this morning, but I haven't really been following the list too much, so you'll have to bring things to my attention directly if you want. I mean, to know about them if there's something that isn't, you know, directly impacting Dev Helper obviously, I guess there is some possible, you know, way to make Dev Helper and DH do the right thing magically if this is set and maybe we can look at doing that. Of course, you still then have to deal with all the rules files that don't use this and that never will, and you know, which is going to continue probably forever. I think we're going to have the old style rules files until the end of time, and I think that's perfectly okay. I don't have any problem with them. Yeah, I mean, dPackage obviously, an awful lot of stuff does use Dev Helper and then if Dev Helper just does the right thing, the maintainers don't need to care, which is exactly what we all want really. Yeah, and if you can get it down to one Dev Helper command or a few Dev Helper commands that need to be modified to do the right thing, that is much easier. If it's a matter of, oh, we want to go and insert, say we're building for Ubuntu, we want to go insert a new Dev Helper command in the sequence automatically type thing, then that gets a little bit more iffy because, you know, DH sequences aren't going to be used for all packages, so that's only solving what was it, 9% of your problem, so... I guess basically anybody who cares about this should come and talk to me and Jerry and people. There'll be an MDB in the box later, which is maybe one place to talk about this. I don't know if there's a better venue, probably not. Is that it? Okay, well, thank you all.


Good afternoon. Today, I have the distinct pleasure to introduce Dr. Marshall Chin. Dr. Chin is a, is the Richard Perillo family distinguished professor of healthcare ethics at the University of Chicago is a practicing practicing general internist and health services researcher who has dedicated his career to advancing health equity through interventions at individual organizational community and policy levels. Through the Robert Wood Johnson Foundation advancing health equity, leading care payment and systems transformation program. Dr. Chin collaborates with teams of state Medicaid agencies, Medicaid managed care organizations, frontline healthcare delivery organizations and community based organizations to implement payment reforms to support and incentivize care transformations that advance health equity within an anti racist framework. He also co chairs the centers for Medicare and Medicaid services healthcare payment learning and action network health equity advisory team. Dr. Chin evaluates the value of the federally qualified health center program improves diabetes outcomes in South in Chicago Southside through healthcare and community interventions and improves shared decision making among clinicians and LB LGBTQ persons of color. He also applies ethical principles to reforms to advance health equity discussions about culture of equity and what it means for health professionals to care and advocate for their patients. Dr. Chin uses improv and stand up comedy storytelling and theater to improve training of students and caring for diverse patients and engaging in constructive discussions around systemic racism and social privilege. Dr. Chin is a graduate of Harvard College and the University of California at San Francisco School of Medicine, and he completed residency and fellowship training in general internal medicine at Brigham and women's hospital Harvard Medical School. He has received mentoring awards from the Society of General Internal Medicine and University of Chicago. He is a former president of the Society of General Internal Medicine. Dr. Chin was elected to the National Academy of Medicine in 2017 and is on the steering committee for the National Academy of Medicine paper series on structural racism and health, and is a co author of the Asian American paper and cross cutting solutions paper. It is my pleasure to introduce you today Dr. Chin and we all look forward to hearing your talk. Thanks very much Megan. So I have an ambitious agenda for us over the next hour that you can see from the title is pretty diverse but integrated and it reflects then a lot of the work that I've been grappling with over the past several years to addressing medical and social needs, racism and payment to advance health equity. So sort of the story that some of my general attorneys and I see patients in the outpatient setting as well as a two to four weeks of the year in the infusion setting. And it's not been maybe a year and a half ago that one of my patients came to see me and this is a retired professor of the social sciences here at USC person that's seven or 70s or getting close to 80 probably and a wise person. And he said to me, I'm concerned about our country, Marshall, and I remember he mentioned three things. One was income inequality. The second was lack of action on climate change. And the third was he said that we need to have two same political parties or two to say political parties will survive the country and he was concerned. And I do think we're entering a difficult period we are in difficult period and it could get more difficult regarding the partisanship in the sense of divide in our country. This Karen Dale, and she co-chairs this centers for Medicare Medicaid Services, health equity advisory team that I am the other co-chair of Karen is amazing she's a nurse by background, a counselor's background. She's now like senior leadership she's like CEO of one of the health plans and Washington DC. So very experienced and she's working Washington DC government also. And she has this phrase distinguishing between what she calls performative virtue signaling actions versus substantive authentic actions to advance health equity. So some ways health equity has become like the flavor du jour, and there's a lot of popularity now. And too often, we're perhaps seeing the former, which is performative actions that really maybe are checking a box in terms of well we're doing something with health equity, as opposed to something that will be truly sort of getting at root causes and addressing the situations. So free learning goals for today. I'm going to talk about addressing medical and social needs, racism and payment to advance self equity. Second, we're going to discuss then the underlying ethics for advancing health equity, and I'll end with a bit of a communication and describing free frank, fearless and empathetic discussion around health equity. Here's the agenda. I'll talk a little bit like my positionality defining health equity. What is equitable health care. I'll talk about anti racist approaches to care transformation and payment ethical issues and I'll end with a communication piece. So this is the young me. This is maybe, I don't know 20 years ago or so, one of my clinic patients at the time, typical patient middle aged, African American woman with chronic diseases. So if you look at this picture, you might superficially see differences. Dr white coat lay person young Chinese American man, older African American woman. And I had trained as Megan said at San Francisco and Boston and many of my clinic patients in Boston were African American from the Roxbury and Dorchester neighborhoods. However, I rapidly realized come into Chicago that that everything is contextual Chicago compared San Francisco or Boston has an absolute numbers many more African Americans and a much higher percentage of the population is African American. And then here in Hyde Park south side of course there was the history, the local history and better within a national history. And so I rapidly realized that well you know I need to understand this history and in this context. At the same time though, if you go beyond the superficial appearance. This actually I think a lot that I have in common with my patients and that I think all of us have across many of our patients. This is my mom and dad's wedding picture. Big immigrant family, like my dad I think it has like 12 siblings my mom, 10 or something like that is big big families. And these are the boys and my, my father's family is siblings. And they all worked in the laundries. So there's Uncle Winthrop on the left was a women ladies man of the group. My father's father in the middle who I've never seen smile in a picture. Uncle Roger who was a die hard Red Sox man and he actually passed away before the Red Sox won the World's Service unfortunately, Uncle George was incredibly good with kids, and then Uncle Gilbert. And many of my uncles were very talented people, but they clearly was a bamboo ceiling in terms of what they could do. And most of the game they be honest and uncles were in service industries, laundries, which classic for immigrant families. Only jobs you get. And so they worked in laundries for hard jobs. This is a Victorian trading card from the 1880s. These were used as advertisements. So in the backlist card would be some firm advertising. So some company thought this would be attractive image to use to advertise their products. So you see Chinese must go the Missouri steam washer, you have the Chinese laundry man with sack of money, Ryan the China the Chinese must go. And so this is a long historical and current interest for structural racism against minoritized populations, oftentimes with an underlying economic basis of you know why why is this so terms of economic interest and all. This is equity. So, many of you seen this diagram I like this, this Robert just foundation visual. So equality, everyone gets the same size bicycle regardless of the needs at the bottom equity, everyone gets the appropriate size vehicle to maximize their physical function. So at the top of the talk about equity being the absence of avoidable remedial differences among groups of people with those groups are defined socially, economically, demographic or geographically. And then importantly, they add the social justice component health inequities also entail a failure to avoid or overcome inequalities that infringe on fairness in human rights norms. So, the CMS group that I coach here, this is the definition that we decide to use for health equity, which is largely the US healthy people 2030 definition with the addition of systemic racism. And you'll see that this definition incorporates the elements of the prior definitions. So equity, achieving equity requires valuing everyone equally with a focused and ongoing societal efforts to address avoidable inequalities historical and contemporary injustices, which includes systemic racism and the elimination of health and health disparities. And the very top you see the attainment of the highest level of health for all people. So you see that again the different elements previously mentioned incorporate into this one definition with the addition of systemic racism. So there's equitable health care. So one way of thinking about it is well how people have thought about how do you measure this, because oftentimes looking health care you want to have a metrics, and you want to be reward ideally, what people have to do well with equity. And so national quality forum they they were these accreditation organizations for metrics. So now six years ago, different domains for health equity, access to care, high quality care structure for equity, more about that a culture of equity partnerships and collaborations such as with the community. So many of you have heard of NC QA so he just measures. So they in the California healthcare foundation and more recent paper from 2023. The amount of overlap in the domains they talk about overall in the middle, which bottom line is the overall well being patients of populations. And then you see around these different domains equitable social interventions like health, social media screening, equitable access, equitable high quality care, equitable experience of care. So for example, is a discrimination and equitable structures that here so for example, how diverse are the personnel at the hospital. Do you have good interpret services for example, but it's just a way of breaking down actual health care into different components conceptually. I think we look at the definitions of high quality primary care, often sort of tracks well with what is equitable here. So some national cash support from three years ago, provision of whole person integrated accessible and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual's health and well being needs across settings and through sustained relationships with patients, families and communities. And I think you start to see too that well, you know, these are things that basically there's no this little incentive in the healthcare system to do this. You know, this is one of the reasons why there's a crisis in primary care. So we've done about a dozen reviews system, the systematic reviews of the health equity intervention literature, and this is the slide that summarizes well the bottom line. And so some ways is not rocket science that they all devolved down to like the bold statement that these successful health equity interventions basically encourage close relationship with patients and the whole city address medical and social needs. They have close follow up monitoring. So when I give a talk to clinicians, they all say, well, yeah, we know that that makes a lot of sense. More specifically, there are these are things like multifactorial interventions that address different drivers of inequities, constantly tailored approaches better than generic approaches. Good evidence for team based care oftentimes nurse like team based care, community health workers lay health workers, and then not surprising involving families and communities in the solutions. So as Megan said, I have, I have these couple of national roles. And the next few slides, so much are a lot of lessons come from these, these learnings, and both of these efforts they try to identify best ways and practices to ensure that payment flows towards healthcare delivery structures personal and partners that provide equitable care and outcomes. So I call this my magic carpet slide. And so I feel like the one of the big problems and equity is that we don't do nearly a good enough job connecting the dots on the pathway to health equity. So the far left represents where we are the far right represents if we had an equitable system. We often will do some general intervention like we may say well we're going to do a cultural competency training right, and then we're going to magically think that's going to lead to health equity or, you know, we'll do a policy intervention like well we're going to change from fee for service payment to value based payment and you know that will solve things, but that's sort of like wishful thinking magical thinking in practice, we're trying to change the behavior individuals that behavior organizations, and it's going to be a large model of why a certain action, whether it's a training, whether it's a policy action, how that leads to a change with each another change was even much change, which would lead to the intended change behavior of the people in organizations are trying to influence. And so one of our Robert, but just one of your program officers her mantra for our program as well. It's not payment reform for payment reform sake, but it's payment reform that supports and incentivizes the care transformation. It's not just any care transformation but care transformation that addresses medical and social needs, advanced health equity. That's one example of we got one sentence, a little bit of a cake in the dots. And there that has to happen then for it to actually work. She like schematic slides here. So, and they both depict variations of a road map to advance self equity. This is from editorial from three, four years ago. So you see at the very top there that this is all moot unless we really are committed to the mission of improving equity, and that we are intentional about things and you can get back to that thing about virtual ceiling performative actions that is everyone from the front line of senior leadership that is kinky lip service. I truly have to prioritize and put the resources in it to be able to then truly advance of equity. You see in the middle there's this this line about implementing a road map to reduce disparities. So losses false quality improvement principle so identifying disparity do your root cause analysis determine why the disparities this designing your interventions towards restless root causes designing payment to support that. On the left, though, you see culture of equity, and oftentimes we tend to focus upon the technical aspects. So something like you know design the intervention. What we found is that if you don't address the cultural part, you're rapidly going to sort of reach a limit in terms of how far you can go, probably because you need to have a buy in again of the different parts of the whole party organization to work the work. So this culture of equity probably is to understand the in your own personal biases this is where the cultural humility train comes in. But then this is newer. Those individuals as organizations identify those systemic structures that bias against an oppressed marginalized populations. So the, you know, Chicago like like pretty much everywhere, you know, hasn't embedded. And I think to the unit there is just credit, we're doing more so than 10 years ago, regarding having that harder inward look and we have a long way to go, but we're making progress. In the middle, the bottom line is that every worker has to know how to operationalize advancing equity in your daily job. So the local story is that we're in like year 12 of our official DEI journey here at university. And maybe four years to the effort we have a survey of the different staff and at the University of Chicago medicine. And at that point, like much the training had been more of the culture humility training at all. And so the feedback we got was that well, love the training, however, we don't have a focus idea of how we actually apply that to our daily jobs. If we are like an accounting or data analytics, or for patient experience and all. So it has to be tangible in terms of how does it, what does it mean in terms of people's daily jobs. At the far right, you see the payment part and then you keep a lot of interest now in the social drivers of health, both addressing individual social drivers for individual people, as well as the partnerships communities to address the systemic structural drivers in the community at the very bottom improving health and health equity. Okay, so here's in some ways the same, the same concepts, organized in a slightly different way. So I talked about how ultimately we have to change the behaviors of individuals and organizations. And if the goal is sustainable change at large scale. No one has all the power. So that's why both like the Robert Johnson Foundation effort and the CMS effort involves multiple stakeholders. It involves the payers and involves the health plans. It involves the healthcare to leave organizations like a university college involved community based organizations. So they have to work together basically to align payment care transformation all. So in the middle there that again for the collaboration is the work that has to be trust and motivation. There has to be a great leadership that has to be well functioning teams. It's got to be a shared mission and purpose and buying it all. You see the roadmap steps around that with the QI steps for your mission. On the far left, you help build a little bit more detailed cultures of equity. And so what we're doing here at the University of Chicago and then we're incorporating a Robert Johnson Foundation program. That perspective on this. I'll talk to you a little bit more about this, but part of it involved specifically addressing structural racism. It's just the intersectional systems of oppression. Addressing power and hierarchy event. Very importantly, there's a relational part to it. A lot of change at a local level, really dependent upon relationships and understanding those power dynamics. If you look at the second to last column, these intermediate outcomes on the steps based on equity, look at the first two up at the top in particular. So on the first stop is the technical parts implementing the care transformation implementing the payment forms. The second one is equally important is shifting the culture is shifting the policies is shifting the processes by which we work and act. And again, we go hand in hand the technical part and the cultural part. And that's one of the challenges because like there's not a lot of efforts that try to do this or do it well. And oftentimes the people who are good at one don't have experience the other. That's less the challenge. Okay, anti racist approaches so we use this as an example of like digging the cultures of equity and then structural racism being just one of a variety of different types of systems of oppression. And we'll make it come through care transformation payment. So some definitional things. So, I'm, I like my Jones's work in this area. She's the best I've seen at being able to describe racism in late terms that everyone understand in ways that are as non threatening as possible. So I'll go over her global definition event or three levels of racism. Her global definition racism a system of structuring opportunity and assigning value based on phenotype, ie race that unfairly disadvantages some individuals and communities, unfairly advantages of individual communities, and undermines the realization of a full potential of the whole society to the waste of human resources. So that last bullet you start seeing the parallel to them the definition of health equity, everyone attending their maximum health potential. Okay, structural internalized racism acceptance by members of the stigmatized races of negative messages messages about their own abilities and intrinsic worth is characterized by they're not believing in others who look like them and not believing themselves. She's a great speaker. And so the example she gives her talks about African Americans use this the example of white white man's ISIS colder. The idea that if an African American had a stigmatize a view.  Personally immediate racism prejudice discrimination where prejudice means differential assumptions about the abilities motives and intentions of others according to their race discrimination means differential actions towards others according to the race. So immediate racism can be intentional as well as unintentional. It includes acts of commission, as well as acts of omission system type of racism I think people tend to think about when they hear the lay word racism so this interpersonal immediate racism. And then more recently there's been more awareness and recognition discussion of institutionalized racism differential access to the goods services and opportunities are decided by race. This is normative sometimes legalize and often manifests as inherited disadvantage. It is structural have been clarified in our institutions and custom practice and law. So there need not be an identifiable perpetrator. Indeed, institutionalized racism is often evident as inaction in the face of need institutionalized racism manifest itself both in material conditions and access to power. There's been a lot embedded in that one paragraph that intersectionality. So the classic Kimberly Crenshaw. So she's like the actual the consequence back centuries, Kimberly Crenshaw is probably the most famous of the modern writers about intersectionality and the University of Chicago legal form is one of the most cited other papers in this area. So intersectionality the combination of intersecting systems of oppression that perpetuate discrimination and disadvantage based on factors such as race, class, sex and gender identity. If you if you have more time Google, Kimberly Crenshaw New York Times Clarence Thomas hearings, then you'll get a sense of like her own personal role that that story and why intersectionality is important to her. And particularly she's looking at like the feminist movement and intersecting with racial politics. So how does this matrix of health care. And so I think like for our Robert Wood Johnson Foundation program for many years we would have what I would call a general health equity lens, which is the the dominant way that think most people have equity think about it health care think about the equity issue. So we might phrase a question, like on the left, why do black children with asthma have higher rates of hospitalization than white children with asthma and anti racist lens might change that to being phrased on the right. Why is our health system less successful helping black children with asthma avoid hospitalization and what children with asthma. So one of the, so I mentioned we had done like these dozen systematic reviews literature. And when you look at the equity literature, the vast majority of interventions address problems at the level of the individual. So there's a lot of good things about that. You know we want to be pitch centered and tailor the individual, but in some ways that it's worse though it falls from the trope of like blaming the individual for their problems as opposed to looking at the structural issues. For example, we don't do nearly a good enough job in terms of thinking about what are the organizational ways that we have a stacked desk against minoritized populations, what are better ways we can organize the University of Chicago to better provide more equitable care, let alone then like the policy aspects of policy level at the areas. So when you ask the question on the right see the different lens it takes you on a different route, terms of the root cause analysis and then the types of interventions that you come up with. There's a lot more about critical theory. So, I thought about like care transformation and payment with equity lens and care transformation with payment form with a criminal consciousness and anti racist lens. So these are three of my colleagues. So the bottom left, that's, so I'm supposed to show up sees the Israeli organization sociologists and and so by and I we thankfully similarly. And elsewhere on the slide this Scott cook in yellow and a totic. There to the left of me politically, and they have very strong background and critical theory. And I would say it took like about a year of discussions between the four of us, where we understood one another language is very important and you use the same word, but have different meanings. So it literally took both myself a year to understand Scott and Yelena and critical theory and more detail. And I had to say that like the more they explain and finally getting it. A lot of what they say makes a lot of sense. So critical theory that emphasizes power analysis as an approach to understanding and transforming structures by targeting the root causes of social injustice. First, the political, social, cultural, historical and economic forces that influence individual behavior and they create principal patterns based on social location. You may hear this phrase critical consciousness. Paulo Freire pedagogy that oppressed the ability to read the world critically and take action to transform it. And then there's the process in a technical term that you may have heard of also the ongoing process of reflection and action aimed at understanding and transforming the world. That's why, for example, and I see David Rubin here. But those of us who I do training of a very bright help professionals about equity. This training does involve some element of self reflection exercises and part of that is, is part of this process of practice. If the goal is to motivate change in action. So what are the implications of this then so at the very micro personal level. So, think about our each of us as individuals is our ability to recognize the structural issues. So the relationship of relationships among people and mentions a little bit earlier. It's addressing the relational dynamics addressing addressing a discomfort with conflict and earning trust and sharing power community. And this is something that, you know, we're trying to get better at like from then our own Robert Johnson foundation program, the power dynamic one is a tricky one for example that some like health care and medicine surgery, incredibly hierarchical structures and you know no sort of server we did. We just organizational survey they're like these four different paradigms of organizational structure. By far the most dominant paradigm at New York Chicago report by staff is a hierarchical culture. So we're embedded sort of in a culture in organization which is just based upon hierarchy. So, and we don't do a very good job of discussing this in detail regarding some ways they're sort of benefits to it. So something like experience and you know the patient care and quality and safety and all the same time. But in terms of having honest discussions about a variety of charged issues. Measel organizational level mid level, ensuring equity focus implementation operations of a place like UCM macro structural and acting policies that support the micro and measel level efforts. So again, just like Kamara Jones is she has like these three different levels. Similarly, it translates to our actions and the way we think about equity in terms of interventions, these different levels. So, this is to me, I sort of think about one of the best examples about racism in health care and interventions and so I think maybe one of the best, the best example I can think of is obstetric racism. If there are any OBGYNs here. So when you read this literature. So racism drives much of the black, white inequities and pregnancy related mortality rates, preterm births and low birth weight births. And then when you look at the different interventions. They tend to address the the interpersonal bias and racism as well as the structural elements. So for example, this intervention is so called community support persons lay people who would be present and accompanying the patient throughout childbirth. And then that has been demonstrated to reduce patient report experiences of obstetric racism. So this pretty horrendous literature regarding qualitative research and the experiences of African American mums with healthcare system. So, it's just sort of like the analysis of like if everyone had, you know, that family member or friend who's going to be the advocate that is going to stick up for the patient. There so the many people here have a health care background and so you know the role when you're playing that role to basically be the watchdog over sort of a loved one or friend or family member. On the bottom bullet. The obstetric equity literature that they talk a lot about sort of reproductive justice and there are those in our here in our university so what really core her talks and whatnot. I have a lot of this. And I'll be another person. So these community informed models that incorporate principles of reproductive justice, such as midwifery, lead and doula supportive care, and also at least improve black perinatal outcomes. So strong literature there. It can apply to payment also so Kim single Terry and I we have this paper and a major on that face from about a year ago. We talked about different mechanisms to which sort of racism is built on the payment and then solutions. I'll give you one example and make concrete. There's a sociologist like Cornell Jamila missionary who's a UC grad teaching sociology I believe, who she writes about this and she writes submission histories about this. So 1965 great society programs president johnson is negotiating with Congress. So medic here national program benefits all to get the southern votes he needed to pass the legislation. The deal that was cut was a trade off of Medicare, Medicaid. So Medicare will be a national program federal control, Medicaid joint federal state control, which allowed the southern states may take control then over their African American populations. So you look at these heat maps, for example, where the greatest inequities are in the US. Well, the South lights up when you look at issues like where this under financing of Medicaid where Medicaid is least generous. You know, again, the South lights up. So, you know, how can you sort of have policy reform without understanding that historical context, which lives to today in terms of thinking about then those dynamics to play out in terms of trying to change. So, again, the thing about like insurance and Medicaid, well, you could do things to improve the scope of insurance to meet medical social needs. So things like covering health related social needs, encouraging partnerships between the healthy liberalizations and these community based organizations to address structural social drives of health. There's another sort of insidious one here where is it double standard like this is so much inefficiency and what what's paid for in health care. Whereas when you think about Medicaid coverage of the poor and marginalized, there's a higher bar, well, you know, policies have to be cost savings or cost neutral. You know, and as we know, there are very few interventions in health care that are cost savings. There's a lot would be cost effective in terms of improving health at a reasonable cost. And the criteria is cost savings, cost neutrality. That's a much higher bar as opposed to something like, you know, you think about Alzheimer's drugs for example and what has been covered by in the past, you know, it's just like double standard. So I just want to slide so more generally about payment so payment, you can rapidly go down these rabbit holes where starts getting arcane and complicated. I think though if you understand these free bullets, they'll take you a long way when you think about any type of payment initiative. So you might think about how can payment can be used to advance health equity. One, the first one is what people tend to think about just create a over incentive to reward someone for reducing disparities, advancing health equity, so called value based payment and performance based incentives that reward equitable processes and outcomes. The second is upfront funding. So for example, a capitation or you have heard like these programs that have a per member per month fee that's given to a place like University of Chicago. So you have upfront money that money could go to different places. You could go to steer holders, you could go towards the orthopedic wing, right, or it could go towards community health workers, right, or the IT systems that link patients then to social services. The third is then risk-adjusting payment for social risks. And so this is what the University of Chicago sort of complains about that they be a larger well. We serve a high percentage of Medicaid population and we get killed because the reimbursement rates are too low. So once putting solutions risk-adjusting payment for more payment for populations at higher social risk. So, about five or six years ago, I spent a summer in Aotearoa, New Zealand, writing a paper with colleagues there, comparing the two countries about how they were addressing health equity. These were the authorship team. Notable things, upper right, that's my mentor for that project, Sarah Derritt. And if you look in the background, you see sheep. And it is true that there are more sheep in Aotearoa, New Zealand than people. The far left, those were three of the co-authors who are Maori, the indigenous peoples of Aotearoa, New Zealand. And one of the best things about the project was that we had like dozens of these tough conversations and they were great. And my experience has been that when you talk to indigenous peoples, whether here in the US or, you know, whether American Indians, L.S. natives or native Hawaiians, Pacific Islanders, or the Maori in this particular case, they often are tough in terms of like really having the tough conversations. I think because, you know, historically they have been treated so poorly. And what they taught me was that when you do the deep dive, the root cause of this type, deeper, deeper, deeper, deeper, the challenge about the assistance of oppression, the challenge about this conversation is that ultimately power is the issue. This control over resources, this control over the historical narrative. So I mentioned a little bit earlier, this issue, I'll talk about more about this issue of like, you can have a historical narrative about blaming the individual. You know, blaming the individual for, you know, their plight versus, you know, to what degree has the system been set up to basically create a no-win situation. Control over frame of equity. So, yeah, we literally had like in many discussions about structural racism, colonialism. This is, we don't talk about this much in our country. And I think I finally have a better sense of colonialism after talking to Maori about this. In the US, we don't have a great issue about this. So the American Indians or things like the Philippines, New York Times had a recent article about this, pretty hard article about our colonial policies. So if you look at the Philippines, why are they, one of the few countries in that area of Asia where there's not sort of a strong tech background, they're very agrarian still. And so really it's a tough situation, how are you going to create sort of an economy that will benefit many of the people that basically have subsistence living upon farming. It's not by chance. And a lot of it's like the post-World War II and earlier policies set up by the US and social privilege. So many of you may have heard of this term and heard of Robin D'Angelo. She's a white sociologist somewhere on the white West Coast. She defined this term that got a lot of lay press, white fragility. Racial stress can lead to defensive emotions and behaviors in whites such as anger, fear, guilt, argument, silence, which is rural. It can be weaponized. And so the way my Maori colleagues put it, and they insisted on the sentence in our paper, discomfort cannot be a reason to avoid dialogue, or then white fragility would in essence be a tool to change inequities in the power structure. Oh, we can't talk about it. It's too politically charged. We can't go there. It's going to make people uncomfortable. A Maori point out that is, you know, when it comes down to it, kind of a lame argument to make to basically justify continued persecution of the Maori indigenous peoples of the minor organized populations. So solutions, looking for racism, searching explicitly and be intentionally into racist solutions, integrating the medical and social. I'll talk about distributed justice in the moment. Engaging the community authentically sharing power addressing mistrust. You've heard this phrase progress moves at the speed of trust. And then communication and I'll talk more about this is storytelling and deep narrative.  This is my wife and we wrote this paper about Asian Americans and a whole variety of reasons why too often all too often Asian Americans are sort of invisible regarding social racism. Okay, ethical issues, McLean conference talk. So, some of this is influenced by one of my teachers do the sclar, and I'll talk more about it later. And so liberalism, I'm talking about liberalism, not as liberalism assertive but liberalism the moral and political philosophy. This values individual rights and liberty. And it's a type of the US holds the individual responsible for their situation. The US downplay systemic structural factors that influence outcomes. One of the best course I took in college was a literature course, it was entitled the myth, the mythology of America. And so if you think about things like the Western and like the mythology of the the rugged individual law man right, or, you know, the old racial Alger, pull yourself by your bootstraps type of stories. Again, that US individualistic perspective downplaying the structural. And then government. So the US brand of liberalism emphasizes the role of government and protecting the freedom of individuals. You know, you can still be have a liberalism philosophy and say, Oh, we're going to prioritize using the government to enable individuals to maximize the potential, including health. But we have a former terms of protecting the freedom of the individual. That has economic implications. So we tend to favor the individual rights to property and take sort of as a given the value of the unfettered free market. So we accept the externalities in the in of a free market system in terms of the problems in terms of distributive justice. So paper, if you haven't seen this well worth reading the first author Joe brush was in the Department of Public Health Sciences senior office calling Rogan from social service administration. Short article very well done. It reviews the financialization of health care in the US. And then it's kind of a sad story the siphoning of healthcare dollars, many of them governmental like Medicare, Medicaid, into profit for shareholders outside the healthcare system. So it's not, I don't think what the, what the public or health or government had in mind then in terms of like a Medicare and Medicaid dollars. So I'll turn to ethical frameworks, I'll talk a little bit about distributed justice and utilitarianism to justice beings the socially just allocation of resources and opportunities society utilitarianism maximizing utilities. So, you know, we've, we've had roles here in terms of like the fellows. I saw him once so I went shopping shopping period I went to first one of one of his classes and it seemed like it's going to be over my head so did not go to class number two, but you know they talk about the veil of ignorance so that I do they might We developed a society based on before we knew our position society before with we knew if we're going to be rich or poor black brown right brown, whether we're going to be a man woman or gender fluid. We would come up with a fairer situation than the current system where inevitably those with more power tried to influence the system so that it accrues their self interest utilitarianism so policy wise we have this in the US, this inherent push back we all see provisions against using societal cost effectiveness analysis to allocate resources. Again, probably a large part is the self interest of organizations that stick special interest they benefit from not having cost effective analysis. And you know my healthcare industry I mean we're guilty also we are reluctant to allocate wasteful resource expenditures towards health equity. And I think you know the healthcare providers and staff here, we're all aware of the plenty of a race in terms of how we allocate our money. Okay, so this is to the sclar she's them. One of the two or three best teachers ahead in college. I am had her as a teacher towards and of her career. Physically short, I think probably less than five people, incredibly intimidating and absolutely brilliant. Wonderful teacher challenge you all the time. This was a course where we read like original texts like 300 pages of original texts, each week so Edman Burke, J. S. Mill, Michelin populism marks hitler we read my com for Nazism. And squires interesting because she was born Jewish in Latvia. And when she was about like 1311 13 years old, her family. I think it was like, somehow like the Canada, eventually ended up in the US but emigrated 39 so just missed Nazism and Stalinism. So it's the miracle that she survived. But I find her compelling because brilliant thinker abstract thinker event you can tell by her writings and her talks that she had her worldview was rooted in live experience of the excesses of the left excesses of the right. So it's a very interesting woman. And so during like like her eulogy or during like a special issue devoted to actually passed away one of her colleagues in Harvard wrote sclar once wrote there were two kinds of political scientists. Those who study power because they like to exert it. And those to study it because they fear it. Those who like to ride the horse of power and those who are scared being trampled by it. They make this distinction between Henry Kissinger being with the former, really a power guy, and then sclar would be the latter terms of like the fear of power. And sclar wrote that she that self that cruelty was the worst sin. She defined cruelty as deliberate infliction of physical and secondary emotional pain upon a weaker person a group by stronger ones in order to achieve some end. And then she argued that by putting cruelty unconditionally first with nothing above us to excuse or forgive as a cruelty. One closes off any appeal to any order and that actuality, and she specifically mentioned like religion or politics being sort of like these extending any arguments to put cruelty first their force to beat us not only with religion but also with normal policy as well. And then you think about it like in health care. Well, you know, I'd argue that two tiered under resource healthcare systems that lead to health disparities for marginalized populations are cruel. The healthcare delivery systems and payment systems that are not designed to meet the medical and social needs of marginalized patients are cruel and that systems that accept the status pool and ignore racism disparities are cruel. Credit to my wife Noko Muramatsu and then Harold Pollack from the epic center for help getting this SEO with a finished line that I kept rejection and rejection and rejection they said look rethink it so they become co-authors help me redo it and then get accepted. One of the great things about writing articles I found this article by Tony Morrison, the Pulitzer Prize winning novelist, which may parallels between racism fascism as tools consolidate power. So I think have and this was written in 1995 so that five 28 years ago, but I think it has incredible relevance for 2024. And so it parallels both say construct an internal enemy, isolate and demonize the enemy, and list and create sources and distributors of information, who are willing to reinforce in that demonizing process criminalize the enemy, reward mindfulnesslessness and apathy with monumentalized entertainment and little pleasures, maintain at all costs silence. So, you know I think like if you read that you would not know whether we're talking the sclar of 1939, whether we're talking today is equally relevant. We end our last paragraph of our articles a sclar understood that persistent cruelty, more frequently results from the failure of bystanders to intervene and what Dr King rightly called the appalling silence of the good people that it does from the outright ended by the few to be serious about American cruelty. We must all use our personal agency to address structural racism and other system oppression, medical and nursing social work and public health communities have special responsibilities to exercise this vigilance, even the severe health consequences of cruelty. So does everyone else. So, sometimes, you know I'll give her talk and people say well yeah so much a lot of sense Marshall sounds incredibly pessimistic so you know what what what glimmers of hope do we have what do you just move on ahead. And so I'm going to spend the rest of the time talking about some aspects of that, above and beyond the special things I've already mentioned regarding things like the payment and care for information. I think through communication. So, ran corporation survey 2016. Basically found that the public supports a fair and just opportunity for health. So question our society whatever is necessary to make sure that everyone has equal opportunity to be healthy. Two thirds of the population degree. So why does he has such as hard time than getting such legislation and policies past part of the problem is communication. And so this is a figure from AMA WC they have this language narrative about equity. And they talked about this pyramid of messaging. So at the very bottom you might have any given thing you you write or say there's a message right in their words images that convey that message. They have a story, you know, conveying a story above that that's a narrative, a collection of stories and messages that represent an idea or belief. They highlight the values, they define the problem, determine the solutions and actions. Then more seriously you have deep narrative, the deeply held values that have repeated and been reduced over time they're baked in. So for example, we're currently working on the structural racism paper Asian American racism, we're highlighting three non health sectors which one is the media. So we give countless example and I think it applies to just what any type of mark my notary's marginalized population of like the biases that stereotypes that are present about Asian Americans in films or Asian American the media and whatnot, you know, you would be able to identify what these stereotypes are. The problem is that like for the most of the population being exposed to this is part of deep narrative, so probably powerful in terms of like the beliefs that people implicitly have. So people that Monica peak of muckabella and I wrote from three four years ago, which while practical tips about teaching about race and racism most one of them is you start with stories you don't start with facts. The point being they start with facts and statistics. People because people are not a, they basically tune out when you start that as opposed to starting with stories and the live experience. So, how do you message. So the rock pretend that just foundation they, they hired a communications firm to do focus groups across the political spectrum so from the far right to the far left. And trying to figure out what was the best way to message about social racism. So this is the visual that works on the left you see the bridges barriers so structural racism will be things like industries put toxic dumps in neighborhoods. And this makes it easier to find liquor and healthy food. The far right you find the proactive part so you have anti air pollution laws, people can get quality healthcare from doctors who respect them public budgets funds schools and parks. And then there's actually words and ways of phrase and organize and message which works. So you have two examples and I'll read you one of them. Again, it's pulled well across political spectrum. So first you start with shared values. We all want to live in the United States where everyone has a fear and just opportunity to reach their best health and well being, no matter their race, ethnicity or class that's a shared value. You think segue into positive vision. That can happen by making sure everyone gets quality healthcare from doctors who respect them. It can happen when families living communities with well funded schools and parks, instead of included air and toxic waste dumps and in neighborhoods with access to safe and affordable homes. We can build society where people can move up economically and socially. Then problem statement. But this is not everyone's reality today. That's because there are barriers built in front of some of us that create an equal opportunity and threaten freedom and prosperity. And then end with call to action by joining together and then unity statement, we can unite create a better future for everyone's children and grandchildren.  And again, they empirically test this in these different focus groups. So I'll end with this. And so one thing Megan put in my the bio is that So my other wife, my wife and I started training and performing an improper standard comedy six or seven years ago. And one of the fun things is we found that the skills were learning actually translate well to the day job. It's translate well to teach you about equity. And so, so we published about this like in the fact like the fellows. We've done such some ethics fellows and prior years. And so anyway, like the Harvard's Kennedy School government. They have this project called the journalist resource where they try to they have this list of like 45,000 journalists and the overall part of that effort is to try to train a journalist to be more informed about different issues they can write better or informed articles. And one of the ways they do that is they participate with the called graphic journalism. And so this thought that this topic would be good for a graphic journalist article and then there's a gift a graphic journalist, Josh Newfield. They're not abridding this article that feature three academics with myself and two others. They're just online at this journalist resource and the show sometimes place in one of the Sunday editions, basically uses comics to then to introduce people to these companies have issues about communication and equity and whatnot. This is the Sun Times story. So classy sometimes a Sunday story, you know, your Chicago advertisement at the bottom, right. So the very top is the reference to our article right below that. So Chicago, Burke now 38th council member convicted in the half century. And then above us. So on the front made the front page, then the reference to article and then a six pages in the middle of the article. So again, that's me. So my my son's, you see, I say, Oh, the article. My son said, no, she says, you know, well, it made you look like the Chinese American Barack Obama in this picture. Yeah. But you can see examples very bottom for example you see like talking about improv and empathy and listening building relationships recognizing how the patient perceives you. And like the work of two of our graphic medicine folks, Brian calendar and Shirley obu obu who have this self portion exercise that's trying to help people understand and their, their colleagues lives better so that actually is my self portion of no artist but you're supposed to do a self portrait and the things that are important to in your life. And this but as an example. So, let's see if it was an PR here, WB easy local Chicago PR they have a week lunch hour show called reset with session and silence so they've heard about they saw this sometimes article, and they ended up interviewing and I think we got like it's like a 15 20 minute segment about that piece and then the water issues raised but equity and teaching and equity and racism, etc. So, you know, it's just a way to reach a broad audience. So a few questions and then then then we'll break and then we'll have time for fellows. So, so, so bad as first question. That wasn't intended so question was like did I intended definition of say that the health care is inherently health care systems inherently racist and is one of the sources of the structural racism. And I think it goes, you know, it's some ways that were the creatures of all of our environments and so it ranges from like as we talked a little bit of the media images and all to essentially how power plays out in regarding trying to create in other other rising people of which race is one way to other people, and to take advantage of that that that population group to enhance his own power so in the case of like race and African Americans well you know, a lot of wealth this country was built upon slave labor, you know. But, but, you know, but I think we're kidding ourselves if we don't say, if we don't admit that a lot of the ways that we have set up health care, the way we organize care, the way we pay for care. These racist structures are already sent in. And it's been organizational and policy level is the regulations to the policy since the way do we do things. So again, as part of this like hard anyways looks that organizations including your Chicago are trying to do now. You know, it's not comfortable and there's no one nice to sort of look at oneself in the mirror and say, you know, there were some things that we've done as organization or the way we're set up that are inherently racist or two tiered. And I'm going to go with them stories, you know, the same stories regarding BAS stories as well as in some ways like this is actually a great history of like on the clinicians and staff here. Saying no terms of like some of this. ED is an example in terms of those stories there. But it wasn't my intention to imply that well the source of the racism is the system. Yeah, so I think regardless of whether you're a conservative or liberal or whether we have a democratic Republican administration. There are a variety of potential ways to improve situations from a public perspective that could work. And regardless if you like if you're a part of a feder free market or or a regulatory approach. The thing to do is well how do you create a business case for doing the right thing, a business case for supporting is so called social return on investment. You know, in some ways, so there are those who are well you can't blame you know healthcare you can't blame your Chicago for playing by the rules the game, you know, this is the way that the system is set up and then so you hear this well no margin and then there's a certain truth to that well you know you have to have a positive revenue line to do the mission of the academic health center and all. But why not set up a set of free market rules and incentives a set of a set of relations where it's in everyone's interest to have search strive for then equitable outcomes equitable process peer equitable quality of care. Yeah. So, you know, it's one example. Why not have a pay performance incentive which is you are giving more money if you have reduced an equity in your care. Yeah. So lots of topics a lot you can ask about fire ahead.