Dr. John Schumann, who has been president at Oklahoma University Tulsa since 2015. He also holds the Gussman Endowed Chair in Internal Medicine at the Oklahoma University Tulsa School of Community Medicine. Dr. Schumann completed his Misclean Fellowship in 2002-2003 and then stayed on the faculty for many years. His scholarly work includes research and advocacy on the ethics of profit-driven commercial screening tests and on social determinants of health, as well as analyses of patients that leave hospitals against medical advice. Dr. Schumann has authored the weekly blog Glass Hospital since 2010, which is aimed at demystifying medicine for lay audiences. And today he's going to discuss with us an ethical and education look at social determinants of health. Thank you. Welcome. Thank you. It's like a lot of people said, it's great to be back in Chicago and I love coming to this conference and it's so nice to visit with Mark and Anna Siegler and Laney Ross, who's been a mentor to me for a long time, and of course an incredible opportunity to hear from Paul Farmer yesterday. So it's nice to be back. Yes. So I'm going to talk to you a little bit about social determinants of health, which is something that I spend a lot of time thinking about. And as someone who moved to the frontier of Oklahoma, really with my wife, who's also, who's a family physician to build a four-year medical school in Tulsa, the satellite campus of our main health science center, which is in Oklahoma City, I now am in the privileged position of being the campus president. So I think about a lot more than just, I always say just medical care, just medical school, but think about these other things down at the bottom of this slide. So as was mentioned, I write a, it's not so weekly anymore, but a blog that's self-funded and non-commercial, and then I'm a frequent contributor to both local Tulsa Public Radio and then a little bit to NPR as well. And then this campus that we have in Tulsa is mostly graduate campus. So in addition to our medical school, which has a PA program, we have colleges of allied health, public health, and nursing, but perhaps most importantly, our biggest program, our biggest single program is social work, and then also our second biggest program is nursing. So I think about social determinants of health from a sort of, I guess you could say multidisciplinary, interdisciplinary, transdisciplinary way. And when we think about the social determinants of health, we think about the conditions under which people are born, grow, live, work, and age. And I actually find this Dahlgren and Whitehead cartoon the most effective. There's multiple representations of social determinants of health, but I like this one because it's like a rainbow, and who doesn't like rainbows? And it's actually called the Dahlgren and Whitehead rainbow. But if you look in the green arc, you can see, I always talk about this to residency applicants and to medical students, but health care services, that thing with which we spend, if you look on this pie chart, health care. So it's estimated between 10 and 20% of our overall health is determined by health care, and yet collectively as a nation, we spend $3 trillion on that entity, and yet we don't really focus on those other aspects. And so really the ethical question, and I think it's been addressed, especially Marshall Chin's panel yesterday, where he talked about advocacy. I've long had this ethical question of how do we get medical professionals, or if we want to talk about it, clinicians thinking about social determinants of health? What is our ethical obligation? And from maybe a Lenny Ross perspective, do we give it the office? Is just being a health care professional enough and seeing patients? Or in fact, is it incumbent upon us as professionals to kind of move beyond the health care realm and into the broader context of health? So this is from the World Health Organization's Commission on Social Determinants of Health, and it's kind of a busy schematic. But you can see on the left what are called the structural determinants of health inequities, and on, I guess you're right, the intermediary determinants of health. And you'll note that the health system is only one small box in those intermediary determinants that have the impact on equity, health, and well-being. And it's really this larger structural element that Paul Farmer, as he said, borrowed from liberation theology. But so what is our obligation as health care professionals? And you'll note, too, there's a small bridge between the structural and intermediary determinants, which is that social cohesion and capital. And I would, of course, submit to you that right now it's stretched rather thinly at least here in the US. So this is some of the suggestions from the World Health Organization report. And I'm not gonna bore you with the text-rich thing, but a couple of these. One is on social stratification and mentions specifically child welfare measures, including the implementation of early childhood development programs. And James Heckman, who is on the University of Chicago faculty, has written about this extensively and won a Nobel Prize for his work showing that every dollar invested in early child education saves approximately $7 or provides a $7 return on investment down the road, whether it's through saved health care costs or incarceration. Additionally, I think Evan Lyon referred to this yesterday with the expansion of Medicaid, for example, in Oklahoma, that unequal policies have been somewhat remediated where additional care and support for disadvantaged patients or chronic catastrophic illness and injuries. So I think it was Evan who talked about people with bullet wounds walking around with helmets and skull wounds that couldn't be fixed. But now with the adoption of Medicaid actually are getting health care. So that's really my question is, what is the role of the clinician in all this? And I thought I would give you sort of a baby, something to smile about, babies and rainbows. So it's this article, which is something I would recommend to you. This is from Academic Medicine. It's written by three Canadian physicians at Toronto. And it's a critique really of social determinants of health as a curricular element in medical education. And it's not a critique of the fact that social determinants of health are now being taught much more widely across medical education continuum. But the critique comes from more of a viewpoint of, is awareness enough and are we reinforcing inequities in health care by only teaching about social determinants of health and not really activating our future medical professionals to actually work in the structural change realm. And I thought this was a pretty provocative article and kind of interesting. But I choose to take the sort of Gretchen Schwarzie approach, which is that culture change has to come from changing the language and the narrative. And if we aren't going to at least teach about social determinants of health, it seems very unlikely that we're ever going to make the kind of structural change that's necessary, but it's important. So now let's focus on the great state of Oklahoma, our 46th state. And where I now come from, I like to joke and call myself an oaky, of course, in Oklahoma. I've never truly accepted it as a real Oklahoma. And although I did get this incredible job that I sometimes still feel like an imposter in, but this is from the Commonwealth Fund's annual state health care rankings. And you can see that number 50 right smack in the middle. The good news is that this ranking includes 51 states because it includes the District of Columbia. So Oklahoma comes in 50, but we always say in Oklahoma, thank goodness for Mississippi and no knocking against Mississippi. But in fact, Mississippi ranked 50 first. But depending on who you look at, this is from the United Health Foundation's rankings in 2016. Overall, in determinants, and these are not just social determinants, but these are behavioral determinants and policy determinants, which arguably are the same thing, we get a 46th ranking. And just because we're the 46th state does not actually mean we have to be 46 in overall health outcomes. But you can see, and so I'm going to focus just on a couple of the social determinants that I want to share with you. So Paul Farmer talked about trauma deserts. He talked about care deserts or clinical deserts. So food deserts is probably something you're all much more familiar with. And I don't really specifically recall, so I apologize if I'm getting it wrong. But I'm assuming I lived here for almost a decade and would think of places like Englewood or some of the poorer South Side neighborhoods as food deserts. But I don't know if that's been remedied. But this map of Tulsa, you can see these yellow areas to the North Tulsa and west of the Arkansas River and west Tulsa are food deserts. So what that is defined to mean is that there's not an actual full service grocery store within two miles of any of those neighborhoods. So that's actually a pretty wide swath of our city and suggests some striking differences. So one in four Oklahoma children go to bed hungry, not every night, but are counted as food insecure. Another of our big social problems is that Oklahoma again leads the nation in female incarceration, in fact leads the world. We have more women per capita in prison in Oklahoma than almost anywhere else in the world. And the question is why? And it has to do with draconian laws for drug possession that provide stiff penalties and sentences for people caught either in the purchase or trafficking of drugs. And fortunately, and this was an op-ed from Nicholas Christoph in the New York Times who's taking kind of an interest in Tulsa. And there's a little bit of a ferment that's going on specifically in Tulsa, not so much sadly the rest of Oklahoma, where we are trying to address some of these social determinants through a combination of public and private work together. So some foundations working with some of the more enlightened policies. So I'm going to show you a couple of examples. So this is hard to read, but at the top you can see that just since fiscal year 08 to 2015 that Oklahoma has cut more of its public spending for education. And this is state appropriation than any other state by a lot. You can see that North Dakota has a more than commensurate rise. And people attribute this to oil wealth in North Dakota so that there was the Bakken shale play where a lot of mineral tax goes into fund public education as well as other enterprises from the state government. Well, Oklahoma's had a difficult when the price of oil fell in 2014. We had three successive years and this is the kind of stuff I deal with now on a regular basis is the state appropriations to education. And this has had devastating effects on our public education, both common education and higher ed. So nearly two-thirds of Oklahoma's students are receiving free or reduced price meals. And so that's really a reflection of the level of poverty in Oklahoma. And then this refers to one of the structural equities. This is actually a tweet from one of the teachers. We've had a massive brain drain of public school teachers leaving the state because of a state funding formula that penalizes local jurisdictions for actually raising property tax to enhance. So for example, in Tulsa, if we were to pass a levy that would raise property tax and we're a low property tax state. So if we were to raise it in our own county and earmark those funds to raise teacher salaries to prevent this brain drain, we'd be penalized by the state formula and an equal amount of our funding would be then taken away from us in the state appropriation formula. So that's one of the things we're working on to try to change at a legislative level without much luck. So there were over a thousand public school teaching vacancies and so the state needed to provide emergency certifications for to fill those classrooms. In many cases those classrooms are going unfilled. So you have classrooms like my own children go to public school where they're often more than 30 kids in the classroom which is highly suboptimal. So I'll ship to some of the good news. So this was another Kristoff piece about Oklahoma and many people don't know this but Oklahoma is one of the states that was earliest to adopt universal pre-kindergarten. And again this was an effort based on the part of someone who had read a lot of Jim Heckman's research and so a billionaire who decided that he was going to have his foundation really lobby and so the state actually matched funding with his seed money and so we actually have universal pre-k in Oklahoma and in the county where I live Tulsa there's universal pre-k available for people below a certain income level. And so at least we're trying to change the inputs to the problem and if you start early it's likely that we can break the cycle of intergenerational poverty but when you figure that kids are getting early child education and getting to public schools that are underfunded it doesn't seem good. And so this is sort of how I address it myself is you know I work in the public schools and now that I'm not a full-time clinician in fact I'm a very part-time clinician I go into a nearby public school and read every week with actually this is the people that I worked with last year but I worked with a different kid this year but we work on reading fluency with this program called Reading Partners that's staffed by AmeriCorps volunteers and you know this is always that wrestling between the individual clinician making an impact one to one versus working on a population level trying to make effect more policy change or work to address it but what's great about the position of being a campus president is when you do this you can role model it and then your institution can become a vested partner of the non-profit organization and so we wound up being a named partner of this organization. So the question is are we gonna be able to shift these paradigms in social determinants hunger, education, employment, neighborhood effects or housing I didn't talk to you about the employment situation or housing given that limited time but I wanted to use this article as sort of a jumping off point to really ask this question and really kind of derived out of Marshall's panel and say I love the fact that at a McLean Ethics Conference we have a whole panel in fact we had a whole award given to somebody who spent his career in the health and human rights arena looking at global health and social determinants and structural violence and we had some University of Chicago faculty because you were unanimously University of Chicago faculty on Marshall's panel talking about physician advocacy again picking an issue and showing that good research makes good advocacy but asking fundamentally how do we translate that energy and that advocacy into our future generations and generations of learners and so with that, I say thank you. Marshall. Marshall Shin, thanks for that great talk John. So Bill Meadows had opened the day with the slide I had that very powerful slide about language and how you just changed one word and it's a whole different meaning and at one point when you showed the article of like the Canadian authors you mentioned the importance of changing the language changing the story and then you didn't really sort of explore further and you were a master at this in terms of like your ability to communicate both with an audience that's very academic as well as the layup audience in Oklahoma City so can you tell us a little bit more about what do you mean in terms of like how would you use language how would you use stories then to change that narrative and to advance in terms of further addressing social determinants? Yeah, so thanks for the question. I don't have a good answer for you but I think that I have made it sort of an academic interest to communicate with the public and sort of I guess leave aside the medical lease and the medical jargon and one of the things I strive for in the blog is to always remember what it's like to be a patient because even though many of us in the room are clinicians, doctors, nurses, what have you we are all patients too and we'll become that if we're not already. So just trying to kind of hold onto that perspective and when I talk about social determinants of health to learners whether they're medical students or residents I find it strikes a very, very strong chord. I mean they're very interested and engaged and I didn't go on to talk about but the four year school that we developed in Tulsa is about, is named the School of Community Medicine and the idea was that it would be a unique curriculum with a design focused on social determinants of health but interestingly the operationalization of that was kind of left out. So we raised funds, we started the school, we have to be LCME accredited and then our residence programs ACGME accredited so the question really becomes with organized medical education how do you shift that paradigm? I mean because we can talk about social determinants and advocacy I think all we want and feel virtuous about ourselves but until the really the funders and the regulators and the creditors are able to somehow grant us whether it's grant us or we seize the upper hand in order to push for that kind of change I think we're stuck feeling like virtuous people fighting an uphill battle. Thank you Dr. Scherlin.