In the wake of the police killing of George Floyd in Minneapolis, protests have erupted around the country. Some of these have turned violent and resulted in injuries to citizens and police, as well as looting and other forms of property damage. Cities have implemented curfews and other restrictions on movement, further stoking tensions due to the coronavirus lockdown, the start of summer, and a 15 percent unemployment rate. The last time the nation faced this level of social unrest was 1968, the year that Martin Luther King and Robert F. Kennedy were assassinated. To help us make sense of the current moment and figure out where it could lead, I spoke with Princeton University political scientist Omar Wasso, who has studied how protests of the 1960s affected public opinion, social discourse, and voting patterns. Will today's protests make policing reform more or less likely? Is it possible that violence in the streets will boost Donald Trump's re-election chances just as events in 1968 helped put Richard Nixon in the White House? Wasso's research also looks at the nature of police misconduct, analyzing whether headline-grabbing incidents such as the horrific killings of Eric Garner and Tamir Rice are the result of a few bad apples or a systemic problem with law enforcement in minority communities. I spoke with Wasso, who is currently in Los Angeles via Zoom. Omar Wasso, thanks for talking to me. Thank you for having me. Can you outline your findings about protest violence and political outcomes? Sure. So the big picture is that a lot of research suggested that protests should have little to no effect in politics. A bunch of people go out on the street, they make some noise, it doesn't matter. Elites dominate politics. And what I found consistent with some other research on protests is that, in fact, protests are influential. And my work in particular finds that protests are influential through the effect they have on media. And so protests shape what the media talk about and what the media talk about in turn influences public opinion. And that then shapes what people in Congress are doing or what kind of legislation gets passed or, in fact, as you mentioned, who might win a presidency. Let's get to the presidential election. I read down the red, and obviously this is wild speculation of the type that academics never want to indulge in, but I'm going to force you to. But you were looking at the period between 1960 to 1972. And before we get into what you found there, is there a difference in the way media back then is very different from media now? Do you worry at all about the relevance of your research? Not for explaining what happened, but what might be going on now? It's a really good question, and I think there are some really important differences and also some important similarities. So why don't I go through some of the differences first? So clearly there are way more media now than there were in the past. And not just that, but it's much more fragmented, right? So every one of us has our own distinct social media feed that is going to be unique and give us a different vantage point on the same event, let alone hundreds of events around the country. We also have a kind of intimacy that comes from people's cell phone footage. And so where the power of a single image in the 1960s that was conveyed on a newspaper might have brought you there to a degree, I still don't think that's as powerful as sitting, watching George Floyd be killed before your own eyes. I mean, the sort of the anger and rage and grief that that triggers when you see a man crying for his mother as a cop has his knee and his neck. Like that's a kind of visceral, intimate, powerful, terrifying, direct experience of media that was only partly conveyed in the past. Right, because even when we were able to see very stark images, dogs being set loose on protesters and things like that, oftentimes it was either a still image or we didn't see it at all because the networks weren't really showing that kind of brutality. Yeah, I mean, one, just given that we have a little bit of extra time to kind of go into some of these details, one of the remarkable things about Bloody Sunday is that there is a national documentary about the Nuremberg Trials that's playing on television. And they cut into, you know, sort of a story about Nazi war crimes to footage in Selma of people like Representative John Lewis being beaten brutally by police and vigilantes. And so that contrast in that moment was exceedingly powerful and there's good evidence that it really did shock the conscience of the nation and for a lot of people made them realize that, you know, what's going on in the South is not normal politics. This is unacceptable. And I think there are moments that are in the past that are that visceral. But I think what's different now is the way in which there are things that black people have been saying for a long time, police engage in abusive behavior in our communities and now people can see it for themselves in a way that really maybe began with the video of the beating of Rodney King but has become much more a part of our common lived experience. And I suspect has played a role in making particularly white liberals more attuned to black concerns about racial equality. One similarity, though, I think between the 1960s and now is that the media tend to rely on some fairly common scripts or narratives for how stories get told. And one of those is a kind of a right script or a kind of a justice narrative. And another is more of a crime script. And what we're seeing, what we saw in the 60s was that nonviolent protests, particularly nonviolent protests, met with state repression, with vigilante violence were much more likely to be presented as a kind of redress of grievances as a demonstration as a march, as a call for civil rights. So a nonviolent protest today produced a headline about civil rights tomorrow. Whereas when protesters engaged in violence, that predicted a headline about riots tomorrow, a headline that was much more likely to focus on crime and disorder, and public opinion moves very closely with that. So when the newspapers are talking about civil rights, civil rights becomes the most important problem in public opinion surveys. And when newspapers are heavily covering crime and riots, crime and riots become the thing that is the most important problem. And so the tactics that are employed by protesters can really make a powerful impact on how the media tell the story, which in turn shapes public opinion. And I think that's still likely to be quite true today. In the 60s, and especially coming out of the civil rights movement, it seems as if, and this might be an artifact, both of my not understanding it fully, but also looking backwards, that civil rights marches were kind of scripted. They were organized. The people who participated in them were taught passive resistance and kind of like, don't fight back, et cetera. Today's protests all over the country seem to be much less organized. Does that factor into this at all? Or did the 60s protesters know what they were doing in a way that it doesn't necessarily seem clear that what's going on today is under anybody's control? I think that's right, that there's a lot of the protests in the 60s that escalated to violence started out as organized, nonviolent, civil disobedience. But when people are enraged about a police killing or some aspect of state violence, it can be very hard to sustain that level of order and focus, particularly if the nonviolent protests which were successful, in part, employed producing lots and lots of images of state violence, of police killings. And so once people are kind of seeing that imagery and getting angry becomes much harder to kind of, I think, to do that very disciplined, as you said, passive resistance that took training that takes incredible perseverance to sort of let somebody hit you and not hit back. But there's another dimension to what you're saying, which is, I think, even more true today, which is that part of what's powerful about cell phones and the internet and the variety of communications technologies is it makes the transaction costs for coordinating a large-scale gathering much, much lower than they would have been in the 60s. And so it's now possible for somebody via Twitter or Facebook to kind of say, we're meeting at this location, and that solves the coordination problem. And suddenly in a very spontaneous and not coordinated in the we trained, we knew what we were getting into sort of way, that makes it possible for there to be this kind of explosion of activity that lacks a center and any kind of coherent agenda or organizer. Of course, there are organizers involved in these events, and there are organizers who have a long history doing work. But they're just sort of one constituency in this kind of explosion of activity. And to be clear, most of these protests have been peaceful, but there are many constituencies, and you're exactly right. It's much less centrally organized. One of the, I was going to say weird, that is quite right. One of the kind of disturbing discoveries of your research is really that the best outcomes from a kind of civil rights perspective were when protesters were nonviolent and the state police law enforcement were violent. Is that accurate? And why did that, why do you think that helps push civil rights forward? Yeah, that's a good summary. And let me step back and sort of set up one part of why that, the logic of that. And so initially, nonviolent protesters in the South were getting attention. But as one reporter said, of a very large protest in Hattiesburg, Mississippi, if there's no conflict, if there's no violence, this is a boring story. What I want is blood and guts. That's what makes a story. And what the leaders of the nonviolent civil rights movement figured out was that what really generated national press was when there was state repression that was excessive. And that partly was useful because it got the press's attention and generated national media. It also was really important because a lot of white moderates who might have had some awareness of a sense of racial, that Jim Crow was this kind of, that blacks were second class citizens in the South, but it didn't really, it didn't move them politically. They could view a nonviolent protest as something that was normal politics. Look, the system's working. It was only when there was an excess of state repression, when there was this kind of brutal, as you mentioned, sicken dogs on young people, fire hoses on young people. In that context, it's very hard for the kind of disengage or maybe even hostile white moderate outside of the country to say, hey, it's working OK. The system is normal politics. So the strategic use of violence where protesters were the object of violence both shocked the conscience of the country into saying, OK, wait, that's a little beyond what we're comfortable with and got the media to become very engaged. What was the role, and I'm thinking of Martin Luther King's letter from Birmingham Jail where that's addressed to white moderates who are saying, you got to wait. You got to wait. The system is working. And he gestures towards, if you don't deal with me, with a peaceful person who's willing to work through the system but is going to push the issue, you're going to have to deal with violent elements in the kind of Black Civil Rights Movement, Black Panthers or the Student Nonviolent Coordinating Council and Committee. Is that kind of dynamic at play here, do you think? Because is there a sense that we, as a country, we need to deal with this peacefully otherwise? There is a set of groups, whether it's Antifa or something else, that's going to cause many more problems. Yeah, so I think that's sometimes called a radical flank hypothesis. The idea is if there's a kind of a threatening, more extreme group that makes the moderates more attractive to negotiate with. And I think broadly that's plausible, and I don't think there's any reason to doubt that those dynamics are at play in any kind of negotiation. In the early part of the 1960s, certainly Malcolm X is a presence, but the Black Power movement, the Black Panthers haven't really come onto the scene when the 1964 Civil Rights Act was passed, when the 65 Voting Rights Act was passed. And the big wave of violent protest activity comes after 65, right? So really the biggest high-profile violent protest is in Watts, and that comes just after the Voting Rights Act. So I think it's very reasonable to say that, in fact, the threat of violent resistance, while certainly always a part of, I think, white leaders' consciousness, is not the thing that's driving the passage of the Voting Rights Act or the Civil Rights Act. I think it's much what I look when I see in my public opinion data is the more people are engaging in nonviolent protest, the more public opinion changes, and both with the Civil Rights Act and the Voting Rights Act, within a year those laws get enacted. And so moving public opinion, growing the coalition of people in favor of those changes, moved politics. In the later period, there is some evidence that violence did, in fact, produce certain kinds of benefits for black communities. But I also find, in addition to those benefits, that violence probably contributed to a growing of the law and order coalition that really was pushing for more repressive policies, too. Can you talk a bit about 1968 in the article that you wrote that comes up, and you basically say that because of violent behavior by protesters or fear of that by white voters, they tipped into the Republican camp. Richard, it's kind of hard to, I guess, recover this history, at least in a common sense. But Nixon, it was a three-way race with Nixon Humphrey and George Wallace, who was an explicit segregationist. Nixon got in with a plurality of votes, not a majority by any stretch. How did, what were the events that made people, made whites scared that they ended up going into the Republican camp and letting Nixon eke out of victory? Yeah, so I think just to put this, you framed it all really well. And I just want to take one step even further back and say, let's start with Goldwater, who ran on law and order, and lost, and lost badly. And so there's a puzzle that was one of the things that motivated my research, which really begins with where did law and order come from? How did mass incarceration become? What is it about what happened in the late 60s and 70s that seemed to lay the groundwork for this hockey stick increase in incarceration in this country? And the puzzle is, why did law and order fail for Goldwater but work for Nixon? And there's even one more dimension to that. Ronald Reagan runs on law and order for the governorship of California in 1966. And so he wins substantially. And so law and order isn't working in 64. It is working in 66. It is working in 68. And if can I complicate or throw in another log on the fire which is that Nixon did pretty well among African-Americans in 1960 when he was running against Kennedy. I mean, he went to get like 25, 30% or something like that. I mean, it was substantially higher than any Republican has gotten since. Yeah. Well, so that's a really important point. And let me try to braid it together with two ideas. So one is that, why does Reagan beat the incumbent Pat Brown, who had been quite popular? There's evidence in my research and others that there's a strong shift among a certain subset of Democrats away from the Democratic Party following the Watts uprising in 1965. So law and order becomes a winning strategy following Watts. And then in 67 and 68, there are very large violent protests. And to be clear, while what we're seeing now is quite dramatic compared to what was happening in the 60s, these are still relatively modest events. I don't want to minimize any particular injury, death, building going up in flames. But in Watts, there were something like 3,000 incidents of arson. So just a totally different scale of unrest. And so that pushes these issues. And again, the media is covering this. There is very dramatic footage. And that means that what we see in public opinion is that issues of crime and riots are moving up in the summer, down in the winter, up in the summer, down in the winter, as we build up to 1968. And so the public opinion data looks very consistent with the story about the public is responding to what's happening on the ground. The violent protest is driving a concern about crime and riots are the most important problem in America. And the other issue that you brought up, which is a really important one, is basically in 1964, the Democrats, in 1960, it's not clear which party is the party of African-American interest. The Republican Party is actually more liberal than the Democratic Party on a civil rights bill that's introduced before 64. But basically, with 64, with Johnson leading the charge on the party side and the pressure from activists with things like the March on Washington in 63, the Democrats become the party of civil rights. The Democrats split from the Southern Democratic wing, which was segregationist, and becomes the party aligned with African-American interests. And in that shift, suddenly Nixon, who might have been more progressive on race, has a, you know, there's a kind of realignment of the parties where one is the party of black interest and one is the party, essentially over time, becomes the party of a certain class of white interests. And that means that law and order, which is not explicitly racial, but it's kind of coded language that translates as, you know, I'm gonna keep those outgroups in control. And so the combination of the Civil Rights Act and the, you know, unrest on the ground sort of produces this competition overrace in our party system. And the Democratic Party is, you know, doesn't have, the Republicans really own the issue of law and order then for the next 50 or 60 years. You know, kind of flash forwarding to contemporary America. Donald Trump in 2016 ran as a law and order candidate. I mean, he used that phrase, harking back at least to the Nixon. In the current context, I mean, it seems like Trump is very much, you know, he's anti-protest, and he equates any kind of protest with rioting, and that type of thing.  He's walked back some of his, what used to be his legislative accomplishments. Is there a clear, you know, like, is there a clear sense of where any of this goes in the 2020 election? Yeah, that's a really important question. I think there are a couple of things that are predictable and a bunch of things that are super unpredictable. And in the kind of predictable scenario, right, we know we've just seen Trump will almost always play to his base and has very little interest in trying to, you know, bridge divides. His just first instinct consistently is to kind of turn up the volume on division. And we're seeing that right now. Although it's also bizarre in a way that he did better with African-Americans and Latinos than either Mitt Romney or John McCain.  Yeah, I mean, he might have done 9% without America. Yeah, like 7%. And I think to be clear, there's a certain kind of, in particular, man who appreciates a kind of macho candidate and that has a lot of appeal. These sort of, there's some evidence that we've seen a kind of sorting of the parties on a taste for what, in political science, is called authoritarianism. What you think of as, you know, sort of a more traditional social order, more patriarchal, more, you know, there's sort of a black and white view of the world. And so if you're an African-American who has those kind of authoritarian tendencies, Trump may be very appealing. But that's still a very small percentage overall. But you're right, it's a higher number among Latinos. And I think the big picture, though, is that Trump is, you know, has already run on law and order. It, depending on how the next few weeks and summer play out, it may or may not continue to be really salient come November, but if it does, it's almost certain that that's going to be a core part of his message because his entire campaign going back to his first address was, you know, there are these criminal elements, you know, maybe they're Mexican, but later they're, you know, blacks in cities, and I alone can fix it, right? And so he's the strong man. And so I think that's, you know, that's a fairly, it doesn't take, it doesn't take a lot of research to say that to a conservative, you know, safe prediction. But what I think is unpredictable is he's the incumbent. And in some cases, it might mean that he is associated with the disorder. And so there may be people who, you know, like some of what he has to offer, but feel like he's actually more of a chaos agent than a source of stability. And the key thing that I see in my research that I think is still at play today is in the earlier era, and I think this is hard for people to really wrap their heads around, there are people who are open to racial equality, right? Like Johnson wins in a landslide in 1964, and there's a lot going on there, there's Kennedy's assassination, but the civil rights bill has passed. And there's a democratic coalition of white moderates and white liberals and African-Americans that holds, right? So it's not just the 64 Civil Rights Act that splinters the democratic coalition. And I think that there's, so the key idea is there are white moderates who are, you know, they don't prioritize racial equality, but they're not opposed to it necessarily, but they do care about order. And so they're kind of adjudicating between a party that they might like some things about and has racial equality as a core plank and a party that says, I'm gonna really fight for order. And those white moderates can really play a critical role in tipping an election. And I find that that, you know, it's mid-Atlantic states and mid-Western states that are the ones that potentially tip in 1968. That's quite similar to what happened in 2016, where the states in play, you know, are Wisconsin and Ohio and Michigan. And so I think it's likely that in 2020, even though whites on average are much more concerned about racial equality, that there are going to be these swing voters who, you know, are sympathetic to block concerns and care about order and are gonna be pulled between Biden and Trump and the kinds of narratives that come out of these protest movements, the kind of narratives that come from the two candidates are really gonna help those folks align with one camp or another. And I don't know quite how that's gonna play out. Yeah, and it's interesting to realize too, you know, the first big explosion of this round of protests come out of Minneapolis, which is a mid-Western state but unreliably democratic and kind of liberal, but then also kind of mid-Western conservative places like Louisville, Kentucky, which is kind of the South, but not really, really heartland. Can I ask, this is a kind of orthogonal, I guess, to this question of, you know, when we look at 1968 versus now in, I would say, and correct me if you disagree with this, in most ways the country is unrecognizable in terms of race relations, in terms of equality, not just for African Americans, but for women, sexual orientation is not an issue. It was unspeakable in 1968. It's less and less of an issue if it's one at all today. How do we talk about progress along racial lines that is incomplete or is still problematic? Because one of the things that was kind of remarkable about this, the event with George Floyd or the killing of him, even versus Ferguson, is that nobody was really defending the police actions here.  Everybody is saying this is wrong. How do we account for that without saying, okay, so we really don't have to do reform? So it's a really good question. And I think the way I think about this is a kind of tale of Tustitti's story, that following the, you know, essentially the breaking of Jim Crow, a really remarkable act of insurgency by African Americans to overturn an oppressive regime. Following that movement, we have both enormous progress for African Americans in particular, and for, call it the bottom, you know, 40% of African Americans, a really terrible, in some cases, even worse situation. And so we have to be able to hold that kind of dual path at the same time. And so on the progress side, you know, you've got an enormous opening up of opportunity, educational employment, housing, I mean, just a real flourishing of the black middle class in a way that is really important to recognize and to appreciate and reflects absolutely progress in America. And at the same time, and this is part of what took me back to school, and you know, when we're talking about issues of mass incarceration and criminal justice, right, we have the rise of the war on drugs. We have this massive hockey stick increase in incarceration and all sorts of other kinds of really devastating social and economic effects in the black community in particular. So, you know, employment opportunities as part of deindustrialization become much tougher and there are any number of other sorts of, you know, sort of kinds of social dislocation that are happening, particularly for that bottom 40%. And I think part of what is so important about what happened with George Floyd, and to be clear again, exactly as you said it, the police killing of George Floyd is that it really focuses our attention on one of the core issues that has been a source of trauma over the last half century, which is that criminal justice has been just a profoundly unequal and a profoundly brutal system for African-Americans and that that is affecting the bottom 40% much more than for African-Americans, the top 50%. I'm not saying that there aren't lots of folks, you know, my former advisor, Henry Louis Gates, getting arrested in his own home. You know, I'm not saying those things don't happen, but it's way more devastating for the people who get kind of trapped in a criminal justice system that just does not let people go and kind of constraints all of their life chances. And so that's how I think of the, you know, has there been progress, enormous progress, particularly on the things you're talking about, the kind of social liberalism stuff, but on a bunch of material wellbeing, and in particular, in kind of terms of liberty, right? The number of people who are locked in cages, we have not made progress. Right. And you know, that was part of, I think, what came out of the Ferguson moment there of recognizing how many levels of kind of social control through fines and other types of policing, which definitely just disproportionately affected and screwed over black communities there was. That was invisible to a lot of people. Yeah, that's right. And so there was a kind of, essentially taxation through fees. So, you know, the state was funding its activities by, you know, petty fines that would accrue and could be devastating. And I just think when I was reading about that moment, I was thinking about a ticket I got for speeding. And I was going the same speed as everybody else. I got, you know, it was the end of the month. It was clear they had a quota. I got picked and I was so angry. I didn't pay it for, you know, another whatever it was. I missed the deadline two times. And I just, I was screwing myself over, but I was so angry about the fee and the feeling of, you know, this wrongful kind of ticket that, you know, my way of protesting was in some ways to screw myself over by not paying it, right? But you could pay it. I mean, then that's the type of thing where, you know, it becomes a never ending sinkhole for people who don't have the, who can't pay it, right? That's right. And I'm coming to that with great privilege.  That can be really maddening.  And you're right that that was invisible and I think it's important on the progress side to note that as much as people might think the Black Lives Matter movement kind of petered out as Trump gained power or came to office, we've seen at the local level reform DAs in cities across the country when there have been changes in use of forced policies that have had material benefits for, you know, reducing the amount of police abuse that we observe. And so I think that's also less visible, but there really has been a reform movement that has made progress. And I suspect that even Trump is kind of operating in some ways in a new set of constraints where he might, you know, say Blue Lives Matter not Black Lives Matter, but he doesn't want to align himself with the guy who, you know, kills a man crying for his mother on camera. Yeah, in fact, I mean, he signed the first step act. He's done, he's made certain gestures towards criminal justice reform, which are actually historic. So, you know, and when you go back to like at the more local or state level, certain types of asset forfeiture laws have been changed and cash bail is being repealed in places which are all, you know, very positive developments. Let's talk a little bit about policing or reform of policing because that is kind of front and center. You know, one of the things that, you know, some of the protests, and I'm in New York City, I was along a protest yesterday that very quickly went from talking about George Floyd and other recent cases of violent death at the hands of law enforcement to, you know, attacking capitalism, writ large and all sorts of other types of things. But to go back to this, you know, primary issue of police reform, you've written on Twitter or you've talked about how people when they talk about reform, they tend to either say, we need like a complete systemic reform or we just need to pull the bad apples out. And you've stressed that in fact, you know, it's both and that, you know, getting rid of bad apples or recognizing who the bad players are in a system is a lot easier than we seem to believe. Could you talk a little bit about what's going on there and what your analysis shows? Yeah, this was really striking to me when I started looking into this a few years ago.  And the sort of system story says, you know, the whole thing is corrupt and you kind of need to have the cops are bad. And what was sort of surprising to me when I looked at some of the data is how disproportionate it is in terms of a very small percentage of cops generate a way disproportionate percentage of the civilian complaints. So in a place like Chicago, it was something like 1% of cops generate 25% of the civilian complaints. In New York, there were cops who had, you know, 20, 30, 50 civilian complaints who were still out on the street. And if you look at the pattern, the cop who shoots Laquan McDonald in Chicago had something like 17 complaints against him. The guy who choke holds Eric Garner and, you know, as he's screaming, I can't breathe, had, I think it was like 12 complaints against him. There are, and so, and the person who killed George Floyd had a pattern of abuse. And so, if you are thinking about this, you know, the bad apples versus systems question, what became very clear to me is, in fact, the modal police officer, you know, I think in New York, was something like 40% have zero complaints against them, right? So, in fact, there are a lot of cops. And I'm, you know, whether you are pro or anti-cop or that's even the wrong frame, like it's clear that there are some cops who are doing way more harm than others. And getting those cops off the street would do a lot of good, right? Eric Garner would be alive, Laquan McDonald. What are the obstacles? What are the obstacles to, you know, when you have such a small percentage of cops causing so many of the complaints, you know, what are the obstacles to pulling them out of the system? Yeah, well, I mean, I think this speaks to the need to kind of focus on both systems and individuals, right? And that clearly there's a systemic failure, which is the, you know, like these cops engaged in repeated abuse aren't being sanctioned in any sufficient way, fired, you know, put on a desk job, demoted in some way that sends a signal to everyone else.  And so that's the systemic part of the failure. Is that part of the question I ask is that like, is that a union thing? Is that a solid area, like a thin blue line type of thing? Or do you have a sense what's causing that? I think part of what's remarkable about this issue is it's actually terrible for cops, right? Having a cop who knees a man to death on his neck is terrible for cops. And if you were, you know, a kind of rational police union, you would be interested in getting the rogue actors out of your, you know, out of your profession. And I think in a lot of contexts, there's it's a thin blue line. It's a kind of, you know, a level of solidarity that defends almost every kind of action by police. And in fact, if the police unions, if the police, you know, kind of, you know, the mayors and governors who oversee these institutions, if they were much tougher on that one to 2%, we could potentially be reducing the level of abuse, you know, 25%, right? And that really matters. Another example of this that's kind of, you know, getting that worst officer out, Tamir Rice, right? A child playing with a toy gun shot by a cop who had been fired by another police station, police force because he was deemed as unfit and then hired by the force that ultimately in which he shot Tamir Rice, right? And so again and again, the people engaging in these kinds of egregious abuse have this pattern. And the other thing I think, coming back to your question about why doesn't it change, and I think in some ways, focusing on the system change is really hard. That's like a big kind of pot to boil. And part of what I was arguing in one piece I wrote for The Root is that it's, you know, part of what you want as a movement is cases that put the opposition on their heels, right? And so a cop in New York who has 51 complaints against him, that's really hard to defend. And that's a really good place to be if you're trying to push for reform and accountability for police. And so my argument was partly, there's a material benefit, right? You might have fewer of these kinds of abuses, but it's also rhetorically very powerful to focus on these extreme cases that while maybe only 1% still matter enormously in terms of the quality of life for black communities.   You know, what are you thinking?  So let me enter in kind of a couple of parts. So I think the pessimistic part of me says, I don't have much optimism that there's going to be any kind of rapid change on criminal justice issues. I think that's a long, slow fight that for which there is real progress, you know, decriminalization of marijuana, you know, these DAs getting elected. There is real progress on criminal justice issues, but the apparatus is so vast that it's gonna take a long time to try and make headway on that.  And that's a terrible thing and I wish I had more optimism about that. But on a more encouraging note, I think in the 60s, there was a sense of the whole social fabric was coming undone. So we had Martin Luther King assassinated to Kennedy's assassinated. The world was just, you know, a level of social unrest. Yes, what happened this past weekend was dramatic, but again, in the 60s, you're talking about, you know, thousands of instances of arson in a place like Detroit, National Guard comes in, shoots 15,000 rounds of ammunition, 34 people die. I mean, it's a level of like low grade civil unrest that looks like a civil war or something kind of akin to that. And this is not at all at that level, at least at this stage. And so I also feel like there's some reason to think that we're moving through this in a way that's likely to not kind of tear the fabric entirely. But I think the really big question that's not specifically about Trump or the unrest is that our kind of our democratic institutions are in some ways being challenged. And so, you know, can we maintain a kind of core commitment to both things like, you know, civil rights and civil liberties and voting and voting rights? And I worry about democratic erosion in this country. So I was trying to find the optimistic note. Yeah, yeah, you know, I was gonna say. That was not it. But I guess it's a more peaceful period. And I think that that stability is good for, you know, for progress. Well, it's odd because, you know, when Trump gave his inaugural speech where he was talking about American carnage and he was describing in America, you know, that was bleeding, you know, from street crime that maybe existed in the 70s, but certainly wasn't anything common. But by the same token, when you go back to the late 60s, the level, the amounts of trust and confidence in the government and other institutions of authority was much, much higher than it is now. So it's kind of, you know, there's much less crime, but there's also much less confidence. I don't know where that leads. Well, I think, you know, we are at the frontier of a challenge that I don't think has been fully appreciated, which is that, and it goes back to your point about, you know, between 60 and 64, what changes, we're trying to build a multiracial democracy and that turns out to be an exceedingly difficult thing and that a bunch of countries that have multi-ethnic states converge to not really being democracies, they kind of become ethno-nationalist authoritarian states. There are examples like Canada that kind of embrace being multi-ethnic states. I mean, I think we're in the middle of this convulsion where part of Trump's appeal is he's saying, no, no, I'm gonna reassert the old social order, right, make America great again with whites and Christians on top and, and there's a kind of counter-mobilization, which to be clear, you know, Trump didn't get a majority of the vote and young people have not much love for Trump. And so, so I think that the transition that we're in the middle of is bumpy. One reason to think that there may be a large constituency in the future for a peaceful, free, multi-ethnic democracy is, in fact, in the social unrest, is a call for enough of the state violence, right? It's not a call for, you know, crush the ethnic minorities. And so, I have some confidence that we're moving in the right direction in terms of building this kind of prosperous, peaceful, multi-ethnic society, but there's still a lot of inequality and a lot of state violence against, in particular, black and Latino people. And so, you know, the point is, in that transition, things are really bumpy. And I think we're in the transition now, but I also have some optimism that we're moving towards a period where the ethno-nationalist contingent no longer has a winning national coalition. Can I, you know, you came into my view, where I first learned about you through both my predecessor at Breeze and Virginia Postural, but through your website, Black Planet. You were part, you always struck me as you were on places like MSNBC, if I'm not mistaken, but you were kind of an avatar of a techno-utopian or techno-optimist moment where one thing that was kind of fantastic about the late 90s, and I realized part of this is just old manism on my part, but that we had gotten to a point where we could be more individualized in every aspect of our lives, you know, in our commercial lives and how we could order things, how we could monogram things, but also on our identities, I mean, on the most meaningful expressions of ourselves that we were no longer just seeing each other in terms of black and white or male or female or East Coast, West Coast, whatever, everything became much more nuanced and complicated in a good way. Did that, you know, like, I mean, that isn't how we're talking anymore. We're talking in the most kind of brute terms of ethnic identity or tribalism, whether it's racial, ethnic or political. Is there any way back to that earlier kind of glimpse of a different future that was not scornful of identity, but rather, you know, it was like, let's, instead of being one of two things, let's be one of 10 or, you know, 10 or 20 things. Yeah, so I think the, you know, Virginia Postrelle once said to me that nature abhors a void as it relates to politics. And so she was always skeptical of the kind of more anarchist schools of thought because to her mind, into that void was gonna come some, you know, more, had probably authoritarian power. And we might think about something similar with identity where people have a deep need to feel kind of rooted in community and in a sense of, you know, peoplehood. And that doesn't mean it's not mutually exclusive with what you said about I can be, you know, black and into anime and, you know, somebody who likes to, you know, I don't know, ride a motorcycle. But I think there's just a profoundly human need for connection and those connections often have a kind of, you know, they're rooted in history of groups that we kind of ascribe meaning to. And I say all of that to say that, like, I, you know, you come to California where I am right now and I remember talking to a friend of mine who teaches at a high school here.  And so in a school that's 90% Latino, there are Latino Goths and Latino skatepunks and Latino, you know, rockers. And it's like, yeah, that heterogeneity is there, but it's not uncoupled from them also feeling very rooted in, you know, like the Mexican-American community in LA or something, right? And I think it's possible for both to exist, but it's also requires something like California where some of those cleavages aren't the organizing cleavages by which kind of power operates, right?   And so I think we're in a bit of a shakeout where those axes really matter in terms of who has power and how laws get made, but they also might fade to agree with time. I think the slightly more concerning version of it is research that suggests we are moving into a world where essentially party becomes the overarching identity and that might mean that, in fact, going back to Virginia's idea about, you know, nature abhors a void, I mean, clearly not her phrase, but when I was talking to her, that it may be that there isn't actually a kind of more atomic state for humans that we're always going to be tending towards and agglomeration and that, you know, quirky editors who have a rebellious streak, you know, you're in the, what I think of, like my father, the Groucho Marx Club, like you would not join any club that would have you as a member, but that's not typical. Yeah, the idea that, you know, the limit of my identity is gonna be either Republican or Democratic. God, you know, that's very depressing.  Thanks so much, Princeton University, political scientists. You can find contact information in the text field for this interview. Omar, thank you so much for talking. Thank you, Nick, really appreciate it.


This is the House Healthcare Committee. It's Friday, February 26th, just after 11 a.m., returning from our floor session. So this morning we're taking further testimony on H210, which is the bill on health equity. And we have with us witnesses from the Vermont Medical Society. And I'm going to leave it to welcome you to introduce yourselves for the record and also to determine who wishes to speak first. Great, for the record, I'm Jill Sutthoff-Garron and I will be speaking on behalf of the Vermont Medical Society, the American Academy of Pediatrics, Vermont Chapter, the Vermont Academy of Family Physicians and the Vermont Psychiatric Association this morning. And we will all be expressing our support for H210. And I will also introduce Jessa Barnard, our Executive Director of the Vermont Medical Society. We thought it would make sense if I talked about just the background of our work and addressing inherent bias in healthcare. And then Jessa will talk specifically about achieving meaningful medical training in this area. So I wanna just start by framing the message that our organizations have made recognizing, addressing and mitigating the impact that inherent bias has on health outcomes, one of our very highest priorities. And I will also say that we are very much in the listening stage of this work in order for us to really thoughtfully create health equity tools that we can appropriately apply to better serve our patients. We really need to listen and we really need to take input from the communities that have been historically silenced and marginalized. And we've really seen the poorer health outcomes in these communities as well. Last week, VMS hosted a webinar and it was called Just Race and Health Equity and it was really looking at what the American Academy of Pediatrics Task Force on Race and Health Equity. This is a task force that was formed last year when the George Floyd murder happened. And so the webinar was really looking at their work and what they're trying to do. This is a 25 member task force mostly made up of pediatricians. And Becca Bell, the pediatrician intensivist who's leading the webinar, she said, we're really in the beginning of the discussion of how we approach this work. We very much in the process stage and we need to take our time. So at the very minimum, we do no harm. And really in order to do that, you really need to take that time to be informed by the communities and really not try to put a one size fits all approach in terms of tool kits or practices or anything of that sort. So we really resonate with that message. Last June, VMS like the rest of the world was really gripped by the murder of George Floyd and we took that time to put out our statement, not only denouncing police brutality, but also really naming systemic racism as a public health threat. We know that systemic racism and other forms of discrimination have really produced devastating health impacts. And these impacts, we've seen it with trauma, chronic stress and the differential access to appropriate medical care. And then of course with COVID, that's really exposed what happens with this differential access to care and it's led to tragic disparities in health outcomes. So really the need for culturally appropriate public health measures, including those with social determinants of health and mitigating this disproportionate impact is really important and critical right now. Since I began working at the VMS, this has been like one of our very, very highest priorities. And in 2018, we actually adopted a policy in which we resolved support system designed to combat biases within the healthcare system, not just for the patient, but also for patients that we're choosing not to go to specific healthcare providers because of these biases as well. In 2018, we also adopted policies to support the humane treatment of migrant families just because we saw so much heartbreak on the border and our members really took an active role in addressing this. And then VMS also adopted a policy in 2019 to protect women's reproductive rights just really with the idea that the sovereignty of your own body is integral to your health. So I will just say that over the last years that I've been at VMS, I've just seen that our members are super hungry for this education, they wanna learn more, they wanna take an active role. And so we are very supportive of this bill and we are very supportive of the office, the idea of the Office of Health Equity. We sent a memo earlier, I don't know if Colleen put it up, but in the memo, I have a number of webinars and trainings that we've put out and partnered with other organizations on. I don't know if it would be helpful for me to pull that up for you to look at, but. Yeah, I think we have the memo, so I think that would be sufficient. In terms of the best use of our time this morning. Yeah, but you'll see that VMS has a webpage on this where we're consistently putting up new information. Our annual meeting is always included health equity trainings. And then there's really good resources being put out with partner organizations, Vermont Program for Quality Healthcare is gonna be doing something with Dr. Avila, which you just had her in this week. And then the areas of health education centers has a great five-part series that's really looking at cultural competency. So just to emphasize that this work is being done and that we are highly supportive of it. I guess we have a couple of suggestions for you and then I'll turn it over to Jessa, but yesterday's Zuzana Davis talked about maybe just starting with the advisory commission and we would support that. We feel like right now the Vermont healthcare system has just been underwater and then BDH, we know that their capacity is so low right now. So we would say that that is a great first step. We also noticed that beyond the commissioners of health and mental health, there are really no healthcare providers on this commission and we would urge you to have clinicians on this commission just understanding that you're trying to develop new systems of care. And so you really wanna have people that can inform with their practice experience, but also just to have the accountability and the buy-in on the ground. So we would support that. We also support section 252 and in Kay, you talk about working collaboratively with UVMC, which we know has done a lot of work in this area. We would also urge you to partner with AHEC and VPQHC just because they're doing the work in this area. And with that, I will turn it over to Jessa and then we'll be here to answer any questions afterwards. Thank you. Thanks so much for having us. Thank you, Jill, for that great framing of the work we've been doing in the area and the interest of our members. And so continuing in the theme of suggestions in the section on mandatory education, we would really encourage the committee to look at the approach taken to professional education in S42-48 that Dr. Avila mentioned in her testimony. This was in one of her slides. This is a bill that's been introduced in Congress. I don't believe it's been passed, but we really appreciate the approach taken by that bill. It directs, in this case, on the federal level, the Secretary of Health and Human Services to award grants to a range of entities, healthcare providers, health departments, professional schools, nonprofits, to support bias and anti-racism training to reduce racial and ethnic disparities. And then it links any entity that's receiving that grant funding to reduce those trainings needs to meet some criteria. So the education has to be evidence-based, community-informed, patient-centered and ongoing. It needs to be culturally competent and accessible. And I think this is really key. It needs to be designed to allow any state licensing body to provide continuing educational credit for those courses. So it needs to be recognized by whatever your licensing board is as meeting whatever hour requirements you have for CME already in your licensing standards. We really support that approach. We think there should be funding and support for the development of courses and the ongoing implementation of those courses and that it should fulfill existing CME requirements. That said, I will move into the reasons we, actually we don't support the current language in the bill regarding a list, a specific list of topics that need to be repeated every two years in order to, as a new licensing requirement. So a lot of these concerns stem from our experience having, seeing our members going through the required courses for the opioid training. So what we've seen is that just having a mandatory hour requirement does not necessarily mean quality education or desired behavior change necessarily. So for example, with the opiate training the quality of education varies widely. We've seen out of state for-profit companies, market CMEs because they know that providers are required to take it. But it's, but in our opinion it's not been very high quality training. And on the other hand, we have some Vermont based entities that offer excellent training in this area. But again, it varies widely. I am not an expert in the science of continuing medical education. There are people out there who are like at AHEC or VPQHC, but I am aware that the research shows the efficacy of CME can vary widely based on how it's done. Its methods, its length, how important it is to the person taking the education. And we got a really, I thought helpful quote from Nicole appointed to the end of our memo who's the executive director of the Northern Vermont, AHEC. And again, it's not specific. She doesn't have a position on this bill, but she did weigh in that she's not aware of a strong evidence base that supports state mandated low contact educational activities to support change in a highly complex area such as this one. So again, with the listed topics that need to be repeated, we think that that could be a useful baseline level of education, but real change is I think we all acknowledge goes far beyond a course, especially in this area of healthcare. We need changes in medical school and residency curriculum, which we are seeing happen, but that needs to continue. Changes in organization and practice level policies, procedures, screening tools. As Jill mentioned, absolutely critical to have conversations with impacted patients and families and changes in workflow and more. And Jill referenced this task force, this Vermont task force of pediatricians really delving into this work. And we see other specialties interested in this work. And in contrast, we worry that requiring the same topics on the same education to be offered year after year does not necessarily continue to move the needle in terms of behavior and culture change. And again, to this point of the opioid training, similarly, as section four, B2 of this bill does, that lists topics that need to be covered. For example, storage and disposal of medications, safe use of medication using VPMS, state laws. And that means that it needs to be a very prescriptive course. There aren't very many courses, honestly, that meet that requirement. And it actually means it doesn't always meet the needs and the interests of certain specialties and clinicians. So we've had members ask for trainings on innovative new research, regarding using CBD or cannabidiol to manage pain or opioid replacement therapy and how that can be adapted to the COVID-19 pandemic, pain management and surgery. All of those are topics that I think we would all agree are important and probably really relevant to certain specialists, but because there's sort of a list of topics that needs to be covered, the Board of Medical Practices had to say, we're sorry, that might be really interesting to you, but doesn't meet this topic requirement. So we would really like to see more flexibility to ensure that education is engaging and relevant to different specialties and practice types. Also, I wanna make a point, I listened really closely to Dr. Avila's presentation. I've actually heard her presentation to the VAH, the hospital association as well. I think she's an excellent speaker, raised a lot of really good points. And she mentioned the language access piece a lot. And I wanted, in my mind, I wanna distinguish that a little bit from cultural competency. I know they're intricately related, but I agree with her, that's a black and white compliance issue. We've been providing information to our members for years that you need to provide translation and interpretation services. It's in our guide to law, on our website. Practices should be doing that, just like all other compliance issues like disability accommodations, complying with employment law requirements. To me, that's again, a black and white compliance issue. We would be happy to continue to remind our members of that. I think it'd be great for the licensure boards to remind their members of that legal obligation. I think that's a little different, again, than a broader educational topic to me on cultural competence, that she, as she mentioned, goes to a lot of sort of emotional level issues and relating to patient issues. So I do wanna just acknowledge that issue and say we completely agree that that's important information, but to me a little more black and white to disseminate to our members. So just in conclusion, I wanna say as with many in society, our members have become much more actively aware of this issue and engaged in this issue of existing and longstanding disparities in society and within the healthcare system and the shortcomings of our healthcare system in the past. And we take responsibility for the special trust put in healthcare providers to meet the needs of our patients. And we support educational efforts, but many of these are really just getting off the ground. Jill mentioned the new training created by AHEK, the five part series, that this series by BPQ is actually just happening this spring, they've just pulled it together. So we support sustaining those, disseminating those, and while we think we're nowhere near the end of this journey, we also don't think now is the time that we necessarily need a list of prescriptive topics to be offered or required every two years. So with that, happy to answer further questions. Oh, and I'm sorry, we've been using some acronyms. Jill and I even yesterday said no acronyms and here we are. So BPQ is the Vermont Program for Quality and Healthcare. They are a state, sorry, they're a nonprofit that's really focused on quality improvement and education around the state. And then I think there was a question, AHEK Area Health Education Centers, there's a central office out of UVM, but then also regional offices around the state and their whole mission really is developing the workforce pipeline and workforce education for healthcare providers. I know you have such limited time for testimony on this bill. I would love if you could hear from them and hear about all their work to design these courses. They again are really the experts and leaders in health education that may not be possible given your time, but maybe they could at least submit some written more information about the courses they're doing and how they've developed them. I think that might be valuable for you to hear again. We just, we're really here to emphasize that how seriously healthcare providers take this issue, how committed they are and that this work is really, as I said, just I think growing every day. Thank you both. Thank you very much. And let's hear some questions. I know I have some questions and when I see some hands from community members, let's go first to represent Cheetah and then represent Paige. Thanks for your testimony today on the issue and for giving us an update on some of what's actually happening in the area of training especially. And when this bill was being written, it was finished quickly. So one of the pieces about the training is that it was more of a placeholder than anything with an understanding that two hours of training is only gonna do so much on any topic. And when you look at cultural competency and anti-racism training, it's culture change and it's ongoing work that really makes a difference. And so I'm wondering, it sounds like you have concerns about moving the bill forward with that piece on it for those reasons, might it make more sense to ask the commission to do some ongoing work in this area with healthcare providers and come back to the state with a report on requirements over time? Because as I'm hearing you, I'm thinking that might make more sense and I'm looking at the bill now and I don't think they have that specific duty, but I don't know what your thoughts about maybe that would be a way to address your concerns without losing sight of why it was in there to begin with. I love that idea. I would love to hear from the commission about their recommendations, what other states are doing. Personally, I would suggest involving the licensing boards in that. They may have suggestions about how to promote this, how to engage with their licensees. So yes, absolutely. I think healthcare providers would be very interested in their recommendations and working on this issue. I think it's a great suggestion. Yeah, so maybe it sounds like what I'm hearing. I don't know if anyone's writing this down. So maybe I should, but like what I'm hearing is something like the commission would work with the appropriate licensing boards of the health professions to come forward with any recommendations for requirements or something like that. Yes, off the top of my head, that sounds like it. Yes, ideally working with the healthcare boards and healthcare providers, I think would be even more inclusive, but yes, I think that idea would be very welcome. Okay, I'll write it down. And I think you've heard you say this to the committee previously, but we would encourage it to be as you, I think you've said for all healthcare professionals, I know you said as well that it was sort of a placeholder just to put one group in there, but we would support that. All right, thanks. I'll take a note for us for later. Please, thank you, Representative China, because I don't think we have Lynch Council available to us this morning, but we will be working with them to craft revisions to the bill as presented to us. Representative Page and then Representative Peterson. Yes, thank you. I was curious, well, actually I have a couple of questions. One, would you say that cultural competency is being presented in our medical schools today? Do you have any knowledge on that? I believe it is, and I should, you really should hear from the medical school directly about that, so I'm probably not the best witness on this. My understanding it is now a required part of most medical professional training programs, not just medical school. And to maintain one's practice, how many, what type of refresher training or courses are required to continue to be licensed? That's a, so great, thank you for that question, because I actually want to point out that state statute, so it varies based on profession. So I will speak for MDs, licensed by the Board of Medical Practice only, because that's where our members sit. I believe state statute, and I saw this edit in the bill or the change in the only requires 10 hours per two-year licensing cycle. I will say by rule, the Vermont Board of Medical Practice goes beyond that and requires 30 hours total every two years, because that's the two-year licensing cycle. There are, by state statute, there have been a couple of topic-specific areas that are required that go towards that 30 hours. Currently, one is on hospice pain, we might get this a little bit wrong, palliative care, hospice and pain management, and then two hours if you have a DEA license and prescribed controlled substances needs to be on prescribing of controlled substances. So three hours out of your 30 hour requirement are currently prescribed. That's been added by state statute, by the legislature, not by the Board rules. On top of that, many, almost all physicians, many, many physicians have board certifications, so you could be board certified as a pediatrician or a family physician in your specialty area. That typically requires many hours beyond that 30 hour every two years. I believe, again, might not be quite right on this, I believe for family physicians, it's something like 100 hours every two years. So again, the current 10 hour in statute is a very bare minimum that goes well beyond that. Okay, thank you. And then we all recognize how important healthcare is for all Vermonters. But do you have any examples, specific examples of health disparities in our healthcare providers or within the month's practice of medicine? Where it would show that perhaps we have a problem or maybe we don't have a problem? Looks like Jill wanted me. I will say that we have recent data that shows the percentage of our BIPOC population that's been disproportionately impacted by COVID. That's just immediate data. And we know that there was kind of a slow data catch on this in general, we've heard that. So we know that our BIPOC population makes up about 6% of Vermonters, but they were 18% of them were impacted by COVID. So that's a much higher impact. That's just a very small example. Yesterday you heard a lot about the LGBTQ community where there's many impacts. There's also just the impact of just the population health and the social determinants of health that increase poor health outcomes. You heard just as a small example, the LGBTQ youth use tobacco at a much higher rate than the rest of the population in Vermont. And that's because they've been mercilessly targeted by the tobacco industry. There's a number of things that we could show but just immediately really looking at the COVID, that's a prime example. But you don't have any reports or specific cases against individuals that are available to the public? I'm sorry, specific cases, you mean log cases or? Yeah, I guess where there's been a, you know where the patient has complained about, you know, certain providers not taking their... Yeah, I think we may not have that data as, you know, we're not the public health department, we're not the licensing entities we have heard. So we don't have a report to show you. I can say anecdotally and, you know, a lot of the testimony you've heard, we know. And I think actually Dr. Avila did an excellent job of saying we all have biases. You know, we all come into this world with judgments we're making about other people. And so we know just like the example she gave of the car dealership, we know healthcare providers come to their job with the same biases other people have. And, you know, acknowledging again that healthcare providers have a special trust with their patients. So healthcare providers are not just a person off the street, they are responsible for creating a trusted relationship with this person and listening to them and acknowledging that we may be missing things. You know, there's a lot of emerging data, things like how are we even using, is race even a legitimate reason to be making diagnoses? In some instances, maybe it is actually a factor, but in many instances, you know, we know race is not a biological fact. You know, we've learned, many of us grew up kind of thinking that, but we actually, in reality, you know, our genetics do not line up with what we may look like racially. And so there's a lot, you know, I think it's a huge topic from all the way from inherent bias to the actual, you know, some of the data in diagnosis and treatment. And so that's why I think we, again, we were coming at this from, there's a lot of healthcare providers can learn about this in a whole different, in many different ways. And so we want to promote that whole range of education. So I mean, I guess to your point, I don't, we are not coming to you today with a specific example, but we know hearing from patients that they have been treated differently and it has impacted their trust in the healthcare system. Okay. And I guess those are particular, maybe particular feelings with the individual, but well, just that's that. Okay. Thank you. Okay. Representative Peterson and Representative Goldman and Representative Cortis. Yes. Thank you. Thank you both for your testimony. The training that you envision, does it involve medical training at all or is it training around how to treat people maybe? What do we see for training that would stop health disparities? I don't know even how to frame the question other than are we getting into the medical part of things or is it something else? I think all of the above is what I was, maybe I didn't do as clear a job as I intended answering this to the last question. I think there are a lot of aspects of this issue from the basic science. What are we learning about diagnosing whatever? I'm not a clinician, so I'm kind of making this up here about a pathologist. Maybe there are things they need to know about differential diagnosis that has a basis in somebody's racial differences, but again, maybe not. Maybe it's let's unlearn things. Maybe we learned 20 years ago in medical school, what's the up-to-date knowledge about this? Some of it could be very clinical. I think there is an aspect absolutely that's around behavior change, listening to patients, the inherent bias we all bring to our life and our profession. And then there's also a lot around practice change, not the clinical practice, but just how we approach our patients and from how the receptionist greets somebody to the checklists and tasks. Does a patient feel welcome at the office? How do we set up our waiting room so that everybody feels included? I mean, it's a very, and again, I don't want to claim I'm an expert in this area. That's why, and again, Becca Bell, the pediatrician, one of the pediatricians leading this effort has said, it's about listening. We need to hear from the patients what we're doing wrong and what we could be doing better. So I think there are many aspects of this issue and ideally education could eventually and is addressing all of those facets. Yeah, and I will just go back to the task force. One of the things in the webinar that Becca Bell talked about that they're working on is creating a culturally safe medical home. What does that mean? What does that mean for our children? What does that mean for our families? So when you talk about medical training, it's really how do we even just start that trust because going back to what Jess has said, this is, people have to trust their physician if they're going to be open about their healthcare issues. And so really creating that safe space is probably like the first step, one of the first steps. So yes, there is behavioral and scientific change that needs to happen. Thank you. Representative Goldman, Representative Cordes and then Representative Lipper. I just wanna take a breath for a minute and take us all back to experiences we've had in exam rooms with medical professionals. There is an important power dynamic inherent in that relationship that cannot be overstated. There is implicit biases that come into it. When we all go into exam rooms, it can be a pretty frightening experience. They're stepping into the room. You don't know what you're gonna hear. You're frightened. There may be something wrong with you. There may not. And if you're in this exam room with a person who is biased against you, it really affects your experience to be honest, to be open and to trust the outcomes. So I think that raising consciousness of providers to understand that power that they have, that's implicit in their position is crucially important. I think because those of us that do this work sort of live in that soup, we often don't recognize it as much as we need to. And I think that that is really important and an opportunity to do better care for people that we care about and that we wanna be healthy. So yes, I think that there's a huge opportunity for learning. There isn't always data because it's subtle. It's implicit. It's based in power. And there's this knowledge dynamic, but there's also the power dynamic. So yes, let's do more work on this. Thanks. Thank you. Representative Cordes. I wanna take a moment to focus on what I am hearing, seeing and sensing is a resistance to believing the testimony that we've heard thus far from providers, from doctorate level professors, from representatives of communities that total tens of thousands of people in Vermont, representing tens of thousands of people in Vermont. From providers like myself, I'll reiterate, I've been a nurse in Vermont for 32 years. I've already said that I have witnessed, my colleagues have witnessed, we talk about it, this kind of bias and systemic bias exists. It's endemic, it's really hard to move. And it's frustrating actually to feel like we're spinning the wheels here and by dismissing the incredible testimony that we've heard this far. And as I just have to point out that the people that we've heard testimony from are largely identified as women and people of color. And I don't know if that plays into any of the resistance any of us are feeling, but it's really super hard to watch that play out in this committee. Thank you for your comments, Representative Cordes. And I'm going to, while I share some of your concerns, I'm going to suggest that we all reserve our concerns for committee discussion rather than for witness testimony where possible because I think some of the same questions have, I think we need to, I share the concern. I feel like at this point, if we have had many witnesses establish the presence of health disparities in the state of Vermont, and I don't know if there are members who really don't believe that that's the case, we can have a further discussion about that. But I think at this point to question witnesses asking for further evidence of that in order to discuss some of the other matters before us is perhaps, well, it's challenging. But I think we can have that discussion when we have our committee discussion. We do not all have to share the same point of view, despite the witnesses that we've heard. So I would like to raise a question because I remember in some of the testimony we heard from Dr. Avila, in fact, one of the comments that resonated for me was that if we don't have requirements, things don't happen. I mean, we can have all the best intentions in the world and I'm going to be candid and say, like you can give us all the assurances that we're really working on this and we're really going to do it. But in fact, some of us also understand that, in fact, I think you shared here this morning some evidence of the fact that language access, it clearly isn't fully happening despite there being federal law, probably requirements from licensing boards as well as quote reminders from professional organizations. So it is a concern to me to just, I mean, I think Representative Chiena had a very helpful suggestion as a way we might move forward. But I also, frankly, am personally concerned that if we don't have some requirement to undergird what might come from the commission or others, that we have no assurance that things will really happen. Now, so my question in part is, I believe Dr. Avila referenced, and if I'm remembering this wrong, others can correct me, but I believe she referenced the fact that there are numbers of states that have professional training requirements for healthcare providers around cultural competency that are actually requirements, not voluntary professional organizations goals. And so maybe I'm making more of a statement, but I'm curious as to what your understanding is of other states' requirements around cultural competency in terms of professional healthcare provider requirements. Yeah, thank you for that question. I have not done a systemic analysis. I believe she mentioned, if I have this in my mind, there were maybe 22 states where it had been introduced. I'm in the 20s, yes. But I think that's been, yes. I think it's, I believe it's only passed in California. There may be one, maybe Washington DC, I'm not positive about that. So there's been legislation introduced. I don't believe it's in place in very many states currently. And I think it's a good question. I guess my response is I think this, if she had been saying this 10 years ago, I would say I agree that there is sort of a lack of baseline interest and desire, not desire may be the wrong word, a lack of awareness. I do think there's been such a growth in the awareness and our own awareness of our lack of information in this area, just seeing it from our own members, I think representative Tina's idea is great. One of the things maybe that group could look at is how broadly it's already been, what the uptake has been with it being voluntary. I don't have that data for you today. So for example, how many providers have already gone through the trainings or are we going through the AHEC and PPQ trainings or does it look like we have a big gap? I'm sure at this point it's not yet everybody, but I will say again, I think there has been a lot of uptake and that my main concern is also that it about it being the same requirements every two years where I think we want to get, again, that may establish a baseline, but I think we need to, I think a more systemic look at what we could be doing to then continue to move the needle would be helpful. And asking that of the licensing boards and the professions to say, how can we make this an ongoing issue you're paying attention to? To the language access piece, I do want to address that because I'm sure I don't want to dispute that there are some practices that are not complying with this. The questions I get from practices are how do I comply? Not whether not do I need to do this, but how do I do it? What services should I use? We actually, VMS is a member benefit, has a discount contract with a language translation service for our members. So, again, not that I've surveyed our members, but I have not experienced, of course, I maybe I wouldn't hear from the ones who don't know they have to do it, but that it's more of an issue of how do we do this? Do you have suggestions? Do we get reimbursed to representative Black's point? I think that is, unfortunately inserts tension in the relationship when practices want to be doing this, but if they're not getting paid for it, it can become quite expensive. And so that's just it's an additional factor we've had. That's typically the question I'll say we get from practices is I know I need to do this, but do I need to pay for it? And I think honestly, that's one of the issues why sometimes practices would want to be able to rely on family members when that's not best practice, because then it's obviously less expensive. So I think there are tensions there, but I don't know it's as much a lack of knowledge that they need to be doing it. Yes, it's always a challenge when we hear testimony that when asked for a specific instance, Dr. Navila shared her experience with her mother and that was not just once or twice, but 47 times. Yeah, I can't dispute that. I mean, that's surprising to me, that's disappointing to me, I agree with you. Yeah, so can I just ask you want to just, I want to make sure I understand because you several times referenced prescriptive requirements of doing the same things for every two years. Is that a reference to the language on page? Well, I don't know if it's the right page, I have it printed out in a certain way, but in the very last section, we're section two of the continuing education requirements where it lists A through D. Yes. Okay, okay, because it seems that they're fairly broad in description so that I'm not sure I would share your analysis that it would be a repetitive every two year, same. I think, and perhaps the words could be, the language could be more broadly worded so that it allowed for the innovative and refreshing information for those who had already completed some previously, but I want to make sure I understood where that reference was coming from. Representative Sheena and Representative Goldman. Go ahead, Brian. I just wanted to say something related to what we were just talking about with interpretation. One thing that I heard you say, this is to our witnesses, one thing that I heard you say is that one of the considerations for providers about using interpretation might be cost. Another thing that I've experienced, and I'm curious if you could speak to is sometimes it's not cost, it's actually patient preference because in a small community, people know each other and sometimes a patient's like, I don't want that to be my interpreter and then you don't have an interpreter because they're refusing to work with the interpreter who's available or you want to use like teleinterpreters and they don't want you to use teleinterpreters because they don't know the person. So it's like either they know the person, they don't know the person and some families they want it to be private, they want it to be a family member. In other situations, it's not that. People do want help, but they're afraid to ask for something different. So I think ultimately, when we talk about cultural competency training, we're talking about better understanding how to work with people and not making assumptions based on someone's culture, but figuring out how do you figure out the needs of an individual and meet them where they're at. And so that being said, do you have any more thoughts around, specifics that we would put into the language around the training requirements or what we'd be looking at besides just cultural competency or anti-racism? Is there any other direction you'd have? But if not right now, maybe that's something you could think about. I'd be happy to think about it. I would love to provide input on language if you're open to that or interested in that. I think you could add to the list of topics. I apologize, I don't have the bill in front of me, the language in front of me right now. I believe the language is focused on cultural competence. You could spell out specifically that the group should look at training around language and interpretation services as well. I don't know if everyone defines that as part of anti-racism and cultural competence training. I don't know if that's inherently part of that definition or not. But I agree with all your points. Yes, we hear those concerns as well. I believe it's been a little while since I've looked at this that while using a family member is discouraged if the patient really wants that. I believe you can ethically honor that even though it's in the typical circumstance, not best practice. Thank you, Representative Goldman and Representative Donahue, and we're getting close to our time. So I think that might be as many questions as we can take this morning. Thank you, everyone for comments and testimony. I'd like to take us back to the exam room for a minute. This morning we had an experience of what it's like to communicate with someone through an interpreter. So put yourself now in an exam room and trying to deal with significant medical concerns and problems and operate through an interpreter. It is very challenging. And I believe clinicians really wanna do a good job for those patients. So we need to support those kinds of services, the availability of those services. And if we can attach any kind of financial support for that, I think that would be important. So I'd like to add that to some place if it's where it might be appropriate. Thank you. Thank you, Representative Donahue. Thank you. Yes, I snuck a quick peek at the VMS 2018 statement about addressing bias. And I was pleased to see that it included the breadth of sort of the health disparity and bias issues that the bill addresses with the various groups, although statement may need to be broadened. For instance, LBGTQ issues are not necessarily just sexual orientation, but it did also include disability. You haven't discussed in terms of training issues and whether there is also ongoing efforts around those other communities. We're gonna be hearing more testimony this afternoon, but we had some earlier issues like diagnostic overshadowing with types of disabilities, which is, we know, is a significant health outcome concern. Is that included or any of the pieces of what you're doing? Can I interrupt Representative Donahue? Can you share what your definition of, again, the phrase you just used, overshadowing? Diagnostic overshadowing. Yeah, I think that's a lot. I'm not sure that's in everyone's wheelhouse. I'll briefly, right, I didn't want to testify and it's coming up this afternoon. Oh, I know, but you're using it to ask a question. We don't know what the question means. It's hard to know what the answer is. Yes, I'm sorry to take advantage of the current witness, but that means when, for instance, as an example, a person with a psychiatric diagnosis comes in and that is foremost in the person making a diagnosis mind that's on the medical record. And so to use lay language, the reaction is, well, it must be all in their head because they have a psychiatric diagnosis. And so they're gonna miss or not treat as seriously physical complaints. Thank you. And I bring us back to your question to the witnesses, but I think that's an important clarification. That's a great question. It is certainly an issue that I am aware of, medical specialty societies, for example, addressing through their educational sessions. I know it's been a big topic and even covered in the media around maternal health outcomes, especially BIPOC women, sort of not their post-delivery complaints being, basically dismissed or not appreciated. I'm starting to think back, Jill, maybe, you know, I don't know if it's been addressed in the sessions that we have put on, but I know there are educational sessions again by national organizations on that issue. Jill, do you recall if it's been?  It's the other specialties where the issue. Yes, and so when I say specialty society, I include actually primary care. Is that not just specialists, but the family physicians, the psychiatrists? Jill, any further? Well, I was just gonna say this is an example of how this issue is really evolving. So we're in 2021. We adopted that in 2018. And I learned another term yesterday, the minority stress model. And I think that really captures a lot of the issues.  There's just bias across the board with any diagnosis.  So, you know, and then just there's the insurance part of that of like preexisting conditions. And so there's all of those layers, I think that you're naming are the concerns that we're attempting to address. I will say the task force, the AAP Vermont is specifically looking at race. And so, but that's only covering like, you know, a small picture of the health equity issues that we have to deal with in our state. So how we get at this is really part of why we're saying, let's not try to do a one size fits all because we really need to understand the breadth and we really need to look at what's specifically going to help our medical professionals give the best care. And I really liked how Zana Davis said yesterday that when we learn how to give culturally appropriate medical care to these, you know, to different communities that have disproportionate poor health outcomes, we're actually raising the level of care for everyone. And we really need to think about that and really underscore that this is where we need to be as a country and COVID has shown us that too. Thank you. Representative Donis here, your hand is still up but I assume that was from previous. Well, again, thank you both, Jess and Jill for joining us this morning. Again, on relatively short notice, but I appreciate you're reaching out actually and saying we would like to be heard. We'd like to testify, so thank you. And I think with that we'll conclude for our testimony this morning.