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Professor: 'Just medicine depends on you'

Dr. Dayna Bowen Matthew delivers the keynote address during the UTSW Martin Luther King Jr. Commemorative Celebration.

On Jan. 15, University of Virginia School of Law Professor Dr. Dayna Bowen Matthew gave the keynote address at the 33rd annual Martin Luther King Jr. Commemorative Celebration at UT Southwestern. Dr. Matthew is the William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law and the F. Palmer Weber Research Professor of Civil Liberties and Human Rights at the University. She also holds an appointment in the School of Medicine’s Department of Public Health Sciences.

During her keynote address, Dr. Matthew talked about the history of racial inequality in the American health care system and how to address ongoing disparities, calling on the medical community to do more to make improvements. Paraphrasing Dr. Martin Luther King Jr., she told the audience: “Of all the forms of injustice … the absence of just medicine in health care is the most inhumane.” Watch Dr. Matthew’s full keynote address above.

View a photo gallery from the event here.




I want to spend our time together today looking at four parts of a story. The story I'd like to tell is about just medicine. I'm a lawyer so I want to talk about justice and what just medicine is, then I'm going to talk about why it depends on you and that's really all I'm going to talk about, why it depends on you. You as clinicians, health care providers, those who work in a health organization. Justice depends on you. I'm going drill down on that and say it depends on UT Southwestern and the people who are training and working here and then I'm going to ask you to hear my call to action, what must be done.  

So what is just medicine? We know that health equity is all the rage. You're taking classes in it, you're spending money on it, you have a department of it - Diversity, Equity, Inclusion - but what's that got to do with medicine? Why a lawyer? Why am I talking about justice and medicine? Well, I'm not going take you to law school but I am going talk for a minute about one law. All this next 15 minutes will be about one law, the Civil Rights Act of 1964. It has several components and I'll use it as a starting place for what just medicine is. Justice is when people are not treated differently based on their race, their color, their ethnicity, their gender, their sexual identity, their ability, but their outcomes don't depend on these intangibles. That is justice. That is fairness. That is equity. And it turns out that Title VI, the law that embodies justice in these United States, indeed even in Texas, happened because physicians, dentists and patients collaborated to bring justice to medicine. 

I want that to inspire you because injustice used to look like this. And it was easy to tell when you saw signs that said "Keep out, your color means you can't be here. Your color, your identity means you can't be there." Injustice used to look like this in Dallas. Now how many of you recognize this? This is a redlining map for the County of Dallas. That's the actual map, 1933 through 1935. Bankers decided where to lend for home ownership in Dallas County based on the color coding of this map. So green meant great investment. That's where we'll give people the money that they need to buy a home. Yellow, less safe. Red, avoid it. And how come? Well because there were, and this was the definition, immigrants, Negros and criminals. So if 10% of the population was immigrants, Negros and criminals, you didn't get a house. That's what discrimination used to look like in Dallas but my message to you today, the reason I put these maps side by side is because the past, as William Faulkner said, is not dead. From a health perspective in Dallas County, it's not even the past. So if you look at the areas on my right your left, that were redlined as having Negros, immigrants and criminals, and therefore, unworthy of a bank's investment, you see there is a correlation to the map on my left, your right, where concentrated poverty exists in Dallas County today. The past is not dead, it's not even the past. So in the past, this is what educational discrimination used to look like. You try to go to school and people would throw things at you. You were told to stay here if you were one color, stay there if you were another color. That's what it used to look like. This is what food discrimination used to look like and it was easy to tell. We could write laws against this. You can sit at a counter without people putting ketchup on you. It's a picture from 1947. That was easy to tell. That's when discrimination was easy to see, right? This one's a little bit more disturbing, right? If you've not been down to the Equal Justice Initiative in Montgomery, Alabama and seen the horrific legacy of lynching in the United States, this is disturbing but let me suggest to you that the past is not even the past with respect to discrimination in the criminal justice system.  

That affects health. Why? These are national, not Dallas statistics. I don't know Sheriff, whether it is true in Dallas or not, but if you look at the incidence of marijuana use, I lived 15 years in Colorado, I know about marijuana use. Of others, right? I have studied it, right? So if you look on my left your right, the light bar shows us the use of blacks, excuse me, of whites and the dark bar shows you the use of marijuana of whites, right? And this goes up until 2014. I haven't changed the graph but I've got the statistics up until 2016, the bars are almost equal use, right? Use. On the other graph is the arrest rate for marijuana violations by black and white. Wildly disparate, right? Not because the use is any different. Not because the criminal activity is disparate by race but because the arrest rate. These are disparities that we call unjust. They violate the law that says that one should not be treated differently based on your race, your color, your nationality, your gender identity, your ability, your gender. Right? And why do these matter? Well, they matter in Dallas because the social determinants of health, not your access to health care, not your biology, the social and environmental factors that tell us where you live, where you work and you play tell us how long you're going to live and how well you're going to live for those number of years. They have a health impact.  

Back to the map of Dallas County and you see that where we redlined in 1937 is where you're having higher all-cause mortality in 2019. The past is not the past, not from a health care perspective. Infant mortality in Dallas, the past is not the past, right? Infant mortality in Dallas, and here it's not only three times almost, for blacks per thousand live births as it is for whites, haven't done the Latinx community. Little less if it's like the rest of the country, but when we control for education, and income, those disparities do not disappear. What does that mean? That means that a black mom remains two and a half to three times more likely to lose her baby in the first year of life. She is college educated and making between 50,000 and $75,000 a year as compared to a white mom who is living below the poverty line and has an eighth grade education. All right? That's the disparity that we call unjust. And that's true in Dallas. Why? Because place matters. Because place matters.  

Now, you know that already but I show this picture. This is the plane that the movie Sully was written about, right? So it's, I grew up in New York City. So this is January in New York City. There's a plane sitting on the Hudson River. 155 souls on board. The plane goes down and the people have to get out of the plane. What I'm asking you to see, and just call it out. We do the Socratic Method in law school. What I'm asking you to see is if you are recognizing two different groups of people on that plane. Two different groups. Anybody? First class and economy, right? First class and economy, right? Right? So first class does not only mean that you get on first so you have your suitcase with you, that they give you orange juice while the rest of us slobs are getting on the plane, right? But it also means that if the plane goes down, you get a raft. Right? You get a life jacket. You get a little rations thing so you don't have to start eating each other right away, right? You get all this stuff and the rest of the people are on the plane wing going down. Right? So place matters. Your life chances are so much better depending on where you sit on the plane. That's true in Dallas. That's true in the United States of America. That's actually true in the world. So if we're looking for just medicine, it really does depend on you. It really does depend on the people in this room.  

It is my hypothesis, and I'm going to go, this part really fast because I have to look, you're going to give me the five minute warning, right? It's my hypothesis that there is no more important actor to achieve justice in health care, justice in medicine, than health care providers, period. No more important action. Not my time on Capitol Hill, my time as a law professor, we can't do it. We simply cannot do it if you don't lead us, right? So the emergency that we're in in the United States I think is because, I'm going the wrong way, because you guys aren't doing your job yet. Now, I hesitated to say that because the job you're doing here at UT Southwestern, it is remarkable nationally. What you're doing with RedBird and HEAL, right? I heard you're going to build a building to connect your HBCU with, remarkable! And I'm still saying you still need to do more. There's more to be done.  

And here's how I'll make the case. This is a waiting room sign by order of the police department for a hospital. It used to be that hospitals were as segregated as any other institution, outdone only by churches in the United States of America. Used to be. In order to desegregate hospitals, you never saw this picture. You never had to see hoses. You never had to see dogs. You led a quiet revolution in the health care industry that touched millions of lives and could touch millions of lives today. I'm suggesting you could do it again today. You could do it again today. Why? Because you serve so many people with a measurable outcome. This is 2018. Total number of admissions in all United States hospitals, your potential influence, this is in billions, right? How many people you touch that have needs that reflect the social determinants of health? Hospitals, health care systems are touching nearly 80 million people a year. Hospitals, right?  

Now, I understand the reimbursement problems. I understand that Medicaid, poor Parkland's CEO had to listen to me say, "You got to do more, you got to do more," but the fact is that you're touching the population and you're doing it better than most, right? If I labored on this part of my discussion, I'd talk to you about how Medicaid expansion is working best in hospital systems in expansion states. I better get off this one really fast, right? But you're lowering the cost of uncompensated care. You're doing remarkable things with less and you could lead us financially to do what we did in that quiet revolution, because how did we desegregate hospitals? I kid you not. In the middle of the night, Title VI was passed, and so there are stories of hospitals that literally rolled their patients from segregated wards out onto the sidewalk, mixed them up, and put them back in the hospital. Segregation over. No dogs, no hoses, no marching. Why? Because they would not get paid otherwise. Right?

You have that same leverage. Title VI applies to any institution that is spending federal funds. You can do it again because you're spending federal funds. You have that leverage, right? You're the biggest employers in your communities. If you change the way that you pay people, that will affect health disparities. If you change the way that you acquire and use land, that will affect health disparities. I understand that your research will affect it. I understand what you screen patients for will affect, but as an institution, as an anchor in your community, hospitals, health systems, health care providers, largest purchasers, large employers, hospitals and health providers are the answer. But that's theoretical and I want to say as I close, that when I say you are the answer, I mean you in this room. UT Southwestern. The staff, the medical students, the clinicians who are here. You are the answer. I've taken a look at your mission and your values. Here I almost get a lump in my throat. Your statement is that you are dedicated to promoting health and a healthy society? Health and a healthy society? You are way ahead of the curve. You already know that the reasons you educate, discover and heal is because you are a part of a whole. You're not just here to teach to treat the patient. You are here to treat the whole person. You are not just here to treat an individual. You are here to treat a community. You are already concerned with the structures. I have so much more work when I walk into a building that does not have a statement that understands that they are treating, working, educating, for a healthy society.  

This is a picture of a group that changed the world and took responsibility for Title VI, that law I started with at the very beginning and here I want to take a minute and tell you about George Simkins, the physician, who along with three dentists, two other physician colleagues, and his patients, really are single-handedly responsible for a fact that we have a Title VI of the Civil Rights Act of 1964. George Simkins was an advocate, not only for healthcare, he is one of 11 plaintiffs, who sued the hospital in Greensboro, North Carolina, because they would not admit his patients at the time that it was segregated. That case, if you go to what we call the legislative history, I'm a little in the weeds now. In order to pass a law, there's debate on the floor of Congress, we record that and that is our legislative history. If you go to the legislative history of Title VI of the Civil Rights Act, George Simkins' suit is the reason they passed that law quickly. It was headed to the Supreme Court. It lost in the Fourth Circuit. He was headed to the Supreme Court. And you will hear senators stand up and say the Simkins suit compels us. Physicians, dentists, and plaintiffs. The physicians, dentists, and plaintiffs who filed that suit compel us to pass the Civil Rights Act. Check it out. Healthcare that is just depends on you.  

George Simkins didn't just start suing when it came to hospitals. I'm going to tell you one more anecdote. How am I doing? Five minutes, good. One more anecdote. George Simkins, this physician was a literal force of nature, right? So I got three or four suits to tell you about. I think I'm going to get one in here. My favorite one is he sued the golf course in Guilford County because it was segregated. He's a black man, wasn't allowed to play on the golf course. Segregated golf course. He walks onto the golf course and he gets arrested for criminal trespass, right? This is his health care move. He gets arrested for criminal trespass. If I had more time, I'd convince you that is health care because recreation, right? That’s a social determinant of health, right? Right? Okay, so he gets arrested. He goes to court. He wins his suit, so he's allowed to go back to the golf course. Look it up. Guilford County, rather than allow blacks to play golf, close the golf house, I'm not kidding, and the good 'ole boys burn it down. We would rather not have a golf course than play with y'all, okay? Long story short, Dr. Simkins, right? He didn't go to medical school for this but this is what it means to fight for health and a healthy society, right? Dr. Simkins eventually, long story short, gets the golf course reopened on a desegregated basis and who's the first person to tee off? I am telling you the truth, it is Dr. Simkins, right? He led protests against Wachovia Bank. He led - because of their lending practices. He led protests every stage of society, all the social determinants of health were his purview and he changed national law. He was on this thing called the Medical Committee for Civil Rights that also marched on Washington. This man changed our future, changed our stars, right? He understood that we are all a part of one organism.  

I'm showing, in closing, a picture of a stand of aspen trees. Colorado, state tree's the aspen, and although the stand looks like it's individual trees. Each trunk looks like its own organism the fact is underground, aspen trees are from one organism in a stand. They depend upon one another. As one grows, the others, as one suffers disease, the others, and Dr. Simkins understood this. I leave asking you, imploring you, to continue in the vein that you have already begun. To understand that you are accountable for the healthy society around you here in Dallas County, in Texas and beyond because truly, Martin Luther King was right, that of all the forms of injustice, of all the forms of the absence of just medicine, health care is the most inhumane. Thank you for what you're doing. 

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