Student-Led Effort to Incorporate Social and Structural Determinants of Health into Undergraduate Medical Education: Civic Engagement, Advocacy, and Anti-Racism.

Background: The recent wave of student and physician activism created a space to discuss racism in healthcare with a more critical lens. Students are interrogating the environment in which they will provide healthcare and the social and structural determinants of health—one being the lack of anti-racist education in undergraduate medical education (UME). Objective: The Black History Month Speaker Series (BHMSS) was formulated to highlight racism in healthcare. Participants learned about race and healthcare policy (RHP), maternal mortality (MM), racial health equity (RHE), voting barriers and civic engagement (CE), distrust of medical institutions among communities of color (D), and health disparities (HD). A list of national and local partner organizations was provided after the series to all participants with contact information and volunteer resources to encourage active community engagement and apply what they had learned. Methods: Students organized a five-lecturer series for February 2021. Pre-BHMSS and post- BHMSS Qualtrics surveys assessed overall knowledge and comfort measured on a 4-point scale (1=very uncomfortable/no knowledge and 4=very comfortable/knowledgeable). Two-tailed unpaired t-test was utilized. Results: The pre-BHMSS population (n=247) included primarily medical students (49%); post- BHMSS respondents (n=61) were majority female (80%) and Caucasian (63%). Post-BHMSS reported increased “knowledge” for RHP, MM, RHE, CE, D, and HD (μ difference=0.71 [95% CI=0.47, 0.95] p<0.001; 0.58 [0.32, 0.84] p<0.001; 0.49 [0.21, 0.77] p<0.001; 0.61 [0.20, 1.0] p<0.01; 0.64 [0.40, 0.87] p<0.001; 0.22 [0.057, 0.38] p<0.01). Post-BHMSS exhibited increased “comfort” addressing RHP, MM, RHE, CE, and D (0.55 [0.30, 0.80] p<0.001; 0.40 [0.14, 0.66] p<0.01; 0.46 [0.18, 0.74] p<0.01; 0.47 [0.053, 0.87] p<0.05; 0.35 [0.09, 0.61] p<0.01); however, there was no change in HD “comfort.” Conclusion: Comfort and knowledge significantly increased across nearly all topics, suggesting insufficient prior awareness and the urgent need for integration of anti-racism education in UME. BHMSS represents an innovative option for the incorporation of historical racial context that influences current medical practices and education. Knowledge acquired may foster valuable relationships between providers and patients and represents a potential solution to improved care for marginalized groups

Improving Conditions for Incarcerated Individuals

Whereas, in 2019, the United States’ incarceration rate was estimated to be 629 per 100,000 people, which is the highest rate globally and over 8% higher than the closest country; and Whereas, in Indiana, the total jail population has increased 526% from 1970 to 2015 and the total prison population has increased 224% from 1983 to 2018, with our incarceration rates being fourth highest nationally; and Whereas, in 2015, Indiana had the second highest rate of pretrial detainees in the nation at a rate of 272 per 100,000 people; and Whereas, since 2000, the rate of pretrial detainees has increased 72% among Indiana’s 48 rural counties, 43% in 21 small/medium counties, 40% in 22 suburban counties, and 268% in Marion county alone; and Whereas, in the United States, the rate of recidivism is 70% within 5 years of release with few resources to assist reentering individuals find housing, gain employment, or access social services; and Whereas, when connected with employment opportunities, financial planning services, stable housing, and physical and mental health services, rates of recidivism decrease significantly, over 60% amongst those who complete programs, among reentering individuals; and Whereas, incarcerated individuals have higher rates of mental illness than the general population, with approximately 14.5% of men and 31% of women in jails having at least one mental illness as compared to 3.2% and 4.9% respectively amongst the general population; and Whereas, nationally, the number of suicides has increased by 85% in state prisons, 61% in federal prisons, and 13% in local jails from 2001 to 2019, with suicide being the leading cause of death in jails; and Whereas, the risk of suicide in recently released individuals is nearly 6.8 times higher than that of the general population, with most occurring within 28 days of release; and Whereas, in a study of 80 jails by Scheyett et al., 68 reported having no mental health staff who provided care within the jail, 15 reported taking, on average, 5 days or longer to retrieve inmates’ medications and none were utilizing evidence-based screenings to assess for serious mental illnesses, highlighting a concerning disconnect between jail staff and mental health providers; and Whereas, re-entering individuals are unlikely to connect with primary care upon release and very rarely seek mental health services in the months following release; and Whereas, inarcerated individuals are often restricted from accessing rehabilitative social services such as the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid either through a lack of meeting eligibility requirements or personally held beliefs by incarcerated individuals surrounding eligibility and accessing resources; and Whereas, when provided assistance and access to expedited Medicaid enrollment, reentering individuals were more likely to access health services and receive prescriptions; and 263 Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; therefore, be it RESOLVED, that ISMA support legislation that improves access to comprehensive physical and behavioral health care services for juveniles and adults throughout the incarceration process from intake to re-entry into the community; and be it further RESOLVED, that ISMA support legislation that removes barriers and increases access to social services and benefits apropos to the respective situations of incarcerated individuals and re-entering individuals, such as: (a) food subsidies; (b) healthcare, including Medicare and/or Medicaid; and (c) housing; and be it further RESOLVED, that ISMA work with relevant stakeholders to create discharge planning and programs that connect reentering individuals with primary care providers and medical homes within the community

IU School of Medicine Correctional Medicine Student Outreach Project

Background: This project was founded on the basis that correctional medicine is an important component frequently missing from medical education. Opportunities to participate in medical care within correctional facilities, while concurrently engaging in discussions about disproportionate incarceration of certain populations and mass incarceration as a whole, will cultivate empathetic, socially-engaged, and passionate young physicians. This student organization was formed to facilitate clinical opportunities within correctional facilities and host events that focus on the broader socioeconomic and political context and forms of structural and cultural violence that have contributed to mass incarceration in the United States. Methods: In order to facilitate organizational goals, a relationship was fostered between IUSM and Dr. Kristen Dauss, the Chief Medical Officer of the IDOC. Following affiliation agreements, students may now gain clinical exposure at any facility in the state. Since its creation, IUCM has hosted virtual educational lectures, panels, and journal clubs, in collaboration with other student organizations and scholars in the field. The organization encourages engagement with original research in coordination with faculty advisors. We have also worked with administration to incorporate correctional health topics officially into the curriculum. Conclusions: As physicians who will practice medicine in the country with the highest incarceration rate in the world, having a fundamental understanding of topics related to correctional health, adverse health experiences while incarcerated, and longstanding traumatic effects of incarceration is imperative. IUCM’s goal is to create introductory materials and share resources relating to the socioeconomic and political context which has led to mass incarceration and the deficits in care for currently and formerly incarcerated people. Developing a better understanding of the justice system as well as the emotional, mental, and physical impact incarceration has on patients, and will stimulate interest in engaging with these concepts through research, volunteer work, educational events, and in patient care

Improving Health in Incarcerated Women

Whereas, research often uses gendered language such as “women” or “woman” to describe patients; however, the authors of this resolution recognize that individuals of all gender identities can become pregnant; and Whereas, between 1980 and 2020, the number of incarcerated women in federal and state prisons and county jails has increased by more than 475%; and Whereas, though more men are incarcerated than women, the rate of growth for incarceration of women has been twice that of men since 1980; and Whereas, the imprisonment rate for Black women was 1.7 times the rate of imprisonment for White women, and the rate of imprisonment for Latinx women was 1.3 times the rate of White women in 2020; and Whereas, in 2020, Indiana had the 12th highest female imprisonment rate nationally, at 64 per 100,000, while the national average was 42 per 100,000; and Whereas, the number of women incarcerated in Indiana’s jails has increased more than 25-fold from 1970 to 2015, while the number of women in Indiana prisons has increased more than 19-fold from 1978 to 2017; and Whereas, a 1999 report by the Federal Bureau of Justice Statistics, which is the most recent report to study abuse prior to incarceration, found that 57% of women in state facilities had experienced sexual or physical abuse prior to their incarceration; and Whereas, the link between domestic violence and incarceration of women is evidenced by the fact that the crimes for which women are incarcerated are often directly related to domestic abuse; and Whereas, a 2008 report from the Bureau of Justice found 4% of state and 3% of federal inmates to be pregnant at the time of admission, while only 54% received some type of prenatal care; and Whereas, Indiana does not provide screening and treatment for high-risk pregnancies and only recently passed legislation to limit the use of restraints; and Whereas, a 2016-2017 survey conducted by the Pregnancy in Prison Statistics Project found 3.8% of newly admitted women and 0.6% of all women were pregnant in December 2016, with 92% of these pregnancies resulting in live births, meaning that policymakers and public health practitioners can optimize outcomes for incarcerated pregnant women and their newborns; and Whereas, a 2008 report from the Bureau of Justice found a statistically significant difference between reported specific medical problems among females (57% in state prisons, 52% in federal prisons) compared to their male counterparts (43% in state prisons, 36% in federal prisons), with arthritis, asthma, and hypertension being the most commonly reported problems; and Whereas, three fourths of incarcerated women are of childbearing age (18-44 years old), and therefore are still menstruating but must pay for their own feminine hygiene products if they do not have the means to afford necessary hygiene products; and Whereas, the AMA (H-525.974) recognizes the financial burden of feminine hygiene products, classifies them as medical necessities, and advocates they be provided free of charge to all incarcerated women; and Whereas, women have specific health needs, including reproductive, gynecologic, and prenatal care, trauma- informed mental health care, and substance abuse care; and Whereas, prisons remain ill-equipped to provide adequate mental and physical healthcare for women inmates; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; therefore, be it 78 RESOLVED, that ISMA seek and support legislation that improves access to comprehensive reproductive and physical health care services to women throughout their incarceration from intake to re-entry into the community; and be it further, RESOLVED, that ISMA seek and support legislation that increases allocation of healthcare for women’s prisons within the Indiana Department of Corrections and local county jails in Indiana; and be it further, RESOLVED, that the ISMA adopt AMA H-525.974, as amended, as follows: AMA ISMA: (1) recognizes encourages the Internal Revenue Service to classify feminine hygiene products as medical necessities; (2) will work with federal, local, state, and specialty medical societies, and other relevant stakeholders to advocate for the removal of barriers to feminine hygiene products in state and local prisons and correctional institutions to ensure incarcerated women be provided free of charge, the appropriate type and quantity of feminine hygiene products including tampons for their needs; and (3) encourages the American National Standards Institute, the Occupational Safety and Health Administration, and other advocates and seeks legislation for the state to provide access to free, readily-available feminine hygiene products to all incarcerated women. relevant stakeholders to establish and enforce a standard of practice for providing free, readily available menstrual care products to meet the needs of workers

Acknowledging Racial and Ethnic Health Disparities in Mass Incarceration

Whereas, the United States incarcerates more people per capita than any country in the world, where the U.S. comprises only 4% of the world’s population, yet is home to nearly 16% of all incarcerated people in the world; and Whereas, in Indiana, the total jail population increased by 526% between 1970 and 2015, while rates of pretrial detainees have increased by 72% in the state’s 48 rural counties, 43% in the state’s 21 small/medium counties, 40% in the state’s 22 suburban counties, and 268% in Marion County alone since 2000; and Whereas, in 2015 in Indiana, when including jail, prison, immigration detention, and juvenile facilities, the incarceration rate was 765 per 100,000 people, well above the rate of the United States as a whole, which was 665 per 100,000 people; and Whereas, Black residents make up 10% of Indiana’s population, but represent 24% of people in jail and 34% of people in prison; additionally, pretrial populations, disproportionately Black and Hispanic, more than doubled from 2002 to 2017; and Whereas, in 2019, Native people made up 2.1% of all federally incarcerated people, larger than their share of the total U.S. population, which was less than one percent; additionally, Native women are particularly overrepresented in the incarcerated population, making up 2.5% of women in prisons and jails and only 0.7% of the total U.S. female population; and Whereas, populations of color are more impacted by the use of money bail, where Black defendants often receive higher bail amounts, even when controlling for legal factors such as offense severity; and Whereas, Black and brown defendants are 10-25% more likely to be detained pretrial or to receive financial conditions of release; and Whereas, significant racial and ethnic disparities exist among policing, arrests, and incarceration rates, which further exacerbate disparate health outcomes for Black communities, including, but not limited to, Black individuals disproportionately being stopped by the police, experiencing use of force and repeated arrests, serving sentences of life and life without parole, being sent to solitary confinement, and receiving convictions that place them on death row; and Whereas, nearly one in three Black men will ever be imprisoned, and nearly half of Black women currently have a family member or extended family member who is in prison; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; however, ISMA has no policy acknowledging the inequitable burden of incarceration and policing on minoritized individuals and communities of color; and Whereas, the AMA (H-65.954) recognizes police brutality as a manifestation of structural racism which disproportionately impacts Black, Indigenous, and other people of color; therefore, be it RESOLVED, that ISMA recognize that unjust and disproportionate racial and ethnic disparities exist in policing, sentencing, and mass incarceration among Black, indigenous, and other people of color (BIPOC) and have devastating impacts on BIPOC communities; and be it further, RESOLVED, that ISMA refer to the Committee on Diversity, Equity and Inclusion for study on what policies would be germane for ISMA to act on regarding racial and ethnic disparities in mass incarceration

Student-Led Effort to Incorporate Social and Structural Determinants of Health into Undergraduate Medical Education: Civic Engagement, Advocacy, and Anti-Racism

Background: The recent wave of student and physician activism created a space to discuss racism in healthcare with a more critical lens. Students are interrogating the environment in which they will provide healthcare and the social and structural determinants of health—one being the lack of anti-racist education in undergraduate medical education (UME). Objective: The Black History Month Speaker Series (BHMSS) was formulated to highlight racism in healthcare. Participants learned about race and healthcare policy (RHP), maternal mortality (MM), racial health equity (RHE), voting barriers and civic engagement (CE), distrust of medical institutions among communities of color (D), and health disparities (HD). A list of national and local partner organizations was provided after the series to all participants with contact information and volunteer resources to encourage active community engagement and apply what they had learned. Methods: Students organized a five-lecturer series for February 2021. Pre-BHMSS and post- BHMSS Qualtrics surveys assessed overall knowledge and comfort measured on a 4-point scale (1=very uncomfortable/no knowledge and 4=very comfortable/knowledgeable). Two-tailed unpaired t-test was utilized. Results: The pre-BHMSS population (n=247) included primarily medical students (49%); post- BHMSS respondents (n=61) were majority female (80%) and Caucasian (63%). Post-BHMSS reported increased “knowledge” for RHP, MM, RHE, CE, D, and HD (μ difference=0.71 [95% CI=0.47, 0.95] p<0.001; 0.58 [0.32, 0.84] p<0.001; 0.49 [0.21, 0.77] p<0.001; 0.61 [0.20, 1.0] p<0.01; 0.64 [0.40, 0.87] p<0.001; 0.22 [0.057, 0.38] p<0.01). Post-BHMSS exhibited increased “comfort” addressing RHP, MM, RHE, CE, and D (0.55 [0.30, 0.80] p<0.001; 0.40 [0.14, 0.66] p<0.01; 0.46 [0.18, 0.74] p<0.01; 0.47 [0.053, 0.87] p<0.05; 0.35 [0.09, 0.61] p<0.01); however, there was no change in HD “comfort.” Conclusion: Comfort and knowledge significantly increased across nearly all topics, suggesting insufficient prior awareness and the urgent need for integration of anti-racism education in UME. BHMSS represents an innovative option for the incorporation of historical racial context that influences current medical practices and education. Knowledge acquired may foster valuable relationships between providers and patients and represents a potential solution to improved care for marginalized groups