In this Feb. 25, 2020, edition of the AMA's Prioritizing Equity series, leaders in health justice discuss how trauma-informed approaches impact advancing equity among minoritized and marginalized communities during COVID-19.

• L. Toni Lewis, MD—President and founder, Liberation Health Strategies; co-founder, Health Equity Cypher
• Nadia Richardson, PhD—DEI trainer; mental health advocate; professor of UAB School of Health Professions, University of Alabama
• Alec Calac—Pauma Band of Luiseño Indians; global public health MD/PhD student at UC San Diego School of Medicine; national policy director for the Association of Native American Medical Students

• Mia Keeys, MA, DrPH(c)—Director, health equity policy & advocacy, Center for Health Equity, American Medical Association

Feb. 25, 2021

Keeys: Hi. Good afternoon, everyone. I'm so very glad that you've taken time and decided to spend this next 30 minutes with us with the AMA Prioritizing Equity series. I'm Mia Keeys. And I serve as the director of health equity policy and advocacy of the Center for Health Equity of AMA. And I'm hoping that these next 30 minutes are really the most meditative that you spent all day, because what we're going to do is talk about trauma-informed approaches that impact how we're able to advance equity among minorities in marginalized communities, particularly during this COVID-19 season. And so, we have just three incredible souls with us today who are going to bring not only their expertise and advice, but then also their full selves. And I'm so very grateful today. And I just want to go ahead and introduce them as you see them on your screen.

We have here with us, Dr. L Toni Lewis, who serves as the president and founder of Liberation Health Strategies. And she's also the co-founder of the Health Equity Cypher. Welcome to you, Dr. Toni. We're so glad that you're here. We also have with us Dr. Nadia Richardson, my earring twin, who is a mental health advocate and DE&I trainer and president and professor at the University of Alabama at Birmingham School of Health Professions. And I'm very glad that you're with us today Nadia. Thank you so very much for being here. And last, but certainly not least we have Alec Calac who joins us today and representing the Pauma Band of Luiseño Indians. And he's also a global public health student, both MD and PhD student at the UC San Diego School of Medicine. So this young man certainly has a lot on his plate and we're grateful that he's able to join us today. He also serves in the capacity as a national policy director for the Association of Native American Medical Students.

So Dr. Toni, Dr. Richardson, Alec, thank you so much. Thank you very much. I just want to know before we get into the conversation, let's just ground set a little bit. How are you? And where are you in the world? And I will start with Dr. Toni.

Dr. Lewis: So, hello everyone. It's so good to be here and I would love to actually take maybe 30 seconds of my time to make it actually meditative and have us all take a nice deep breath in and breathe out. Maybe let's do two more. Breathe in and breathe out. And one more good time. Breathe in and breathe out. So, with that, I'm immediately maybe a little bit better than I was 10 seconds before or three hours before, because it's been a hectic morning, but I'm good all things considered. And I am in Bed-Stuy, Brooklyn. I'm also on Leonatti land. So that's where I am.

Keeys: I don't have words to offer the deepest appreciation for where you just taken us in so very quick of a time period. Thank you, Dr. Toni. Nadia, Dr. Richardson, how are you? And where are you in the world?

Dr. Richardson: I'm doing good. And I appreciate the start to this call too, because I do those breathing exercises often, and it makes a huge difference in your mental wellbeing, but also physically. I feel it immediately. So, I appreciate that. I'm located in Birmingham, Alabama. So, living that virtual life and trying to strike a seeming balance because sometimes when you love what you do this virtual life makes you feel like you have more time to do it. But we really need to be intentional about checking out and resting. I'm not always good at it, but I do have some accountability partners. And I appreciate that.

Keeys: And I appreciate you for sure. Thank you so very much, Dr. Richardson. Alec, how about you, what's going on in your world? And where in the world are you?

Calac: A lot going on. Hello, everyone. It's so great to be here with all of you. I'm calling in from sunny San Diego, finally above 70 degrees. So happy to be enjoying some sunlight from the occupied land of the Kumeyaay Nation. I'm doing okay all things considered with navigating graduate school during a global pandemic, but being a public health student, really no better time to be learning in the classroom, but also applying what I'm learning in these conversations. So very much excited.

Keeys: Definitely excited for sure to carry this conversation on with you. So, I have another question for all of you and Alec, I'll actually start with you, especially because you are carrying so much on your plate as all of us are. You embody really being able to use Nadia's word “balance” in a lot of ways. But I just want to know, given that COVID is affecting all of us maybe in the same way, but in different ways. Right? But there are others who are specifically experiencing increases in depression and feelings of anxiety and substance abuse. Self-harm is also one arise, particularly among marginalized and minoritized communities during this time. I just want to know what are some strategic approaches you've seen being used or that you have used in your work or in your daily life to address these traumas around the pandemic?

Calac: Certainly, it's such an important question Mia. I think with one in 475 Native Americans dead from COVID-19, everyone has been affected in some way. And we know that intergenerational trauma and adverse childhood experiences are major contributors to the disproportionately high rates of depression, self-harm and other mental health challenges that we already see across Indian country. And these of course are not the only factors when we consider chronic underfunding of the Indian health service and really a lack of robust behavioral and public health infrastructure that centers Indigenous perspective. And there are of course, geographical variations in these inequities, but I really want to speak to the work that is being done and not simply paint a negative picture because our communities are much more than a simple statistic. The SAMHSA and the IHS have long supported community directed grant programs to implement early intervention and treatment services for our youth who, to be frank, represent the future of our tribal nations. After decades of ill-informed federal policies like boarding school and urban relocation it seems that we're never more than a generation away from cultural extinction.

And connection to culture has long been recognized as a behavioral health protective factor for our youth. So many programs have shifted to the virtual space, which is of course no substitute for physical interaction, but I think really trying to ensure that we're reaching as many communities as possible and community partners have really worked to bridge the digital divide. And personally, you can always find me on Facebook checking out the latest posts on Social Distance Powwow. And their mission is to foster a space for community and cultural preservation and to retain cultural knowledge through Indigenous voice. And they really work to bring our historically disregarded, but unquestionably needed perspectives to the world for future generations because we are all going through crisis and it's really important to root ourselves in community.

Keeys: Wow, Alec, thank you so very much for sharing that. And I hope that we can make sure to reference Social Distance Powwow in the chat. You said so much, but the thing that really strikes me is you gave us the connection to culture as being the strategy that holds us. But you're also talking about surviving and fighting against past oppressions that are so very current even today. So it's not just about survival for the moment, you're talking about survival on top of survival. And when you're talking about, this I want to then throw to you, Dr. Toni, when you're talking about depression, anxiety, and in these things, what else are you also recognizing in addition to cultural connection to keep us keep us well during the pandemic?

Dr. Lewis: I'm so appreciating everything Alec said about cultural connection and understanding that this is a multi-tiered astral, future focus, all of the things at once. And so, what else am I seeing? I think when we talk about trauma, a lot of times that comes with a particular picture, but I love how, in conversation with folks, it's just like, we're just talking about our wounds, what hurts. But we're also talking about sharing our strategy, almost like we're in the kitchen together, figuring out our recipes and sharing our tweaks, whether it's ginger or scotch bonnet or whatever. Then to Alec's point again about, we're not just our trauma or our wound, this focus on the love of joy within our culture. There's a reason why people were with D-Nice and why Queen Sugar talked about, let's not let people steal our joy.

I think people are getting creative because even those of us who claim to have a deep and strategic spiritual toolkit on how to deal with depression, mental health, intergenerational, we're in a whole new time where we got to kind of mix it up. So that thing where we have to stay in community and find who our mental health pod is in this time where we can just be able to snotty cry when we need to. And also be able to bring your fullness of the here are three things that worked for me and not be afraid to say depression, anxiety, miscarriage, suicide, to say these things so that we can all get about our truth and then use our light and our shared recipes to reveal what we need and deal with what we have and then heal for our future.

Keeys: It's really the togetherness in that way is liberating. And I very much appreciate that. Both of you mentioned media, social media togetherness, you talked about D-Nice and dancing and music togetherness, and you mentioned Queen Sugar. I appreciate all of these cultural points and Nadia, same question for you. What are some approaches that you're seeing are really helpful or that you use with respect to addressing these traumatic experiences, this traumatic experience overall too, of COVID?

Dr. Richardson: Absolutely. So, I'm absolutely inspired and encouraged by affinity groups that are using social media, because at this time where we can't be with each other to create these intentional spaces where they can share, but not just share and learn from each other, celebrate our resilience. I agree with what was said earlier is that sometimes we focus so much on what's going wrong and the disparities that we have to live within all the time and these oppressive environments that we go into every single day, whether it's our work environment, navigating the health care system, navigating criminal justice system, navigating whatever systems you may name. Being able to meet with each other, build resilience, celebrate ourselves, encourage each other, and also share resources with no more martyrs. Again, we're a mental health awareness campaign for Black women and girls. We connect individuals to not just Black providers, but providers who are culturally responsive. You know how they say not all skin folk are your kinfolk.

I'm not just going to send you to someone because they have the same melanin. I want to send you to someone who is committed to acknowledging and supporting and encouraging your full holistic wellness. Another thing that we're doing through our organization is, I think a lot of times social media gets a bad rap because there is so much information and images on there that can be traumatizing, but empowering individuals to curate their timeline. When I go to my timeline, whether it's Facebook or Instagram, I am fed by wonderful individuals who are posting wonderful things. And the same individuals who are running these social media platforms, who record the algorithms, acknowledge what I like to see. So if there's something that pops up that I don't like to see, I have the power to take that off. And it's recorded in the algorithm that says, you know what we're not going to show you this. We're going to show you a little bit more of this.

So I see positive images of wellness. I see positive images of women and affinity groups doing community work. And, so that's another thing too, is within these groups getting connected to resources, being reminded of your resilience and being empower to curate your space.

Keeys: I was going to ask you to. Yes, go ahead.

Dr. Lewis: Because when you said the power to turn that off, boundaries is such a whole tool, whether it's shutting down the screen, turning off the TV or the news, or just whatever, being mindful of the energy that's coming your way and having some intention on the balance. Balance feels bidirectional, but we know it's more like this, right? So, thank you for bringing that part up because I feel like that whole, even if it's just figuring out, do not disturb and airplane mode on your phone, and who gets through and just giving yourself time to rest and understand that it's a lot is such a key part for all of this.

Keeys: I want to stick with your Dr. Toni, because between the two of you, you are helping too, in a lot of ways, enumerate some key components to wellness during such a traumatic time. So if you had to count or enumerate those approaches, those trauma-informed approaches, to best address the trauma of COVID-19, what would you name them?

Dr. Lewis: Well, it's interesting, for the key components, and I think one of the first things we need to do from an equity lens, view, screen, however you want to say it, is get outside of there being like one particular type of trauma or one definition of wound. Because I think that has a lot of people who are suffering thinking, well maybe my hurt doesn't count because it's not COVID or because it's not depression or because I'm not suicidal. So, I think if we step back from an equity lens and begin to rewrite all of that historical context and say, let's get real about what our wounds are mentally, physically, spiritually, economically, community to identify them. I think that's the trauma informed as we define trauma. And then, I'm going to speak to some of my clinicians here about in terms of the soap note format. Once you identify the kind of problems and you can start to figure out what wounds need addressing.

And so I love how there's a body of work and a community that's bringing up this vibe and instead of just saying trauma-informed, let's say trauma-informed, but liberation focused or healing focused or love focused or joy focused or whatever, so that we understand how we're addressing and where we're getting to. So key components are the first kind of just get really quiet with yourself, your community, your people, your family, whoever it is, so you can know your wounds and then address them. And in this moment, it's COVID, it's racism, it's economics, it's sexism, it's all of the things, it's politics, it's all of the things that might be calling it. Let's not make it a hierarchy of whether or not you're personally attached to COVID, but that whole piece of identifying it and then addressing it. And then again, getting in the kitchen to pick your tools.

And that tool may be a therapist. I love my friends, Shannon, Marie Brown at therapy that liberates, there are many different kinds of sources out there or healing circles like we do at Liberation House Strategies, like they do at Genesis Healing Institute, where we just have a collective of folks that have modalities that address mind, body and spirit. And we all get together and create that stew for whatever we need. So I think those are components. If you think of ingredients, what are the wounds? What do they need? What do we have? And then bringing together what we need to address and then understanding when you need to pull that other lever, when you need to pull that lever and you need additional help.

Keeys: I really appreciate that. Calling it what it is, addressing it, finding your tools. But then you also said come to the quiet, which we were talking offline earlier a little bit about yoga. And what I absolutely from yoga and it certainly maps onto life, people have a hard time coming to the quiet. It is really hard to get to stillness in a world that has us doing all of this. Right.

Dr. Lewis: Just a little bit. I'm going to play and I want Alec and Dr. Nadia to jump in because stillness and quiet, again these terms that try to put it in one particular thing, like mindfulness and meditation, but that was my grandma telling me to sit in the corner and be quiet for a second. That's also me taking a drive or maybe listening to my favorite song where I can just surrender into it for a second. There's so many ways to still that we have to find so we can listen in here.

Keeys: And this gets back to Dr. Richardson's point about resilience and self-informing. So I want to pitch the next question to you then Dr. Nadia. You all have to know, this is my good soul friend too. So every time I see you on the screen, I just get so excited. I'm very excited for all of you, for sure. But this is a very healing and good space. So I want to know what health care advances have been made, in your estimation, through these trauma-informed liberating approaches, joy approaches to care as Dr. Toni mentioned and how do we continue to build on those advances and spread the access to them.

Dr. Richardson: Absolutely. I think some of the health care advances is just the fact that it's patient-centered. Right? It's patient-centered. It puts patients in the middle of the conversation and allows them to name the trauma for themselves. Right. And it empowers them to create their own wellness plan, their own treatment plan. And what we're seeing now through research is that, that is giving rise to a more bio-psycho-social approach to care. Right? I think we've seen that in writing. We've seen it in research. We know the benefits of it, but we've still been operating very much in a very traditional medical model and not one that really acknowledges the personal and the societal and the other things that are going on that impact wellness. What we're seeing now is that trauma-informed gives rise to better patient outcomes. And I think that that's very positive. I think the next step that we need to go is getting that embedded in some of the curriculum that's required for medical doctors. Right?

So when you think about some of the medical curriculum, you have the traditional epidemiology, you have the traditional anatomy, you have these traditional curriculums that are important and necessary and needed. But I know when I was working with the medical school and I thought, wow, they're not talking about social determinants of health. We're not talking about health disparities. This isn't required curriculum. And if we can't talk about that then how could we ever really embed, truly embed, intentionally embed, conversations about trauma-informed. I'm seeing it now more, so I'm hopeful for that, but I'm also seeing it offered as electives. And what I want to see is that offered as required curriculum, because if you're really going to sit and create a space where patients feel heard, seen, and we know that, that will lead to better drug adherence and better health outcomes, I need to know that you know how to do those things before you get into that patient doctor interaction.

So, I'm inspired by that. I'm glad to see the things that are happening. We know that Samson, the CDC came out with these guidelines, principles for trauma-informed approaches to care. And some of those things do include an acknowledgement of culture and history and race, gender issues. And it does include peer support. And it does include collaboration. I think all the wording is there. Now we just need intentional strategies to put those things into action. And I believe that's going to happen because I think the patients now see it for themselves. And so they're going to demand it.

Keeys: Yeah. What you don't see happening in my mind is me grabbing onto these really very powerful points that you're making and Alec, I want to actually harken back to something that you said, which really reminds me of what Dr. Richardson just mentioned. You're talking about culture, you're talking about specifically the needs of the American Indian populations. Right? And so I'm wondering if you can expound on some of the things you were talking about earlier and loop in some of the things that Nadia mentioned. So if you were to talk to your peer student physicians, medical students and other physicians, what would you want physicians and medical students to know about American Indian trauma-informed systems of care specifically?

Calac: I think, as evidenced by the last two questions, this moment really demands transformative action. And according to the AAMC, only 11% of us medical schools teach anything about American Indian and Alaska Native health. And when you don't center these perspectives and contextualize thousands of years of history, you tend to really just focus on the negative. And at UC San Diego, I was the only American Indian student in my class. And people often asked me, what motivates your advocacy? And I would tell them isolation and working with our faculty, working with our leadership, first year medical students now have a two-hour lecture on California Indian history to really contextualize our communities on the land that our medical school sits on. And I'm much more than a medical student. I am a Luiseño man who happens to be going to medical school.

And when we talk about health, I think we really center this Western definition that focuses almost exclusively on your physical health, but it's so much more than that. It's this complex interplay between your physical, mental, social and spiritual health. And, if you neglect one, you may find yourself really out of balance. And I look to what tribal leaders and those in health care are doing in California. And there was this project published in 2015 that aims to improve the integration of behavioral health and primary care for urban American Indians. And I want to point out to our viewers that the majority of the American Indian population lives in urban centers like Los Angeles and Chicago, but that was not necessarily by choice. Because in the 1950’s, the federal government relocated thousands of native families from reservations with a promise of economic opportunity and a better future.

And it represented one of the final attempts to assimilate our communities into American society. And in their report, they go into the dismantling of Indigenous systems of wellness from cultural genocide to relocation. And it was almost surgical like in terms of what was done to ensure that we could not connect to our traditional practices and provide these services to our community members. And for example, how does an Indigenous provider bill insurance where traditional health practices that don't align with the DSM-5? So, what I want physicians and medical students to know about these issues is that there's this complex history of genocide, structural racism and trauma that continues to this day. And they should be able to realize that trauma, as was pointed out earlier, is very multilevel and functions at the individual, family and community level, and you should be able to recognize the signs of trauma, how it is culturally specific.

There are 18 tribes in San Diego county and 574 in the United States. Each one is different. There's no such thing as American Indian culture and history, because it is specific to each tribe and your organizations should be able to respond to these crises and partner with tribal practitioners to develop trauma informed systems of care, and really resist passive and active retraumatization of patients through micro and macro aggressions in the clinical space. And I can't emphasize how important language is here and you should really develop a relationship with the communities around you. And I don't use it as a cheap point, but don't rely on the annual cultural competency training to get you through a situation that could have been prevented with an active effort to center Indigenous perspectives. So, a very long answer, but I think it really demands an explanation.

Keeys: Alec taught us earlier how to use the reactions. And I was really trying not to clap and heart every single thing that you were saying but thank you for that. Let me just briefly, and I know we have a couple of minutes left, but Alec in your experiences with communicating to medical students, to physicians, those very words, what have been some of the responses?

Calac: And I think, depending on where you grew up, you may not be too familiar with American Indian history. And that is unfortunately by design when we think about the structuring of our K through 12 curricula. And many of my peers have been very receptive and they've acknowledged their gaps in knowledge, and they really don't seek me out necessarily for information. They seek it out for themselves first, as opposed to burdening me with being the one-stop shop for information. And I really appreciate that. And I couldn't be happier where I'm going to school today.

Keeys: We're very glad to hear that. And Alec, of course, we'll continue to stay in touch with you because there's a lot of work that's really bubbling within the AMA, particularly amongst our MedEd related works. And so this is something we're really very keen to and something that we're deeply sensitive to. And we're looking to advance that work that the center for health equity and our partners across the business unit. So thank you. So we have three minutes left, folks. I wish we had 30 more, but for the sake of being respectful of everyone's time and space, I just want to go and hear some words from you about what you're personally doing, to use Dr. Toni's words, to go on airplane mode these days, and then to just find your own spaces to recenter and relax whether for a moment or for extended periods of time, if you don't mind sharing. I'll start with you, Nadia.

Dr. Richardson: Okay. So I'll give you a couple of different examples. Some of the things I do, I love to dance. I love to dance. And so, I will turn up music in my house and dance. I can't necessarily go to the classes I would like to go to, or a studio would like to go to, but I turn up music and I dance. That's a release for me. It's energy. You know how they were talking earlier about finding your different types of quiet? Dance is quiet for me. Going out in nature is quiet to me. I've never been someone that could meditate inside. I really need to be outside and even preferably by some water. So there are a few lakes that are not too far from my house. I can drive out there and sit. And I do that from time to time, but my work is a part of that too. I feel like sometimes with all the injustice we're facing, we can easily fall into this feeling of hopelessness and helplessness.

And one of the ways I offset that is by becoming action-oriented. So to me, advocacy and activism is a mental health strategy for me. It takes that energy and says, I'm going to do something about it. It acknowledges injustice and what that does to my psyche, but it says, you know what, I have the ability to bring about change that's not going to just impact myself, but it will impact others. So I do that in my education work. I do that in my work through no more martyrs. I do that by supporting other efforts and programs and campaigns. So those are just a few of the ways I do that. And then of course, there's always that beautiful luxurious unapologetic sleep.

Keeys: Thank you for that, Dr. Richardson. Dr. Toni?

Dr. Lewis: So I'm going to hang out with Dr. Richardson, like for real, for real. I'm going to shout out two things, one water, by every means. Drinking it, bathing in it, listening to oceans and waterfalls, understanding the sacred of it and just appreciating all of that, in addition to Dr. Richardson's amazing list. And then kind of piggybacking on some of the amazing things that Alec was talking about. I feel like this white supremacy culture has benefited from us not telling the fullness of our stories and our love, and our joy in our culture. And the way to get equity and justice and liberation is to lift that. So I'm loving the culture that's out that showing that before the Tulsa massacre was joy and family and resilience and flyness and Lovecraft Country that was doing that.

And listening to my mom talking about the fun that was around the West side of Chicago. So, finding all the stories and all the art and all the places, and just inundating myself with the music, the art, the love, the joy, the poetry that either came from those times of struggle and resilience that was lifted, or that's being birthed now is amazing. I keep that stuff on so that I'm tripping over joy and creativity to inspire me and to feed me.

Keeys: Thank you, Dr. Toni. Alec, do you care to share?

Calac: I'll keep it pretty short. I think in the course of the pandemic, I've really seen this period of academic hyper productivity. And I've really learned the power of saying no. It seems like there's a new opportunity in my email inbox every day. And, it says, we hope we find you well. And I just want the emails to stop finding me. And I've really taken power in centering my own mental health and telling myself and others that it's okay to not be okay. And I've also started to bake bread, which is a new venture for me, which has been really interesting, but to each their own.

Keeys: Yes. Well, I think to each their own, but then we can also potentially borrow from one another, derive strength. And just in closing, I share some things that you all mentioned, but one in particular is also just symbols of strength and surrounding myself with symbols of strength. And in fact, today I wore a literal symbol of strength and Nadia's wearing the same symbol. This is a Ghanaian Adinkra symbol that actually signifies ram's horns. And it's a bird's eye view of ram's horns. And so when you see rams kind of going at one another, it's certainly a symbol of strength, but it's also a symbol of humility. And just understanding that they're not mutually exclusive, just perspectives to have and postures to take. So again, I'm really grateful for the time we spent. I wish we had more, but I certainly hope that we will spend time together in the future. My hope and highest paths consists of wellness for you and for your family.

And I will leave it there Alec. I'm not going to ask you for anything else, but back to L. Toni Lewis, thank you for your time. Future Dr. Alec Calac, thank you so much for coming through. Dr. Nadia Richardson, I very much appreciate you and your space. I'm Mia Keeys and for health equity thank you all viewers. And we look forward to the next time we can spend time.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.