Okay. Hello folks. I think one of the deadliest assignments is to speak . to be the last speaker on a Friday afternoon at 1:18 after lunch. Now, we were talking about culture and different cultural aspects. We have some cultures where right now we would be having a siesta, this is not being said to be suggestive and if I see any siestas going on I might just call you out.

But, I want to thank Sarah Troy, the General of Civil Rights and Social Justice for this invitation. The speakers who have gone before have been very informative. They laid a wonderful basis of the history of health disparities and I think they.ve done very exhaustive and excellent job of so doing, the challenges afternoon is ready to talk about how do we respond to that, what could be done, what is being done and how effective can that be.

I ought to thank one of your board members. I drove down here yesterday from Baltimore and I was trying to describe my experience coming down the highway. And she gave me a good . she.s not here though . for me to give her a full credit but she called it the aeromatic farm experience, which I thought was quite appropriate and is quite enjoyable, in some respect. Look, when Katrina was heading towards Louisiana, our gulf coast, I will never forget that I was on an island called Margarita island off the coast of Venezuela and my wife and daughters were around me and I said: Oh my, this is going to be disastrous. And my younger daughter: Why daddy? And I said: Because, no one is ready for this and the black community especially is gonna be hit hard and that was a predictive factor in talking about racism and what constitutes racism and why racism and so on, and it is a very complicated issue but we could have know prior in the Lawrence case that the black community in the 9th war, was gonna suffer disproportionately. As it happens, they did and as it happens they.re still suffering from that week.

One of the things that I.ve come to realize, when we talk about things like Katrina, like disasters, I want to talk about health disparities and I want to talk about cultural competency which I.ll be touching on today. It reminds me very much of the Civil rights movement back in the 60.s when . you weren.t here before . but you can part still on Vietnam, because in motive aspect of what happens when disproportionate discrimination happens, evokes a certain sense that you have to respond, that you can.t take this, that you must do something and back in the 60.s we used to think of ourselves as change agents, agents of social change and we were convinced that was true and to some extent it worked out.

In other aspects, we failed. But the challenge is always in front of us. The challenge to adjust to a new reality, to a society that demands of us to make things better, and as law Participants I would imagine that you face that kind of an issue on a daily basis, in your courses, in your discussions, because one presumes that one gets into the law in order to adjust in justices, so I.m making that presumption and if I.m wrong, tell me so. But there.s a warning, though, that I give myself all the time and that is that as one discusses these issues we have to be caught by this effect, that we.re actually trying to change minds, we.re trying to change the way we approach things and one time I gave a talk and the chaplain followed me said, he thought complimentarily, he said, .Boy, that was very evangelical,. and when he said that I felt I failed. Because, this is not about being evangelical, this is about being persuasive and trying to get more people to join the choir, the choir being those who are committed already to social justice, those who are committed to how to make the changes that we.re talking about. So every time . those of us who believe in these issues speak, we.re looking to grow the choir, we.re looking to make this a bigger movement so that we can in fact bring forth the change that we have. Remember . Katrina, other disasters, healthcare form, all of the issues that are confronting our country is happening in the midst of an immense change in the country itself.

The demographics of our country are changing every day. We.re changing the make-up of our society, hence we.re changing the needs of our society as well, so we need to be aware of all those kinds of issues as we move into the talk that I want to give. What I want to cover is shown here. Jonathan was crying to me every time we set off as a Minority health, but the truth is I am not from the office of Minority health I work with the office of Minority health as a contractor, and office of Minority health, the program that I.ll be describing is actually run by gentleman named Guadalupe Pacheco, who actually was supposed to be here today, but I.m substituting for him, because I run the program that he had, so to speak.

Anyway, I want to talk about Office of Minority health, histories of the equity and the reasons to response, cultural competence in a disaster response, a little bit about some disparities in our communities and then I.m going to really focus on some tools that I think we have, that might help in the history that we.re talking about. So the first few slides I.m not going to run too quickly, the reasons you.ll see in a minute. The mission of the . us in Minority health is to improve the health of racial and ethnic minority populations by developing health policies and programs that will help eliminate health disparities and the awkward [unclear 8:08] there.s health, because health disparity is such a large issue in a world today that it.s going to take a range of programs to eliminate them and it.s going to take long time so we can only talk about helping to eliminate the issue of health disparities. Now, what this slide that you see already, so I.m not going to spend a lot of time on this but the limit of ability to take planning and resources contributed to the lack of preparedness of minority populations, the lack of awareness of knowledge of culture and language diversity also affected communities and the things that we said before I don.t need to repeat here.

This other slide also talks about . it caught some specific orthodox issues, give me a second to gather in what is being said there which has already been entailed in our previous speakers. presentations. Another example here of the disproportion of impact of disasters due to a variety of factors and the due in English proficiency, cultural insensitivities, acculturation level, all things that we have mentioned as contributing factors to the disproportionate of good that minorities have to handle in disasters. Now, how do we address the problem? I believe that improve language access services can help disaster respond as overcome cultural language barriers between the violence and responders which are decided as obstacles to appropriate emergency response. After Andrew in 1992, the relief information was provided only in English as we heard before as well and yet they were dealing with Latino or Hispanic populations after that disaster.

Research also indicates that understanding culturally specific responses to the disasters is important for reaching out to disaster affected minority communities and for the planning the delivery of disaster mental health services that also has been discussed. Now, cultural competence in the emergency response; this to me is an issue that as a society we have to face. Often when I talk to professional groups particularly I have to say, surgeon for reasons I have my own thoughts about it, this never happens with lawyers though, but when you use the term cultural competence, there.s a sort of immediate medium response saying: How dare you say I.m not competent? What is not being said that you.re not competent, it.s being said that you need to have more cultural competence, no one has ever said . I never say that people are incompetent but professionals tend to reject the notion that they necessarily need to have any improvements because, well, they.ve been through law school, been through college, what else is there to know?

But now to introduce the idea that all of us are engaged in a journey and the destination is a far away off, so when you talk about cultural competence, it.s a daily living, growing kind of dynamic that all of us are capable of benefiting from. But the definition that we use for cultural competence is that cultural competence or cultural competency is effectively providing services to people of all cultures, races, health backgrounds and religions in a matter that respects the worth of individual and preserves their dignity. Worth and dignity I find two very important words in life. The adaptation of preparedness, response and recovery efforts to fit cultural context, improves disaster personal ability to provide the appropriate and effective services in order to best meet the needs of the communities.

Now, you would think that that would be something that would be understood but I.m always surprised of how often that kind of thinking is overlooked. Because here in emergency responses, the rational, first of all is that you want to improve the experiences of those who are responding in order to help eliminate health disparities and since most of our institutions are based on profit if you wish, you want to help improve health outcomes, because in fact, it increases effectiveness and efficiency of services. So one of the other things we have to make is the business case which says: If you treat people better, you.re going to have a better result, not just for the people but for yourselves as well. Now, here.s what I was talking about before about cultural competence as a journey not a destination; I myself . I feel that I learn something new every day, I learned something new yesterday and today just by being here and therefore I think the whole idea of looking at cultural competence as a journey is to be open to the new experiences that you are going to face.

I.m sure, as lawyers, when you go to represent different clients, you see it in Law and Order all the time, my wife.s a big fan of it so I kind of get sucked into it, but you see it all the time the innocence of the defendants who are not properly represented, people.defendants who.s culture was not understood, all kinds of episodes come to mind about that but the fact is that in order to serve someone well you have to understand that person, you have to know the context on which they.re living, and so therefore what I wanted to know is to walk through the three phases of the disaster and talk about some ways to implement cultural competency during each phase. By no means would this be a comprehensive discussion but it is merely an overview of a few cultural competency concepts as they are lived to disaster preparedness. But I think it also relates to the life in general, I think.

So, first of all, the preparation fees - most of us in this room would probably not necessarily be involved in a specific disaster event, but will be involved in something where you need to be ready to respond appropriately. So when it comes to any of this kind of issues we have to be ready to communicate with the community in order to ensure that the organizations early warning systems are comfortably and linguistically competent.

We heard already that we have to know and understand cultural norms and [unclear], use appropriate languages or language, recognize strengths and limitations and take advantage of the strengths of communities. I always think, in whatever situation I happen to be, whether it.s working with my staff or working with a group of people, that you want to heighten and emphasize their strengths, not their weaknesses, you can use the weaknesses more as a punishment, and I don.t like to be in that situation, so you want to emphasize the strengths, take advantage of the strengths and find ways to buttress the weaknesses.

Now let.s talk about further on the response phase. This is rarely tailored mostly for first responders but we talk about just in time training which offers right and correct information at the right time and in the right form.

And then, whether it.s an emergency response or anything else that we do we need to be covers in the recovery phase of things like, depicted here, or in this very slide, I got to go back to that one, I need to explain something. We.re talking here about disparities in recovery, the . I wish I had a pointer - the left column, it.s how the even actually develops, you have the honeymoon, then the disillusion, the curve is the result of the time of recovery and then you have the coming to terms with the recovery and then you have the reconstruction, that.s under left.

On the right side, when you start having to deal with the positive and negative aspects of the recovery event, evenly the sway, so to speak, you go to the more positive side from time to time and then on one negative side depending on the community mood and depending on how reconstruction activities are coming along. But you also have to be able to do a good evaluation of how you.ve done and you probably need to do a good evaluation not just in disasters but in how you handle the cases that you.ll be handling, whether it.s about the insurance industry and how that goes, insurance some things came to be in looked of and so on.

But first of all, the evaluation has to be transparent, because a transparent evaluation must involve practices that are open enough to allow stakeholders such as local partners, project staff, etc, to see what is being done, so you need transparency. Then the evaluation needs to be independent, because an independent evaluation has to be nonbiased and objective in order to be credible and ultimately useful. It also needs to be consultative and that it allows those that you.re trying to evaluate, the issues you.re trying to evaluate to participate in the evaluation process and of course it needs to be relevant, because the roll of evaluation will address the needs where only a relevant evaluation can address the needs of the affected communities.

Jonathan.s talking earlier about, a piece about the center for preparedness for certain communities, these are the goals that they have and this is a scent of it actually was developed for the office of Minority and is based at office of Minority health. Ok, so now I want to talk about some of the tools that we have in what we call the Think cultural health program. We have quite a few things that I think will - can help you and your future and specifically people in recovering from disasters.

The National CLAS standards, I.ll tell you a little bit about it in a second, we have e-loading programs, we have communication tools and we have a CLAS clearing house. Give you a little bit of a story behind a CLAS standards; they stand for culturally and linguistically appropriate services. Initially they were intended just for health care, but we have a set of new ones coming out next month, that expands from health care across the board and I think that they apply everywhere, in fact, two deans I.ve spoken to, one in a school of oral health, dental health area and another in the medical field who want to start implementing these CLAS standards, I.ll talk a little bit more about that in the future. Maybe your law school might want to do that here in Lexington, if I make a good case for it. So just a little bit more on the O&H cultural health tools, we have, first of all a comfortably competent curriculum for disaster.

There is a cultural competency curriculum that we have up online. And it is at, as you can see here thinkculturalhealth.hhs.gov. It.s free online continuing education, it equips disaster personnel with the knowledge of awareness and skills needed to provide emergency health care. It.s accredited for first responders, emergency managers, disaster mentor health workers and dentists and 2500 individuals have already registered for the program with 10.000 credits have been awarded. The idea behind each if these curriculum that I have mentioned is to weave through these culturally and linguistically appropriate standards so that as you take the course and each of these courses . I think that the physician - the disaster run for 6 hours . the ones who are physician a little longer and the one for this is about 7 hours, and they get credits at the end of the . continuing medical education credits at the end of each one.

So in addition, as you can see here, no . as you can see here, we started off with an introduction to the CLAS, to CLAS in the disaster preparedness and crisis response, then we talked about implementing the CLAS standards in the preparation phase, implementing in the response phase and implementing in the recovery phase. We also have the Cultural Competency Curriculum for Disaster Preparedness. From the field we have examples and case studies, video clips, [unclear] facts, it.s a very good . I think . interactive curriculum. And finally, we have guidance for integrating the communities in the plan for the response, pilot-testing the tool kit and an Emergency Managers Tool Kit as well.

So there.s a lot of resources there for those people who are interested in the disaster recovery aspects. But we also have, as I was saying other curricula as well, we have one for nurses, we have one for physicians, we.re developing one for oral health and we.re developing one for, what are called Promotores which are the people who work in the community to improve health care of Latino and Hispanic members of our community.

I mentioned earlier about the National CLAS Standards which were originally promulgated back in 2000, seems like yesterday but it was really 12 years ago. At that time there were 14 standards that provided a framework for all health organizations to best serve the nations of those communities and to inform practices related to cultural and linguistic competency in healthcare. As a result of their use over the years it became clear that they needed to be upgraded and we did this for the past year and a half, we had a national project advisory committee and many other interested constituencies across the country involved in looking at how to improve a CLAS standards, how to innovate them, upgrading them up to 21 century standards that they need to be.

So we conducted a lot of activity over the last 18 months with meetings around the country and many meetings of the National project advisory group and that has resulted in these new standards which I wish I could share with you but they.re under embargo until their release by 18th next month but I would ask you to keep an eye out for them, I think that they will . they can have lots of relevance to your lives as well as to the lives of people in the healthcare industry. The reason they.ve been expanded is to be able to be used for law, for dentists, for any institution that wants to be more relevant or more in touch or in sync with their communities. I think that, as I said as the country continues to evolve and change that we would be well advised to change with it to be able to understand that change, and to be on the wave of the future rather than doing a sort of rail around the tree as sometimes happens in our political dialog. But, before I get into that, I better stop here and ask you if you have any questions. Thank you.

Political competency seems like it.s very broad are there examples of the specific cultures?

I think that . sure, I think cultural competency is something that is very broad and the principles that are outlined in these CLAS standards can apply in any culture, so if you put together . if you have an institution and you understand the community that.s around you, you need to be able to deal with the members of that community whatever cause they happen to be, so you train according to the need using these standards as principles that you can use as guidance. Yes?

What are some examples of CLAS standards?

Ok, we have several standards. We have some that talk about the institutional need to understand the community, then we have guidance standards that talk about taking the pulse of the community, having the right kinds of data that will inform you about what your community looks like. Then we have standards that will talk about responding to those communities whether it.s in signage or language or other appropriate kinds of material. There is . there are some of the standards that certain federal organizations . federal agencies will use as prerequisites that you have to have in place if you receive a federal funding. Those are mainly dealing with language proficiency issues.

So there are 15 standards now, it used to be 14, they.re now 15 and they will give guidance on all aspects of the need for cultural and linguistically appropriate standards. I wish I could have shared them with you but if I did I might get sued or something I don.t know what they would do to me but they will be rolled out . I.m told it.s going to be a big press conference that HSS is going to be holding at the National Press Club. I think it.s going to be in April and I could certainly send you the dates, you still would not have graduated yet so you might still have . need to pay attention, but I will do that. Yes?

I think it.s pretty well recognized that there is a round in a lot of other communities, especially the black community in the US, I was looking in the area of District of government which is I think is historically based and we all have it, and I was wondering if that plays any role in developing of these standards or the government looks to, whoever the leaders of those communities, to establish their own authority.

I think one of the things that distinguishes this particular initiative is that it was developed . funded by the government but developed by nongovernmental people. The National project of advisory committee has two thirds of nongovernmental people.

All of the hearing.s that we held or the public meetings were held in communities; we had one in Baltimore, one in Chicago, one in San Francisco and we.ve got lots of other comments online. So my sense is that when we were around the country talking about the standards people looked at them as their own standards, standards that they have been using in their communities as oppose to something that the government is saying: You shall do so and so and that.s what I was alluding to earlier when I talked about growing the choir, because the people who currently use the CLAS standards and appreciate the CLAS standards are not governmental folks, they.re people who held applicant row that are using these standards and I.d like to see that . the size of that choir grow a little bit . because I think that the standards are not preachy, they.re not beating you over the head, they.re saying, we have a need to do a better job of implementing our services across the country. We have a population that is changing every day in rapid fashions; we have a country that is a changing place, that is dynamic in nature so let.s try to use as many tools as we can to address the needs that are existing. But so far, there has not been a back lash of anti-government field. Yes?

Are there any international models that you guys look out to guide you?

Yes, we did actually, they.re . I wouldn.t say to guide but rather to inform. If we look at several Scandinavian models, we looked at the British model, but this is not so much about a healthcare systems as much as its use of how do you relate better to your communities, so I didn.t . I personally didn.t spent a lot of time on the international front because I think we have a great laboratory right here. Yes?

Yes, thank you for your presentation. I know you.ve been talking about cultural competencies well and I.m glad to see it being able to help in disaster preparedness. So you talked a little about structural, and you called it a structural racism here today and I know that there.s been a critic or if cultural competency is not always addressing the underlying structural qualities, but I want to ask you about that, how cultural competency interacts with and mitigates the effects of structural incompetence?

In the earlier talks there was the question of where do you factor in or factor out or in to change or see the interaction of racism with societal issues and so on, and the CLAS standards are intended to address basic issues of dignity and the worth of the individual to that extent they inevitably have to take note of those issues in our society that are inherently unjust so that I see the interaction as having to be there all the time so if you.re talking about institutional inequities . okay - and those equities are based on class and race and culture and so on, these CLAS standards can be taken and applied to that institution in order to address the very fundamental issues that are creating the situation in the first place.

Now, will they by themselves redress those inequities? Not, not by themselves. There has to . it seems to me anyway . a commitment on the part of the institution itself to adopt the kinds of approaches that are caught for in CLAS standards to make them an institutional priority and not for instance to just say: Okay, in order to address these issues with another point, somebody to be the head of minority affairs. That.s not the answer. It.s not . this is not going to respond to [unclear 38:48] it has to . it needs to be an understanding that for us to serve any of our constituencies better, we have to reflect what those constituencies care about, we have to be aware of it and we have to as an institution commit ourselves to making the changes that will allow us to provide a better service. So it.s all interrelated. Kind of a long answer for a short question.

No it isn.t and thanks for responding.

Yes?

You.re talking about how the increase of the choir will help to implement the standards or help to change the institution to get these standards, from the individuals that make up this very choir, are you voting for awareness, or funding or just participating in these organizations?

Good question. From the people who get involved I think the most important thing is an appreciation of the value of addressing the needs of one.s constituencies or one.s patients or one.s clients. The institutions will not necessarily have to find what people like to call unfunded mandates, the institutions . I think . can respond by implementing these standards and then seeing how it approves to their benefit when those standards are in place. The funding . okay . is always gonna be an issue of where does that come from and who can afford it, and what my initial take on that is, is that the federal government has funded this to the very limited degree, just in terms of getting these standards set up.

Now there.s some hospitals that have already implemented these standards and I.m waiting to see the data as to how much it has cost or how much it has benefited them. So I think as they get developed we start seeing what kinds are evolving, how is the funding coming on street. State of Maryland just put out a big - a bigger port on health disparities which none of the pretty progressive state . and yet they have air marked any specific funding forehand. Health disparities up to now has been a nice sounding term with a very little [unclear] behind it, but I think that more and more institution have start recognizing the need to make a commitment in that regard, so the commitment will come from the individual, from the institution, from the community . it.s the kind . that.s why I call it . it.s a kid into what those of us old enough remember used to call movement, because there are lots of different elements that are involved in making all this happen. So I hope I.ve addressed your point, but I can.t put the percentages in place as to the money pot and the commitment pot, it.s a mixture. Commitment across the board, funding from some sources, implementation from others, evaluation from others, assessment and then trying to make the case for continued development in progress. Yes?

Is this under SANSA or as far as laying the future looking for, reporting on the outcomes and thinking about where [unclear] for further support, is it SANSA.

Well, the agency that is spearheading this is the Health and Human services and SANSA is under Health and Human services as is the Office of Minority Health which has taken the lead in developing these standards. When they.re announced, they will be officially coming from HHS through the assistance of [43:37] name . but so I would think that you.ll see some . you.ll be able to find out more and more of it if you go to this website as a matter of fact because the part of the implementation aspect is for us to find ways to document the extent to which they.re being implemented, to share success stories, to share difficulties, to give a picture of how this thing is developing. And there.ll be cross references all over the place, I mean you.ll see some on O&H site and then there.ll be HHS site. So I expect that you.ll be able to easily keep up to date on what.s happening with them. Did I answer what you were asking?

Yeah, I guess if it.s in the HHS budget, you would be under the secretaries.

Yes. Correct. Any other questions?

Well, I.m glad to say that I didn.t see anybody nodding off. I appreciate that and it.s been fun being here and I.ve enjoyed sharing these thoughts with you. Thank you very much.