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Racial Justice Series: “Interrupting the Impact of Racism on Health” SwatTalk

with Miriam Zoila Pérez ’06, writer, speaker, and activist

Recorded on Tuesday, Dec. 15, 2020



Ayanna Johnson: So good evening everyone, and welcome. Tonight's talk is part of our racial justice series for Swat Talks, and it is entitled "Interrupting the Impact of Racism on Health". My name is Ayanna Johnson and I'm a member of the Swarthmore Alumni Council, and I am Swarthmore class of 2009, and I will serve as tonight's moderator. Before we get started, I just want to go through a few housekeeping items. Swat talks is an initiative of the alumni council to engage the broader Swarthmore community in free virtual seminars, featuring professors, students and alumni excelling in their fields and sharing their knowledge and experience. We were a little bit fortuitous in that we've been doing this before the pandemic, so we're really excited to be able to continue the Swat talk series and actually create this new one, which was inspired by the work of President Valerie Smith through the recently created President's Fund for Racial Justice. This special series features alumni who are working in fields, including art, law, education and reproductive justice. The conversations focus on racial identity, representation, access to resources and the structural changes and solutions we need necessary to move forward. Today's session is being recorded and will be made available online, and we will have ample time to ask and answer questions, so please use the chat feature to send your questions to Miriam, and include your name and class year, if you are an alum. You can also register for upcoming webinars and find recordings of past Swat Talks on the alumni page of our website, so now I'm excited to introduce you to Miriam Zoila Pérez, class of 2006, is an award winning Cuban writer and activist. Pérez's 2016 Ted talk, "How Racism Harms Pregnant Women - and What Can Help.", has been viewed close to a million times, wow! That's amazing. Their writing has appeared in The New York Times, The Guardian and ColorLines among other outlets, so Miriam, take it away, thank you so much for being here.

Miriam Zoila Pérez: Thanks so much for having me. It's an honor to be here and it's exciting to be in a room full of Swat alums. Yeah, I'm sad that it's a virtual room, but I'm happy to be connecting with you all. So I'm just gonna talk a little bit about my path to focus, and my focus on this work, and then dive into kind of the substance of it, in terms of what we know about racism and health, and what we know about the interventions that exist. So it's funny cause I do these talks a lot and I always start with talking about college, my college experience which now like you all are very intimate with, and I always share that, you know I grew up in North Carolina, to two parents who were immigrants from Cuba, so it was kind of an interesting cultural upbringing. I spent a lot of time in Miami where my family was, and that was a time in North Carolina kind of history when the Latino community was very, very small, and then in the '90s there was like a huge growth of immigration to North Carolina, from Central, Mexico and Central America, but so I grew up with a really kind of like confusing sort of racial and ethnic identity around like being Cuban, and not really being white, but like trying to sort of assimilate and pass but not really working very well, and then being in Miami with a Cuban community, so a lot of interesting and confusing experiences in that way. But I was always really interested in health, and women's health specifically and was kind of like the nerd at like slumber parties who wanted to like talk about health and like look at my friend's health books and stuff, and so when I went to Swat, I was like, okay I'm pre-med I wanna like be an OB-GYN, I'm gonna be a biology major do the whole thing, and then I think probably many, many of you can relate that organic chemistry was like the end of me on that path. And I made it through Orgo I, like spring of freshman year, and then we had a visiting professor and he was terrible, and he was like, on the final exam, he was like, did anyone get it? Did anyone get even close? Like he was just trying to make it impossible for us, it's terrible. Anyway, so I passed it, I got like a B, but I got, and I did physics over the summer at UNC where in my town, hometown, there I was like really committed to this whole like pre-med path. And I got there to campus, like first week of sophomore year and I got my first Orgo II lab assignment and I had like a panic attack and was like, I'm done with this, I can't do this it's too hard, and so I dropped it and took art history instead, and really never looked back at the track, and I always say that as a joke, and there's usually a lot of laughs 'cause a lot of people can relate, but it's actually I think a part of the bigger problem around disparities and health that these things that are considered like weed out courses for something like a medicine medical track, like really, who are you weeding out? Who are the students that excel; who doesn't excel? So I think there's like a bigger issue there, but that was my sort of experience, so I was like, "Okay well, I don't know about medicine, I can't really do this, I can't do this in this way." But then I actually had the sort of serendipitous experience of getting to do, I took a class at Bryn Mawr, my sophomore year that was about the anthropology of reproduction, and it just kind of like hit on all of these things that I was so fascinated by, and I didn't know a lot about how pregnancy and birth happened in the U.S but I, it kind of opened my eyes, I was already like kind of an abortion rights activist, and like cared a lot about sexual health, but hadn't really learned much about how babies are born, or what that looks like in the U.S. And we watched a documentary called "Born in the USA" and I literally left that seminar and was like, that just changed my life, I felt so activated by what I learned in that documentary which was really comparing kind of what hospital birth looks like in the U.S, to like home birth, to birthing center. And it just kind of really talked about mostly focusing on the field of overmedicalization of birth and the ways in which our interventions can do more harm than good. And so there's a couple people here from my class, like shout out to Harris, there might be some other folks, but I don't know. I started like was on like such a focus on that issue in college, and I was like talking to everyone how they should have a home birth, and like most people are like trying not to get pregnant. So it's just kind of a funny thing to be talking about, but I got really excited about that, so that kind of became my path, and I thought I was gonna become a midwife. And I got to spend time with a midwife thanks to, and shout out to the Externship Program, Robyn Churchill who was an alum. I got to shadow her and she's a midwife in Boston, and she was like, you should really, if you really want to do this, you should become a doula first instead. And so I was like, "What's a doula?" This was 2005, things are really different than they are now in terms of that role and what people knew about it, and I knew very little, and so she explained the doula is a person who's trained to provide support to people during pregnancy and childbirth, and if you're the layperson you're not a medical provider, but you're a support person. And so then there was sort of another serendipitous moment that there was a flyer on Kohlberg Hall or something that was like "Doula Training", that was like the wife of a professor was like helping to organize this doula training in Philly. And so I was like, okay, sign me up. So I did a doula training and it really just like, gave me this opportunity to be involved and to be supporting people through this process, in a way that felt like a really small way to have a big impact on somebody's experience. So I did a summer of volunteer doula work. I wrote my thesis for Farha Ghanim about birth in the United States. I went through a Judith Butler phase and try to incorporate that, like I did all the things very Swat experience. But yeah, I really left with this sort of like passion- yeah shout out to Farha- this passion about maternal health in the U.S and did all the like academic readings, was a SocAnth major, the whole thing. But when I left college I actually ended up with a job in, I wasn't ready to go straight to midwifery school, so I ended up with a job with an organization called, the National Latina Institute for Reproductive Health, now called the National Latina Institute for Reproductive Justice. And that really kind of like blew my mind on a lot of levels, including really understanding the reproductive justice framework, understanding the political work, in the Latino community, in the Latinx community, understanding the broader like where I fit in, and what my role was in terms of kind of broader communities of color, understand the impacts of racism, it really just like changed my world in a lot of ways. And I still really cared about pregnancy and birth, but was trying to figure out how that fit in, and I realized starting to do that more political work, and work that was led by women of color, that a lot of what I'd read and studied in anthropology around pregnancy and birth was very whitewashed. It was very like a devoid of a race analysis, and which you know, in anthropology it's like not surprising. But it wasn't something that I really like understood, what was missing from these things I was reading, and so that kind of led me more toward thinking about this work in a more political framework and with more of analysis around race and racial justice. Because when you actually look into the reality of maternal health and pregnancy and birth in United States, you see that there's a real crisis facing particularly black women, but also some groups of Latinas, and some groups of indigenous women, some groups of Latinas and some groups of API women around health outcomes in pregnancy and birth. And so while, the people that I sort of was reading about and like the people who cared about medicalization of birth were really kind of advocating for, changing people's experiences of birth, less interventions, less C-sections, blah, blah, blah. Really they were talking about and focusing on upper middle class, straight, white women and their experiences of pregnancy and birth, and not actually focusing on the fact that black women are four times more likely to die during pregnancy and childbirth than white women in the United States. I didn't learn those statistics until much later, and so I ended up kind of starting to do more writing around these questions around maternal health and doula work and started a blog called Radical Doula back in 2006, which makes me feel so awful, talking about like the sort of what does it mean to do work as a doula?  And from a political perspective, what does it mean to center the experiences of the most marginalized, which is what reproductive justice really offers, as a framework, it says, you put the most marginalized people at the center of your work, and if you meet the needs of those people, you meet everyone's needs. And so if you look at that, when it comes to racism and health, you have to look at, and even just health more broader, you have to look at what are the experiences of people of color particularly black folks in the United States and particularly African-American folks, because when you look at the research about health disparities, there's actually a pretty big divide between black immigrants to United States, or POC immigrants in general, and people who are native born, who are of African descent, or, Latinx or indigenous, so there's actually a divide there and immigrants tend to do better. Recent immigrants tend to have better health outcomes which, might sound surprising to somebody who doesn't know the issue, but actually it's because racism, right? It's like actually the lived experience of race in the United States has a negative impact on people's healths, so that's like the sort of bottom line, I guess of this in some ways is that's what we know, that racism makes people sick. And so I got the opportunity to do a TED Talk, I got an invitation to do a TED talk and I was like, okay, what do I want to say to the largest group of people I will ever speak to in my life? Because I knew that, you know, at that point I was focusing mostly in writing, and journalism, and also still doing some reproductive justice activism, but mostly writing about issues around race and gender and you know, for smaller outlets, like I hadn't written for New York Times yet, I was writing for ColorLines, progressive outlets, but small audiences. And so I was like, okay, this has the potential to be the largest audience I'm ever gonna get to talk to, what do I wanna say to this audience? And so what I wanted to do is try and make the case that the disparities that we see when it comes to maternal health, which by the way exist in other areas of health too. They're not just in maternal health, if you look at diabetes, heart disease, hypertension, like these race disparities exist across health issues but this was my focus, was maternal health. So sometimes when you explain those those disparities to people they make these assumptions like, "Oh that's because of poverty. Oh, that must be because of lack of access to care." Or even more racist assumptions about people's behaviors or their health behaviors, and the reality is that even when you account for something like income level, the disparities still exist. And particularly with black women, the disparities actually increase.So if you compare a middle-class black woman to a middle-class white woman, the unlikelihood, like the difference between the white women's likelihood to have something like maternal mortality, or a baby born too early, or an infant mortality, or those kinds of outcomes that we track that, that lead to, serious illness or death, the disparities is even wider among middle-class women. So it's not about lack of access to care or poverty, it's actually about racism. So that was what I wanted to do with that TED Talk, was try and really make the case for, that racism is what's making people of color sick. And so, I did a lot of research into the physiology behind that, and it starts to really make a lot of sense, and I mean, the beautiful thing now I think is that this concept is much more understood and accepted now than it was then, even just a few years ago. This was like right before the 2016 elections when I did that talk, so four years later, I think the understanding and acceptance of the impact on racism on people's health I think is more broadly known. But at the time I felt like I really had to make the case for why this is true. And so the physiology behind that is really about the nervous system, and the impact on a constant threat on the nervous system. So when someone's experiences a consistent, it doesn't actually have to be a real threat, it's just the fear of threat, the anticipation of threat, it has an impact on the nervous system. And so in my TED talk, I talked about, that I was nervous, I was sweating. I talked my own physiological response to being on the stage in front of other people, as an example of what the nervous system does in response to stress. And what happens for people of color who experience racism on a daily basis is that you're constantly in that sense of fight or flight, your nervous system is constantly in that, and this is a very rudimentary, there's like scientists and stuff in this talk or positions, this is a very basic way to explain this. But if you're constantly experiencing that sense of threat and fight or flight, what the research shows is that, that has a negative impact on your health, and there's a bunch of really great research now about the impact of discrimination specifically on health, and it shows that people who report more experiences of discrimination, and it doesn't actually matter if they're being discriminated against, but if they're afraid they're going to be discriminated against, there's a correlation with negative health outcomes. And it's actually not just about race, it's also true around sexual orientation, gender. It's not just about race but race has been the most significant factor, when you think about the United States on population. I mean, there are other groups that are also really impacted, but race is the biggest one especially when you think about maternal health, the trans community, for example, faces really high levels of discrimination and stress. There's not a lot of research about trans pregnancy so it's starting to be a thing, but it's not as, studied. So that's the real sort of mechanism behind it, and so, it starts to put in context things like microaggressions, and, you know they don't seem as micro anymore if you think about the cumulative effect of those moments of stress and threat actually have a negative impact on people's health. And you can imagine that if you're pregnant, it's a really important time, physiologically, for obviously the development of the fetus and all the things that are happening. You could think about how the impact of stress, particularly like consistent stress during that period could be really, could have a really negative impact. And so, I mean there's a lot of statistics you can see out there, but like I said black women are four times more likely to die during pregnancy and childbirth than white women, and also have elevated rates of, like I mentioned, low infant birth weight, so a baby being born too soon, and preterm labor, and low infant birth weight, so born too early, born too small, which might not seem like a big deal, but it's actually really correlated with health problems for that infant throughout the lifespan, being born underweight or early and then infant mortality, so death of infants and death of the pregnant person too. So those are all, and like I said it's the biggest disparity is for African-American women in United States, and then indigenous women, and then some groups of Latinx folks and then some groups of API folks, so it spans the sort of demographics that way. So what I wanted to know, I didn't want to just focus on the problem and explaining the problem, which is this like constant sense of threat impacting the nervous system meaning that you don't spend enough time, your body doesn't spend enough time in, the rest and digest part of what the nervous system can do, you spend too much time in the sense of threat and that has a real impact on people's health. I mean there's also studies about lifespan, right, that people of color live shorter lives. There's a real, real impact, and impacts the length of people's telomeres, it has a very concrete impact on people's health. So, but I wanted to also look at, well what can be done about it, or what is being done about it? Obviously the big picture is, end racism, end White supremacy, and what do we do in the meantime? Like that's a long haul, clearly like a long haul project, clearly not  something that we're like on the cusp of achieving in the United States. And so what are people doing to improve the health of people of color right now in this moment? And, we know that there have to be some things that are protective factors because not every person who is like at risk for these issues has them. So it's not 100% likelihood, it's only some people, so what's the difference between those groups of people? And it's not, income or some of the things that people think it's not access to care, there are other things at play. So that's what I wanted to look at, was what can make people, help people particularly in pregnancy and birth have better health outcomes. And so I focused my research on two different providers, who are midwives, who have two different healthcare environments that whose statistics for the populations they work with that are mostly black and Latino women do way, way better than they should they should do based on the statistical norms. So one of those providers is Jenny Joseph who's in Orlando, Florida, and she's a midwife from the UK of African descent, and she's what's considered a certified professional midwife, so she doesn't work in hospitals, she's not a nurse, she's trained in the UK, they use midwives a lot more than we do in the United States, and she has a clinic, a prenatal care clinic outside of Orlando, but serves mostly black and Latino women and has really incredible statistics, like no mortalities, most of the babies are born when, she says chunky babies, born at term, and nice and big and healthy, despite the fact that these women based on their demographics, where they live should have really high rates of these interventions, of these problems. So I went and spent some time with her, and I've known her for many years and she's starting to get a lot more attention for her work, which I think is really important, to see what she's doing, that's being so successful at keeping these folks from having these problems. And the interesting thing about her is that her clients are not giving birth with her. They're giving birth at the high volume maternity ward in Orlando. It's one of the highest volume maternity wards in Florida. But they're doing all their prenatal care with her. And she does have a birth center, they could deliver with her, most of them choose not to for a whole host of reasons that we could talk about if folks are interested. But a lot of people in the birth activist community really focus on place of birth, like home birth, and as like the thing that makes the most difference but actually what she's showing, what other people have shown, is that prenatal care actually makes the most difference for people's health. And like, I'm gonna kind of tie back why the learnings from the maternal health world also apply to like health more broadly, and racism the health. So they're not disconnected, like what we know about what can help for people even who are not pregnant or giving birth, in terms of ameliorating the impacts of racism on health. And so, Jenny's model, there's a few things that are really kind of significant about it, I think that are part of why she has had such good statistics and what I think, and what she thinks is happening is that, her prenatal care environment kind of provides like a buffer to the impacts of racism on health for these folks in this time period, and so they're able to get through this particular period with much better outcomes than would normally be seen because she's providing this protective buffer through her model. So the stuff that she's doing is like pretty basic in a lot of ways, but it doesn't exist in a lot of healthcare environments, particularly healthcare environments for low-income people of color, so it's a really compassionate environment, she's really big on the person at the front door treats you, you know, the front desk treats you just as well as the provider that you meet with in the room, she's really big on creating an environment that is really compassionate and low stress, right? So think about, you're somebody who's pregnant, you're probably, most of the people she sees are low-income. What are you walking in the door with? What did it take for you to get to the door? What happens if the first person who greets you is rude, tells you you can't stay because you're late, chastises you like things that are really common in low-income healthcare environments, she really is like, no, this is not happening. The person at the front desk is gonna know your name, is gonna be kind, is gonna be flexible if you're 15 minutes late, not gonna send you away like you need to be seen, so things like that. Her staff is pretty predominantly women of color, so you know, there is something important about providers and the people involved reflecting the people who are in the care environment. I don't think, she doesn't think it's necessary, it doesn't have to be the case, but it definitely creates some supportive environments, and you have to do less, I think kind of undoing bias, unconscious bias in those environments. And then it's a really, it's a team approach, so the midwife is not like the top of the hierarchy, she sees everybody that this person interacts with when they're in, for prenatal care as really, really important to the model, and actually because she needs to do high volume work because her clients can't pay and Medicaid in Florida's terrible, she doesn't spend that much time with each client. But they spend a lot of time in her clinic meeting other people in the waiting room having like kind of a social experience, so there's a lot of parts of her model. But it's midwifery, it's usually like you spend like an hour with the midwife, and also it's a really connected experience, she can't do that and have a high volume prenatal care practice. So she's had to find ways to still create a supportive environment that doesn't rely on this expensive health care provider at the top of it. And so the other model that I looked at was Ebony who runs, Ebony Marcelle, who leads the only freestanding birth center in Washington, DC, and it's in Northeast, DC which is, you know, rapidly changing but still predominantly black and low income area, and it was started by a midwife many years ago, kind of meant to serve that community. And again there's a birth center, but most of the folks decide to give birth at the hospital nearby. And so you know, she's also a black woman, and some similar things happening in her clinic as well, so similar, something that was really that both of them emphasize was, we don't turn people away who are late. It seems really basic, but it happens really frequently in low-income healthcare environments, and you can imagine the stress of that, especially when, they understand that people are taking like two buses to get to their appointments, they have other kids, they're dealing with all these different things. But so a lot of the things that Ebony was doing really mirror she just does a centering pregnancy model which is, it's group prenatal care, so it's a little bit different than Jenny's model, but a lot of the same themes that show up. So after I did this like work, so focusing on pregnancy and birth, I wanted to take a step back and look at, well, what do we know can help more broadly? Like, I know what I could tell you about prenatal care and how important that is, for particularly for women of color during pregnancy and birth and how that's the way in which to create a prenatal care model that could provide that buffer, but what about outside of prenatal care? What about outside of pregnancy? We know that racism impacts people's health more broadly what are the interventions that can help? And so I looked into three different areas that were, I was led to by the social science research about this question, about the only, there's lots of people who are asking these questions about racism and health. And so what I had to look, well, not a lot of people, there are some people ask some questions about racism and health, there are a lot of people looking into Adverse Childhood Experiences, ACEs, which is like a scale that was developed to try and basically measure like the amount of trauma that someone experiences in their childhood and the impact. And there is people looking at the impact of how many ACEs you have, and your health outcomes, and more ACEs would be more negative health outcomes. We're also more likely to have more Adverse Childhood Experiences if you're a person of color, or if you're other marginalized identities. So there it's all kind of linked, so I looked at that research as a way to say, well, what do we know about the interventions that help people who've had a lot of Adverse Childhood Experiences do better with their health as a corollary to look at racism, racism itself not an adverse childhood experience, I think it should be, it's not in the scale. But a lot of the things that are described in that also are show up more among communities of color. And things that are considered Adverse Childhood Experiences, being physically abused as a child, divorce, family separations, things like that, those are all considered Adverse Childhood Experiences. So there were three things that seem to, that the research shows have an impact a positive impact, on people like the people who do better, the people who have adverse experiences but do better with their health. There's a few things that, kind of patterns that show up, one of them is self-regulation. So self-regulation is this concept of a set of skills in order to cope with difficult emotions, and it's a little bit of a misnomer, because it's not actually like a self, it's not actually something you have to do by yourself. Self-regulation actually often happens in kind of community with other people. Particularly for kids, it happens usually in relationship to a caregiver, but it is a set of tools that allows you to deal with, essentially like you think about, that nervous system thing happens where you feel flooded, you feel triggered, you feel threatened. Do you have any skills to help you calm down to help you deal with that that are positive coping mechanisms versus some of the negative coping habits, like drinking, or drug use, or violence, or whatever some of the ways in which people might manage stress that aren't as, you know, have a negative impact. So self-regulation is a set of skills. And there's a lot of talk about this in psychology research and in early childhood education. The cool thing about it is that I thought, or the hopeful thing was that you don't have to have these self-regulation skills, like, if you're three and you don't have them you're done. They can be taught throughout the lifespan, even into adulthood. So you can teach people these skills and you can see an impact and improvement on health outcomes connected to self-regulation tool. So you know, things like mindfulness that's a self-regulation tool, there's a lot of different ones, but the bottom line is sort of helping people to cope with difficult experiences or emotions, in a way that creates resilience. For me, it's connected to that nervous system thing that the nervous system, if you learn to regulate, come back to center, do things that kind of help you calm, by, you know, it's basic stuff, and a lot of it can happen in community, it's not an individual behavior that, that can create resilience for people, even if they deal with difficult experiences. Another big one, there's a lot of research about cultural connection for communities of color and that the cultural connection can foster resilience, even in the face of trauma and adverse experiences. So there's research for indigenous communities in tribal communities that kids who learn indigenous language, or learn indigenous games, or practices that they have better health outcomes than kids who don't. So I think that sort of bottom line for that health outcome, is like, the sort of tip there is like, not assimilating, creating opportunities for people to stay connected to their culture in whatever way possible language or otherwise, that creates resilience for people. And then the last one, which I think shows up a lot in models like Jenny and Ebony's model is social support. And that provides a huge buffer for people's experiences of adversity and racism, so creating opportunities for social support, which I think they do in their clinics, and they do through the prenatal care environment, and where people are connecting with each other the folks who are pregnant. So that's, probably seems kind of logical, but, and it also supports, I think why doulas as an intervention can be really effective, is offering kind of that sort of social support to somebody during that time period. So those are some of the things that I found in the research and that, again, the real task at hand is ending racism. And some people kind of dislike this idea of, well how do you help people cope with something that really is horrific it should be  dismantled. And I think it's a both, and what do we do in the meantime to help people survive? And the bigger picture is ending racism, so I'll stop there. And I would love to hear from you all about your thoughts or questions.

Ayanna Johnson: Yeah, that was great, I mean, we in the health field, some people know about this, you know the impact that racism has, especially on you, you can go all the way to the biological level like the telomeres and your allostatic load. So how stressed are you? What does that impact? And like you were saying, beyond the maternal child health, beyond pregnancy, how you are at increased risk for high blood pressure, for stroke, for heart disease, for diabetes, and then your coping mechanisms, like you were saying, things that aren't necessarily healthy, so is it eating sometimes not so healthy foods? And then what does that impact look like long-term over a long lifespan, and so, yeah, I think this is, it's so great. I love this topic and talking to you about this and it's funny when you started talking, you talked about your experience being a pre-med student which is a similar experience I had, but I made it to physics and then I stopped, but I know some of my friends in pre-med are on today and they actually continue through, so I'll be excited to hear what some of our MD friends said, have to say about this talk. But so now we're gonna just open it up, but I think I wanna start with one question. Because of the pandemic, because we have seen just how in equal our society is, we're really seeing that huge stark of literally your race is actually changing your impact, your likelihood of, one, catching coronavirus but then most more importantly, from actually dying, and so, how in this situation it's the pandemic, it's not something that, is just, accumulating over time, so I think, how can we use some of the lessons that we've learned from the pandemic to really hone in on the impact of racism, how our society is structured, and how it's actually making it, making me sicker? I don't know, that's a lot in one, but maybe we can start there.

Miriam Zoila Pérez: Yeah, I mean, you would think that if there's a moment where people understand that racism makes you sick, it would be now right? Seeing the coronavirus, like the really severe disparities, of who's getting sick and who's dying, and I haven't kept up with the most recent stuff, but I know at the beginning, it was the Latino community that was really at the highest rate of, in terms of infection and also really high death rates, and a lot of that has to do the economics and who's an essential worker, and who's in environments that, but I also know that, the black community also has really high disparities around it, so again, I would hope that, that would be the takeaway for many people, but I think also the unfortunate thing is that, it also impacts how seriously people take this pandemic, and like the lack of attention on a federal level, and in other ways is also I think correlated to the fact that the folks who are suffering the most are people of color. So, but my hope would be that it would be that it would really reinforce just how much racism impacts people's wellbeing, and yeah, it makes them more likely to have asthma for example, which is a such a risk factor for COVID and for serious COVID complications and stuff. So there's so many different layers there on top of, housing and like how many people are living in your home, what's your work? Can you work from home? Is your industry something that can do that? Are you able to protect yourself? Do you have an intergenerational household where you're exposed to people, all those different things. So I don't know if that answers your question.

Ayanna Johnson: Yeah, no it does. Those are some things that come up. Yeah right, yeah those are some issues we have to tackle as we develop, like it's not just getting the vaccine to distribute it, there's so many other things that we have to continue to work on, go back to normal. Let me ask you one of the questions that has come in from the chat. So this is from Caitlin Killian from class of '95, "so why are the women in DC in the clinics that you mentioned in the midwifery centers in Florida and DC choosing to go to the hospital for birth instead of the centers? Can we unpack this little bit?"

Miriam Zoila Pérez: Yeah totally, it's a great question. So there's a few reasons, I mean, one has to do with the history of maternity care and hospitals, and sort of like the dynamics at play. And so, when hospitals became like the place to give birth and over sort of the first half of the 20th century, black women weren't allowed in hospitals. There was like a segregation issue, so the people had access to hospitals were white women who had privilege and resources. And so, there we're seeing sort of in the '70s we started to see this somewhat of a flip of like, then white women were like we don't wanna be in the hospital, we wanna go back home. But there was a delay in some ways to, in terms of culture and community and Claudia Booker who's unfortunately passed away from cancer a few months ago but was an amazing black midwife in DC, was the one who kind of pointed this history out to me early on. There's a delay there because for some people, privilege means going to the hospital, like you go to the hospital, that's what you do if you can, you stay at home with a midwife, if you don't have another choice. And so folks in the black community, that's a more recent experience, sort of being forced to have care in a certain way and not having access to the hospital than white folks, and so there's somewhat of a cultural piece there. And then that's also true for folks in the Latinx community, because in Central and South America and Latin America the same thing is kind of happening influenced by the U.S which is this push toward hospital birth, and away from midwifery care across Latin America, and with like a lot of really terrible implementation with very few resources. I have spent time in Ecuador when I was in college, and it could go into a whole different piece about what it looks like to apply U.S medical model obstetrics without the resources, it's really pretty horrific. So people who are immigrants themselves, they're also like, no, I'm in the United States now, I'm gonna give birth in the hospital, my abuela gave birth at home with that community midwife but like, maybe I didn't hear something good about that, or that's what she did 'cause she had no other choice, but I have choices, and the hospital is my choice. So there's still a lot of like hospitals best, and I mean, that exist in the white community too, that there are people who think home birth isn't an, you know, a wild idea. Why would you ever do that? The hospital is the safest thing. So that also exists. Then there's also dynamics around like, is your home safe to give birth in? What do you think about birth centers? Is it a place that feels comfortable to you? And in a birth center, you're there, you give birth, and two hours later, you go right back home. When you go to a hospital and you give birth, you stay for a night or two and you get 24 hour care and attention. Some people really want that, they wanna go to the hospital and have that, they see that as a benefit rather than going home to whatever family situation might be there and having to kind of manage on their own. So those are some of the things that Jenny and Ebony talked about for why the women they work with. I mean, they would love to have more of them give birth in the birth center, but at the end of the day, it's their choice. And the only other piece of it is epidurals, a lot of people want pain medication, and you can't have pain medication at a birth center or at home. So if you want an epidural you go to the hospital. And then the last thing I'll say is just the influence of family members and people's opinions about what is safe, what isn't safe, so, the rates for birth centers and home birth are very, very low for non-white communities, except in certain places like on the border in Texas. There are a lot of birth centers that serve predominantly like Latino women, but there's other dynamics at play there. So it's not been very successful. And then, okay this is actually the last one I'll say, that the people who advocate for birth centers and out of hospital birth are not the white women who aren't talking to women of color, and that's a very broad generalization, but and there's a lot of people of color in this arena. But there's an issue there too, like who are they talking to? Who are they marketing to? What not, obviously Jenny and Ebony their clinics are centering the experiences of black women, but that there's a lot there, the campaign wasn't necessarily directed at women of color.

Ayanna Johnson: Okay, okay, let's see, we've gotten quite a few questions and maybe I'll start with one that's sort of structural in nature, so you're talking very freely and openly about racism, how it's impacting, how it can be both perceived discrimination, racism, and actually what you experienced and then the social system, and the political system in which someone finds themselves, how that is either perpetuating racism or even creating it, a brand new, and so we've gotten a few questions I'll just kind of like lump them together. One, is there a very clear acknowledgement? Have you seen an acknowledgement from the health community or the public health community of the impact of racism on health in a very clear institutional way? And then another question that we had is, yeah, I think that's pretty similar. And then also just, can you maybe unpack, I think some folks find that sort of racism, the stress due to outside of the hospital really comes in, is more sort of unconscious bias that's experienced when they actually are at the doctor's office, and how does that impact health? I can rephrase it, but we'll just go with it.

Miriam Zoila Pérez: Yeah, I mean, I do think that, and I saw this I think in the chat too, that like, so, some people might think, well, the reason that health disparities are the way they are is because of the treatment people experienced at the hospital or in the health. It's racism on behalf of healthcare providers, healthcare are doing things that are influenced by racism that are directly impacting people's health outcomes. And I think that is true, that's a yes for sure. But I don't think it's the big picture. Because it doesn't explain something like, a long-term chronic illness like diabetes or something. It can't be just explained by the experience people have. It can definitely be worsened by that. And there's studies about, you know, like racist pain management and how people of color, particularly black folks are not given as much pain medication. There's definitely ways, very concrete ways, in which racism plays out on people's healthcare experiences. But I think the research points to the bigger picture which is what people experience on a daily basis. And then the question about whether the healthcare like the provider community has acknowledged the impact of racism on health. And sorry, I know I speak very quickly so I'm gonna try and slow down a little more. I think it's 'cause my people are from the Caribbean. I think the answer to that question is no. I think that there are strides that are being made. But, no, I mean, you know, and if anybody here is a medical, has gone through medical school recently or something, but my understanding is that these topics are still kind of segregated as a special populations course or something like that. Or even sort of worse, in some ways this is seen as a public health, this is a public health issue. The public health researchers, and clinicians, they're the ones who care about disparities and social determinants. We're clinicians, we're medical providers, that's not our issue. So, I don't, I mean I think there's more acknowledgement, but I know I don't think it's been acknowledged to the degree it needs to be. And I think there are still medical providers who believe that people of color experience disparities because of their race, that race is to blame rather than racism, which is in some ways an even more racist belief that like you know, there's something about Latino people inherently that makes them I don't know, more susceptible to COVID rather than it being about the systems and structures. So my answer would be no, that there's still a lot that the medical community has to do to acknowledge this and to believe the reality of it.

Ayanna Johnson: Right, we got a comment from Maria Alena, class of 2004 who said, that the American Medical Association, just started acknowledging racism as a public health crisis, until that's happened sometime in June of 2020 because of all of the police brutality, and systemic racism, discussions that were happening. I know that the American Public Health Association definitely has for very long time talked about racism as a public health issue. And I think until you see those big organizations and bodies actually talking about it you're not gonna see it sort of trickled down into the curriculum or maybe the continuing education credits. I think there's just obviously a room for more and more acknowledgement, like saying that racism exists does not mean that we are saying that you as a provider in your individual moment are, but you may be contributing to the system, that's creating all of this that's happening, and what can we do to sort of like change the narrative? And in that vein, someone asked actually not someone, one of my former classmates, Robin from class of 2011 asked, have you looked at maternal outcomes for black women in other countries who, maybe in the UK for instance, or even in Africa, in countries in Africa, do we see similar sort of maternal mortality? I mean, I think there's a couple of ways to unpack that, maybe let's take people who are more developed, and giving birth in more developed countries versus others, do we see similar rates of maternal mortality?

Miriam Zoila Pérez: Right, so I know that the U.S, is one of the worst places, like our disparities, our outcomes when it comes to maternal health are some of the worst in the  developed world. So we're like, we lead some of that, in the worst way possible in terms of these disparities. And a lot of that is because of the disparities that exist among women of color in the U.S right? So if you separated white women, the U.S would fall in terms of like, internationally would be very different. And I know that there are places in the United States, like in Georgia and South Carolina where the rates of maternal mortality for black women are equivalent to the rates of maternal mortality in parts of Sub-Saharan Africa. So we are really, really horrible, we do a really bad job, especially then you add the context of how much money we spend on healthcare, the per capita, you know. It's just, it's really horrific kind of where we're at, I don't know the answer to that question about other developed countries, what are their statistics around race and health disparities? I would imagine that they see some of the same disparities but I can't actually answer that because I haven't looked at what is it, in the UK, particularly for immigrants? How does race play out? I've only focused domestically on that question.

Ayanna Johnson: Yeah, yeah, that's a good question, I don't know that answer either. We got a question from Judy class of 2013, and said, "as someone in medicine I want to be able to deconstruct medical institutions and prioritize minimizing disparities, or eliminating disparities, for the midwifery groups that you talked about and others just at large. What are some examples of other ways women get social support, if they can't spend an hour with a midwife?What are some of the other interventions that you've seen? Or maybe give us a sense of like, what did cultural connection look like? What does self-regulation look like?

Miriam Zoila Pérez: Yeah and I wanna be clear that neither of these models like Ebony and Jenny's models, neither of them are actually that midwifery model where you spend an hour with the midwife. In Jenny's clinic you spend 10 or 15 minutes with the midwife, you spend an hour or two in the clinic, in sort of the whole process of what you're doing. You're meeting with her kind of nursing assistants or also like educators and support people. So, and Jenny is very clear, she's like, you don't need to be a midwife to do this prenatal care model, you don't have to be a midwife. The learnings from it are taken from the midwifery model, but you don't have to. She's like, I don't care what kind of provider you are, you can be an OB, you could be a PA, you could be a nurse practitioner, you can do this too. And so I think that's really important to understand because the midwifery model is beautiful and it's not scalable in the United States. We don't have enough midwives to serve everybody who we would wanna serve. And our healthcare environment is not built for hour long appointments, you know? So I think that the stuff around the appointment is the stuff that I would say to focus on. So yeah, what's your reception experience like? Are there opportunities for education in the waiting room, when your clients are waiting to be seen? At Jenny's clinic, there's videos playing on the screens, that are educational videos, there's somebody whose job it is to hang out in the waiting room and talk to people and kept them connected to resources, you know, somebody there who just gave birth and the person in the waiting room talks to them and realizes that they need diapers, or they need formula, or they need you know, and so that kind of stuff happens. So it's like more of, almost like a wraparound model, but those folks are just, they're staff people. They're not highly trained clinicians or anything but they're there to provide that additional support. So I think that's what's to me is inspiring about that model. Ebony. it's group prenatal care, so it's called, Centering Pregnancy and it's a model that's been researched a lot, where you have, everybody comes together and they're in kind of like a cohort and they do group prenatal care throughout their whole pregnancy. And there's usually an educational topic, and then as that's happening, people go into the corner behind like a screen, and they chat with the midwife, and they get their belly checked and whatever. And so there's a lot of research about that as particularly as a social support model. So, and I would point people to Jennie Joseph's work because she's a big part of what she's trying to do is promote this model beyond her, she calls it The JJ Way. She has a lot of resources for how to implement it, so if any people here are actually prenatal care providers, I would point you to her resources and I can put links in the chat to her stuff. These lessons are not just about, that everyone should have a midwife, I mean, I think midwives are amazing, my partner's a student midwife, I think they're incredible, but the reality is like we need something that can be implemented more quickly than the number of midwives we have in the U.S.

Ayanna Johnson: Okay, one question, so I think we kind of answered this but maybe you have some other tidbits to share but,"how much of the disparities of outcomes are related to the lack of universal access to basic health care, including prenatal care?"

Miriam Zoila Pérez: I think it's less than we think, I mean, I 100% support universal healthcare, I think it's a travesty that this country doesn't provide that for everyone. And definitely you see better health outcomes in places with universal health care. But I think that it's one of those things that people assume, oh these disparities must be because people aren't getting care. And the reality is that when people are pregnant, most people get care. You don't have a lot of people in the U.S who go without any prenatal care. There might be late prenatal care, people don't get into care until later. But like even the states with the worst Medicaid programs, offer Medicaid to pregnant people, even if they're undocumented like that's the case in Pennsylvania. You could get Medicaid if you're undocumented and pregnant, but once you're not pregnant anymore then you're kicked off right, and so there's some kind of up nativist thing around like the child inside of you being a citizen and you're not. So the reality is people are getting care. I'm not saying that there aren't gaps around how early people get into care, and the kind of care they get, and Jenny definitely sees a lot of people who are getting turned away by other providers for many, for other reasons, and so, there are challenges, but I don't actually think that's the biggest issue. I think that the bigger issue is, I mean the lack of access to care is a product of racism, the lack of access to universal healthcare the fact that your healthcare is tied to your employer, that most low income employers don't offer healthcare, that's racism. But I don't think it's as big of a, it's not the main reason from my perspective. I think these other things make a big difference, but obviously if you can't get access to care and you're pregnant, that's a huge source of stress. And so that's gonna have a negative impact on your health in that time period.

Ayanna Johnson: Right, let's see. I know you can see these too, so let's see.  How can the repeal of the global gag rule on reproductive health care serve to educate the public on gender, race and health? That's a big one.

Miriam Zoila Pérez: Yeah I don't know if you can work on the global gag rule, it's like your specialty. I mean, I know it's one of those things that like, every time the, so the global gag rule, somebody's asked, it prevents entities outside of the United States to get U.S aid from talking about abortion in their work, providing abortion, but even talking about it. And so one of those things that like every time the administration switches parties, the global gag rule gets repealed, and it gets reinstated, and then it gets repealed, and it gets reinstated. So we're probably about to see a repeal of it. I don't, I'm not an expert on it, so I don't think I can actually answer that question that could be the subject of a dissertation. Yeah. But I do appreciate the question.

Ayanna Johnson: Very, a lot to unpack. I think one question I had when you were talking is sort of, we know the statistics, we know what's wrong, so how do we scale up this work? How do we scale up sort of trading social support systems with what is the next step? What do advocates need to do? What do folks who are working in this space? What to do if someone's friend and you have friends who are pregnant, what is your role? What is our role as the larger community?

Miriam Zoila Pérez: Yeah, that's a good question, and I'll just answer, there's one clarifying question about the state, the U.S being the worst, when I'm talking about, when I said the U.S has the worst outcomes. I'm talking about infant mortality, maternal mortality, those problems like U.S some of the worst in the world. What I don't know about other countries is what their race and health disparities are. I know where the U.S falls in terms of maternal health outcomes, more broadly, those are not broken down by race. So that's what I don't know about other countries. I mean, I think what's hopeful about this to me, about this work is that like at the most basic, providing supportive environments to people helps them thrive. So like, providing, creating opportunities for people to feel supported, and held, and witnessed, and encouraged in their own journey and processing has a positive impact on people's health. And so whether you're a healthcare provider who's trying to think about, how do I create a supportive environment for my patients, or a person who's thinking about how do I support the people in my life? That's like the sort of, take away for me is that- so if I'm talking to white folks, it's like, well how do you not enact microaggressions? Like microaggressions actually make people sick. You might not be somebody who's actively working, doing racist things in a like a real overt way, but you probably employ an unconscious bias kind of way microaggression. So can you think about how do you interact with people of color on a daily basis? And is there a way for you to potentially be someone who limits microaggressions with people that you interact with? So that's a task that could have a net positive impact on people's health. And then from a more proactive perspective, and then also for people of color, it's like, how do you create, be part of being, part of people's social systems and social support in a way that encourages their wellbeing? So, obviously for your medical provider you have a much bigger stake in that, but even if you're not, how do you support somebody who yeah, who might be pregnant in your community and give them the support they need? And, the last thing I'll say is, one of the things that Jenny I think is really good on is, believing that people can have good outcomes, you don't look at someone and decide, oh, because of your race you are definitely going to have these problems. She's like, no, you're gonna have a healthy baby. There's something about like a fulfilled prophecy, self fulfilling prophecy, and I think that it's important for healthcare providers, and that's where it becomes sort of racist to think about it this way, to assume that just because someone is black they're going to have certain problems. You wanna be attentive to the risks that are involved, but you don't wanna assume that someone's gonna go in that direction because that in of itself changes the way you treat somebody, so creating an environment that believes that people can have good outcomes and that you can be part of making that happen by providing good quality supportive care.

Ayanna Johnson:  That's great, I think that's a good place to stop if you do, I know we could probably talk for hours about this subject and it's both of our passions. So I thank you so much for being here tonight and for everyone who participated and listened in and sent really great questions, this is so informative, and I hope you all took something away from this. We also have, I think a survey that pops up when you finish tonight, and as the alumni council we really value your feedback, and if you know of other Swatties or alums, or alum adjacent, who are doing interesting work as well, especially those focusing on some of the hot button issues of our time, please send us a note. There is a link on the Swarthmore website for Swat talks and you can find a way to reach us. So any last words, Miriam?

Miriam Zoila Pérez: I just wanna, I'm gonna look up Jenny's website and put it in the chat, so that people can look up her work because she's great. But no, I just, thanks so much for inviting me and for folks for participating and your great questions and yeah, thank you for moderating.

Ayanna Johnson: You're welcome. Well yes, we will, you can let, we'll wait to close it.

Miriam Zoila Pérez: I should’ve had this pulled up.

Ayanna Johnson: No it's okay, I think everyone really wants to see it, so we, we will wait for that, but in the meantime, some of our past talks in social justice, racial justice series have been- you can see it, hopefully you should see it, it's Jenny Joseph, and you can see her work, great! Okay well, we've had some really great talks, our most previous one was on the census and its impact on everything, and we've had some other really great talks. So please go check out our archive and this one will be up there in about two weeks, so thank you everyone. Thank you Miriam, so great talking with you and well have a good evening.