The Civil Rights of Health

By Adem Lewis / in , , , , , , , , , , , , , , , , , /

to introduce Angela Harris, and it is an honor and
a pleasure to do so. I want to say that
the accolades that are in the program,
the information about her scholarship and her
work that are easily accessible are not where I
would like to focus my few words of introduction. I want to tell you that
the first time that I heard of Angela’s work
reinvigorating civil rights or medical civil rights was
at a workshop at the ChangeLab Solutions– at
ChangeLab Solutions office in Oakland, California. Angela was holding forth. She was creating a new paradigm. She was thinking
aloud and working with people who
were funders, who were think tank workers, who
were community organizers, who were lawyers, who
were clinicians, and she was creating from
scratch a new way to think and a new way to attack
inequality and inequality that produces health inequities. I left that meeting
thinking, I have to know more about what she
does with this germ of an idea that I saw start on that day. Well, what she’s done
is create something that will be, in
frankness, going across the country
like wildfire. We are quite lucky
to have Angela here to present the idea of
medical civil rights. I think we’re the first
academic institution that gets the pleasure of
hearing this new paradigm in combination with the
ChangeLab Solutions folks, who will also show us the
blueprint for bringing it to life. After this, I know she’ll be in
Washington DC at the American University. She’ll be at several
universities, and our hope is that
what you hear today is the start of something
big and something new. I thank you very
much for helping me to welcome a creative
thought leader and change agent, Professor Angela Harris. [APPLAUSE] ANGELA P. HARRIS:
Thank you so much. Thanks to all of
you for being here. And I do need a little
bit of tech help, because I don’t know how
to make my slides appear. Does anyone know how to– oh, there they are. Perfect. It was like magic. All right, so first, please join
me in acknowledging and paying respect to the traditional
custodians of the land we’re on today,
the Monocan people. So just take a
moment and remember that there were stewards
who are still here who have endured for centuries. Thank you. So I also have a few personal
thanks before we get going. Thank you to Dayna for
that amazing introduction, for really taking us into the
feeling of where we want to go, what we want to do with
this time together. I appreciate that. Thank you to all the organizers,
to Dean Goluboff for inviting me to be part of this
amazing event, and all of you for putting your time and
energy into being here. A few personal
shout-outs, I want to thank the amazing people at
ChangeLab who are over there. Marice Ashe, who is the founding
ED of that organization, was a former student of
mine from Berkeley Law. And a couple of months
after I retired, I ran into her at
the Berkeley Y, and she said, oh,
you’re retired. I have a project for you. And that was the
beginning of my journey into this work, which
I’m still a novice at and I’m still
learning, and I’m so looking forward to learning more
from all of you, the experts. I want to thank my
amazing co-author on this article, Aysha,
who is both a lawyer and a public health expert. I’m really sorry that she
couldn’t be here today, because this work is 100%
hers as well as 100% mine. And finally, I want to
thank and acknowledge a couple of the supporting
institutions that have made this project possible. The Robert Wood
Johnson Foundation for supporting
ChangeLab and allowing me to come onto the team, and
the American Bar Foundation for supporting me
this year while I continue to work with Aysha
on making this article better. OK, so I want to start with
this quote from the sociologist Ruthie Gilmore, who created
this definition of racism for the purpose of talking
about the political economy of mass incarceration
in California. And this definition has
become popular in the academy among people who write and talk
about race, because it rejects our conventional, legal, moral,
psychological understandings of racism as either
something that’s in the mind or something
that’s in the heart. Racism, she says,
specifically is the state sanctioned or
extra legal production and exploitation of group
differentiated vulnerability to premature death. And this definition
is especially useful for our purposes in
the next couple of days, because it starts to orient
us to the life and death impacts of racism and other
forms of subordination. Healing Hate is a wonderful
title for this conference, but the change is that we’re
not just talking about hate. We’re not just
talking about morality and who’s a good or
bad person, we’re also talking about structures
and institutions that create this group
differentiated vulnerability to premature death. So here’s the
takeaway of the talk. First, new research on
disparities in public health has begun to recognize
that to fully eliminate those disparities,
we have to uproot all forms of subordination,
by which we mean in our article, all
unjust forms of caste, from the personal
to the structural, whether perpetrated by
private or public action. And although most of my examples
in this talk for reasons of time are focused
on race, you’ll be hearing in the
next couple of days the many different directions
and dimensions along which subordination operates. And secondly, in order to uproot
all forms of subordination, we need to build
strong alliances, as Dayna was telling us
about, alliances in particular that we talk about in
our article between three kinds of actors, public
health advocates, civil rights lawyers, and advocates
for social justice. So here’s what the talk’s
going to look like. I’ll first give you a little
taste of the new public health research on how political and
social inequalities are written on the body with a focus on
racialized health disparities, but I won’t spend very much
time on this because I am not an expert, and there are
people in this room who know far more about
all of the details and will tell you more
as the days continue. Secondly, I’ll talk about
some of the legal strategies that Aysha and I have begun to
imagine, with help from many of you in this room, as ways
to address health disparities, and more broadly, to make
structural and institutional discrimination more visible. And this is one of
those points where we need the help,
particularly of those of you who are law students
and lawyers in the room. We need your creativity to make
this part of the project real. I’m so glad that we have time to
make this a real conversation. Third, I’ll lift up the
health justice model as a framework for pursuing
the civil rights of health and explain why we think
social movements are a key third partner
in the initiative. And then finally,
I’ll acknowledge some of the political challenges
to doing this kind of work, and I’ll suggest that the
best strategy to overcome these challenges is
John Powell’s notion of targeted universalism. So for those of
you who are like me and don’t know very much about
the public health literature, and I apologize to those of you
who are deeply steeped in this, just a couple of definitions. The first definition or
first term that you may hear is the social
determinants of health, and this definition that
I put up on the slide comes from the Centers
for Disease Control. The social determinants of
health, the CDC tells us, are shaped by the
distribution of money, power, and resources
which come to rest through the social environment,
the physical environment, health services, and structural
and societal factors, and these structural
factors drive health disparities,
the second term, defined as groups of people who
have systematically experienced greater obstacles to health
based on their race, ethnicity, religion, socioeconomic
status, gender, age, mental or physical disability,
sexual orientation or gender identity, or geographic location
when compared with majority populations. So now, we think back to
Gilmore’s definition of racism, but note that these disparities
are not just racialized, but reflect almost every
form of social stigma that we’re familiar with. And finally, nirvana for
public health advocates would be health equity. That’s where we want to get
to, a world in which everyone has a fair and just
opportunity to be healthy. So in our article, Aysha
and I used the literature on the social
determinants of health to identify three broad
pathways through which socially constructed group
differences come to be written on the body,
population, place, and power. These pathways are overlapping
and somewhat intertwined, as you’ll see, but they’re
also somewhat distinct. So I’m going to give
just one example of each, and again, you’ll be hearing
from experts in the field who can give you many, many more. So first, population. So last week– I’m living in Chicago this year
at the American Bar while I’m at the American Bar Foundation,
and I read last week in The Chicago Tribune that
a black woman or a Latina in Chicago is almost
three times more likely to die of cervical cancer than
a white woman in the same city, even though cervical cancer
is almost 100% preventable. This chart, which is
probably too small for you to see all the details
of, uses CDC data from the 2000s to illustrate
the black-white health gap in general. The blue circle is the white
incidence of ill health, and the red circle is the
black incidence of ill health, so farther to the
right means bad. And these are statistics
for childhood obesity, infant mortality, childhood
asthma, female breast cancer mortality, and adult
HIV infection diagnosis. And the question is,
what’s the source of these population-based
health disparities? Is it bad choices, bad genes,
disparate poverty or education rates, lack of access to health
insurance, lack of access to primary care? I will let the
researchers in this room give you much more detail
about each of those answers, but the piece of the puzzle that
I want to identify right now is the biological impact
of social discrimination. So here’s a questionnaire
developed by a public health researcher to investigate
the physiological effects of interpersonal discrimination
as reported by its targets. These questions look like
questions a civil rights lawyer might ask their client,
but it turns out that a doctor might have reason
to ask the same questions. For unfair reasons, have you
ever not been hired for a job? Have you ever been
unfairly stopped, searched, questioned,
physically threatened, or abused by the police? Have you ever unfairly
been denied a bank loan? So how does discrimination
get written into our bodies? There are a number of ways. One mechanism seems to be
overwhelming and chronic physiological stress without
adequate supports and a chance to come back to baseline, such
as that caused by daily life as a person subject to
interpersonal, institutional, and structural discrimination. This chart just illustrates
some of the many organ systems that can be
harmed by chronic stress. Another mechanism
is discrimination within the health care
system itself, another driver of population-based
health disparities. This is an
influential paper that found that black Americans
are systematically undertreated for pain
relative to white Americans. The authors found first that
half of a sample of white medical students and residents
endorse false beliefs about biological differences
among the races, such as black people’s skin is
thicker than white people’s. Second, the study also
found that participants who more strongly endorse
such false beliefs about biological differences
reported lower pain ratings for a black versus white target. And third, participants
who endorse these beliefs rated the black versus the
white patient’s pain as lower and made less accurate
treatment recommendations. So that’s another pathway
for these population health disparities. And then a third way in
which population-based health disparities can be
written on the body is through transgenerational
biological transmission. The new research on
epigenetics demonstrates that environmental insults can
create biological changes not only in the person
who’s exposed, but sometimes even in
that person’s children or grandchildren. This research has implications,
for instance, for the children and grandchildren of
people exposed to toxins, such as lead, which
notoriously remains rampant in low-income housing,
and was involved in the Flint water crisis, as well as
agricultural fungicides which disproportionately
affect farm workers, who also happen to be
disproportionately poor and Latinx. The next pathway through
which health disparities are transmitted that
we talk about is place. And here’s a slogan
that’s become popular in the public health
community, your zip code determines your health more
than your genetic code. It’s some such research
showing that even putting group identity
aside, where people live can produce a life expectancy
differential of decades. Here’s something
else, another factoid that I read in The
Chicago Tribune last week, residents of Englewood, a
poor, mostly black Chicago neighborhood, have an
average life expectancy of about 60 years compared to
about 90 years for residents of Streeterville, a wealthy,
but predominantly white neighborhood. These neighborhoods are
about 9 miles apart. Of course, in many places,
what place represents is subordination,
again, but now operating at a structural rather than
an interpersonal level. Here’s a list of
some of the factors that create place-based
health disparities. Many of them are related to
past or present race and class dynamics that have now
been written into the built environment and endure
for generations. Unsafe or unhealthy housing
that exposes residents to allergens and other
hazards, opportunities for residents to
exercise, walk, or cycle, proximity to
highways, factories, other sources of toxic agents,
unreliable or expensive public transit, and of course,
residential segregation, and features that can
isolate communities from social cohesion,
stifle economic growth, and perpetuate
cycles of poverty. The trouble here, of
course, is that we tend to think that systematic
racial subordination is in the past, and so no longer
is a problem, because now it’s illegal. But I want to introduce you to
work being done by the Seattle Civil Rights and
Labor History Project at the University of Washington
on the after life of redlining that shows how
outlawing a practice doesn’t necessarily make
its effects disappear. So this project surveyed
deeds and cataloged 416 racial restrictive
covenants still present in deeds in the Seattle area,
and in fact, the project estimates that tens of
thousands of Seattle homeowners still have restrictive
covenants in their deeds, even though, as
you all know, these were made illegal by the
Supreme Court decades ago. The researchers found that
Seattle neighborhoods that had been redlined
in the 1950s today still have the most infant
deaths per year, the lowest life expectancy, and the highest
rates of low birth weight infants. For example, they found
that a 10% increase in the percent of a
health reporting area considered a redline
neighborhood was associated with a 6.7% increase in the
risk of low birth weight babies. And the third pathway that
we discussed in our article from structural inequality,
to differential vulnerability, to illness and death is power. And here, we mean good power
in the sense of capacity rather than their ability
to restrict other people’s choices. Here, the fascinating evidence
from the public health literature is that powerlessness
is bad for your physical and mental health. Lack of personal and
collective agency, whether caused by trauma,
toxic stress, discrimination, poverty, political
marginalization or disenfranchisement,
increases both the risk of mental illness, and the risk
of chronic physical disease. Conversely, the experience of
exercising self-determination, believing that
you have the power to control your life, whether
at the individual or collective level, has a protective
effect on health. Sadly, a fair amount
of this evidence comes from literature
on child abuse. One way that
individuals experience power in this positive
sense is by being able to exercise enough
control over their environment to meet the basic human
need for a sense of safety. Children who are exposed
to physical violence or emotional abuse without the
ability to affect or change their situation are vulnerable
to the long-lasting set of changes that we
call trauma, and trauma is associated with mental and
emotional distress, as well as vulnerability to mental
and physical illness. One well-known measure
for the risk of trauma is ACEs, Adverse
Childhood Experiences. ACEs include physical and
emotional abuse, neglect, exposure to intimate
partner violence, and parental incarceration. The idea is that the
more ACEs a child has, the more of these
experiences a child encounters, the more likely that
child is to suffer as an adult from conditions such as heart
disease, obesity, depression, and substance abuse. ACEs also appear to alter brain
development in young children, leading to a host of
other negative outcomes. Once again, of
course, this pathway is only partly distinct
from the other pathways. So children who are exposed
to racial discrimination, along with adults, are
also collecting more ACEs. Researchers building on
the original ACEs framework look at discrimination alongside
family violence and divorce as a risk factor for
developmental disparities. And you can see here on the left
and comparing to the right how researchers are starting
to build on the ACEs model to look at social conditions
and local context, and even to look at
historical trauma as part of the ACEs framework. One of the projects at
ChangeLab that’s really exciting is studying the
health effects of what they call serial forced
displacement, repetitive coercive upheavals in
neighborhoods, including evictions, arrests,
and gentrification that break up communities
and scatter the residents. And we know something about the
health effects of displacement from New Orleans post
Hurricane Katrina. OK, so we have this incredibly
interesting evidence base of how systematic inequalities
create health disparities, and I’m looking forward to
learning more from those of you who do this work. Researchers and policymakers
in public health have increasingly
been looking to law to address these disparities. And of course, law has always
been relevant to public health, as in campaigns for
mandatory vaccination. But in the past,
public health advocates have concentrated on
universal campaigns, like vaccination, hoping
that a rising tide would lift all boats
rather than targeting the distinctive vulnerabilities
of subordinated groups. Now, they’re starting to look
at anti-subordination legal initiatives as a critical piece
of the health disparity puzzle. Of course, from a
legal perspective, as the civil rights
advocates here know, although we’re well aware of the
need to combat subordination, a problem in doing
this work is how to attack structural and
institutional subordination, indeed, how to even
make it visible. So it’s not only the
view of many individuals, but to a great extent, the
view of the US Supreme Court that racism is just that
tiny little triangle at the top, the interpersonal
explicit bias, the hate that people feel for one
another in their hearts. The law is pretty good at
recognizing and challenging this kind of bias, but
existing civil rights law is terrible at
recognizing and uprooting implicit bias, institutional
bias, structural bias. Nevertheless, even if
the legal tools still need to be developed,
part of the force of this new public health
research that I’ve described is the possibility of
measuring and documenting large-scale health
effects of subordination as a way to make visible
the bottom of this pyramid. And it’s mind-blowing
to me to be able to show that just because
slavery ended or restrictive covenants were made
illegal does not mean that the
health consequences of those injustices
have disappeared. So bringing public health
and legal advocates together can help us have a much
more realistic conversation about subordination and its
implications, conversations that’s informed not
only by morality, but by medical research,
informed by history, geography, and social context. So later today,
we’ll have a chance to brainstorm together
about specific ways to bring public health and
civil rights law into one. I’ll only mention a
couple of possibilities to pique the interest,
perhaps, of some of the students who are here. Litigation, what
role, for example, might the Americans
with Disabilities Act and other related civil
rights statutes play in helping litigators
frame the health harms caused by systemic
discrimination as disabilities that
require accommodation? State and local
level litigation. An increasing number
of law school clinics have formed medical-legal
partnerships between law students and medical students
or public health graduate students. Some of these clinics
use state and local law to adjust to health concerns
of low-income families, such as sanitary
or housing codes, specific laws focused
on health threats like lead paint, asbestos,
pests, mold, and adequate heat. State constitutions. At least 12 state constitutions
address either the state’s role with regard to public
health in general, or health care for
the poor specifically, but lawyers haven’t really
built out these provisions. What might be done with
some of these laws? Legal and administrative law. State statutory law,
municipal ordinances are a rich source of innovative
health-related protections. Cities have done a lot to
establish universal protections for public health, such as
smoke-free environments, safe and affordable
housing, paid leave, minimum wage increases. And what about
vulnerable groups? You’ll hear more
later this morning about impact assessments
that focus on race, the idea being that before agencies
approve new projects, the project has to undergo
a health assessment to find out what will be
the disparate consequences of this change. And then with respect to
policy, we don’t necessarily need litigation
or new legislation to use the civil rights of
health to affect policymaking. Being able to simply see the
consequences of discrimination over time, as in the afterlife
of redlining project, can be a powerful way to get
policymakers and lawmakers to understand institutional
and structural discrimination better and to act accordingly. Sometimes a picture is
worth a thousand words, and data-driven policymaking
is more informed policymaking. For example, Legal Services
of Northern California has been successful in
its race equity project by just showing
government policymakers the disparate effects of
their current policies on different communities. Once the data are accessible
and visible for all to see, ignoring the effects
becomes much harder. However, I do want
to acknowledge some of the big challenges
to this project, even beyond the poor job
that US civil rights law does with institutional
and structural discrimination. First, with the
exception of some of the state constitutional
provisions that I’ve mentioned, here in the US, we just don’t
have a lot of legal rights that are specifically
attached to health. Our federal constitution tends
to enshrine negative rights to be let alone rather than
positive rights to support. Second, in terms of
existing civil rights, not all the groups that
suffer health disparities have sufficient
legal protection. For example, poverty is a
powerful driver of poor health. Discrimination against
the poor is common, and economic mobility in the
United States is quite limited, but the Supreme Court has not
recognized poverty as a status that uniformly receives
anti-discrimination protection. Third, presently
existing civil rights law has an increasing number of
procedural and substantive limitations that make it
hard to use, particularly with respect to class
actions, and that even might be a threat to
legislative, administrative, and policy initiatives
that attempt to target stigmatized groups. And finally, I want to
touch on the possibility that an alliance between public
health and civil rights law might not just be ineffective,
it might cause more harm. We have to move carefully
when we think about this. We increasingly live in
a surveillance society. Most of us already carry
our mobile tracking devices with us 24/7. Private companies and public
actors in the criminal justice system collect and
consolidate data at scale. Now, suppose we imagine
that a city decides to go big on protecting its
black and brown citizens from chronic health risk caused
by years of discrimination. The first thing
it’s going to need is data on them, lots
and lots of data. And because we’ve
seen how the health effects of
discrimination compound through multiple pathways
and through multiple forms of discrimination,
the most useful data would be drawn from multiple
sources and interconnected so that we could
measure and visualize the health impacts of
housing stock, employment rates, employment
discrimination, preschool quality, exposure to
neighborhood violence, water quality, drug use,
family violence. But we have a huge privacy
and security problem already, and now add to it the
problem of stigma. The hope of public
health advocates is that by documenting the
impact of unjust inequality on vulnerable
populations, policymakers will be moved towards helping. But what if the overall
result is instead, that black and brown people
in this imaginary city are stigmatized as biologically
broken or even dangerous? Some of you may
remember the panic in the 1980s over crack babies. Public health research
then suggested that babies born to
crack-addicted mothers faced distinctive health
risks, but the overall reaction in the public wasn’t
a compassionate one to provide more and better
health care to mothers and babies, it was overall
a punitive response, such as using the criminal law
to threaten addicted mothers with prison time for
harming their babies, even charging women
under laws meant to punish drug dealers for
transmitting illegal substances to their fetuses. There was a wholesale
panic, which turned out to be completely unfounded,
about how these babies were going to grow up
to be monsters who were destined for the
criminal justice system. Another historical
example is the early days of the HIV-AIDS crisis, when
some public policymakers called for immigration restrictions
against Haitians, and quarantine policies for
gay people and prostitutes as a public health measure. So how do we respond
to these are obstacles? So Aysha and I
argue in our paper that for this reason
in particular, we need not just a
two-way partnership of law and public health, but
a three-way partnership, engaging social movements,
community people, frontline communities on
behalf of vulnerable groups so that these groups can
be active partners in law and policymaking. And this is the kind
of alliance exemplified by justice movements, such
as environmental justice, climate justice, water justice. Specifically, we can
look at the example of environmental justice,
where community advocates, public health researchers,
and government officials both work together, but also
sometimes challenge one another and check one another, resulting
in policy and legal advances that are both innovative
and more likely to be socially just. So in my home state
of California, environmental justice
advocates have been very active in state legislative
lobbying and policymaking. As a result, the state’s
climate change initiatives are sensitive to the
disproportionate health burdens and vulnerabilities of poor
and minority communities. The environmental
justice framework focuses on building power
for the most vulnerable in health-challenged
communities. EJ advocacy in
the state has been robust, often quite
adversarial with respect to both public health
research initiatives and vulnerable communities,
and state law and policymakers, but the result of this
checks and balances system has been climate policy that
fosters the overall health of Californians without
unfairly burdening certain communities,
those with the least money and political power. In similar fashion, engaging
not just law and public health, but also social
movements on behalf of vulnerable communities,
which might include economic justice, environmental
justice, children’s rights, elder rights, LGBTQ
rights, and other groups in the quest to recognize
health as a civil right can increase the positive
potential of this initiative while decreasing its risks
to these very vulnerable populations. So our model for the
civil rights of health is this triangle
of social actors. But before I close,
I would be remiss if I didn’t acknowledge
one other challenge, in some ways, the most
difficult one of all. Evidence of health
disparities has been around for a really long time,
and those disparities still have not been fixed. And one reason why is
that, as Derrick Bell spent a lifetime arguing, these
disparities aren’t a system bug, they’re a feature. Subordination is pervasive in
political and economic life because it works for
those at the top. Consider the research
on social inequality, finding that the more unequal
the income distribution in a country, state, or city,
the lower the life expectancies for people at all income levels. So we should expect
lots of support for equality if it
helps everybody. And yet, some research
also indicates that the bigger the income gap
between the rich and the poor, the less inclined the
well-off are to pay taxes for public services that they
either do not intend to use or that they use
in low proportion to the taxes that
they pay, and that’s because under conditions
of extreme inequality, societies get divided into
us and them, and if we’re us, we don’t want to pay for them. It gets even sadder. Sociologist Jonathan
Metzl recently did focus groups and
interviews among people in politically
conservative areas on their policy preferences. And I’m quoting him here. “I found that if you
lived in a state that rejected the Medicaid
expansion and blocked the full passage of the
Affordable Care Act, you lived about a 21 to
28 day shorter lifespan on the aggregate, so
it was costing people about three to four weeks
of life in those states. When I looked at states
that made it incredibly easy for people to buy and
carry guns pretty much anywhere they wanted, I found
that this correlated with hundreds of deaths
that wouldn’t have happened otherwise, particularly in
white populations, because gun suicide rose dramatically. And I found that if you lived
in a state that cut away infrastructure in
schools and funding, that correlated with higher high
school dropout rates,” unquote. But Metzl also found, of course,
that support for policies like getting rid of Obamacare,
cutting food stamps, rejecting Medicaid expansion
was also highest in these areas, and so Metzl’s
provocative conclusion is that people in these areas
were dying of whiteness. Not because of hatred
in their hearts, because they’re worried
about the policy implications of paying for those people. So we, as legal
and policy experts, as public health advocates,
have to grapple with the fact that simply presenting good data
and constructing sound policy is not necessarily going to make
fundamental structural change possible, not unless we struggle
with the political legacy of subordination. And that’s another
reason why we need social movements to be part
of the civil rights of health. It’s only social movements
that can change a culture. Professional
expertise, no matter how impressive the research or
how well-qualified the expert, can never do that. So what do we do? In terms of strategies
going forward, Aysha and I see the
civil rights of health as being a campaign
that embraces what my former Berkeley
colleague, John Powell, calls targeted universalism. His insight is that
neither universal nor targeted
approaches alone are sufficient to bring about
equity in an unjust world. In the public health space,
universal approaches, like campaigns to stop smoking,
have improved overall health, but left health
disparities in place. Targeted approaches alone,
like focusing on prostitutes or gay people in
the AIDS crisis, create political obstacles,
foster accusations of special interests,
and at worst, create greater stigmatization. So we need to combine universal
and targeted approaches in thoughtful ways. On the one hand, we
need universal campaigns for more positive legal
rights and policies that center human
health and flourishing as the goal of our political and
economic systems for everybody, and we also need
targeted strategies that seek to close the unjust
disparities that will persist unless we take account of them. So only by combining
universal strategies, targeted strategies, and
campaigns for social change by and on behalf of
subordinated groups, only by combining all
of these can all of us get to health equity,
that world in which everyone has a fair and just
opportunity to be healthy. So I thank you very much
for your time and attention. I’m looking forward to a
wonderful conversation, and thanks again for
letting me be here. [APPLAUSE]

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