Confronting Racism Denial – Equity and Inclusion Speaker Series

On May 4, Camara Phyllis Jones, MD, MPH, PhD joined the School of Pharmacy Community for the fourth installment of the Equity and Inclusion Speaker Series.

In her illuminating presentation, Dr. Jones used allegorical tales to explore the ways racial barriers to health and well-being are maintained in our society. Recognizing that racism saps the strength of the whole society through the waste of human resources, she aims to mobilize and engage all Americans in a sustained National Campaign Against Racism.

Dr. Jones is a prominent family physician, epidemiologist, and past president of the American Public Health Association whose work focuses on naming, measuring, and addressing the impacts of racism in order to provide tools for dismantling these inequities. She is currently the 2021-2022 UCSF Presidential Chair and recently completed her roles as a 2021 Presidential Visiting Fellow at the Yale School of Medicine and as the 2019-2020 Evelyn Green Davis Fellow at the Radcliffe Institute for Advanced Study at Harvard University.

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[Sharon Youmans]
Good morning, everyone and welcome to the School of Pharmacy's Equity and Inclusion Speaker Series. We are very fortunate and blessed to have with us this morning, Dr. Camara Jones, who is our 2021-2022 UCSF presidential chair, working with us this past year on issues of racism. I will take a few minutes to introduce Dr. Jones, and then she will take over to provide her presentation. So Dr. Jones is a family physician epidemiologist, and past president of the American Public Health Association. Her work focuses on naming, measuring and addressing the impacts of racism on the health and well being of our nation and the world. Dr. Jones has taught from 1994 to 2000 as an assistant professor at the Harvard School of Public Health, and she served from 2000 to 2014 as a medical officer at the Centers for Disease Control and Prevention, and she continues as an adjunct professor at the Rollins School of Public Health at Emory University and as a senior fellow and adjunct associate professor at the Morehouse School of Medicine. Dr. Jones was recently elected, and this is in 2022, to the American Academy of Arts and Sciences. This organization honors excellence and convenes leaders to examine new ideas, address issues of importance to the nation and the world and to advance the public good. Dr. Jones's allegories, and I love her allegory stories, they're fantastic on race and racism, illuminate topics that are otherwise difficult for many Americans to understand or discuss. Recognizing that racism saps the strength of the whole society through the waste of human resources, she aims to mobilize and engage all Americans in a sustained national campaign against racism. And I'm sure we will all get a lot out of her presentation. So Dr. Jones, thank you again for making time to be with us today. And I'll turn it over to you.

[Camara Jones]
Thank you very much, Dean Youmans. And I am delighted to be sharing this time with you. I know that we have just under an hour, and I hope to reserve five to 10 minutes of time for conversation. And I am going to be sharing my allegories. I've entitled my sharing with you Confronting Racism Denial, Tools for Naming Racism and Moving to Action. And I'm going to tell you in a minute why I even use that terminology. But let me get first of all to the fact that six years ago, when I was president of the American Public Health Association, I launched our association and as many other partners as would join us on a national campaign against racism with three tasks. Now, this is in 2016, the three tasks being to name racism (because you must name a problem in order to even get started on the solution) but as necessary as naming racism is, it is insufficient, we must move to action. So the second of the three tasks is to ask the question, "How is racism operating here, in my work, in my child's daycare?" — you know, with regard to the disproportionate impact of COVID-19 on communities of color, with regard to the second opiod epidemic and the like. Doing landscaping, identifying levers for intervention, targets for action, and then once you've done that landscaping to organize and strategize to act (because, yes, we can act as individuals, but collective action is so much more powerful). Indirectly, but out of my efforts, there are now at least 230 local jurisdictions, so city councils, county commissions, state legislators, sometimes governor statements. 230 statements that racism is a public health crisis across 41 states and the District of Columbia. And if you look at this list, those states that are listed in all caps, something has happened at the statewide level, so a governor statement or a state legislative action. Or I actually think for a few of them, it's actually the State Public Health Association making such a statement. You'll, if the if the name of the state is in lowercase, and it hasn't happened yet at the state level, and you will see in California, there are 32 jurisdictions and this is as of mid-December, the last time that I updated my map. We will also be aware that there are many states right now where the legislators are also passing anti-critical race theory measures. And so, you know, there's, there's in each of our states and probably within UCSF and probably perhaps within the School of Pharmacy attention there. Everybody is not all in. And even the states where there are local jurisdictions that have made such declarations, some of the declarations are just putting a stake in the sand, we recognize that racism exists. Public hold us accountable for that. Some of the declarations go beyond that to say, and therefore we are going to make these investments or therefore we're going to invite this expertise from community or therefore we're going to use this kind of checklist when we're making policies going forward. But whatever it is, there are four key messages that I have distilled when we are naming racism, whether it be, you know, a public declaration or something on our web pages. The first is that we must communicate, we must understand and then communicate that racism exists. So that does get us to the whole point of racism denial, I have only recently, I would say within the past year and a half recognized how racism denial is operating in our society, like a huge black hole in our national landscape. And here, I reference the black holes in the universe, black holes, which are massive, and powerful, they suck things into them, but you can't even see them. Because in the universe, when light gets nearer black holes, that gets sucked in too. It doesn't even reflect. And that's how racism denial is operating in our society. So I will keep coming back to that thing. But the first and perhaps the most important message for us to be able to communicate, communicate in our national landscape is that yes, racism exists. The second of the four key messages is that racism is a system. The third is that racism saps the strength of the whole society. And the fourth is that yes, we can act to dismantle racism. So I'm going to share with you three allegories during our time together that helped to illustrate these four messages. And I'm also going to share with you a tool to help understand how is racism operating here, a tool that I didn't answer for the School of Pharmacy or in pharmaceutical practice, but I'm going to tell you how you can take that question with you, and get started and I do have some ideas to get you started. But the first allegory I'm going to share is my dual reality restaurant saga. This story, based on my own real life experience as a first year medical student, is to help people understand and then communicate to others that yes, racism exists, even though your whole life experience might have been that this is the land of equal opportunity. So step into my shoes as a first year medical student. Here we are on a Saturday morning, we're like on most Saturday mornings, because I was so studious, so diligent, I had awakened early and hit the books, studying, you know, non-stop. And already it's mid-afternoon when some friends of mine also medical students stopped by my apartment. Now do they distract me from my studies? Oh, no. We all get to studying long and hard. And now it's getting late. And now we're getting hungry. And I have no food in the apartment, which was so typical of me that my friends actually understood and they were like, "Okay, never mind, Camara, we got that. But we are hungry. So let's go into town and find something to eat." So we do. So we walk into town, we find a restaurant, we walk in, we sit down, menus are presented, we order our food. Food is served. Here we are eating. So maybe not the story about racism at a restaurant that people in my generation thought I was about to tell. But here we are eating.

And as I sat there eating with my friends, I looked across the room, and I noticed a sign that was a startling revelation to me about racism. So now I've intrigued you, right? And you're wondering, "What, Dr. Jones, what did the sign say?" Well, what did the sign say? Sign said "open." So now maybe I have lost many of you. So let me recap because how is that? A startling revelation about racism? So let me recap here we are sitting in a restaurant eating I look across the room I see a sign that says "open" and thinking no more about it. I would assume that other hungry people could walk in, sit down, order their food and eat. But because I knew something about the two-sided nature of both sides, I recognize that not only did the restaurant was closed due to the hour but firmly closed and that other hungry people just a few feet away from me, but on the other side of that sign, would not be able to come in, sit down, order their food and eat. And that's when I recognize that racism structures, open closed signs in our society, that racism structures, if you will a dual reality. And for those, we're sitting inside the restaurant at the table of opportunity eating, and they look up and they see a sign that says "open," they don't even recognize that there's a two-sided sign going on, because it is difficult for any of us to recognize a system of inequity that privileges us. So, for example, it is difficult for men to recognize male privilege and sexism. It's difficult for white Americans to recognize white privilege and racism. In fact, it's difficult for all Americans to recognize our American privilege in the global context. Although we are really living at so large right now, with how much of the global supply of COVID-19 vaccine we have sequestered in this nation. I've already had my fourth shot. And there are many parts of the world as close as Haiti where some people haven't even had their first. Now those on the outside are very well aware that there's a two-sided sign going on, because it proclaims "closed" to them. But they can look through the window and see people inside eating. So back inside the restaurant to those who asked, "Is there really a two-sided sign? Does racism really exist?" I say, I know, it's hard for you to know when you only see "open."

In fact, that's part of your privilege, not to have to know. But once you do know, you can choose to act. So it's not a scary thing to name racism, it's actually an empowering thing to name racism. It doesn't even compel you to act, but it does equip you to act so that if you care about those on the other side of the sign, which is an if, but if you do, why you why you can even talk to the restaurant owner who is, after all, inside with you. And you can say, "restaurant owner, they're hungry people outside. Why don't you open the door, let them come in, you'll make more money, and oh the conversations we could have?" Or maybe what you'll do is pass some food through the window. Or maybe you try to tear down the sign or break through the door. But at least what you won't be doing is sitting back saying, "Huh, wonder why those people don't just come on in and sit down and eat?" Because you'll understand something about the two-sided nature of that sign that proclaims "open" to you. So I use this story when I have five or six minutes to share with an audience, particularly an audience in which you know, their whole life experience has claimed that this is everything is open, that actually racism does exist and a destruction two-sided or multi-sided signs. It's creating a dual- or multi-faceted reality. And actually, I have started on two separate occasions, three hour conversations each time with the following question. How could people who were born inside the restaurant know something about the two sided nature of that sign? And each time it was a three hour conversation? Because there are many ways to know. I would say that I am actually heartened that more people who were born inside the restaurant and just two years ago, might have been sitting inside eating and saying, what are those people outside saying? Black lives matter? Don't they know all lives matter? More of those people are now actually proclaiming: Yes, Black Lives Matter! More people who were born inside the restaurant are saying the word "racism," putting together the phrases, you know, structural racism, systemic racism, this is heartening. But here's my warning for all of us. If we just say a thing, if we just name racism as essential, as I said, you know, we have to name a problem in order to get started on the solution. But if that's all we do, six months from today, we may forget why we said that thing because racism denial is so staunchly held by so many in our society. And it is so seductive, that six months from now, we may fall into what I describe as the sleepiness, the somnolence of racism denial. So we must go beyond naming racism into action, which means we need to tear down the sign. And of course, racism is not just a sign, it's a sign, it's a door, it's a lot. There's a whole system going on. We need to dismantle the locks, take the door off the hinges because once we start acting, we won't forget why we are acting. So I hope that you can remember this story. And as you know, and the other two that I'm going to tell you and share at least one of them with somebody in your family today or somebody in your community, your coworker, a neighbor anybody because these are communication tools. And after all, I'm trying to give you tools to help us confront racism denial. Now I know I've said the word "racism" a gazillion times already, but haven't defined it. So when I say the word "racism," I'm clear that I'm talking about a system. So I'm not talking about an individual character flaw, personal moral failing, even psychiatric illness, as some people have suggested. And yes, it can show up in those ways. But in its essence, it's a system of power and a system of doing what? Well, a system of doing two things of structuring opportunity and assigning value. And on what basis is the opportunity structured? And on what basis is the value assigned? Based on so called race. Based on the social interpretation of how one looks, which is what we call race, in this race-conscious society. What are the impacts of this system? Well, when we do recognize that racism exists, then we understand that racism is unfairly disadvantaging in some individuals and communities. But it shouldn't take any of us long to recognize that every unfair disadvantage has its reciprocal unfair advantage. So that racism is also unfairly advantaging in other individuals and communities, which is, you know, the whole issue of unearned white privilege that we hardly ever talk about in this country, because it makes some people, especially some people who are living as white, uncomfortable. I used to almost apologize for that discomfort when I could see people in person, you know, and I see them start to fidget in their chairs. When we got to this part of my definition. I would say, "Well, I'm not trying to make anybody uncomfortable," which is true. And I would say, "Well just shake it off. Stay with me." But you know, I don't apologize anymore. I, what I actually say is, "if you feel uncomfortable acknowledging that racism is unfairly advantaging in some individuals and communities, I encourage you to lean into that discomfort because I have come to understand in my own life, and for all of us that the edge of our comfort is actually our growing edge. And how do you lean in, you lean in by reading, reading more, reading widely, reading history. You lean in by talking to strangers, going across town and staying a while. And so that's an important thing for us to do. I will say that when I was at the CDC,

somebody who toward the end of my time at CDC, which is why it was the end of my time at CDC, but I had somebody who had to clear my slides for presentation. He told me I needed to take that bullet off that point off about unfairly advantages because it makes white people uncomfortable. And that experience made me understand that there are many people in this country who would describe two states of being, you know, like I have here, but they would describe them as "disadvantaged" and "normal." And the reason that there are many people in this country who would describe two states of being "disadvantaged" and "normal" is that we are ahistorical in this country, we act as if the present were disconnected from the past. And this if the current distribution of advantage and disadvantage with just a happenstance. And those people who describe their situation as normal, do not recognize that their so-called normal is built up on a whole mountain of unfair advantage. But there is a third impact of racism that many of us miss. And that is that racism is sapping the strength of the whole society through the waste of human resources. And although I could spend, you know, half an hour on this slide, talking about examples of that, I'll just lift up two. The way that we don't vigorously invest in the full, excellent public education of all of our kids, because the blinders of racism, have made some decision makers think that there's no genius in the barrios, the ghettos, on the reservations, we can get along very well, thank you without those kids, when, of course, I'm hoping all of us recognize that there is genius in all of our communities. And if we were only to vigorously invest in that genius, we could be doing so much better as a nation, or even as a world. Another manifestation of how racism saps the strength of the whole society, is how those same blinders that have made us, you know, value people differently, have also made us complacent with what I described as a wholesale warehousing, and disproportionately, of so many black and brown men in our prison system, as if that didn't sap us, you know, separate us from human potential. It's the same thing, those same blinders that made us not recognize with the so-called crack epidemic, that it was an epidemic that made us not have Narcan, you know, over the counter in drugstores, had made us not have EMTs routinely carry Narcan that now with the second opioid epidemic that is more pronouncedly affecting white populations, that now we have all of those things that we're even calling it an epidemic, as opposed to blaming those people as being drug users and dispensable. So anyway, I thought that I could talk a long time into this slide. But what I will say is that, that third point about how racism saps the strength of the whole society is the point that I think all of us need to lift up most urgently, these days, because, well, we need more conversations and media about that. We need more data collection. And we need more conversations around faculty room tables, board room tables, dining room tables, so that more of us will feel a sense of urgency to dismantle this system, and put in its place a system in which all people could know and develop to their full potentials. Now, I have learned while at CD, CDC, while here at UCSF, that there are many people who value comfort, right? And there are many people who value social justice. But what I've also understood is that is the current status quo, those are at opposite ends. They're polar opposites. You can't value comfort and value social justice at the same time. And I actually have just recently started understanding that I can put those polar opposites in the context of this. Of this, you know, dual reality, where those who value comfort are benefited by the status quo. That's why they value comfort, they are comfortable in the status quo, they do not wonder why no one else is coming in the restaurant, they're so involved in their conversation and their food, they may not even notice. Or if they do notice, they aren't troubled by it. They don't want to examine the sign, they may have heard whispers that there's a two-sided sign going on. But they're actually passing laws to prevent anybody from going anywhere near the sign to kind of peer and see does it really say "closed" on the other side, right? The passing these laws because it might make the children uncomfortable. They don't care to know what the outsiders are saying. They don't even believe that an outsider could add to their conversation. They have heard that if they, you know, diversify at their table inside the restaurant, that it can be better. But I think maybe it'll make a nicer, politically correct picture, that they don't think that anybody coming from the outside could actually have, you know, brilliance to contribute or insights or different life experiences.

They don't even wonder how the food they're eating gets there. And they don't recognize that many of those people who are on the outside and can't come in and eat, that they're the ones who grow the food, transport the food, come into the kitchen, cook the food even come and serve them, but can't come inside and eat. And they certainly don't want to budge from their seats at the table. They jealously guard that privilege, and that comfort. On the other hand, those who value social justice know two things. They know that there's a two-sided sign going on. Many of them know that because they have been on the outside either born on the outside or been injured on the outside and seen that it says closed but they also know, and I have to say they know it says "closed" and they also can look through the window and see people inside eating. So that's how they know it's two-sided. They also know that the operation of this two-sided sign saps the strength of the whole society. I will have to tell you that circumstances of birth do not completely constrain our or determine our values. So there are people who were born inside the restaurant who might wonder whether those people outside saying "Why isn't somebody else coming in?" And it's relatively easy for them to go through the door on the outside and see the closed nature of the sign and listen and be part of the lived experience of those who have been locked out. There are also those who were born outside who might be able to make their way in. It is much more difficult. You know, they have to know the password of, you know, I worked hard and blah dee blah while denying, they have to promise to deny that they will ever say anything about the two-sided nature of the sign. Sometimes they have to promise that, but they make their way in. Usually when they make their way in their way in their place close to the windows so that people looking from outside can see that there's somebody here, right? One of them. Sometimes they're close enough to the door that they can put their foot in the door and kind of prop it open to make it easier for more people to come in. But sometimes they're so close to the door that they act as gatekeepers to prevent other people from coming in. All I need to say is, what we're trying to do, actually, is to move more people from valuing comfort to valuing social justice. We're also trying to break down the barriers and all of that, but we in order to do that we need to have more people who value social justice, recognizing that in the current status quo, valuing social justice will not always be comfortable. There now I'm going to move from that. And I actually spent quite a bit of time with that more than I thought. So I am going to share my second allegory, but very quickly, and I'm going to tell you that the preamble for the second allegory is that I was trying to figure out how could racism turn into health outcomes. So how could racism turn into differences in the numbers of our babies dying before their first birthday or differences (so that's an infant mortality rate differences) or differences in our with the mother's dying within a year of pregnancy, the maternal mortality rates. How can it turn into differences in asthma prevalence? How can I turn into differences in obesity prevalence or differences in COVID, mortality and morbidity, right? So these three levels of racism are my way to understand that institutionalized, which we would now call structural, personally mediated and internalized, I usually would define each of these in great detail. I'm going to define them briefly so that I can get through everything that I've prepared to say. And we can have time for Q&A. So

institutionalized or structural racism. What is it? It is the system, the constellation of structures, policies, practices, norms, and values, which taken together result in differential access to the goods, services and opportunities of society by race. So this, you're going to see my definition, so differential by race. This is the kind of racism that doesn't require an identifiable perpetrator, because it's been institutionalized in our laws, customs, background norms. This is the kind of racism that shows up as inherited disadvantage, or its reciprocal inherited advantage. And it shows up in material conditions, as well as an access to power. So examples include differential access to quality housing by race, or excellent educational opportunities, high rates, or Equal Employment Opportunities, or even equal income at the same level of employment. Clearly, those things impact health. Differential access to medical facilities, including physical access, including financial access, including linguistic access. And here, I have to say, I'm so happy that pharmacies are becoming part of medical facilities in a way to increase access, although even is that really equitable? And where are the pharmacies located? And do you have you know, is that instead of having, you know, a broader range of, of services, so I'm stet, so happy that pharmacies are standing in the breach, especially with regard to the COVID-19 pandemic, but there are pharmacy deserts, even as we recognize there are food deserts and the like. Differential access to a clean environment. And the very well documented disproportionate placement of toxic dump sites, or bus transfer stations and communities of color. And then in terms of access to power, differential access to power as information, which could be health information, or even information about our own histories. Differential access to power as resources, so capital resources, but it's social networking resources as well, knowing somebody on the board, and differential access to power as voice — voice in government, voice and media and the like. And I'm going to shorthand here is something that I often called deeply into, which is sometimes people ask me to take a close look at my examples. And they say, "Dr. Jones, that first set of examples, housing, education, employment, income, isn't that what we call social class? Why do you have that on the slide about racism? Are you talking about racism? Are you really, really talking about social class?" That's such an important question that I'm going to answer it, but in an abbreviated way, but the most important part of the answer is that it doesn't just so happen, that people of color in this country are overrepresented in poverty, while white people in this country are overrepresented in wealth. That's not just a happenstance. And for every marginalized, oppressed, stigmatized group of color, there's been some initial initial historical injustice. So, you know, for indigenous North Americans, American Indians, the initial historical injustice was the taking of the land and you're just moving folks to reservations. And in some instances, something good was found on a reservation oops, you had to pick the people up and move them somewhere else. We've had Mexican families lived in Mexico for generations for centuries, never crossed the border, the border crossed them, and they're being targeted and demonized, dehuman, you know, dehumanized. We had Chinese laborers brought to this country to build our transcontinental railroad, but the Chinese Exclusion Act, you know, unable by law to bring their families, unable by law to marry. We had the internment of Japanese Americans during World War II without the internment of Chinese, I mean of Italian Americans or German Americans. And for people of African descent, we had the kidnapping of West African people, or importation across the Atlantic with tremendous loss of life in the Middle Passage, and then for generations and generations, the you know, the progeny and for generations and generations of the original people, the coerced usury by those people of those people, the coerced usury of our labor for centuries to build this country. And then I then people stop me and say, "Oh, Dr. Jones, there you go talking about slavery. You know, we all recognize that slavery was an unfortunate chapter in our nation's history. But, Dr. Jones, the enslaved people were emancipated by 1865. We are now in 2022. That's 157 years ago, Dr. Jones, all else being equal, don't you think the impacts of slavery would have washed out by now?" Well, the answer is in the question, isn't it? All else being equal, all else has not been equal since 1865. All else still is not equal today. And there are present day contemporary structural factors that are perpetuating that. And all of these initial historical injustices. And these contemporary structural factors are part and parcel of institutionalized or structural racism. So when you ask me, am I talking about racism or am I talking about social class, my response is that structural racism explains why we see an association between social class and race in this country. It is not just a happenstance, that's a very important, "Aha." I need to say that this level of racism can operate through acts of doing, acts of comission, as well as acts of not doing, acts of omission. And very often it shows up as lack of action, inaction, in the face of need. The second level of racism, personally mediated racism, I define as differential assumptions by the about the abilities, motives, and intent of others by race, and then differential actions based on those assumptions. So that's what most people think of when they hear the word "racism." Somebody did something to somebody, and includes the different idea that prejudice and the different actions, that discrimination, and it shows up as police brutality and differential assumptions about what you could have in your hand and often mistaken your cell phone as a gun and then you're dead. Physician disrespect, or even pharmacy disrespect. So physician disrespect, shows up as a physician not giving a patient, it can be as subtle as I will say, a physician not giving a patient the full range of treatment options because the physician figures that patient couldn't afford, wouldn't comply, wouldn't understand or whatever they assume. Or quite blatant, like sterilization abuse, which has had many iterations in our nation's history. I think in terms of pharmacies, you know, many people will present some pharmacies don't even carry pain medications that are needed by patients that live in that area. And there are pharmacists, who, because they don't want to get caught up in the opioid epidemic, make an assessment, they just look at a person and decide, well, this person really isn't you know, I'm not talking about you guys, but there are in this country pharmacists who might decline to fill prescriptions, or whatever just based on a person's appearance. Shopkeeper vigilance being followed around in stores, waiter indifference not getting quick, respectful treatment, which are just two ways that what some people call everyday racism show up, you know, the microaggressions that subtle communication of disrespect, which could turn into elevated blood pressures in communities of color, elevated blood pressures that don't even go down at night. Teacher devaluation, teacher interpreting a child's question at a low level of sophistication as opposed to a high level of sophistication, or looking at a child or thinking that child can't learn and putting them off in the attention deficit disorder track, where they may not even know their full potential, much less have the opportunity to develop to their full potential. And this level of racism, like the structural, can be through acts of doing as well as acts of not doing, but even more important is that it can be unintentional as well as intentional. That is, we do not have to have intended to do something racist to have had a racist impact.

The third level of racism, internalized racism, is also differential by race. For members of stigmatized races, it shows up as acceptance by members of stigmatized races of negative messages about our own abilities and intrinsic worth. For members of races that have been structurally advantaged, it shows up as a sense of entitlement. Right? Which actually is related to racism denial, because if you feel that entitled to what you have, if you feel that your current status is normal, you have to deny that there's an unfair system going on, right? But I will just say this, if you look up ever, and you see a sign that says "open," that sign will only be necessary if there is a closed aspect, right? The only reason to have open signs is because it is closed to others. So just always remember that when you say, oh, it looks open to me. So my in terms of health impacts, because I haven't figured out how a sense of entitlement turns into bad health impacts. I actually haven't addressed that on my slide, although I do recognize that if somebody has a sense of entitlement thwarted, or a sense of grievance that may actually be at the root of what some people are calling the diseases of despair in a white population. So the suicides and the second opioid epidemic and the like. But the rest of this slide is about health impacts from the point of view of members of stigmatized races, where it shows up internalized racism shows up as self-devaluation feeling maybe I'm really not as good as, maybe I shouldn't try to graduate from high school, applied to that college, tried to live in that neighborhood, try to get that job. It shows up as the white man's ice is colder syndrome, where that phraseology came to me from my parents and their generation, and what it meant then for people of color, it still means for many of us today. So say I'm black and I need a lawyer, I might seek out a white lawyer over a black lawyer. If my lemonade were warm, I might go way down the street to get the white man's ice over the black man's ice, deeply believing that the white man's ice is colder, deeply internalizing the myth of white superiority. And it shows up as resignation, helplessness, hopelessness, which turns into a lot of self-destructive health behaviors. And really, internalized racism is about members of stigmatized races, accepting the limitations to our own form of humanity of the box to which we've been placed. So now I'm going to illustrate these three levels of racism and their relationships with one another with my Gardener's Tale allegory. And I'm going to briefly stop sharing so that you can see my hands really big, because you start using my hands a lot, my hands are, are necessary in this story. I'm first going to tell you what I saw with my own real life, and then I'm going to enlarge on it to make it a story about racism. So my husband and I had been married about a year when we moved down to Baltimore for me to finish my PhD at Hopkins, and we bought our first freestanding house, cute little house with a big wraparound porch with flower boxes dotted all on the porch. Now we bought the house in October, which was not really the time to plant. So we waited. But when spring came because my husband loves to garden, he ran out with our marigold seeds to decorate our cute little house. But then he ran back into the house and he said, "Camara, some of these boxes have dirt in them, but some of the boxes are empty, so I need to go to the gardening store." So he does. Goes down to the garden store. He comes back hauling big ol' bags of potting soil, right? And so then we fill up those empty boxes. And then we take equal numbers of our marigold seeds and put them in all of the boxes. And then we water all of the boxes equally. And by this time, because I am not the gardener in the family. At this time, I am exhausted. So I, I figure I'm just gonna sit back now and be delighted. Well, three weeks later, as I'm walking out of my front door onto my porch, I finally pay attention to these flower boxes. And what I saw made me literally stop in my tracks. Because what I saw make me think we had planted completely different species in some boxes versus others, because some of the boxes were full of plants and the plants were tall and vigorous looking. But some of the boxes just had a few plants in them. And they were kind of scrawny and scraggly looking. And then I realized what had happened. That potting soil that my husband had bought turned out to be rich, fertile soil, so that every single seed planted in the rich fertile soil had sprouted, the strong seed had grown very tall and vigorous, but even the weak seed had made it halfway up. That old soil that we found there turned out to be poor rocky soil. So the weak seed planted in the poor rocky soil just died. And even the strong seed in the rocky soil had to struggle to make it to a middling height.

So, you know, maybe you guys are nodding about now. Maybe you've seen this with your own garden, because maybe you've composted half of your garden. And the image, of course, is about the importance of the soil, the importance of the environment, right? But I'm going to take this image, and I'm going to make it a story about racism by introducing a gardener. So now we have a gardener who has two flower boxes, one which she knows to have rich fertile soil, one which she knows to have poor rocky soil. And she has seed for the same kind of flowers, except some of the seed is going to produce pink blossoms and some of the seed is going to produce red blossoms, and the gardener prefers red over pink. So what does she do? She puts the red seed in the rich fertile soil pink seed in the poor rocky soil. Three weeks later, she sees in her garden boxes what I saw in mine, in that you know, rich, fertile soil, all of the red seeds sprouted strong red sea tall and vigorous, weak red seed makes it halfway up in that poor rocky soil we think see dies strong pink seed struggles to make it to a middling height. And then in those two flower boxes, those flowers go to seed. And the next year, same thing happens. And then those flowers go to seed. And year after year after year after year after year after year, same thing happens. Finally, okay, but 10 years later, the gardener is looking at her flower boxes. And she says, "you know, I was right to prefer red over pink." So we're going to interrupt the story there. To say the first part of the story illustrates structural or institutionalized racism, where you had the initial history, you know, historical injustice of the separation of the seed into the two types of soil. You had the contemporary structural factors of the flower boxes, keeping the soil separate, and then lack of action (inaction) in the face of need, perpetuating the inequity. But where would personally mediated racism be in the garden? Well, the garden is looking at the red flowers thinking, "Oh, red is so beautiful." And then she looks at the pink flowers and she says, "Oh, those pink flowers sure are scrawny and scraggly." So she plucks off the pink blossoms before they can even go to seed. Or maybe she notices that a pink seed has blown into the rich, fertile soil. So she plucks it out before it can establish itself, which is some of the anti-affirmative action stuff that goes on. And where, what internalized racism would be in the garden? Well, the pink flowers are just living their lives enjoying being red, many of them not acknowledging or perhaps not even recognizing that they're benefiting from enriched soil. The pink flowers are looking over there thinking that is mighty fine, and wishing with all their hearts that they too could be red. And here come the bees minding their own business, collecting nectar, pollinating at the same time. So here comes a bee into one of the pink flowers and then to another pink flower to this thing. So this flower is like, "Get away from me bee! Don't bring me any of that pink pollen! I prefer the red!" Because the pink flower has internalized that red is better than pink. So now the question arises, what can we do to set things right in this garden? Or we could start by addressing the internalized racism. So we could go over to the pink flowers and say, "Pink is beautiful! Power to the pink!" And that is an important intervention. But if that's all we do, it's not going to change the situation in which the pink flowers find themselves. So you might say, oh, okay, well, I got that. Let's address the personally mediated racism. Let's have a conversation with the gardener. Or better yet, let's have a workplace multicultural workshop for the gardener. So we do. And in the workshop, we say, "Dear gardener, would you please stop plucking those pink flowers. And maybe she will, and maybe she won't. But even if she does, it's not going to change the situation in which the pink flowers find themselves. If we really want to set things right in the garden, we must address the structural racism, which means we have to either break down the boxes and mix up the soil. Or if you are wedded to having separate boxes, or you know, I don't think that's a very good idea, because it makes it easier for this same gardener to continue segregating resources going forward. But if you insist on keeping separate boxes, but you're going to set things right, it means you need to enrich that poor rocky soil until it is as rich as the rich, fertile soil. And when you do that, the pink flowers will flourish, to be looking beautiful, grand and glorious. So that in that intervention on the structural racism, you will have also addressed the internalized racism, because pink won't be looking over it red thinking that red is better or wanting to be red. And in that intervention on the structural you may also address the personally mediated racism. Now the original gardener may have to go to her grave preferring red over pink, but her children who grow up and see the flowers equally beautiful, will be less likely to have that kind of attitude. So this story has been to illustrate these three levels of racism to strongly suggest that if we want to set things right in the garden, we need to at least address a structural good to address all the levels at the same time.

And that if we do address the structural, the others may take care of themselves. But there's a question I haven't asked yet, which is who is the gardener? After all, the gardener is one that I gave the power to decide, power to act, control of resources, which are actually the elements of self-determination. So who is the gardener in the U.S. context? Well, government is a huge part of the gardener, but not all, you know, media, foundations, corporations, health systems, including pharmaceutical systems and all like that. Communities to the extent they have self-determination. But whoever the gardener is, it is dangerous when the gardener is allied with one group. I painted her red. That's why she prefers red over pink. And it's also dangerous when she's not concerned with equity, which you can look at her flower boxes and think that her garden and it's beautiful, thank you, because she's not even counting the pink flowers as part of her garden. So what do we do about the gardener? Do we make the gardener striped, polka dotted, a fuchsia? Do the pink flowers have to grow or recruit their own gardener? So many questions that can come out of this. I hope, again, that you take this story with you and share it with others or Google it. It's in a paper that was published in 2000. And there's you know, you can find it. But here are two questions that have come up before. The first is, "Excuse me, Dr. Jones, but why should the red flower share their soil?"

When I heard that question, I love the question, because it showed me the power of this story to start conversations about racism that might be otherwise difficult if we were talking about racism between you and me. My answer to that question, why should the red flowers share their soil, is actually that soil doesn't belong to the red flowers. It belongs to the whole garden. Here's the second question. "What if that's not the original gardener we're looking at in this picture? What if that's the gardener his great, great, great, great grandchild?" Because here we are. And the great, great, great, great grandchild has always seen the flowers looking like that may not even think there's a problem to be solved. So it's three steps which are quick for me to say but we'll take time to implement that here. The first thing we can definitely do today right now. The first thing is to put the differences in the height and bigger of the pink and red flowers, make that a problem requiring urgent solution, put it on our urgent action agenda. But then now it's on the agenda, what are we going to do? Well, the second thing is we must make those flower boxes transparent so we can be talking about the differences in the quality of the soil so that we can address the differences in the quality of the soil. But the third step is, as we make those follow boxes transparent, we need to make sure that everybody understands that the pink seed did not just go launch themselves into that poor rocky soil. So we must talk about history. And we must talk about how the gardener's initial and continued preference for red over pink set up the whole situation where that initial and continued preference for red over pink is what we would call cultural racism. What in our U.S. context is clearly white supremacist ideology. We must call that out. Because if we do not, even if we're able to compel that red gardener today to enrich the poor rocky soil today, until it is as rich as the rich, fertile soil today. If she continues to prefer red over pink, she will continue to privilege red over pink going forward. So when I defined racism as a system of doing two things, structuring opportunity and assigning value, we have to address both of those to set things right in the garden. Here's the third story very quick. I call it cement dust in our lungs. It's my newest allegory, it's not so smooth yet, I mean, I still have room for growth. As you listen to this story, when I say "cement dust," I want you to think "cement dust." And I also want you to think "racism." So imagine that there's a cement factory spewing cement dust, and the cement dust fills the air. And if any one of us is anywhere near this factory for any amount of time, we're going to develop cement dust in our lungs. And the cement dust in our lungs is problematic for all of us, even for people who don't recognize that they have cement dust in their lungs. For some people, cement dust in my lungs, for example, might make me feel that I'm less than, whereas some intestine, somebody else's lungs might make him feel that he can with equanimity crush the life out of another human being with his knee for nine minutes and 29 seconds. But whatever it is, the cement dust in our lungs is problematic. So how do we address it? Do we focus on the individual? Well, I'll share with you two strategies about that. And I'll give you tiny critiques for each. But what do we have a machine that could screen how much cement dust people have in their lungs? And then if they come across somebody with too much cement dust us...[makes alarm sounds: ahn, ahn, ahn] alarm would go off. Well, this is a useful strategy for people who don't believe they have any cement dust in their lungs. But how, how much is too much dust? And what do we do with those people who have too much dust. Do we put them on the edge of society, vote them off the island? And the most, the biggest problem with this, I think, is that this approach might make people not want to talk about cement dust at all. So just go switching into the racism vote right now, many people don't even want to say the word racism or hear the word racism because they think when you talk about racism, you are trying to divide the room up into who's racist and who's not. Or peer deeply into their soul to ask exactly how racist are you? So this approach has limitations, although it does have some value. If we want people to understand that they do have cement dust in their lungs. What if there's somebody who has cement dust in their lungs, knows it, and they want it out? Well, we could set up cleansing spas, right, and people could volunteer or be encouraged to go into the cleansing spa and read and talk to strangers and all, and come out as good as new. But if they come out into that same cloud of dust, the dust is going to re-accumulate in their lungs. So this is not a very permanent solution unless people live inside the cleansing spa. And what does it make us think then also? The problem with this really is that they come back into that same cloud. So does that mean we need to all acknowledge the cloud? What would that look like? Well, at least I wouldn't know if I'm acknowledging the cloud that I wasn't born with cement dust in my lungs. And it also gives me an idea for an intervention. Maybe I can put on a gas mask to filter out any additional cement dust from getting in my lungs, recognizing that in and of itself, the gas mask is not going to extract the dust that's already there. But then I also recognize I need to keep this on 24/7. Right? Because the dust is always around me. And I'm encouraged when I see myself reflected with the gas mask on. And you all start asking me questions. "Dr. Jones, why are you wearing a gas mask?" And then I say, "Well, we're living in this cloud of cement dust. You know, I've started my individual anti-cement dust journey." And so the more and more of you might choose to put on gas masks and start your individual anti-cement dust journey. So is that the answer then? All we need to have is 330 million gasmasks. tiny baby gas masks, old people gas masks, all kinds of gas masks. Well, it's a start, but I think it's insufficient. What we really need to do is dismantle the factory. So especially those of us who have started our individual anti-cent dust journeys, right? We have we can breathe more clearly, we can see more clearly. We need to move into action to get closer to the cement factory, which has been obscured by so much dust that some people don't even recognize there's a factory inside it. And then we need to start asking the question, "How is this factory operating here?" looking at structures, policies, practices, norms and values, and then we need to organize and strategize, to act to dismantle this factory, and to put in its place a system in which all people can know and develop to their full potentials. So not only is this story about the fact that racism is a system, but it also strongly suggests that if we want to set things, right, we must address racism at the systems level, you know, good to have the other interventions, but we must address it at the systems level, if we're going to set things right. That question, "How is the cement factory operating?" Here is the question, "How is racism operating here?" Which is a legitimate question because racism is not a cloud or a miasma that we can't get a handle on. It is a system with identifiable and addressable mechanisms, which are in our structures, policies, practices, norms and values. And now I may have just given you a headache. Structures, policies, practices, norms and values. What am I to do with that? Until we recognize that these are actually the elements of decision-making.

Structures are the who, what, when and where of decision making, especially who is at the table and who's not, and what's on the agenda and what's not. And I charge you hence forth. Whenever you find yourself at a decision-making table or set one, your first job should be to look around and say, "Well, who is not here, who has an interest in this proceeding?" And then your job is not just to represent their interest, although you might need to do that in the very short term, but your job is to create space to find them a way to the table. And of structures of the who, what, when and where of decision-making policies are the written how of decision-making. Practices and norms are both the unwritten how of decision-making. Practices, the way we do things today. The norms, the way we've always done things and the way we expect to do things going forward. And values. Values are the why. So I encourage you to take this question, "How is racism operating here with you everywhere?" And if you just spend five, 10, 15 minutes with it, you can identify five, 10, 15 possible levers for intervention, targets for action to get you started. First as individuals using your own tools, but really to organize and strategize to act. So what can we do today? We need to look actively for evidence of two-sided signs. Is there something differential going on here by race, by language, by immigration status, by gender, by zip code by whatever — looking not only at outcomes, but also an opportunity structures? We need to burst through our bubbles of experience to experience our common humanity on the other side of town. All of us are in some kind of bubble of experience. Some of them are, you know, you know, vast bubbles within soap bubble boundaries, some of them are smaller bubbles, thicker Plexiglas boundaries. Some of our bubbles have been tented. Some of our bubbles are polarized. Some of our bubbles in the current climate have been hardened by fear. But in our bubbles, most of us do not recognize that just across town, there are people who just as kind, funny, generous, hardworking, smart as we are. We're living in very different circumstances. We need to create at the individual and institutional levels bubble bursting opportunities. So we can experience our common humanity and start building common cause. We need to be interested in the stories of others, believe the stories of others and then join in the stories of others. And we need to believe the stories of others without requiring cell phone video documentation or body cam footage. We need to develop a sensitivity to see the absence of, to see who's not at the table, what's not on the agenda, what policies are not in place that are put in place to bring about social justice. We need to reveal inaction in the face of need, because that is how structural racism very often shows up these days. But all the power is not restricted to those who are in the restaurant. Those of us on the outside need to know our power, we need to recognize that action is power, and especially that collective action is power. And I would say part of the action is moving more people from valuing comfort to valuing social justice. I want to leave you with four habits of mine for social justice warriors that I call my four B C's. They are to be courageous, be curious, be collective, and build community. So when I say be courageous, it means speak your truth, be unafraid of controversy, embrace challenge and know that the edge of your comfort for all of us is your growing edge. When I say be curious, ask why. And then ask why again and ask why again. And when you ask these serial whys, you will not be satisfied with superficial explanations, but you'll be able to identify root causes. Read widely and read history. Learn more than one language. That's a huge bubble bursting window right there. And travel as much as you can. Really across town as well as around the world. When I say be collective, I mean care about the whole, which means share your ideas, your time, your energy, your stuff with others and organize, because collective action is power, collective action informs us. It inspires us. It propels us and it protects us. And when I say build community, it is to be interested in, believe in and join in the stories of others. So, talk to strangers, create bubble bursting opportunities, speak up and take action on behalf of others and really go across town and stay a while. Stay join in the experiences of others. And understand that anti-racism is not charity, it's not generosity, it's not allyship. Anti-racism is for all of us because this system is sapping the strength of the whole society. Thank you for giving me time. And we have three minutes for questions, maybe more, but I'm so delighted to have this opportunity.

[Levi Gadye]
Thank you so much, Dr. Jones. Let's see if we can get through maybe one or two questions here. So the first question is, "What do we do with the comfortable red flowers that are perhaps even unwittingly assuming that soil mixing would be bad for them because there is no more rich soil?"

[Camara Jones]
Right? So this is so that gets into the myth of a zero sum game, and I've actually identified seven. At first, I was calling them cultural or societal barriers to achieving health equity. I will just name them. And then I'll come even more into that, that question. But these seven barriers to achieving health equity, which I now call the values targets for anti-racism action are: Narrow focus on the individual that makes systems and structures invisible or seemingly irrelevant. Our ahistorical stance, the fact that we act as if the present were disconnected from the past (and isn't the current distribution of advantage and disadvantage, which was just a happenstance). The endorsement of the myth of meritocracy (the story that goes something like this, if you work hard, you will make it) I give you most people have who have made it have worked hard, but then many other people working just as hard or harder, who will never make it because of an uneven playing field, which has been structured and perpetuated by racism, sexism, heterosexism, all of these systems of structured inequity. The fourth is the myth of a zero sum game, that if you gain, I lose, which sets us up in competition with one another. It's almost like I'm sitting at a potluck dinner, I see you coming, I don't want to come in anywhere near this table because I think you're going to eat up all the food, I can't even see that you are bringing with you all kinds of cakes and pies and roasts and trout, salads and fruits, because the blinders of racism have made me not even be able to see that. The fifth is our limited future orientation, understanding that the parts of the future that each of us can touch today that hopefully will survive us are the children in the planet, we have a disregard for the children in this country and a huge serious relationship with the planet. The sixth is our myth of American exceptionalism, which makes us feel so you know, so we feel so special, so unique, so ordained by God that we think we're entitled to all the stuff that we have, and we can't learn from others. And the seventh is white supremacist ideology, the false idea of a hierarchy of human valuation by race, there is no such hierarchy, the false notion not only that there is such a hierarchy that but that will put white people at the top is the ideal or the norm. But that ideology gives many people who are living as white a sense of entitlement, it results in the dehumanization and devaluation, and truly the dehumanization of people of color, and fear at the browning of America that is underlying a lot of our political divide today. So what do I do about those people? So we have to address all these myths. And, and really, there's so much in our culture that I don't know, if it's in the religious institutions, if it's in the schools, if it's in the media, if it's an all of us in our conversations, if it's in going across town and staying a while that we can blow through these myths, and understand that there is enough for all of us, and that we are all in this together. I could talk much more, but I want to hear the second question. Okay.

[Levi Gadye]
Let's see if you can do it quickly. So the second question is simply how do you balance a policy at a big institution like a company or university with what happens in real life at the company? How do you hold a company or university accountable to ensure that policies are enforced?

[Camara Jones]
Well, sometimes it takes an inside outside strategy. So you have the people inside who want the policy and all but you need to let community people outside know about the policy and know that it's not being, you know, held to because they can have different levers, and all but so we all need to recognize the importance of inside outside strategies. But the real job is to make the institutional walls more porous, to make it easier to do inside outside work. So I think that's my, my fast answer to that.

[Levi Gadye]
Thanks, Dr. Jone's. Pass to Sharon.

[Sharon Youmans]
Thanks, Levi. Bye, Dr. Jones. Thank you so much for such an inspirational presentation. I think it's set a lot of us on fire. So to wrap up quickly, I want to thank all of you who took time out of your schedules to participate in this session. And Dr. Jones on behalf of the School of Pharmacy, faculty, staff, students and leadership we thank you so much again for your presence today and for your presence and coming to UCSF this past year. And I'm sure now that we all know you, we may be tickling you with questions and suggestions as we move forward on this journey to dismantle racism at UCSF. So thank you. And thanks again to the audience.

[Camara Jones]
Thank you all. Thank you very much.


School of Pharmacy, Department of Pharmaceutical Chemistry, Department of Bioengineering and Therapeutic Sciences, Department of Clinical Pharmacy, PharmD Degree Program, BMI, QBC, CCB, PSPG, Bioinformatics, Biophysics

About the School: The UCSF School of Pharmacy aims to solve the most pressing health care problems and strives to ensure that each patient receives the safest, most effective treatments. Our discoveries seed the development of novel therapies, and our researchers consistently lead the nation in NIH funding. The School’s doctor of pharmacy (PharmD) degree program, with its unique emphasis on scientific thinking, prepares students to be critical thinkers and leaders in their field.