Addressing Racial Disparities in Health: Part 1 - The History of Racism in Medicine

The history of racism in medicine dates back to the early days of our country. 

Join us for our two-part series—Addressing Racial Disparities in Health—as Dr. Terralon Knight, Board Certified Family Physician and CEO/Founder of Knight Coaching, Dr. John Vassall, MD, FACEP, and Physician Executive for Quality, Safety and Equity at Comagine Health, and Dr. Kellee Randle, MD, Hospitalist and CEO of Equity Ventures Plus discuss the history of racism in medicine.


Terralon Knight, MD,  CEO/Founder of Knight Coaching

Terralon C. Knight is Medical Director of a major health insurance company and CEO/Founder of Knight Coaching, LLC. She is a native of Mississippi and received her undergraduate degree in Biology from Tougaloo College. She obtained her medical degree from the Warren Alpert Medical School of Brown University and completed her family medicine residency at University of Texas at Houston. 

Dr. Knight has a passion for the underserved, with much of her career spent serving communities in the District of Columbia, Maryland and Virginia. She has been a Medical Director with United Healthcare for eight years and she professionally coaches medical professionals looking to move into leadership and administrative roles. When she’s not working, she enjoys traveling, photography, and family game nights with her husband and three children. 

John Vassall, MD, FACEP, and Physician Executive for Quality, Safety and Equity at Comagine Health.

John Vassall is the Physician Executive for Quality, Safety and Equity at Comagine Health. The product of an immigrant family and an inner-city childhood, Dr. Vassall has his Master of Science (Microbiology) and Doctor of Medicine degrees from the University of Washington and internal medicine training at Grady Memorial Hospital, Atlanta Georgia’s public hospital. 

He has been a pioneer in addressing racial disparities—opening a clinic for Black Americans in Seattle and serving in the 80s as the Chair of the Board for the Carolyn Downs Family Medical Center, the last currently operating medical clinic in the United States started by the Black Panther Party. In addition, he has served in many leadership roles on a statewide and national level, including serving as member of the Board of the Institute for Diversity and Health Equity.  

Kellee Randle, MD, Hospitalist and CEO of Equity Ventures Plus, LLC.


Dr. Kellee Randle (Doctor Kellee) is a board-certified physician in internal medicine. She received her doctor of osteopathic medicine from the University of North Texas Health Sciences Center in 2010, and went on to complete her internal medicine training at Broward Health Medical Center in Fort Lauderdale, Florida, in 2013. Currently, she is a hospitalist in Dallas, Texas.

As the founder and CEO of Equity Ventures Plus, LLC, her mission is to educate healthcare professionals about implicit bias and empower minority communities to advocate for themselves in healthcare settings. She is respected for her medical opinion and known for her ability to make complex medical concepts understandable for her audiences.

In her spare time, Doctor Kellee enjoys volunteering with medical missions, traveling, exercising, reading, and spending time with her family. She is also an active member of Delta Sigma Theta Sorority, Inc.

Transcript

Dr. Enrique Enguidanos 

Welcome to this month's edition of Caring as Communities. I'm Dr. Enrique Enguidanos, CEO of Community Based Coordination Solutions. And today we will be exploring the issue of racial inequities within healthcare.

We're joined today by three innovative and accomplished panelists.

Dr. Terralon Knight is a Board Certified family physician and CEO and founder of Knight Coaching. She's a native of Mississippi and received her undergraduate degree in biology from Tougaloo College. She then obtained her medical degree from the Warren Alpert Medical School at Brown University and completed her family medicine residency at the University of Texas at Houston.

Dr. Knight has a passion for the underserved and has spent much of her career, serving the communities within the District of Columbia, Maryland and Virginia. She has been in medical torture for one of the largest insurance companies for about a decade and she currently professionally coaches medical professionals looking to move into leadership and administrative roles. Dr. Knight, thank you so much for joining us today.

Dr. Terralon Knight

Thank you. Happy to have you, honored to have you.

EE

Dr. Knight is joined by Dr. John Vassall physician executive for quality, safety and equity at common gene Health, Dr. Vassall is the product of an immigrant family and spent his childhood in inner city New York. Dr. Vassall has obtained his Masters of Science and his Doctor of Medicine at the University of Washington in Seattle, and then performed his internal medicine training at Grady Memorial in Atlanta.

Dr. Vassall has been a pioneer in addressing racial disparity issues—opening a clinic for Black Americans in Seattle, and serving in the 1980s as the chair of the board for the Carolyn Downes Family Medical Center, the last currently operating medical clinic in the United States started by the Black Panther Party. In addition, Dr. Vassall has served in many leadership roles on statewide and national level, and I've actually had the pleasure and honor of serving with Dr. Vassall on a couple of boards. One of those includes having served as a member of the board of the Institute for diversity and health equity. Dr. Vassall, thank you for joining us today.

Dr. John Vassall  

Thank you for having me. It's a pleasure.

Enrique Enguidanos  

And our third panelist is Dr. Kellee Randle. Dr. Randle is a Board Certified physician in internal medicine. She received her Doctor of Medicine from the University of North Texas Health Sciences Center, and then went on to complete her internal medicine training at Broward health Medical Center in Fort Lauderdale, Florida. She currently works as a hospitalist in the Dallas area and is also CEO and founder of Equity Ventures Plus where her mission is to educate healthcare professionals about implicit bias and empower minority communities to advocate for themselves within healthcare settings. Dr. Randle is also an accomplished podcast speaker and author. Dr. Randle, thank you so much for joining us.

Dr. Kellee Randle  

Thank you for having me. It's an honor.

EE

And you know, let me say this topic is so important that we realized early on we can't do justice, with just one podcast, so we'll be doing both this month’s, and next month’s podcast on this issue with you three leading the discussion. Thank you for helping lead this discussion on such an important issue. 

It's difficult to grasp the issue without a real good understanding of the long history of racial inequities in our country. And so we're going to start this podcast today just by launching into that discussion of the history of racism within medicine in our country, evolving that hopefully into beginning to look at some of the inequities. Today, Kellee I'm wondering if you might launch us into this historical discussion of racial inequities within healthcare in our country.

KR

Absolutely. I think it's really important to kind of understand how we got to where we are at the present day. This is definitely hundreds of years in the making. And it basically is rooted in the experience of black and brown folks in this country, particularly for African Americans. With the onset of slavery, the very institution came at the cost of dehumanizing and demoralizing the African slave. And so, that system was perpetuated over the years and has changed its space but still has the same undercurrent, and has led us to a place where social determinants are still an issue in minority communities—and that includes African Americans, Hispanic Americans, you know, our immigrant communities and that's just something that's historically happened to what society has kind of deemed as the underbelly, if you will, of society. It happened to Chinese Americans, it happened to immigrants from Europe at different times, so I mean this is kind of just a running theme within the American social context of how we see people and how we treat people. And unfortunately for some that ideology and that viewpoint has not changed, specifically for those of European descent. But what remains present day is a disproportionate health care allocation of resources for black and brown communities. It is absolutely rooted in systemic racism, which has its bearings and it's started with slavery.

EE

Thank you so much, Kellee. John, Terralon—I wonder if you'd like to add anything to that.

JV

Actually I would. You know my undergraduate degree is in bacteriology, my graduate is in microbiology, and I have a medical degree. But one of the things I had to learn about was genetics. 

And you know it's interesting to me that if you go back we know that slavery here in this country started in the 1600s and racism is a product of that slavery. Interestingly enough, Gregor Mendel who did the experiments that unlocked genetics for us was born in 1822. So, races were and racism started before we understood genetics, Charles Darwin, who saw how species evolve, was born in 1809. So, this whole idea of racism evolved before we understood evolution; races were determined before we understood genetics. So it's really kind of ironic that in medicine we claim to be science based, and yet we're using a concept that cannot possibly be based in science because it was invented. Before we understood genetics. And before we understood evolution, so if there's any strong argument that race and racism is fiction, and certainly not scientific I think that is it.

EE

Well, and thank you John. As you were speaking, I thought about a piece of data I recently came across. One of the most respected organization healthcare organizations in our country, the Kaiser Family Foundation, puts out a lot of respected data and they recently put out a poll that identified that barely 50% of black Americans trust what doctors say to do the right thing, whereas over 80% of white adults, trust them. Terralon, I know you've had some experiences within your family and communities that kind of speak to that, and I'm wondering if you might dive into that a little more for us.

TK

For sure I know we've, we've had conversations before about how the more educated we are, how culturally our mistrust still runs. So I was just remarking the other day that I was actually teaching my son about the Tuskegee syphilis experiment because he had to pick a history project that centered on communication and how communication has changed throughout history. And me, being the scientist, I wanted to inject, I wanted to teach him about informed consent, that was the first thing that popped in my mind. And so I thought what a great project to talk about how unborn consent, how human experimentation without consent is not legal. 

So I don't want to get too far off the mark but I just started thinking about, and I wanted to teach him about, how now how relevant that is about down—we have their clinical trial going on, related to the COVID-19 vaccine and how the development, but I've talked to many many family members, and I was astounded when I surveyed a number of family members who are very educated folks who are still not interested in getting the COVID-19 vaccine when it comes out. Almost 100% of them are against getting it, you know, at least when it first comes out. And it just took me back to the fact that the Tuskegee experiment. It wasn't actually that long ago. And here it is, you know, it ended in 1972. And so this you know this was run by our government. We're in 2020 and we’re generations removed. We're more educated, but we still that mistrust still runs so so deep so it's very interesting.

EE

Kellee, you turned me on to Harriet Washington's book Medical Apartheid. And it's just full of of events of exploitative and abusive experimentation that's happened over several centuries in our country, and, you know, even today, in 2020, I imagine that each of you and your communities must still be seeing we all see evidence examples of that distrust price still lingering and wonder if we might speak a little bit to what we're seeing today that that you feel might be just a carry on from that if you would.

KR

I think it manifests itself in a lot of ways, and to be quite honest with you, I think, for minority communities, just the inherent mistrust from years of being in a system that, you know, was stacked against you. And so, there are so many experiments of course the Tuskegee experiment is probably one of the more well known. I think the story of Henrietta Lacks, and how her cells have revolutionized medicine, and her family lives in poverty and died of some of the conditions that person her very sales were used to create chores for or treatment plans for is very telling and it says a lot about, you know, while a lot of things in our society have moved forward so many things have not. And so that mistrust  is very real, it's very palpable for a lot of black and brown communities, because their only interaction with the greater culture has been negative. A lot of times they live in communities that look like our folks look like they look, and they interact with folks who have similar experiences. And I've definitely heard in the hospital, more than, more than once. About Oh no, I'm not coming to the hospital y'all kill my mama, or you know y'all kill Big Mama, or you know y'all just trying to get us to take these drugs you know there's a perception that we make money off of the things that we prescribe.

But on the other side. I gained a lot of trust because I look like some of my patients, and that's a rarity. And it's very, I think, as African American physicians, we're aware that we're a rare unicorn in this field. But we're not always so conscious of that with every patient encounter and a lot of times, at least for me and in my experience, my patients bring that to my attention, you know they're looking at me, and they're like, Oh my god, you're a doctor? I've never had a black doctor before, and then the light bulb kind of goes on for me because it's not the first thing I think about, and going to a room I don't actually even know some of the time what the race of the person I'm going to be seeing is. I don't find that out until I get there. 

So, it is definitely still very pervasive within black and brown communities and there's so many issues so many social determinants that give people pause. We could talk for days about what some of those are but the most glaring that comes to my mind is the fact that it's 2020 and all six of us are in a different location, and we're all communicating, but Flint, Michigan doesn't have clean drinking water. You know, and we have medical mission trips to go abroad to provide well water and communities, and one of our own does not, you know, and so that's basic. We’re not talking about systemically changing the infrastructure of Flint's government, we're talking about water. And that's a battle we fall in one in third world countries. We're in arguably the richest, most powerful country and our citizens, mostly black and brown don't have clean drinking water in 2020, that I think that says everything

EE

John, I've heard you speak to some of the food issues that come up within the medical settings. What if you might elaborate on some of the additional social determinants of health and historically how you see that present in today's interactions with patients.

JV

Yeah. Food is very interesting. Food is not just nutrition. Very often when we're in medical school and they're teaching us things, they teach us about calories and diabetic diets and all those kinds of things. They talk about food as nutrients, you know and what we learn as we go along with it is a lot more than that, first of all, nutrients, vitamins, minerals, those kinds of things are expensive, calories are cheap. And that's one of the reasons why you find poor people are obese and people think, well, how is it that they're a poor and obese if they if they don't have money well, they have money for cheap calories, but they don't have the, the money for expensive nutrients and fresh. And then they may not have access to those expensive nutrients which are often found in fresh fruits and vegetables, and every. 

Many of us have heard of food deserts, where the only place you can get food is love, you know, at the dollar store and where they have canned and boxed goods. There's no fresh fruit, or produce within, within miles for some people. So, food is more than just those, those nutritional aspects of them. Everything about food is food is culture. Food is memories, food is an experience, food is family. You know food is celebration. I mean there's so much to it that you have to take that into account when you are taking care of your patients and if you don't understand your patients, it's very hard for you to understand the meaning of that you know you can't reasonably tell a black patient to to eat toast and cottage cheese you know i mean i don't know anybody in my neighborhood who eats cottage cheese. But that's kind of what they tell you in medical school. 

I'm in Seattle and I'm in the Pacific Northwest. And we have many Indian tribes. And, you know, it's kind of irritating to me when I hear them talk about when we hear experts quote unquote talk about the Mediterranean diet as an ideal diet for reducing heart disease. You know the original Northwest American, Native American diet had everything that Mediterranean that had lots of seafood salmon is very big out here, and fishing is a lot easier than hunting buffalo. So you eat a lot more fish than red meat if you're a Native American, lots of grains, maize or corn. It was a very healthy diet. And then what happened then. The government came along and gave some of the Indian tribes cheese and flour and starches and really kind of got them away from their traditional diets and the incidence of diabetes went sky high as did obesity in the Native American population. So again this is social determinants that by not understanding the value of the cultural diet and imposing on that culture, something that was foreign and really unhealthy. That caused a lot of health problems in the Native American population in this part of the world. So those are some of my thoughts about diet and about food, and the value of food and culture.

KR 

I love that comment about cheap calories and expensive nutrients—that's brilliant.

EE

When I'm listening to what all three of you have mentioned, personal or community interactions, I'm thinking about piece of data I came across on a different podcast I think John might have even been a part of, mentioning that the maternal mortality is about three to four times higher in black women giving birth than in the general population—and it was recently reported that black newborns have a greater chance of survival if they're cared for by a black physician. As a primarily Spanish speaker, when I go into a room for a native Spanish speaker and I begin interacting with them I can see on their face, the whole interaction changes and there's a trust that develops but you can attribute that to an obvious language difficulty. I wonder if you could speak a little bit to this data on improved survival for newborns cared for by black physicians. Can we dive into that a little bit more because there's got to be a whole lot in there, leading to those changes? Certainly beyond just language...

JV

Yeah, that was recently reported. So I can give you my ideas about it but I don't think it's been dove into very deeply, but this was interesting is that having a black physician for a newborn—particularly one that is premature—makes that baby much more likely to survive. Then having a provider or a physician of another race, that's not necessarily the case with maternal mortality, but it is with infant mortality. And the first thing that comes to my mind is how quickly do you write off a child and say this child is not going to make it?

I speculate that many black physicians who take care of black children are not going to write them off right out of the chute and say “Premature. Poor lung function, etc etc. Let me slow walk this.”  I think it's more likely that the black physician is going to say, “we got a chance here; let's give it everything we got.” And so that's my speculation as to why black infants have a better chance with a black practitioner,

TK 

I was thinking along the same lines as John I do think that we tend to, at least when I was in our nursery. We treat them like our own children, for we, especially those of us who who have children, we probably look at them as our own and probably like he said—I like that term “slow walk”—it a little bit. I definitely think that we look a little bit more closely and probably pay a little bit more attention, because I think we think of it as our community and our own kids, so I can't think of a stronger reason why. So, I totally agree with John on that point.

EE

When I think about the flip side of that for those of us that don't have that community understanding as Anglo physicians, we probably could be quick to label an activity as paranoid or strange when in fact they that may very well be a normal reaction for that particular community—whether it be a community of color or otherwise. I go back to Washington's Medical Apartheid, I think about what can we all do, those of us not of color, to gain deeper perception into some of those issues so we can be more cognizant at those important points.

KR 

One thing that came to my mind while I was listening to both Terralon and to John's speaking is when you think about your experiences when you travel abroad.

Let's say you're in Italy, and everybody is speaking Italian, and then you go into a bistro or a restaurant and you hear somebody who's American. You're both like, Hey, where are y'all from?? and it doesn't matter if you're black or white, or Hispanic—the common denominator is that we're all American, and then we'll start talking and there's no barrier there. And I think it underscores the fact that racism is so very American, because we even forget about it when we're not here in our country. It just brings us back to our genetic predisposition that “like goes with like.” And so when you're someplace else that makes you an outlier, you're just super excited to hear somebody speak English and you're not fumbling all over someone else's language. And you bond over that; you could sit down have a conversation, talk, share your vacation photos, and you know you can have this whole discourse placed in commonality. But if you go home, those same two families may walk past each other, and never say a mumbling word to each other because now we're back at home and you're black and I'm white, or I’m black and you're Hispanic, or whatever the dividing line is. And so, to John's credit about the comment with seeing yourself in a child, I think that also goes to just our sense of community, because for so long that's really what immigrant cultures, minority cultures were. Very community based, and we've always had to be, because we couldn't count on the larger infrastructure to support us. So the same thing is true even if you are in a situation where there's there's minority children or black child, and you're chaperoning, you tend to kind of coddle them and make sure that they're safe and okay because they're they're like you they're an extension of you, and you, you want them to see that hey I'm here, and I got you, I've got your back if you need. And so, you know, we don't all agree we're not a monolith, not all black people are the same. We don't grow up the same. And not every black person's in American black person right you can be from Jamaica, you can be from Africa, you can be from anywhere you can be from born in London. But here, it's a very American thing to look at someone and decide that you know everything about them. So I think, you know, just getting back to kind of like why the preemies probably do better and in the hands of someone who looks like them is because it's experience it's the sense of saying,

EE

I think we're coming towards the end of our time for this month's session, but I do feel like we've laid a strong foundation for tuning in next month, as far as where we are today, and where we might go moving forward. But there is one more piece of data I want to get your thoughts on. 

There was a study about five years ago from the American Hospital Association diversity study that mentioned that, while minorities make up 37% of the US population, they're only 14% of hospital board memberships, and only 11% of executive leadership posts. Now I have three black leaders here I'm speaking to and I feel fortunate to have you here. But do you have any thoughts on how we might continue to build on those numbers elsewhere?

TK 

It's interesting that you said minority. I'm not sure what the makeup of “minority” is, what that actually means...

EE 

I'll have to go back and look, but I believe that was looking at Black and Hispanics, Terralon. But I'll have to go back and look specifically at this study.

TK

I recently read that there are less African Americans admitted to medical school than there were back in the 1970s, which means that there are systems now in place that are actually keeping us out of medical school. There were more systems in place back in the 1970s to encourage our admissions to medical school. So we're actually going in the wrong direction right now, because now we make up, I believe, for anywhere from three to 5% of physicians. That was the last that I saw for African American in medical positions in this country. We really need systems in place that encourage more people who reflect the races of the people that we take care of. And that's the first thing that we need to do, because I wholeheartedly believe that we need to have people in place that take care of the communities that look like them and I think that will make for healthier communities and that's that's the one plug—that's the biggest thing that I see that we need to do first.

JV 

I would think that the numbers in medical leadership boards and medical organizations are probably not much different from other organizations because you know when it comes to boards and leadership, you're talking about our influence, and people very jealously guard their power and influence. You tend to find birds of a feather flocking together and inviting their friends and their associates when positions open up. That's one of the reasons why women were so scarce, and still are scarce, at the highest levels of power and leadership, because the men are guarding their privilege closely, so it's going to take time to kind of pry that power and privilege out of the hands of the current holders and into people who look more like the populations that are being served.

KR 

I think they both bring up really excellent points. I again would agree with John that medicine and healthcare are no different than the other industries. White men predominate anything with money and power; that's been historically true and it remains true.

The NFL, the NBA—essentially, black sports, there's maybe 1% of other minorities (and then I don't know what the percentages of white men in those leagues but it's probably 30% at best), but look who, you know, owns them. It just goes to show where power and influence are. When I was growing up there was like one black quarterback in the league at a time. And we're in an unprecedented time right now (I'm a huge football fan if it doesn't show!) where the top five quarterbacks in the league are black men. That's amazing. Now we need to see us in the upper echelons of ownership because that's where the real power and influence comes from, but it's not surprising. 

We've had 45 presidents; they've all been men. And we've only had one that's actually been Black or been minority, and that's of any ethnicity. So I mean, that just goes to tell you, you know, that it is what it is. There's a huge game of nepotism that's being played. And you can't get a seat at the table if you weren't invited there, and this is not a rank where you can just make your own seat at the table. Somebody's got to invite you in. And I think really what's more important in the conversation is figuring out why don't you want us at the table. What's so threatening about having a woman—whether she's black white or Asian or Hispanic? There's something about the female voice that they don't want. And there's something about minority representation that you don't want. Well, why that is is because we're going to have these types of conversations, this type of discourse. And when you're marketing and advertising and deciding where to spend your money, we're going to tell you “hey this league is 90% black, your money needs to go in those communities.” That's where you're picking your talent from, but that's not where you're putting your money. So that's really how you start moving the chess piece, and they don't want us at the table because we're going to start bringing up those issues that force them to make some changes. So, I think, we can go industry to industry healthcare sports, finance, God forbid politics, but you're going to see the same issue.

TK

So I think conversations like these are very helpful. So while we continue to have these conversations and continue to fight for a seat at the table, I think John and Kellee bring up a good point: We also need allies. I think that those are the keys.

EE 

Well if we can be just a small drop of positivity in that small pond that becomes a lake that becomes an ocean, that is what I'm hoping we can help with through our podcast today and I can't thank the three of you enough for helping us move this dialogue forward.

I think we have laid a strong historical foundation, and I do look forward to next month's conversation on where things are at now particularly within the COVID environment, and continued conversation about what we can do moving forward to improve things. We do ask all of our guests, when they speak to specific topics. If there are any particular resources, whether they be books or websites or even personal organizations that we might promote that you'd like our listeners to know about. And so, before we wrap up, let me ask each of you if you might have particular resources you'd like us to promote.

KR

I thank you again for the opportunity. It has been amazing. It's so refreshing when you can just talk to people who understand what we're talking about and are all on the same page. It just makes it easier, so again thank you so much for the opportunity. I do have several things in the in the works. I have a project that is scheduled to launch next month. But in the meantime, I would invite our listeners to follow me on Facebook. I am Dr. Kellee. I am a board certified internal medicine physician and equity and inclusion healthcare consultant. And so I have a lot of things that are coming in the pipeline in that vein, and I would love to engage with the listeners on those platforms. And thank you, again.

JV

I read a lot, so you there are books that I'd like people to think about. First would be How to be an Anti-Racist by Ibram Kendi. I think everybody should read that book if you want to understand racism and understand how to be an anti racist. The second book is Caste by Isabel Wilkerson. I thought that was a remarkable book—explaining how we live in a caste society, but we never talk about that, and racism is really sort of an overlay on caste. 

And my third book may be a surprise to you, which I read right after I read Caste is Hillbilly Elegy by JD Vance. This is a nice book to read in concert with Caste because Caste talks about the extremes in our society. However within each of those castes there are gradations—even among whites. There are the Nordic whites who are considered the model. And then there are the southern European whites—the Italians, Spaniards, etc. So, in the United States, you've got whites, but you've got hillbillies who are on the low end of the caste and what was remarkable to me is how you can separate some of the things that are actually cultural—and not racial—and you can see so many similarities in the culture of poverty regardless of the race. Poverty has its own culture, and poverty and black folks and the culture of poverty and hillbillies and white folks is really not that much different if you're astute enough to separate out what we call race from culture. So those are the three books that I would recommend for you to read.

EE  

Thank you John, and I will say I'm in the midst of Caste, and I find it fascinating and just a wonderful showing of how to view things that perhaps we've taken for granted for some time. And I also recommend Medical Apartheid, which Dr. Randle introduced me to. Dr. Knight, would you have any resources you'd like to recommend for our listeners?

TK

Much like Dr. Randle, I am working on a book, but it is much in its early stages. But I do a Facebook Live almost every Monday. I am a career transition coach; I help women who are considering moving from clinical careers to non clinical careers, or just are just contemplating. You can follow me on Facebook, Twitter, LinkedIn, you can follow me @DrTerralon. And I'm there every week. 

EE

Thank you very much, we will get those resources on our website as well to promote those. I can't thank you enough Dr. Knight, Dr. Randle, Dr. Vassall not only for joining us and helping lead this conversation, and for next month, but for the work you're doing both within our communities as well as within leadership. Thank you. Thank you for today, and I look forward to our conversation, next month.