Keywords

History of Latino and Student Advocacy

The revolution is not a quenepa that falls when it is ripe. You have to make it fall.

—Modified from Che Guevara, MD

Introduction

Latino history in the Americas is a pastiche of indigenous and African identities seen through the aperture of European cultural assimilation. The nascent story of advocacy within the Latino Medical Student Association (LMSA) builds on this identity, evolving from a long history of Latino health advocates.

Current trends in Latino advocacy within the United States have evolved as a response to U.S. militarization of its foreign policy within North America. These forces coalesced in the mid-twentieth century around a core of disenfranchised Mexican-American and Puerto Rican citizens who organized into advocacy groups such as the United Farm Workers (UFW) and the Young Lords Organization (YLO) to pursue health equity and social justice. Political movements led by cultural pioneers such as Cesar Chavez and Jose Jimenez created a precedent for prioritizing health care needs within Latino organized advocacy movements, but these efforts did not lead to meaningful Latino representation in political or academic institutions. Moreover, the heterogeneous characteristics of Latino communities in the U.S. promulgated ethnic and regional divides in advocacy initiatives. Political and healthcare trends since the 1960s highlight a need for physician leadership with training tailored to the Latino communities’ needs across the U.S.

Communities that have succeeded in creating political agency often have social structures that support continued generations of leaders and community enrichment. Failures to create similar Latino resources were not due to deficiencies of individual leaders, but reflect the lack of resilient academic structures that can galvanize organized policy development and community advocacy. Expanding on historical traditions of community advocacy LMSA developed policy programming that would allow physician trainees to advocate for Latino patients not only as clinicians, but also as community advocates, policy experts and leaders of academic health centers.

Recent health care reform in the United States has focused on policy solutions to rising epidemics of chronic disease, including several sections of the Patient Protection and Affordable Care Act (PPACA) that target disparities in underserved and marginalized communities [1]. Successful implementation of these and future systemic reforms will require a highly dedicated physician workforce with literacy in health policy. Latino health advocacy presents specific challenges, as Latinos are likely to have lower levels of health care access than comparable minority groups [2,3,4]. As the Latino community continues to grow to represent approximately 1 in 3 individuals in the U.S. by 2050 [5], so do the challenges of recruiting and training physician advocates.

Students and educators have shown interest in increasing their exposure to health policy training, [6, 7] and the Liaison Committee on Medical Education mentions health policy and advocacy within its current curricular standards [8]. However, few institutions have integrated the academic skills necessary for successful physician advocacy within their medical curricula. Physician advocacy organizations such as the American Medical Association (AMA) do provide practical health policy training opportunities for medical students, yet no educational setting focuses specifically on the healthcare needs of Latino communities, or attempts to foster an environment of creative policy innovation based on the Latino identity. Into this void stepped LMSA, creating a platform for Latino leadership development and community advocacy.

History of Medical Student Political Advocacy in the United States

In the 1950s the AMA developed a forum for students to participate in medical advocacy. The Civil Rights Movement, peace activism during the Vietnam War, and a push for systemic reform in health care led a group of progressive students to break from the AMA, forming the American Medical Student Association (AMSA). As a student-run organization without a physician counterpart, AMSA created a blueprint for the infrastructure needed for students seeking social change through student-driven discourse, legislative debate, and community advocacy.

Student advocacy did not end with the growth of AMSA, but rebounded across the country as various constituencies organized and advocated for the growth and improvement of the U.S. healthcare system. In 2014 students in the University of California San Francisco, Mount Sinai and Harvard collaborated over virtual platforms to protest worsening trends of police violence. Connected by shared ideals and a growing social media network, students coordinated seminars, protests and academic publications to advance the national discourse on race and ethnicity in both healthcare and medical education. Their work, and the contribution WC4BL made to the #BlackLivesMatters movement was reflected not only in reputable academic publications, but in the political debates that began to recognize the role race plays in U.S. society. If AMSA awakened the political consciousness of medical students in the United States, WC4BL showed how, armed with versatile social media platforms and reinvigorated beliefs in justice and humility in medicine, students could effectively change their surroundings. The rise of WC4BL lit a fire in the hearts and minds of medical students across the United States. The question now was whether the Latino community could harness the flames of creative destruction for the benefits of their education, patient care and public health.

Latino advocacy in health care during the Civil Rights Movement suffered from a lack of Latino leaders in leadership positions within the medical industry. The cohort of Latino medical students who were tasked with creating the LMSA policy process thus faced the challenge of building organizational infrastructure without institutional precedents or cultures of policy development. Educational theories of Frierer and Dewey further exemplified how policy programming can synergize with effective experiential educational content. The LMSA policy process strove to center scholastic programming on these ideals, integrating advocacy, structured mentoring, and competency development into a conference geared towards community advocacy and leadership development.

Maturation of Student Advocacy: Exploring the Basis for Latino Medical Student Advocacy

Medical students and residents have increasingly represented a progressive political reform agenda through their organizational advocacy work. The disruptive nature of rising generations of physicians in training, individuals who have yet to forget the ideals of humility, empathy and collaborative health that marked their initiation into medicine, drives the innovations and political reforms in medicine that has helped focus our health care systems on patients and the communities in which they live. However, prior to the development of policy programming, LMSA students existed without a clear educational forum for their growth and development as physician advocates. Organizations such as the Student National Medical Association (SNMA), with a historical grounding in the Civil Rights Movement and strong links to its physician counterpart, benefitted from an established professional network that provided mentoring and financial support. Without these resources Latino students could not easily avail themselves of educational curriculum based on their unified ethnic experience, participate in processes to share ideas and innovations tailored to Latino patient communities, or access national networks of Latino physicians who could role-model leadership in community advocacy and health politics.

In 2009 the national LMSA policy agenda was limited to its role within the AMA-Medical Student Section (AMA-MSS), where LMSA was awarded a position as an affiliated organization within its student House of Delegates. LMSA students were allowed to present resolutions and participate within the AMA-MSS’s general legislative process and didactic sessions, but this programming did not necessarily support the growth of Latino students as advocates for their communities. Scattered regional efforts to provide policy training within LMSA did take place, but were often sporadic and focused on regional priorities.

The years leading to the founding of the first LMSA sponsored advocacy programming in 2014 saw a political cataclysm that continues to define our society today. Students in LMSA saw the Latino voice ignored as neo-conservative constituencies attacked immigrant and minority communities, followed by legislative failures and continued militarization of U.S. immigration policy. Though progressive politicians gave voice to the travails of Latino communities, no successful legislative victories were obtained, and adoption of regulatory reforms such as Deferred Action Childhood Arrivals (DACA) received increasingly aggressive threats from conservative leadership.

Through these political trends grew the LMSA policy infrastructure, first implemented in the 2014 NHMA National Conference. Initially christened, the LMSA Student Policy Section (LMSA-SPS) conference programming allowed students to share their innovations in healthcare with their peers, and flourish in an environment that reaffirmed their cultural heritage. Unburdened by the social expectations as the only Latino representatives in a group of hundreds, as occurred in organizations such as AMA-MSS, LMSA students were free to grow and mature, to unlimber policy and academic skills that previously went unused or ignored. The LMSA policy process would grow into an annual policy conference that would cement the culture of policy education and community advocacy that continues today.

Developing LMSA Policy Programming

With just about every script (Orange is the New Black), in almost every corner of the set, I was faced with the truth: This was my parents’ life. My mother had sat in handcuffs; my father had once worn an orange jumpsuit…for Mami and Papi, it could not have been any more real or painful...they’d spent years handling the nastiest jobs, the ones often avoided by others. Manual labor. Low pay. No respect. They must’ve felt so trapped. It must’ve been so hard for them to maintain their dignity when others looked down on them or, worse, didn’t see them at all [9].

―Diane Guerrero, In the Country We Love: My Family Divided

The Academic Basis of the LMSA Policy Programming

LMSA policy infrastructure has thrived due to the academic foundations that support the educational content training students in health policy. The Kern model was used to develop a common narrative running through conference didactic sessions as well as interactive health policy learning activities [10]. Student organizers found synergy between the Kern model’s cognitive model for curriculum development and those used for policy development such as the CDC Policy Development Framework [11]. Combining these two frameworks allowed student facilitators to integrate educational and policy models into a single edifying experience where student growth coincided with community advocacy and systems reform. Through the non-traditional service-learning this engendered students participating in the LMSA-PS gained not only an understanding of the policy process and related topical content, but also practiced the skills of interpersonal communication, public speaking and leadership commonly used by successful physician advocates. The methodological approach of the Kern model also ensured novel curriculum met the needs of novice policy advocates, and evolved with the growth of an institutional culture grounded in health policy. These efforts created and maintained an active pool of students in LMSA who had the interest, understanding and ability to implement advocacy interventions in a professional, well organized manner.

Reflected in both policy and academic models, documentation and investigation of programming outcomes is a critical component of the Kern and CDC models. In addition to annual needs assessments, surveys embedded within LMSA educational and advocacy programming described participants general satisfaction as well as their perceptions of personal improvement in knowledge and competency-based learning objectives. Changes in behavior and tangible advocacy results was also monitored as participants experience in rally’s, legislative visits and the COD drove both advocacy initiatives in LMSA and leadership within students institutions and regionals.

Administrative Logistics Behind LMSA Policy Programming

Though LMSA has a history of community advocacy, student engagement in the novel policy process was not guaranteed as many students were inexperienced in policy development. Existing leadership understood the theoretical role of health policy in addressing Latino health disparities, but without leadership development purposefully targeting student advocacy and policy training the political agency of LMSA constituents was rudimentary. To assist in the evolution of LMSA policy resources, a National Policy committee was created to supervise programming in health policy. An equally important goal of the national policy committee was to identify individuals in regional and chapter leadership with interest in health policy. As policy-related educational programming grew within LMSA, prospective student leaders were recruited from active participants to help build on institutional knowledge and competencies. This process engendered peer-to-peer and faculty mentorship and stimulated candid group discussions on ongoing political trends. Student leaders were then dispatched to their individual regions and chapters to develop policy projects guided by the national policy platform.

Implementing policy initiatives through regional infrastructure provided additional opportunities for student leaders to receive targeted organizational support, empowering each to become conduits of ideas, innovations and educational materials between regional and national governing bodies The academic context in which LMSA policy programming was created also ensured student leaders were taught how to evaluate and publish their advocacy work. With the organization primed for a pivot towards a proactive advocacy stance, the national policy committee began to develop and implement programming that would establish a longitudinal policy training and development process. These efforts lead to the founding of the LMSA-Student Policy Section (LMSA-SPS), a predecessor to the LMSA Policy Summit template used today.

The LMSA-SPS

The first LMSA-SPS took place on March 27th–30th, 2014 at the National Hispanic Medical Associations annual conference. To begin the process of developing student participants’ foundational knowledge in health policy, the SPS hosted a brief series of conference lectures geared towards the novice student-advocate. Content was chosen based on an informal needs assessment which identified a deficiency of general health policy knowledge on historical political trends and advocacy-related competencies. The didactic series thus included sessions on basic policy nomenclature and definitions, the resolution writing process, and careers in health policy.

Following the scholastic series students were encouraged to participate in the first COD. Resolution submissions were limited to regional policy chairs to ensure a smooth inaugural event, and to help groom students for national policy leadership positions. Though resolutions were submitted by invitation only, the Congress was opened to all students. During the COD participants were encouraged to implement knowledge developed in previous lectures. In total 6 resolutions were proposed, debated and voted upon. The six resolutions submitted addressed the right to health care, health literacy, and diversity in medicine.

The SPS’s agenda combined traditional didactic programming with the active learning activities hosted by NHMA, allowing students to develop a fund of knowledge that could be reinforced by participation in advocacy events. Efforts were made to involve high profile Latino role-models such as Julian Castro, the 16th United States Secretary of Housing and Urban Development, who gave a virtual key-note address. Collaboration with the NHMA also created opportunities for students to network with policy leaders in medicine, public health, and non-governmental organizations.

To help defray the costs of student attendance several strategies were implemented to raise funds. Scripts were created for students to solicit donations from their institutional deans or office of diversity. Students were also encouraged to approach faculty mentors to help fund individual travel scholarships for mentees. In the first year approximately $700 was raised, helping to cover attendance for over 30 students. The 2014 conference set the precedent for content development, organizational discourse and fundraising in subsequent years, culminating in 2016 when LMSA transitioned to hosting a stand-alone policy conference, the LMSA-Policy Summit (LMSA-PS).

The use of the Kern model allowed LMSA student leadership to identify the lack of health policy training for medical students on Latino health and provided a framework to develop an educational intervention that addressed existing inadequacies [12]. Student advocacy groups that serve underrepresented ethnic minority groups may also benefit from a venue that focuses on providing scholastic and practical training in health policy centered on their identity. The process of developing and implementing the LMSA-PS, and its positive outcomes, elucidates the benefits similar policy and academic resources can provide to students of all ethnic and cultural backgrounds.

Ankeeta Mehta, DO, University of North Texas Health Science Center of Osteopathic Medicine Co-Founder of the LMSA Policy Committee and Student Summit 2014.

The creation of the first policy summit provided many challenges and learning experiences. I understood that implementing a large change in an established organization would be challenging; however, the challenges faced were different than the ones I initially anticipated. Throughout the development of the summit, I was met with hesitation from LMSA board members as well as supporters of the organization. No one wanted LMSA to become an advocacy only organization with a largely political mission; however, the policy committee and I strongly believed that it was important to equip members with the skills in resolution writing and advocacy in order to advocate for Latino patients throughout their careers as physicians. As a non-Latina, my passion for LMSA stemmed from wanting to improve health outcomes in one of the most medically underserved populations in the U.S. In my opinion, advocating for patients in a structured way and empowering others to continue to do so was imperative. Though other organizations’ infrastructures were used as guides to creating LMSA’s own, creating the infrastructure that met the needs of LMSA to allow for equal representation of all members was important. Many regions had experience with policy, therefore uniting the regions who did, and engaging the regions who did not was crucial to the success of the summit. All documents used to train members in the process had to be created as no curriculum for policy and advocacy existed within LMSA at the time. Balancing medical school responsibilities as well as creating this infrastructure was difficult, but the support of the policy committee, and the conviction of each member that this was a crucial initiative, made it possible. Although the first policy summit was a minor footnote of the NHMA annual conference, it led to a much larger summit in subsequent years with the addition of legislative visits shortly after. Many students who participated in the first summit seeked opportunities to be more involved with LMSA policy. The interest generated from the first policy summit grew quickly.

Dr. Franklyn Rocha Cabrero, MD, University of Illinois College of Medicine-Rockford, Past National VP of Policy 2015

I met Dr. Pamela Del Valle in 2014 at the national conference at the Baylor College of Medicine in Texas. She played a pivotal role in generating my policy interest. Dr. Del Valle, then a medical student, was part of the student policy leadership. The policy committee developed the national LMSA Policy Committee infrastructure, strategic vision and agenda, with support of the LMSA Board of Directors (Regional presidents). As a junior medical student finishing my term as an LMSA chapter president, I was ready to embark on a national leadership role in the organization. Although I had no experience, health policy captured my interest. The first LMSA-PS impacted my professional development forever, and was an impetus for personal and professional development. For me, this was an opportunity to develop the leadership structure of the Policy Committee. Dr. Mehta, Dr. Sola, and Dr. Del Valle participated in panel discussions promoting the accomplishments of the policy committee, including the successful development of policy committee workshops that sought to teach members how to be engaged in advocacy. This was developed in a time where policy curriculum in medical education focused in Latino health was non-existent.

Outcomes of the Inaugural LMSA Policy Conference

The success of the LMSA-SPS was measured by the level of student participation in the legislative process, as well as collaborative initiatives pursued by LMSA members after the policy section. The six resolutions submitted addressed the right to health care, health literacy, and diversity in medicine. Resolution authors were from an array of political, geographic and cultural backgrounds. Eight students and physicians acted as primary authors on resolutions, with an additional seventeen students providing testimony and expert witness during the COD. Only two contributors had past training in health policy, supporting the positive effect LMSA-SPS didactic programming had on participants’ knowledge and confidence in participating in policy exercises. Students who gave testimony before the COD included pre-medical students, medical students, and physician faculty members.

The overall mission of the LMSA-SPS was to help train future leaders in Latino health policy, and set a foundation for further maturation of LMSA as an organization focused on community advocacy. Participants’ increased involvement in policy activities represented an improvement in knowledge and competencies, and changes in behaviors and activities. Seven of the eight primary resolution writers gained further organizational policy leadership positions in addition to continued participation within the LMSA policy process. External collaborations blossomed, reaching into student and professional networks that provided important peer support, mentoring and role-modeling. In addition to a growing conference participation and policy leadership, the first LMSA policy conference helped engender collaborative advocacy initiatives that augmented future conference activities. External collaborations are discussed further in Sect. 5.

Post-Conference Activities

After the first conference, deliberate efforts were made to evaluate the policy experience of students participants at the SPS. Formal needs assessments were used to guide future educational and advocacy programming. Survey data showed an overwhelming interest in augmenting existing policy training curriculum and endorsed a belief that health policy is important to serve future patients. The inaugural SPS participants also showed increased confidence in their policy knowledge and competencies. Though these findings did not achieve statistical significance, they were useful in galvanizing support for further policy programming within LMSA.

Core objectives of the national policy committee evolved towards creating a streamlined, longitudinal, student driven policy development process that extended beyond a single annual conference. Regional leaders helped extend the effect of the SPS by inserting educational programming on health policy into subsequent regional conferences and local advocacy events. Students were encouraged to share their policy successes in peer-reviewed publications, develop collaborative projects with external student advocacy organizations, and expand innovative policy projects within home institutions. However, further growth would require dedicated administrative support from regional and national leadership. The national policy committee (2015) transitioned towards promoting policy committees within regional executive boards and creating sub-committees to work on specific policy projects. Educational materials were also distributed to LMSA chapters on the fundamental legislative policy skills, including resolution writing, testimony development and obtaining mastery of the parliamentary rules.

2015 LMSA-SPS

In March 2015, the second LMSA-SPS was held at the NHMA annual conference with similar educational and advocacy programming. With an opening of the legislative process to any student who wished to draft a resolution proposal, the number of submitted resolutions doubled. Topics addressed included the effects of social determinants of health, immigration reform, health in detention facilities, the founding of a scholarship supporting LGBTQ+ researchers, and school meals.

After a second year of organizational development, policy infrastructure in LMSA flourished into strong collaborations with external student organizations. Exciting alliances materialized with the BlackLivesMatter movement and by Students for a National Health Program (SNaHP), along with diversity initiatives sponsored by external advocacy organizations with interest in Latino leadership development. The policy committee structure continued to evolve in response to issues in Latino health relevant to participating medical students, including LGBTQ+ health and immigration reform. Health policy programming was codified through LMSA constitutional amendments, reinforcing not only policy-related didactics and the COD, but also collaborations with external advocacy organizations. These successes helped affirm the policy activities of LMSA and helped recruit ongoing support from institutions, faculty, and the growing LMSA student body.

Transition to the LMSA-Policy Summit (LMSA-PS)

Many factors contributed to the transition from the LMSA-SPS to the LMSA-PS. The transition started with the application of policies incorporated into the LMSA platform through the COD. In addition, a decision was made to search for alternative venues to the NHMA national conference. LMSA student leaders often felt that the sponsors of the NMHA National Conference at times perpetuated rather than remedied health inequities for Latino communities. For example, the decision by NMHA to have The Coca-Cola Company (TCCC) as a major sponsor, despite Latino children having higher childhood obesity rates than their peers at nearly all age groups [13], philosophically differed from how student leaders expected to champion Latino health equity. Student organizers of the 2014 and 2015 LMSA-SPS were also disappointed by the lack of partnership and collaboration afforded by NHMA. The student organizers were often given time slots that limited student engagement, inadequate meeting rooms (e.g. no AV equipment, limited spaces, lack of water), and last minute communication about changes in conference scheduling.

In response to these concerns, in 2016, LMSA student and faculty leaders, including Dr. Sola and Dr. Sánchez, met with Dr. Norma Poll-Hunter of the Association of American Medical Colleges (AAMC), leading to robust discussions on supporting health policy training amongst Latino communities. Sponsorship of the first annual, stand-alone LMSA health policy conference by AAMC in 2016, now titled the LMSA-Policy Summit (LMSA-PS), represented a major breakthrough. The AAMC was supportive of LMSA’s vision of curriculum focused on experiential training in health policy, combining leadership development in policy and academia, community outreach, and advocacy activities in Latino health.

The LMSA-Policy Summit: Kern Model as a Theoretical Framework

Introduction

Based on the successes of the SPS, the LMSA-PS evolved in several significant ways. The conference included an exhibitor fair, expanded didactic sessions, a student-led rally, and legislative visits with congressional officials. This required new efforts in fundraising and development of interactive programming. Students worked to raise funds through a mix of outreach to local businesses, networking with national Latino advocacy organizations, and sponsorship by both academic institutions and individual faculty mentors. Organizational collaboration extended beyond the AAMC to include exhibitors from the Congressional Hispanic Caucus Institute (CHCI), medical schools and professional advocacy organizations such as the Hispanic Serving Health Professional Schools (HSHPS).

Inspired by the educational pedagogy of Dewey and Friere, LMSA used student advocacy activities to drive the broader scope of didactic content centered on community advocacy. Three educational tracks were created, divided into the core elements of Latino Health, Academia in Health Policy, and Health Policy Skills. Facilitators ensured educational content complemented experiential activities within the conference programming, such as legislative visits, rallies and the COD. In this manner, LMSA linked knowledge development with policy competencies that could lead to effective community action. Below is a discussion of novel programming developed for the inaugural LMSA-PS, a model followed with fidelity by future policy leadership.

Health Care Rally

To kick-off conference activities and to energize student participants, the LMSA-PS began with a public rally titled “Social Justice in Latino Health Care’‘, where students marched to bring exposure to the unjust trends in Latino communities. Rally themes were informed by student discourse and advocacy activities focusing on immigration reform. Organizers created posters with messages such as ‘I’m a Bad Hombre”, “Trump is an Immigrant”, “Latinos Unidos for Health”, and ensured permits were granted to march in public spaces on Capitol Hill. Additional messages trumpeted at the rally emphasized the importance of healthcare access, immigration status, cultural humility, and the institutional and structural contributors to the healthcare burdens affecting Latino communities. Prior to their planned march to the Spirit of Justice Park, students gave speeches to rally-goers highlighting student advocacy efforts and the growing challenges facing immigrant communities. Though the students marched in the present, they followed the path laid by generations of Latinos in the United States from whom a culture of action, advocacy and reform was inherited. Lasting a quarter-mile, the rally linked historical militarization of U.S. foreign policy and military conquests of Mexico and Puerto Rico to ongoing attacks on Latino culture perpetrated by the conservative republican leaders of the time. The social justice rally had a high level of student participation, creating a sense of righteous action that permeated the remainder of the conference. Building off the work of students who participated in the WhiteCoats4BlackLives movement, social media became an important conduit to promote rally speeches with medical students. LMSA rally’s also became an important tool to advertise organizational priorities and stimulate civil action that was informed by ongoing student discourse.

Legislative Visits

Following the rally, students met to prepare for legislative visits with their elective officials. Senior student leaders on the policy committee identified elected officials who either came from a Latino background, represented large Latino constituencies or whose agenda included issues relevant to the LMSA policy platform. Scheduling meetings with elected officials presented a unique challenge for conference planners due to their busy agendas. Congressional offices were called and emailed regularly to stimulate engagement with congressional staffers and publicize the existence of LMSA and its activities in the Latino community. These efforts produced successful meetings with prominent Democrat and Republican leaders from multiple states including New York, California, Texas and Massachusetts. Congressional representatives included representatives Serrano, Napolitano, Warren, Cruz, and Cornyn, among others.

Prior to each legislative visit students discussed organizational priorities and best practices in how to interact with congressional staff. Students then divided into smaller workgroups each assigned a set of elected officials. Within each workgroup, student participants were assigned specific roles that included discussion of the mission and history of LMSA, the reach of LMSA constituents, review of LMSA’s advocacy priorities, and ensuring continued communication with elected officials over the coming year. More than 25 students representing political constituencies from 10 different states were trained rigorously on strategies to ensure a successful legislative visit, including the art of persuasion, political etiquette, and 2-minute “elevator speech” interpersonal communication skills. The policy committee provided biographies, legislative histories, talking points, and summary of issues for each work-group. These supporting documents were critical in ensuring student attendees were able to present professional expertise on the topics discussed, the organization’s goal as policy advocates, and actionable items elected officials could take to address concerning trends in Latino health. Topics of discussion included healthcare access, DACA, immigration health, the Latino physician workforce, and mental health.

Networking and Mentorship

The first evening of the Policy Summit was an opportunity for LMSA members to meet, converse with peers, and share experiences from the day of marching on Capitol Hill and interacting with their Congressional representatives. At a networking activity sponsored by the AMA-Minority Affairs Committee, students had the opportunity to interact with physician and student leaders, sharing best practices on academic growth and professional development. The sponsored networking event represented an important organizational milestone where a professional advocacy organization legitimized the outstanding success of LMSA and reinforced the need for venues dedicated to policy-related leadership development within the Latino community.

Keynote Speakers and Panel

The second day of the LMSA-PS offered the first opportunities for students to meet policy leaders working in academic institutions, government agencies, and advocacy organizations through a series of addresses and didactic sessions. Karen Fisher J.D., Chief Public Policy Officer for the AAMC, welcomed students to the LMSA-PS, focusing on federal advocacy efforts to promote academic medicine. Captain Kenneth Dominguez M.D. M.P.H., a prominent public health leader involved in the HIV/AIDS epidemic, discussed trends in infectious diseases in marginalized communities and his professional arc as a CDC employee. Dr. Kathy Sykes Ph.D. gave the keynote address as the Senior Advisor for Aging and Public Health of the Environmental Protection Agency (EPA), discussing efforts to develop health policy regulations addressing Latino health disparities.

The morning session concluded with a panel discussion populated by veteran health policy advocates and the previous speakers, allowing interactive discussions with students on contemporary healthcare issues faced by Latino patients. Panelists accentuated their professional and academic experiences in health policy, including the pursuit of professional networks, influential mentors, and strategies to promulgate policy platforms into real impact in the Latino communities. This interactive panel prepared students for the subsequent small group breakout sessions offered within 3 tracks addressing Latino Health, Leadership and Academica, and Health Policy Skills (see figure for detailed list). Throughout the day participants were also invited to an exhibitor fair with over 20 booths representing academic and advocacy institutions. A poster fair held during breaks between sessions allowed students to share success in advocacy research and stimulated further evidence-based discourse on health care reform.

LMSA Congress of Delegates

Informed by health policy programming in external organizations, the LMSA policy development process centered on the legislative activities in the Congress of Delegates (COD), held on the third day of the LMSA-PS. The COD helped guide future LMSA advocacy programming, shaped policy-related educational offerings and set the boundaries for political activities within the organization. Within each congressional session students presented their resolutions for debate, which were then voted upon by nominated regional delegates. Potential actions taken on resolutions included adoption, non-adoption, tabling for further research, or referral to the National Board for discussion. A simple majority was necessary for adoption of most resolutions, though those involving reforms to the organizational constitution required support from two-thirds of voting delegates.

Though voting was limited to regional delegations, all students were invited to provide testimony for or against proposed resolutions. Representatives with relevant professional expertise from external organizations, as well as individuals with relevant professional expertise, were invited to provide testimony before the Congress. Like the U.S. political system, resolution language was actively amended while on the congressional floor using parliamentarian rules of order. Approved resolutions became part of the LMSA policy platform.

To ensure policy resolutions submitted to the COD met the organization’s professional and academic standards, student participants were encouraged to work through a methodical preparatory process. After identifying a problem amenable to policy solutions, students were encouraged to share their research and policy proposals with regional leadership. Drafted resolutions were then presented to the virtual reference committee, an online forum allowing regional boards, national leadership, and topical experts to review and comment on proposed resolutions. Feedback provided to student participants can include general advice, suggested word-smithing and strategic planning that foreshadows likely points of debate on the floor of the COD. The national policy committee also reviewed each submitted resolution, providing commentary that contextualizes proposed policy actions within the historical precedent and ongoing policy activities of LMSA. Through this process students received expert opinion both on their resolutions topical content and the internal political and administrative levers that could be utilized to implement each proposal. The period between the virtual reference committee and the COD allowed regions to discuss submitted resolutions with voting delegates while students perfected their legislative proposals.

Procedural aspects modeled from the AMA-MSS included a modified parliamentary version of Robert’s Rules of Order, and the infrastructure used to provide educational and mentoring programming necessary to support a student-run legislative process. AMSA structure was utilized less regarding procedural infrastructure but provided a template for a student-driven policy and educational process. Most importantly, adaptations ensured that the systems built around the LMSA policy programming centered on the experiences of Latino students and patient communities.

Resolutions submitted to the 2016 Congress addressed corporate influence on medical organizations, voting rights for Latinos, diversification of the workforce, and immigration health. After the energetic, organized chaos of legislative testimony and debate, LMSA delegates moved to approve 18 of the proposed resolutions. With these inputs the LMSA policy platform grew to reflect the needs and concerns of Latino medical students across the U.S.

Evolution of LMSA Infrastructure

If you’re not careful, the newspapers will have you hating the people who are being oppressed, and loving the people who are doing the oppressing.

El-Hajj Malik El-Shabazz Malcolm X

Evolution of Advocacy Strategies in the LMSA Policy Committee

The 2016–2017 years were notable for a divergence in the policy strategies and vision of LMSA leadership. The student founders of LMSA policy infrastructure had a goal of not only educating LMSA students in health policy, but also building specific competencies that could be actively applied. To date these goals coincided with the vision of academic development embodied within the mission and goals of LMSA. The nascent years of the LMSA policy infrastructure flourished within national political discourse guided by political leaders whose interest paralleled LMSA goals of health equity, immigration reform and public safety.

The rise, and electoral success, of conservative populism that culminated in the election.

of Donald Trump changed these factors. A group of student advocates within LMSA pushed for further political action, using LMSA resources and brand to counter the escalating vilification of Latino communities. Specifically, efforts were made to have LMSA actively advocate for students who had accepted DACA status by raising funds, actively contributing to the political discourse and creating a presence within rally’s taking place across the country. However, as this evolution was seen as a transition to partisan politics that could place the organizations academic mission at risk, a chiasm grew in the organizational leadership that saw a small cohort of students leave LMSA to apply their efforts in external organizations with a higher focus on committing resources towards tangible outcomes within the Latino community. Academic development, peer-support and policy training became a larger focus within the organization, limiting resources dedicated to direct political action.

During this re-alignment towards an academic context, other caucuses hosted by LMSA also suffered. The 4 caucuses recognized by the LMSA policy committee in 2016, including those focused on LGBTQ+, immigrant and Latina communities, and health care equity, became inactive in 2017. Though these continue to be themes highlighted within the organizational policy platform, lack of structured support led many active students to migrate to external organizations. In lieu of these advocacy activities, further resources were dedicated to the development of academic resources addressing policy training.

Yaritzy M Astudillo, MD, New York Medical College’20, LMSA Chair of Policy 2018–2020, incoming fellow Ann & Robert H. Lurie Children’s Hospital of Chicago

I was first invited to learn more about the policy resolution process by the 2016–2017 Chair of Policy, Tania Marin- Saquicela. My interest in the LMSA had been present as chapter president at NYMC and policy piqued my interest. I had not had any experience with health policy although I knew I wanted to learn more about the underpinnings of achieving healthcare goals within our system and I specifically wanted to understand this within and for the Latino community. Dr. Marin- Saquicela took me under her wing and exposed me to the community that is the LMSA and specifically the health policy committee. Through time I learned the resolution process, led the following year’s effort, and was Chair from 2018–2020 leading two Health Policy Summits in Washington DC. I grew tremendously working on developing a space in which physicians-in-training could better inform their work and efforts in policy, advocacy, and community.

LMSA-PS Programming - 2017–2019

The purpose of LMSA-PS has remained to provide a venue for medical student leaders across the U.S. to share in the practical and scholastic lessons of health policy. Over the following years the LMSA Policy Summit became one of the most popular events of the LMSA calendar, attracting from 100 to 150 students for training, networking, and advocacy opportunities. It has led to widened interactions between the LMSA and medical students with government and local agencies. The second and third LMSA-PS continued along the in-person format, composed of a rally, legislative visits, didactic sessions and a legislative session over a 3 day period. Policy debates in the 2017 COD ranged from supporting internal resource development such as additional Medical Spanish curricula and anti-racism/anti-ethnoracism in medical education, to addressing specific legislation before the House and Senate such as the Resident Physician Shortage Reduction Act of 2017. Resolutions in 2018 were equally diverse, there was a continued focus on medical education as well as research with the vision of advancing health equity. Academic medicine saw resolutions providing additional resources for the recruitment and development of faculty from under-represented minority backgrounds. Advocacy efforts had a strong focus on mental health and gun violence both on legislation and community work. There was also support for post-Hurricane Maria resources in Puerto Rico. The two conferences together accepted 28 resolutions that had the dual functions of introducing LMSA to new policy topics while building on common themes of Latino academic development, support for specific sub-groups within the Latino community, and general health care reform. The LMSA programming in this period saw growth and continued support from the academic community as students made it clear health policy was an area of importance to medical trainees.

LMSA Policy Process 2019–2021

2019–2020 saw the beginning of a changing tide with upheaval within the global community, as marginalized communities bore the brunt of the COVID-19 pandemic and mis-steps in the governmental response. Within this environment LMSA faced methodologic challenges, as requirements for virtual programming raised problems for a conference that was based on in-person, active participation. In response to the transition to virtual life, LMSA worked to develop virtual advocacy programming that could continue to honor learners’ needs and address political trends affecting LHS+ communities. One example was a national virtual advocacy event held in response to family separations at ICE detention centers. Regional and national policy chairs organized a large advocacy effort titled: Cage-in: White Coats for Human Rights Nationwide Rally, a virtual rally where students provided testimonies to advocate for humane treatment of people in immigration detention centers. The 2020 and 2021 policy summits were also held virtually. Through the efforts of student leaders, fidelity was maintained to the original LMSA-PS conference template. Policy discussions continued to evolve with the ongoing political trends in the United States, focusing on immigrant health, resource allocation during the COVID-19 epidemic, and LHS+ leadership development. The creation of the LMSA Policy Curriculum in 2019 as a virtual educational experience complemented these moves towards the non-traditional approach to policy and leadership development taken by LMSA students.

Creation of the LMSA Policy Curriculum

To further enhance policy training, a longitudinal policy curriculum was developed and implemented in 2019. Curriculum development followed the Kern Model and was divided into two sections. Modules that addressed funds of knowledge, each composed of pre-lecture reading materials, recorded lecture and an in-person virtual review session. Content was driven by learners’ needs assessments and included topics ranging from introductory health policy information to policy trends within the LGBTQ+ and immigrant communities, COVID policy responses and the pharmaceutical industrial complex. Student-run informal review sessions allowed learners to contextualize each module’s learning objectives within the current political environment through candid, peer-driven discourse.

Workshops requiring active student participation were developed in concert with didactic programming, creating a space where students could apply foundational knowledge gained in previous didactics. Competency based workshops address health policy communications, developing advocacy programming, resolution writing and legislative debate. These workshops actively involved students using small-group breakout sessions where work-groups discussed specific policy topics and worked on drafting resolutions, communication, advocacy and legislative plans in more intimate settings. Each workshop ended with assignments that allowed students to work directly with faculty mentors on policy topics of personal interest. Efforts were made to ensure the workshop schedule fit into organizational programming, improving the quality of legislative debates, communications with external organizations and constituents, and advocacy programming implemented at chapter and regional levels.

Curriculum facilitators strove to ensure educational content reflected the needs of learners as student interest frequently evolved. Ongoing surveys assessed students’ interest in specific topics and the quality of scholastic programming using qualitative and quantitative methods within the Kern model of curriculum development. Adjustments continued to be made as students’ interest followed policy trends of the day. Facilitators also made efforts to highlight the open nature of the curriculum, inviting students to create new content, lead review or workshop sessions, and modify curricular schedules to meet the specific needs of student learners. When paired with LMSA policy programming, the curriculum provided a powerful tool for leadership development and training.

LMSA Policy Outcomes

Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly.

— Martin Luther King “Letter from Birmingham Jail,” April 16, 1963

LGBTQ+ Caucus

The LGBTQ+ caucus exemplified how LMSA policy programming catalyzed both discourse and political action on health care issues important to Latino communities. In 2014, a group of students self-organized into the LMSA LGBTQ+ caucus after identifying an absence of policy language addressing Latino LGBTQ+ disparities in LMSA and other advocacy organizations. The caucus was able to gain an evidence-based understanding of Latino LGBTQ+ health trends and submit a policy resolution for the 2015 COD. They then educated their peers on Latino LGBTQ+ issues by contributing to conference programming development and encouraging organizational discourse on the role of LGBTQ+ communities within the Latino experience. The caucus grew, achieving recognition of the dual marginalization of Latino LGBTQ+ individuals and creating a funded scholarship to support LGBTQ+ research after the 2015 COD. Additional caucus activities included holding regular meetings to develop content and collaborate with external organizations such as GLMA, an advocacy organization representing sexual minorities in medicine. The LGBTQ+ caucus leveraged its organizational connections to successfully pursue adoption of policy language within advocacy organizations such as the NHMA and Hispanic Serving Health Professional Schools recognizing the role of LGBTQ+ individuals in ethnic-minority communities Participants in the caucus published their work in a pub-med listed journal LGBT Health [14], and created a template for additional caucuses to be developed including an Immigration caucus, Women in Medicine caucus, and a Puerto Rican caucus.

Immigration Caucus

In 2014, a group of Deferred Action Childhood Arrivals (DACA) -eligible students joined the LMSA policy committee, looking for peer support and a venue to advocate for their rights within the United States. This group of leaders became the seed of the LMSA Immigration Caucus, a collection of students, residents, and physicians focused on advocating for the rights of immigrant medical students and the patients they served. The immigration caucus was formally created in summer 2015 and was a driving force behind increasing LMSA activity in the immigrant-advocacy community. The immigration caucus worked to ensure LMSA continued to advance academic discourse on immigration, establishing immigration themes in newsletter and conference programming. Student leadership collaborated with advocacy organizations such as the PHD Dreamers, Loyola University medical school and Chicago Medical Association, among others. They hosted community rallies, institutional teach-ins and published in local media.

The 2016 elections also energized student policy leaders to develop structured advocacy initiatives, leading to the creation of a GoFundMe campaign to support DACA students along with continued contributions to policy discourse and movements towards civil disobedience. These initiatives were eventually shelved in early 2017 to protect the academic agenda of LMSA and its institutional relationships, leading to an exodus of student leaders in the Immigration Caucus to alternative advocacy organizations more active in the ongoing political discourse on immigration policy in the United States.

Corporate Sponsorship

Students active in early LMSA policy programming honed many of their skills collaborating with student groups on the role of corporate sponsorship within medical advocacy organizations. Advocacy initiatives included the creation and distribution of marketing materials such as fliers and pins, soliciting signatories on petitions, and publications in regional medical newsletters. All these activities were aimed at increasing awareness of the business practices that feed into growing pandemics of metabolic disease in Latino communities. These initiatives created friction with NHMA, whose mission of reversing trends in Latino health care were seen to be at odds with direct and visible organizational sponsorship by companies such as The Coca-Cola Company (TCCC). Recognition given by NHMA to TCCC marketing highlighting lack of exercise as drivers of metabolic disease over consumption of sugar-sweetened beverages was also incompatible with the growing LMSA policy platform. Though both NHMA and LMSA were natural partners in policy development and implementation, these differences led to the organizational divergence after confrontations between students and TCCC marketing staff at the second LMSA-SPS, held in conjunction with the annual NHMA conference. In response to failed attempts to end the corporate relationship between NHMA and TCCC, LMSA students adopted policies in the 2016 COD that not only advocated against supporting the business model of the sugar-sweetened beverage industry, but also pushed Latino leadership to limit the industry’s targeted advertising towards children in communities of color. Whereas TCCC and NHMA’s relationship was evident at the NHMA Annual Conference, the group of student advocates were able to dissolve sponsorship relationships between medical organizations such as the American Academy of Family Physicians, a primary-care advocacy group, and TCCC.

LMSA External Policy Work: Coalitions with External Advocacy Organizations

While LMSA continued to develop internal policy structures and programming, the organization also enjoyed robust external collaborations on specific advocacy initiatives. An early collaborator was WhiteCoats4BlackLives, which had a presence in the 2014 LMSA-SPS. With the adoption of policy language in 2015 condemning the excessive use of police force in Afro-Latino and African American communities, LMSA had a platform from which organizational participation in the 2015 #ActionsSpeakLouder advocacy event could occur. #ActionSpeaksLouder called on academic medical centers to take action on social injustices perpetrated in their local communities. Medical students across the country were provided an advocacy tool-kit to help develop and submit videos asking their institutions to promote equity in health care and education. Additional collaborators included Students for a National Health Program (SNaHP), AMSA, SNMA, and the NHMA-Committee of Interns and Residents (CIR). By leveraging the policy development process, LMSA students were able to guide internal policies that facilitated collaborations with national student movements that responded to unfolding cultural events.

SNaHP, a student organization focused on supporting universal health care in the United States, became an ongoing collaborator with LMSA. Student leaders from SNaHP participated in legislative sessions, leading to the adoption of resolution language pledging organizational support for a single payer system. The adopted policy allowed LMSA to be an active member in a SNaHP led national initiative titled “Ten One Medicare for All”. Activities included a vigil and action day, along with programming promoting health equity, access to health care, and racial justice. LMSA joined numerous local, state, and national organizations in the push for health care reform.

The AMA had a historical reputation for failing to include the voice of historically marginalized communities in their political advocacy. Leveraging skills gained in LMSA policy programming, Latino students were able to challenge this organizational status-quo through the AMA-MSS resolution process. Writing resolutions, debating policies on the legislative floor, and establishing coalitions that would advance LMSA’s organizational priorities allowed for recruitment of additional financial resources used in PS development, most tangible with sponsorship of policy networking events. Additional policies pursued within AMA student policy infrastructure included advocacy for DACA students, improving health care standards provided in immigrant facilities, limiting access to sugar-sweetened beverages, police brutality, and LGBTQ+ rights, among others.

An active advocacy presence within the AMA allowed LMSA contributions to the Young Health Pipeline Program Initiative, a mentoring program which supported collaboration between a wide range of advocacy organizations. Composed of representatives from AMA, SNMA, LMSA, the Asian Pacific American Medical Student Association and AMSA, the National Outreach Diversity Coalition worked on a common goal of supporting marginalized student communities pursuit of healthcare careers through structured mentorship and role-modeling. This initiative included strategic planning, awareness, and mentoring toolkits distributed to LMSA chapters across the country. Although the coalition was temporary, it showcased how students activated by the LMSA policy process were able to work across organizations to pursue equity and representation within medical organizations.

Publications

Academic and scholarly activity within the LMSA policy infrastructure became an important tool to validate, quantify and communicate the impact of the experiential policy curriculum. Ranging from peer-reviewed, data-driven publications to editorials and public communiques, students were encouraged to transform their policy work into publishable content. Publication of the successes of the LGBTQ+ caucus was discussed previously, but additional peer reviewed publications emphasized student interest and activity within LMSA. Adopted resolutions in the 2015 COD led to an editorial written by students interested in reform of firearm and policing policies. “Medicine, not Bullets for our Patients’‘, published in a blog hosted by the Huffington Post [15], described the case of Alan Pean, a patient receiving acute psychiatric care in a hospital in Texas who suffered from the effects of implicit bias, systemic racism, and aggressive escalation techniques inappropriate in a healthcare setting. Students advocating against corporate sponsorship published editorials in several state medical journals. Student facilitators also shared their educational innovations in peer-reviewed venues such as MedEdPORTAL and in evidence-based blogs such as PolicyRx.

In addition to external publications, LMSA sponsored several internal publications to ensure students could contribute to ongoing discourse on policy topics of interest. At different times these have included policy newsletters, journals, and regional communications. For example, in the LMSA Policy Committee 2016 newsletter, several members submitted policy papers on healthcare issues regarding the candidates Hilary Clinton and Donald Trump, police brutality as a social determinant of health, Texas’s bill HB2 impact on Latina health access and rights related to conception, immigration law reform, and how to build coalitions within organized medicine.

Conclusion

Un pueblo ignorante es un instrumento ciego de su propia destrucción; la ambición, la intriga, abusan de la credulidad y de la inexperiencia de ciudadanos ajenos de todo conocimiento político (Ignorant people are the instrument of their own blind destruction…)

—Simón Bolívar, “El Libertador: Writings of Simón Bolívar”

The Latino medical student advocate in 2023 and beyond has a range of advocacy options to work on, from continued attacks from conservative leadership to increased levels of morbidity and mortality due to COVD-19 and other health stressors. It may be easy to loose hope in the morass of inequity and discrimination present in the U.S. Yet the need exists for continued advocacy efforts as political entities in the U.S. implement agendas contradictory to the general moral beliefs held by a majority of Americans.

The development of student driven policy infrastructure, including a longitudinal policy curriculum and the annual Policy Summit, has sparked enormous health policy interest in LMSA leaders and members, with an exciting trail of local, regional, and national advocacy events. To create a LHS+ physician workforce that has the tools to advocate for their community, it is important to provide early educational experiences in health policy and advocacy. The absence of policy curriculum in traditional medical education highlights the need for academic organizations such as LMSA to supplement existing scholastic resources. Challenges remain for medical students pursuing systemic reform. Limited protected time for advocacy within a rigorous clinical curriculum, lack of focus or funding for policy research and action in medical schools, the disparities in LHS+ matriculation, scarcity of LHS+ senior faculty mentors, and lack of structured programs that can help LHS+ students focus on their community advocacy projects all work towards the degradation of an empowered LHS+ physician workforce. This further emphasizes the importance of developing and training LHS+ student leaders that can obtain leadership positions in private and public institutions to influence policy trends in the United States. As we now stand on the shoulders of community LHS+ who fought for recognition during the Civil Rights Movement, future students will use the infrastructure developed by the early LMSA policy committee’s to further improve the LHS+ experience in the United States.

The future for LMSA student leadership is bright. As we move towards a country that values diversity, equity, and inclusion of marginalized communities, it is imperative that we understand where we came from. A study of the past shows that history will repeat itself, and it is the duty of future LHS+ advocates to ensure our community prepares itself to face the bigotry, xenophobism, ethnoracism, and racism that will undoubtedly manifest in future political and social trends. With these tools the LHS+ community can only succeed, and ensure our children, and our children’s children, are able to pursue the pan-American dream of freedom in actions and beliefs.