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The demise of the 'racial reckoning' that followed George Floyd's death in 2020 occurred without definition, scrutiny or attempts to revive it. In this compelling new book, David Dante Troutt explores the 'what,' 'so what' and 'now what' of this period when much of the US sidelined the pandemic to confront racial inequality. It details how a rare focus on embedded racism shifted toward awareness, leaving deep disparities in wealth, health and policing unaddressed, and how this was overpowered by an enduring conservative backlash. Troutt unpacks how legal doctrine favored colorblindness over inequality, and examines government policies that created segregated zones of racial bargaining in health and wealth. The book also exposes deterrence-proof policing rules and explains the problems and promises of DEI. Reckoning the Racial Reckoning argues that democratic struggles over local resources are essential for creating justice and well-being for Black American communities, and ultimately for all Americans.
Racial reckoning should only address material racial inequality, not mere claims of hypothetical constitutional injury. This chapter defines racial inequality in measurable, visible terms and shows how Blacks experience disadvantage in institutional environments. Place, or residency, determines the access to resources that flow from key institutions like schools, neighborhoods and social capital networks. Place has a leveraging effect, amplifying advantages for some and compounding disadvantage for others. Less visible, race-neutral means perpetuate racially segregated places. The chapter shows how conservative constitutional doctrine conspicuously ignores these mechanics of inequality, and produces empirically bizarre results like the Supreme Court’s 2023 anti-affirmative action opinion about getting into Harvard. Colorblind antidiscrimination law offers a radical view of equality at odds with lived reality and core principles of racial equity, which reproduces more inequality.
This chapter reintroduces the U.S. mood in the spring of 2020 when George Floyd’s death and the Covid pandemic launched an uncanny “racial reckoning” based more on awareness of racism than accountability. The focus on one and not the other proved a shortcoming that contributed to a backlash that continues under the Trump presidency. The organization of the book shows that racial reckoning involved three major areas of racial inequality: disparities in policing, wealth and health. Future chapters present evidence that accountability is necessary despite the rise of federal legal and political developments in support of white supremacy and the denial of racial inequality to Blacks. The book ultimately argues that racial reckoning resembles Black wellbeing, which reflects the goals of most Americans and may be most achievable through local democracy.
This chapter examines how Covid-19’s devastating effects on Black people’s health and mortality reflected their overexposure to risk based on socioeconomic inequality, a disproportionate incidence of “underlying health conditions” and a distinct lack of trust in American healthcare. The combination shortens Black lives at all times. Racial reckoning after Covid demands asking why Black people suffer so many racial health disparities in the first place. This critical public health question leads to discoveries about the social determinants of health and the experience of pervasive implicit bias among healthcare professionals. All the underlying conditions associated with dying from Covid are exacerbated by environment and treatment dynamics that weaken trust, produce toxic psychological stresses and, unless reckoned with, put Blacks at heightened risk of the next pandemic.
This chapter argues that disproportionate police brutality against Black people is a fact of every American generation because the systems of oversight are not designed to deter it. The history of unchecked misconduct shows that criminal charges are almost unheard of because police criminality is not perceived as criminal. Civil constraints also face numerous structural obstacles--from a failure to monitor to a range of doctrinal roadblocks judges have imposed on federal civil rights laws. Many cases never get to court because of administrative hurdles drafted into collective bargaining agreements. Despite a small number of exceptions, the consistent result is a mutual lack of trust between Black communities and the public safety officers they count on and a systemic lack of deterrence when policing goes wrong.
This chapter reviews the 2020 “racial reckoning”, critiques its unfinished approach, evaluates the backlash against it and chronicles the rise of racial retribution with the second Trump administration. The original protests sought only awareness of racism in policing, wealth inequality and racial health disparities, not the accountability that could bring about structural changes in material inequalities. The Black struggle over inequality required recognizing racial equity as a core American value, something identity-oriented awareness and DEI programs could not establish. Instead, a structural backlash unwound performative support for reckoning and supported a radical inversion of antidiscrimination aligned with both a MAGA Republican political ideology and a Federalist Society legal movement called colorblindness. The country’s cynical pundulation on race undermined reckoning, challenging future progress.
The racial wealth gap, risks of housing displacement and lack of affordability that we see in unequal racial terms today has clear roots in urban renewal policies of post-WWII America. This chapter examines how the massive urbanization of Blacks in American cities as a result of the Great Migration led to race-conscious policies at the federal and local levels, entrenching segregation as a national policy and dictating the economic terms of Black-identified neighborhoods ever since. Urban renewal was a grand racial bargain. It destroyed hundreds of vulnerable communities at the same time other U.S. policies created generational wealth for non-Blacks through policies we call the American Dream. This chapter shows the decades-long accumulation of economic harms called “racial bargaining” as an example of systemic racism by modern U.S. governments.
This chapter is a critical evaluation of DEI, which became confused for racial reckoning and a target for the continuing backlash. It argues that there are two strains of DEI, the more popular corporatized DEI that seeks enhanced institutional belonging and economic pluralism and the more inclusive DEI that values increased representation of groups left out. Only inclusive DEI offers remedial possibilities for racial reckoning. Historically, both versions of diversity emerged as compromise positions for true racial accountability after remedial objectives were discarded by the Supreme Court in cases like Bakke. However, the viciousness of recent attacks on diversity and DEI by both conservative judges and the second Trump administration demonstrate its continued importance as an idea associated with racial reckoning, which must be vigorously defended on First Amendment grounds or risk the disappearance of Black presence and the erasure of Black identity.
This chapter argues that racial reckoning may mean something more to Black people than either awareness or accountability for racial inequality—it may mean material wellbeing. It tells the little-known story of 21st century Black migration away from traditional Back-identified urban spaces and suggests that these movements teach us a lot about the ingredients of racial reckoning according to Black households themselves. Millions have moved. The original research discussed here shows three trends rooted in affordability: involuntary displacement, local movement in search of better options and relocation by the most mobile for a reset of opportunities. Though some questions remain, the evidence of exodus shows how important local, state and democratic conditions are to a sense of Black wellbeing—and probably most Americans’.
The epilogue reviews the central conclusion—that racial reckoning must focus mainly on material accountability for cumulative racial inequality, especially at the local and state level—before summarizing many of the principles, goals and strategies discussed in the previous chapters. For instance, a key principle is to view policies about the way public goods are distributed through the lens of racial equity, even if the solution is to pursue race-neutral means. An underlying goal is to promote democracy through the deconcentration of social capital. The strategies that follow include specific, mostly localized policy choices in the areas on which the book focuses: place-based inequality, the racial wealth gap, racial health disparities, deterrence of police misconduct, DEI and equitable growth at the local level. There is also a brief example of a reparations program for urban renewal.
Background: Midlines and peripherally-inserted central catheters (PICC) have increased in use due to their ease of insertion, low insertion risk to patients, and relatively low cost. Three common complications are central line-associated bloodstream infection (CLABSI), upper extremity deep venous thrombosis (DVT), and lumen occlusion. The literature reports PICC-associated CLABSI rates of 0.5-2.1 per 1000 catheter days, DVT rates of 1.4 to 9.5%, and lumen occlusion 5 to 16.1%. Both CLABSI and lumen occlusion are more common in multi-lumen than in single lumen (SL) PICC. Our objective is to evaluate the appropriateness of midline and PICC lumen selection, to assess for rates of complication, and to identify targets for clinical decision support intervention. Methods: Setting. This is a retrospective cohort study of adult patients ≥18 y.o. with a midline or PICC placed by the Vascular Access Team (VAT) between 1/1/24 and 6/30/25 at a 500-bed academic safety net and teaching hospital. Data abstraction. Indication for line placement was determined by VAT consultation order or manual chart review. Upper extremity DVT was screened by ICD10 codes and confirmed through manual chart review. CLABSI was determined through cross-reference to National Healthcare Safety Network data. Alteplase administration was used as a surrogate for lumen occlusion. Appropriateness criteria. Appropriateness of midline and PICC lumen selection was determined by adapting the Michigan Appropriateness Guide for Intravenous Catheters and Michigan Multi-Lumen Appropriateness Criteria (Figure 1). Results: Six hundred twelve midline (n=97, all SL) or PICCs (n=515) were placed into 524 patients in the study period (SL PICC, n=213; double lumen [DL] PICC, n=243; triple lumen [TL] PICC, n=59). The indication for line differed based on the line type (Table 1). The majority of midlines (95.9%) and SL PICCs (99.5%) were deemed appropriate; in contrast, 74.1% of DL PICC and 3.4% of TL PICC were considered appropriate. Complications of midline and PICC were rare (CLABSI: 0.19 per 1000 line days; DVT: 1.1%; lumen occlusion: 11.8%). Any complication occurred in 12.9% of cases and was more common in multi-lumen as compared to SL devices (i.e. midline or SL PICC) (19.9% vs 6.1%, P). Conclusion: Opportunities exist to reduce multi-lumen PICC insertion. This may decrease device-related complications. Optimizing lumen selection through clinical decision support may improve patient safety and vascular access outcomes.
Background: Electronic surveillance for hospital-onset sepsis using CDC’s Adult Sepsis Event definition could provide an efficient and objective method to identify a broad array of serious healthcare-associated infections, many of which are missed through current reporting processes. We developed risk adjustment models of varying complexity to support facility-level comparison of hospital-onset sepsis rates, evaluated trade-offs between model performance and feasibility, and quantified residual inter-facility variation that may reflect gaps in care. Methods: We conducted a retrospective study of adults hospitalized for <3 days within 113 community hospitals between 2022-2023. Hospital-onset Adult Sepsis Events (HO-ASEs) occurring on day 4 or later were identified using updated CDC surveillance criteria. We used logistic regression to develop three risk adjustment models of increasing complexity using covariates from administrative and electronic health record data: basic model (hospital and aggregate patient descriptors), intermediate model (replacing aggregate patient descriptors with patient-level descriptors), and maximal model (adding detailed physiologic and clinical data from hospital days 1-3; Figure 1). We evaluated model performance using Area Under Receiver Operating Curve (AUROC), calculated hospital-level Standardized Infection Ratios (SIRs) for each model and assessed concordance in hospital rankings using Kendall’s tau coefficient (τ). Results: The cohort included 1,557,252 hospitalizations of <3 days, of which 24,169 (1.6%) met HO-ASE criteria and 8,500 (35.2%) died in-hospital. The basic model had limited discrimination (AUROC 0.589, 95% CI, 0.585-0.593). Adding patient-level characteristics to form the intermediate model markedly improved performance (AUROC 0.839, 95% CI 0.836-0.841), with further inclusion of detailed clinical data in the maximal model yielding modest additional improvement (AUROC 0.850, 95% CI 0.848-0.853). Concordance between hospital rankings derived from the crude or basic risk-adjusted HO-ASE rates versus rankings derived from the intermediate or maximal models was moderate (τ 0.40-0.51) whereas concordance between rankings derived from the intermediate vs. maximal models was high (τ 0.86). There was a wide distribution of HO-ASE SIRs across facilities even after risk adjustment using the maximal model (Figure 2), with high signal-to-noise ratios and good calibration. Conclusions: Risk adjustment models incorporating hospital characteristics and patient-level data perform well and might explain substantial variability in HO-ASE rates between facilities. The persistence of residual variability after highly detailed adjustment may reflect differences in care processes, suggesting that risk-adjusted HO-ASE comparisons can help identify gaps and opportunities in the prevention of severe healthcare-associated infections. Our findings support the use of HO-ASE as an electronic, scalable, risk-adjusted metric for facility-level benchmarking to inform quality improvement initiatives.
Resting-state networks (RSNs) consist of coherent spontaneous activity patterns that support a wide range of sensorimotor and higher-order cognitive functions. In schizophrenia (SZ), RSN alterations reflect disruptions in the brain’s functional architecture. Given the heterogeneity of SZ, accurate spatial mapping of RSNs at the individual level is crucial for characterizing altered brain connectivity in a more personalized manner. To achieve this, we used single-subject independent component analysis (ICA) to extract RSNs at the individual level, preserving unique functional patterns and accounting for variability among SZ patients.
Methods
We analyzed a resting-state functional magnetic resonance imaging dataset from 74 SZ patients and 74 matched healthy controls (HCs) obtained from the publicly available COINS database. Using single-subject ICA, we extracted 14 distinct RSNs associated with sensory, motor, and higher-order cognitive functions. Voxel-wise statistical comparisons were performed to identify spatial differences between the groups.
Results
The SZ group exhibited widespread RSN alterations in regions associated with visual, motor, and cognitive processing. Significant spatial differences were observed within each network, with the most extensive changes occurring in the somatomotor network and three cognitive networks: the cingulo-insular, medial prefrontal, and left frontoparietal networks. Within the default mode network, differences between SZ patients and HC were observed exclusively in visual areas.
Conclusions
Single-subject ICA provides a valuable approach for investigating RSN alterations in SZ and enables a detailed, individualized characterization of functional connectivity disruptions. The extensive connectivity alterations in visual, motor, and cognitive networks highlight the complex interplay among these systems in SZ.