In anticipation of continued political threats to women’s comprehensive healthcare in America, I wrote an article about how reproductive justice is not just about our women, it is about our girls.
Check it out here!
In anticipation of continued political threats to women’s comprehensive healthcare in America, I wrote an article about how reproductive justice is not just about our women, it is about our girls.
Check it out here!
During the 2016 election, Americans opened a public discourse that sparked new and old fears, evoked unsettling and painful emotions, and surfaced certain real and perceived divides. When elections center solutions in the background to highlight problems in the foreground, it can be distracting and confusing, for adults and kids alike. Post-election, often those intensities fade. But this time, parents may find themselves confronting sustained and sometimes increasing worry, in the emotions and experiences of their children and their children’s classmates. These are the times when parents consider how they will explore complex and potentially charged topics with their children and teens.
As parents examine their values and their hopes for their children in this post-election climate, it may be helpful to consider how to approach a topic that is as oft-used as it is misunderstood – racism.
What are we talking about when we talk to our children about racism?
And how do parents start the conversation?
When we talk to kids about racism, we are primarily talking about 3 things.
First, we are talking about history – things that happened in the past that are important to understand what is happening now and why it matters.
To illustrate the history of racism in America, some parents may find it helpful to review age-appropriate details. For example, teenagers may have knowledge of historical events like slavery and the civil rights movement. Starting with what they know, consider extending the conversation to other demonstrations of institutional racism like government-sanctioned red-lining practices that decreased the home values of people of color, particularly African Americans, and contributed to current racial wealth disparities in America. Or examine the implications of Japanese internment camps during WWII that used race and nationality to deny Japanese Americans their civil liberties. These events and the history they represent are the embers of old fires still kindling in our present and the more we understand them, the more we are equipped to recognize their reemergence.
Second, we are talking about feelings – the prejudiced assumptions and ideas about others based on race. When stated aloud, as a part of targeted comments or unintentionally as a part of repeated narratives, prejudiced feelings can result in trauma, stress, and anxiety for the people who become the butt of a hurtful joke or the demeaned character in a story. These types of one-on-one interactions highlight episodes of personally-mediated racism.
Third, and perhaps most importantly, we are talking about actions – everyday choices, big and small, to treat people differently because of their race. This is called discrimination and it is powerful because it not only hurts people’s feelings, it can also make them sick.
Simply put, racism – like many of the “isms” that have been heightened by this recent election – is about exclusion and harms. That exclusion can happen at the lunch table just as much as it can happen through laws. And the resultant harms can range from emotions like embarrassment, humiliation, and shame to physical violence, psychological stress, poverty, and disease.
As kids come home crying or with troubling stories of what they’ve seen or heard, resist the urge to dismiss their emotions with avoidance or denial. Instead consider these helpful tips:
DON’T tell kids it is unconditionally going to be okay, because for children and families who stand to lose their health insurance, residence, or civil freedoms, it may not be.
DO offer reassurance by discussing and modeling how to unconditionally support and care for classmates and friends who may be facing unique worries and stress at this time.
DON’T avoid conversations about racism, sexism, nationalism, xenophobia, Islamophobia, and intolerance.
DO put those conversations in an age-appropriate context that includes ways children and teens can stand up for peers when they witness their exclusion.
DON’T try to minimize a child’s fears by normalizing distressing language and behavior.
DO listen to their fears and talk about reasons for hope, including their ability to actively express empathy, support, and advocacy for peers whose fears may be different, more acute, imminent, or sustained.
These moments are opportunities to model engagement, tolerance, and compassion for children and teens trying to make sense of a world in which their values may be challenged, demeaned, or disregarded. Ultimately, what we are talking about when we talk to our kids about racism, is the type of person they can actively become.
The president-elect’s victory, and the tacit validation of his divisive and dangerous rhetoric and policy proposals, challenges those who call themselves liberals to be the values they espouse. Until 2 weeks ago, those values came at little cost. Aside from the news you read, the company you keep, and the places you buy produce, the daily politics of American life were, for many, comfortably cosmetic and consumer-oriented – simple public identities crafted by the items you purchase, relationships you explore, and content you share online. Then, Americans elected a xenophobic candidate who ran on an openly Islamophobic platform and has since designated overtly racist, nationalist, sexist, and homophobic advisors and federal appointees.
This. Is. The. Wake. Up. Call.
I fear we are missing it.
Despite eruptions of private emotions, public protests, and hashtags du jour, in the short 11 days since the election, some have returned to their daily lives, unscathed, and continue their daily work, unchanged. Perhaps seeking emotional refuge from their liberal outbursts, they hasten calls for stability rather than quicken the pace of resistance. They find room to wait while the marginalized among us live under the threat of violence, displacement, internment, and the insidious affront to their rights and their America that is hate speech and hate crimes that go unacknowledged and unatoned. This form of liberalism is privilege incarnate. It is the white tears that dry quickly, the fickle fetish of media sensationalism, the limited attention that only spans the interests and people that look and feel like “us” or “them,” and the normalization of public exclusion in the most powerful democracy in the world.
There is literally no time to waste. And every moment a “liberal” person, organization, or institution spends calling for caution in place of critique, pause instead of preparation, and waiting as opposed to imminent action are lost opportunities to defend the values and people liberals’ claim to hold dear.
This includes hospitals, and other public entities erected in service of community. “Carry on” attitudes that simply re-assert an existing mission without delineating concrete plans to defend or extend that mission should allied populations be endangered, are frankly not enough. And should employees fall victim to local or federal aggression, they offer no protection at all. If progress relies on accurate recognition of the problems, “carry on” stances silence the uncomfortable realities, conversations, and sacrifices required to look those problems in the face.
It is not alarmist to get prepared. And that preparation entails mobilizing the volume of resources necessary to support a diverse set of populations who now worry for their safety and security in this country. If the urgency of that need is somehow lost on you, don’t hide behind your liberal leanings and co-opt progress.
The challenge liberals are facing is a kind of active democracy many have never known and it may be painstaking and overwhelming. It is also a burden people of color, the LGBTQ community, immigrants, and other marginalized groups have carried, often silently and alone, for years, centuries, as the spaces to publicly express, wear, and own their person-hood is narrowed.
Vigilance is too often inherited through wounds endured. For those who now find themselves unaffected or disaffected, it is time to ask, how many wounds must be sustained for you to move from the waiting room to hold space for action?
Every day since Tuesday feels like walking a plank. Stepping toward a jagged and uncertain future with hands bound by the votes of neighbors, friends even. How deep do these dark waters go? When no bridge spans the troubled reaches, where is the solace for what lies beyond the edge?
To those of you who are now, just 2 days later, shrugging your shoulders and saying, “It may not be that bad.” Or “Let’s wait and see what happens.”
I get that perhaps you do not wake to the terror and nausea that I do. That you must not have felt personally accosted by the toxic insults that diminished your love, your color, your nationality, your body, your traditions, your abilities, your rights, your neighborhood, or your God. You must not have felt your physical safety threatened, trivialized, or commoditized for a political punchline. But the wounds I carry weren’t opened 2 days ago. These wounds predate the president-elect, but are pained all the more by his malicious campaign, growing crowd of supporters, and electoral win. That pain is inflicted on old scars, shared scars, some more vulnerable than others, and the process to heal them will require more than mere distance from Tuesday.
The 2016 election is personal. While we can await the policies and procedures that empower the president-elect and embolden the unveiled hatred of some unhooded supporters, the toll the weeks and months of unfettered attacks on American values, American people, and American diplomatic relations, has already begun.
It is here that I depart from calls for insta-unity.
To quiet the disquiet that illuminates the darkest recesses of America and Americans is to turn away from our problems at the moment they fully surface. No, the lines have been drawn. They are stark. They are real. And they must be confronted. While the unrepentant divisiveness of the republican nominee’s rhetoric and thin political strategies may have stoked an old fire of racial, patriarchal, gendered, economic insecurities – make no mistake about it, what is set aflame is the roof that covered existing, widening, engrossing tensions that divide America down the middle. And to reconcile those tensions we, you and I, must look them in the face and make some decisions. One decision was made on Tuesday. But more decisions are coming.
White people who call themselves allies, now is the time to do the work. And that work does not mean organizing black and brown people. It means talking to other white people. Go home, go to class, go to work, and have difficult conversations about what Tuesday means for many Americans. Look honestly at the rationalizations of “small government” idealism and “anti-establishment” deviance and explore what it means to prioritize those values above the safety and inclusion of people of color, homosexuals, transgender individuals, people with disabilities, women and particularly those who have suffered sexual harassment or assault, Muslims, immigrants and the wealth of diversity that calls America home. Examine how the freedom to vote on ideals when the rights of fellow and marginalized Americans are at stake, is a privilege that comes with responsibilities, the least of which is identifying as a liberal, or a conservative.
To republicans, especially those who depart from the president-elect’s divisive words and claims, your congressional and local power and proximity to constituents may be all that stands between some and their future. While Obamacare may be a contentious policy, its repeal without swift and comprehensive replacement of a structure to insure and assure Americans affordable access to baseline health services, will almost certainly result in rising ranks of uninsured, increased health disparities, and more untimely deaths. This is avoidable and should be prevented. Also, as immigration reform is likely to be an early priority of the incumbent administration, please deeply consider what the separation of American families, children from parents and siblings from caregivers, means for those who remain. Immigration is the foundation of this country. When the vote arises, we will call on you, republicans, to honor that value for all of us. More decisions will certainly come, but let us start there.
And lastly, to black women. To the black female voters, more than 90% of whom voted for Hillary Clinton. Thank you. I see you. You are the cornerstone of this democracy. You who labor and serve and nurture and endure, who have given from the depths of your womb and through the pain of your wounds. Thank you. You who stood in line without hearing a candidate utter the intersections of your lives, elevate your contributions to community, or value your consistent, historic presence at the polls as both patriot and rebel – ever challenging your nation to rise to its values. Thank you. This nation owes you great thanks.
And to all of us. We do this work for the children and youth who must live under the fruits or failures of our efforts. We do it so we can say and show what already made America great.
Now is the time for organizing.
The fight is not yet won.
The night is the time for organizing.
The fight begins at dawn.
Until dawn, will you do the work?
2 weeks ago, my family and I visited the National Museum of African American History.
It is said the museum was a century in the making.
When you walk in the doors, you know exactly what that means.
We happened to enter behind a black family of four. Two parents, who appeared in their mid-late 30s, and two young boys, both of whom could not have been more than 5. It was raining that day and they were all bundled up – hats, vests, scarfs, boots. Despite the aggressive gear, as soon as we got inside, off those boys ran, like they were in their own playground. While a lot of kids run everywhere they go, to see these little black boys, brothers, running free and unencumbered in this building, their building, on the National Mall, erected to honor their ancestors, standing in honor of them, was the perfect prelude to what lay before us.
The whole day, we saw babies and watched children, crawling, running, sitting, climbing. Like the little one, maybe 3, who walked up, alone, and sat next to me on a bench. Together, in silence, we watched a short video about the contributions of African American athletes. Shortly afterwards, his father and brother arrived, obviously happy to have found him. But there he was, drawn to the images, sitting still and watching intently, as people who look like him did great things. I can’t imagine what the moment felt like to him. Perhaps it was simply another age-appropriate act of independence and environmental curiosity. But sitting next to him, the moment felt full and hopeful.
But it wasn’t just the young who captured the moment, it was also the elderly. Those who entered the museum with canes and walkers, who moved with the support of their family or church or neighbors. Those draped in t-shirts commemorating their visit, who traveled across states just to be there.
I think of one woman in particular.
She walked slowly, with her weight heavily upon a cane, her white hair curled, her lips peach with pigment. A women who seemed like her daughter walked at her side, supporting her, and a young woman, maybe age 20 or so, walked in front of them guiding them towards an exhibit on Greenwood in Tulsa, OK. The walls were flanked with images of a town that looked ravaged by a natural disaster. The air in the small exhibit felt thin and heavy. You stood, surrounded, by a town decimated in ash. Only the actor was not an unruly Mother Nature, but rather the destructive, unpredictable, and irrepressible swell of White Supremacy that leveled, literally burned, an entire neighborhood, notably one of the wealthiest black neighborhoods in the country at that time, to the ground. As I stood, solemnly confronting the wall-sized photos and recovered personal items, next to what appeared to be a family of women, I watched as the elder asked the youngest to read the inscriptions to her. I don’t know if it was the photos, the women, or the collective recognition of what black people have endured, suffered, and lost in this country they have called home – but I cried openly there. Left my tears, my heart, my gratitude, to those women, to that place, to the grit that rose from those ashes to trouble and inspire me.
My experience of the newest Smithosonian museum was captured in small moments and big. Moments when I stood shoulder to shoulder with history and watched as the future crawled along the floor, with a certain mix of joy and pride I can only remember having felt so vividly the morning after Barack Hussein Obama became President of the United States. There was a palpable shift in the world as this black girl turned black woman saw and was seen. Standing with my family only added to the consequence of the moment.
As science, history, literature, the arts, and public consciousness inch towards full acknowledgement, engagement, inclusion, and elevation of our presence, our personhood, our importance, and our centrality in the American experiment, this building will stand in tribute and truth. The gift is our ability to return to it, in reverence and expectation, to share that truth with our future generations.
In the US, we live in a world of limited public resources and yet massive investment in healthcare services. Healthcare spending accounts for almost 1/5th of our country’s entire GDP. When compared to other peer nations, that huge expense significantly limits how much we can spend on social services. Now, there are 2 important programs that allow medical systems to pay for social services. One is old and one is new.
The old program is called Community Benefit. It requires non-profit hospitals, which make up almost 8 out of 10 hospitals in the country, justify their tax-exempt status by sharing the benefits of that status with the communities they serve. The new program is a Medicaid Waiver Demonstration or an opportunity for states to apply for money to meet the health needs of their population in innovative ways that include supporting community-based social services.
Sadly, both programs may result in hospitals keeping the money! And more than supremely selfish, it seems deeply problematic, inequitable, and yes, oppressive. I’ll explain.
Historically, only 15% of Community Benefit funds actually make it back to the community. Most are spent in-house, to reimburse charitable patient care. Additionally, some states are considering using their Medicaid Waivers to build social services inside hospitals, instead of supporting existing community-based programs.
Hospital systems will probably cite a myriad of reasons to build their own suite of social services rather than rely on the community. Some of those reasons may even sound credible. For example, some healthcare systems will likely point to a lack of community capacity to handle the volume of need this funding will generate. Because if we know anything, it is that if you pay hospitals to do something, they are going to get really good at it, and here that means potentially identifying more individuals who need a service than there are services to provide them.
But it has to be recognized that “lack of community capacity” doesn’t happen in a vacuum. It occurs as a direct result of the resource scarcity engineered by systems siphoning funds away from neighborhoods and public spaces back into conglomerate enterprises, like hospitals and large medical systems.
Similarly, concerns regarding scale when large systems must interface with a diverse network of community-based social service providers, highlight the dysfunction of the system, not of the smaller players, as may be assumed. The onus for adaptability must always lie with the more resourced-partner, which in this case is the hospital. That means when certain referrals are difficult or meet a dead-end, hospitals will need to provide resources to help community-based organizations figure it out. Note that here the hospital is providing the money, staff, or training, but not driving the actual process by which communities determine how they want to be served.
This is the transformation. This is the re-design.
Payment reform does not simply challenge the conceptual ways we pay for care, it challenges the very notion of relationship between providers, care systems, and the patients, communities, and neighborhoods they serve. That relationship has been historically strained by competing financial priorities, exploitation of people and communities of color, and the commodification of disease to the extent that it bankrupts people and devalues holistic notions of wellness.
The solution then, is not to further strain this already charged relationship by usurping the role of community members and community-based organizations in serving their own needs. But, to admit the ways in which our instinctual preference to reinforce our walls, tears theirs down. To acknowledge the ways our desire to have more power in the shaping people’s lives, even if for the better, may minimize an individual’s power to shape their own life. And to confront the ways medicine historically and currently contributes to gross wealth and racial inequity in this country, through exorbitant costs of care and limited workforce diversity.
At their best, programs like Community Benefit and Medicaid Waivers are a foremost way to redistribute wealth in the United States through the healthcare system. That is a powerful imperative in these times of great inequity and those of us who understand that, must hold our field accountable for proceeding with humility and most of all integrity, when distributing these vital funds.
Although I write a blog that centers people of color in exploring the connections between the medical system and race – an activity that has always been fundamentally personal – I rarely discuss how it personally affects me.
The occasions in which I have, were driven by my need to make sense of Trayvon and Walter, Tamir and Freddie and to reconcile their lives with how I move in my life, as a black physician. But there is no sense to be made of state-sanctioned murder and each time I left the task weary with emotion.
I used those emotions to power 6 months of writing and editing my first submission to Pediatrics, the most important academic journal in my field, on police violence; both begging and demanding this type of violence be considered a devastating threat to public health and safety for children of color. The first comment my co-authors (also black women) and I were asked to address was what the editors called our “anger” and the last was to “say something nice about the police.”
Here I was, asking to be seen; asking for black children and families to be seen; but having to respond to why I don’t see police and why what a white man perceives as my emotion, is a problem to be addressed, in writing. My emotion. That they named anger.
To be labeled angry and asked to publicly disavow said emotion for professional legitimacy was nothing new, for me, my co-authors, or centuries of black women accosted by the limited public characterizations of our person-hood. But when they named my emotions anger, did they also name my tears? Did they name the deep humiliation I processed to explain, to a pediatric medical journal, why the deaths of black parents and children should be a priority?
Did they furiously, nauseatingly, mind-numbingly, cry over the public executions of their people? Did they choke and swallow those emotions back everyday just to function as a productive adult in the world? Did they wake to bury the devastation that allows them to hold academic conversations about the threats, challenges, and disparities that may amount to the extinction of their people?
In medicine, if we talk about racism at all, we talk about how it is unfair – but no ones fault really. Short of bias training that validates a generalized lack of explicit accountability – we primarily do nothing. It is as if medicine thinks the solution to centuries of systematic racism and racial inequality that continues to poison black bodies, young and old alike – through public divestment, disease and varying degrees of despondency – is self-reflection.
But it is killing us.
Racism. Is. Killing. Black. People.
Sometimes I feel the poison in me. Squeezing my chest in anxiety, fear, or fury as I navigate the complex terrain of my public female black-ness, trying to wear my emotional and intellectual complexity in a way that at best, allows me to be seen but at least, prevents me from being dismissed altogether. The daily work of avoiding the silencing that accompanies being mistaken as simply an “angry black female” while also finding safe spaces to be a black female who can hold anger and the emotional complexity inherent to full humanity – is an extra job, that I do, at my regular job and on vacation.
Sometimes I see the poison in my family, as they do the work of making space for their whole self in a world that can easily, effortlessly limit them to an assumed identity. I watch them negotiating other people’s comfort in an exhausting performance of excellence and I understand the raw pain blackness chafes on their humanity.
Racism excludes black people from public goods and private sympathies. It is the root cause of health disparities, the education gap, the wealth gap, the gender wage gap for black women, and the unconscionable incidence of institutional violence against black bodies.
And in so much that medicine ignores that root cause, it is and will remain complicit in the maintenance of institutional racism, both inside our walls and out.
So just in case you have wondered or are wondering, yes, I am angry.
I feel intense and unapologetic anger. But know, my anger isn’t the poison, racism is.
“The arrogance of success is to think that what you did yesterday is sufficient for tomorrow.” – William Pollard
In health care right now, lots of people are talking about innovation as a generic way to describe the new holy grail to some of medicine’s biggest problems. Of course this line of logic might lead some to think medicine is in some state of “innovation-deficiency,” a condition for which innovation replacement therapy is the clear and sole treatment. While this obviously isn’t always true, introducing new technologies and processes, if done the right way, can certainly help minimize waste, control cost, improve efficiency, and introduce equity into existing public systems.
So if medicine needs to up its innovation game, as many are suggesting, who’s it going to turn to? Where is the pipeline of leaders to fill the holy grail and how do you turn on the faucet of new and better ideas?
I’ve been thinking a lot about these questions over the past few weeks as I start my Fall semester at Harvard’s TH Chan School of Public Health. And no that wasn’t a name drop. It was a point of reference drop, to help place the problem I am about to describe, into context.
For the past 3 weeks I’ve been taking a pretty stand out course on quality improvement taught by the incomparable Maureen Bisognano and her enviable squad of colleagues and friends. For a bit of background, Maureen is the President Emerita of the Institute for Healthcare Improvement, basically a healthcare innovation incubator based in Boston, and her friends include people like Don Berwick, Atul Gawande, Brent James, Ellen Goodman, and Derek Feeley, to name a few of the powerful speakers who inspired us. For 3 weeks, we reviewed international examples of ways to radically redesign the US healthcare system.
And then, I had fall registration.
Excited to push the boundaries of existing systems, I was eager to take classes across the University, and like Maureen showed us, find examples from other industries, sectors, and disciplines that could be applied to the great challenges facing medicine and build solutions that translate across public systems and private incentive structures. But to my surprise, that inter-sectional, open learning, not only wasn’t a requirement, but was incredibly difficult to find. And if it is hard to find at places branded on leadership, I worry it may be symptomatic of a larger issue.
Which got me thinking, just how are we going to train this next level of leaders when the educational pipeline through medicine looks remarkably similar to what was suggested in the landmark Flexnor Report in 1910, that established a system of medical education, that with few exceptions, continues today.
Courses continue to be divided by discipline, learners are isolated to their field of study, and for those who select to learn outside that box, they do so singularly, as a function of personal interest or a non-degree program rather than systematic integration of agents and ideas. Then is it any wonder why our systems remained silo’ed with divergent (and sometimes antagonistic) incentive structures despite overlapping public interests?
Don Berwick is often quoted as saying, “Every system is perfectly designed to get the results it gets.” In medicine, as we move upstream in our interventions for disease, to target root causes rather than downstream effects, we must do the same thing for the education pipeline. We have to challenge ourselves to teach future leaders how to think, reason, and execute rather than prescriptively guiding them, formally and informally, to reproduce the same system, with the same challenges we already have.
It has been more than 100 years since the last massive shift in professional medical education, perhaps parting with apprenticed dysfunction and practicing principled disruption is a good start.
What does it mean to understand police violence from a public health lens?
It starts with understanding how police behaviors can result in harm and who is most affected.
In the Cure Violence podcast link below, I introduce what I term adverse police exposures, or a conceptual framework to understand how harmful police behaviors can impact health and public safety. I then explore ways public health leaders, providers, clinicians, advocates, community activists, and students can advance our understanding and commitment to addressing adverse police exposures as important threats to public health and safety.
For more resources on the topics and data discussed in the podcast, see the frequently asked questions below.
Have professional medical associations addressed police violence in the past?
Yes. Here are the American Public Health Association’s 1998 Impact of Police Violence on Public Health policy statement, the National Association of City and County Health Officials’ 2015 policy statement on Public Health, Racism, and Police Violence, the American Academy of Family Practice’s 2015 resolution declaring Discriminatory Policing is a Public Health Concern, and the American Academy of Pediatrics’ 2016 Initiative to Confront Violence in Children’s Lives.
Was Stop-and-Frisk only employed in NYC?
No. While the phrase “stop-and-frisk” is derived from a tactic utilized by New York police departments (and was ruled unconstitutional in 2013) similar tactics have been and are being used in many other cities. For example, in 2015 and 2016, the Department of Justice released scathing reports detailing similar discriminatory tactics utilized by both the Ferguson and Baltimore Police Department. Notably, these tactics are also ineffective, as noted here,
What does “ban-the-box” mean?
This is a national campaign to provide a fair opportunity for employment to those who are formerly incarcerated. In 2015, President Obama took an important step to do this for federal workers.
What do pediatricians know about how stress affects health?
While some stress can be good, too much stress can be toxic, particularly to the developing brain and body. For babies and young children aged 0-5, exposure to toxic levels of stress can have longstanding impacts on adult health. Having an incarcerated parent or caregiver is considered an adverse childhood experience that can contribute to toxic stress.
What’s problematic about police in schools?
For some children, their police contact is structured by their school’s disciplinary policies. According to the Department of Education, across public schools nationally, students of color are more likely to encounter police in this way. Specifically, black male and female students are disproportionately more likely to be referred to law enforcement and have school-related arrests, than all other students. These early exposures criminalize children of color in places where they should be safe to explore, learn, and grow and can contribute to barriers to higher education, employment, and successful participation in community.
What can doctors and health departments do?
We can collect data that captures the magnitude of police violence by counting injuries, morbidities, and deaths related to police encounters. Here is one way to start, authored by Nancy Krieger, a public health champion for this work, and colleagues at Harvard’s School of Public Health.
We can support community organizations that are seeking to redefine what safety means to communities of color. Here, the Ella Baker Center for Human Rights’ Justice Teams stand out as incredible leaders for their work to deploy community-led crisis response networks in California. Here is a list of other organizations working at the intersections of police accountability and racial justice from Funders For Justice, the member organizations representing The Movement for Black Lives, and Blackout for Human Rights, a collective of filmmakers, artists, activists, musicians, lawyers, tastemakers, religious leaders, and concerned citizens lifting the voices of the movement through media engagement.
And we can mobilize communities to go to the polls this November and speak up for public safety and health. Confused on the issues? Check out Campaign Zero, which lists comprehensive federal, state, and local policy agendas and a side-by-side comparison of where each presidential candidate stands on these important issues.
As the screens we carry narrow our proximity to random and targeted acts of violence, many parents and families are rightfully questioning the impact viral violence has on shared perceptions of public safety and child health.
In pediatrics, we have long considered the link between media, violence and health.
We know kids who watch fake violence in movies or play violent characters in video games show signs of increased aggression. But what happens when the violence kids watch is real? Or when the cameraperson is only a teenager?
Today, youth can easily capture and consume real violence, in real-time, as a part of their daily routines – from snapping school violence, live streaming police violence, recording sexual violence, or sharing images of political violence. This is the new normal* and it’s more complex than the simple relationship between simulated exposures and aggression.
A child watching real violence from their cell phone now understands something tangible about the world; and a kid who records or shares violent imagery online can contribute to others understanding of the world. That elevation of the voices and experiences of youth can be extremely valuable. Indeed, in terms of activist’s movements like Black Lives Matter, the perspective of youth, magnified by social media, has become a national catalyst for police reform, criminal justice reform, and racial equity.
Yet, perpetual exposure to viral violence takes its toll – often manifest in feelings of victimization, grief, fear, intimidation, anger and sadness. And kids and teenagers may be most vulnerable to this kind of trauma because they are still developing the emotional and intellectual maturity to process troubling events. What is more, they rely on trusted adult figures to provide safe spaces in their life.
As we face these harrowing challenges, consider two thoughts:
1. While it’s okay to be protective, thoughtful and proactive regarding how youth experience and contribute to violent images online, we, as parents, caregivers, or providers, cannot simply turn a blind eye. While distressing, some images of violence advance our collective understanding, compassion, and empathy for the suffering that exists outside the walls of our private communities or our segregated social groups, and the privileges those spaces confer. In this way, confronting the visual of violence with a particular effort to center the interpretation of the events around the marginalized populations disproportionately affected, is the first step towards collective healing. And that healing begins with rigorous and vigilant public exploration of the ways systemic racism, sexism, Islamophobia, homophobia, xenophobia and intolerance threaten public safety.
2. As we live-stream our lives, we open windows to the neighborhoods we live in, the spaces where our kids learn and play, and the ways we perceive and are perceived in the world. When we don’t like what we see on the other side of that window, it can be easy to hide discomfort or insecurity with blame or shame or to create narratives that distort the humanity we witness. But each time one of us resists the opportunity to understand the burdens or experiences of another, we all move further from the co-existence necessary to bring peace.
*This is a piece I wrote with my friend and colleague, Dr. Wendy Sue Swanson, that was published in the July 2016 Pediatrics. It is available for free online for the first week of publication.
A “Health in All Policies” framework has been touted in the past few years as a strategy to illuminate the intersections between public health and other areas of civic life. It’s one way to incorporate health metrics into existing and proposed public policy – from education to transportation. But the question is, will it work?
It seems fairly obvious that health-centric framing may obstruct interdisciplinary collaboration. But at a more fundamental level, will replacing multivariate, silo’d interests with the singularity of health effectively capture the complexity necessary to create shared agendas across public sectors?
The short answer is no. Here’s why and how we got here.
The former structure of medical education and training was rooted in the idea that the greatest knowledge in medicine was best revealed through individual patient inquiry and the greatest challenges in the field were best understood and addressed through individual clinician excellence. So clinicians were evaluated based on their individual aptitude, patients were assessed based on their isolated symptoms, and each sector of the health and human service network operated in silos, training and treating pieces of the problem, without ever quite appreciating the inter-connected whole.
This paradigm of education and practice placed clinicians at the center of care and patients and allied partners at the periphery. Allied learners were taught separately and systems communicated poorly, both of which resulted in fragmentation – in how problems were evaluated and in how care was delivered.
A more recent iteration of this care ecosystem, like the “Health in All Policies” approach, now places patients and health at the center of delivery models and public policy strategies to treat disease and advance wellness. These patient-driven, health-specific metrics ensure that systems are oriented to serve and public policies are structured to mitigate health impacts.
However increased focus on individual patient outcomes may obscure population-level drivers of health disparities and unilateral dependence on health as the primary outcome, may ostracize allied disciplines, institutions, and learners whose work or study contributes to advanced understanding of human behavior and the complex relationships between structural environments and the pathophysiology of disease.
The bottom line is: the intricate problems that threaten child and community health will not be solved by the individual capacity of excellent clinicians or public servants, but rather by the ability of leaders to organize interdisciplinary teams that learn, work, communicate ideas, translate interventions, and are evaluated across shared infrastructures, in the service of shared outcomes.
If identifying health as the primary outcome of interest or individual patients as the primary drivers of systemic priorities, alienate important partners and dilute the input of minority populations, it is time for a new centering principle. In my mind, that principle should be equity.
Placing equity at the center of the care ecosystem ensures each sector of the health and human service network and each provider and recipient of care has a role and contributes to the shared societal realization of public safety, economic security, and wellness.
Shared values, like equity, are important foundations for building integrated public systems. And integrated public systems are important to create parity in resource dissemination and improve productivity through partnership with allied disciplines and institutions. Although the process of integration may generate new financial costs, it will hopefully save money on the back end by aligning incentives and improving efficiency.
In the end, equity will be the framework for the future of care and policy that aims to improve health. So as we move towards the future, let equity be our guide.
* In appreciation for their wisdom: I want to acknowledge Dr Rajiv Bhatia who’s novel work on The Civic Engine, and Dr. Damon Francis whose generously shared expertise, informed the ideas presented in this piece.*
In April 2014, Flint transferred its water supply from Lake Huron to the Flint River. It was meant to be a temporizing, cost-saving measure. But what followed was one of the most devastating recent failures of public infrastructure and a heartbreaking example of how social inequity ultimately leads to public health crises.
To quantify just how bad the problem is, here’s a schematic from USA Today.
To add insult to obvious injury, the areas of Flint most affected, were disproportionately poor, communities of color.
Last weekend, I was fortunate to join other activists and Flint community members in an online panel discussion hosted by Black Public Media about the impact of the crisis and what people are doing to address it. This weekend, as the nation prepares to broadcast the latest democratic presidential debate from Flint, Michigan, I wanted to revisit what has and is happening there, who it affects, and what we can do about it.
1. Lead is toxic.
There are no safe levels in the blood and it can affect every organ system. Adults exposed to lead can have high blood pressure, joint or muscle pain, headaches, memory loss or mood changes. In utero exposure can result in miscarriage, premature birth, and low birth weight. Children who are exposed are at risk for learning problems, developmental delay, weight loss, and hearing loss. And the most disturbing data shows maternal exposure may even be transmitted to grandchildren, making the adverse effects of lead, generational.
2. Infants and children are more vulnerable to lead exposure from water contamination.
Infants and children can absorb more water-soluble lead than adults. And infants whose primary nutrition is reconstituted formula mixed with contaminated tap water, likely absorb the most.
3. Low-income, people of color are increasingly vulnerable to lead exposure.
4. To fix this, more than clean water is necessary.
Access to clean water is essential to decrease water-based lead exposures but the magnitude of this exposure (2 years worth!), lead’s potent toxicity, and it’s long-term effects on cognition, behavior, and child development, will require wrap-around social services. That includes access to affordable, healthy food, education supports, behavioral health services, early childhood programs, and sustained investment in local infrastructure to mitigate the short and long-term impacts of these exposures.
Additionally low-income, communities of color should be prioritized to receive these services because they have been disproportionately impacted.
5. For more information about lead exposure for families who are affected or concerned:
When things like this happen, and know it is happening all over the country, it’s important to take an honest look at what it means. And I don’t just mean environmentally.
Americans are only as free as the choices at our disposal. And when poor people and brown people have no choice but to take poison because of failures of public systems, systems that dismissed concerns raised time and again, it corrodes the promises on which our democracy is built. From contaminated tap water to neighborhoods that lack fresh produce or communities disproportionately subject to violence or school systems that fail poor, brown youth – it is inequity that is poisoning America and betraying our unalienable rights to life and liberty.
Make no mistake, this is about more than water. And while we can bottle short-term solutions now, it is time to take affirmative steps to close disastrous equity gaps in America that underpin future crises.
As many of you know, I took a 6-month hiatus from my blog last year to write and edit a piece on policing and pediatrics. I am excited to finally share my work entitled Police, Equity, and Child Health, that was published in Pediatrics this month! AND because this is a topic of public interest and concern, I’m also excited to announce the journal has agreed to allow free access to the piece online for the entire month of February! Check out the pdf version here and feel free to share your comments below. I can’t wait to hear what you all think!
For me, this issue is personal and writing and defending this piece for the past 6 months has been incredibly emotional. But it has also been one of the most rewarding experiences of my early career and I only hope to continue to push myself and my field to consider and engage issues that uniquely and disproportionately affect the health and well-being of children and people of color. To use a line from Black Lives Matters co-founder, Alicia Garza, at its best, this piece is a love letter, and I hope those who read it feel my deep love for my people and my people feel loved and cared for by me, and by proxy, by my profession.
I also want to publicly acknowledge and thank my mother, Avis Boyd, who reviewed every word, every line, and every intention of this piece. She is the backbone that kept this piece afloat when biting critique wore at my resolve. For this and everything, she is everything.
Last year, when Walter Scott died, I pleaded in exasperation, for my colleagues and my field to consider his death and the death of other young black folks an affront to our professional commitment to promote health. But it wasn’t enough. And although these words were powerful for me to write, they will not be enough either.
So I’ve also drafted a resolution to the American Academy of Pediatrics’ Annual Leadership Forum taking place this March, where the academy sets the agenda for child health for the coming year. The resolution is #71 The Impact of Adverse Police Exposures on Child Health and it urges the academy to both advocate for community and school policing policies that place children’s health first and to research and fully articulate the disproportionate impact children of color face from adverse police exposures.
If you are a pediatrician or a student member of the American Academy of Pediatrics, click here, to comment on and support this resolution, bringing the issue of policing and pediatrics across the country and helping the academy take an important step to better serve children and families of color.
If you live in the San Francisco Bay Area and are interested in joining a local coalition seeking to understand and address how police practices and policies can protect, promote, or harm health in our community, leave a comment and I’ll add you to our email list.
Happy Black Futures Month!
The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.
The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.
To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.
Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”
But the baffling thing is, that is not what is happening.
Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.
But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.
Thinking outside the “doc in a box”
In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.
The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.
It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.
If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.
There will likely always be a need for physical care of patients with ailments that require treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.
With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.
So let’s talk about it.
According to the numbers, the most recent of which come from the FBI’s 2014 crime report, the critics are right. Black victims of homicide were overwhelmingly killed by black offenders. This occurred in almost 90% or 9 out of 10 homicides and includes both male and female victims and offenders.
This is also true of white on white crime.
In fact, most victims of homicide are killed by someone of the same race or ethnicity. For white people, more than 8 out of 10 homicide victims die at the hands of another white person. And though Latinos have the highest rates of inter-ethnic homicide, 7 out of 10 victims still succumb to a fellow Latino.
So while it is true that black on black crime accounts for most black homicides in America, racial congruence between homicide victim and offender is hardly unique to African-Americans.
What is unique is the rate at which African-Americans are killed by police.
Let’s review the evidence.
Most data on police-related deaths come from the FBI and Bureau of Justice Statistics. The FBI counts deaths they term “justifiable homicides” or incidents in which the victim was a felon shot in the line of duty. The Bureau of Justice Statistics data is more robust, in that it includes deaths resulting from any use of force while a civilian is in law enforcement custody.
However, these agencies have been criticized for generating unreliable and out-dated data. For example, the exact number of “justifiable homicides” are difficult to pinpoint in any given year, because the tally relies on precinct reporting that is largely voluntary and often incomplete. And the Bureau of Justice Statistics’ most recent metrics are from 2009, and have since been replaced by the Death in Custody Reporting Program, whose latest data is from 2012.
This lack of accurate data clouds the public’s ability to understand the racial context surrounding recently publicized police-related injuries and deaths, and may be leading some to short-sighted conclusions.
The good news is, people are working on it.
Powered largely by news reports, social media announcements, and civilian tips, crowd-sourced databases and other open access portals are keeping public records on incidents of police violence and most importantly, providing real-time, interactive access to the critical numbers necessary to appreciate the size and scope of the problem.
But one database in particular, Mapping Police Violence, is leading the way in illustrating how this issue uniquely affects African-Americans.
Here are 3 moving charts from their work which chronicles police violence from
January 2013 to Dec 29, 2015.
These findings are alarming. But what is more disconcerting are assertions that the deaths of some Americans are not “real” problems because those same people face additional threats to health and safety in their communities.
It is certainly easier to indict “cultural” pathologies instead of confronting systems that serve us – systems we pay for and participate in – to demand for our neighbors what we demand for ourselves. But the legacy of racism that results in poor, communities of color suffering heightened risk of violence, displacement, and resource scarcity, continues to structure vital access to justice and safety.
Thus, perhaps the “real” problem is our collective inability to feel empathy on behalf of communities facing complex and compounding traumas, traumas we contribute to through our general apathy for a people and their color.
As many of us begin the time-honored tradition of celebrating what lies ahead, I want to briefly look back and review a year that has meant so much to me. In true New Year’s Eve fashion, I thought a countdown would do the trick.
4. One Degree
For the past year and a half, I’ve coordinated a partnership between our regional American Academy of Pediatrics and One Degree, a SF-based tech non-profit. One Degree and their incredible staff are the brains behind an ambitious project to not just digitize social service referrals, but to do so in a way that strengthens the capacity of the safety net to understand and respond to social needs. By maintaining a platform that is freely available to the public, in English and Spanish, One Degree is also endeavoring to transform referral agencies, from gatekeepers whose staffing capacity determines access to bridges that open access to resource information. They also launched an affordable housing portal this year!
Together, in 2016, we are embarking on a multi-site clinical pilot, to test the feasibility and usability of One Degree’s technology in diverse clinical settings in the Bay Area. We are partnering with a mobile asthma clinic, a clinic for homeless families, a teen clinic, a primary care pediatric clinic, and a free clinic with a large immigrant population. With a team of faculty, providers, and research assistants we hope to refine this technology for use in the clinical setting and broaden the ways healthcare providers address social determinants of health. Here’s a picture of our fearless team!
This year, I was fortunate to meet Christine Chen, an inspiring undergraduate student at Stanford University who founded DiverseCity, a website where students “will find the stories advice, and reflections from a diverse range of inspirational people, to show [them] that no matter where [they] come from, or what [their] background, [they] can do incredible things.”
Through Christine’s work, I can hopefully encourage students and trainees to use their voice to make a space at the table for those of us with unconventional interests or underrepresented backgrounds.
In 2015, I had the opportunity to teach 1st and 2nd year Stanford medical students as well residents! When I was a medical student, I was eager to learn about the connections between health and inequality, but early in my education, I found few outlets for my curiosity. Since becoming an attending, introducing medical students to these topics has been a dream of mine. Through the work of students Jessica Steinberg and Brandon Turner, I got to participate in the development and execution of a seminar entitled “Clinical Excellence and Best Practices: Delivering Healthcare to Changing Populations.” This experience was a highlight of the year and something I won’t forget. Here’s my 1st class!
I, like many who share black skin, have watched, witnessed, black bodies killed without reason or hope for just retribution, by the very agents charged with our protection. And every time, it affects me. Like others, I know the actions of officers in Oakland, Ferguson, New York, Cleveland, Baltimore, Charleston, Chicago, and San Francisco upset more than sensibilities and implicate more than the random carelessness of a select few. It shakes my personal sense of safety and unearths an uncomfortable, non-random reality about being black in America.
But unlike many, whose fear for black lives is more personal than philosophical, I also know the physiology. I know that witnessing violence has important health implications and the impact of police encounters may not be limited to the transience of bruises. For survivors, far more may suffer incarceration, a sustained trauma that separates families, disrupts social networks, and generates new barriers to economic security. I know what is happening to black lives matters, but it isn’t simply an ethical supposition, it’s a biological one.
So I’ve been writing about it, first for my blog, then KQED radio and now Pediatrics (this piece is coming soon!). And I’ve been coordinating a local group of public health leaders, community advocates, and funders to help our public health infrastructure capture and address the health impact of police violence and other harmful police exposures.
More than any work I’ve done this year, this has been the most personal. Addressing social determinants of health is why I became a doctor but elevating the needs and priorities of communities of color within society’s trusted institutions is my life’s work. I feel overwhelming grateful and humbled to begin that work here and now.
Looking back, I never could have guessed the things that happened in 2015 (some that took me away from my blog for months at a time!). Though I hit the highlights here, know it was a year marked by challenges just as much as it was marked by opportunities – lost grants, extended paper revisions, and growing professional relationships. But I made it! I embraced the things that wake me up in the morning and light me up inside and I can’t wait to do it again in 2016.
Happy New Year blog family!
As Baltimore erupts in fiery protest following the death of Freddie Gray, the city joins scores of others who have recently challenged the role of police in community.
With the disproportionate representation of Black males in the correctional system and the videotaped deaths of those approached by police for seemingly petty infractions, the longstanding concern for a criminal justice system that differentially treats communities of color, is finding new relevance in cities across the nation.
But as young and old, gang-affiliated and religious alike take to the streets of Baltimore in unified protest, somehow the public unrest has garnered more attention than the issue itself. It seems, the fight for justice shouldn’t be a fight at all.
Labeled as “looters” and “thugs,” even in the very moment a community mobilizes to denounce their victimization, they are simultaneously recast as criminals, undeserving of the autonomy to freely express public discontent.
Now, my purpose in saying this is not to condone violence but to examine the ways we characterize communities of color, particularly around public displays of anger, and to look deeper at the role policing practices play in the tensions building in cities across America.
First, the idea that African-Americans are strong, aggressive, and prone to violence are antiquated stereotypes that continue to plague the public image of African-Americans today. So despite justified cause for outrage, the media often lazily resurrects these archetypes of blackness instead of investigating the source of community distress. This is both dismissive and misleading. It dismisses the understandable concerns of African-Americans by denying them the humanity of basic emotions and misleads the public by playing into the drama of stereotypes that distract from the issue.
Second, to cast the community as violent miscreants and the police as authorities of order, is to ignore the reality that both groups stand face to face at the line of protest, in confrontation with the other – and that confrontation has been violent, on both sides.
Baltimore has a long history of police misconduct and those abuses have been well-documented in Baltimore local news and recently in national outlets like The New York Times and The Atlantic. So it is problematic to disavow police of any responsibility in the tensions unfolding in Baltimore and beyond, because much of that tension stems from prior police conduct. It is also important to note that when police are outfitted in riot gear to patrol neighborhoods shield-first, it may incite conflict between the authorities and the community demonstrating for respite from police control and violence.
But ultimately policing practices are driven by local and state public policy, and it is that policy that criminalizes poor, communities of color and gives police license to penalize insignificant infractions. Those infractions lead to incarceration rates that cumulatively threaten the cohesion of Black families, the strength of the local economy in Black neighborhoods, the voting power of majority Black districts, and the upward mobility of young Black males seeking to enter the workforce. The mass incarceration of African-Americans may also impact child and community health.
So as we critically look at the role of police in communities, we must also investigate the policy environment that makes that role possible. Because while the police are the front lines of the justice system, they are certainly not the extent of the problem.
And as tensions unfold across the country, we have to shift the conversation to the reasons for protest. Instead of dismissing demonstrators as thugs defiling the sanctity of American business, perhaps we should look beyond stereotypes to uplift the sanctity of their lives and acknowledge the exasperated plea of a community seeking justice. Sometimes that plea is venerable in its non-violent supplication, and sometimes it is marred by the violent frustration of a community long-ignored. But aren’t we all, both the civil and uncivil among us, deserving of justice?
In the wake of Sandy Hook, the response from physicians, and pediatricians in particular, was astounding. The tragic deaths moved doctors to address gun violence and its health consequences.
But week after week, as black boys who could be my sons and black men who could be my father, are shot and killed by police, doctors remain silent. As a pediatrician, I’m appalled.
We are watching a public health problem unfold in front of us and we aren’t doing anything to stop it.
When someone is involved in a police shooting, they are at risk for injury, disability, and as we’ve seen, death. But those who witness the trauma may also be affected. And if they are children, that effect may follow them into adulthood.
Public police shootings turn neighborhoods into minefields where African-Americans fear suddenly finding themselves in harms-way. Those who escape the line of fire are then victimized by the ever-present fear of harassment, incarceration, injury or death.
Like the trauma experienced by war veterans, living under the threat of unprovoked police violence triggers intense emotional and physical stress, even in moments of relative safety.
The chronic stress that fear generates, may place African-Americans at increased risk for health problems like heart and lung disease, and depression.
If we’re going to understand and address the impact police violence has on community safety and health, particularly for communities of color who are disproportionately victimized, we have to treat it the way we treat all threats to health. That means collecting data to quantify the magnitude of the problem, developing screening guidelines to identify those at risk, training medical staff to refer those at risk of impending danger, and funding interventions that address community violence including police violence.
Tonight, too many parents will tuck their children into bed, only to worry that tomorrow, their curious 10-year-old may be the victim of a police shooting because the combination of a growth spurt and black skin threatened their life. Today, we have to do
more to recognize the worry in our community and prevent those fears from becoming reality.
* This piece was featured on Northern California’s NPR affiliate KQED as a perspectives piece. It airs live on April 29th at 6:43am, 8:43am, and 11:30pm. To hear an audio reading of the piece on KQED’s website, click here.
For centuries, humans have used science to explain their world. From the principles that suspend the planets in orbit to the relational pull of predator and prey, we turn to science to both examine and rationalize the experience of life. But does our reliance on science have a limit, particularly in medicine, where the “why” of disease can often escape scientific explanation?
For example, historically, medicine has poorly understood why one person gets sick and another doesn’t, particularly for complicated illnesses like cancer, diabetes, or heart disease, where multiple factors contribute to risk. Similarly, it’s been difficult to pinpoint why one medication works well for one person but not another.
And in the case of social determinants of health, medicine has yet to chart the physiology of disadvantage. That means, while we know poor people tend to be sicker, we don’t fully understand how poverty and discrimination manifest physiologically to produce disease; although there are exciting theories about stress hormones and organ function.
And so the why has evaded us, until now.
In January 2015, President Obama invested $215 million in a national Precision Medicine Initiative to use what science knows about the human genome to personalize the way doctors diagnose and treat disease.
The idea is that by using a wide range of biomedical information — including molecular, genomic, cellular, clinical, behavioral, physiological, and environmental parameters, physicians and scientists will have new tools to understand disease and determine the treatments that work best for each individual’s illness and DNA.
With such a sizable investment from the Obama administration and the partnership of trusted institutions in the scientific community including the National Institutes of Health (NIH), National Cancer Institute, and the Food and Drug Administration, this Precision Medicine Initiative promises to improve the diagnostic strength and treatment success of modern medicine. The significance of that promise cannot be underestimated.
But as we turn to science to answer the elusive why, we have to be mindful of where science has failed in the past. This is to set reasonable expectations but also to avoid repeating past mistakes. So as we move forward, here are 2 things to keep in mind.
First, as we narrow our focus from the population to the individual, it may be easy to overlook the way certain diseases are disproportionately prevalent in certain communities. If we then, limit our evaluation to the individual, their DNA, and their illness, we may miss the aggregate data that compels us to also investigate disease at the community level, where local resources and public policy may profoundly shape disease patterns and prevalence. Which is to say, while some disease is best explained from the lens of a microscope, other disease is best appreciated with a panoramic view of the environmental conditions in which that disease persists.
Second, to capture enough data to understand the human genome, the NIH and its collaborators are aiming to enroll 1 million American volunteers in the Precision Medicine research cohort. But a study published in 2014 found that non-whites account for less than 5% of clinical trial participants. More specifically, of the 10,000 clinical trials reviewed in that data, only 150, or less than 2%, focused on a racial or ethnic minority population.
So, if the Precision Medicine cohort is anything like the clinical trial cohorts from the past, women, minorities, and the elderly may be underrepresented; not to mention undocumented “non-Americans” who are generally excluded from scientific research. That means, while some patients will receive care uniquely tailored to them, women, minorities, the elderly, and the undocumented, may get care that was studied, tested, and developed, mostly for young white men. So as we endeavor to improve our understanding of human biology and disease, we have to make demonstrated efforts to enroll those science has historically forgotten.
Probing the human genome for the answers to medicine’s greatest questions will almost certainly lead to innovations and improvements in the health of our population. But as with most innovations, without careful and thoughtful execution, the impact may be limited. In Precision Medicine, we risk continued exclusion of certain populations from the benefits of science. This is when science fails, when it is unable to capture the breadth and meaning of the human experience. So if Precision Medicine does not couple its inquiry into DNA and disease with an equally rigorous examination of the biologic imprint of social stress, poverty, and discrimination, we may be no why-ser, than when we started.
Scalability is the end goal of nearly every tech start-up, systems innovation, and teenager you-tubing their cat – it’s going viral, business-style. And traditionally, it’s been seen as a marker of relevance and success. Growth is good, right?
But in healthcare systems transformation, do we lose something meaningful when we measure the value of our work by its national impact?
Take Iora Health, a new healthcare venture out of Massachusetts that contracts with large companies and insurance plans to provide care for employees or insured patients. Iora clinics have a for-profit model and are seeking to capitalize on saving money. They charge companies and insurance plans monthly fees and in turn endeavor to keep their patients out of hospitals and emergency rooms, the most expensive places to receive care. If they successfully prevent costly services, and save their company or insurance plan money, they take a percentage of those savings as profit.
The Iora model is essentially beefed up the primary care services offered in the comfort of a patient’s community, sometimes even as convenient as a local shopping center. They argue that by providing health coaches, lower doctor-to-patient ratios, around-the-clock availability, excellent customer service, and unlimited visits per patients, they can effectively manage most chronic illness before it progresses and requires hospitalization or emergency services. Now, nothing they are offering is particularly new, as primary care practices across the country are considering or implementing similar strategies. But what is intriguing, is their plan for growth.
As The New York Times recently wrote, Iora’s “ultimate goal is hundreds of practices across the country, a kind of Starbucks for healthcare.” And as their CEO Dr. Rushika Fernandopulle stated, “Building one good practice is mildly interesting, because a few people have done that. But how do you scale that across the country? That’s much harder.”
Hard, yes. But meaningful, I’m not so sure.
See, Iora’s foundation is venture capital and their business model aims to create a revenue stream providing services most clinics cannot afford; because most financial incentives in healthcare favor hospital and emergency visits. On the surface, it’s a win for doctors because many physicians want to provide comprehensive care, and it’s a win for patients, because Iora is paying to provide a care experience consumers want. But what about low-income populations? They lose here.
To maintain the for-profit status that supports their model, Iora Health purposefully doesn’t take patients off the street, the uninsured, or the unemployed for that matter, I guess unless some unemployed individuals are buying insurance with a plan they contract with. And yet, Iora says their model is going to “transform healthcare” and scale across the US.
When 5.5% of the population is unemployed and more than 1 in 7 live below the poverty line, how is this model “transforming” the system for everyone? The truth is, it’s not.
So I return to my initial question, do we lose something meaningful when we measure the value of our work by its national impact?
In Iora’s case, as with many clever and highly specialized health systems innovations, I think we do. Iora’s business model is what drives their innovation, but it is also what makes their services irrelevant in populations that don’t qualify or need their comprehensive care. It doesn’t make what they are doing any less valuable, but it does mean they may not find significance with every population. In addition, since their model excludes populations already under-served by the healthcare system, their national dissemination may actually threaten access to care for low-income families.
Healthcare is a complicated enterprise where the needs of the consumer are variable and evolve overtime. That diversity of need and resource distribution defines the challenge in our current system. And in the end, that variability may be too complex for a one-size-fits-all, Starbucks model.
Perhaps healthcare doesn’t need cookie cutter solutions imposed on populations with distinct assets and needs. Perhaps just like politics, all healthcare transformation is local and finds meaning in its local application, not its national prominence.
We all know ideas with traction and those that find their way to a national stage are exciting. But I think there is something to be said for offering a unique service to a distinct population, and doing that well for the long-term. So instead of looking for the next big thing, the actual big thing is made up of small things that are changing the way each of us experience our healthcare.
The recent killing of Walter Scott was another brutal reminder of the home African-Americans wake to daily. Their America, is one where your father might not come home at night, because his brake light went out and that cost him his life. It’s a place where petty crimes are penalized by life sentences, doled out on the streets by the very men and women charged with their protection. But too often, they don’t find protection. And black men and boys are left lying there, without aid or comfort, in a pool of their own blood, for all to see the boundaries of permissible police conduct.
For there is no crime too small for which black fathers and sons may face imminent death. For some, death may merely be a traffic ticket away. And for others, no crime is even necessary. Simply disobeying social expectations, or committing crimes against the social order, can threaten an African-American’s life, if one encounters the wrong officer or wrong neighbor, wearing the wrong hoodie or playing with the wrong toy. For them, their public presence can be a justifiable cause for homicide and their assailant may not even face trial.
So as the death toll rises, the leading cause of death for black males aged 10-24 fails to shock anyone – it’s homicide. But you might be surprised to know that doctors are doing little to nothing about it.
In the wake of Sandy Hook, the response from physicians, and pediatricians in particular, was astounding. But as boys who could be my sons and men who could be my father, lie in the street, week after week, the medical profession is silent and I’m frankly appalled.
These deaths should weigh on every physician’s professional conscience. They rip into the very fabric of our degree and challenge the meaning of practices essential to modern medicine – harm reduction and disease prevention. If we, as a field, fail to even acknowledge the lives lost, let alone devise systematic interventions, at a certain point, we fail to honor the oath of our practice and to serve the core of our professional obligations.
Targeted police violence against African-Americans is a public health problem and it uniquely affects children. Yet to this date, there has been no public statement on behalf of the American Academy of Pediatrics, or any other professional medical association to my knowledge, recognizing the tragic deaths of African-American men and boys across this nation. So while my lone voice is hardly sufficient, I offer these words as a part of my professional responsibility to care for the lives of all my patients, big and small.
Too many parents tuck their children into bed, only to worry that tomorrow, their curious 10-year-old may be the victim of police-related violence because the combination of a growth spurt and black skin threatened their life. Too many physicians either don’t know that, or don’t care. Because I’d have to imagine that if we knew and cared, we’d be doing something very different in medicine.
This is my plea for us to do something different. Silence is not okay. This is our responsibility, just as it is for all Americans to re-think what these deaths mean for our society. Because if this legacy of violence isn’t weighing on everyone’s conscience, we are all doing something wrong.
The tragic deaths of Oscar Grant, Michael Brown, Eric Garner, Tamir Rice, Walter Scott, and untold others, deeply grieve our national conscience. But more black men die in America from heart disease than from police brutality, and we never mention those parallel realities in the same breath, let alone collectively mourn those dead.
Why is that?
Because it’s not just that African-Americans have higher rates of heart disease and its related risk factors. It’s that being black IS a risk factor for dying from heart disease in America. Yet few connect the dots between black death by police and black death by disease, although both disproportionately take of black lives.
Just look at the data.
Evidence shows African-Americans have a shorter life expectancy and higher rates of illness and disease than any other racial or ethnic group in the country. Even black babies are more than twice as likely to die before their 1st birthday than other infants in the US. Considering America’s overall infant mortality rate ranks behind its first world peers, that finding is far from benign. In fact, it makes African-American babies less likely to survive the first 12 months of life, than babies born in Botswana, Cuba, or Kuwait; to name a few of the 94 countries who have better infant mortality rates than black newborns in the United States.
And these gaps are far from new. Back in 2004 Congress asked the Institute of Medicine to investigate these racial disparities. After reviewing more than 100 studies,
“The committee was struck by the consistency of the research findings [that] indicated minorities are less likely than whites to receive needed services, including clinically necessary procedures.”
For almost every disease studied, black patients received less effective care than white patients, including routine treatments for common health problems; from cancer and diabetes to, you guessed it, heart disease.
Now, I know what you’re thinking. Just because African-Americans are disproportionately sicker and die younger, doesn’t mean common medical practice added to the disparity, right?
Wrong. Titled Unequal Treatment, the authors concluded,
“(Al)though myriad sources contribute to these disparities, evidence suggests bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care. “
There is something about being black in America, that places African-Americans at increased risk of death; and that something is a quantifiable systemic bias.
So while it is important to scrutinize policing practices that disproportionately harass and kill black males, we must also critically appraise equity in health and healthcare.
How else will we explore the extent of the injustice weathered by Eric Garner who ultimately died of a heart attack? Police training may prevent his unprovoked asphyxiation, but it would do little to address an already shortened lifespan. And yes, the banned chokehold and subsequent failure to indict seemed unjust, on the surface. But is it right to invoke Garner’s haunting last words as a rally cry, if we ignore the inequity that may have pulsed beneath the surface?
And how can we learn from Darren Wilson’s description of Michael Brown as a “demon…bulking up to run through the shots, like it [made] him mad that I [shot] him”? Could the former officer’s misinterpretation of anguish, on the face of a black youth who sustained multiple gunshots, be related to medicine’s well-documented racial disparities in pain management? Because in healthcare, data indicates black children and adults are less likely to have their pain accurately perceived and appropriately treated; and this mistreatment limits medicine’s ability to protect and serve black patients well.
In reality, the threat of police violence that endangers black lives is intimately related to the threat of death and disease that disproportionately burdens communities of color. These are not isolated issues. Together, they tell of a nation that remains profoundly influenced by race, from the mandates of justice to the delivery of healthcare. In time, that influence ceases to publicly alarm. So while some black deaths are made a media spectacle, the vast majority go unacknowledged and unaddressed; the collective impact of which subtly normalizes inequity and codifies injustice.
In the end, there will be no justice without accountability. To save black lives, we have to change how we think about black life – not just how or if, it matters, but where and when, it is most at risk. Now the arc of injustice includes the well-intentioned and malicious alike, each of whom may harbor attitudes and preferences that ripple across systems and threaten the lives of people of color. These threats expose the reality that racism kills and the death toll is much greater than you think.
Incentive structures in healthcare have to change. Right now, we pay for services, or have a so-called, “fee for service” system. The idea is that the more patients doctors see, the more expensive tests doctors order, and the more patients doctors hospitalize, the more money clinics and hospitals make. This incentive structure has transformed our health care into sick care.
The reality is, in America, we are adept at caring for complicated medical problems that require multiple tests, specialists, long hospitalizations, and frequent clinic visits. We focus a lot of resources and attention on this part of medicine because it is what we are paid to do. And to further our efficiency in providing this model of care, many medical systems have adopted business practices, like Toyota’s Lean Strategy, to run our hospitals and clinics more like factories. We essentially increase the number of cogs, or patients in this case, on our conveyor belt, to increase profit margins.
Now, it is only fair to acknowledge that “Lean” and other strategies to improve healthcare efficiency also have real hopes of lowering healthcare costs. In fact, there may be evidence of that. And streamlining health services so that every patient gets a standard quality of care, will likely create equity in the system and reduce costly medical errors, preventing patients from receiving disparate care based on race, gender, or cultural affiliation.
But as we extol the benefits of these patterns of practice, we must also be critical of their overall impact. Is the way we are paying for medicine coming at the expense of delving deeper into the heart of our field? As care becomes more standardized and protocolized, with each patient treated with machine-like accuracy and precision, we do improve “quality” and efficiency in the system. But where is the healing? Where is the prevention? Where is the practice of medicine caring for the human condition and working to keep us well?
Being well isn’t simply having your diabetes under control, it is preventing you from getting diabetes in the first place. If we continue to commoditize patients, valuing their ailments over their wellness, we miss the opportunity to provide the very care we claim to offer, health.
So how do we re-organize the way we pay for care to build a health care system instead of perpetuating a sick care system?
First, if we recognize that social needs have profound and costly health impacts, then as we transform our payment structures under the Affordable Care Act (ACA), we have to support innovative models that address social inequity. That means, using healthcare dollars that are typically spent on clinic visits and hospitalizations to also pay for education, food, housing, and job creation in low-income communities of color. That also means that in the spaces where we provide medical care, we should also be equipped to address patients associated needs. There are models for this.
Second, we have to change the narrative about what it means to provide care. We need to think about the overlap between natural life processes, like birth and death and medicine, and learn the limitations or boundaries of the medicines we wield. When there are no quick fixes or magic pills, how will we care for the human condition? In the spaces where listening is better than treating and healing doesn’t come at the end of a needle, we need to foster the relationships in our communities that provide healing and build resilience.
Third, it is time to transform the physician-patient relationship, a dynamic historically limited to a clinics and hospitals, to team-based care. In team-based models, physicians use their trusted relationship with patients to lead a team of community health advocates to address patients’ health needs in the places where they arise. Sometimes those places are hospitals and clinics but more often they are in homes and neighborhoods. The future of care, if we are smart, will deploy complex networks of healers that extend the reach of the system into people’s lives, supporting their wellness as we address their disease. This will require thinking across sectors, partnering with unconventional liaisons in the social service and for-profit sector, to have a coordinated approach for health.
Right now, The Department of Health and Human Services (HHS) is doing historic work to re-design how we will pay for healthcare. With the guidance of the ACA, HHS is laying out a plan for a population-based payment structure that incentives providers to be efficient with precious medical resources. Doing less for more means we will have to learn how to keep people well. These new changes have the opportunity to shift the focus of our system, towards health. Looking down the pike, let’s be actively engaged in ensuring quality, efficiency, and equity guide how care and healing are provided.
This piece was co-authored by my friend and colleague, Dr. Jessica Schumer. Follow her on twitter @schumerj.
Black History Month is probably one of the most underutilized opportunities to re-ignite the national conversation around social justice in America. As it is typically celebrated, like a random recollection of various contributions by “notable” African-Americans, it feels more like a stale tradition on the verge of irrelevance, than the opportunity to engage issues of racism and social inequality as historical American values that continue to define modern American life.
Last year, I shared why Black History Month remains an essential moment to nationally recognize the lives and works of African-Americans. Right? The original #BlackLivesMatters movement started in 1926.
This year, I want to flesh out examples of how historical American values around race continue to inform national issues and particularly examine how those issues impact health. I’ve talked about mass incarceration, gun violence, and gender inequality a bit in the past.
This month, I’m going to take on the industry of poverty, and child poverty in particular, and how national, state, and local public policy may engineer disadvantage in ways that have profound impacts on health. I also want to talk health systems transformation and consider new models for healthcare delivery that may uniquely serve low-income, communities of color.
And lastly, I want to speak openly and honestly about my dismay with the medical community and our lack of public acknowledgement of the deaths of Oscar Grant, Michael Brown, Tamir Rice, and the other recent victims of police brutality. Lest, we begin to believe that police are the only modern manifestation of our nation’s tragic history with race, I am going to talk about institutional racism and how physician bias directly impacts the health of communities of color, threatening their lives in quantifiable ways.
We are never farther than our willingness to look at where we’ve been allows us to be. In our plight for justice, to move forward, we have to understand where we’ve come from. In February, we are sitting in a powerful moment to look honestly at our nation’s troubled history with race and inequality and find clarity around the pressing issues of our time. Join me this month in discussing how those issues impact our health!
And if there are topics you’d like to talk about, join the conversation and leave a comment below.
To my medical colleagues, fellow health advocates, and concerned community:
As the recent measles outbreak continues to spread, spurred largely by at-risk, unvaccinated or undervaccinated children and adults, it is time to elevate our voice as physicians, scientists, and health advocates to educate the public on the importance of immunization. Let’s counter the misinformation dominating the headlines with the truth about vaccines!
10 Minutes For Truth: Measles
This Friday, Feb 6, 8am PST/11am EST, join the American Academy of Pediatrics, physicians, scientists, and health advocates across the nation in a live Twitter and Facebook storm. For 10 minutes, let’s sound off on measles and why vaccines are vital for the health of America!
Use the hashtag #10Minutes4Truth AND #MeaslesTruth to create a social media storm. Let’s get the truth about measles trending!
What Should you Tweet or Facebook?
It is important to share the power of science in communicating this message. But also consider personalizing your content, ie “I immunize myself or my children because…” OR “Ask your pediatrician if they immunized their children on time?”
Consider referencing these informational links in your message:
The time is now. Raise your voice and spread the truth! #10Minutes4Truth #MeaslesTruth
Also, we want our impact to be as big as possible, so please share this with your networks, colleagues, and fellow advocates. Thank you!
Rhea W Boyd, MD
Pediatrician, Palo Alto Medical Foundation and UCSF Children’s Hospital Oakland
Wendy Sue Swanson, MD, MBE, FAAP
Pediatrician, Seattle Children’s Hospital
Unprovoked and un-prosecuted police brutality that preys upon people of color.
Separate and unequal education systems that consistently fail poor children of color.
Segregated housing that concentrates poverty and consequently, crime, in communities of color.
A discriminatory wage gap for women and people of color that bolsters growing wealth inequality.
And preventable patterns of disease that plague poor communities of color.
The contemporary threats to equality in American life are disturbingly similar to the injustices that emboldened leaders of the Civil Rights Movement more than 50 years ago. But while the issues that define our time are unsettlingly familiar, the opportunities to act are profoundly different.
With the advent of social media, ordinary individuals now have unprecedented access to both publish and consume publicly curated news. This step to democratize information creates a space for enduring public discourse and a real-time portal into the many faces of racism, sexism, classism, and cultural ethnocentrism that endanger our most basic American values.
The legacy of the Civil Rights Movement freed us from the tyranny of these “isms” at the ballot box, in the classroom, in our neighborhoods, in our work places, and in the public spaces of American life. In so doing, the acts of thousands of courageous Americans set a new precedence for our nation to reaffirm its commitment to liberty and justice.
Today that commitment is under attack. And although the challenges we face are formidable, our responsibility is great. So who will rise to the challenge? Who among us is willing to take the protests and the hash-tags into the daily routines of our lives where the insidious acts of racism, sexism, classism, and cultural ethnocentrism threaten the values we hold most dear? Who will fight for equality today?
Dr. Martin Luther King Jr. was an exemplary American who challenged us to rise to the height of our humanity. But we cannot wait for another visionary to bring us to the mountaintop.
The urgency of justice demands we act now, one institution, one industry, one community, one person, one step at a time.
If you are a teacher or school administrator, challenge the “zero-tolerance” policies that forge the school-to-prison pipeline, disproportionately shunting students of color and students with disabilities, as early as preschool, into the criminal justice system for routine school infractions.
If you are a local government official, question the redistricting policies that dilute the voting power of minorities and overturn voting registration policies that may prevent the elderly, the poor, or people of color from exercising their constitutional rights.
If you are a housing developer or real estate speculator, invest in mixed-income housing that enable people, regardless of race and class, to share the public benefits of education, parks, and recreation that flourish in proportion to local tax appropriations.
If you are an environmental advocate, lobby to protect poor communities of color from the industrial pollution that threatens their air,soil, and water quality and ultimately jeopardizes their health.
If you are a police officer, challenge “stop and frisk” policies that disproportionately target Black and Latino individuals and confront the biased assumptions that may lead you to suspect persons of color or treat them with excessive force.
If you are an writer, publisher, producer, or actor, demand that our films and books offer a genuine look into the lives of all Americans. This requires equal representation on the written page, behind the camera, and in front of it, to reflect the diversity of the American experience.
If you are a student, consider if women are disproportionately subject to sexual violence on your campus, and stand in solidarity with the victims in demanding that your faculty and administration protect young women and their bodies.
If you are a business administrator or owner, critically look at your workforce, from the leadership to the average employee to the staff and ensure that the process by which you recruit, hire, and compensate employees reflects equity in opportunities for women and people of color.
As Dr. King sagely foretold, “injustice anywhere is a threat to justice everywhere.” The racism exacted with the lethal precision to take the life of Eric Garner is just as pernicious as the sexism that ostracizes and threatens the lives of victims of sexual assault on our college campuses. It is time to connect the dots between all forms of oppression in American life and work towards justice.
The modern movement for equality will be powered by the daily diligence of the masses, not the brilliance of one leader. We all must summon the courage to go to into our work place, our classroom, our community, and our home, and engineer justice, create equality.
As we remember, with pride and gratitude, the life of Dr. King, let us not rely on his memory to ensure our liberty and justice. Without his living example, let us be his voice for change.
I am MLK.
This week, join @schumerj and I, as we tweet out our commitment to change our workplace, community, or social networks using the hash-tag #IamMLK and let’s build a coalition of leaders for justice. Also look for an upcoming 2-part piece on racism in the American health care system and what we can do about it. In solidarity, Rhea MD
There is little to say once you’ve said this before. Although the sadness brings fresh tears, they are also old tears. The grief becomes familiar and so too the inevitable resumption of everyday life. The pain bores to the soul but settles in the subconscious, where it rests, privately born and quietly hidden, lest frustration and bitterness mire the work we do – trying to forget, but ever-reminded. So although there is nothing new to say, perhaps there is something new to do.
Here, I am looking squarely at you, my fellow physicians. We, who deal in health and disease must think critically and act effectively to address the issues raised by the death of Michael Brown and those who came before him. We are the trusted public servants charged with protecting the populations in our care, to promote health and prevent and treat disease. But are not health and disease simply the crude boundaries of life and death? Then, how will we move to protect the lives of black and brown youth that are threatened by violence? How will we confront the reality that the #1 cause of death for black males aged 10-24 is homicide? What are we doing about the death rate for young black males that is the highest among all adolescents in America? Black male teenagers are 37% more likely to die than any of their peers. And according to the CDC, because these deaths are secondary to external injury, they are by definition, preventable.
So I will ask again, what are we doing about it?
Because, despite the vaccines given to ward off the threat of disease, and the medications prescribed to prevent seizures, kill cancer, and treat infections, black males may not make it out of adolescence alive if we don’t address the violence.
In preventative medicine, we talk about risk factors to identify patients who may suffer from an illness in the future, and prevent it, before suffering and/or death could ever occur. In oncology, we talk about getting to the diagnosis and treatment early, so that in cases where it makes a difference, everything that can be done, will be done. And yet, as black youth die in the streets because of where they live, and how they dress, and the volume at which they listen to their music, we are silent. We, as a collective field, say nothing and we do nothing.
Black lives matter because all lives matter and no one gets that more than we do. So as young black bodies line our streets without reason or recourse, we must start asking what that means for all of us. We must start changing the way we teach and practice medicine. Because if we fail to protect these youth, because we don’t understand their music, or we don’t like the way they dress, or we don’t feel comfortable with the way they speak – whatever the because – then we fail ALL of our youth. We fail to do service to the highest honor of our profession, to protect the lives we care for.
Now, this issue is complicated and deeply rooted in the legacy of discrimination that defines American history and continues to inform America’s present. And you may even avoid talking about it in your personal life, let alone your clinical practice. But your, or my, discomfort does not make it any less our responsibility.
So let’s start dealing with it. I’m talking about poverty. I’m talking about racism. I’m talking about structural inequality. I’m talking about the gender wage gap, the academic achievement gap, and the housing equity gap so wide whole generations fell in and got lost. It is time to engage these topics as legitimate and enduring parts of medical education, public health messaging, and clinical prevention strategy.
If you don’t have the faculty to teach this material, call upon our colleagues in the social sciences to share their expertise. If you don’t know how to address community violence, reach out to non-profits who have made this struggle their life’s work. And if you shy away from the institutional failings that underlie the policies that contribute to the disparities, then call on your local, state, and federal policy makers to change the law.
There is literally no time to waste. Every faceless, nameless brown child who drops dead in the streets could have and should have been prevented. Let this issue not settle in the subconscious recess of our field while children suffer. Because in the end, it is not about Ferguson, it is not about Michael Brown, it is not about the countless others who met a similar fate, it is about what we are doing to ensure that all lives matter, regardless of the color of that life’s skin.
In the post-Affordable Care Act healthcare landscape, sweeping hospital closures have created new barriers to access in a system already criticized for its fragmentation and saturation. Looking back over the past 20 years, urban hospitals, and urban trauma centers in particular, bore the brunt of this impact, closing at the highest rates in the country. Now, evidence suggests the impact of urban hospital closures may disproportionately affect those living in poverty, racial and ethnic minorities, and the uninsured.
This concerning trend begs an important question:
If urban hospitals are a trusted point of access for low-income communities of color, does their closure undermine the national safety net OR does it create opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations?
To answer this question, let’s look at the contentious 2007 closure of Martin Luther King Jr. Harbor Hospital in Los Angeles.
As a bit of background, MLK-Harbor opened in the wake of the 1965 Watts riots and general unrest regarding the lack of sufficient public investment in communities of color in South Central (now termed South LA). The hospital was to provide healthcare in one of the poorest and most violent neighborhoods in LA. At the time of its closure, it remained the only public hospital to serve a large part of South LA, treating more trauma patients than almost all other hospitals in the region. Its closure was prompted by a series of egregious medical errors that eventually threatened the hospital’s accreditation.
Mounting quality concerns aside, what was most notable about its closure, was the staunch community protest. In the face of unquestionably dangerous medical practices, the community rallied to protect their safety net; even garnering the support of Congresswoman Maxine Waters, who rose to the cause’s defense in 2004. Despite their efforts, the trauma center was shut down in 2004 and the general acute care hospital closed thereafter in 2007.
So why would a community fight for the failing care of their discredited hospital? Is the safety net worth protecting when it is offering poor care or is the community’s advocacy tacit admission that poor care is better than no care at all? And ultimately, does “no care” threaten the safety net or does it provide an opportunity for something better?
Let’s dissect these questions piece by piece.
First, it is a basic human instinct to protect what you perceive as yours. Even if what you have is broken. Now superimpose on that instinct, a history of having no say in what is taken from you; a history of abandonment by public institutions charged with investing in your community infrastructure; and a history of displacement driven largely by resource scarcity and discrimination. When viewed in this structural context, the motivations to fight to protect resources become obvious.
Second, let’s explore the idea of fighting for “failing” or “poor” care. Here, the assumption is that low-income communities of color either don’t understand or don’t want, quality. Why else would they protest the closure of a bad hospital, right? In this case, I think we’ve got the assumption wrong. Americans love a deal. We want more for less. Whether it’s super-sizing our french fries or buying into the housing market at the right time, we want quality and we want it at a bargain price. In this way, quality is an American value that translates across the economic spectrum. But sometimes, “the deal” trumps quality. So the real question is, what is the “deal”?
In the case of MLK-Harbor, if there is not another medical facility near your home and public transportation is unreliable, or if you are uninsured and you cannot afford a second opinion, or if the medical specialty you need is only available at your local provider; then the deal is access, the deal is cost-savings, the deal is specialization. This is why low-income populations are vulnerable. Because their lack of resources offers them a bad deal, around which there is little leverage.
So it is not that poor care is better than no care. It is that no care should no longer be an option, but for many, that is the deal they are left with. So as engineers of the system, we have to create something better.
And herein lies the answer to our initial question. It does both.
Because urban hospitals are a trusted point of access for low-income communities of color, their closure undermines the national safety net AND creates opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations.
In attempting to forge a better healthcare system in the midst of our broken one, every failure is an opportunity for improvement.* As the Affordable Care Act re-organizes the medical landscape into regionalized, micro-systems that are accountable for local populations, it provides the opportunity to consider our past failures and the global impact of shifting costs and shifting care on the vulnerable.
The tension between eliminating inefficiency, maintaining quality, and controlling cost while elevating the voice of the community and prioritizing the needs of the under-served, remains. These are the challenges that loom at the forefront of a healthcare system that seeks to cut costs and maximize quality for all. But this is a cause worth fighting for and I’m all in. Are you with me?
* To see how MLK-Harbor (now MLK Community) is improving their system to re-open in 2015, click the link.
That means, where people live and how they function in their local environment, potentially matters more to their long-term survival than what doctor they go to, or what medicines they are prescribed.
That is a powerful statement about a complex phenomenon – what happens in our communities impacts health in profound and lasting ways. So if health is predominantly determined by community-level factors,* perhaps we should re-design the traditional medical model to place community at the center of health care.
This idea isn’t new, and is probably why Dr. Steven Schroeder aptly titled the article from which this graph was taken, We Can Do Better. One look at the data and it is obvious more can and should be done to address the social, economic, and political drivers of health in this country. But the question of who and how somehow remains.
For many physicians, taking on structural inequality may seem overwhelming or outside their job description. Common retorts I hear are, “This is a social workers job.” Or “This sounds good in theory, but how would it work in practice?” To the first point, the evolution I am alluding to is a systems-wide change in the practice of medicine, such that the way we conceptualize medical care draws upon the skills of an interdisciplinary team of practitioners charged with addressing social determinants of health. So while this vision certainly includes social workers (and public health departments, local government, social service agencies, etc) it also necessarily includes physicians.
To the second point, there is a long history of community-oriented primary care (COPC) theory and practice. It dates back to the 1940s, and the work of giants like Sydney Kark, who created a model of government-funded, community-based, preventative care delivery in South Africa; and Jack Geiger who directed 2 exemplary, community health centers in the Mississippi Delta and Boston, MA in the 1960s. Dr. Geiger’s integrated clinics were the first of their kind and used government funding to pay for community-level health issues, like hunger and housing. Today, there are over 1200 such clinics nationwide serving an estimated 20 million Americans, or 5% of the US population, annually. These clinics are the backbone of the national safety net and the front lines of the medical response to growing inequality.
But as the issues of poverty begin to knock on all of our clinic doors, we can no longer afford to ascribe to the notion that this is the niche work of a minority of physicians.
So where do we begin?
The ballot box.
Data suggests physicians have a relatively low rate of civic participation as compared with professional peers like lawyers and the general population. As local policy informs local resources, the ballot box is the space where physicians find voice to address the pressing needs of our communities, needs that have an undeniable impact on this nation’s health.
The future of medicine requires physicians confront the impacts of concentrated poverty, a tiered education system with gaps big enough for entire communities to fall through, immigration and population displacement, and racial and gender discrimination, among other indicators of health. Still, the traditional physician role and our current training paradigms largely ignore these modern threats to health and wellness. So in the absence of a clear system-wide charge, vote in a way that makes a difference.
If community health centers are the backbone of the social safety net, voting is the backbone of physician advocacy.
Civic participation is the new frontier for physicians to combat the effects of poverty and inequality on health in enduring ways. It is how we can reach beyond the limits of our clinical role to engage the issues that matter to our patients and our communities.
Visit Vote411.org to find a polling place near you, trouble shoot election-day problems, and find a state-specific voter guides.
Definitions used in this piece:
* Community-level factors are things like where you live, how safe your neighborhood is, if you have a park within walking distance of your house, or if the property values in your neighborhood are high enough that your local public school is well-funded and thus if you are of school-age, you are more likely to go to college as a result of living in that neighborhood. These community-level factors are intimately related to the choices people make or their “behavioral patterns” (as referred to in the pie chart above). For example, if your neighborhood is relatively safe and there is a park within walking distance of your house, you may be more likely raise your child in a lifestyle that promotes and values physical activity, a known method to prevent obesity. Conversely, if you live in a neighborhood that does not have a grocery store that sells affordable fresh produce, you may be more likely to eat processed food, and more likely to battle obesity and related health conditions.
For more on how community level factors or structural inequality affects health, check out my piece on structural inequality here. If you are an educator thinking about teaching these topics, check out my piece on teaching structural inequality here. This piece also includes the syllabus and reference guide I use when teaching on this topic.
After a 3 month hiatus from writing, I’m back! And although things went radio silent on my blog, I’ve been busy working on projects that I am excited to share with you guys! But first, let me tell you why I took a break.
For those of us who think critically about the delicate social safety net that is fraying under mounting pressures of growing inequality and finite public resources, it is clear that more than thoughtful rhetoric is required to bear this heavy load. It is also clear that there are new opportunities for the healthcare industry to unite with the social sector to address the most egregious impacts of poverty in our society – death and disease. So while I took some time away from talking the talk on here, it is in part because I found new opportunities to walk this walk in my professional life.
Now, I’m back, and with new experiences that will hopefully inform our conversation on this blog. So look forward to new posts as I continue to think about the intersections of race, gender, social inequity, structural inequality and health in our society and ponder aloud how we might address these issues together, through our unique work.
Here are the questions that will drive my next posts:
1. Is worse care better than no care? Do new models of care trialed by pharmacies (think CVS, Walgreen’s) and internet giants (think Google and Facebook) suggest access is more important than quality? How should what we know about quality drive how we provide care across the medical infrastructure?
2. How can technology bridge the gap between the healthcare and social sectors, as we both endeavor to address the impacts of poverty on society? This question is intimately related to a question I frequently ask on this blog: If patients bring doctors their social needs and doctors know those needs impact their health, what is the physician’s role in addressing social needs?
3. Cultural Competence vs Cultural Consciousness. What is the correct framework for understanding and addressing health disparities? How should we teach physicians and trainees to engage their unconscious bias in clinical encounters such that all patients receive and perceive quality care, regardless of their “cultural” background?
Okay, those are a few teasers to tide you over for now 😉 And if you have other topics you’d like me to address, please leave a comment and I will do my best to include them in upcoming pieces. Looking forward to walking the talk together!
Until then, be well!
Earlier this year, I started teaching a course to first year pediatric residents at Stanford. In it, I challenge the trainees to identify the structural contexts in which patients and families make choices that may impact their health and well-being. Termed structural competency, the goal is to enable young physicians to understand and confront stigma and inequality as key determinants of health. We talk about educational attainment and health literacy, socioeconomic status and health access, social norms and health practices, institutional discrimination and health disparities, and the built environment and health behaviors. Together, we examine the fragile balance between resources and health, recognizing that local forces that manipulate resources effectively legislate health, by structuring choice and opportunity.
To illustrate these fundamental connections, it is often necessary to convert what otherwise exist as invisible forces in society into accessible, clinically-relevant language. This allows us to conceptualize the structural framework in which patients’ live, work, and play, within a medical model. It shrinks what seems like a diffuse and disconnected system of local policies and institutions into tangible drivers of health and disease that require socially-informed, clinical interventions. It transforms inequality, a sociopolitical phenomenon, into a silent but active participant in the clinical encounter. This makes addressing local infrastructure a central component of any community-centered, health promotion strategy.
But as we expand our purview beyond the exam room and encourage young physicians to adopt a global approach to clinical medicine, we must be very careful not to succumb to, what I will call, “the perils of pretending.” Here, there are 3 common pitfalls that warrant discussion.
1. The Poverty Simulator. In any educational endeavor, experience is perhaps, the greatest teacher. Without experiencing poverty first-hand, it may be difficult for residents to understand the challenges families living in poverty face when seeking medical care or selecting medical treatments.
One such simulator offers “players” a chance to live on a low-income budget. Other programs ask residents to navigate public transit to various appointments. At Stanford, I ask the residents to live on the average food stamp budget for a week. These self-reflective exercises are meant to influence learner attitudes about inequality and build empathy among providers as they realize what it takes to survive under certain conditions.
The problem with poverty simulators is that the process of pretending to be poor unfairly and inaccurately reduces the daily struggle of living in poverty to a series of poor choices, no pun intended. The “game” motif insinuates that some choices are superior to others while completely obscuring the larger network of policies and institutions that concentrate disadvantage and manipulate choice in low-income communities.
For example, if you live in a food desert, the choice to eat fresh produce is constrained by the proximity of those resources to your home. This “trade-off” requires bargaining between necessities and results in a loss either way. Buying cheaper food in your neighborhood may have adverse health consequences and expending the time and money to obtain healthy food on a fixed income makes other necessities unaffordable. This zero-sum reality profoundly limits choice.
To avoid this pitfall, it is important to be clear about the purpose of the exercise, which is to acknowledge that resource limitations have health consequences. The lesson is that poverty is not a deficiency of ingenuity or the manifestation of good or bad choices. There are no “right” choices when selecting between food and medicine. So if poverty is the result of eroding urban infrastructure and imbalanced resource allocation and is associated with poor health outcomes, then building infrastructure is a health intervention.
2. The Absence of Clinical Models. While the associations between social determinants of health and poor health outcomes are well-documented, we lack comprehensive, evidenced-based clinical models for addressing complex trauma and chronic stress, physiologically significant exposures that are the downstream sequelae of poverty and inequality. Short of co-locating same-day necessities in medical clinics, like food pantries or legal assistance, there are few models to describe how physicians in particular and the medical system at large, should engage the sociopolitical drivers of health through clinical work.
In the absence of these models, some physicians pretend there is nothing that can be done, or worst yet, that these issues are not “medical.”
The problem is that we are complacent in our current clinical practice. Stagnated by the dearth of evidence and overwhelmed by the magnitude of the issue, we simply avoid it. We fail to universally screen patients for social determinants of health because we don’t know where to refer them. We refuse to inquire about these issues because we essentially lack confidence in our ability or aptitude to address them.
The solution here is to do it any way. Just as all politics are local, so too will be the formation and dissemination of novel clinical models that address these issues. So we must encourage our trainees to identify the most pressing needs in their communities and trial socially-savvy interventions in their continuity clinics. This is quality improvement at its best.
3. The Conflation of Race and Risk. When seeking to address the “cultural” influences in a clinical encounter, it can be easy to minimize “culture,” to the readily identifiable traits in the visit. Here, “culture” becomes a monolithic, static archetype we project onto patients based on our unconscious bias about their physical attributes, like ethnicity, nationality, or language.
When we do this, we are pretending that socially-assigned attributes, like race, are a proxy for risk. We track patterns of disease prevalence by these attributes and over time, come to associate the attribute with the disease. This logical fallacy then informs clinical practice and leads clinicians make inaccurate assumptions about certain patient populations, their relationship with disease, and the efficacy of certain medications to address their complaints (remember BiDil?).
The solution is to replace cultural competence with structural competence and educate young providers to interrogate the local context in which patients live, the resources at their disposal, and the networks they rely on to make medical decisions. We must of course, when doing this, not turn a blind eye to the ways in which local policies and historical discrimination produce predictable patterns of disease in certain communities. These patterns may make it seem as if the risk factor is easily recognized in the exam room (race, nationality) as opposed to the real risk factor that lives in our communities – structural inequality.
As medicine advances to address inequality as an important driver of health, we must be thoughtful about the way we educate our trainees to tackle this new frontier in primary care. While there will be pitfalls along way, if we tread carefully and together, we can transform the future of medicine in powerful and meaningful ways.
* Update: To learn more about my course, please check out the syllabus and reference guide I have shared below.
It is no secret that growing income inequality is one of the major issues facing the nation today. Close to 50 million Americans, or 1 in 6, live in poverty and 1 in 3 children are now projected to live in poverty at some point in their lifetime. But did you know, up to 1 in 3 kids in San Francisco may go to bed hungry tonight?
As the price of housing transforms our city into one of the most expensive in the country, the national income gap seems to have landed on our doorstep. And while this topic has garnered robust media attention and local public debate, the focus on poverty remains cursory, at best. Here, the housing crisis is literally changing the face of the city, and yet it is hard to identify who is most affected by the fickle pendulum of the economy and it is easy to make affordable housing the center of the conversation.
But the impact of poverty extends from the most recognizable needs in our community to one of the least – hunger. So let’s talk about it. Who’s hungry in our city?
Meet Lani. Lani’s grandmother originally came to San Francisco from Samoa in the late 1970s and her family has lived and worked in the Bay Area ever since. Like many of us, she dreams of owning a home in the city one day, but like a growing population of San Franciscans, her immediate need is food for her family.
Lani is a 35-year-old working mother of 2 and the only employed adult in her household. Her husband was a construction worker who, because of poor health, is physically unable to work. And after losing her mother in 2008, she and her husband became legal guardians to her younger siblings. That means, it’s all up to Lani to make ends meet.
As a high school graduate, she’s worked in food and cleaning services, but with the downturn in the economy, consistent work has been hard to find. In 2012, she became a certified nursing assistant and found a part-time position that offered $14 an hour but no benefits. She took it.
All 6 members of her household live in a government subsidized apartment in Hunter’s Point and yet because of her new income they recently found out they no longer qualify for food stamps or CalWorks. Struggling to get by without any additional aid, they rely on food from her church to make it to the end of the week. Sometimes, that is only a bag of rice and a can of vegetables. Her kids, aged 6 and 7, are just starting primary school. Without the free breakfast and lunch they receive there, she says she “probably wouldn’t be able to find something nutritious for them to eat at home.”
Hunger is a problem. But the issue here is more complex than the physical sensations of inadequate caloric intake. The more insidious challenge facing family’s like Lani’s is food insecurity, or limited or uncertain access to the resources to buy, store, and prepare the nutritious and culturally appropriate food necessary to support a healthy lifestyle.
According to the 2013 San Francisco Food Security Task Force’s annual report, 1 in 4 San Francisco residents live at or below 200% of the federal poverty level. For a family of 4, that’s about an income $47,100 per year. These low-income families make up a quarter of the city’s residents are the most likely to be food insecure. But the population we seldom recognize, despite having similarly high rates of food insecurity, is our city’s children.
For these communities, food insecurity is literally changing their lives. There is mounting scientific evidence showing that food insecurity is related to poor health outcomes like increased risk of adult chronic disease including diabetes and heart disease, and in children, increased risk of obesity and learning and behavior problems. And recent data from San Francisco General Hospital’s Community to Clinic Linkage Program, indicates almost half of the patients seeking urgent care at our county hospital are food insecure.
This is a public health problem and it sits at the intersection of income inequality and poverty in every city in America, including our own. In December 2013, the San Francisco Board of Supervisors issued a charge to local legislators and community organizations, to eliminate food insecurity in San Francisco by 2020. In collaboration with the San Francisco Food Security Task Force, help address this important issue!
Here are some things you can do today:
National rates of poverty are the highest they have been in decades and they impact our city in unique ways. But when you ask Lani what she wants for her kids, she doesn’t talk about eliminating financial stress or putting food on the table. She simply says, “I want them to become someone.” Healthy food and snacks are the building blocks to “become someone.” If recognizing the problem starts with asking the right questions, perhaps it is time we all asked, “Who’s Hungry?”
Dr. Maya Angelou’s words decorate the walls of our classrooms, fete the ceremonies of presidents, and illuminate the conscience of a nation. By formal account, she was a poet, playwright, memoirist, dancer, singer, stage actress, streetcar conductor, single mother, college professor, civil rights activist, and cultural humanitarian. But, perhaps most importantly, she was ours.
With the rare clarity that comes from lived experience, Maya Angelou captured the curious reality of the American black girl; the girl who awakens to a home she is told, is not hers. The paradox of being born black and female in America is that although you are as quintessential to the American story as the slave trade that brought your ancestors, by virtue of your existence, you are displaced. Despite birthing the generations whose unpaid labor sustained the American economy for more than a century, it is the black woman who lives as a foreigner in her own home. As the social construction of race animates and personifies blackness, the color of her skin eclipses the content of her character. Thus historically, it is the African-American woman’s blackness that shrouds her femininity and obscures her nativity. It renders both her beauty and her personhood, foreign. She is the acquired taste. And as she awaits her palatability, she remains in the shadows.
But as Maya showed us, the shadow is not just a vacuous darkness left in the background. It is the evidence that you exist, that you were here, and that the sun shone down on you. By embracing the lived experience of our blackness, Maya helped us embrace the light in which black women were cast into existence. We were aching to be seen and see us, she did.
The lens with which Dr. Maya Angelou captured the African American experience was transcendent. She humanized us. As she recounted the lives of her mother, brother, father, aunts, uncles, cousins, and friends, she gave living testimony to the pain, humor, love, and tension that pulses beneath the surface of American life. She made survival a virtue and cast black girls as repositories of the national wisdom held in the seemingly insignificant happenings that pepper everyday life. She refused to trivialize the lives of children, the poor, or African-Americans, despite the fact that they so often go unnoticed or uncelebrated. Revealing our inner truths like nursery rhymes, exclaiming our bountiful beauty with exacting wit and unwavering reverence, she told us of a woman, who was once a girl, who was once a black girl in the south, who was once invisible (and mute). Rendering us visible with the audacity of her authenticity, she offered us voice and if you are like me, you took it.
Truly good prose looks into the deepest crannies of human experience, and reveals you, to yourself. By bravely telling her story, Maya told our story. Standing in a line of Sojourner Truth’s, Phillis Wheatley’s, Gwendolyn Brook’s, Rita Dove’s, Audre Lorde’s, Nikki Giovanni’s, Alice Walker’s, and scores of other black female poets, playwrights, and authors, she shone a light onto the very soul of us. I know why the caged bird sings. It sings because Maya lifted its very existence, that it might know it was made to soar.
Maya once said that the greatest thing you can say to another person is thank you because thank you is what you say to God. Where words fail to capture the depth of my sorrow for her loss and the extent of my gratitude for the life she lived and the words she left us to live by, I say, Maya, oh sweet Maya, thank you. You will be missed because you were always ours.
As growing income inequality continues to divide the nation into the have’s and have not’s, more and more families are finding themselves having not. For too many, the tight rope of financial stability has frayed and as we are realizing, more is dangling in the balance than dollars and cents. America’s future is on the line.
With many struggling to survive without basic necessities, like quality education, meaningful employment, affordable housing, nutritious food, or accessible healthcare, poverty is the contemporary atrocity that challenges our most fundamental American values; that everyone is created equal and endowed with rights to life, liberty, and the pursuit of happiness.*
Today, liberties are constrained by access to resources, the plight of the poor is hardly a pursuit of happiness, and for many, their very lives are at risk. Just look at this graph that illustrates the association between income and life expectancy. I guess rapper 50 Cent had it right. In America, if you don’t get rich, you will certainly die sooner, trying or not.
The implication here is that poverty not only threatens the health and well-being of a growing population of Americans, but its persistence also threatens the foundation of our democracy. So, at a certain level, understanding the impact of poverty is central to understanding what it means to be an American today.
So let’s talk about it. What do you know about poverty?
Take this 10 question quiz from Marketplace public radio and see how you stack up!
How’d you do? Post your score or thoughts on this exercise in the comments below!
Now that you’ve seen the facts and figures, let’s look at what those numbers mean.
To understand the impact of poverty, we have to engage the context and ask the right questions. For example, take the statistic that says, “of all working age people living in poverty, about half (7.2%) had full or part-time employment in 2010.” I took this fact directly from our handy quiz link above. You can translate that figure into a number of questions. One question might be, “Why don’t poor people work harder to lift themselves out of poverty?” Or if you are Paul Ryan** you might ask, “Why don’t poor people value work?” These questions create value-laden assumptions about individuals and communities and ignore the local systems that contribute to poverty.
Better questions might be, “What is the relationship between employment and poverty in the United States?” “If half of the poor are already working, what role do for-profit corporations play in the perpetuation of poverty?” “Should conditions of employment include provisions for basic needs, like a minimum wage that approximates local housing costs or health insurance coverage for part-time employees?” “How does race, gender, or educational status influence opportunities for upward mobility?” These questions interrogate the economic, political, and social systems that disseminate resources, structure local opportunities, and define the face of poverty in the US. Asking questions in this way allows us to formulate an actionable agenda to address poverty.
It is time to transform the national conversation around a topic that is literally redefining what it means to be an American. Today, the long reach of poverty extends throughout every state and city in this country, influencing lives from cradle to grave, and intimately shaping the ways we live, work, and play. If all meaningful action starts with knowledge, what’s your poverty IQ?
* Here, I should clarify that the Declaration of Independence specifically declared “all men” created equal. This of course purposefully excludes women and people of color. Slaves were not considered people until 11 years later, when it was decided they would be 3/5 of a person. This was known as the three-fifths compromise.
** Paul Ryan was quoted on the Bill Bennett Morning Show in March 2014 indicting “a culture, in our inner cities in particular, of men not working and just generations of men not even thinking about working or learning the value and the culture of work.” Here, he conflated institutional failures with cultural pathology. Given his influence over the federal budget, it is concerning to hear him voice this deep misunderstanding of the forces of poverty in the US. Charles Blow, an op-ed columnist at The New York Times addressed this point here. For a bit of a longer read on the nuances between culture and poverty, check out this beautifully written piece by Ta-Nehisi Coates, an op-ed columnist from The Atlantic.
Today is Equal Pay Day, or the day that marks how many extra days the average US woman must work into 2014, to earn as much as her average male counterpart in 2013. Given this momentous occasion to spotlight gender wage inequality in America, let’s take a brief look at the wage gap, why it matters, and what our President is doing about it today!
Did you know there is a gap inside the gap?
According to US census statistics, the average, full-time, female worker in America makes 77 cents to the dollar of what the average, full-time, male worker earns. But this statistic only refers to White women. The wage gap is far wider and deeper for women of color in the US, who face both a larger disparity in pay deferential and also fewer opportunities to rectify this great imbalance. The average African-American female worker makes 64 cents to the dollar and the average Latino female worker only makes 53! Part of that deferential is related to lower educational attainment among African-American and Latino women. And yet, “you can’t educate your way out of the gap!” Even as higher education raises everyone’s wage, African-American and Latino women continue to earn less than their White peers with the same educational background. This reveals a racial gap, inside the gender gap that may reflect discriminatory hiring practices, disparate access to meaningful employment by neighborhood or region, and disparate opportunities for upward mobility for professional women of color.
There is also geographic variation in the wage gap. Check out this chart to see how your state compares to Washington, DC or Wyoming, the areas with the smallest and largest gender wage gap in the US!
Why does the gender wage gap matter?
Since 1960, the number of women who are the primary wage-earners for their household has almost quadrupled, such that women now comprise nearly two-thirds of the breadwinners or co-breadwinners in their family. And as it turns out, more than 6 and 10 of the women who are the primary breadwinners in their home, are single mothers.
That means, average American families are increasingly depending on the earning power of women to make ends meet.
So when Mom brings home 23% percent less than her male counterparts (remember, that percentage can be as high as 44% less for Latino women), that is less income for everyday needs including healthcare, less investment in our children’s futures and education, and when added over a lifetime of work, significantly less for retirement.
AND, as a pediatrician, I know that children who live in poverty are more likely to have poor health as adults, including increased risk for cardiovascular disease, high blood pressure, diabetes, arthritis, and depression. What is more, there is evidence to suggest that these risks persist, despite changing social class in adulthood. So in many ways, investing in women is also vital to our country’s health and wellness!
So what is today’s big news?
Today, President Obama continued his commitment to the economic empowerment of women by signing one executive order and one presidential memorandum that take the legislative steps necessary to level the pay-ing field for women, well at least, female federal employees. This week the US Senate is also considering the Paycheck Fairness Act, which would extend the standards put forward by the President’s executive order to all employers covered by the Fair Labor Standards Act. To see President Obama’s complete legislative agenda to address gender income inequality click here!
And finally, any quality discussion of income inequality would be remiss to leave out the debate on minimum wage. Suffice it to say, raise the wage! Doing so, would especially benefit women who are more likely to occupy low-wage sectors of the labor force or to participate in part-time work (given many women’s commitment to their education or their growing family). It is also estimated that increasing the national minimum wage may be essential to lifting more than half of our working poor families out of poverty.
As Martin Luther King Jr said in his 1965 commencement address at Oberlin College, “The time is always right to do right.” And for income inequality in America, that time is now.
4 weeks ago, I published an article on Kevin.MD that garnered a lot of attention. It was titled The Myth of the Entitled Single Mother Remains as Relevant as Ever.* In it, I reversed the popularized notion that single mothers are a societal liability and suggested that instead, they are powerful forces in our local economies and influential leaders of future generations. I presented the idea that how society thinks about single mothers affects how we fiscally prioritize their needs. The point was, stigmatizing public rhetoric informs pubic policy in ways that perpetuate inequality and contribute to poor health. In response, however, I received a number of comments, many from other physicians, suggesting that such a topic was not “medical” enough to warrant physician concern.
That sentiment sits at the crux of one of the most contentious debates in medicine and frames one of the most important questions facing clinicians today. If inequality drives poor health, what is the physician’s role in addressing the structural forces in society that perpetuate inequality?
To answer this question, we must first unpack the ways enduring public narratives inform our institutions and shape opportunities in America. We must talk about how structural forces in society can align to create predictable patterns of disenfranchisement, including inter-generational poverty and poor health. Let’s get started!
The archetypes society erects to distinguish populations, commonly by race, gender, socioeconomic, marital, or immigration status, are not simple social tropes that define broad categorizations of people. Over time, and historically in fact, these social constructs lay deep roots in the political processes that govern society, processes that in turn, inform many of the institutions on which society relies, including the justice system, the education system, and the public health system. This pattern of influence is problematic because it allows shared public stereotypes to drive major public policy. This institutionalizes bias and creates inequality. And as we know, inequality drives poor health.
Let’s take one example of this and flesh it out. Look at the effect of race and gender on incarceration rates in America and the associated health consequences.
African-Americans make up 13.1% of the US population and yet African-American males alone, make up 38% of those incarcerated in federal and state prisons today. That means Black males are 6 times more likely to be incarcerated than White males and if these trends continue, 1 in 3 Black males will be imprisoned at some point in their lifetime.
The origin of the stark racial disparities in the US criminal justice system is complex and multifactorial. It is, in part, related to the disproportionately high rates of poverty,** unemployment, and low educational attainment in African-American communities. But it is also driven by a public narrative that associates Black males with criminality. That is why, even when you control for the crime rate, Black males are more likely to be arrested, once arrested, more likely to be convicted, and once convicted, more likely to face longer prison sentences than their White peers. This criminalization of African-American males is far from benign and, in fact, may have adverse health consequences for Black children and Black families.
When 1 in 3 African-American males are projected to be removed from their communities, often at the age of greatest productivity, it has profound effects on the communities in which these men live.*** Without their earning potential, these families disproportionately rely on the income of single mothers, many of whom live on the brink of poverty.**** Children who live in poverty are more likely to have poor health as adults, including increased risk for cardiovascular disease, high blood pressure, diabetes, arthritis, and depression. What is more, there is evidence to suggest that these risks persist, despite changing social class in adulthood. That means, there are physiologic pathways whereby systems of inequality and social stress may act to create immutable changes to children’s bodies, affecting everything from their brain development to their DNA. These changes can potentially be passed down to future generations, allowing under-resourced social environments to create predictable patterns of disease.
When considered in this way, it is easy to see how shared public narratives can become entangled in policies that systematically disenfranchise families and communities, dismissing productive members of society, shaping local economic opportunities, and informing the health of our future generations. When the life expectancy of a child can be predicted by the zip code in which they live, it exposes important drivers of health and disease in America. As physicians, we must dissect the threads that connect sociopolitical environments to biological consequences. If that is not “medical” enough to warrant our concern, I don’t know what is.
This is the future of medicine and it requires physicians confront issues of stigma and inequality as a function of their clinical duty to promote health and wellness. Doing so will certainly be a challenge. Success will rely on our ability to understand the impact social, political, and economic environments have on the population’s health and, to systematically incorporate this framework into the canon of medical scholarship and medical education. From there, we will need to build interdisciplinary models that bridge political action with health impacts. Jonathan Metzl and Helena Hansen have mapped a way to do that in their article entitled, “Structural Competency: theorizing a new medical engagement with stigma and inequality.” There is much to do be done. Let’s get to work!
* Kevin.MD. is an online medical publication. You can also find this article on my site here!
** Communities in poverty have higher rates of crime regardless of racial composition.
*** This lends a new urgency to addressing the national gender wage gap, a gap that is wider for women of color, as communities of color may disproportionately rely on the income of women. It also underscores the importance of creating pipelines to higher education for men and women of color, to both supplant the pipeline to prison and to position women of color to occupy leadership roles in the community.
**** Many states also legally revoke prior felon’s voting rights and increasingly, laws and policies are being enacted to limit prior felon’s ability to: obtain employment, receive government benefits like food stamps, access public housing, or qualify for student loans. This results in 1 in 13 African-Americans no longer being able to vote today and prevents countless others from making meaningful contributions to their families and communities.
I have a confession.
It is a secret I have held for more than 10 years and it is a lesson I have learned from other women.
As society continues to debate the terms and conditions required for women to be leaders, what is often missing is the lens of the woman of color. It is time to talk about the socialization of girls, and brown girls in particular, and the guise we are raising women to wear to navigate the complexities of race, gender, and politics in the classroom and the workplace.
So here goes…
I change my voice to make other people comfortable.
In general, I have a high-pitched voice. It’s genetic. My grandmother spoke in a higher register and I guess I’m following in her shrill footsteps. But my grandmother had style and when she squealed in laughter or sang the soprano out of a church hymn, it sounded like wind chimes in a summer breeze. Her piercing tone commanded authority and carried assurance. She was authentic and her voice was the instrument that ushered her power.
My voice may be naturally high, but when I’m the only African-American or woman at the table, or when I hold a particularly contentious opinion, I go EVEN higher. Instead of wielding the power of my pitch, I ritually sacrifice my self-expression somewhere in the back of my throat and barter my pride for the perceived benefits of social normalcy. I phonetically transform what I physically cannot change, I am an educated black woman with an opinion.
My sister calls this guise “good girl, up speak.” It is the rising tone of voice I enter to placate others. I summon the “good girl” voice as a part of a physical transformation I have grown accustomed to, first in the classroom and now in the workplace. At some point, I have, consciously or unconsciously, accepted the misogynist edict that women, and women of color in particular, are to be seen and not heard. And I have learned that edict from other women.
Careful experience has taught me that speaking assertively may make males, and white males in particular, uncomfortable. Why else would intelligent women, in the media, in my classroom, and in my profession, soften their voice almost to the pleasant vacancy of a child, to communicate their thoughts? We’ve all seen it. So rather than fully challenge my male colleagues to engage in the mental and social exercise of trying to understand what my black, female body is communicating, I too make my words, however cutting, fall softly on their ears, lest they be offended by both my point of view and my tone of voice.
It is not so much playing dumb as it is playing docile. But what’s the difference when you are trying to be heard? In Harvard Business Review, Deborah Tannen, a sociolinguistic researcher, wrote a piece called The Power of Talk: Who Gets Heard and Why. In it she says, “Language is a learned social behavior.” As such, it is infused with the power dynamics that are socialized into each of us as children; dynamics that communicate competence and confidence, and dynamics that can translate into stereotyped gender roles. According to her, “Language negotiates relationships” and the way you address people and how you are addressed, reveals an unspoken social order that defines how we understand each other and how we value each other.
Lately, much has been made of the sociopolitical posturing (“leaning in,” if you will) women must undertake to exercise their power and influence. Yet our greatest instrument of power is our authentic voice. Any time we silence that voice, we miss the opportunity to value other women. For example, by assuming “good girl, up speak,” I validate the antiquated social order that decrees women, and women of color in particular, must infantilize their voice to be heard. Each time I do this, I implicitly encourage women around me to adopt similar positions of subordination to express their feelings. In so doing, I am complicit in the creation and maintenance of the very systems that oppress women in leadership and suppress female thought.
So instead of “leaning in,” the real exercise women may need is “thinking in” or creating a space to re-evaluate how our patterns of behavior undermine our authentic voice and contribute to our disenfranchisement as a group. One of those patterns of behavior is how we speak, another is how we conceptualize our role as leaders. If we continue to define ourselves between a 2-dimensional chasm of “should” and “should not” quandaries that pit domestic aspirations against professional salience, women will always lose. This rigid dichotomy ignores the important and dynamic roles women can fulfill over their lifetime and the opportunity we carry, either in our wombs or our briefcases (or backpacks, as the case may be), to shape the world in which we live with our authentic presence and voice.
When we, as women, strip away the guise, we can be more “I am woman. Hear me roar.” and less “I am woman. Don’t call me bossy.” Instead of being afraid of words, let’s own them. Let’s speak with the authority that our education, experience, and the roles we fulfill, provide us, be that sister, mother, student, physician, or CEO.
New feminism is about women, work, and the will to be authentic. And future generations will rely on us to use the tools at our disposal – the vote, free speech, globalization, and growing numbers of college graduates – to dismantle the structures that demand we conform to misogynist inventions of who we are. For modern American women, we don’t have to be the “good girl” to be the boss. As Deborah Tannen says, “The way we speak is who we are and who we want to be.” Our influence spans the home, office, clinic, and classroom, and who we can be and what we can be is defined by how we use our voice to empower other each other. At its best then, feminism is a collective notion that lifts each of us, despite our color or creed, to live authentically.
Update: This post is also being featured on Kevin.MD. Click here to check it out!
Every February, some of you invariably ask, why do we have Black History Month? Predictably, some of you will pose this question to the black people you know. As a black person, I offer you my final word on the subject, my manifesto, if you will.
Why Black History Month? Consider these reasons.
#1. You don’t know black history and if you are an American, that means you don’t know part of your own story.
The struggle to teach African-American history in our children’s classrooms continues. Take Chicago Public Schools, for example. They represent the 3rd largest school district in the country and despite having a mandate to teach African-American history for more than 2 decades, it was not until December of 2013 that they officially announced plans to implement a formal, yearlong, integrated African-American Studies curriculum into their public schools.
Without normalizing and institutionalizing African-American history into our collective forums for public discourse, we segregate ourselves from the breadth of the American experience. In so doing, we fail to capture an essential truth about America, that we are a multi-cultural, multi-ethnic population that has benefited from the contributions of people of color from our founding.* Every time we resist that central truth, we deny the very thing that makes us American, our shared history.
#2. You need to say thank you.
As does everyone who has benefited from the contributions of African-Americans to American life. Whether it be for the traffic light that safely regulated your morning commute (thank you Garrett A Morgan!) or the blood transfusion that saved your loved one’s life (thank you Charles Richard Drew!) or the vaccine that prevented your child from dying from a preventable illness (thank you Henrietta Lacks!), we must acknowledge the ways in which our lives are enriched because black people consistently made, and continue to make, defining contributions to our society.
And here I’ve only listed a few examples of notable inventions.
What of the impact of African-Americans on the evolution of music in this country? It is almost unquantifiable. From the folk music, bluegrass, and jazz that drew from the tonality of negro spirituals to the rhythmic beats of rock-n-roll, doo wop, disco, funk, soul, rap, and hip hop that emanate from urban America, African-American culture has created or influenced virtually every aspect of American pop culture through music, including the trending fashion, dance, and American vernacular that grew out of these popular genres. Just ask Elvis Presley’s modern-day protegé Miley Cyrus. Twerkin’ ain’t easy and that charismatic rump-shakin’ didn’t start at the VMAs.
Generations of Americans are being raised in a culture that has deep and expansive roots in the African-American experience, but one that is equally devoid of public and enduring recognition of the contributions of African-Americans. Assuming the cultural expression of a group of people, without acknowledging said group, undermines their importance and in some ways, denies their humanity as it assumes they do not have the right to own their own expression. This is called misappropriation and it is the result of an amnestic historical memory, that is so short, it fails to encompass the areas in which our stories are linked and our lives find common ground. But fear not, the cure for misappropriation is simply a proper thank you.
And what of the countless unknown African-Americans who have given of their lives to protect the honor and safety of our country? Next month, President Obama will celebrate some of those men for their distinguished military service and award them the nation’s highest commendation given for combat valor, the Medal of Honor.** If the President’s actions here may serve as an example, when people give of their time, service, and sometimes their lives, for the betterment of our free republic, we must, even if belatedly so, say thank you.
Finally, I think it generally true, that when you honestly appreciate another person’s culture and life and consider their past and their future indelibly connected to your own, you are less likely to instantly think them a criminal, and “stand your ground.” Perhaps what we should “stand our ground” for is the recognition of the humanity in each other. Because when you appreciate people, you don’t shoot them and if Black History Month offers nothing else, perhaps it can serve as a moment for you to embrace African-Americans and in so doing, help bring our sons home safely at night.
#3. You don’t know black people.
If you keep a running tally of how many black people you know or feverishly defend the fact that you “have black friends,” you may not have had the intimate interactions that allow you to disconnect individuals from the stereotyped characteristics you associate with their race. In other words, if Joe is your “black friend,” he’s not really your friend and you don’t really know Joe.
But that’s okay. Perhaps you live in one of the few ethnically monolithic enclaves in our country, or somehow your only exposure to black people has been through The Cosby Show, or The Chappelle Show, or when Kanye upstaged Taylor. If this sounds like you, maybe it is time to branch out, meet new people, new BLACK people, and see what all the hype is about. The African-American experience is as varied as it is rich and our limited representation in the media doesn’t nearly approximate what it might be like to actually know us, dine with us, laugh with us, grow with us.
On a deeper level, if, as a society, we continue to live segregated lives in which we form ethically homogenous social circles, we will never have a basis from which to collectively digest, interpret, and process the complicated transactions that take place between the disparate cultures represented in our communities. Furthermore, challenges that require understanding another culture’s experience and the historical impacts of institutionalized discrimination, like for example, health disparities, or the educational achievement gap, or the disproportionately low rates of African-American women in the health professions, or the disproportionately high incarceration rates of African-American males, will remain insurmountable.
#4. You don’t like black people.
And frankly, black people may not like you either. And yet here we are, continuing to co-exist. So what should we do about it?
Get over it!
There is a reconciliation that needs to occur around issues of race in America and I’m not talking about tolerance. Tolerance is complacency in the face of continued unrest. It is offering separate but equal, instead of demanding that equal be the standard for equal. To heal the massive division in this country around racial injustice, we have to actively confront our bias to move on, even when that bias is unconsciously harbored.*** Black History Month offers us the first step to do this. As the great American poet, Maya Angelou said, “History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again.”
Today, we face continued affronts to equality in this country as some Americans seek to marginalize groups they just don’t like. Look what is happening in North Carolina and Ohio to undermine voter’s rights, or in Arizona, where a bill to refuse service to gay Americans made it all the way to the Governor’s desk before being vetoed! Here, our broken history repeats itself and if we aren’t careful, we may all eventually find ourselves less free to pursue liberty and happiness. As Dr. King said, “Injustice anywhere is a threat to justice everywhere” and we must take a lesson from black history to see the trend repeating itself and threatening all of our freedoms. The solution is to challenge prejudice at every point it rears its ugly head, starting with ourselves.
#5. You are black and yet you feel disconnected from the African-American experience and the Africana Diaspora.
When historian Carter G. Woodson started Negro History Week in 1926, it was a part of a larger effort to cultivate ethnic pride. As the trans-Atlantic slave trade scattered Africans across the western continents, it violently divorced black people from the rich ancestry that informed who they were. The absence of that foundation created a dangerous space for black people to be defined outside themselves, by their new roles and their new lives.
One dynamic of racism that is as inconspicuous as it is pernicious, is the effect of internalized racism on the African-American psyche. It is the wilted acquiescence to the accusers taunts, that you are as they say you are, be that ignorant, useless, dirty, ghetto, lascivious, pugnacious, unworthy, or unlovable. Internalized racism breeds a self-hatred that dissolves the bonds between people who share the detested characteristic.
In short, racism shames blackness.
And internalized racism is the insidious acceptance of inferiority. It acts to separates people from their value and their ethnic community.
For these people, for us, Black History Month is a moment to affirm and accept our value; to remember who we are and where we come from. Despite the positions of poverty and war in which many of our peers struggle today, both here in urban America and abroad in Latin America, Haiti, and Africa, we are not how and where we live. Our worth is not defined by our struggle but rather by the fervor with which we reclaim what has always been our gift, our blackness.
Now, I am not as presumptuous as to conclude that a month is sufficient time to heal a pain that stretches centuries into our past and finds new meaning in the systematic marginalization of black people across the globe. But I will say this, we have to start somewhere and we need to start together. Perhaps, at its very best, this month can cultivate the ethnic pride needed to combat racism, whensoever, and howsoever, we may face it. Because when you don’t feel worthy, you don’t act worthy and racism has become a self-fulfilling, self-injurious prophecy in the African-American community, and I would argue across the African diaspora. It is time to mend the broken fences in our community, to let people in and heal together. Let this be our chance.
Here’s my final word.
As the thread of African-American culture weaves throughout the American experience, it informs who we are as a nation. While a month is hardly sufficient time to truly appreciate the weight of the African American influence on American culture, perhaps it can serve as both a reminder and an invitation:
A reminder to engage in the self-exploration required to overcome the distraction of modern racial discourse that dichotomizes and compartmentalizes our history in a way that disconnects the culture we consume from the historical process by which it was created;
And an invitation to collectively share in the creative brilliance, ingenuity, and public service that defines the contributions of Black artists, musicians, writers, activists, playwrights, poets, scientists, philosophers, physicians, engineers, civil servants, lawyers, filmmakers, educators, servicemen and women, entrepreneurs, athletes, and entertainers.
These contributions enrich our experience as Americans. So on this, the last day of Black History Month 2014, let this be the start of celebrating our shared America history. Because, we, too, sing America.
* Although I must clarify here, that sovereign nations existed on this soil prior to the arrival of Europeans or Africans and the true founding of this land must always be credited to the Native, indigenous people of this continent.
** This award was also given to Jewish and Hispanic soldiers who were previously overlooked for recognition because of discrimination.
*** If you are ready to confront your unconscious bias, take the Harvard Implicit Association Test here!
Last week cable-mega-provider, Comcast, announced it is merging with Time Warner, the 2nd largest cable company in the US. Together, this deal nets Comcast an estimated 57% of the cable subscriber marketplace and heralds a new oligarchy in US media and entertainment. It’s big news for Comcast, but some people aren’t as excited.
Because both Comcast and Time Warner have been consistently rated the worst providers of customer service in the cable industry. Now as they grow their consumer base and build unprecedented influence in their field, the concerns are mounting. When choices are limited and quality is poor, what recourse do consumers have to demand more of their providers? And, what will drive quality, cost-containment, and new product development in a market-vacuum where the experience of the consumer is at the periphery of the business? The risk is that, with little competition, consumers may be forced to choose between service and no-service and the cost of services and breadth of services provided will be divorced from consumer demand.
No-service isn’t such a problem when you are talking about cable. But, did you know the same thing is happening with your health care?
Since 2009, there has been a surge in the number of hospital mergers and acquisitions. The name of the game is market-share and across the country, hospitals, clinics, and in some cases even insurance plans and pharmacies, are combining forces to form large conglomerates that will control where, how, and at-what-price, you receive your health care. This is being touted as the future of medicine, an organized system where regional populations receive coordinated care. The question is, will the consolidation of health care networks create a vacuum where patients’ choices are constrained within a narrowing marketplace? To answer that question, you need to know a bit of the back story.
Basically, the Affordable Care Act changes how we pay for (read: how profits are made off of) your health care and hospitals are realigning their relationships with each other and their referring clinics, to vie for your health care dollars. Now, instead of receiving care from independent physician practices and hospitals that contract with local doctors, most Americans will be placed into regional systems where the local physician practice not only works with the hospital, but is in many cases, owned by the hospital. Combined, the hospital and clinic will be given a lump sum of money to be accountable for your care (hence the name “Accountable Care Organizations“). This new payment structure incentivizes collaboration between hospitals and clinics, distributes the costs of managing health and preventing disease across the system, and encourages the appropriate and thoughtful use of limited health care resources.
But despite these obvious advantages, there are some important things to consider as we enter this new oligarchical era in medicine:
1. While it may not be a problem if the hospital that owns your local clinic is down the street, what if it is in another town entirely, and like many working class families, you don’t have the resources to get there? Does regionalizing care create geographic barriers to access?
2. What if the hospital that buys your clinic charges higher prices? What recourse will patients have to ensure their care is affordable when clinics choose sides and the local options for providers dwindle? If this happens, will more patients opt for “no-service” because they simply cannot afford the cost of care?
3. What will happen to the county hospital systems that rely on serving insured members of the community to off-set the costs for serving those who do not have the ability to pay? Do large conglomerate hospital systems upset the local order by cherry-picking insured patients out of the community and, in so doing, threaten the viability of public organizations that care for marginalized populations, including undocumented immigrants, children, and the poor?
4. How will quality be maintained across regions to ensure health equity? Will the quality of health care be higher in regions that serve higher income populations? And in areas with only 1 or 2 health care networks to choose from, particularly in rural America, how will patients’ needs impact quality measures and cost-containment standards?
5. With such expansive reach into your health care experience, can a one-size-fits-all model really provide patient-centered care to populations with diverse sets of health care needs and priorities? Can health care conglomerates be too big to succeed?
In the end, the economic climate in medicine has changed and traditional independent physician practices are being forced to state their allegiances or risk extinction. It is the birth of big medicine and it is coming to an area near you. In a lot of ways, that’s good news. Integrated health systems promise to decrease the fragmentation in care delivery, provide continuity of services throughout regions, and build payment structures that may contain costs. At the same time, building organizations that are too big to compete with and too expansive to be responsive to the ever-changing needs of the American consumer, risks alienating important populations from our health system, including children and the poor. The goal is to create organized models of care delivery, in which the sum of the whole is greater (read: more cost-effective) than its individual parts. As the business of medicine informs the practice of medicine in important and meaningful ways, the patient experience must remain at the center of the care we provide. Ultimately, it is patients and not profits that must be our impetus for change and our litmus for success.
Update: This post was also published on Kevin.MD. Click here to check it out!
This piece was co-authored by my friend and colleague Dr. Jessica Schumer. Follow her on twitter @schumerj.
Last week there was a seismic shift in the healthcare marketplace. Did you feel it? CVS publicly announced plans to stop selling tobacco in its stores and simultaneously declared itself a major player in our nation’s healthcare system. According to CVS’ CEO Larry Merlo, “by removing tobacco products from [its] retail shelves, [CVS] will better serve [its] patients, clients and healthcare providers while positioning CVS Caremark for future growth as a healthcare company…This is the right thing to do.”
A healthcare company? Does selling medicine make you a healthcare company?
With a growing number of newly insured patients and a shrinking physician workforce, innovation is needed to stretch resources in a smart way, and CVS is paying attention. The recent passage of the Affordable Care Act (ACA) offers a new opportunity to re-envision the delivery of medical care in the US. Last week, CVS made a power move to take advantage of this opportunity and share in the profits of one of our nation’s largest industries. In the last 10 years, retail clinics have arisen as the in-store solution to the increased demand for primary care services, including vaccinations and urgent care. Leveraging the talents of our nation’s nurse practitioners, these clinics offer convenience at a competitive cost, and it is estimated they are serving 6 million patients per year. According to Larry Merlo, CVS’ “26,000 pharmacists and nurse practitioners [are already] helping patients manage chronic problems like high cholesterol, high blood pressure and heart disease.” But is that enough?
The short answer is no.
CVS may be the place for a quick vaccine or office visit, sure, but what if you need something more? What happens when CVS’ retail clinic doesn’t have what you really need? What are the implications of receiving piecemeal care that may be convenient and accessible, but is so limited in scope it is unable to provide the comprehensive, coordinated and community-based care required to address complex, chronic medical conditions.
What is the right thing to do?
CVS has found an interesting and important niche in the healthcare marketplace. It is offering relatively affordable care for a number of routine patient complaints. Going forward, hospitals and clinics should consider partnering with CVS to leverage its resources in serving these specific health care needs. After all, we call it a health care system for a reason. It works best when all the pieces and parts work in concert to serve the whole. The key is finding a way to encourage retail clinics to do what they can do and not pretend to do what they cannot.
Today, poverty and economic inequality are driving many of the major health problems in our country. Healthcare organizations that do not address these issues in their care models risk exacerbating the core problems underlying chronic disease. Part of the brilliance of the ACA is the focus on medical homes – a clinical foundation for every patient problem, including the ones that originate outside the clinic, in the community. Medical homes offer continuity of care, coordinated specialty care, and community engagement. They are not where you buy your prescription medicines, they are the community-based drivers of overall good health and wellness. In addition, the convenience of the retail clinic model lends itself to serving low income communities who may disproportionately rely on proximity to services when selecting where to receive their care. While these clinics may have a long way to go to engage underserved populations and appropriately integrate their operations with local medical homes, they can play a useful, influential, and necessary role in extending the reach of healthcare and providing essential services that more fully meet the needs of patients.
What’s the bottom line?
The secret is out. Medicine is a business and public-private partnerships are the future of a thriving health system. The costs to cover our big, expensive care models have to come from somewhere. Why not balance those costs across industries that share in the gains? Imagine your local CVS was the site of a family and child community center. What if they sponsored a community garden that housed locally grown foods at a discounted price, and offered community programs related to health and wellness? And what if the retail clinic was affiliated with the local medical home, such that patients received the right type of care at the right place, and at a lower cost?
The complex needs of the medical system require integration of various models of service delivery. In the end, every healthcare organization’s bottom line should be the same and it’s not just centered on profits. Innovation requires building social equity while providing cost-effective, patient-centered care. Together, CVS and similar partners may enable our health system to extend its reach to provide the quality, convenient, affordable, and accessible care that is needed across the US.
Today, the CVS Caremark Corporation announced that starting October 1, they will no longer be selling tobacco products, including cigarettes, in their CVS stores. Taking a bold and unexpected stance on the issue, CVS’s CEO Larry Merlo reasoned to ABC news that “We’ve come to the conclusion that cigarettes have no place in a setting where health care is being delivered.”
Hmmm, what does he mean by that?
Here, he is referring to CVS’s robust market of retail clinics, MinuteClinics. Retail clinics, or the clinics nestled within large grocery store and pharmacy chains (think Target, Wal-Mart, Walgreens), first popped up about 10 years ago and have grown to provide an estimated 6 million patient visits per year at the more than 1600 sites nationwide. Of those 1600 sites, MinuteClinics make up the largest share of the market, with more than 800 clinics. Staffed by nurse practitioners, they are touted as the convenient and cheap answer to the shrinking primary care physician work force. You can make a visit without an appointment, be seen by a health care provider without insurance, and even buy some handy items on the way out. Now, it seems, those handy items will no longer include cigarettes, at least at CVS and Target, which hasn’t sold tobacco products since 1996.
In light of the Affordable Care Act, and the millions of Americans who will now be seeking a primary care home, it seems CVS is positioning themselves to really contend in the new health care marketplace. But the real question is, what does it mean to brand a corporation as a health care organization? If the brand is dependent on messaging, is banning cigarettes enough? Furthermore, is there any conflict of interest when a health care organization is seated within a business whose primary objective is to sell you things? While we can debate about whether the current reimbursement incentives in health care (i.e. how much clinics, hospitals, physicians, and other health care providers are paid by insurance companies to provide various services including clinic/hospital visits, laboratory tests, and imaging studies) encourage over-selling or the inappropriate use of medical tests and services to make money; I think we all can agree the goal is to create incentive structures that reduce the costs of health care, not conflate them with other retail purchases.
Although CVS’ statement today is estimated to cost them about $2 billion dollars a year in profits from tobacco sales, perhaps the biggest cost will be to our health care system as it seeks to provide coordinated, primary care services, to new populations and the standards for the landscape of those services remains unclear. In my mind, while promoting tobacco cessation is extremely important, the standards for health care organizations must be extremely high if we are to provide the best care to all Americans. As my colleague Dr. Vartabedian pointed out in his blog today, 33 charts, why does CVS not also ban high sugar, high calorie food and drinks, like chips or soda? There is ample evidence to show that consumption of these items increase one’s risk of disease and early death. In addition, the convenience of the model makes retail clinics particularly apt to care for underserved and poor populations, and yet they have yet to really reach out to and be utilized by these groups.
The bottom line is, retail clinics could be an innovative solution to providing care to diverse populations in new and affordable ways. But to truly be a health care organization, the messaging around health and wellness has to be consistent, clear, and free of commercial bias. Hopefully, banning cigarettes is just the start but as it seems to me, CVS still has a long way to go.
Update: This article is also being featured on Kevin.MD! Check it out here!
There is a disconcerting myth about single mothers that has been circulating in our society for some time. It was popularized in the Regan Era as a denunciation of US social welfare policy and resulted in a pointed caricature of a woman on welfare, forever to be known as the “welfare queen” or the entitled single mother.
The narrative of such a woman goes something like this: Not only is she poor, but worse yet, she is unpatriotic and weak. She is nothing more than the vessel for her lascivious desires as she has child after child out-of-wedlock, abusing the luxury of government aid to ensure herself a life of leisure. Her welfare dependency is as much a result of her moral failings as it is of society’s willingness to foot the bill. If “real Americans” get by on what they make out of their bootstraps, then her crime is never wanting bootstraps at all.
Sound intense? Apparently not for Senator Rand Paul of Kentucky, who invoked this relic of American political discourse this week to shame single mothers out of their welfare benefits. He was quoted at a Lexington Commerce Meeting as saying, “Maybe we have to say ‘enough’s enough, you shouldn’t be having kids after a certain amount.’ I don’t know how you do all that because then it’s tough to tell a woman with four kids that she’s got a fifth kid we’re not going to give her any more money. But we have to figure out how to get that message through because that is part of the answer.”
It is clear that at a time when both Democrats and Republicans seem primed to address the issue of growing income inequality in our country, the myth of the entitled single mother remains as relevant as ever. That problem is, this false characterization of single mothers, particularly those receiving government benefits, ignores the real lives these working mothers lead, undermines the contribution of women to the American economy, and ultimately prevents society from understanding how government funding should be spent to address income inequality.
The bottom line is, the myth of the entitled single mother separates us from the reality that women are the core of the American economy, including single mothers. In the words of President Obama, “when women succeed, America succeeds.” And the truth is, single mothers are single-handedly controlling the future of America. Let me tell you why.
Women are bringing home the bacon unlike ever before.
Since 1960, the number of women who are the primary wage-earners for their household has almost quadrupled, such that women now comprise nearly two-thirds of the breadwinners or co-breadwinners in their family. And as it turns out, more than 6 and 10 of the women who are the primary breadwinners in their home, are single mothers.
Women are using that money to boost the American economy.
Although some have speculated that women influence anywhere from 70-80% of the consumer spending in their household, it is hard to argue that single mothers don’t control 100% of their household spending. That’s anything from buying cars and computers to purchasing healthcare. With the struggling auto industry, surge in online technology, and new changes in healthcare, that means single mothers are literally at the center of the markets that are defining the ways we live, move, communicate, and stay healthy.
Women are redefining the social contract.
Without a second income in the household, families lead by single mothers are also the most vulnerable to economic stress, and in the words of Maria Shiver’s latest report, many are living on the brink of poverty. Growing income inequality and poverty may be the defining issues of our time. The urgency of these problems require us to push new boundaries. Although the traditional social contract exists between the US government and the people, in which we give the government authority to rule if the government will protect our rights and help us when we fall on hard times; the new social contract defines the relationship between businesses and the people. That if we are to work for you and buy your goods, then businesses must also contribute to the general well-being of society by paying fair wages and providing various benefits (health insurance etc).
To make a long story short, businesses aren’t holding up their end of the deal, and it is time to remind them and raise the minimum wage. It is estimated that doing so may be a real solution to lifting some families out of poverty, many of whom are led by single mothers. And as we know, poverty poses one of the greatest threats to the health and well-being of children in the United States, making it also one of the greatest threats to the health of adults, as most children grow up to be adults.
Taken together, it is clear that our ability to succeed as a nation will be defined by our willingness to support single mothers and their families. Be it through their economic contribution to their community or their role in raising the future leaders of this country, these women are fearlessly facing the adversity in their lives, daring to raise children without Rand Paul’s approval, and working towards a better future for themselves and their families. They are not entitled, they are in need of our utmost regard for enduring despite the odds and we should invest in them. Period.
This post is also being featured on Kevin.MD! Check it out here!
Each year, as our nation reflects on the life and legacy of Dr. Martin Luther King Jr., I look for contemporary signs of change, examples of how we as a society have evolved in our understanding of race and how and where African-Americans have folded deeper into the American story and been embraced by the country they’ve called home for centuries.
This year, I didn’t have to look any further than my own backyard. Last week, the Sun Reporter, a Bay Area weekly that runs local and national news involving African-Americans, featured a story on Jahi McMath. Jahi was a 13-year-old African-American girl whose untimely death, following a tonsillectomy, lead to weeks of contentious debate between her family, her medical providers, and the national media regarding her diagnosis of brain death. Being a local pediatrician* I was well-aware of the story. But what struck me when reading this particular piece, was the way the periodical characterized the family’s mistrust of the medical system.
Historically, there has been “bad blood” between some African-Americans and the US health care system. In many cases, that tension can be directly linked to documented cases of exploitation and deceit. Like, for example, when the US Public Health Service purposely withheld treatment from African-American men infected with syphilis, allowing them to suffer and sometimes die, to study the effects of untreated disease from 1932-1972.
Or take the case of the Henrietta Lacks, the African-American woman from whom the world’s oldest and most commonly used line of human cells (HeLa cells) were obtained in 1951. Despite being the substrate for some of the greatest advances in medical research, biological science, and pharmaceutical development, neither she nor her family received any financial compensation or recognition. Her cells were obtained without her consent, manipulated and sold without her family’s knowledge, and her genome and her family’s medical records were made public without their approval. In August of 2013, less than a year ago, the National Institutes of Health finally publicly acknowledged Henrietta Lacks’ contribution to science, agreed to protect her family’s private medical information, and allowed her family to be privy to future research utilizing her cells.
Given these egregious missteps in US history, you might not be surprised to know that some African-Americans actually believe the US government introduced crack into their neighborhoods or created AIDS to kill them. The woefully unsuccessful, and I would argue, recklessly enforced, War on Drugs aside, some black folks just don’t trust the core institutions that are created to serve the public good, and chief among them may be our health care system.
In the case of Jahi McMath, I have to wonder if feelings of distrust ran deep and strained the relationship between Jahi’s family and her medical providers, as they sought to find a common ground to discuss an incredibly difficult and distressing reality – a young girl is dead. Add to that discussion the general public’s confusion regarding the medical definition of death and the media-bolstered accusations that everyone, from the family and their lawyer to the hospital and its personnel, mismanaged the situation, and it is easy to see how the private bond between the medical system and the community it serves can fray and break.
Underlying this all has been the hurtful allegation that the hospital wanted to discontinue Jahi’s life support to save money or that the family’s limited resources affected their ability to advocate for her care. The obvious comparison here is the Terri Schiavo case, in which a 26-year-old woman was kept on life support at the insistence (and in part through the financial support) of her parents for 15 years. Although, I must say, that case was very different because the ultimate diagnosis was a coma-like condition called persistent vegetative state where the brain continues to function, albeit at a significant deficit, and in Jahi’s case her brain was determined to no longer be functioning at all.
Ultimately, it seems, despite being cared for at a hospital that local doctors like myself revere as a leader in practicing in and for, communities of color, a disconnect remained. To me, it suggests that perhaps it was the family’s distrust of the system to adequately care for Jahi and the complicated medical language surrounding the diagnosis of death that created an impasse. That impasse gave way to an unnecessarily long period of suffering for Jahi and her family and it must be prevented in the future.
But how? And why is this so important? There are two lessons here.
First, it is just as important now as it has ever been, to elevate the national dialogue about race as we continue to seek to understand each other as human beings.
Second, and most importantly, part of that understanding is rooted in communication and in every area where we miss an opportunity to effectively communicate with each other, we risk alienating people from the very institutions on which our communities rely, including medicine, education, and justice.
It is on this note that the media completely missed the point. Part of our national evolution to understand race involves recognizing and acknowledging the nuanced ways it remains relevant in our lives. One of those ways is in the way we communicate across cultures.
Effective cross-cultural communication (and one can argue that any communication outside one’s area of expertise is cross-cultural), requires identifying the contextual clues – the values, knowledge, and historical roots that contribute to how individuals interpret information and make important decisions. This is key to understanding any human behavior from basic lifestyle choices to the painstaking and charged decisions involved in end of life care.
In America, there is a history there that makes dying while black a particularly contentious issue, one fraught with fear of mistreatment and maligned intention, and one that must be addressed openly, honestly, and with compassion. Whenever we are able, those of us in positions of institutional power, must acknowledge and uphold the dignity of all human life as we practice across centuries of experience and knowledge. If we can do this for the most marginalized, then we have some hope of healing the scars of our past and addressing the ongoing struggles of our present.
I write this post in loving memory of Jahi McMath and Dr. Martin Luther King Jr, beloved members of the African-American community who died challenging all of us to learn to understand each other better.
*Disclaimer: Although I am a pediatrician in the Bay Area I was never involved in Jahi McMath’s medical care and this piece is not intended to discuss any details of her clinical course or treatment. In addition, this post is not meant to speculate on the feelings of the McMath family or the intentions of the medical providers who rendered her care but rather to stimulate a larger discussion about the ways race may remain relevant in each of our lives and how we can confront that reality in a meaningful way.
Update: Thank you to everyone who read, commented on, and shared this post. Given the significant interest it garnered, it was published in the San Francisco Chronicle on Sunday, February 2nd! Check it out here!
Warning: This is not your typical physician blogger post. But, as you’ve hopefully figured out by now, I’m not your typical physician blogger.
There have been but few times in my life when the power of the written word has changed me.
When words, so delicately crafted, approximate both the splendor and the obscenity of human experience, and the light can overcome the shadows. When I was liberated because they spoke it so.
Those are sacred moments between me and Langston Hughes, W.E.B. DuBois, Zora Neale Hurston, James Baldwin, Maya Angelou, and Amiri Baraka.
When I read Amiri Baraka’s Black Art I was a sophomore in college and about 19 years old. I was living in a world dominated by the images, opinions, and interests of white people and trying to figure out what it meant to be a brown girl like me. He said:
Poems are bullshit unless they are teeth…
We want “poems that kill.” Assassin poems,
Poems that shoot guns…
Clean out the world for virtue and love,
Let there be no love poems written
until love can exist freely and
cleanly. Let Black People understand
that they are the lovers and the sons
of lovers and warriors and sons
of warriors Are poems & poets &
all the loveliness here in the world.
We want a black poem. And a
Let the world be a Black Poem
And Let All Black People Speak This Poem
What a thought.
What if blackness was the perspective from which all other experiences are compared?
What does it mean to conceptualize blackness beyond a race card or a problem or a conversation about affirmative action, inner city violence, or health disparities?
Is it possible that black people could be “all the loveliness here in the world?”
If it is possible, then how can I embody that pride effortlessly or “say it loud?” Both, of course, being equally acceptable.
Historically, this poem framed a time of anger and unrest at the centuries of injustice suffered by black people in America. It was the 60s. It was the beginning of the movement for civil rights. It was the birth of the Black Arts Movement, the contribution of black artists, writers, philosophers, and activists to not only chronicle the emotion and the intentionality of the movement, but take the greatest weapon at their disposal – the written word – and BE the movement.
Amiri Baraka was the movement. He was bold. He was fiery. He was unabashedly committed to re-claiming blackness and the beauty it embodies. As a young black woman who found my passion for social justice in medicine through the ethnic pride I discovered in college, I can only hope my writing will do justice to the beauty of the people I seek to serve. For the overlooked, vulnerable, and marginalized among us, thank you Amiri Baraka for fiercely embracing our power and showing us how to live in the beauty in us all.
In the wake of the tragedies at Sandy Hook Elementary, it seemed America had finally lost its taste for the spoils of gunfire. Despite what gun lobbyists would have us believe, animals aren’t the only victims of loaded weapons. Guns kill kids. And while the events at Sandy Hook were horrific, only 1-2% of youth homicides occur at school.
The truth is, kids are dying in our neighborhoods.
And just when we finally seemed ready to have a responsible discussion about rights in this country, namely the right to protect ourselves from the tyranny of guns, we wait. We wait for our federal and state legislatures to grasp that the sanctity of the 2nd Amendment can never be placed above the sanctity of precious American lives.
What gives? What other lethal weapons are so protected in this country? Cars require registration and training to operate. Unsafe chemicals require warnings (and if they are particularly toxic their manufacture, distribution, and use are regulated by the government). Cigarettes cannot be sold to minors, are heavily taxed, and many states now prohibit their use in public spaces. New York even considered banning soda because it may kill someone in the future, from complications of diabetes and heart disease (which have been linked to high sugar intake).
In America, it seems, we have no problem placing limits on things we deem a threat to public safety and public health. And yet, we wait on expansive federal and state gun control. And more importantly, while we wait, polls show our collective conscience is losing sight of the urgency of the issue.
Homicide is the 2nd leading cause of death for young people aged 15-24; and if you happen to be an African-American male, it is the number ONE cause of death. In 2010, 13 kids a day were victims of homicide and more than 80% of them were killed by a firearm. And in the 3 and 1/2 months following Sandy Hook, more than 2,200 lives were lost to gun violence (a number akin to a Newtown every single day since the mass shooting).
The data is clear. People are dying and we have a system that protects gun ownership at the expense of our lives.
Tomorrow, December 14, marks the one year anniversary of the tragedies that took place in Newtown, Connecticut. Despite our nation’s horror and resolve to protect our children from further tragedies, woefully little has been done to prevent it from happening again. To see just how little, check out this New York Times chart. According to their data, it is estimated that 1500 gun laws have been introduced in various states since the massacre and of those, only 109 have become law. Of those 109 new gun laws, 70 loosen gun restrictions, making it easier for individuals to register, conceal, and use firearms in various states across the country. Some of those laws even made it easier to carry concealed firearms at churches, public parks, and schools!
This is outrageous.
It is truly shameful that as we mourned the loss of those precious 26 lives, we at once made it easier for a similar tragedy to occur.
If America doesn’t have a crisis of consciousness over the incredible inaction that has surrounded the death of our children, I am not sure what it will take. I pray that more children don’t fall victim to firearms before we make some changes. It is time to put our children first and prevent further injury and death by taking the responsible steps towards sensible gun reform.
* This article is adapted from a piece I wrote following the tragedy at Sandy Hook Elementary. To read the full piece, click here.
* To check out what the American Academy of Pediatrics is doing to respond to gun violence, click here.
But somehow I wonder if
Despite their silent exterior
Away from the purview of others
In a darkness all their own
They endure the painful pruning of transition
Old is new
And new is you
And butterflies bleed too.
There are those among us who are treading on unmarked ground, fresh soil devoid of the comfort of patterned steps heralding the way. We are straying from tradition and daring to redefine the boundaries of our professions as we venture in new directions. It is not just that we don’t fit the mould, but that in some ways, we reject the idea of moulds all together.
For me, social justice medicine is the new direction. It is the practice of clinical medicine in a thoughtful way that creates and sustains health equity. It requires community engagement, civic participation, political advocacy, apt use of new media and technology, and interdisciplinary collaboration with local organizations and community leaders. It is essential to build a more just, equal, and free society and so far, it doesn’t really exist.
6 months ago, at the end of my pediatric residency, I took a position as a community pediatrician and have been eagerly piecing together a career in the practice of social justice medicine ever since. Sometimes, in moments of uncertainty, when my mind is quiet enough to admit my fears, I find myself in the throes of a great transition, worried I have no idea what I’m doing or where I’m going.
In medical school, I took a class called Let Your Life Speak. It was based on a vocational guide by the same title, and it helped medical students identify our gifts and consider potential careers. In the book, author Parker J. Palmer presents the idea of “way” or the path on which each of us walk toward our purpose. I’ve been looking for my “way” since college and as my blog header articulates, it is an ongoing journey. Recently, I found some clarity.
In any hierarchical assent, “way” seems to form in front of you, with each opportunity striding towards the next. But the truth is, that “way” was already there, worn by the feet of others, and ending at a predetermined destination. Sometimes paths are created as “way” closes behind you. When opportunity doesn’t knock, it quietly closes the door, making new, unseen paths available.
To stretch the confines of what it means to be a doctor, I have to stretch my understanding of how to get there. In doing so, it has become clear that “way” is not linear and does not have directionality. It is the iterative process of curiosity, experiment, discovery, and failure that builds the experiences necessary to create an unconventional career. Although the cyclical process of preparation, pruning, and readiness may be difficult, the product will be beautiful and uniquely yours.
But somehow I wonder if
Despite their silent exterior
Away from the purview of others
In a darkness all their own
They endure the painful pruning of transition
Old is new
And new is you
And butterflies bleed too.
I thought that point was obvious. But apparently, there remains some debate because on November 1, 2013, the federal government effectively cut 5 billion dollars from the most powerful anti-hunger program in our country – food stamps (or SNAP as it is now called, which stands for Supplemental Nutrition and Assistance Program).
Here’s the quick history on the issue: During the recession, unemployment rates spiked. As family incomes fell, more families were at once eligible for food stamps and in need of extra money to put food on the table at the end of the month. To account for this increased need, the federal government issued a “stimulus package,” technically called the 2009 American Recovery and Reinvestment Act. The Act did a number of things, one of which was to boost food stamp benefits. That boost expired on November 1.
So let’s break that 5 billion dollar cut down to real numbers. For a family of 4, it means they will lose $36 dollars per month to cover their food costs. That is equivalent to losing 21 meals per month OR if you try to stretch the money out, having about $1.40 per person per meal, each month.
To put that number in perspective, in case $1.40 seems reasonable to you, the USDA has actually calculated how much it costs to eat on a super tight budget. They call that estimated value the Thrifty Food Plan. According to this bare-bones estimation, the cheapest, nutritious meal in America costs at least $1.70-$2.50 (the exact value depends on age and gender). For millions of American families, that gap between $1.40 and $1.70 will be the difference between being fed and going hungry in 2014.
In medicine, we refer to “being fed” as food security, or access to sufficient, safe, and nutritious food to maintain a healthy life. It is estimated that 1 in 6 Americans are food insecure. In 2012, that was about 49 million people. As of November 8, 2013, SNAP provided food for more than 47 million people, nearly half of whom were children.
Imagine I said 1 in 6 people have swine flu or the plague or a terrible form of cancer. There would be outrage. Frankly, we’d call it an epidemic, a real problem that someone has to stop! And yet, when nearly 20% of Americans do not have enough food on their table, there is debate about what should be done.
The answer is simple, #saveSNAP.
In 2011, it was estimated that SNAP fed 1 in 4 children in the US. Children need healthy food to build bones, grow their brain, and control their behavior. Try hurdling the achievement gap without breakfast. The challenge is obvious. People need food to live and succeed. As a society, we simply cannot tackle the major problems ahead of us if we fail to provide for the most basic needs of our country.
In the coming months, I will re-address this issue as the House and the Senate consider bills that would eliminate food stamp benefits for millions of Americans.
In the meantime, check out what pediatricians, community advocates, and I are working on to tackle hunger in the Bay Area.
This past Sunday a woman I had never seen or met before, stood in front of our church and moved me. She spoke about the importance of environmental justice. She asked that we be stewards of our planet and protect it from the preventable destruction of climate change and wasteful pollution. But it wasn’t WHAT she said that moved me, it was what she offered – a moment to be mindful – and I took it, and was moved. I was present, in the moment, as she shared the sighs and tears and exuberance over what she loves – the earth.
Now, I don’t litter and I try to recycle as much as I can, but I can’t say I think about the earth on a daily basis. Yet hearing the passion in this woman’s voice inspired me to be more mindful about my relationship with my planet and the other life (outside of my own) that it supports. As I left church, I wondered:
What other amazing people might live in my community and have inspiring stories that can enhance my life?
Health, at its essence, is a communal notion. It involves the way we care for ourselves and those around us. It relies on the spaces in which our bodies stretch and move and feel their power and the places where our minds think and learn and grow. But isn’t it curious that many of the spaces and places that define our health, are filled with other people – often silently going about their life, with their joys and fears and hopes and lessons hidden quietly beneath their public persona – beneath even who they allow themselves to look like on Facebook.
Ultimately, I think, health is the result of engaging the world around us and being present to both the vital resources like clean water, clean air, and nutritious food that keeps us alive and the social connections that fuel our emotional, physical, mental, and spiritual wellness.
What if we could learn about the other people who share our public spaces?
The older Korean woman who owns my local corner store…
The Spanish-speaking family who lives next door…
The 40-year-old white man who sits in the sandwich shop behind my house every day for lunch…
What are their stories? Who do they care about? What are their life lessons?
If health happens in community, then maybe when we engage those around us and are present, we can heal as we learn from each other.
I want to start right here!
In the next few months, I’m going to start posting pieces written by people I know and some I don’t, sharing thoughts, lessons, and stories about what they love and what they’ve learned. For this project I will define community as people who want to share together and include posts from friends, mentors, acquaintances, and strangers from however far my blog reaches. If you want to participate in this project, comment on this post and I’ll email you!
Ultimately, I’d like to host a Community Speaks session where people actually physically gather to be present and hear others’ stories and hopefully we can create a live feed on my blog to share the moment.
So, what do you think? If your community speaks, will you listen?
One of my goals as a physician and particularly as a pediatrician is to touch young lives and make them better. Health is not just about check ups and sports physicals and vaccines (although all of those are important components of healthy living). Health is about embodying a spirit of wellness and adopting a lifestyle that nurtures that spirit. This is part of what drew me to medicine – the opportunity to look into the face of our youth and encourage their spirit; to see the potential rising in children and partner with families and communities to protect that potential and mold young lives around healthy concepts of living and growing. For me, this goal is personal and professional.
This past week, I completed a project where I hung old photos of my family and dearest friends around the head of my bed. I did it so that when I dream, when I think of all the possibilities of what life holds for me, I am surrounded by the faces of people who love me and support me and whose encouragement lifts me up.
I think James Baldwin said it best when he said, “Your crown has been bought and paid for. All you have to do is put it on your head.”
What an important and wonderful concept to internalize. The idea that –
You are valuable and you cannot escape that value because it is already yours by virtue of the work and sacrifices of the people who have gone before you – be they family, community, or historical ancestors.
This principle reminds of why those faces now hang above my bed; they create a space where I am free to acknowledge my personal worth and the people whose love, time, support, and prayer softens the ground below my daily steps.
As a professional who works in the art of healing, this lesson from my personal life also finds meaning in my professional life.
As a pediatrician, I know there are vulnerable periods in a child’s life when physical, emotional, financial, and social stress can impair mental and physical development. Some refer to that stress as “toxic stress,” because when chronically exposed to it, the physiology of children’s bodies and brains are changed – down to their very genes – in a way that places them at risk for a number of poor health outcomes over the course of their lifetime AND passes that risk on to their progeny (Have you ever wondered why poverty can be generational?). If I know that stress retards growth and development and keeps children from realizing the potential of a full and healthy life, what is my role as a pediatrician in providing children and communities with the tools to build resilience – a psycho-physiologic shield against the adverse effects of stress, or, a potential protector.
Others, have also pondered this and it is becoming more professionally accepted that physicians and pediatricians must be the faces in the community that encourage the spirit of children to protect their value and potential.
So how can pediatrics as a field and I, as a professional, systematically create spaces that recognize and utilize the value of every child; such that children are free to know their potential and build healthy relationships and lifestyles in partnership with the community around them? And how do we as a field, begin to understand how issues of poverty separate children and adolescents from knowing and working towards their value, a value that has been paid for generation after generation?
The short answer is, I don’t know. But I have joined a group of bold pediatricians from across the nation charged to address issues of poverty and toxic stress through medical practice. While part of our work will challenge traditional concepts of the role of physicians in community and increase public awareness of the adverse health effects of poverty, I also hope the outcome of our work directly helps children internalize their value and rise to their potential. Because the longer answer recognizes that poverty does not just create physical barriers to health, but also complicates the path by which children come to know and live out their value in the world. Thus as doctors, as champions of health, we must also be purveyors of justice and defenders of the value and potential in the most vulnerable among us.
If it takes a village to raise a child, what will you do today to embrace your value and the value of those in your community to raise resilience?
I have recently noticed a trend in my social circle and wonder if this is a broader phenomenon.
Single working women have increasingly fewer single working female friends.
After we finish our marathon of training in business, law, medicine, education, or whatever makes our hearts sing (or pays our hearts’ bills), single working women emerge simultaneously more educated and more isolated. And I’m not just talking about professional isolation where “good ole boy” traditions (or discriminatory favoritism) leave young women outside the complicated social dynamic of the workplace. I’m talking about looking up at the end of a long journey to meaningful employment and finding less and less women around to relate to (or to share your professional aspirations and watch movies in your pajamas on a Saturday night).
What happened to all my girlfriends? To the brilliant young women I studied and grew up alongside?
Well, they moved. And so did I.
I mean, it makes sense. Without the consideration of marriage or children, many of us move to our nation’s epicenters to start a budding career and social life. We bloom, finally stepping out of a truncated adolescence into the spoils education and employment offer (mostly stimulating conversation over moderately priced dinner and drinks). And more importantly, we change. Eager to finally contribute to the world, we are ready to embrace opportunities and without a reason not to (namely family constraints) we are doing just that; despite the consequence, which lately for me, has been more social isolation. Adept at multitasking in a world where social and professional responsibilities can overlap, we sometimes over-commit in the workplace to seem eager and approachable while under-committing in our personal lives to remain flexible and focused. We are walking the thin line Sheryl Sandburg encouraged us to lean across (where being ambitious can be confused for being a bitch, but by acknowledging the tight rope of gender politics in the work place we are freed to succeed, or something like that) and sometimes it is a lonely trek.
So what’s a girl to do? How can we stay connected despite the miles between us and how can we meet new wonderful women along the way?
Maybe we should start a friend exchange, where we share the amazing people who have made our life better with our sisters across the country, posting online profiles or something for women looking for other supportive gals. Or maybe it’s just early in my professional life (I’ve been working approximately 2 weeks now!) and now that I finally have time to be more social, I actually have to work at it a little bit. Maybe I am not trying hard enough and everyone else is somewhere having a great time without me. Or maybe I just miss all my amazing friends who moved away.
In other news, anybody up for dinner and a movie this week?