The Final Word on Black History Month: My Manifesto

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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!

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Comcast and Your Health Care

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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.

Why?

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?

And finally,

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!

CVS and the Dirty Secret of Medicine: Is our bottom line the same?

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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.

A Deeper Look into CVS

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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!