Protest as Plea: The Uncivil Fight for Community Rights

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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?

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Police Violence and Public Health

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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.

When Science Fails: The Promise and Limits of Precision Medicine

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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.

Is Scalability Overrated?

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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.