Tribute & Truth: Experiencing the National Museum of African American History

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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.

Community Benefit and Community Exploitation

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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.

My Anger

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Although I write a blog that centers people of color in exploring the connections between the medical system and race  Рan activity that has always been fundamentally personal РI 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.

Upstream Learning & Downstream Dysfunction: How to Train Leaders for a New Future

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“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.