Walter Scott and a Pediatrician’s Conscience

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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.

  • The toll police killings take on black families, including those not directly involved in the events of violence, matters and the chronic stress it generates may adversely affect family dynamics, community safety, and the mental and physical health of African-Americans of all ages.
  • Adolescents, both male and female, commonly participate in risk-taking behaviors as a part of their development as youth. Those same behaviors can have significant and lasting costs for African-Americans, as they may suffer higher rates of arrest, incarceration, and death.
  • Efforts should be taken on behalf of physicians caring for black families to discuss the toll police killings have on health. If there is concern for impending danger, appropriate referrals to local authorities and community organizations should be sought on behalf of the physician, nurse, or medical staff.
  • Preventative health screening guidelines for children and adults should include risks of gun violence, including police violence.
  • Training will be needed for physicians to appropriately discuss these concerns with families, screen youth for risk behaviors, and refer at-risk individuals to further services.
  • Funding for clinical interventions to address police killings should also support local organizations that work to decrease community violence.

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.

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Walking the Talk

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I’m back!

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!

Rhea

Structural Inequality and the Future of Medicine

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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!

Footnotes:

* 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.

Dying While Black

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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!