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  – 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.

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.