I am MLK

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Unprovoked and un-prosecuted police brutality that preys upon people of color.

Separate and unequal education systems that consistently fail poor children of color.

Segregated housing that concentrates poverty and consequently, crime, in communities of color.

A discriminatory wage gap for women and people of color that bolsters growing wealth inequality.

And preventable patterns of disease that plague poor communities of color.

The contemporary threats to equality in American life are disturbingly similar to the injustices that emboldened leaders of the Civil Rights Movement more than 50 years ago. But while the issues that define our time are unsettlingly familiar, the opportunities to act are profoundly different.

With the advent of social media, ordinary individuals now have unprecedented access to both publish and consume publicly curated news. This step to democratize information creates a space for enduring public discourse and a real-time portal into the many faces of racism, sexism, classism, and cultural ethnocentrism that endanger our most basic American values.

The legacy of the Civil Rights Movement freed us from the tyranny of these “isms” at the ballot box, in the classroom, in our neighborhoods, in our work places, and in the public spaces of American life. In so doing, the acts of thousands of courageous Americans set a new precedence for our nation to reaffirm its commitment to liberty and justice.

Today that commitment is under attack. And although the challenges we face are formidable, our responsibility is great. So who will rise to the challenge? Who among us is willing to take the protests and the hash-tags into the daily routines of our lives where the insidious acts of racism, sexism, classism, and cultural ethnocentrism threaten the values we hold most dear? Who will fight for equality today?

Dr. Martin Luther King Jr. was an exemplary American who challenged us to rise to the height of our humanity. But we cannot wait for another visionary to bring us to the mountaintop.

The urgency of justice demands we act now, one institution, one industry, one community, one person, one step at a time.

If you are a teacher or school administrator, challenge the “zero-tolerance” policies that forge the school-to-prison pipeline, disproportionately shunting students of color and students with disabilities, as early as preschool, into the criminal justice system for routine school infractions.

If you are a local government official, question the redistricting policies that dilute the voting power of minorities and overturn voting registration policies that may prevent the elderly, the poor, or people of color from exercising their constitutional rights.

If you are a housing developer or real estate speculator, invest in mixed-income housing that enable people, regardless of race and class, to share the public benefits of education, parks, and recreation that flourish in proportion to local tax appropriations.

If you are an environmental advocate, lobby to protect poor communities of color from the industrial pollution that threatens their air,soil, and water quality and ultimately jeopardizes their health.

If you are a police officer, challenge “stop and frisk” policies that disproportionately target Black and Latino individuals and confront the biased assumptions that may lead you to suspect persons of color or treat them with excessive force.

If you are an writer, publisher, producer, or actor, demand that our films and books offer a genuine look into the lives of all Americans. This requires equal representation on the written page, behind the camera, and in front of it, to reflect the diversity of the American experience.

If you are a student, consider if women are disproportionately subject to sexual violence on your campus, and stand in solidarity with the victims in demanding that your faculty and administration protect young women and their bodies.

If you are a business administrator or owner, critically look at your workforce, from the leadership to the average employee to the staff and ensure that the process by which you recruit, hire, and compensate employees reflects equity in opportunities for women and people of color.

If you are a physician, confront your implicit bias and how your differential treatment of patients by race, gender, or class may contribute to deadly health disparities.

As Dr. King sagely foretold, “injustice anywhere is a threat to justice everywhere.” The racism exacted with the lethal precision to take the life of Eric Garner is just as pernicious as the sexism that ostracizes and threatens the lives of victims of sexual assault on our college campuses. It is time to connect the dots between all forms of oppression in American life and work towards justice.

The modern movement for equality will be powered by the daily diligence of the masses, not the brilliance of one leader. We all must summon the courage to go to into our work place, our classroom, our community, and our home, and engineer justice, create equality.

As we remember, with pride and gratitude, the life of Dr. King, let us not rely on his memory to ensure our liberty and justice. Without his living example, let us be his voice for change.

I am MLK.

This week, join @schumerj and I, as we tweet out our commitment to change our workplace, community, or social networks using the hash-tag #IamMLK and let’s build a coalition of leaders for justice. Also look for an upcoming 2-part piece on racism in the American health care system and what we can do about it. In solidarity, Rhea MD

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Fighting for Failing Care: How Hospital Closures May Impact the Safety Net

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In the post-Affordable Care Act healthcare landscape, sweeping hospital closures have created new barriers to access in a system already criticized for its fragmentation and saturation. Looking back over the past 20 years, urban hospitals, and urban trauma centers in particular, bore the brunt of this impact, closing at the highest rates in the country. Now, evidence suggests the impact of urban hospital closures may disproportionately affect those living in poverty, racial and ethnic minorities, and the uninsured.

This concerning trend begs an important question:

If urban hospitals are a trusted point of access for low-income communities of color, does their closure undermine the national safety net OR does it create opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations?

To answer this question, let’s look at the contentious 2007 closure of Martin Luther King Jr. Harbor Hospital in Los Angeles.

As a bit of background, MLK-Harbor opened in the wake of the 1965 Watts riots and general unrest regarding the lack of sufficient public investment in communities of color in South Central (now termed South LA). The hospital was to provide healthcare in one of the poorest and most violent neighborhoods in LA. At the time of its closure, it remained the only public hospital to serve a large part of South LA, treating more trauma patients than almost all other hospitals in the region. Its closure was prompted by a series of egregious medical errors that eventually threatened the hospital’s accreditation.

Mounting quality concerns aside, what was most notable about its closure, was the staunch community protest. In the face of unquestionably dangerous medical practices, the community rallied to protect their safety net; even garnering the support of Congresswoman Maxine Waters, who rose to the cause’s defense in 2004. Despite their efforts, the trauma center was shut down in 2004 and the general acute care hospital closed thereafter in 2007.

So why would a community fight for the failing care of their discredited hospital? Is the safety net worth protecting when it is offering poor care or is the community’s advocacy tacit admission that poor care is better than no care at all? And ultimately, does “no care” threaten the safety net or does it provide an opportunity for something better?

Let’s dissect these questions piece by piece.

First, it is a basic human instinct to protect what you perceive as yours. Even if what you have is broken. Now superimpose on that instinct, a history of having no say in what is taken from you; a history of abandonment by public institutions charged with investing in your community infrastructure; and a history of displacement driven largely by resource scarcity and discrimination. When viewed in this structural context, the motivations to fight to protect resources become obvious.

Second, let’s explore the idea of fighting for “failing” or “poor” care. Here, the assumption is that low-income communities of color either don’t understand or don’t want, quality. Why else would they protest the closure of a bad hospital, right? In this case, I think we’ve got the assumption wrong. Americans love a deal. We want more for less. Whether it’s super-sizing our french fries or buying into the housing market at the right time, we want quality and we want it at a bargain price. In this way, quality is an American value that translates across the economic spectrum. But sometimes, “the deal” trumps quality. So the real question is, what is the “deal”?

In the case of MLK-Harbor, if there is not another medical facility near your home and public transportation is unreliable, or if you are uninsured and you cannot afford a second opinion, or if the medical specialty you need is only available at your local provider; then the deal is access, the deal is cost-savings, the deal is specialization. This is why low-income populations are vulnerable. Because their lack of resources offers them a bad deal, around which there is little leverage.

So it is not that poor care is better than no care. It is that no care should no longer be an option, but for many, that is the deal they are left with. So as engineers of the system, we have to create something better.

And herein lies the answer to our initial question. It does both.

Because urban hospitals are a trusted point of access for low-income communities of color, their closure undermines the national safety net AND creates opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations.

In attempting to forge a better healthcare system in the midst of our broken one, every failure is an opportunity for improvement.* As the Affordable Care Act re-organizes the medical landscape into regionalized, micro-systems that are accountable for local populations, it provides the opportunity to consider our past failures and the global impact of shifting costs and shifting care on the vulnerable.

The tension between eliminating inefficiency, maintaining quality, and controlling cost while elevating the voice of the community and prioritizing the needs of the under-served, remains. These are the challenges that loom at the forefront of a healthcare system that seeks to cut costs and maximize quality for all. But this is a cause worth fighting for and I’m all in. Are you with me?

* To see how MLK-Harbor (now MLK Community) is improving their system to re-open in 2015, click the link.

Is Civic Engagement the New Frontier of Physician Advocacy?

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We Can Do Better - Improving the Health of the American PeopleThe figure is simple. Health care plays, at best, a minor, and at worst, a relatively inconsequential role in reducing early death in America.

That means, where people live and how they function in their local environment, potentially matters more to their long-term survival than what doctor they go to, or what medicines they are prescribed.

That is a powerful statement about a complex phenomenon – what happens in our communities impacts health in profound and lasting ways. So if health is predominantly determined by community-level factors,* perhaps we should re-design the traditional medical model to place community at the center of health care.

This idea isn’t new, and is probably why Dr. Steven Schroeder aptly titled the article from which this graph was taken, We Can Do Better. One look at the data and it is obvious more can and should be done to address the social, economic, and political drivers of health in this country. But the question of who and how somehow remains.

For many physicians, taking on structural inequality may seem overwhelming or outside their job description. Common retorts I hear are, “This is a social workers job.” Or “This sounds good in theory, but how would it work in practice?” To the first point, the evolution I am alluding to is a systems-wide change in the practice of medicine, such that the way we conceptualize medical care draws upon the skills of an interdisciplinary team of practitioners charged with addressing social determinants of health. So while this vision certainly includes social workers (and public health departments, local government, social service agencies, etc) it also necessarily includes physicians.

To the second point, there is a long history of community-oriented primary care (COPC) theory and practice. It dates back to the 1940s, and the work of giants like Sydney Kark, who created a model of government-funded, community-based, preventative care delivery in South Africa; and Jack Geiger who directed 2 exemplary, community health centers in the Mississippi Delta and Boston, MA in the 1960s. Dr. Geiger’s integrated clinics were the first of their kind and used government funding to pay for community-level health issues, like hunger and housing. Today, there are over 1200 such clinics nationwide serving an estimated 20 million Americans, or 5% of the US population, annually. These clinics are the backbone of the national safety net and the front lines of the medical response to growing inequality.

But as the issues of poverty begin to knock on all of our clinic doors, we can no longer afford to ascribe to the notion that this is the niche work of a minority of physicians.

So where do we begin?

The ballot box.

Data suggests physicians have a relatively low rate of civic participation as compared with professional peers like lawyers and the general population. As local policy informs local resources, the ballot box is the space where physicians find voice to address the pressing needs of our communities, needs that have an undeniable impact on this nation’s health.

The future of medicine requires physicians confront the impacts of concentrated poverty, a tiered education system with gaps big enough for entire communities to fall through, immigration and population displacement, and racial and gender discrimination, among other indicators of health. Still, the traditional physician role and our current training paradigms largely ignore these modern threats to health and wellness. So in the absence of a clear system-wide charge, vote in a way that makes a difference.

If community health centers are the backbone of the social safety net, voting is the backbone of physician advocacy.

Civic participation is the new frontier for physicians to combat the effects of poverty and inequality on health in enduring ways. It is how we can reach beyond the limits of our clinical role to engage the issues that matter to our patients and our communities.

Visit Vote411.org to find a polling place near you, trouble shoot election-day problems, and find a state-specific voter guides.

Definitions used in this piece:

* Community-level factors are things like where you live, how safe your neighborhood is, if you have a park within walking distance of your house, or if the property values in your neighborhood are high enough that your local public school is well-funded and thus if you are of school-age, you are more likely to go to college as a result of living in that neighborhood. These community-level factors are intimately related to the choices people make or their “behavioral patterns” (as referred to in the pie chart above). For example, if your neighborhood is relatively safe and there is a park within walking distance of your house, you may be more likely raise your child in a lifestyle that promotes and values physical activity, a known method to prevent obesity. Conversely, if you live in a neighborhood that does not have a grocery store that sells affordable fresh produce, you may be more likely to eat processed food, and more likely to battle obesity and related health conditions.

For more on how community level factors or structural inequality affects health, check out my piece on structural inequality here. If you are an educator thinking about teaching these topics, check out my piece on teaching structural inequality here. This piece also includes the syllabus and reference guide I use when teaching on this topic.

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