The Room to Wait

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The president-elect’s victory, and the tacit validation of his divisive and dangerous rhetoric and policy proposals, challenges those who call themselves liberals to be the values they espouse. Until 2 weeks ago, those values came at little cost. Aside from the news you read, the company you keep, and the places you buy produce, the daily politics of American life were, for many, comfortably cosmetic and consumer-oriented – simple public identities crafted by the items you purchase, relationships you explore, and content you share online. Then, Americans elected a xenophobic candidate who ran on an openly Islamophobic platform and has since designated overtly racist, nationalist, sexist, and homophobic advisors and federal appointees.

This. Is. The. Wake. Up. Call.

I fear we are missing it.

Despite eruptions of private emotions, public protests, and hashtags du jour, in the short 11 days since the election, some have returned to their daily lives, unscathed, and continue their daily work, unchanged. Perhaps seeking emotional refuge from their liberal outbursts, they hasten calls for stability rather than quicken the pace of resistance. They find room to wait while the marginalized among us live under the threat of violence, displacement, internment, and the insidious affront to their rights and their America that is hate speech and hate crimes that go unacknowledged and unatoned. This form of liberalism is privilege incarnate. It is the white tears that dry quickly, the fickle fetish of media sensationalism, the limited attention that only spans the interests and people that look and feel like “us” or “them,” and the normalization of public exclusion in the most powerful democracy in the world.

There is literally no time to waste. And every moment a “liberal” person, organization, or institution spends calling for caution in place of critique, pause instead of preparation, and waiting as opposed to imminent action are lost opportunities to defend the values and people liberals’ claim to hold dear.

This includes hospitals, and other public entities erected in service of community. “Carry on” attitudes that simply re-assert an existing mission without delineating concrete plans to defend or extend that mission should allied populations be endangered, are frankly not enough. And should employees fall victim to local or federal aggression, they offer no protection at all. If progress relies on accurate recognition of the problems, “carry on” stances silence the uncomfortable realities, conversations, and sacrifices required to look those problems in the face.

It is not alarmist to get prepared. And that preparation entails mobilizing the volume of resources necessary to support a diverse set of populations who now worry for their safety and security in this country. If the urgency of that need is somehow lost on you, don’t hide behind your liberal leanings and co-opt progress.

To Plan:

  • Place those most affected in positions to advise and lead how organizations respond to new needs or evolving threats facing the populations it serves.
  • Anticipate the needs of clients or patients with intersecting identities and consider forming coalitions with organizations best equipped to serve needs that may fall outside given expertise or capacity.
  • Vulnerable populations can be employed in positions that offer the least schedule flexibility. Consider adjusting those constraints as needs to care for family may rival needs to be present in the workplace.
  • Consider a buddy system or a phone tree between employees to increase the visibility of those worried about their ability to get to and from work safely.
  • Consider creating a safe space for affected employees to seek emotional or legal counsel should the need arise.
  • Consider supporting organizations that champion the needs of the marginalized with donations or service, and if possible, reflect their needs in joint legislative agendas.

The challenge liberals are facing is a kind of active democracy many have never known and it may be painstaking and overwhelming. It is also a burden people of color, the LGBTQ community, immigrants, and other marginalized groups have carried, often silently and alone, for years, centuries, as the spaces to publicly express, wear, and own their person-hood is narrowed.

Vigilance is too often inherited through wounds endured. For those who now find themselves unaffected or disaffected, it is time to ask, how many wounds must be sustained for you to move from the waiting room to hold space for action?

 

Police and Pediatrics

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As many of you know, I took a 6-month hiatus from my blog last year to write and edit a piece on policing and pediatrics. I am excited to finally share my work entitled Police, Equity, and Child Health, that was published in Pediatrics this month! AND because this is a topic of public interest and concern, I’m also excited to announce the journal has agreed to allow free access to the piece online for the entire month of February! Check out the pdf version here and feel free to share your comments below. I can’t wait to hear what you all think!

For me, this issue is personal and writing and defending this piece for the past 6 months has been incredibly emotional. But it has also been one of the most rewarding experiences of my early career and I only hope to continue to push myself and my field to consider and engage issues that uniquely and disproportionately affect the health and well-being of children and people of color. To use a line from Black Lives Matters co-founder, Alicia Garza, at its best, this piece is a love letter, and I hope those who read it feel my deep love for my people and my people feel loved and cared for by me, and by proxy, by my profession.

I also want to publicly acknowledge and thank my mother, Avis Boyd, who reviewed every word, every line, and every intention of this piece. She is the backbone that kept this piece afloat when biting critique wore at my resolve. For this and everything, she is everything.

Last year, when Walter Scott died, I pleaded in exasperation, for my colleagues and my field to consider his death and the death of other young black folks an affront to our professional commitment to promote health. But it wasn’t enough. And although these words were powerful for me to write, they will not be enough either.

So I’ve also drafted a resolution to the American Academy of Pediatrics’ Annual Leadership Forum taking place this March, where the academy sets the agenda for child health for the coming year. The resolution is #71 The Impact of Adverse Police Exposures on Child Health and it urges the academy to both advocate for community and school policing policies that place children’s health first and to research and fully articulate the disproportionate impact children of color face from adverse police exposures.

If you are a pediatrician or a student member of the American Academy of Pediatrics, click here, to comment on and support this resolution, bringing the issue of policing and pediatrics across the country and helping the academy take an important step to better serve children and families of color.

If you live in the San Francisco Bay Area and are interested in joining a local coalition seeking to understand and address how police practices and policies can protect, promote, or harm health in our community, leave a comment and I’ll add you to our email list.

Happy Black Futures Month!

Freeing the “Doc in a Box”

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The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.

The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.

To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.

Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”

But the baffling thing is, that is not what is happening.

Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.

But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.

Thinking outside the “doc in a box”

In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.

The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.

It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.

If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.

There will likely always be a need for physical care of patients with ailments that require  treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.

With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.

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.