Police Violence and Public Health

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In the wake of Sandy Hook, the response from physicians, and pediatricians in particular, was astounding. The tragic deaths moved doctors to address gun violence and its health consequences.

But week after week, as black boys who could be my sons and black men who could be my father, are shot and killed by police, doctors remain silent. As a pediatrician, I’m appalled.

We are watching a public health problem unfold in front of us and we aren’t doing anything to stop it.

When someone is involved in a police shooting, they are at risk for injury, disability, and as we’ve seen, death. But those who witness the trauma may also be affected. And if they are children, that effect may follow them into adulthood.

Public police shootings turn neighborhoods into minefields where African-Americans fear suddenly finding themselves in harms-way. Those who escape the line of fire are then victimized by the ever-present fear of harassment, incarceration, injury or death.

Like the trauma experienced by war veterans, living under the threat of unprovoked police violence triggers intense emotional and physical stress, even in moments of relative safety.

The chronic stress that fear generates, may place African-Americans at increased risk for health problems like heart and lung disease, and depression.

If we’re going to understand and address the impact police violence has on community safety and health, particularly for communities of color who are disproportionately victimized, we have to treat it the way we treat all threats to health. That means collecting data to quantify the magnitude of the problem, developing screening guidelines to identify those at risk, training medical staff to refer those at risk of impending danger, and funding interventions that address community violence including police violence.

Tonight, too many parents will tuck their children into bed, only to worry that tomorrow, their curious 10-year-old may be the victim of a police shooting because the combination of a growth spurt and black skin threatened their life. Today, we have to do
more to recognize the worry in our community and prevent those fears from becoming reality.

* This piece was featured on Northern California’s NPR affiliate KQED as a perspectives piece. It airs live on April 29th at 6:43am, 8:43am, and 11:30pm. To hear an audio reading of the piece on KQED’s website, click here.

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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.

Raising Resilence

One of my goals as a physician and particularly as a pediatrician is to touch young lives and make them better. Health is not just about check ups and sports physicals and vaccines (although all of those are important components of healthy living). Health is about embodying a spirit of wellness and adopting a lifestyle that nurtures that spirit. This is part of what drew me to medicine – the opportunity to look into the face of our youth and encourage their spirit; to see the potential rising in children and partner with families and communities to protect that potential and mold young lives around healthy concepts of living and growing. For me, this goal is personal and professional.

This past week, I completed a project where I hung old photos of my family and dearest friends around the head of my bed. I did it so that when I dream, when I think of all the possibilities of what life holds for me, I am surrounded by the faces of people who love me and support me and whose encouragement lifts me up.

I think James Baldwin said it best when he said, “Your crown has been bought and paid for. All you have to do is put it on your head.”

What an important and wonderful concept to internalize. The idea that –

You are valuable and you cannot escape that value because it is already yours by virtue of the work and sacrifices of the people who have gone before you – be they family, community, or historical ancestors.

This principle reminds of why those faces now hang above my bed; they create a space where I am free to acknowledge my personal worth and the people whose love, time, support, and prayer softens the ground below my daily steps.

As a professional who works in the art of healing, this lesson from my personal life also finds meaning in my professional life.

As a pediatrician, I know there are vulnerable periods in a child’s life when physical, emotional, financial, and social stress can impair mental and physical development. Some refer to that stress as “toxic stress,” because when chronically exposed to it, the physiology of children’s bodies and brains are changed – down to their very genes – in a way that places them at risk for a number of poor health outcomes over the course of their lifetime AND passes that risk on to their progeny (Have you ever wondered why poverty can be generational?). If I know that stress retards growth and development and keeps children from realizing the potential of a full and healthy life, what is my role as a pediatrician in providing children and communities with the tools to build resilience – a psycho-physiologic shield against the adverse effects of stress, or, a potential protector.

Others, have also pondered this and it is becoming more professionally accepted that physicians and pediatricians must be the faces in the community that encourage the spirit of children to protect their value and potential.

So how can pediatrics as a field and I, as a professional, systematically create spaces that recognize and utilize the value of every child; such that children are free to know their potential and build healthy relationships and lifestyles in partnership with the community around them? And how do we as a field, begin to understand how issues of poverty separate children and adolescents from knowing and working towards their value, a value that has been paid for generation after generation?

The short answer is, I don’t know. But I have joined a group of bold pediatricians from across the nation charged to address issues of poverty and toxic stress through medical practice. While part of our work will challenge traditional concepts of the role of physicians in community and increase public awareness of the adverse health effects of poverty, I also hope the outcome of our work directly helps children internalize their value and rise to their potential. Because the longer answer recognizes that poverty does not just create physical barriers to health, but also complicates the path by which children come to know and live out their value in the world. Thus as doctors, as champions of health, we must also be purveyors of justice and defenders of the value and potential in the most vulnerable among us.

If it takes a village to raise a child, what will you do today to embrace your value and the value of those in your community to raise resilience?