Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the Journal's editor in chief, Dr Audiey Kao, with Drs. Joniqua Ceasar and Dorothy Charles. Dr Ceasar is a Resident Physician in Internal Medicine and Pediatrics at the Johns Hopkins University School of Medicine. And Dr Charles is a Resident Physician in Family Medicine at the University of Illinois College of Medicine at Peoria. They joined us to talk about systemic racism, police brutality, and the role of health professionals in securing racial justice and health equity. To watch the full video interview, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Kao: Good afternoon, Drs. Ceasar and Charles. Thanks for being a guest on Ethics Talk today. [music fades out]
Dr Dorothy Charles: Thanks for having us.
Dr Joniqua Ceasar: We're happy to be here.
Kao: So, White Coats for Black Lives was founded on Martin Luther King Jr. Day in 2015. Later in that same year, the AMA Journal of Ethics published an article that you both co-authored, along with Nicolas Barcelo, as members of the White Coats for Black Lives National Working Group. To begin our conversation, I think it would be helpful if you could explain to our audience the original impetus for and current mission of White Coats for Black Lives.
Charles: Sure. So, I can go ahead and kind of give some background about our origins. December 2014 was when we organized the National White Coat Die-Ins, and around that time, folks around the country were responding to the deaths of Eric Garner and Mike Brown and the acquittals of their murderers. And there were communities who organized die-ins as signs of solidarity with the communities affected by these rulings. And so, around that time, there were pockets of medical students at different institutions across the country who were having discussions about what our role is as medical students and as future physicians in responding to police brutality. And we were able to connect with people across institutions and found out that some people were interested in essentially showing our solidarity with communities affected by police brutality, by also doing a die-in specifically by medical students, but some clinicians who also wanted to join in as well.
And so, in December of 2014, we went ahead and organized that. There were thousands of medical students who were involved across 80+ medical schools. And so, coming off of that, we realized that we would want to harness that energy more long-term, and so we created the organization. And so, our two main demands were to call attention to police brutality as a public health issue, and then also look inward at our own medical institutions and address the institutionalized racism among, within our ranks, in our medical schools, the way we design a curricula, how we recruit under-represented minorities, as well as in our hospitals and patient-centered care, segregated care, insurance discrimination, and those policies being a way of reifying racism in medicine.
Ceasar: Yeah, I think that's a great background, and I think through just our internal reflection and trying to see what we want to see changed within this institution of medicine, we've committed to forming values. And so, first and foremost, we're committed to anti-racism, especially anti-Black racism, because we know that sometimes that gets lost under the talks of discrimination. We also are really committed to being anti-capitalism and anti-imperialism and prison abolition. And so, these are four main values that we hope to shed light on and hope to use our white coats as physicians and physicians-in-training in order to bring awareness to and produce real change, especially with regards to just the way that we police Black bodies, regarding mass incarceration and police brutality, knowing that that's come from the centuries' old problem that originated out of slave patrols and that has contributed to this capitalistic society and dehumanizing Black people. And so, we hope to make changes to regards to that.
And so, Dorothy hit on a lot of the metrics that we've been addressing: looking at med schools and URM recruitment, looking at support for faculty and students once they are brought into institutions, and looking at segregation within health care with regards to our residency-run clinics versus attending-run clinics, looking at policing on campus. And all of that is evaluated in the Racial Justice Report Card, which has been one of our initiatives that's been going on for the past couple of years. In addition to our current campaign right now, being Actions Speak Louder, which kind of hits on all of those things and has people making demands at their local institutions about what they want to see changed.
Kao: Yeah, I appreciate that. I think that will help our audience better understand the original motivations and passions that contributed to this organization being founded.
You just noted a moment ago that White Coats for Black Lives was created at another time when there were national protests about the acquittals of police officers responsible for the deaths of Michael Brown and Eric Garner. And obviously, we're here today because other Black people and people of color, including George Floyd and Breonna Taylor, have died recently at the hands of police officers. Police brutality is obviously one of the main focus areas of your group. So, can you tell us why it's important for health professionals to focus on police brutality? And probably more importantly, what should they do about it?
Ceasar: Yeah. So, police brutality, the way we see it, it's a public health concern, just like lead poisoning. And we see the Flint water crisis and how that's an example of how racism can cause harm to particularly Black communities. And so, we see it just like lead poisoning, just like immunizations, just like physical activity. For these issues, we see health care professionals, especially doctors, get involved. They educate their patients, they don their white coats, they lobby, they join nonprofits, they organize. And so, just like those issues, we feel we should be doing the same thing for police brutality, and honestly, for mass incarceration as well. Because we see how both of them have caused a lot of emotional trauma for Black people. They've ended lives of Black people prematurely. And so, we hope to be able to join that conversation and lobby and be able to just help people realize that this is a national problem that's been really bad for a lot of people within this society. And what is it that we can do about it? How is it that we can organize and lobby and get involved with grassroots organizations in order to eliminate this problem?
Charles: Yeah, and I think Joniqua bringing up the prison industrial complex as a whole, as like a subset of this, or with police brutality being a subset of that larger problem, it helps us to also frame some of our abolition work, not just around the police brutality aspect, but also what happens if someone were to go to prison, and thinking about issues of overcrowding. There's violence that happens within prisons, sexual assaults. The close quarters puts people at higher risk for communicable diseases, and especially now that we have the novel coronavirus being spread. These are conditions that disproportionately harm Black and brown people because our justice system or injustice system disproportionately targets people in these communities. And so, when it comes to organizing and using our privilege and our power as respected members of society, I think it's really important that we take our cue from grassroots organizations.
And so, there are local organizers who have set up bail funds, who do jail support for people, who they're street medics. There are people who are very plugged in to local community issues such as problems within the school systems, which is another pipeline to prison for many of our young folks. Which is near and dear to Joniqua and I's heart, because we're both in careers where we're going to be taking care of adults as well as children.
Charles: And so, thinking about this is an all-encompassing issue where we can find ways to support local communities who know what's best about the conditions in their area, that's something that we can lend our voices to, our money to, our time and energy to. And that can also guide the way we advocate on more quote-unquote “traditional” levels in terms of speaking with Congresspeople, talking with local politicians, things like that.
Kao: Yeah, I appreciate both of your points. And I'm reflecting on some of the interconnections that you've pointed out, which is that there's this nexus between mass incarceration, the prison industrial complex, capitalism, all of which are part of a larger system that oppresses people of color and has oppressed people of color for decades.
Motivated by a study commissioned by the American Medical Association, AMA President Ron Davis publicly apologized in 2008 for the fact that from the 1870s through the late-1960s, the AMA failed to take action against state and local medical associations that had racist policies that functionally excluded most African-American physicians from membership in the AMA. At the time of the apology, there were calls for actions to be taken to increase the diversity of the physician workforce. Yet today, Black, Latinx, and Native American students remain under-represented among medical school matriculants compared with their numbers in the overall U.S. population. In fact, this under-representation has only increased over the intervening period. As you alluded to earlier, promoting greater diversity in medical student classes is one of the goals of White Coats for Black Lives. So, how is White Coats for Black Lives working to advance this goal? And what should educators and leaders in academic medicine be doing to realize greater student diversity?
Ceasar: Yeah. So, we know that yeah, the medical field has been overtly racist from just experimentation of Black and brown people to even learn how the body works to begin with, to justifying slavery with pseudoscience, and the social hierarchy that we have in place according to pseudoscience. We know that it's been very exclusionary, and so it won't happen overnight, being able to get this diverse workforce. Unless we put in effort, it's not going to just happen on its own because they have these policies in place that have prevented it from occurring. And so, I think that one step that the institutions should take is just to go for true diversity and inclusion. I feel like a lot of times it's very tokenized. And as medical students of color, we often talk about what it is that our departments are doing nationwide. And we see a lot of tokenism with regards to how when institutions do recruit URM faculty, they're often siloed into being the Dean for Diversity. And then they often have very limited budgets, and they often have their hands tied. And so, if institutions truly want to make change, then how do they equip those departments to actually make stuff happen? And how do they empower the local community so that people surrounding the institution have an opportunity to become physicians if they so choose?
So, I think it also takes us going outside of those four walls to look at what is a living wage like for the institution? What does mixed housing look like around that area? The AAMC did that report a couple of years ago, looking at Black men in medicine, and they saw that it's not just the pre-meds that they're excluded. This happens well beyond that. This is happening when people are born into just places of poverty and not being able to have access to certain resources. And so, I think institutions, medical schools that are hoping to build a greater diverse workforce, they need to be intentional about going outside of those four walls in order to make changes that way, too.
Charles: Yeah. And so, in terms of recommendations for how medical institutions and health care professionals can be involved in making this change, we have been putting out the Racial Justice Report Card for the past couple years. And several of our metrics involve, first, collecting data. What does the representation look like at my institution? And finding out what is the proportion of students in each of their classes? What percentages of Black students, of Latinx students, as well as Native American students. And then you look at each level of training thereafter and intern classes and residency classes and among fellows and finally attendings. And then finally, the decisionmakers and the people in the C-Suite, as well as other Deans, what does leadership look like? And then like Joniqua wa saying, there's one thing about having people in those positions and actually allowing them to have power to actually create the change.
Charles: You can have as many, you can have a diverse looking leadership structure. But if that doesn't lead to functional outcomes where you're actually seeing increased representation from the ground up, where when students or residents say that they've experienced racial discrimination from their attendings or from colleagues, that disciplinary action is taken and that those complaints are taken seriously, we're not going to see that long-term change. And so, another thing I like to remind people of is that there are plenty of Black premedical students who apply for medical schools every year. Same thing with residencies. And, you know, we exist in a system where, if we wanted things to change, we just have to do it. And that's not a very popular or particularly glamorous sort of action or recommendation. But if you're serious about having your student body look more like the community around you, especially if you're like….
So, Joniqua's in school in Baltimore or in residency in Baltimore. I went to medical school in Philly. And those institutions are in predominantly Black neighborhoods serving those communities, reportedly. But if we're not actually just being explicit and saying, we actually are going to have like 25 percent of our class be Black students. Which that number sounds, should sound less extreme. We have one of our fellow working group members, Kayty Himmelstein, has done some of the math of how much that we have to correct for the under-representation of Black, Latinx, and Native American physicians in this country. And we could admit entire classes of just Black medical students for the next 20 years, and we'd just be addressing the issue. Like that's how serious and how big of a problem this is. And so, if we want to make a change, you just have to make it happen. It's going to be unpopular. A lot of the powers that be are not going to want to just suddenly switch their entire classes. But if that's something that we're truly committed to and that institutions are committed to, the reality is you have to do something very drastic and unpopular.
Kao: Yeah, I think both of you make some excellent points about both the need for and the challenges to make seismic changes if we want to see a more diverse physician workforce. And I think your work with Report Cards through White Coats for Black Lives, I think, is a very important element of showing kind of where schools stand along various justice and diversity matrix. And I think that's an important contribution that your organization, White Coats for Black Lives, has provided.
So, last June, the American Medical Association's House of Delegates nearly voted to overturn their longstanding opposition to single-payer health care; 47 percent voted to eliminate opposition to single payer as an official position of the AMA. In fact, many long-time AMA watchers would have thought that unimaginable not so long ago. Recent public polling has also found that about half of Americans support a Medicare for All plan. So, while the general idea of a national health plan, whether accomplished through an expansion of Medicare or building on the Affordable Care Act, may enjoy fairly broad support in the abstract, it remains unclear how this issue will play out in the 2020 election and beyond. So, what do you see as the physician's role in educating their patients about important public policy debates, such as achieving universal coverage and police brutality as a public health emergency? And more specifically, how should this role of physicians be exercised?
Charles: Yeah, that's a great question, and I actually think that the framing of the question is interesting. Because I think in many ways, physicians have a role to learn from our patients and communities about these issues because they're the ones oftentimes who are facing the issue of under insurance or un-insurance. And they already know the realities of what lack of insurance does to them. And I think from their lived experience, they already understand that we need universal coverage. They understand that police brutality is an issue. They live it in their day-to-day lives. And I think in many ways, the issue is more in educating ourselves and educating our colleagues about these issues. Because I think we can be so siloed in our hospitals and clinics that we forget that we actually maybe don't have the…we don't have good advice to give patients as much as we can learn from them. And so, I think our challenge as physicians is to really expand our colleagues' minds and their political imaginations. And then in turn, we can use our positions, as a powerful group in society, whether we want to accept that or not, to push for change from people who are policymakers.
And so, I think specifically, this is a forum hosted by the AMA, and the AMA is a powerful lobbying group. And in Congress, I think about the insurance lobby, the hospital lobby, and how all of these factors are very much invested in this capitalistic, for-profit type of a system, which is one reason why it's been really hard as a country to finally make progress when it comes to single payer. And so, when we, as physicians, begin to essentially push a lot of these powerful institutions to do better, I think that will eventually lead to more equitable policies around insurance, as well as addressing the prison industrial complex and the issues of policing and police brutality down the line.
Ceasar: Yeah. I think Dorothy brings up some excellent points. And I think if we were to be in a position where we were educating, like she said, we have a lot of learning to do as the field from the people that we hope to learn from with regards to the issues that they face in their communities. But even if we were educating them with our current state, what good would it be when historically marginalized voices have been silenced and ignored for so long? So, even if I were to go into the clinic and say, “Hey, police brutality is an issue,” what good is it if they cannot exercise their right to vote? We've seen rampant voter suppression even recently with Southern elections, right? We know that we've repealed the Voting Rights Act. We know that there have been just a lot of ways to kind of silence particular voices.
And so, if anything, if we truly believe that—and we have so many studies showing that help is so much more than the clinic, so much more than that clinic visit—how do we intervene outside of, like I said, those four walls to help make sure that once we do educate, if we were to educate the patients, that they are empowered to do something with that education, with that knowledge? How is it that powerful lobbying institutions or groups like the AMA or other medical organizations can lend that platform to help fight against voter suppression and to make sure that people do have a right and that they don't have to just sit by and see policies like the 13th Amendment, for example, that makes it okay for someone to be used as a slave in the circumstance that they're deemed a criminal, right? We have no say in certain policies. And so, how do we expect to change people's health if the structures that govern them are producing these horrible health disparities?
Kao: Yeah, I appreciate your last points about listening and hearing the lived experiences of patients, because they can teach us more than what textbooks or seminars can.
Kao: And trying to work with and partner with our patients to amplify their voice and aspirations to make change, I think, is all the issues that are confronting our society at this moment. How do we collectively channel our voices to make meaningful change that benefits all, but especially those who have suffered the most over the decades due to racist policies?
Kao: So, I appreciate your last thoughts about that.
So, as we near the end of our conversation today, I want to give my two colleagues here today time and space to share any other thoughts about the difficult and trying times that our country is going through right now, as well as any advice for health professions students and practitioners who are trying to find ways to advocate for and work to achieve health equity and social justice.
Ceasar: Yeah. So honestly, it's been tough, and this isn't anything new; this happens in waves. We see it. It happened with Rodney King. Like you said, five years ago, we were in the same space having a very similar conversation. So, we seem to just go through this in cycles, and people kind of decide to listen for a moment and then kind of just proceed back to business as usual. And so, I'd like to see real change result from these conversations. Now, it is encouraging. A couple years ago, I was an eager medical student, and I had joined, I think the Minority Affairs Committee and was super excited to get with the programing committee to plan for the upcoming regional conferences. And I was like, “Hey, guys. Let's talk about racism and medicine.” And people were really taken aback and saying, “Oh, let's not use the R word, and let's rephrase this. Let's talk about discrimination against the providers instead.” And so, I am encouraged to see that we are naming racism right now. I think that is an important first step, but I hope that it doesn't stop there.
So, I hope people who want to actually join in this fight and advocate, I hope that one, that they would just give grace to their Black colleagues. It has been a really traumatizing time for academic institutions to not immediately reach out to the only Black medical student or the only Black resident or faculty and ask them to represent all of Black people on how it is that they're feeling. Because we have to remember that Black people are not a monolith. There's so much diversity within that. And also, we have to be aware of the minority types, so the idea that we do care about these issues, and of course, we do want to see a change. But we are not the sole people responsible for making that change happen. We're not the ones who have to write all of the response statements and decide what exactly it is that we're going to do.
Ceasar: And so, consult experts or whatever it is that, whatever resources you have available, and capitalize on those during this time as well.
Charles: Yeah, I think if I were to speak to my colleagues in health care as a whole, saying this is a perfect opportunity to learn and to read, especially right now. Right now, I think the Defund the Police and Abolish the Police movements are really making headlines. And I think there's also this tendency to think that these ideas have come out of thin air when really, especially Black scholars have been discussing this at length. There is a large body of Black scholarship about these issues. And especially now where we have the Internet right at our fingertips, don't be afraid to look things up. If I could recommend just one reading right now, Mariame Kaba, who's an organizer based in New York, previously was in Chicago. She wrote a piece for the New York Times about abolition. So, listening to voices like hers, Angela Davis are two major abolitionists in our time. And they have so much more expertise than didn't even I could claim. I learn so much from them just listening to their talks and reading their work. And so, approaching those new concepts and ideas with an open mind and realizing that so much of what abolition is about is envisioning an entirely new future, an entirely new way of relating to other people in our communities, and just approaching that with an open heart, open mind.
And then if I were to speak directly to my Black colleagues, I would just say, like Joniqua saying, we've been here before. Unfortunately, we will always be in this space. And I think the priority is, is you and your families and making sure that you can secure your mask before assisting others. And so, taking the time that you need to rest and set boundaries. Lots of people are going to be asking for our labor, whether it's actually making some of these statements or just listening to people like say, “Oh, my God. I am so sorry. I didn't realize that it was so bad.” That's a lot to take on. And being okay with setting boundaries and protecting your own mental, spiritual, emotional health is really important and will sustain us for the long run. And really to focus on your work as medical students, as physicians, and knowing that we don't exist just to be everybody's personal anti-racism coach. We're allowed to focus on our craft.
We spend a lot of time essentially working against racism in our institutions, but at the same time, especially coming straight, or recently coming from medical school, you're there to learn medicine. And your existence in this space is important and needed. And at the end of the day, you're there to get your degree and to serve the communities that you come from, that you feel connected to. And just never forget the communities where you come from, and take it one day at a time. And know that there are plenty of Black residents and attendings who've gone before you and have been in that space. And we're surviving [laughs], and I think that's something you should take heart in. And just be good to yourself. I think that's something I would just leave with…for Black colleagues.
Kao: I'm sorry. Was there something else you wanted to say?
Charles: No, that's just, that's the only thought I would leave with my Black colleagues.
Kao: Yeah, I really appreciate your final thoughts about this very important topic. And I want to thank both Drs. Ceasar and Charles for sharing their deep insights and lived experiences with our audience today. Thank you both for being a guest on Ethics Talk.
Kao: To learn more about White Coats for Black Lives, I encourage you to visit their website and support their essential mission. Finally, as we continue to respond to public health threats posed by a natural pandemic and human-made racism, I want to encourage everyone to continue to wear cloth face masks, especially in large gatherings. While the novel coronavirus doesn't know or care who you are, we as human beings should know and care, especially for those among us whose lives are disproportionately affected by COVID-19 and racism. Thank you for joining us today. We'll see you next time on Ethics Talk. [bright theme music plays]
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