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Episode 5 – Racism, Power, and Policy: Building the Antiracist Health Systems of the Future

Learning Objectives
1. Recognize that racism is both structural and interpersonal, and that both aspects must be addressed simultaneously.
2. Appreciate the importance of acknowledging history and sustaining institutional memory in advancing anti-racism efforts and achieving structural change.
3. Understand that collective action and a focus on community, rather than individualism, are most effective in combating racism and achieving health equity
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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers. Learn more.

Audio Transcript

LaShyra Nolen: How are you all doing? This is LaShyra Nolen. And welcome to another episode of the Clinical Problem Solvers Anti-Racism and Medicine series. As you all likely know by now, in this series, our mission is to equip our listeners across every level of training with the consciousness and tools to practice anti-racism in their health professional careers. Today's episode is titled Racism, Power, and Policy: Building the Anti-racist Health Systems of the Future. I am joined by two of our incredible team members, Naomi and Rohan. So I'll let them introduce themselves and our guests.

Naomi F. Fields: Hi, everyone. My name is Naomi F. Fields. I'm a third-year medical student at the Perelman School of Medicine at the University of Pennsylvania, by way of Miami, Florida and Massachusetts. And I am just beyond excited to be here today and share this space, looking forward to learning and sharing lots with my teammates and our guests.

Rohan Khazanchi: Hey, you all. My name is Rohan Khazanchi. I know you've heard my voice before on the podcast, and I just want to say I'm thrilled to be here with Naomi and LaSh, and just want to dive right into the episode. So let me introduce our guests today.

Our first guest is an illustrious scholar, exceptional leader, and skilled communicator who is known for breaking down race, racism, and anti-racism with incredible clarity. It's Dr Camara Jones. Dr Jones is a family physician and epidemiologist whose work focuses on naming, measuring, and addressing the impacts of racism on the health and well-being of our nation. She is a past president of the American Public Health Association, a senior fellow at the Morehouse School of Medicine, an adjunct professor at the Rollins School of Public Health at Emory University, and a former fellow at the Harvard Radcliffe Institute. And I'm going to just add as an aside, that if you haven't watched Dr Jones' allegories on race and racism, I highly, highly recommend clicking over to YouTube and just scrolling through and watching every single one of them. They are incredible, you all. We'll absolutely be, including some links to Dr Jones's work in our show notes. And Dr Jones, thank you so much for joining us.

Camara Jones, MPH, PhD: Oh. It's my real pleasure. Thank you.

Khazanchi: Our second guest is someone I am proud to call a mentor from whom I've learned an incredible amount, Dr Aletha Maybank. Dr Maybank is a pediatrician and preventive medicine physician who has held multiple public health leadership roles, including as the founding director of Suffolk County's Office of Minority Health, the founding deputy commissioner and director of the New York City Department of Health's Center for Health Equity. And she now serves as the American Medical Association's inaugural chief health equity officer and director of the AMA Center for Health Equity. Dr Maybank's exceptional ability to embed equity across health departments and organizations has been recognized by the CDC and the WHO. And I know she is just a phenomenal advocate, activist, and organizer for justice. Dr Maybank, thank you so much for joining us.

Aletha Maybank, MD, MPH: Thanks, Rohan. Thanks for the kind words.

Nolen: Yeah. So to kick us off, Dr Jones, we want to start with you. And I think that it'd be great if you can help us understand, how do you frame racism and anti-racism, specifically thinking about your latest allegory, cement dust in our lungs. Can you do that for our listeners?

Jones: Oh, yes. Thank you for that opening. The first thing is that--well, actually, I started thinking about four key messages now, when we start talking about racism. And the reason I would even say there are four key messages when we're naming racism is that more and more people are saying the word racism, but we're not necessarily all clear about what we're talking about. So the four key messages are that racism exists, that racism is a system, that racism saps the strength of the whole society, and that we can act to dismantle racism.

So that newest allegory, cement dust in our lungs, is to help people understand that we must be focusing on racism as a system. Every time I say the word racism--if I'm sitting on an airplane, which I used to do before the coronavirus, right, and people would ask me, what do you do? And I'd listen to them about what they did. And then I'd say, "Well, I am a family physician, epidemiologist. My work is on naming, measuring, and addressing the impacts of racism on the health and well-being of the nation." The next thing out of that person's mouth would be, "Well, how do you feel going around calling people racist?" Right? This is the big confusion. People think that when you say the word racism, you are calling people racist. Now, there are people who do racist things in this society, right? But I am clear that every time I say the word racism, I am not trying to divide a room into who's racist or who's not, or peer deeply into anybody's soul about exactly how racist are you. But that I am talking about a system, a system of power, a system that structures opportunity and assigns value based on so-called race, the social interpretation of how we look in this race-conscious society.

If there's a cement factory spewing cement dust, anybody around that factory is going to have cement dust in their lungs, right? And the question is, do we focus on how much cement dust each one of us has in our lungs? Do we even try to create a machine that's going to extract the cement dust out of our lungs? Or do we focus on the factory itself? Try to understand how is that factory operating here, and then shut it down.

Nolen: 100 percent. And I think, Dr Jones, do not worry. We'll make sure that that link is in our show notes so that our listeners can listen to that entire allegory. But I think that even when we had our conversation just last week, we talked a lot about how can we get to the root cause of this thing called racism, which is the cement factory. So I think that that would be great for our listeners to listen into some more. So, Naomi, what are your thoughts?

Fields: Absolutely. I mean, I really appreciate the way that you sort of concretize what can be these abstract ideas for people in ways that become both tangible and sort of undeniable, really. You can't really argue with something that has been made that clear. And on that note-- so, Dr Jones, your professional trajectory involves an impressive tenure as president of the American Public Health Association, which you leveraged to start a national campaign against racism back in 2015. And Dr Maybank, your career path has now brought you to the literal helm of the AMA's Center for Health Equity during the time when the AMA just passed policies to declare racism a public health threat, a huge move. So, Dr Maybank, we're wondering to what extent is your work creating the AMA's first Center for Health Equity, built upon the foundations set by the National Campaign Against Racism and other grassroots movements? And then for both of you afterward, how do you view the AMA and APHA movements as similar or different?

Maybank: Thanks for that question, Naomi. And I would say there are many things that have set the foundation for creating the Center for Health Equity at the AMA. In the most recent past, it was really the work of the board of trustees. There was an appointed task force that was comprised of AMA members. And they really set in motion the recommendation and eventually the passing of a resolution into AMA policy sometime around the year 2018. And this instructed the AMA to literally, "to develop an organizational unit, for example, a center or its equivalent, to facilitate, coordinate, initiate, and track AMA health equity activities."

So that's a tall order for one person to be able to do that, and one center to be able to do that. So usually, I say I was hired to really facilitate a process and hold accountability to that process for staff and membership to embed equity and justice values and strategies and actions into our culture, into our practices, our processes, innovation, organizational performance, and outcomes. And so I was hired in 2019 to start and lead this new center. And one of our key theories of change in doing this work at the institutional level is really employing an inside-outside strategy. And we must interrogate how organizational leadership, development, how everyone usually typically understands workforce equity. And that's where people tend to go, in terms of hiring and pay and promotion and recruitment. But you also have to look at budgeting and contracting, the data, how is it collected, the quality and safety within the environment of the healthcare institution, and how are we engaging with our partners and community, how was power distributed, who gets what, and who doesn't get what, how are these things resourced, and how are resources redistributed.

So it's about interrogating systems inside and outside of our institution. And those are not typically really mutually exclusive. And as Chandra Ford and Rhea Boyd--I know you've had on the show before--building on the roots of Kimberle Crenshaw's work on critical race theory, they recommend that this interrogation and institutional transformation should be done through the lens of public health critical race practices. So you identify [inaudible] racism in your mental models and analysis. You address racialized power dynamics that include the centering of the work and the margins. You acknowledge the social construction of knowledge.

So I say that I'm a strategist and a operationalist. I take the theories, the knowledge, and frameworks that folks like Dr Jones created and just explained, and figure out how to put them into action at the institutional level. And so in terms of setting the foundation for our direction, it relates to the anti-racism work that has been done in the past, a little bit at the AMA. But to be quite honest, I was really unclear on how far and fast we were going to be able to lead with racism at AMA. I came from Dr Mary Bassett at the School of Public Health. In quotes, it's not really her school of public health, but we all were there at the health department. She's a bold and forceful leader. And she made it undeniably clear that we would be leading with anti-racism work within and outside of the health department. So starting the Center for Health Equity at the AMA, or starting the Center for Health Equity there, there was no question or compromise. And so AMA is a different place. It's a different culture, a different level of readiness. And I think healthcare, overall, is a little behind public health in embodying and accepting social justice principles. But AMA was ready for the equity work. It was written explicitly, and we received commitments, in terms of funding.

So I had to initially strategically find ways to make sure that the conversations that I was having, that I named structural racism as a fundamental cause. But it really wasn't until this past summer, after the advent of COVID, and the exposure of these long-standing harms and injustices, and the public murder of George Floyd, that we started to have this door open to unflinchingly name and talk about anti-racist practices. And it was a powerful moment, sitting in that board meeting, when the board decided to put this pledge forward. And really to hear them-- they were doing a video recording. They wanted to do some marketing and promotion around it. So it wasn't a collective, "We're all going to say it at the same time." You can't do that when you're virtual. They each had to repeat it over and over again. So you can imagine just sitting there hearing, "The AMA recognize as racism and its systemic, structural, institutional, interpersonal forms as an urgent public health threat. The AMA opposes all forms of racism. The AMA will actively work to dismantle racist, discriminatory policies." You hear that over and over again. At one moment, I was like, "I just can't believe this is happening." And it was really surreal. And I do have a sense of pride around it, for sure. It's long overdue, but I still have a tremendous sense of pride around it.

And so there's that work. And then there's the work of, clearly, the Black Lives Matter movement, the White Coats for Black Lives. All these things set the foundation for how we have been thinking about how to proceed with our work at the Center for Health Equity. And so I'm going to let-- it was interesting. So Dr Jones and I, we were on a call yesterday. And we were talking about just the history of AMA and APHA. It was a perfect setup for that. So I'm going to let Dr Jones start because-- for that question about how do we view the AMA and APHA movements. Are they similar or different? It's really a fascinating question in light of that conversation. So I'd love to hear her, and what her thoughts are post that conversation.

Jones: Well, thank you, Dr Maybank. And even before I get to that question, I want to say that I so appreciate your understanding the importance of history and contextualizing all of these efforts. Because sometimes, we enter these efforts, and we think that things began when we entered. And sometimes, I think I'm even guilty of that, right? But so we have to know that for centuries, there have been people who have been trying to make these agendas and all.

So that's the first thing. And then the other thing, when we acknowledge each other's work, then we acknowledge the power of collective action. And so those are just two things I wanted to say that you embody so well, Dr Maybank, every time you tell the story of this work. And I just wanted to raise that for the younger people who are coming behind. Thanks for getting those of us who are older in this work and letting us have a platform here. Thanks for giving us an opportunity to reach across the generations, to pass the torch, to pass our knowledge, and the energy. This is so important. And congratulations on doing this as a collective effort. Because it's going to take all of us, and it's going to take time. But as long as we as we keep in action, as we keep being focused in action, not inaction, one word, I-N-A-C-T-I-O-N, but in action. Because inaction, the other word, is actually how structural racism most often operates these days. Inaction in the face of need is what we have to combat. So as long as we are in action, then we can keep going. So that's that.

But in terms of public health and medicine, I really think that the AMA's three policy points, the policies that were just passed, are more revolutionary from the American Medical Association because medicine is intrinsically, as practiced or understood in our country, individually-focused. And maybe, if you're a family doc, then maybe you start thinking about the family and the individual in the context of family. And then maybe if you're a preventive medicine doc, maybe you think about the individual family and community, right?

But rarely does medicine really think about systems. So I actually would like to just share seven barriers to achieving health equity that apply, especially to medicine and then more to public health, but to our whole society. Because I think that if you all, as younger people launching into this work or continuing the work that you were born to do, if you can help us think about how to address these seven barriers to achieving health equity, which I now think of as the seven values, targets for anti-racism action, then maybe that will be helpful.

So the barriers are our narrow focus on the individual that makes systems and structures invisible or irrelevant. And that has been core to people denying that racism exist. Because like, "I'm not racist. So if I'm not racist, and we're not talking about systems and structures because they're invisible, there is no problem." Right? The second is that we as a nation are ahistorical. And so, again, kudos, Dr Maybank, for always bringing history, even into our conversation between representatives of AMA and APHA yesterday, where we were caused to keep backing up and backing up and talking about in both associations, when did these conversations start? Because if you're ahistorical, you act as if the present were disconnected from the past, and as if the current distribution of advantage and disadvantage were just a happenstance, that also leads to our national denial of racism.

The third is our endorsement of the myth of meritocracy, that if you work hard, you will make it. And I have to say that a lot of us who have made it endorse that myth of meritocracy. I do say that most people who have made it have worked hard. But even as we acknowledge that, there are many, many other people working just as hard or harder who will never make it because of an uneven playing field that's structured by racism, sexism, all of these systems of structured inequity. And then when we deny the uneven playing field, we're endorsing the myth of meritocracy. We're blaming people who haven't made it for being lazy or stupid.

And it's so easy to deny racism. Some people just say, "I don't think racism exists." But to the extent that we don't say the word racism in the context of widespread denial--even if we're talking about disparities, disproportionality, structural competence, diversity, equity, inclusion, we could be talking about all those things. But if we never say the word racism, then we're complicit with that denial. I don't want to go into the others and others. So I'll just say that the fourth one I'll list of the seven--but the fourth one is white supremacist ideology. The false idea of a hierarchy of human valuation by race with a false notion of white people being at the top of that is the ideal or the norm that causes the dehumanization of people of color and fear at the browning of America. It results of white folks having this sense of entitlement. That is the fourth thing that results in racism denial. So all I want to say is, right now, I feel like we're not in racism denial so heavily right now. All kinds of people are out there outraged at the public execution of Mr. George Floyd and so many others. But that racism denial is still deeply embedded in our society. It is so seductive. It's going to lure us back into the somnolence of racism denial, unless we act. And we have to understand what we need to act against.

Fields: I feel like I've been taken to church. I feel like what some of the themes that I'm hearing and what you and Dr Maybank just talked about harkened back to the principle of rooting and shifting, which is a principle of basically sort of centering ourselves at the margins and sort of learning how to position ourselves in ways that are taking into account other people's history, other people's stories, other people's journeys. And so, Doctor Maybank, when you were talking, I sort of heard you talk about institutionalizing and operationalizing that. And then, Dr Jones, when you were speaking, I heard you sort of talking about all of the different vantage points that we can use in order to better do that rooting and shifting, in order to better center ourselves at the margins and bring ourselves into collective action. And I'll just pass over to Rohan to keep on. Because I think our next question goes well off of that.

Maybank: Can I just add before we do that? I know, this is--but to that point. And this came out again in our conversation yesterday, that part of that, I guess, rooting and shifting and centering other people, it's not only that, but it's being able to center ourselves as the leaders and the people doing the work, as well. Because what has happened for people of color and really elevating our conversation yesterday was that we've had both the burden and the privilege to fight justice within organizations.

But many folks, the actions and contributions have been made invisible. So the stories have gotten lost. And sometimes, I think they were probably outright erased or changed. And I've seen that happen and attempts to do so. And I was on again on this email exchange yesterday with Dr Bassett, who's at FXB now at Harvard. And she was sharing how she regretted that building our anti-racist culture at the health department, we never really wrote it up. And there was so much that we did. And in not writing it up, there's potentially so much that we lost, could potentially lose. Now, thankfully, there are people on board who are able to kind of transfer the knowledge and the history, but not writing something down-- and I think that is something that's very similar to what probably are AMA and APHA history, that the people who are doing this work, they get lost in the shuffle.

Jones: And invisibilized.

Khazanchi: Yeah. No. There's so many amazing takeaways here. And I completely echo kind of what Naomi got from the conversation. I'll say what I took away is a couple of things. The first is that all the work we do, whether it's at this podcast or otherwise, is because we're standing on the shoulders of giants. There are people who have come before us. And we're privileged to have the foundation that they've set for us as the grounds for us being able to even sit with you all and have this conversation.

And the second is this passage of institutional knowledge. And I think part of that knowledge comes with acknowledging our history a little bit. So I want to jump into our next question, which is to dive deeper into the history. And as Naomi mentioned, the AMA House of Delegates just passed these massive policies in November, which declare racism as a public health threat. They denounce racial essentialism in medicine. They name police brutality as a manifestation of structural racism.

These are the AMA's words. That's powerful that it's coming from them. And the positions aim to move the organization forward. But at the same time, we still have to reflect on the AMA's past. So this is the organization that drove the Flexner Report, which caused the closure of all but two Black medical schools in the country. They excluded Black physicians from the organization entirely until the mid-20th century. They had past presidents like Dr J Marion Sims, who gained professional recognition through experimentation on enslaved Black women. So I want to ask Dr Maybank, these new positions are huge.

But what do you think about when we think about the history of the AMA, as far as what these policies mean? And in addition, recognizing that the intent of the resolutions was to go beyond what we call declarative or performative advocacy. It's not just declaring racism a public health threat, it's acting upon it. So how do we sustain these movements as we move towards the practice of anti-racism and move past these brief snapshots in time towards those resources and change and operationalized decisions that actually help the people who are impacted by these inequities?

Maybank: Right. Thanks, Rohan. So first, I have to acknowledge the power of the med students of the American Medical Association. You all have just the right analysis to do this justice work at this moment in time. I have to acknowledge Rohan. He's not giving himself credit for this. And a lot of this is strategy, right? It's inside-outside strategy to help push these things forward. But it is the med student's action that drafted these anti-racism policies along with the minority affairs section. So those are the shoulders that I stand on, as well, just so that you know that. You all are powerful. You all are doing it. And it just inspires me to kind of stay in the space and to do this work.

When people have skepticism, oftentimes, about AMA's commitment to really do equity work, but even more specifically, anti-racism work. And so I always talk about the med students, and what they've done, and what you all have led over the last couple of years. So I want you all to really own that and sit with that in the power in that. And so to the question, I really believe that it's already been mentioned that no set of commitments to anti-racist can really begin without an honest assessment of our institution's own history and really present practices, as well. And for those who are not fully familiar, Rohan just mentioned several of the kind of atrocities and harms that AMA has put forward. But there were times where we declined to embrace a policy even on non-discrimination. And I think what's important to also mention about the exclusion of Black physicians, as it relates to memberships, was also tied to receiving privileges in hospitals. At that time, medical societies were very responsible for providing license and acceptance and approval to work at a hospital. So you can imagine if Black physicians can't be members, they can't work in the hospital. They can't support their families. And how do they support their community? So there's just tremendous exclusion and harm at a large scale.

There was also the time when they listed Black physicians as colored in its national physician directory and was really slow to remove the designation, even after the National Medical Association, which was created because AMA excluded Black physicians, and the mention of the Flexner Report. And then the AMA was silent in the debate over the Civil Rights Act of 1964, and put off repeated NMA requests to support efforts to amend what was known as the Hill-Burton Act, or what is known as the Hill-Burton Act, that had a separate but equal provision. And this allowed for the construction of segregated hospital facilities with federal funds, which is very much connected to the passage of Medicare. So there's a great documentary also by Barbara Bernie on this that really tells the story. So in listening to physicians across the country and their experiences with AMA, even in this present day in local medical societies, I'm convinced, absolutely convinced that there is way more, in terms of kind of exclusion and potential harm just based on the stories.

And I think this truth searching and telling has really only just begun for us as the AMA. It is critical work for our journey on truth, reconciliation, racial healing, transformation, dare I say, remediation, and reparations, but I think I just wanted to set that foundation really first. Specifically to the policies in our journey and doing anti-racism work, again, I'm going to contextualize in history because I just think it's important. I think it's important for validation, again, of the folks who have been led--who have been leading this work. And AMA did start to do racial justice work in the early 2000s. Our AMA president at that time, Ellen Nelson, was actually one of the three co-editors of unequal treatment in 2003. I never knew that until I came to AMA. Brian Smedley, who was one of the other co-authors, is the one who told me that. We did start the commission to end healthcare disparities.

And then in 2006, there was lots of intention by our ethics department to convene an independent panel of experts to really do a deep dive into the racist pasts of American medical organizations overall, and specifically with Black physicians. And this was done in partnership with NMA. So there are two papers that are published that everybody could have access to in the Journal of National Medical Association that really describe the two watershed moments that helped institutionalize racism in this country. And we've already mentioned the denial of physicians and the closure of the five of the seven Black med schools. And then as a result of all that was learned during that time, in 2008-- and I think what's also important to contextualize is what was happening in our country in 2008. Obama was elected president. And we had our first Black president at the American Medical Association. And he delivered an apology on behalf of the American Medical Association at NMA's National Convention. And the AMA pledged "to do everything in our power to right the wrongs," and that our apology was the first step toward healing and recognition.

So I see these policies as connected to that history. Their passage is undeniably historic for the AMA in the field of medicine, whether or not people think AMA is relevant or not. It still has a lot of power to influence. Even in light of its racist past, I see it. And we see large-- yesterday, New York City health and hospitals, the largest public health care hospital in the country--system in the country, declared racism as a public health threat. And in their opening line, gave a nod to the AMA. So it just allows me to really see the influence of how this public messaging, this public declarative, even though we know it's not sufficient enough, but it is important enough to inspire others to do the same thing. And so this is part of that arc of the work that we're doing. And this will build our foundation and get us on the path of figuring out what is that work to disrupt, dismantle, reimagine, redesign via anti-racist practice. But we're in its very infant stage.

Nolen: Yeah. Well, we're just in here in amazement and listening to these amazing scholars talk about the work that they're doing. And you all are such an inspiration to so many of us. And all of these nuggets that you're leaving us with, we appreciate. And I hope that our listeners are taking notes because this is definitely an important conversation. And I think that as we sit back and listen, I hear a lot about how--Dr Jones, we talked about how much it was important for you to do work that could continue even if you weren't physically here. And I think that you've continued to do that with your work as a Radcliffe fellow and also your allegories that are all over the place. People are always talking to me about your allegories. And they've been shown in my classes and so many across the country. And, Dr Maybank, the work that you're doing, as well-- I'm wondering, how do we make sure that all of the work that we're doing is work that will outlive us, and work that will continue even after we're not physically in these spaces, so that it can be sustainable?

Jones: So for those of us who are older, we need to actively reach to younger people. We need to be actively seeking to mentor folks. So that means making ourselves available. Not that I pick out my mentees, but to say, young people, if you're interested in this, I'm available. And I want to support that work. I also have been struggling-- when I define racism as a system of structuring opportunity and of assigning value, it has two things that it's doing. I have sometimes wondered, if we had to choose which to address first, the opportunity structures or the value assignment, where would we go first? And my answer to that is that we need to dismantle the structures. Because if we did the other thing about the values, we could cleanse everybody's minds, hearts, souls, right? But if the structures remain in place that don't require an identifiable perpetrator, and will continue to differentially give people education, housing, all of that, clean environment, all of that, then we would not have succeeded.

On the other hand, when we address the structures first, what if the values stuff still is passed down from one generation to the other, the devaluation of Black and brown and indigenous life, what if that-- so what we need to do is address the structures and interrupt the transmission of negative values. So to that, and getting back to your question, LaSh, and alluding to my allegories, I actually have just now maybe 5 or 6 allegories in the public domain, but I have about 20 or 30 on my computer. And part of the work is-- of my work is going to be turning each of these allegories into a separate children's book.

Because I think that we need to address how we transmit values to the children, or how we instill new values into the children. So you guys are past children. But we need to get to the children, picture book children. We need to equip parents and librarians and teachers with tools to help children understand the existence of systems of structured inequity, not just across race, but across many [inaudible] of inequity to understand what does collective action look like, that systems do exist, how do we keep understanding our history not just as a background, but to guide our movement forward? So there's so many important stories there. So I think that that is our work. I know that I went past your question, LaSh, and around it. And I hope that I hit it.

Nolen: That is okay. I'm just thinking about how I need this collection from my kids and from my nephew, everybody.

Maybank: Well, I was thinking the collection for myself. Dr Jones is getting to the root causes, right, in terms of that process. What I will say at kind of the institutional level and, like I said, I have to think very strategically. Because oftentimes, I've been in a political environment, big P political, and little P, as well. And when I think about sustaining the moment and the movement, the reality is that we have to act quickly and strategically and operate with a sense of urgency.

I have experienced, and I see when leadership changes, it's removed. These doors of opportunity can close just as quickly as they have opened. And unless we have really pushed hard and quickly found ways that you actually do embed into institutional culture and practice and policy, it's going to go away. It absolutely will go away. And I've seen it. I've seen it where kind of superficial work, light touch work, just doesn't exist anymore. But the work that really embeds it in the culture, in practice, and policy, and it's really my experience in New York City Department of Health, it was a rocky road.

It's not easy to do this work. When you start to agitate culture and people, there's a lot that happens that you have to be able to manage and work through. But if you can get over that hump, and you have leadership that's going to be present and hold the process and people accountable, then you can really start to think about and really see and experience sustainability. And I will say, even at New York City Department of Health, it hasn't--I use it because it's I think the shining moment that I've had in my experience. But it hasn't died out, and it actually has strengthened. And now, they have a chief equity officer who's a first deputy commissioner, and that's impacted what they're doing across the city and ensuring that there are equity folks in other departments across the city.

So I think just really operating with a sense of urgency. There's a nuance to this, though, because I often get asked, so what do we have to do to keep that sense of urgency, right? And I think that's a hard question for me. Because I'm like, "Who's the we? Who's the we in this?" I feel as somebody who's Black or brown. I have the experience. I have family, friends. It's me. I'm four times more likely to die at childbirth as a Black woman. That urgency is built into who we are. And so the fight for justice for the majority of people who are experiencing injustice would never think to ask themselves a question about how do we keep the sense of urgency. There's no question for most of us who are of color or marginalized that this work is-- it's life and death. It's urgent, but it's life and death. And I think this is a question for white physicians and leaders oftentimes, who have a greater place in power and privilege.

And what will they do to keep that sense of urgency and consistently hold themselves accountable to the people and the systems that they're working on behalf? That's the critical part of the change and transformation and sustainability oftentimes now. Because that's what our data shows. They are in power. And so this work, as I am now at the AMA, I agree with Dr Jones clearly on many things. I've learned from Dr Jones that there are the technical pieces of doing this work. There are the value pieces of doing this work that are important. And tied to that value, I really believe in order to move at an institutional level, as you're in the nitty-gritty of doing this work, you have to get to the heart. You have to share those stories. And so more recently, I would say, now being at AMA, I am way more expressive, honestly, in my feelings, because what I have noticed is that is what causes people to pause. They may not want to hear it. And white dominant culture is usually not ready for that. And right now, I'm kind of protected. I get it could be risky for people to do that, or there's a feeling that there's a risk to do that. But I really believe that you have to get to that story part. You have to get to somebody's heart for them to feel and see the emotion of what it does to us, to somebody in terms of harm.

Jones: There's also the piece of the message, I think, that we need to lift up, that racism is not just unfairly disadvantaging some individuals and communities and unfairly advantaging other individuals and communities. Because there's always that thing. But that racism is sapping the strength of the whole society. It's sapping the strength of the whole society through the waste of human resources, how it divides people one from another, and even divide some people from their own interests. And so I have a challenge for all of us, especially the younger ones of us who have more time on the planet, we hope. And that is, how do we lift up the truth that racism is actually sapping the strength of the whole society. So it doesn't just take a white leader to feel the sense of urgency that is in the lives of those of us who are of color, but that they understand that this is their struggle, too. In other words, it's getting us to like, are we asking for feeling allies?

Maybank: No.

Jones: Or are we asking patriots? Are we asking for co-conspirators, people, fellows in the struggle, recognizing that this is all of our struggle and the white people who were like, "Oh. Well, I don't know if I should go into the Black community to talk about anti-racism". Well, no, you don't have to there. Go into the white community. Go into the boardrooms. Go into your faculty meetings and talk about anti-racism. So I just want to--I don't actually know. I don't have the perfect allegory yet to communicate clearly how racism saps the strength of the whole society through the waste of human resources. We see it all the time. But in terms of that story piece, I am still looking for that. But then we also need some data collection around that, and we need media stories around that. And we need more conversations around our dinner tables around that, so more people will be filled with a sense of urgency to dismantle the system and put in its place a system in which all people can know and develop to their full potentials. One concrete thing that people can do is try to burst through the air bubbles of experience to experience our common humanity on the other side of town, to experience the fact that there are people just as kind, funny, generous, hardworking, smart as we are, who live on the other side of town.

Fields: Absolutely. I am just so grateful for this back and forth and this exchange that we were able to just have. And I feel like these ideas are really building on each other. I think, as a means of transitioning to the next question, I've heard--of course, we have, Dr Jones, your definition that racism structures opportunities and assigns value and the prioritization of restructuring opportunities. I think what I heard from listening to the two of you is that we have to do that with an eye to--or not even an eye to, but really active integration of reconfiguring what value is as we are restructuring these systems. Because otherwise, sort of, Dr Maybank, as you said, someone will leave after something has been restructured.

And then you'll still have a system that is unfairly valuing other people-- unfairly devaluing other people, sorry, and just sapping all of our strength. And so I think going off of that, we're definitely at a point where we recognize that this work requires, not only consciousness-raising, but really embodying frameworks and turning paradigms into practices, which I think we've been touching on these past 45 minutes or so. And so we wanted to ask about how interventions across different levels can really help to build an actively anti-racist healthcare system. So I think just thinking about the grassroots level and then sort of governmentally because we've talked a good deal about healthcare systems so far, Dr Jones, I think we can start with you. What might building an anti-racist US healthcare system look like on a grassroots level in a way that we're doing this movement alongside and in stride with our communities? And then how can we prioritize an agenda of racial justice and health equity on a governmental level? And even what might that look like to prioritize these interests in our coming administration?

Jones: Wow. So that's just a tiny question. Oh. My God. It's a huge question. So it made me think of two things that I'll put into our pot for consideration. And then I look forward to what Dr Maybank thinks. So one is a model of healthcare. You ask, how can we do it at the grassroots? But this is a model of healthcare where grassroots are included. So this is community-oriented primary care as a way of delivering healthcare. That's an old model that was developed in the 1950s by Sidney and Emily Kark-- Kark, K-A-R-K, in Pholela Township in South Africa. They were Israelis. But it was brought here. And basically, what it is, is a model where a health facility takes responsibility for the health and well-being of a geographically-defined community, so not only wanting to provide excellent healthcare to those who present to the door, but also addressing unmet and even unrecognized need. The premise of it is that the health entity is in strong partnership with the community, with community leaders. And it's almost like the health facility has taken the community as a patient.

So in the same way that you have to have-- somebody comes in. They have a chief complaint. Well, talking to community leaders, what are the main problems here? Not just health problems, but maybe the main problem is that police officers are killing our children, right? Or the main problem is we don't have street lights. Or the main problem is that we live in a so-called sacrifice zone. And the EPA, the Environmental Protection Agency, knows that this industry is polluting us and not doing anything to help us or whatever. But identifying the problems. And then doing a differential diagnosis and all of that with the community. The strong investment in and listening to community, and usually, these models involve the hiring, training, and deployment of community health workers, right? Not as patient navigators, so that you have an asthma community health worker, and then you have a prenatal care. No.

These are people who are really--they might be paid, should be paid by the health facility, but based in the community to be around a community building--they might do home visits and assessment and follow-up and that kind of thing. But they might be about community organizing. They might be about tenant organizing. They might be about bringing resources to the community. Anyway, this model, which has health center and community in partnership, responsibility for the health and well-being of a geographically-defined community, hiring, training, and deployment of community health workers, investing in the education and in the incomes of people in the community is a model that if we divided the whole nation up into places where nobody--because if it's geographically-based, there's nobody who can fall through the cracks that we have when we have health maintenance organizations or whatever. They also consider themselves to be population-based. But there are lots of cracks there. Then this is a way that we could structure healthcare there. It could even be very much like the Cuban nurse-physician partnership, where they're four square blocks and all of that.

The second innovation, I would say, is who is in the health workforce, right? And right now, we think about pipelines and leaky pipelines or whatever, digging into pre-K to start the pipeline and all of that. I think that we could reconfigure our health workforce education to be what I call a pyramid with hairs. What do I mean by that? Right now, if you want to be a doctor, pretty much you should have started thinking about you wanted to be a doctor by eighth grade. I mean, that's even late, right? But what if we had after high school, anybody who thought they wanted to do anything in healthcare could enter this school, this medical--but it's also nursing. It's also pharmacy. It's also health care. It's also community health worker school.

Enter everybody after high school who wants anything in healthcare. The first year, they get the same curriculum. If something happens in your life, and then you have to leave after that first year, say you have a baby or you have to take care of your parents or whatever, maybe you leave as a community health worker. But when you decide you want to come back, 2 years later, 5 years later, 10 years later, you come back in the second year, right? And then if you decide to leave after 2 years and maybe whatever, mid-nursing, then after 3 years, 4 years, at some point, then you're going to have to decide if you're going to keep going higher and higher, in terms of the amount of schooling. Are you going to be a nurse or a doctor or a pharmacist or whatever? That's when you start getting the hairs.

But what this does is it means that you can become a doctor without having to know from when you were 5 years old, you wanted to be a doctor. You could become a nurse without having to know that or a pharmacist. It also means that you will have trained with all the other people who will be in your healthcare team, and you will have respect for those people because those were your classmates. And it does. And it's a flexible way of accessing and entering the health workforce.

Maybank: I totally agree in terms of the geographic opportunity at the neighborhood level. And just to kind of bring that home, my work at the New York City Department of Health was to oversee our local offices of health in communities across New York City that had the worst health outcomes.

And so, again, under the leadership of Dr Bassett, we actually reimagined the neighborhood health center movement that started in the early 1900s, post-World World--one of the World Wars, and where the Red Cross made the theme at that time, I would say. And the Red Cross is actually very much a part of doing this kind of post-disaster work. And we see it happen now. In times of disaster, we break down structures. We find ways to coordinate optimally. But then when the disaster is over, we go back into our silos of operation.

And so the vision was, how do we keep that structure at a neighborhood level, where we have this ultimate kind of coordination with community folks and those living in neighborhoods, the city agencies, the healthcare organizations, continually planning and coordinating with the goal of achieving optimal health for the neighborhood. And so when I was at the Health Department, we launched what they were called Neighborhood Health Action Centers, and it was reimagining that movement. The greatest barrier to being able to have that be sustainable and to really reach the vision of its potential was the lack of funding. And the lack of funding because oftentimes, many Americans and many politicians understanding of health really is just rooted about the healthcare system. It's about health services, not understanding that all of these things outside of the walls of the doctor's office are very important and critical to, not only having and working well, but engaging with in order to achieve optimal health for the patient and the individual.

So the barrier around what people's understanding of what is health and what creates health was critical. And I think that's somewhere where we need to move forward. And I've heard you mention this too, Dr Jones, about how we help support this broader framing, about what creates health. And physicians play a huge role in it.

Physicians have been trained on basic and clinical science. There are huge gaps in our education. We have a lot of power. So that narrative has over-- it has taken over, I think, historically because of the power that we hold around healthcare being health, and not this broader context that many people in public health and etc. have been shouting really for a long time.

And that brings me to, in terms of the government--so I would say, first one, fund these opportunities and put money behind these opportunities. That's a basic, right? That is a core component of equity, as well, right, redistribution of funds and power--of money and power. And, Dr Jones, I want you to speak more on this, because we just had this conversation before this. It's about health and equity in our policies and having that type of approach. That is not a new model. It was really developed by the World Health Organization several years ago--more than several years ago, a couple of decades ago. The idea of embedding health and understanding that education impacts health. That all policy is health policy, right? Housing impacts health.

So it should be the role of all of these agencies in government to understand the health impacts of the work that they are doing. And now, I think we're at the point of, so what is the equity in our policies, right? So it's not just health in our policies, but it's the equity in our policies. And we tried to do that at the New York City level. But in all honesty, again, because of the folk's understanding about what creates health and that being a barrier, it was really hard to push through. It's been really hard to push through in this country overall in the last couple of decades. Only certain states have really been able to kind of embody this model of health in all policies.

Jones: Yes. I think that what physicians don't recognize is that health is not created within the health sector. I mean, that's how I say it in one sentence. And this idea of individual versus community is so important. We have seen the failure of our nation to address the COVID-19 pandemic as vigorously as we could because we have been treating COVID-19 as if it were a medical care issue as opposed to a public health issue. And that shows up in how we have been approaching testing to confirm diagnosis in those who are symptomatic, as opposed to doing public health surveillance testings to assess the real-time prevalence of the virus. That is testing asymptomatic as well as symptomatic people to assess the real-time prevalence of the virus.

But we also saw it show up in terms of how we were talking about should the kids return to school? When it was more about, well, the kids don't seem to be getting so sick from this, as opposed to understanding the kids are vectors, right, in a public health approach. It has been showing up in terms of how we have been so focused on the vaccine and therapeutics, as if this was going to deliver us and not understanding the public health strategies that we needed to put in place at the individual level, in terms of mask-wearing, as well as at the community level, the government level in terms of supporting people's income so more people could safely shelter in place, or making workplaces safe and equipping bus drivers and grocery workers with full PPE and the like. And it's showing up in terms of our attitudes toward mask-wearing, where people think about the individual. "Well, I think it inhibits my freedom, and I'm not afraid of the coronavirus. And I don't like re-breathing my air," When it's not really about the individual, it's about saving others, protecting others.

So this narrow focus on the individual in our country, which has shown up as thinking of this as a medical--COVID-19, as a medical care issue and not a public health issue, has really hamstrung our control. And as much as I'm happy that we have a vaccine that's been tentatively emergency use authorized for use in this country, if that's going to be another shiny object taking us away from doing the public health things that we should have been doing all along, it makes me scared.

Khazanchi: Yeah. Dr Jones, I think that's amazing how you managed to circle back to the point you made at the beginning of the episode, which is that one of the biggest barriers to health equity in our country is the narrow focus on the individual instead of the structure. And I just want to acknowledge--I know you've talked a lot about structure and policy in this episode, and it's with good reason because you all have done such incredible work about how policy and structure are the key contributors to the how of racist systems.

But I can imagine some of our listeners--and our listeners are primarily clinicians and trainees--sitting back and saying, "I don't go to APHA meetings. I don't go to academy health conferences. I don't put policy forward at the AMA. This isn't my wheelhouse." And that reminds me of another principle that you both push us toward, which is that everybody, all healthcare providers, all physicians need to adopt intentional anti-racist practices as their mode of operating.

So I'm just curious as kind of our final question to close the episode here, if you all can illustrate for us why this is so important, why is it insufficient for only those of us who have feet in the health services space or the public health space to be attentive to anti-racism, and kind of illustrate for us what vigilance toward anti-racism might look like for individuals who don't consider themselves explicitly involved in policy or public health work, but they still hold a responsibility as health professionals and citizens. And the way that we ask this question to every one of our guests is, for our listeners who are going to take their headphones off and re-enter the clinical world tomorrow, what's one thing they can take with them and start using today?

Jones: I'll start. When I launched my national campaign against racism for the American Public Health Association, I said there were [inaudible] tasks to end racism, to ask how is racism operating here, and to organize and strategize to act. So we, as individuals, can do that. We can say the word racism. I think it's important. If we don't say that word, and if we don't call out racism, even when it happens, when we're part of a situation where, say, I'm white and a Black person next to me, and we're waiting to be served at a counter. I came up after the Black person, but the person behind the counter reaches out to serve me first, to say, "Excuse me. I think that other person was here first." To recognize what was going on, that I was, as a white person, kind of valued or seen and maybe the other person was invisibilized, and to rectify that situation in the moment.

But on the wards, when you hear people described in disparaging ways or when you see different therapies being discussed with different patients, to ask the question, "Why did that happen? Why did we say to Mrs. X this and Mrs. Y that?" Or, "Why didn't we spend more time with Mrs. Z when she had questions to ask?" Or to recognize when differential things are going on and to interrupt those, to recognize that you can have a role. And you don't have to say, "You racist so-and-so, you just did such and such." But to acknowledge, to name racism is to understand it, to see it, to develop a sensitivity to understanding when it's going on, to not have to be brought into the conversation by somebody else, but to develop your own sensitivity to understanding differential actions and differential assumptions and all of that.

The question, how is racism operating here? You should take, how is racism operating here, in my child's school? How is it operating here in my medical school? How is it operating in our society? And the way you answer that question is not just to look generally at structures, policies, practices, norms, and values, but to recognize that those things are the elements of decision-making, where structures are the who, what, when, and where of decision-making, especially who's at the table and who's not and what's on the agenda and what's not. So whenever you find yourself at a decision-making table, you need to look around first thing and ask, "Who is not here at this table who has an interest in this proceeding?"

And then your job is not just to represent their interests, but it's to actually create space to find them a way to the table. And if structures are the who, what, when, and where of the decision-making, then policies are the written how of decision-making practices, and norms, the unwritten how values or why. Well, you can ask these questions everywhere. How is racism operating in my sorority or my fraternity or in this community meeting? To take that question with you everywhere. And then the third thing to organize and strategize to act is don't feel overwhelmed. Sometimes, our narrow focus on the individual makes us think, what can I do about this system? It is too big for me. Maybe I'll start a walking group. Yeah. That's nice. Walking group is nice, but the question is wrong. It's not, what can I do? It's what can we do? And to understand the power of collective action. So join groups. Join collectivities. Start a group, right? Become part of a bigger whole. Because when we say, what can we do about it, we have the power among all of us. Each one of us is going to bring something special, something unique to the struggle. And we don't have to have it all, but we each do have a piece of it.

Maybank: And to I guess, build on because Dr Jones does the great job of the framework and kind of the vision, just to get a little bit more specific, because folks oftentimes, even in the context of doing the work before and at the AMA and putting a vision forward or a framework, there still is, "I don't know what that is. I don't know what that means." So just some other tangible opportunities are establishing performance standards that are related to structural racism and equity within your systems that you work. They can be incentivized or not, making sure you're implementing medical training and competencies that not only include awareness of racism, but how to address it, and asking questions around how is operationalizing--or how is it operating, rather.

Desegregated health care, I think this does not get talked about enough. And the two-tiered system that is in many of our countries--many of our cities, rather, and communities. We need to sound the alarm of that and look at our data and what we're doing, as it relates to people trained at the interdisciplinary nexus of medicine and the disciplines that highlight how deeply entrenched social dynamics of power and opportunity and wellness are delineated against-- I mean, across racial lines. I think tools need to be created, as Dr Jones already mentioned, that help challenge people's mental models and day-to-day decisions that may perpetuate and exacerbate racism and inequities.

And then, as we talked about really earlier in the show, is addressing the legacies of our institutional legacies, of structural racism within our clinical settings, and then advocating for our patients. Health is political. I'm a strong believer that we, as physicians, need to be a part of the political environment and conversation in order to move medicine. And I would say, in terms of the question around what's the one thing, it's related to the history part.

So when you have your group, as Dr Jones suggested, and we're operating in solidarity with one another, learn the history of your institution. Some of you, your organizations have archives. You can search through those. Find and learn from the stories of the people who have worked there in your institution and the people in the communities that you're serving, keeping the lens, again, of centering those who have been most excluded and harmed and marginalized, and then share this truth that you've learned with all the ecosystems, so that they know it. And then you can figure out collectively on how to act upon it. And I really think that history will help contribute to finding a way forward to meaningfully do anti-racism equity and justice work.

Nolen: Amazing. Amazing. Amazing. I think all of us can say that this has been a truly powerful and inspirational hour. And we want to thank you all for spending this time with us. And for our listeners, we have spoken about so much. And I think the first thing that we have to remember is that we stand on the shoulders of giants like Dr Maybank and Dr Jones. And it is so important for us to continue to acknowledge the contributions that they've made and continue to make as a way to form and create solutions as a collective, but then also to fight against erasure.

And then the second thing that we talked about is really eliminating structures of oppression as a way to fight against inter-generational oppression that could be spread from families to the next generation. So we really have to make sure that we're getting to the center of these issues. And we talked about urgency. And going back to Dr Jones, cement dust in our lungs allegory, there are some of us who have a greater sense of urgency because we're closer to that factory that's spewing out that's cement dust. So it's so important for us as a unit to realize who of those are closest to that factory. And we have to work as a unit to shut it down. So thank you so much, Dr Maybank and Dr Jones, for joining us. And thank you all for rocking once again with the Clinical Problem Solvers Anti-Racism and Medicine series. And we hope you all enjoyed this conversation.

Fields: I can't wait to go back and listen.

Khazanchi: Yeah. I know. That's what I was thinking too. I've got to get my pen out.

Jones: Thank you, Aletha, and LaSh and Naomi and Rohan.

Maybank: I'm on the verge of tears right now. When I was in my office of Minority Health Job, at Suffolk County Department of Health, there was a conference, I don't know where it was. And I'm very new. I'm totally green to doing this work. I'm new to government, all of it. And I hear Dr Jones speaking to--I definitely chase her down. And she was just completely accessible. But what I remember is just being able to talk about the challenges of doing this work in an organization. And she was at CDC at the time. And it wasn't easy for her in the CDC. And it was just that instant knowing that somebody out there knows exactly what I'm going through. And so these conversations are so helpful, so validating, so comforting, and so important for us to be able to progress and just continue to do this work. So just you all providing the space for this to happen, not only for yourselves and the listeners, but even for myself to be able to connect with Dr Jones and be in communication and conversation more deeply, it's just truly powerful and meaningful.

Jones: And I just have to say on my side, I feel like there's a generation of mentees and then a generation of their mentees. And I'm just so grateful to still be connected as part of that flow of energy and flow of knowledge.

Audio Information

© Copyright 2022 The Clinical Problem Solvers, Inc. All rights reserved.

Disclaimer: The CPSolvers provides information for educational purposes only. It is not intended to be medical advice.

View show notes for each episode at https://clinicalproblemsolving.com/antiracism-in-medicine/.

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