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The History of Racism in US Health CareRoot Causes of Today's Hierarchy and Systems of Power

Learning Objectives
1. Explain how past historical practices have fueled current structural inequities in health care
2. Describe the role health care professionals have in advancing equity
3. Identify opportunities to advance equity in medicine through individual, institutional, and structural solutions
0.75 Credit CME

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Audio Transcript

Emily Cleveland-Manchanda: Hello, and welcome to the first National Health Equity Grand Rounds. I'm Emily Cleveland-Manchanda, the Director for Social Justice Education and Implementation at the American Medical Association and an emergency physician at Boston Medical Center. Today's event, The History of Racism in US Health Care, Root Causes of Today's Hierarchy and Systems of Power, is the first in the National Health Equity Grand Rounds series. These events have been developed by the Accreditation Council for Graduate Medical Education, the American Medical Association, the National Center for Interprofessional Practice and Education, and RespectAbility.

This series has been designed as a national platform for critical, complex, and urgent conversations. Throughout the series, we'll highlight the root causes of present-day health inequities by tracing the social, economic, political, geographic, and environmental forces that shape opportunity for health in the United States. And we'll present opportunities for each of us to intervene as individuals, within our institutions, and collectively through structural change. Next slide, please.

We're grateful for each of our amplification collaborators shown here who are all working to advance health equity in their communities and who brought you information about this event. Next slide. We'll begin with the land and labor acknowledgement with which all of us at the AMA's Center for Health Equity start each of our talks. We acknowledge that we are all living off the stolen ancestral lands of Indigenous peoples for thousands of years. We acknowledge the extraction of brilliance, energy, and life for labor forced upon people of African descent for more than 400 years.

We celebrate the resilience and strength that all Indigenous people and the descendants of Africa have shown in this country and worldwide. We carry our ancestors in us, and we are continually called to be better as we lead in this work. Next slide, please. We also want to note that speakers in the National Health Equity Grand Rounds series have been invited to share their individual perspectives. The views expressed are those of the speakers alone and not their organizations.

In the interest of open and respectful dialogue, the series may include speakers who may not at all times align with the official positions and policies of the collaborating organizations who created the series. We invite you today to join us with an open heart and open mind. Next slide, please. You see before you here today's learning objectives. We hope that after the session, you will be able to explain how past historical practices have fueled current structural inequities in health care, and that you'll be able to describe the role that health care professionals have in advancing equity.

We also hope that you'll be able to identify opportunities to advance equity in medicine through individual, institutional, and structural solutions. None of our speakers have any disclosures today. A few technical notes before we begin. You can submit questions using the Q&A feature, which also allows our event host to communicate directly with you. Questions that you submit will not, however, be visible to other audience members. If you need any guidance on making your screen resolution better, that will be placed in the Q&A function to the right of this viewer screen.

I now have the pleasure of introducing you to Dr William McDade and Dr Aletha Maybank. Dr McDade is the Chief Diversity, Equity, and Inclusion Officer for the Accreditation Council for Graduate Medical Education. and an adjunct professor of anesthesiology at Rush Medical College. He'll provide us with some introductory remarks. After his remarks, we'll hear from Dr Aletha Maybank, who currently serves as the chief health equity officer and senior vice president for the American Medical Association. Aletha will serve as our moderator for the remainder of the event.

2: Introductory Speaker

And I'll now turn it over to you, Bill.

William McDade: Thanks, Emily. May I have the first slide, please? So this conversation is going to be a very brief one, but I want to thank everyone in the audience for attending. I think this is going to be quite exciting and informative.

Next slide, please. So the ACGME is the group that accredits the nation's core residency and most of its fellowship programs. A physician can't be board certified in their specialty unless they've trained in an ACGME accredited residency program. We therefore touch the professional life of nearly every U.S. physician. And since we accredit the training environment for the U.S. physician workforce, in 2018, the board set forth requirements that all residency programs and partnerships with their sponsoring institutions increase diversity in their workforce and provide inclusive and equitable learning environments.

Next slide. So when we opened the office nearly four years ago at ACGME, we felt we must do something that physicians recognized. And how we do this is through equating the health and health care disparities as deficiencies in health care quality. And we think because of the work of crossing the quality chasm now over 22 years ago and that of the famous and well-read book, "Unequal Treatment" back again 22 years ago, that we can bring this voice to physicians.

We also reason that health care equity is a means to achieve the elimination of health disparities. We think that by increasing workforce diversity, we have a means to help to achieve health equity, health care equity. And then finally, we believe that inclusion is important as a tool to ensure that diversity is successful. Maybe the next slide. So why does diversity matter in the United States? Well, mostly because people in the United States live in racially segregated communities where disease burden, health and health care inequities are strongly concentrated.

We also know that people tend to seek care within their own communities and that historically marginalized practitioners tend to practice in these underserved communities serving its patients. We know that the odds are that if you're black, Latinx or Asian, that you'll disproportionately see a patient of your same race or ethnicity. Now I'll show you a slide later on that shows the percentage of historically marginalized physicians trained in the US hasn't changed much in the last 15 years. Next slide. But having people who are the same race care for you, which is referred to as racial concordance, isn't forcing people to work where they don't want to work.

It's not limiting patient access to only racially concordant physicians. It's not stopping patients from seeing the most appropriate physician. Proximity is an important factor, but not the only one. You have the physicians who are willing to work in these communities and accept governmental reimbursement, and patient choice also plays a role. Next slide, please. Why would a patient want to seek a physician of their same race and ethnicity? Well, there's been a lot of literature on this over the years, where comfort and familiarity has been shown to increase.

This is work of Neil Poe, Lisa Cooper, Janice Blanchard, so many others, that language concordance, improved communications, is actually affected that psychological and physical safety are often self by the patient, that there's increased trust and respect in concordant relationships, that there's perceived or shared worldview between the patient and physician, and also proximal locations important. And then why would a physician practice in these underserved areas? Well, we think it's because of race conscious professionalism, a concept I'll tell you about in a second, but it's a sense of doing societal good, recognizing your unique role as a minoritized physician.

You identify with the population, there's a sense of belongingness. but then there's also the harsh reality of exclusion from markets by such things as discrimination, racism, or elitism. Next slide. This race-conscious professionalism was an idea that was put forth in academic medicine several years ago, and it really describes a process by which black professionals attempt to navigate the competing demands of professionalism, racial obligations, and personal integrity. Papers on the left side by Wilkins and Brown suggest that when black and Latinx individuals lead one city and settle in another community and settle in another city, they often settle in communities that have very similar demographics from where they came.

Next slide. But this isn't a new idea. This is the infamous or famous, this case may be, Flexner Report from 1910 in which Abraham Flexner, commissioned by the Carnegie Foundation and the American Medical Association's Council on Medical Education, published this book that really discussed the medical school educational process that was to impact the United States education for the next hundred years and more.

In chapter 14, Medical Education in the Negro, it speaks to why it's important to train Negro physicians. And at the time of the Flexner Report, there were seven predominantly African-American medical schools that was reduced to two afterwards. And those two medical schools, Howard and the Harry, were still in existence today. And when I was a first year medical student back in 1980, 50% of all black doctors graduated from either of those two schools. The rationale for training black physicians was to ensure that there would be a physician mass to take care of a population that would probably be untreated by white physicians, were that to be the case.

And so in order to prevent the white population from being infected by contagions from the African-American population, it was necessary to train physicians who would be at least hygienists, if not surgeons, in order to better care for them. Next slide. There's a fundamental problem or hazard in depending on racially concordant care to eliminate health disparities. And that's all the things on the right side, which we now commonly refer to as the social determinants of health.

And those things that Daniel Dawes, our colleague now at Meharry, discusses in his book, The Political Determinants of Health, which talks about how policies, politics, practices, regulations, and laws have impaired access to care for those who are in minoritized groups. And the final slide, it is the idea that, next slide, is that we just not graduated enough Black, Latinx, and Indigenous physicians over the last 40 years to satisfy a demand for concordant care. And so we can't depend on it, which is why all physicians must learn to embrace cultural humility, a concept that Nellie Turblan and Jan Murray Garcia brought for in the late '90s, which really speaks to the idea of subjugating your own personal dominant cultural views in favor of listening to your patients and developing a lifelong practice of understanding and learning, as opposed to thinking that you've achieved the competence in that particular race.

What I show you on the right side are the percentages in green for African Americans who are in graduate medical education. And you'll see that that number back in 2004, 2005 was 4.9%, and it has not budged from that in the ensuing now 17 years. Same thing is true for Latinx individuals, increased marginally over that period of time, but not very much. And the final slide. Health inequities just don't happen. The past is prologue.

What we now have is a system that was designed to create the results it's obtained. And right now, we're creating the history of the future. So I'm very excited to hear our colleagues' opinion about how racism and the history of racism in our country impacts the health care that we deliver and teach in our programs today. Dr Maybank.

3: Introductory Speaker

Aletha Maybank: Thanks, Bill. Really appreciate your voice and your leadership over these last couple of years and just really honored to be a part of this first of four sessions in the National Grand Rounds and to be with all these partners that have been mentioned earlier. To really build on what Bill has said, you know, our science and evidence, it shows us repeatedly that there are differences in health and inequities that exist that are within the context of race and ethnicity in this country and that evidence really pointing to the root cause of being racism at all levels that are embedded into our policies and our systems and our culture and the mental models that we hold as individuals.

And, you know, Kamara Jones and Dr Kamara Jones, who many of us know for her leadership, you know, really speaks to system, racism as a system of power and oppression that assigns value. and disadvantages those who are identified as black or of color and advantages those who are white. And it also structures opportunity and basically saps really society of its full potential and energy. And it's completely fueled by the myth that there exists a hierarchy of human value that's based on skin color with the political and social designation that white is on top.

And so it's this fuel in the system that really shortens the lives of individuals communities that we are all serving across the lifespan and across generations. And they were created really to also persevere, I think, to this point at this time. And I think important to and really aligned with what Bill just said, you know, it's the result of decisions made by people within institutions over generations and at this current time. And this is not about, you know, only understanding the intention of people.

A lot of folks will say they have good intention, but it's the impact of decisions. that are made that could be helpful or harmful. And so to really better understand these impacts of the decisions that are made. So a decision that Bill just elevated as a related to the recommendations provided that led to five of the seven black med schools to shut down or three of the women med schools to shut down during that time as a result of the Flexner Report, what are the impact of the decisions? And we can see that the lack of diversity within the physician community as it relates to race and ethnicity is one of those impacts.

So we have to really look at our past rather, and future, but our past and excavate and reimagine our deep past so that not to make sure or to make sure that we do not repeat it and to really understand kind of the errors in the context of what many of those decisions were made and why they were made. And so, you know, in this work, I don't really feel like any institution can move forward and make real commitments to equity and justice anti-racism without looking at their past.

AMA is founded in 1847, really began its journey in truth and reconciliation in the early 2000s. And it was sparked by the report that also Bill elevated by then the Institute of Medicine, now the National Academy of Medicine, Unequal Treatment, of which actually one of the former presidents of AMA was a co-editor along with Brian Smedley and Adrian Smith. And in partnership with AMA, that we, in NMA, rather, we developed a writing group that examined the contributions and the historical roots of the racial divide in medical institutions as they referred to it at that time.

And Ms. Harriet Washington, who you were going to hear from in a little while, was among some of the other preeminent ethicists and historians that were engaged in doing this work for us as the AMA. And it led to the next slide, please. Their findings actually led to the 2008 apology to the National Medical Association, NMA as I referred to before, as a national medical association that was created because black physicians really had difficulty becoming members of, excuse me, of AMA.

And it was part of a policy environment here. And so this was provided by Ron Davis, Dr Ron Davis, who was then the past president in 2008. And while AMA was working with others in organized medicine at the time to collectively really understand disparities, there really was little to no explicit intention further regarding truth and reconciliation efforts as was outlined in this apology. And then in 2018, the AMA House of Delegates passed policy for the AMA to actually develop an organizational unit, which became the Center for Health Equity, to facilitate a process to embed equity throughout the entire AMA enterprise and to develop a strategic plan on how this was going to be done.

And so the center launched in 2019. Next slide. And so we know in 2020, all that kind of happened within our kind of global society really, and the impacts of decisions that were made in many of our cities across and countries across the world. But we're all very well aware of the far-reaching realities that propelled and shaped our efforts of racial justice, one being COVID and the other being the public murder of George Floyd.

And in that summer of 2020, as many organizations did, AMA Board made a pledge similar, again, to many others, and then followed that, I think more importantly, or equally importantly, in the fall, thanks to the leadership of our med students and our minority students and our student section, our mind and our day affairs section, three policies were passed and anti-racism policies were passed. Next slide. And as that was happening, I also feel the critical consciousness of our leaders within AMA and I really look to and really thankful for the leadership of Dr.

Jim Madera, who's a CEO and my boss, you know, who after reading the piece that I mentioned earlier, that was a collaborative NMA and AMA on what's happening within medicine and the divide. He didn't realize until he read that piece the explicit nature and role that Nathan Davis considered the father of AMA had in the exclusion of black physicians and really took it upon himself to have the bust of his, his bust removed from visibility in the floors of AMA and moved to the archives.

Next. And so the policies really helped that I mentioned earlier create this space and door that we really needed as AMA to ensure that we were able to approach this work and really have a strategy around fostering pathways for truth reconciliation and healing for AMA's past. Next. And since then, the AMA has also passed many policies as it relates to equity and other anti-racism efforts, but specifically to the space of restorative justice.

As was mentioned, we passed policy as it related to acknowledging the harms of the Flexner Report, but also being active and working towards creating a committee of sorts to help look more comprehensively into our past. We've come a long way, but clearly much, much further way to go to really fully affirm the truths of those who are often made invisible and not valued. It's not easy, probably outright exhausting that many of us would say, but to see a path forward, as Ida B.

Wells would say and has expressed, to right the wrongs of the past, we have to shine the light of truth upon them. Next. And I get during even this conversation and other conversations as are moving forward and our partners and we've all kind of spoken a lot about this. People may be uncomfortable. Some may be in disagreement or denial that equity is existing in their work as health institutions. But I always value this quote by Isabel Wilkerson that I'm not going to go through because I want to make sure we move forward.

But she wrote this powerful quote in The Origins of Our Discontent. and really saying that this is the house that we have and we have to work within the context of this house and what has been dealt with us, dealt for us and with us, I guess. Next. So now I have the amazing honor of introducing our keynote speaker, Harriet Washington, who will discuss the work that she's led, the pioneering work that she's led.

I have known Harriet for actually the span of my entire career. And I'm always just blessed and honored that she's able to impart her knowledge and wisdom and brilliance upon us. She's an award-winning science writer and ethicist who has authored books such as "A Medical Apartheid," which many of us have heard of, "Carte Blanche," and she'll probably talk about that, and "The Terrible Thing to Waste." She has lots of experience across different universities, academic centers, and she's won many awards.

So with that, I would love to turn it over to Ms Harriet Washington.

4: Featured Speaker

Harriet Washington: Thank you so much, Aletha, and thank you so much for inviting me to share with you what I have learned about history of medicine and the very efficient way in which the history of African Americans in medicine has been elided from the history of medicine. Next slide, please. It's really important we all know this, but it's important to be reminded that although we are taught, certainly I was taught, that science and history are two ways of knowing that are privileged.

It's a scientific fact, one can't argue with it. It's historical fact, it can't be denied. But we know better, we know the truth is that both science and history are recorded by human beings, human beings who are flawed, human beings with agendas, with biases, with political principles, that result in the elision of some people's history. Churchill said it best, "History is written by the victors." And that's why we now have to deal with the fact that our history is in dire need of revision, of correction, in order for us to eliminate this problem that as we've just learned, we've all inherited.

Next slide, please. I want to point out some really basic facts about the medical exploitation of African Americans. It's not that medical research are especially venous people, venal people. There tend to be people who are idealistic who want to help others. That's why they began this work. But the reality is that medicine mirrors the larger society. And in our larger society, for a very long time, enslavement was a law of the land. During that time, medical enslavement was not only common, but was actually the conventional mode of advancing medical science.

While segregation was a law of the land in this country, we had medical segregation, which is not completely ended, of course. And now the disparate access still haunt so many areas of American life. Despite great strides, we now have medical disparate access, which is driving the deaths in disproportionate illness of huge numbers of people in this country. Next slide, please. From the beginning, it's important to understand that the agenda for African Americans in medicine was different than the white agenda.

We think of the Western patient physician dyad, a relationship characterized by a strong sense of responsibility of the patient for the subject or for the patient they're caring for. Doctors had a strong sense of love and responsibility for their subjects, which drove them to care for them in painstaking manner. And patients and subjects implicitly trusted the doctor. That's a beautiful relationship, but it did not characterize African Americans' experience with medicine. It was very different.

For African Americans, it was not maintenance of health or a militarization of health that was important from the medical point of view. Medicine wanted to maintain the fit for work of African Americans. That's because that was the need of American economics. Our country, North and South, depended on a free labor force, and maintaining fitness for work was paramount. That's what doctors were paid to do. And by the way, the person who decided when a doctor would be called in, what a doctor could and could not do to the patient, and when a doctor could or could not be paid was not the patient, was not the African American.

It was a slave owner. So in every important sense, the slave owner was the patient. That was the person the doctor had to satisfy. And this had huge ramifications for African American health yesterday and today. We still have remnants of this mentality. And more to the point, it was the reason why from the very beginning, there was a state of undeclared war, or at least a destined uneasy truce between Black people and their doctors.

And although I remember when "Medical Apartheid" was published in 2007, I contended with a lot of people who just found it too difficult to believe that certain things occurred. They could not believe that doctors were intentionally advertising for sick enslaved people so they could do research on them. But the truth was right there, not only in medical journals that I took the information from, but also newspapers that would publish advertisements regularly from Doctors said, "I'm looking for sick Negroes," and being very open by the fact they wanted to experiment on them.

So yesterday's horrors were indeed real and were indeed documented quite heavily. Next slide, please. Appropriation of African-American bodies for teaching material or medical experimentation for display in clinics was the norm in this country. And we know of cases like Henry the Lax, The truth is there were thousands, if not millions, of handmade alacks in the early years of our country. I detail a lot of them, not only in Medical Apartheid, but in a later book, Deadly Monopolies.

It goes through the 1990s. This has been a very horrifying pattern in this country, and it's one that has gotten insufficient attention. Next slide, please. Appropriating the bodies of African Americans. They were not the only bodies but they've been appropriated in far greater numbers. And in the past, they were appropriated legally. There were no laws protecting enslaved people as they were protecting white people.

And so body appropriation is something that has been knit into the fabric of medicine in a very insidious manner. Next slide, please. As an aside, I want to point out that I'm not going to read all these slides to you. You can read them. And I'm trying to preserve our timeframe here. But it's really important to know these myths promulgated by African Americans that we still suffer under have been promulgated since at least the 19th century earlier.

But it was in the 19th century that science first began to edge out religion as a predominant way of knowing. Before the 19th century, you had physicians and scientists saying, just like other people. Well, we know that black people are inferior because the Bible says so, even the children of Ham. They're made to be subject to white people for their use as they see fit. But as science began to become the preeminent way of knowing, these scientists and doctors began to understand that they had to bolster these opinions with data.

And that's what they did. They collected copious amounts of data, columns and columns, huge amounts. George Morton collected 600 skulls and measured their interiors to prove that the brains of African Americans and people of color were smaller than whites and therefore they were less intelligent. Now, this data could be very impressive if you were not a scientist, but the reality is it wasn't very logical. Skull volume does not speak to intelligence.

And skull volume means little if one doesn't make it proportionate to the person's body weight. So it was not really logical, however, It fit the bill. It was a thin veneer of science that could be applied to these old mythologies about African Americans. And they were very old. The Roman physician Galen said probably in-- I forget which century, the fourth century. He claimed that African men had oversized genitalia and small brains.

This opinion could be found very frequently in the 19th century writings The beliefs encompass a great deal of information about not only the physicality, but the minds of African Americans. The invention of race, which paralleled advances in animal husbandry, was based on taxonomy. And the taxonomy was a racial taxonomy supported by the thin veneer of science, which led to biological dimorphism. The entrenched belief that African Americans differed from white people in terms of their illness, partly because their bodies were profoundly different than white's.

So different that most of these scientists of the American School of Ethnology thought that Africans and African Americans and white people belong to different species. They didn't feel pain or anxiety. They weren't intelligent. They also lacked adult judgment. They were incapable of understanding science or rationality. They were preternaturally credulous and fearful, paranoid. They were responsible for their own illnesses and conditions, either because of their profoundly different bodies or because of their profoundly inferior minds and cognition.

They were sick because they were inferior, because they were not intelligent, because their bodies were flawed in some way. They weren't sick because of the treatment by slave owners, although we know that treatment was horrific, routinely starved, beaten, ill-clothed, and not treated by doctors unless the slave owner thought he could make a profit by so doing. but the real cause of their spirit illness and early death was laid to their own bodies and their own minds. Next slide.

The American School of Ethnology, the nation's most prestigious scientists, all were in agreement about the profound difference between Black and white bodies and Black and white minds and the profound inferiority of people of color. Next slide, please. And biological dimorphism became a very common belief, not only among scientists, but doctors and scientists exerted a lot of effort to make sure that everyday people, lay people, who did not know much about science, could understand that black people were inferior by birth.

And they did this in a variety of means. One of them were circuses. White scientists actually had circuses in which they displayed the beast bodies of African Americans, bodies in which they had implanted horns and tails to show that they had more in common with the apes than they did with human beings. But also, you had a lot of scientists like Samuel Cartwright, who wrote not only for medical journals, but also for popular magazines in which they expounded at great length how inferior African Americans were.

In addition, There were scientists and thinkers in the government who produced government documents that quote unquote documented African-American inferiority. The most infamous of these is probably the census of the 1840 where John C. Calhoun, Secretary of State and former medical student, oversaw a census that produced data showing that enslaved African Americans were much healthier than free African Americans.

Free African Americans, according to the US census, were 11 times more likely to have mental illness than enslaved ones. The message was that enslavement was necessary to preserve the health of African Americans who were not able to survive without the control and guidance of white. Next slide, please. The belief in different diseases that struck black people and different immunities they enjoyed was universally accepted by American scientists, with the exception of the few Quaker scientists and African Americans who were able to obtain medical educations and scientific educations.

But most scientists thought that the diseases like hebetude, dysthesia Aethiopica, pellagra, drapetomania, these things were black diseases that only struck black people. And drapetomania was that disease, the most infamous one, evinced by African Americans who ran away. A slave in ancient Greece and Rome might run away and that's normal, but a black slave who ran away was held to be, have a psychiatric illness with a strong forensic component. I already mentioned pain, but also African Americans were held not to commit suicide.

They were not held to suffer from diseases because of their primitive neurological systems. So white people who developed syphilis could end up with tertiary syphilis, profound damage to the brain. but it was held, these doctors held that black people with syphilis would not suffer brain damage and neurological damage, they'd only suffer muscle damage. Their brains and nervous systems were too primitive to be affected by the spirochete. So again, blaming black people for their own diseases, saying that some illnesses were inherent in them, was a way of a shirking responsibility or addressing these illnesses.

Also a way of reinforcing the beliefs that they were not really sharing the species, not truly human. And pain is a really particularly evocative belief, you know, immunity to pain. What does it mean to be immune to pain? It testifies to one's lack of humanity. If you look at arguments for certain types of procedures more generally that have nothing to do with African Americans, you'll see that claim that someone does not experience pain is tantamount to denying them humanity.

Some ill-advised, I think, arguments in behalf of, to support abortion, claim that the fetus cannot feel pain, and therefore it's less of an ethical freight there. So that's one example of the way that pain is often used. And we might find it laughable that doctors from the past, next slide please, thought that black people didn't feel pain. But doctors were not only in this country, but even in England began to believe that black people did not feel pain and came with these testimonials which are completely absurd and yet were adopted.

The claim that you could amputate a black person's leg and he would hand it to you. Completely absurd. Obviously false, but doctors subscribed to this. And we might find this laughable or like the crudest type of racism, but what are we doing today? Next slide. We hold very similar beliefs. A slew of very well-conducted studies, most recently 2016, the University of Virginia, showed that half of medical student respondents believed that Black people did not feel pain the way whites do.

A good proportion of practicing doctors also think that. They had other beliefs too that were consonant with 19th century beliefs. They thought that Black people needed more radiation, that had thicker bones, thicker skins, and their treatment had to be adjusted. This is completely absurd and yet we are subscribing to it. And where on earth are our medical students learning this? You won't find it in textbooks. I hope that nobody is lecturing this. And it's my, I think it very likely that medical students are learning this on clinical floors.

As they begin their clinical years, they see routinely, black people presenting in pain and being sent away without effective medication and labeled as drug-seeking. Next slide, please. So there's no time, of course, to go through the many, many areas in which many, many reading of American medicine in which African Americans were subjected to non-therapeutic, non-consensual, abusive experimentation.

But I just want to point out there are 15 chapters in the book. Interestingly, though, there's no sphere of American medicine which African Americans were not treated this way. And yet chapter seven, the one dealing with Tuskegee, this is what one hears most often when the topic comes up of medical experimentation on African Americans. Oh, you mean Tuskegee? Because people don't know of the wide suite of abusive experimentation, many people know only of this one study, and it has been very unfortunate during the coronavirus pandemic.

Next slide, please. During the pandemic, we've heard very often that African Americans refused to accept to join clinical trials for the vaccine, refused to accept the vaccine once it was perfected and approved, and that African Americans did this because they were afraid because of the Tuskegee study. This is fiction. Clinical trial data shows that African Americans participated at 10% of the population, very close to the 13% of the population they represent, we were there in numbers, represented with the population.

So it's a fiction that we were not there for the clinical trials. It's also a fiction that Tuskegee is the reason why African Americans avoid medical experimentation, medical treatment. They avoid treatment experimentation. The 400 years of widely varied abuses in the medical system. And Thomas LaVise points this out. in painstaking reports, several of them, four or five reports he wrote around 2004 and 2005, he among other things, he showed the people who had never heard of Tuskegee were more likely to fear medical research than those who had.

This fiction somehow is promulgated still and it's, I don't know why, but I'm not actually concerned with understanding why people have done the things they've done in this arena. What I find more important is the foreseeable effect of behaviors. So when we have people claiming that African Americans are avoiding care, are avoiding research because of Tuskegee, what is the effect? Well, again, it's part of the blamed victim paradigm.

It's their fault. They're so credulous and fearful that they're avoiding the very people wanting to help them. And that's why their health profile is so deleterious. Next slide, please. It's also worth pointing out that when the Tuskegee study was being conducted and treatment was withheld from these black men in Alabama, at one point, penicillin was found to be effective against -- was found to be effective, and the question rose and was posed to Thomas Parran, Surgeon General, "Aren't we going to give these men penicillin?

Aren't we going to cure them now that we know how to treat syphilis. He said no, because the opportunity will never come again now that we have treatment. But that's not what he told researchers, that would be told the American public. What was said to the American public was, these men are afraid of medicine. They wouldn't take penicillin even if we gave it to them. This is a very long standing excuse under the guise of futility. Treatment is withheld from African Americans. This has happened repeatedly time and time again.

This is why this myth is so dangerous. Next slide, please. I'm getting very close to the end of my time, so I'm going to summarize really briefly. It's really important to understand that we still have belief in lack of disease and immunities. Next slide, please. And indeed, many of the abuses that have been chronicled through the years are things that are still occurring today.

Partly because people do not know the history, are not able to recognize an abuse, the identical one that happened, say 200 years ago. Next slide, please. And partly because people are wedded to this idea of biological dimorphism, where black people having different bodies than whites, and therefore, which would therefore justify their disparate treatment. Next slide, please. James Marion Sims is well known. He's a very typical physician who abuse African-American women by using only them to try to perfect reproductive surgery.

And a statue honoring him, one of several, sat across from the Academy of Medicine for a very long time. When I lectured at the Academy talking about James Marion Sims, a medical student jumped up and said, we ought to tear that statue down. And it took 10 years. But the women who lived in that area, mostly Black and Hispanic women, and a consortium of medical students continually assailed the Parkes Department the city, anybody who would listen, trying to get the statue removed. And finally in February 2017, it was removed.

Aletha Dr Nabel was there. Many people were there. We were very happy to see the statue removed, taken away to a cemetery where it belongs. And it's really important because honoring people who have abused others is a very good way of perpetuating that abuse. It sends a message to people who are being trained that this behavior will not be punished for this behavior, that it's acceptable.

Next slide, please. And it's something that we have to keep in mind when it comes to—next slide, please—prison research. Because prison research—next slide, please. Next slide, please. Next slide. One more. Next slide, please. Prison research has been conducted for a very long time in this country, unlike many other countries.

In 1976, J. Catt's book, "Experiences with Human Beings," noted that only two countries at that point, industrialized countries, allow research with prisons. That's because prisoners are living in an inherently coercive environment. And informed consent, in my opinion, cannot be obtained from prisoners. And yet, we conducted all kinds of abusive research with prisoners. continue to do so. Next slide, please. Next slide, please.

Prisoners are -- in Holmesburg Prison, Dr Albert Kligman ventured far beyond his specialty dermatology to use -- to do CIA research, oversaw that MK-ULTRA used administering Carare, LSD, other hallucinogenic drugs to prisoners, and I was struck by a quote from Dr Kligman. "Many of the prisoners for the first time in their lives find themselves in the role of important human beings. We say to them, 'You're important, we need you.' Once it is established, these guys will knock their brains out to please you.

The capacity to respond to love is greater than most people realize. I feel almost like a scoundrel, like Machiavelli, because of what I can do for him." That's what's called convicted out of his own mouth. Next slide, please. And Dr Kligman taught many people, including protégés, among which were doctors Howard Ryback and William Etstein, who conducted research at California prisons. Using Kligman's model, they conducted a wide swath of research -- next slide -- and were honored for it.

Next slide. What's interesting is that one of their defenses is the many honors that they have won, and they have won many honors. And this is an issue because over a gun in American history, we have honored people who have made great advances perhaps, but made them through the abuse of African Americans and other vulnerable populations. This is a very good example of that. It's something that we need to rethink in terms of our practices because the strong message we send it sends to doctors in training and to others about what is not acceptable, what will and will not be punished or stopped is very important, very strong.

It's something that gets too little consideration and I think that we need to rethink honors given to people. I'm happy to see that this is being done in some institutions. It's a very good move. Next slide. Next slide. Now, just close with this quote by Jesse Williams. "We had lunch in Philadelphia and he pointed out to me that after being used in MK Ultra experiments, he saw a change in his personality.

He became, in his opinion, a worse criminal." And the exact opposite of medicine's goal. Medicine's idealism is to cure people, to help people, to help them find not only their wellness, but their best selves. This is the exact opposite and this is why we have to be uncompromising in my opinion in ending abusive medical research. Thank you so much for listening to me.

5: Panel Discussion

Thank you so much, Harriet. I appreciate always, knowledge, I always learn something new every single time. And it's so important for us to be grounded. I talked about As I evolve in this work, I feel like I've become more radicalized, but I don't mean in the context of whatever a lot of people think about, but in the context of being rooted and rooted in history and evidence and knowledge and facts and stories that oftentimes we don't hear and we don't have knowledge of.

So I really always thank you again for everything that you've done and your leadership in this space. So I went to it, we're going to continue the conversation. I'm going to bring in our other conversationalists and I'll ask them a first question. But first we have Dr Rupa Marya, who is a physician activist, a writer, a mother, a composer. She is a professor of medicine at the University of California, San Francisco, a co-founder of the Do No Harm Coalition.

Her work sits at the nexus of climate health, racial justice, and she works to decolonize food and medicine through the organization that she founded, the Deep Medicine Circle. And Dr Marya is co-author with Raj Patel of the book, "Inflamed Deep Medicine and the Anatomy of Injustice," which is remarkable. And I've had the honor of actually writing a review for the Lancet of that book. So thank you for being here. Next, we have Dr Jack Resnick, who is the current president of AMA, as well as president and chair of the Department of Dermatology at UCSF. He became president in June 2022. And for more than 20 years, Dr Resnick has demonstrated an unwavering commitment to organized medicine, absolutely passionate about the lives and the roles of physicians and patients. The prominent spokesmen person for innovation and really also during this time of COVID and for racial justice in many different platforms and spheres and definitely a champion of a more equitable health care system.

He served as a residency director for the Derm program at UCSF and is chair of a committee that oversaw the school's modernization of the school's curriculum itself and he is professor and chair of the Department of Dermatology at UCSF and holds an appointment at the Philip Lee Institute for Health Policy Studies. And next we have Dr David Ansell, my buddy from Chicago, who is Senior Vice President of Community Health Equity at Rush University Medical Center and author of The Death Gap.

He is the Michael E. Kelly Presidential Professor of Internal Medicine and a Senior Vice President and Associate Provost for Community Health, as I mentioned, Health Equity at Rush. He is a graduate of SUNY and did his training in Chicago as well and also has served as an attending in Cook and now also, or also at one point in time was appointed as chief of the Division of General Medicine, the Internal Medicine at Cook County Hospital. So thank you all for being here.

Thank you all for your leadership. I really am fans of every single one of you and I have had very close conversations with all of you over the years. You all supported me in the work that we are doing as it relates to equity and racial justice and the center overall. So I just, I really thank you all for that because it's really essential in order to do this work. And so I would really love to hear from you any reflection or anything that stood out and hearing is part of this conversation too.

So just know you can chime in as well. So, you know, you're with us here. Anything kind of stood out to you in Harriet Washington's talk and conversation with us? Rupert, I'm going to start with you. Yes, that was a wonderful presentation, Harriet. Thank you so much. I'm also a big fan of everybody here. You know, what really struck me as I was listening to you in the heart was You know the the most common question I get from medical students right now over the last 10 years and trainees is how do you survive in a racist work environment such as you know the US medical institutions, the academic institutions and specifically the one of my favorite medical students, a brilliant neuroscientist has left medicine altogether, a black physician in the making because of the presence of people like Howard Maybach at our institution.

Because these histories have gone unexamined, because there have been no meaningful consequences for these kinds of things. So as we look into the bones of our own basements, may we have the courage to correct. And that's not going to be an easy process or a comfortable process. It's a process that really requires a lot of courage and a lot of compassion and a lot of truth telling. When you said that, the quote, "Don't let the lion tell the giraffe's story." I love that.

And what's happening right now in our country is don't even let the giraffe speak. Don't let anyone tell the giraffe's story, let alone the giraffe's friends and allies and, you know, co-conspirators. And so there's a real desire to silence these histories, to not have them be told, to not have this reckoning, which is a first step, but then from there comes restoration so that we can you know, really create the kind of culture that we need as we watch this current system, you know, heave with so much suffering in the last three years, especially, but I was very touched.

Thank you. - Thank you. Jack, do you want to share a little bit as well? - Well, thank you for having me and including me in this important conversation and thanks for your leadership, Harriet. The talk was fantastic. And I was sort of, one thing that struck me was just how easy and damaging it is to simplify the whole story of racism and medical research into the Tuskegee story. I think that was thought provoking for me.

As somebody who's firstly on an arc of learning and who doesn't have the lived experience that many others in our audience and on our panel have, I think I'm mostly just overwhelmed after a talk like this with the immense gift of teaching that so many have given me. And whether it's Terry's presentation or Alif, things that you and your team have patiently taught me over the last few years so much about additional layers of history related to systemic racism in medicine and in health and parts of the evidence base related to equity gaps that I may have been ignorant of or didn't know or the impact of words that we use but hadn't really thought about.

I'm just appreciative of that gift. Thank you. Thank you. And David? You're on mute. My favorite position. I appreciate being on the panel with everyone and I'm left reflecting about the normalization of deviance and reflecting on the fact that this idea of when you sort of have to view black experimentation or any kind of human experimentation that's done with such a plum and nonchalance.

You understand that, you know, the when we talk about whiteness or racism, it's that this idea of racial advantage and disadvantage has gotten normalized. And, you know, I hope as we get into discussion is how it's sort of normalized into the current day. It's not like that was then, and this is now. It's, you know, that was then, and we haven't overcome this. And That's the work we have to do is to not allow this to be normalized.

And that requires a huge amount of interrogation of oneself, one's institutions, and one's history. And I think, you know, this idea of acknowledgement is central to that, but we have to bring redress as well. Absolutely. And you just kind of said, well, I hope we talk about that. Do you want to kind of, since we're on you right now, do you want to just go ahead and further? Yeah, it just, you know, for me, as a white physician, I've always felt this, my parents were immigrants and their families were wiped out by the Nazis.

And sort of that the placement here in this country growing up, boy, being white is a nice place to be. This sort of acknowledgement, this positionality here. And even though, you know, my work has led me to Chicago and West Side of Chicago, I realized at some point in time that we had all normalized the situation and just said it's okay. And it required me to begin to speak about racism publicly as a leader and to talk about it in all the ways, but also to ask why didn't I speak about it before?

And I always talk about the root cause analysis I did on myself, the five whys. And well, I wasn't comfortable naming it, you know, this whole idea of acknowledgement and why wasn't I comfortable? Well, I wasn't used to talking about it. Well, why wasn't I used to talking about it? Because the people around me weren't talking about it. Well, who were the people around me? Were there all white people in leadership? And I do think it required for me, you know, that personal journey of not just observing and normalizing, but naming as the first step, because naming itself is not enough.

I mean, just acknowledge them is just the beginning. We have to really think about what does that mean in terms of the actions we have to take, you know, now, the urgency of that action as well, given the atrocities that have occurred and are still happening in many places. Absolutely, thanks for that. Jack, I'm going to turn to you. And kind of building off of story and personal story, this past year of your inauguration speech, that was in June, you shed light on your personal and longstanding commitment to racial justice and mentioned that as a 16 year old growing up in Shrewsport, Louisiana, you actually wrote an op-ed in your city's newspaper about the need to remove the Confederate monuments on the courthouse lawn.

And I think many of us, you know, I'm very big in stories and I'll talk about it a little later, but, you know, your ears kind of turn and listen in a different kind of way. And so, you know, you're no longer 16, but you are in this role as AMA president and the chair of the department at the prestigious academic medical center, have considerable power and influence. Do you remember, you know, why you felt the need to write that letter then and how has all of that really informed and inspired kind of your leadership now with institutions, you know, as a physician, but also identifying as a white man too.

Well, if I'm honest, Aletha, my understanding of racism when I wrote that letter was pretty darn unsophisticated. It certainly wasn't informed by adequate dialogue with people experiencing racism or oppression or even violence. But I was, I think, lucky to have people in my family and in my life who were opening my eyes. setting me on a path to listening and learning from those with different lived experience. And that maybe helped get me on that start.

You asked about being a white male leader. If I'm going to say anything about being a white male leader, it has to start with me acknowledging that that's a position of extraordinary privilege. In terms of being an insider, I talked in that same inaugural address about my own personal approach. And I admitted that, yes, on some level, I'm a pretty I'm pretty much an institutionalist. And I don't mean the kind that defends institutions as they are, but the kind of institutionalist who wants to use them to create change.

And I get it. Some prefer and are more drawn to the outsider approach. Some don't even have access to even choose the insider approach. And I think we need both insiders and outsiders. But for myself, I've always kind of been drawn to finding and using levers of power to confront our system's flaws because I'm lucky enough to have access to them. And I also point out in that speech that the insider approach doesn't have to be a meek or apologetic insider approach. It can be really powerful and focused and infused with purpose.

And I've been inspired by a lot of people I've seen doing those things. I guess another thing that comes up for me about being a middle-aged white guy right now, and it comes up a lot, is this question of whether to be occupying leadership roles and use my privilege as an ally versus standing aside so that others who have been marginalized can lead. And I think that's a pretty hard question these days when to lead, when to partner, when to get out of the way, and that same issue comes up whether we're talking about racial justice and health equity. It comes up when we're I'm thinking about whether it's the right thing to be a male AMA president in the post-Dobs era when access to reproductive health care is threatened and again being honest, I've not figured that out. I try to approach this with humility that I don't know all the answers I've definitely made some choices to step into some of those leadership roles because I think this is all of our work, but I Many times don't know if I'm if I'm doing the right thing by doing that or not I Appreciate that and Rupa, you know, would you And I don't think I've ever referred to myself as an institutionalist, but maybe that's what I am. And, oh, there you go, I couldn't imagine.

I wanted to know, like, what do you, you're inside of an institution, but you're an activist, you're an organizer, you do both, you know, inside and outside. And so can you just speak to that, you know, kind of role as a physician and a health professional, overall and kind of what that means in terms of being able for an institution and society to examine its past. Yeah, thank you. First of all, I just also want to say thank you for inviting me to be here in the presence of everybody here and everyone listening.

I'm speaking to you today from occupied unceded territory of Huchin, what is now called Oakland, California. And I'm grateful to all of my teachers of what we call deep medicine, which is a system of diagnosis to analyze exactly these things, how history and power are sedimenting in our bodies, in our institutions, how that's impacting our health, of our people, of our societies, and the planet itself. My great teachers are my ancestors who struggled under colonial rule in Punjab for centuries. My father, who came to this country as an immigrant and made us stop every time we encountered a reservation to talk with people about what happened in this land as opposed to what happened in our lands under the brutal impacts of colonization.

I'm grateful to Tiny Gray Garcia, Poor Magazine in Oakland, who continues to be my teacher of deep medicine, formerly unhoused mama, who has been organizing with poor people for their own solutions to homelessness, to Karina Gould, Ohlone matriarch here, who's working to get land back. So these are the people who continue to teach me about how to have health without doctors, basically. How to change structures to lead to better health outcomes for wellness of people on the planet. And the most effective ways I think are exactly what Jack just talked about, like making broad coalitions that are purposefully interdisciplinary, that are characterized by radical solidarity, building radical solidarity across class, across those things that have been dividing us through colonial capitalist structures of power, and working together to center the agendas of those most impacted by a particular issue.

So this is why strikes, labor organization, direct actions, these things are so critical to the work of structural change, whether we're talking about an institution such as medicine or whether we're talking about the petroleum industry that is, you know, making life uninhabitable on planet Earth. And so I think it's important that we really get down to rejecting the logic of the liberal project and really embracing the radical legacies of people on whose shoulders we stand.

Thank you. And you all are more than welcome again to chime in, add anything. I want to create that space and that opportunity as being on the panel. There is something I'd like to say. And forgive me, I've forgotten exactly who, probably more than one of you spoke about. It's really wrenching to me to hear about young physicians in training leaving because they don't feel, well, they don't think that they can have a voice or safely have a voice.

And when I lecture, I'm often asked by medical students, how do we speak up? I tell them, it's so important for you to speak up if you think you're seeing something wrong. It's very important, partly because you're socialized partly as physicians, but not all the way. You can still see more easily see things the way that a patient will or a subject will. And you may see things that believe it or not, your superiors with their better training and better educations may no longer be able to see.

So you've got to speak up. But how can they? It costs them a great deal. It's a dangerous thing to do. They can and will be penalized. We know that physicians with a lot of education, a lot of stature, they're punished. for speaking up sometimes. And so one thing I try to make clear to them is that there's no guarantee, but there is safety in numbers of 12 point.

I think about the physicians in London who spoke up against doing pelvic examinations on non-consenting women who are unconscious. They actually got their hospital to change the policy, but they went in en masse and asked for this. And then we had students across this country seeing this and then going to their institutions, they weren't all successful. Most women, you know, it's still happening very frequently, but some women are being spared it because they spoke up. Anyway, I think that's really important to focus on empowering students to use their voice and protecting them as much as we can.

And I would agree, students, residents, even attendings as well. David, I see you going off and on and want to say something and add to the conversation.

- Yeah, I think this idea of acknowledging racism as one of a key critical root cause of poor health is like the first, almost like the first step of actually naming and acknowledgement. But it's very critical and so many people are unable to feel comfortable speaking.

And it's across medicine. It's now it's so corporatized structure in a sense that people don't feel like they have autonomy, whether you're a student or an attending physician, frankly, in the nature of this. And so it takes courage, I think, to speak. And we've got to encourage people how to speak. It's so important that one think through about sort of what are the actions that could be taken and how do you move ahead with this both inside institutions and outside.

I think both of those parts are really important. You're talking about that dyad of the institutionalization, but also the personal piece of it. Rupa was talking about sort of the community partners. And I think both of those are critically important to move ahead. And I'd like to say as part of the reason we named racism as such a powerful cause of poor health is the same way that in malaria we have to describe the vector.

It's a vector as a social pathology among many social pathologies that actually causes biological change, causes poor health, and premature death and mortality. And for people, and I didn't learn that in medical school, I would even bet in medical school training just around the country now is probably very rare when you're looking at disease causations or mechanism of disease. People are not talking about social pathologies such as racism and other forms of systemic exclusion as causes of poor health and disease.

But we must both, we have to speak first, we have to name it, and then we have to do the hard work of mitigating and eradicating. And I think that's the that's the work whether in an institution or outside an institution. But thank you, Harriet, for your comments. - Yeah, I value that too. And I just think, were you going to say something Rupa and I cut you. No, no, no, okay. Well, I was just going to piggyback off of that, David.

That's why Raj Patel and I spent so much time developing this concept of deep medicine, that we actually have to be trained differently. Because if the pathologies are coming in from the social structures around our bodies, we need to learn how to diagnose the pathologies in those systems, whether it's capitalism, racialized capitalism, so that we can act there on the changes that need to happen. That's where the therapeutic interventions need to start happening.

So I think as we teach our medical students the importance of increasingly reductive precision medicine, we need to simultaneously teach them how to zoom out and understand, you know, why communities, how they understand why they are sick, because they're always right. And how they've understood their health agendas, what needs to be changed in order to advance health. And so that kind of work is a different kind of work that we are functionally illiterate in, in medicine and need to develop as like core curriculum.

Agreed. So, you know, and going back kind of a little bit to, and thank you for elevating that, Rupa and going back to Harriet's context of kind of it's like it's the real psychological safety, the literal safety or lack thereof that people feel within the institution to be able to have these conversations. And so, you know, in doing this work, this has in my life in one sense to kind of remind not my life, but my work to work inside institutions to help spur change.

And there are signals that begin to happen. oftentimes by leadership, whether they're really ready for this work or they're not ready for this work. And the ability for a leader to kind of speak forward in spaces that they typically don't is, I think it's a rare opportunity from my experience in doing this work and especially in the context of health care. And but when leaders do, you know, I think it's important to kind of acknowledge and offer the space to share what it was and what they led, but also how it feels.

And so I'm going to go to Jack because Jack and I, we talk a lot. And I think there's a context of leadership that in medicine, we're stats and data and, you know, the technicalities, but we are moved. We move based on what it is that we feel, how somebody made us feel, what the situation feels like, do we feel safe, do we feel loved, all of those things. And I think when we do this work at an institutional level, it's important to draw those pieces out in order to bring the fullness of our human selves.

And so, Jack, you know, over this last year, and probably the last couple of years, you've kind of embarked on a process. And I would love to kind of, you speak to that in terms of reckoning at UCSF. I feel actually pretty lucky to work at a place like UCSF and AMA as well that they're not perfect and that have complicated histories of harm, but that are sending a lot of signals to faculty and trainees and board members and others that moving forward is encouraged.

And where students and residents actually do push us really hard in wonderful ways and we see a new generation coming into medicine and we see new curricula that are actually trying to create future physicians who will go out into communities and actually do anti-racist work and fight inequities. You mentioned reckoning and I think all of our institutions that are engaged in this are doing it so much later than we could have or should have. So we deserve way less credit for doing it decades too late, but it's still really vital in order to make space for healing and transformation and to rebuild trust with communities that have truly been harmed.

In terms of how it feels, it's a little, it's tough to answer. It shouldn't be surprising. I think that the work is messy. The work is uncomfortable and you're going to encounter people who want to bury the past or skip this painful step. I get questions all the time about why the AMA or UCSF are doing the reckoning part. And at the same time, you're going to have others who hold you account for not moving fast enough. I think that's all normal and to be expected.

You know, nobody's going to throw confetti or rose petals at your feet because you're finally doing some really important reckoning work to wait. And there's no blueprint to follow, but that humility and listening are so important. And one of the things I've observed with reckoning is that, no matter on what level or what institution it is, there are parts of harmed communities that don't know about yet what you're reckoning with. And so there's a period right when you start where actually people are more upset with you because they're more aware of your past and your history.

And that's just, but that's part of the journey and it's okay. So I think Aletha at AMA under your leadership, we talk a lot about the times we've been on the wrong side of history and AMA. And some of those were mentioned by other speakers. So I won't run through them, but I do really regularly try to talk about that. And at UCSF, I've only been a department chair since September, but I've been in this institution ever since I was a medical student. And we've begun a reckoning process at UCSF related to experimentation on prisoners conducted by faculty in my department in the 60s and 70s and really try to also take a 30 000 foot view of all the broader system failures that allowed that to happen, that encouraged it even, that made it take so long to address it.

And so our vice chancellor actually created a program for historical reconciliation, the PHR that was commissioned about a year ago. And the research that they did was carried out by historians and medical anthropologists. And that team did recently release an initial report of its findings and some recommendations. And we've worked really hard to be transparent about the history of what occurred, to talk openly about how much it contradicts our ethical values, to apologize openly for the roles played by the department and our failure to investigate this for so long, and talk about how others really share blame.

Just didn't occur in a vacuum. They occurred in systems that allowed them, that rewarded them, that again prevented that reckoning. So just finally, I've been reflecting a little bit. You mentioned the apology from AMA several years ago. And Ron Davis, who actually was president at the time and spoke that apology, called it a modest first step in the healing and reconciliation process. And he wrote that acknowledging past wrongs lays a marker for understanding and tracking current and future actions.

So I guess, What I'm really focused on now is that the reckoning can't be an end unto itself. It has to be followed by actions that actually stop ongoing harms and that move the needle on equity and that affect the health of marginalized communities. Thank you for that and sharing. David, anything that you're leading up, well, I know you're leading up a lot, but anything in terms of reckoning and the work that you're doing at Rush and how it's felt for you in terms of leadership.

I'm from the generation that talked about the personal being political and you know so that's just where I come from so I want to sort of connect these two ideas for a second. You know what I had to come to as a white man is going from a point of neutrality that I'm a good person and a good doctor with, you know, this awful family history landed in this country from neutrality to accountability. That my actual presence, and Jack you mentioned in the position in this, that the actual, my ability to rise up as a human rights activist, how I identify myself, because I was a white man and my Y chromosome and my pigment allowed me to rise up into positions of power that I have a personal accountability and responsibility for the problem.

And it's well over the 50% mark in terms of what I have to do personally in this world. But our institutions also have that kind of accountability and responsibility. And when we identified, not new, the life expectancy gap outside of our door, we said we are accountable if not responsible for it, because it happened while our institution has been here for 180 years. And I'm really, and so I think that it's so important to say that and then to name why it's happened, and that's the naming of racism and other forms of oppression or afflictions like economic deprivation as a cause of poverty that causes poor health.

But I want to talk a little bit about the healing artwork of Graham Wacelea and Michelle Morse as a framework for this, because I think they give a good framework that this idea of redress, which is a little, it's more than reckoning. It's that you owe something back now to the community that's harmed, that has to be paid back. It's not reparations, but it's in that reparation frame. It's something that an institution can do, because reparations have to be national.

But what does an institution do to pay that pay that redress back and closure of this can only occur when you are relieved of that by the community that's been harmed. And if you think about this in a big way, and that's so, you know, gets to some of the ideas of, you know, Paul Farmer popularized around accompaniment and what does it mean to do accompaniment, not only personally, but bring an institution around to doing that. And so I just think that that we, at the end of the day, it's got to be framed into what actions are we going to take to provide that redress that institutions owe these communities that have been harmed.

So that's kind of my take on how do we do those next steps and it has to be, they have to be overt in concrete material and even capital. It has to be something that you can feel, touch versus an apology. An apology is good, but we have to go beyond apologies. And then in what form does that redress take? Thank you. And so, Rupa, what should institutions be doing?

What should they do to reckon, redress, reparations, the restorative justice? I think they need to compost themselves and be reimagined. I don't hold any belief that institutions that were created through white dominance and supremacy can be tweaked to become vessels for equity. I don't think we can do that. So when we're talking about redress, and thank you so much for that, David, I think it's critical that we see meaningful consequences as these things come up. And I think Harriet talked about that in a previous call that we had, that we look at who has been harmed, who is being harmed today, not just within our patients, but within our structures of low wage workers.

We were watching our cafeteria workers freaking out, being exposed to COVID because even though we had mass mandates, the cafeterias were left open. So all those people who came from communities in our institution who were suffering the hardest brunt of COVID's death rates were still being exposed. So the architecture of power is baked into medical institutions themselves. So this has to be not just a reflexive process to the communities who have been harmed by medicine, but also within the institutions itself.

And it doesn't also mean that you can just replace the white male leadership power with brown female or other gender people and hope you get a better outcome. Yes, you do see better benchmarks met when you have more people of color in positions of leadership when you're looking at racial equity. However, the structures themselves are inherently oppressive. So how do we reimagine? How do we abolish the C-suite, for example? How do we reimagine health care in the United States not to be a for-profit entity, but to be a care economy?

How do we reimagine our duties of care to each other along different frameworks? And it's critical that we engage in these creative practices because climate change is here. You know, we had raging fires here in California and now we had raging floods. We have farm workers who have no housing who are going on shooting rampages just 40 minutes south of San Francisco. So there's these dire like pressure cooker dynamics which are causing poor health. And so I think that in this process of you know reckoning and redressing we also need to maintain our creativity and know that we are you know we are you know brilliant people.

Speaking in my institution, brilliant people who are deeply committed to justice and we've inherited a framework that's inherently violent and flawed. And so what is our duty in this moment? And I think it has to involve a lot of reimagining and that's where bringing in people from other disciplines is absolutely critical. Medical doctors and the medical community cannot figure this out by ourselves. Thank you. And so we're coming to an end. So as we're reimagining, and we're imagining, how do you on, so this is going to be slightly brief, so just because we want to make sure we close on time, but how do you imagine and reimagine actually your rest and kind of your spaces, your personal spaces for rest and reflection?

This is something that I have been talking a lot about this year. I've made a cognizant to myself and to my team. Everyone got rest is resistance. as their new year gift? What do you do? And Jack, I'll start with you. - Oh, it's such a mistake to start with me on this one. - Okay. - I really haven't figured this out and I'm looking forward to learning from others.

I mean, I think for me, I signed up for a lot of this. So I actually, and the AMA piece has this one year where I really want to make the most of it. So maybe I'm not resting, but in return, But to make up for that, I have incredibly wonderful support structures, whether it's folks I work alongside on the team or friends or family. So I try to take respite in that and the support that comes from that and in lieu of rest, but I'll defer to others on the rest front.

- Got it. Well, hopefully next year is a little better, maybe, maybe. David? - Okay, well, I got a lot of love in my life and You know, I'm also inspired because my worst day is not even as close as the worst day of patients and communities that I work with. And that just gives me solace. And then I work on like big ideas. I wonder if I could put a pitch for equity.dootankdoo.com. We are doing a NAD for health institutions that want to interrogate their journey to be anti-racist institutions.

We have partnered with the Commonwealth Fund to create a scorecard, a racial equity scorecard, that can show your progress around several domains. And we're going to send out some materials afterwards so you have it. That stuff energizes me to move these ideas ahead nationally. And Rupa, rest and recovery. I spend time on farm. So we're working on a land-back project in San Mateo County called the Ticonderoga Quetin-O'odham farm.

It's 38 acres. It's beautiful. We have a whole team of farmers there growing food and giving it away to community in San Francisco. Beautiful organics and first yummy, delicious food. So I get my fingers in the dirt. I guess it's more work, but it's a kind of a work that's really restorative and beautiful working alongside people who are just trying to take care of one another and take care of the earth.

And Mrs Washington, Ms Harriet Washington, how about you? The work I do is what I love doing. I don't need any rest from it. I know it's the wrong answer, but it's the truth for me. I love it. And I feel also at this point in my life, I don't have time for rest. I'll rest when I'm dead.

I'm really having a great time doing what I do. Wonderful. Well, I just want to thank all of you for being present, being in the conversation. Again, your leadership, your vision, your heart, your ability to be humble and to connect with one another, but also to be direct and be truthful and what we need, especially at this moment in time. So just thank you all for, again, your presentation, your participation. I'm going to turn it over to Emily Manchanda for us to close out today.

6: Closing Remarks

Great. Thank you all so much for joining us for this inaugural National Health Equity Grand Rounds. We deeply appreciate the participation of each of our speakers, for all of the collaborating organizations who helped us put this together, and particularly for each of you in the audience. We hope you took away some new insights from today's discussion, and we truly appreciate all of the thoughtful questions that you submitted. Some of them we were not able to address in our conversation today, but we still appreciate them and your input.

We hope you'll join us for the second event in the National Health Equity Grand Rounds series, which will air on May 9th. It'll be called Follow the Money, Understanding the Structural Incentives for Inequity in Health Care and Beyond. In this event, we'll explore topics including leadership engagement, organizational change, and some of the other ways in which we can reimagine our system to create more health for more people. To register for the second event, you can scan this QR code here. You can also click on the link in the question and answer box on your screen, or you can scroll down on our website, healthequitygrandrounds.com, and click on the name of the second event in the upcoming events section.

Later this afternoon on this same web page, you'll see a registration button at the top of the page, in addition to a button that will allow you to claim CME credit for attending this event. If you'd like to access the recording, we'll also be sending the information out afterwards with a link to the AMA's Ed Hub website where you can view that recording. Thank you again for attending, and we look forward to seeing you again in May.

Audio Information

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Accreditation Statement: The AMA is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement: The AMA designates this Enduring Material activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


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