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On Blood and Bridges: Remembering Congressman John Lewis

I was recently reading a Time magazine article, which included previously unreported coverage of Congressman John Lewis, the Civil Rights icon, who succumbed to cancer last week. When asked why he continued to tell his story, he responded:

          …it affects me — and sometimes it brings me to tears. But I think it’s important to tell it. Maybe it will help educate or inspire other people so they too can do something, they too can make a contribution.

As history tells us, Congressman Lewis, then a 25-year-old leader of the Student Nonviolent Coordinating Committee (SNCC) and coordinator of “Freedom Rides,” helped lead a march for voting rights from Selma, Alabama towards the state capital of Montgomery over the Edmund Pettus Bridge. The protestors were met with force by the state and local police. Mr. Lewis’ skull was fractured by the strike of a club. His was just one of numerous injuries endured by protestors. This fateful day—“Bloody Sunday”—March 7, 1965, is commemorated annually. People at home watched in shock and dismay as the protestors were brutalized. The ferocity of the images pricked the consciousness of the nation and resulted in many joining the cause. Their humanity wouldn’t allow them to sit passively and watch other humans decimated.

          I gave a little blood on that bridge

Fast forward 55 years…

On March, 13, 2020, the US declared a state of emergency in response the COVID-19 pandemic. US citizens across the country were advised to shelter-in-place to slow the spread of the novel coronavirus that had invaded our shores. Away from typical distractions of work, traffic, and the hustle of everyday life that usually occupies our minds, many sat fixated on the television as we watched cases and mortality increase. Amidst this vacuum, we were confronted by shocking visuals: a video of a police officer kneeling on the neck of an unarmed black man for 8 minutes and 46 seconds. In the context of social distancing, Americans were challenged to face themselves. The reality of racial inequities in the US, previously shielded by a cognitive dissonance (e.g., “we don’t know what happened before the video”), was now proximal and palpable. We had nowhere to go. We had to sit with it. As in the 1960s, we were outraged by the inhumanity – as we should be.

As a Black woman, it’s difficult to think of a time when I wasn’t completely aware of race relations in this country. Seeing others enlightened and even corroborating the stories of injustice in the US that I have known to be true as early as middle school was encouraging. However, I’d like to challenge our comfort a bit further. The same racism that cracked the skull of a peaceful protestor and kneeled on the neck of an unarmed man is the racism that ignores a black mother’s request for medical attention, dismisses the reports of pain of a black patient with a clearly broken bone, or assumes that black bodies die sooner as a matter of biology. Racism is both the lifeblood and the heartbeat of racial disparities in health and healthcare.

Racism built the communities in which we live, the public schools we are able to attend, and the types of businesses in our neighborhoods that provide basic necessities, such as food. It built our Capitol building and the home of our nation’s chief executive. It even built our most premier educational institutions and their medical and research empires. Racism lives in our silence as much as (if not more than) it lives in violence. It quietly sits within the foundations of our institutions and leaches its contaminants into our social spaces in a way that is both proliferative and reinforcing.

So, where do we go from here? Congressman Lewis once recounted a story of hearing Dr. Martin Luther King, Jr. speak. He spoke of:

          …the “spirit of history” inviting him to take his place.

Though it may mean protesting, it may also be interpreted as taking an active role in addressing health disparities in our respective places. If you’re reading this, your place is probably in healthcare, research, policy, or in the community; if not, it could also be finance, criminal justice, human resources, or administration. Regardless of your position, everyone can and MUST make a contribution if we desire to see the best of what our society could be. As during shelter in place, if we can steady ourselves long enough, we will hear the echoes of humans in despair beckoning our individual and collective humanity to act. Together, we have to “slow the spread” of racism—a pandemic1 that stretches as far back as our nation’s earliest years.

Let’s honor Congressman Lewis. This is our bridge. Let’s be human.

 

References

  1. Williams DR and Cooper LA. COVID-19 and Health Equity—A New Kind of “Herd Immunity” JAMA. 2020;323(24): 2478-2480.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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The COVID-19 Pandemic: A Master Class in Health Inequity

In my course, Social and Economic Determinants of Health Disparities, we spend the semester discussing the complex web of factors rooted in social and economic policies that propagate disparities in health. These include education, employment, housing, broader neighborhood structures and, of course, healthcare. We also contextualize individual and interpersonal health behaviors within those structures. When news of the virus really gained steam in mainstream media, one of my students commented that this was an “inverse disparity”—that predominantly rich, white people who’d vacationed in far-off places were affected. I assured him that as data by race and ethnicity surfaced, we would find minorities bearing the brunt of the burden. Unfortunately, as data began to roll in state-by-state, my prediction was accurate. Further, I knew that this was bigger than who was or wasn’t wearing a mask in public, or of the disproportionate number of minorities with pre-existing conditions that may place them at higher risk. It is about a system that consistently favors the physical, mental, emotional, and financial health of certain sects of the population over others.

When the novel coronavirus came to the US public’s attention just months ago, very few of us expected that our lives would change as much as it has in subsequent months. There were so many uncertainties with this unique virus—its transmission, incubation period, symptoms, and appropriate treatment—that we were left whirling in unpreparedness. US culture, built on the foundational value of individual freedom, found itself at odds with the need to protect a more social interest: stopping the spread.

Our best defensive effort was to stay away from each other, or social distancing—a solution (with all of its benefits) that is fundamentally steeped in privilege. It didn’t account for an invisible, operational background of millions of people who occupy the less educated, often undervalued workforce who, ironically, have come to be regarded as “essential”. There are people who must travel on crowded buses to work elbow-to-elbow in order to feed us, sanitize spaces that we might encounter, and help maintain a semblance of normalcy. While some of those workers may view their efforts as an act of service, there is undoubtedly some life or death decision-making happening. On the one hand, they face the risk of exposure to a potentially deadly virus. On the other hand, they face the equally compelling risk of not being paid if they choose not to show up to work, or if they fall ill. For many, there is really no choice at all: the financial strain posed by the latter and its negative effects on their families is non-negotiable. So, they put themselves in harm’s way, hoping against hope that they won’t contract the virus and/or bring it home to their loved ones.

Although we’re “in this together,” we have left many of the most vulnerable to fend for themselves. They live in food deserts and now have even fewer options at their disposal than before, as those with disposable income and time stocked up on supplies. They are disconnected from accurate, timely information, which is even more important as we learn new lessons about the virus daily. For some, their experience with this pandemic can best be described as “inconvenienced,” while others don the armor of homemade masks to preserve their (and our) lives.

My students are learning the same lessons many are starting to awaken to: when systems fail, the marginalized become more marginalized. The pandemic operationalizes the very definition of “disparities” that we discussed during the first lecture. We are all seeing that “differences rooted in social disadvantages that further expose individuals to additional disadvantage” mean that those who are the least equipped with the resources to withstand a pandemic are placed at higher risk of exposure, unable to effectively employ best-practices for protection against an unpredictable virus. The novel coronavirus has set the stage for a master class in health inequity and demands that we pay attention to the socially and racially stratified patterns emerging from the COVID-19 pandemic.  Luckily, experts have provided a game plan for helping the most vulnerable. Hopefully, this experience will build our empathy towards the overlooked among us as we tackle health inequity together.

Class is in session.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Vaper Vapor

January 2020 has come and gone. Resolutions were set (and some broken). I suspect—given what we know about the effects of smoking—that somewhere among the estimated 34.2 million smokers in the US 1,2  lie a few who resolved to shake the habit. Cigarette smoking is the leading cause of preventable disease and death in the United States accounting for more than 480,000 deaths every year (about 1 in 5 deaths).1

But, What About Vaping?

In November 2019, the AHA launched its #quitlying campaign to address the youth vaping crisis. As an AHA Early Career blogger, I began to tweet (@DrAnikaLHines) what I was learning about vaping (a topic that I’ve otherwise not broached) from the 2019 Scientific Sessions:

  • From 2017 to 2019, e-cigarette use among high school students increased by 135%3 (about 25% of high school students have “vaped” in the past 30 days).3 E-cigarette use tripled among middle school students—from 3.3% to 10.5%.3
  • E-cigarette use drove a 59% increase in use of any tobacco product among high school students (from 19.6% in 2017 to 31.2% in 2018).3
  • While more research is needed, the Surgeon General has concluded that several studies show E-cigarette use is “strongly associated” with the use of other tobacco products among youth and young adults, including conventional cigarettes.3
  • Many questions remain about the long-term health effects of these products and their effectiveness in helping smokers quit.4
  • The evidence is already clear that it is unsafe for young people to use e-cigarettes or any other product containing nicotine.4
  • Some of the flavorings found in e-cigarettes have been shown to cause serious lung disease when inhaled.5

Well, fellow bloggers and I were met with backlash and cries of “vaping saved my life” and “vaping is harm reduction” and “vaping is promoted as a cessation technique in Europe” and my favorite—‘big heart, quit crying” by individual (adult) users and small retailers. As I mentioned before, I don’t research vaping, so I had no retort. I do, however, live in a department that happens to be seated in the hotbed of the tobacco discourse (Virginia) and jam-packed with researchers who have devoted their careers to cancer prevention and tobacco products. Literally! VCU has a Center for the Study of Tobacco Products. Here’s what I’ve learned about alternative tobacco products being used in Virginia (and nationally):

  1. Not every vape is created the same. The two products at the core of discussion are e-cigarette and tobacco-heated products.10 E-cigarettes are battery-powered and heat liquid usually containing nicotine in order to produce an aerosol. There’s a wide variety of designs, electrical power, levels of nicotine delivery, and flavors.10 Devices include cig-a-like, refillable tank systems, and pod mod innovations. On the other hand, heated tobacco products (also electronic), heat tobacco to produce an aerosol containing nicotine.11 (This is where tobacco giants like Phillip Morris have become involved, including their “I quit ordinary smoking” (IQOS) product approved for sale by the FDA in April 2019).10
  2. Adult and youth reasons for use differ; so, there are separate sets of issues. Adults cite quitting/reducing smoking and health reasons for using e-cigarettes. Youth attribute their vaping to their social networks (friends and family who use them) and/or the availability of flavors.6 Data from 2013 indicated that 13.1% of high school e-cigarette users had never used another tobacco product.3 E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including conventional cigarettes.3,7,8
  3. The long-term effects of alternative tobacco products in adult smokers, including e-cigarettes and heated tobacco products, remain unclear; however, preventing nicotine addiction among youth is a priority. Studies of the effectiveness of products as smoking cessation approaches are inconclusive. The Centers for Disease Control and Prevention says that e-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.4 Heated tobacco products, such as the IQOS device, have been linked to pulmonary disease and cancer, but not to the same extent as combustible products.9

Summary

We don’t know everything, but we know enough to say that vaping is not a “harmless” habit. It is not recommended for youth, young adults, pregnant women or adult non-smokers.4 Smokers who opt into e-cigarettes should know that there’s no guarantee that it will help them quit and that e-cigarettes bear their own risks of injury and mortality. E-cigarettes are not recommended as a smoking cessation aid. Further, a recent CDC study found that most adult e-cigarette users don’t stop using combustible products, but become “dual users”.11

My Take

As I see it, the biggest issue is framing vaping as harmless. More alarming, is the interplay between peer influence and attractive flavoring that draws youth into a nicotine addiction long before their brains have the capacity to make an informed decision.

Vaper vapor, indeed.

 

References

1. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States, 2019.

2. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019, 68(45);1013-1019.

3. Campaign for Tobacco-Free Kids, “Electronic Cigarettes and Youth”, November 8, 2019 / Laura Bach. Accessed at: https://www.tobaccofreekids.org/assets/factsheets/0382.pdf

4. CDC, “Electronic Cigarettes.” https://www.cdc.gov/tobacco/basic_information/e-cigarettes/.

5. HHS, E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016, p 184.

6. Tsai J, Walton K, Coleman BN, et al. Reasons for electronic cigarette use among middle and high school students – National youth tobacco survey, United States, 2016. Morb Mortal Wkly Rep. 2018;67(6):196-200. doi:10.15585/mmwr.mm6706a5

7. Barrington-Trimis, JL, et al., “E-Cigarettes and Future Cigarette Use,” Pediatrics, 138(1), published online July 2016. Wills, TA, et al., “Ecigarette use is differentially related to smoking onset among lower risk adolescents,” Tobacco Control, published online August 19, 2016.

8. Berry, KM, et al., “Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths,” JAMA Network Open, 2(2), published online February 1, 2019.

 9. Salman R, Talih S, El-Hage R, et al. Free-Base and Total Nicotine, Reactive Oxygen Species, and Carbonyl Emissions From IQOS, a Heated Tobacco Product. Nicotine Tob Res. 2019;21(9):1285-1288. doi:10.1093/ntr/nty23

10. Barnes AJ and Snell LM. Alternative Tobacco Products Use in Virginia. https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_eCig_10-19_F2.pdf

11. CDC, Electronic Cigarettes, What’s the Bottom Line? https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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On Mentorship, Leadership, Volunteerism: An Early Career Recap

Throughout my career, I’ve been coached that mentorship is the key to success. I found this to be true throughout my doctoral education, during my stint as a research consultant in industry, as a research fellow in a primarily clinical fellowship, and, now, as junior faculty. I won’t say that I’ve mastered mentorship (or being mentored), but I have been fortunate to benefit from the efforts of some of the best. Here are a few notes that I’ve found helpful in seeking meaningful connections at AHA Scientific Sessions 2019 and beyond:

1. It takes a village to raise a child (and an academic career). Similar to the diversity you would find among village members, I like to use a team-based approach to mentorship. There are different types of mentors with different functions. I’ve found that my mentors fit into at least one of three categories—having similar training and/or experience, interests, or expertise. Some fulfill 2 categories, but very rarely have my mentors matched on all three domains. I find myself as the unifying point in the center.

For example, some of my mentors have earned PhDs. They offer important advice on a career path in academia that includes teaching responsibility rather than clinical load. Other mentors are physician-scientists with shared interests in health equity and or cardiovascular disparities. Still, others may have mastered methods in an entirely different field that I hope to apply to my own. All three make a contribution to my development whether it be learning implementation science or how to manage a clinical trial or balancing the duties of an academician or just being a good person.

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2. Take your seat at the (unknown) table. Sometimes, you find the best mentors in unintended spaces. At the AHA Scientific Sessions, I had the opportunity to attend the “Lunch with Legends” session for early career scientists and trainees to interact with seasoned scientists. In the hustle of running from one end of the enormous Philadelphia Convention Center to the other, I arrived late to find that the list of legends with their bios had been removed. I was going to have to gamble. So, I selected a table where an older gentleman with a friendly face sat with a captivated audience of 3 trainees, who turned out to be one of the leading cardiologists in hypertension among African Americans. (I study hypertension in African Americans!) It seemed serendipitous that I’d landed with a senior scientist with shared interest and expertise from which I could glean.

I’ve learned that more often than not seemingly by-chance opportunities are often the most fruitful. Because I’m interested in personal narratives (see blog), I always ask senior scientists how they found their niche. Most often than not the answer is that they were moving about their work and they were offered the challenge to do something that they’d not yet done—to consider a topic that they hadn’t considered or to work with a person with a different perspective or expertise. There’s apparent synergy in the mild friction at the interface of differences that may carve out entirely new spaces.

3. Think globally, act locally. Most would recognize this quote as an environmental call to action. I would argue that it also applies to approaching volunteerism in our personal careers. In the Go Red Women in Science and Medicine Lounge, Drs. Stacy Rosen and Michelle Albert spoke about Volunteerism to Advance Your Career. One of the main take-home messages from this session (as interpreted by me) was that lending your services and expertise at local AHA chapters may build opportunities to work in larger capacities on bigger stages. As young professionals, volunteering in local efforts builds our capacity to lead in broader contexts.

Being an effective leader—of teams, of labs, of thought—is a required complement to scientific expertise to succeed in academic medicine. As it relates to points 1 and 2 above, we may also find that some of our most impactful mentors aren’t scientists at all.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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The Power of Storytelling: Where Personal and Professional Truths Meet

I’ve always been invested in lived narratives of others. Whether through a PhotoVoice project of patients with hypertension in Baltimore or people I meet in passing, I’ve never taken the presentation of a person or their behaviors at face value. As in my chosen field of inquiry—studying mechanisms underlying racial/ethnic disparities—each person I encounter presents a series of new questions providing revelation to some truth at his/her core. It’s this curiosity that has drawn me to qualitative methodologies that place the perspectives of study participants at the center of understanding their health and building sustainable interventions.

During these AHA Scientific Sessions, I’ve met people on buses, at lunch tables, or through formal mentoring sessions, who were unsurprisingly, in some way, just like me. This could be a reflection of certain similarities in personality, passion, or interest that draw individuals to a convention. Conversely, it could be that I immediately found our areas of convergence, because subtly, or even subconsciously, I was seeking it. (After all, we always like people who are like us and I like liking people—a blessing or a curse depending on who you ask). How might we envision the world to be if we each sought to find something “likeable” about the people meet—in our professional roles or otherwise? How might healthcare transform if every physician assumed they had some experience or value in common with a seemingly “different” person encountered face-to-face in clinic? What might that mean for health equity? Our stories help us to connect.

Our personal stories, as do other truths, will always find their way to the light. We can offer them up courageously, thoughtfully, and readily, or have them seep out through our conversations and actions (often inconveniently). When Dr. Harrington, President of the AHA, stood on stage after Hamilton performers and mentioned his experience as a first-generation college graduate, my heart soared, “me, too!” When he spoke of the loss of his mother, grief gently warmed my face as I was reminded of my own who succumbed to a heart attack just last year. Immediately, I felt seen. It was a connection that, on the surface, our phenotypical differences might’ve masked (see below).

dr harringtonAnika Hines

 

 

 

 

 

 

 

 

 

Of the myriad duties that we’re challenged to perform in our roles as clinicians or researchers, “seeing” other people (and being seen), is arguably one of the most important and impactful. That’s not to say we should bare our souls at every turn—that would be unwise. However, we should probably consider not guarding our personal and professional boundaries so aggressively. Authenticity in our human-to-human interactions—with patients, study participants, collaborators, mentors, and mentees—is where we all learn. The sweet spot lies where we can embrace and respect our diversity without discounting our shared human experiences.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.