racism – The Early Career Voice

Equity & Inclusion in Medicine – Part 1: my experience as a BIPOC in medical training

January 18, 2021January 15, 2021 Mary Branch, MD, MS

As someone who integrated her elementary school in Ohio (a Yeshiva), enrolled in an exclusive prep school in New England and became the first AA female in her cardiology program, I’ve spent my life analyzing how to adapt to environments in which I was different. When I enter an environment, I learn the lay of the land, identify key players, and observe interactions. I am a fourth-generation African American physician and was raised learning about my relatives’ experiences as minorities in medicine. If I, as early as age 9, could learn how to thrive in diverse environments others can too. I would like to share these experiences and make a case for diversity in cardiology. With this blog, I will help kick off the New Year with part 1 of a multiple part series that aims to define bias in medical training; openly make a case for and provide solutions towards inclusion in cardiology.

In this blog, I will review specific features that demonstrate bias, which can lead to less diversity in training programs. These are topics related to experiences in medicine that are shared by myself as well as my BIPOC and women colleagues.

Affirmative Action, The myth

There’s this assumption that BIPOC has a leg up unfairly given by Affirmative Action, and therefore are enrolled in academic programs without earning it and being unqualified. Truthfully, nepotism and ease of identifying mentors provide more opportunities than any small % quota which does not seem to translate to faculty positions. In research, at times I have had to become my own mentor to continue to propel myself forward. Without visible faculty mentors, it is difficult to envision a role in academic medicine which makes this career aspiration less likely for many BIPOC. The educational system’s balance as a whole has been skewed related to the American Caste system (consider reading Caste by Isabel Wilkerson). This affects testing metrics and exposure to certain educational experiences. However, with the right inclusion, training, and belief in someone; talented students will become great physicians and cardiologists. In fact, this idea that BIPOC is all unqualified is ironic; many of us feel we have to work twice as hard with a cool and steady temperament all the way through (think of President Obama) to get half as far. Despite strong backgrounds; I often hear colleagues make comments like: “ They are not as clinical.” I already know the race before hearing the full story. We can’t all be inept; not possible.

Double Standards/ Lack of Benefit of the Doubt

Double standards, a topic at this nation’s center as we watched different responses to the siege on Capitol Hill. In cardiology and medicine, it is not uncommon that the same errors in one person may receive a different response from leadership compared to another. One cardiologist stated that he, like many of his colleagues, inadvertently caused a coronary dissection. The response, however, was harsher than what his colleagues experienced for the same incident. One simple misunderstanding with a BIPOC resident or medical student led to unnecessary poor feedback to this resident that could have been remedied with a conversation. She was not given the benefit of the doubt like her peers would have; in fact, I don’t think the incident would have been reported at all considering how trivial it was. At times, we feel closely observed and overly scrutinized. At times by other women and BIPOC as well. Perhaps there is a “crabs in a barrel” mentality when there are so few represented in one place, this can actually create tension. What’s most difficult is, there’s less ability to be human; which is amplified when it seems as if there is not always a trustworthy authority to turn to. It may not be that one BIPOC placed in a leadership position; they may not want to rock the boat.

So we feel that we must work twice as hard; smile (wear the mask long before COVID19), with only marginal to no room for error (there is a great scene in the movie about the Tuskegee Airmen on HBO that highlights this point).

Abstract Feedback

Often we receive feedback that is very vague and abstract and seemingly more personal than constructive. It’s generally a vague comment that has one racking their brain over and over with no real tangible solution provided by the person giving the feedback; this was described in “Research: Vague Feedback Is Holding Women Back.” For example, I was once told, “You’re too confident.” How do I change my confidence? How can I be less confident, but at least somewhat self-assured? Do you see how this happens? Not too uncommonly we receive nonactionable feedback that has one racking their brain and can have an emotional impact. It’s distracting. Actionable feedback is more helpful especially if it is not something very personal and aimed more at patient care. One mentee of mine received an overall vague evaluation and marked her with critical deficiencies without good evidence. I did not want this practice to continue, and I wrote to the associate program director to describe the scenario and shared my concerns. It was determined that this evaluation was a mistake after a larger review. Imagine a situation had it stayed on her record; it could have had negative implications to her career, especially, when she is planning to pursue a selective fellowship.

Assumptions

During a medical school interview, I was asked if they should accept fewer women due to pregnancy. I was never comfortable sharing my pregnancy considering this was my first introduction. He assumed women couldn’t make these decisions, and that, affirmative action should be taken away (this was 2008; not long ago). I have also found that, before really knowing one’s interest, it is assumed a female cardiologist will pursue a career in imaging. I am often asked “ You’re doing imaging, right?” Or I’ve heard, “ she is an imager, typical.” This can impact cath scheduling if there are no fixed schedules for all fellows. In fact, scheduling is where bias can creep in ( I have heard of giving longer hours to BIPOC forcing one group of residents to threaten federal intervention.) This can be avoided with as much equal scheduling as possible (not always perfectly feasible) without assuming anything. Assumptions are not meant to be hurtful; it’s human nature. However, at times it may pigeonhole folks to roles that must end with women’s health, equity, or inclusion (exceptionally relevant roles). These folks can also have leadership roles related to other clinical interests as well.

Certainly, these may not all be unique to BIPOC and women; however, I hear similar stories over and over again, as if they are told by the same person. As we enter into a new era, I hope cardiology joins the future of progress. In parts II and III, I will answer why inclusion is important and some solutions on how to cultivate an inclusive specialty.

For this series, we will be discussing –

Part 1. My experience
Being hypnotized that I am lower in the caste system and limited. The emotion clouded my abilities and held me back from further progress. I have to prove my resume more than my colleagues every time and it’s exhausting. In research, I’ve felt like an outsider constantly having to build my own way and have been directly judged for lack of prolific publications.

Part 2. Why?
Embracing difference can help a program evolve (% diversity at Harvard ) it’s a win-win; a synergistic relationship in which we grow together. Representation matters, and to diversify the workforce will help the patients’ comfort and compliance.

Part 3. How?
Aim for a standard similar to Goldman Sachs’s 25%¹. Provide resources and assistance to BIPOC. Show up for each other. Engage ABC and uplift ; normalize discussing differences and being different. Check in with your BIPOC trainees’ wellbeings, if there are issues driven by bias speak up with your peers in a collegial way.

Reference

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774738?utm_source=twitter&utm_medium=social_jamajno&utm_term=4395647160&utm_campaign=article_alert&linkId=108893385

“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.”

Structural Racism: A Call to Action

November 15, 2020November 17, 2020 Anika Hines, PhD, MPH

If there is any silver lining to the horror that the COVID-19 pandemic has invoked, it is that this time has positioned us to take a critical look at systemic failures (or successes). Undoubtedly, the COVID-19 pandemic has magnified the institutionalized inequities that scholars have pointed to for decades as the root causes of health disparities. It is easy to point out the ways that we perceive the system has failed. It is much more sobering to consider that the system, in fact, has done exactly what it was designed to do. Rooted in structures as old as slavery and maintained by subsequent post-slavery policies aimed at maintaining white privilege well into the 20^th century, structural racism represents a stronghold in American society hundreds of years in the making. As aptly drawn out by the AHA’s recent Presidential Advisory, these historical structures are tied to modern-day health outcomes. In a volley between ideals and policies, at face value, the effects of structural racism are easily disguised as individual behaviors, but we must be keen.

Structural racism (as defined by Lawrence and Keleher and employed by the advisory) is “the normalization and legitimization of an array of dynamics—historical, cultural, institutional, and interpersonal—that routinely advantage White people while producing cumulative and chronic adverse outcomes for people of color”. For example, Dr. David Williams pointed out during Saturday morning’s Structural Racism keynote that African American people earn $0.59 to every $1 earned by White people—a disparity that has existed since 1978. Moreover, regarding wealth—an even stronger predictor of health—African Americans have $0.10 to every $1 of wealth for White people. At every education level, race matters. Inequities reverberate through every social sector, including housing, the physical built environment, education systems, access to capital, and manifest in health outcomes. Indeed, “racism has produced a truly rigged system” by which the marginalized life and, ultimately, die.

The AHA highlights its strategies to address structural racism, including advocacy, quality improvement, leadership, human resources/business operations, and, of course, science (see Figure 3, below). CEO Nancy Brown summarized the AHA’s role as one of “catalyst, convener, and collaborator”.

Assuming that “the long arc of the moral universe leans towards justice”, speakers during Tuesday’s press release and Saturday’s panel discussion emphasized that undoing structural racism should not fall solely on the shoulders of the communities that already bear the burden. Instead, the issue of achieving equity should be of interest to all. Further, Dr. Regina Benjamin emphasized that “allyship is more important than collaboration and that the privileged should work hand-in-hand” with the affected to dismantle these social ills. Solutions entail reforming the science and healthcare workforce, according to Dr. Lisa A. Cooper, to include more diversity, which leads to improved academic and workplace environments, organization academic excellence, improved access to care, and reductions in healthcare disparities. Others emphasized that we should evaluate our “investments as a moral template” and that real change may require “remapping entire curriculum and rethinking mentoring”.

In summary, as an early career scientist, I’m encouraged by the direction of this discussion. Though the length of my career in health disparities research pales in comparison to the giants on whose shoulders I stand, the attention to structural racism as a fundamental driver of health disparities feels like a long-awaited arrival. The path ahead will be even longer, but admission is the first step towards recovery. Moreover, I believe that all involved in the AHA’s thrust to acknowledge structural racism would agree with the African proverb,

“If you want to go fast, go alone. If you want to go far, go together.”

Quotes from AHA 2020: Structural Racism in Healthcare

November 15, 2020November 15, 2020 Dapo Iluyomade, MD

In a year wrought with challenges spanning social, political, and healthcare spheres, one issue has risen to the forefront of our collective consciousness. Structural racism.

What is structural racism? A recently published presidential advisory from the American Heart Association states that “structural racism refers to the normalization and legitimization of an array of dynamics–historical, cultural, institutional and interpersonal–that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color.”

The planning committee for this year’s AHA Scientific Sessions took it upon themselves to address the presence of structural racism in Cardiology with a comprehensive series of lectures and discussions on the topic. The sessions kicked off on Friday, November 13^th with an awe-inspiring fireside chat featuring legends in the education and treatment of cardiovascular disease, Drs. Eugene Braunwald and Nanette Wenger. The discussion was moderated by legends in their own right, Drs. Clyde Yancy and Robert Harrington.

“When I arrived in Atlanta in the early 1960s, racism was prevalent…and sadly, it continues more than half a century later” – Dr. Nanette Wenger

The morning continued with the main event session, “How to Use Behavioral Interventions to Advance Equity in Cardiovascular Health.” Drs. Keith Norris, Eberechukwu Onukwugha, and LaPrincess Brewer eloquently proposed solutions for tackling disparities in hypertension management and post-discharge care, as well as shared a bold new vision for cardiovascular health interventions to address disparities across the board.

“I am issuing a call for us, as an American Heart Association, community to integrate community-based interventions to promote cardiovascular health […] First, we must recognize the historical improprieties and wrongs in research, from events such as the Tuskegee syphilis study and the Henrietta Lacks cell line, which have led to a lingering mistrust of scientists and clinicians among racial and ethnic minority groups.” – Dr. LaPrincess Brewer

Arguably the main highlight of the morning was the AHA Fellows-in-Training session, titled “Racism in Medicine: What Medical Centers & Training Programs Can Do to be Antiracist.” This program sought to implore early career cardiologists to engage in the fight against structural racism, as well as provide trainees with a forum to learn more about racism in Medicine. The esteemed panelists, Drs. Clyde Yancy, Ileana Pina, and Michelle Albert led an incredible discussion with plenty of teaching points and actionable items to strengthen and support diversity, equity, and inclusion in medical training.

“It’s not about the number of people in the room or what they look like […] it’s about the diversity of thoughts in the room” – Dr. Clyde Yancy

This year’s AHA Scientific Sessions is off to a great start! Judging by the quality of programming on Day 1, there will be plenty more to write home about after this weekend.

Social Justice and the Polypill: A Strategy for the Future of Health Equity

November 14, 2020November 14, 2020 Shreya Rao, MD, MPH

The American Heart Association Scientific Sessions kicked off this morning in everything but the usual fashion—socially distant, virtual, absent the normal red regalia and buzzing convention center. And yet, it felt as though the necessary distance created space for a kind and level of discussion and introspection I’ve never before experienced during a large scientific conference. In particular, the Opening Session set the stage for the day with a thoughtful and deliberate discussion of racial and gender inequity featuring the inimitable Drs. Nanette Wenger and Eugene Braunwald along with moderators Drs. Clyde Yancy and Robert Harrington. The session covered historical aspects of the fight for equity in medicine told from the experienced perspectives of Drs. Wenger and Braunwald, while recognizing how far we’ve come—and have yet to go—in realizing the promise of an equitable society and equitable healthcare. That the session was quickly followed by one on how best to use behavioral interventions to advance equity, and then another forum on how training programs can adopt antiracist behaviors and policies, demonstrated the depth of the commitment to address equity and disparities during this year’s Scientific Sessions.

I was, however, most enamored by the first late-breaking clinical trial presentation of the day, summarizing the results of the International Polycap Study 3 (TIPS-3) clinical trial, simultaneously published today in the New England Journal of Medicine.¹ In an introduction by Dr. Dorairaj Prabhakaran, it was immediately evident how TIPS-3, a clinical trial evaluating a polypill containing low-dose simvastatin, atenolol, hydrochlorothiazide, and ramipril, fit perfectly within the context of the broader discussions of equity and social justice that permeated the day. The polypill, after all, is less the new-tech that many of us have come to expect in late-breaking sessions, and more a study in improving access to care. Noting the enormous burden of cardiovascular disease (CVD) in low- and middle-income countries, and the marked inter-and intra-country disparities observed in cardiovascular outcomes, Dr. Prabhakaran set the stage for how the polypill was—when all is said and done—a strategy study with the goal of improving equity. He summarized this idea simply and eloquently, concluding that while “medicine is inherently reductionist… the solutions have to be holistic.”

The TIPS-3 study, subsequently presented by Drs. Salim Yusuf and Prem Pais, evaluated the effects of the polypill and primary prevention aspirin against placebo in a two-by-two factorial design within an intermediate-risk population without preexisting CVD. The trial recruited 5713 participants from more than nine countries including India, the Philippines, Colombia, Bangladesh, Canada, and Malaysia, among others. Participants were followed for more than 4.5 years for a primary outcome of major CVD (including cardiovascular death, non-fatal stroke, non-fatal myocardial infarction), heart failure, resuscitated cardiac arrest, or revascularization. Despite achieving lower-than-anticipated levels of blood pressure and LDL-cholesterol reduction (5.8 mmHg and 19 mg/dL, respectively in the polypill arm), the trial saw a 21% reduction in the primary outcome in the polypill arm when compared to placebo (HR 0.79; 95% confidence interval [CI], 0.63 to 1.00), and an even more impressive 31% reduction in the aspirin + polypill group (HR 0.69; CI, 0.50 to 0.97). Unsurprisingly, aspirin alone did not significantly reduce the incidence of cardiovascular events, though this finding does make the additive reduction in CV events in the polypill + aspirin arm more unusual. The benefit of treatment with polypill + aspirin was, moreover, seen early (within the first two years of the trial), and was evident despite relatively high rates of discontinuation of therapy in the follow-up, driven primarily by logistical challenges in obtaining therapies.

With these findings, TIPS-3 adds to the growing and consistent body of evidence from prior trials including HOPE-3² and PolyIran study³, demonstrating that polypills have the potential to impact both intermediate endpoints and cardiovascular outcomes in a primary prevention population. The potential of the strategy to impact cardiovascular disparities is apparent, but the true test of our commitment to health equity globally will be seen in whether we are able to translate such findings into meaningful programs and interventions in the coming years.

REFERENCE

Yusuf S, Joseph P, Dans A, et al. Polypill with or without Aspirin in Persons without Cardiovascular Disease. New England Journal of Medicine 2020.
Yusuf S, Bosch J, Dagenais G, et al. Cholesterol Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med. 2016;374(21):2021-2031.
Roshandel G, Khoshnia M, Poustchi H, et al. Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial. Lancet. 2019;394(10199):672-683.

Advancing Cardiovascular Health for All

November 13, 2020November 13, 2020 Nasrien E. Ibrahim, MD

Finally, some excellent news in a year ravaged by innumerable tragedies, the first Black Indian American woman, Kamala Harris, is vice president-elect of the United States, and the American Heart Association has made a commitment to advance cardiovascular health for all-; what a great start to November 2020. I got to attend the American Heart Association’s news conference on the organization’s Call to Action: Structural Racism as a Fundamental Driver of Health Disparities, and unlike many of the committee, workgroup, and taskforce meetings I have attended or the emails and newsletters I have read since the newfound interest in structural racism, this felt real.

The American Heart Association’s Impact Goal read: As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality. What struck me was the emphasis on structural racism being a major cause of poor health and premature death. Many of the other meetings I sat in on, you know, the committees, the task forces, and the workgroups, rarely acknowledged structural racism as the root cause. We cannot fix healthcare until we acknowledge that structural racism has contributed to the grave inequities in medicine.

One of the saddest things to me is that marginalized individuals may not even be aware that they are recipients of disparate care. One of my best friend’s uncles, a Black man, was turned away from an emergency department with a new diagnosis of diabetes and unrelenting nausea with some paperwork to apply for insurance coverage and died of a massive myocardial infarction at home. The patients we turn down for heart transplant or left ventricular assist devices because of lack of financial security- souls that will haunt me forever. The Black non-English speaking man who presented to an emergency department with acute myocardial infarction and then delayed in his care led to his death. I read these statistics in medical journals and saw stories on television, but when I started witnessing the injustices firsthand and became the go-to person for my Black friends who wanted assurance that their parents, grandparents, aunts, uncles, and they themselves were receiving “good” care (oftentimes they were not), I became even more determined to do my part in dismantling these oppressive systems.

And just so we are clear, dismantling structural racism does not mean adding Black and Latinx members to a committee, for example, that continues to be led by individuals perpetuating oppressive systems; it means removing the oppressors and replacing them with individuals committed to driving change. Being part of the change means looking around the spaces you are in and recognizing what the problems are, and fixing them. Everyone is responsible. Until we address societal racism, we will never address inequities in medicine. Expecting a patient who is a single, working mother, who lives in a food desert, and who did not have the privilege of going to a top-rated public school to be successful with the same tools provided an executive at a Fortune 500 company is ludicrous. We must provide each patient with the tools that will contribute to their success, but ideally, no provisions would be necessary if we lived in a just society. Justice is the overarching goal.

The highlights of the American Heart Association’s advisory are direct- 1. The ascertainment that structural racism is a current and pervasive problem, 2. The acknowledgment that structural racism is real and produces adverse effects, and 3. The burdens of mitigating the impact of structural racism is a shared responsibility. Profound. All hands on deck; the individuals that deny the pervasiveness of structural racism, and it is the root cause of healthcare inequities must be phased out. Additionally, the American Heart Association listed key areas to address to eliminate structural racism and its negative effects, including restructuring systems, implementing policies, eliminating inequities, fostering allyship, and supporting research. And allyship does not mean supporting the mission when you are around people passionate about dismantling systemic racism, allyship means looking within your own families, circles, and workplace and driving change. Allyship is not wearing a Black Lives Matter pin on your white coat, kneeling with a White Coats for Black Lives sign, sitting on a diversity and inclusion committee, or Tweeting an article on the late, great Congressman John Lewis; allyship is using your privilege and platform to drive change.

I do not claim to be an expert in racism, far from it, but I do know we each have to play a role in dismantling the oppressive systems that have left Black and Latinx patients without access to quality healthcare. For me, my contribution to driving change is mentoring and sponsoring Black women and men interested in careers in medicine so we can change the face of medicine and secondly, working to eliminate inequity in organ allocation in heart transplant by improving outreach to neglected communities and creating pre-transplant “Bootcamp” programs where, instead of turning a patient down for smoking, for example, providing them with the tools necessary to become an ideal transplant candidate. Just like transplant centers are penalized for excessive mortality, transplant centers should be penalized for not expanding outreach to BIPOC communities.

I want to end with the powerful words of Reverend Dr. Martin Luther King, Jr, may he continue to Rest in Power because I cannot end this better myself- “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Physicians, advanced practice providers, scientists, nurses, technicians, administrators, policymakers, and anyone with a stake in healthcare- we have so much work to do, but I remain full of hope.

From Race-Based Medicine to Fighting Structural Racism

August 5, 2020August 5, 2020 Elizabeth Knight, PhD, DNP

“Race is the child of racism, not the father.”

-Ta-Nehisi Coates, Between the World and Me.

BiDil, a combination of isosorbide dinitrate and hydralazine, was approved by the FDA in 2005 to treat heart failure in African Americans— the first race-based indication in the U.S. Though some groups lauded this move as a win for the underserved Black community, controversy soon emerged— and rightly so. Why did the researchers come to the conclusion that this combination of drugs worked better for one racial group than another? Why did the FDA take the action to approve it this way? The answers were not reassuring.

Did you know that there is no genetic basis for discrete racial categories? If not, this is likely because of what you were taught in training. It’s time to unlearn some falsehoods! The concept of race is not, in fact, biological, but social. It is not race, but racism that creates and perpetuates inequities.

Race-based medicine is bad medicine. Period. Dorothy Roberts gave a seminal TED talk in 2015 explaining this concept. The persistent myths that characteristics like pain tolerance vary by race are damaging and false. It is up to us, as clinicians and scientists, to dismantle the racist structures and processes within health care and within our larger communities that harm people of color. We cannot allow the fiction of biological racial difference to obscure the reality of racism.

Race can be an important variable to include, analyze, and understand in science and medicine, but not because of biology— because of structural racism. Diagnosis and treatment should not differ by race. Rather, social determinants of health must be part of all the care we provide, and all the research we conduct. We need to fundamentally reexamine the characteristics we use to ensure diversity and external validity. Yes, we need data on race, that that’s not enough.

As we see stark and alarming differences in COVID-19 among racial groups, the realities of racism’s health impacts are writ large. Living and working conditions, rather than biological differences, drive the differential infection and death rates. We, as the next generation of scientists and clinicians, can seize this moment to create lasting change and move toward health equity.

How?

Question assumptions. Race-based decisions in medicine are often due to force of habit, tradition, and education. Ask why and if there’s not a good reason, stop. Why do we give race as a defining characteristic in our case presentations? Why do we calculate creatinine clearance differently? Why do we prescribe differently?
Assess your biases. Try the Harvard bias test, for example. No one is without bias! Seek out training. Eradicate blind spots. Form accountability groups with colleagues. This work can be uncomfortable, but it’s necessary.
Solicit input. Whether you are a researcher or a clinician, the community you serve needs to be involved. Do not assume you always know what’s best. If you ask, and listen, you will discover the values and priorities of the community. Trust-building takes work and time. Demonstrate trustworthiness and remember that iatrophobia is justified by history.
In research, define race and specify the reason for its inclusion. Use a sociopolitical rather than biological framework, and name contributing factors. Name racism and related forms of oppression that may be operating[1].
In clinical care, assess and address social determinants of health. Advocate for equity-focused community practices: food banks, suspension of evictions, support for access to broadband internet to increase access to healthcare and education, and provision of paid time off for sick leave & quarantine, among other actions. Identify needed resources and provide them.[1]

Sustainable change is never straightforward, never easy, and rarely rapid. As early-career professionals, we have many years to fight this fight. Let’s not waste any of them.

References:

[1]Boyd, R., Lindo, E., Weeks, L., & McLemore, M. (2020). On Racism: A New Standard For Publishing On Racial Health Inequities. Health Affairs Blog.

https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/?utm_medium=social&utm_source=twitter&utm_campaign=blog&utm_content=Boyd&

[1] Haynes, N., Cooper, L., & Albert, N. (2020). At the Heart of the Matter: Unmasking and Addressing the Toll of COVID-19 on Diverse Populations. Circulation, 142 (2).

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048126

On Blood and Bridges: Remembering Congressman John Lewis

July 28, 2020July 28, 2020 Anika Hines, PhD, MPH

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

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

Diversity, Equity, & Inclusion Are Not Just Buzzwords— Practical Steps for People Who Teach

July 2, 2020July 2, 2020 Elizabeth Knight, PhD, DNP

Those of us who work in science, healthcare, and academia often find ourselves teaching others, whether or not we set out to be educators. Residents teach medical students. Nurses precept new nurses. Graduate students teach undergraduates. And faculty roles for researchers and clinicians also include teaching loads. Yet for many of us, our training did not include any grounding in how to teach. We might not have brought the same theoretical rigor and deep expertise to our teaching that we have to our other roles. Now, as we are teaching in a world of rapid change and increased awareness around structural racism, we must approach equity in our educational practices with intention, but some among us may not feel prepared and we are already overwhelmed. We are already adapting to enormous change related to COVID-19, and the intellectual energy required to reexamine another entire part of your professional life can feel paralyzing. It can feel like an impossible task that there will never be time for.

Despite these barriers, I strongly believe that you can start (or carry on) right now, no matter where you or your institution are in the struggle for antiracism. Here are some immediate suggestions to make your practice as an educator explicitly equity-focused and antiracist, for folks who teach in all kinds of contexts (these topics work for self-education, too):

No matter what format you teach in, there are some basic practices you can adopt to establish a “floor” for equity and inclusion.

Can you pronounce the name of everyone in your group? Do you know what they prefer to be called and what pronouns they use? Some teachers inadvertently avoid calling on students because they haven’t bothered to learn these things and don’t want to make a mistake. Don’t be that teacher.
How much time does every person (including you) speak? Is anyone taking up more space than they need? Now, the era of video calls, some platforms can actually show you how much time each individual speaks for, and this can be eye-opening. I encourage you to actually measure and observe this at least once. It can be surprising to see how some groups are consistently dominating conversation at the expense of others.
Have you adopted principles of Universal Design for Learning in your teaching? If not, now is a good time to start. UDL is a set of principles that improves the experience for all learners by focusing on accessibility and flexibility and assuming diversity.
Are you yourself familiar with concepts of antiracism? Have you examined your own privilege, bias, and ignorance? Are you learning?

For those who teach in a classroom or seminar format, Dr. Valerie Lewis has shared some more tips:

Include an equity-focused reading with every topic (e.g., if you are teaching about asthma, include an article about disparities related to race and social determinants of health).
Message that equity isn’t a specialty; every field should address it as part of ongoing professional practice.
Create a dedicated class session for equity, and if possible do two— one at the beginning to frame the ideas for learning, and one towards the end to integrate the content you’ve covered with broader ideas around equity. This can help to lay the groundwork for ongoing reflective professional practice.
Audit your syllabus: can you include AT LEAST one scholar of color every week? You might have go-to reading lists that you’ve inherited or developed, but if your list doesn’t measure up, you can change it. Go to PubMed or google scholar. Look at professional societies. Ask colleagues. Crowd-source on twitter. This is a key way to amplify voices— remember that citations are academic currency.
Don’t be afraid to make mistakes. Be open with students that you are doing this intentionally and why, and take feedback.

This is not a checklist or an exhaustive resource for inclusivity. But I hope that if you are floundering as you try to figure out how to teach with a focus on equity and inclusion, that you’ve got a good first foothold. Let’s keep the conversation going— I’d love to hear more ideas. Hit me up on twitter @TheKnightNurse and let me know what you are doing.