April 23, 2021
Dear Interested Readers,
The Challenge: Recognize What We Have Been. Ask What We Are Willing To Become
It would be a mistake to think that the only important or even most important issue of the last fourteen months was the COVID-19 pandemic. The election and the violation of the Capital while Congress was meeting to certify the election of Joe Biden were historically significant as was Donald Trump’s refusal to accept the result of the election. Either our continuing problem with gun violence and the continuing deterioration of the climate would be challenge enough alone for any year, and it appears that both will be issues for years or perhaps decades to come long after we have conquered COVID and Donald Trump has become a joke that has no punch line. As important COVID, politics, gun violence and the climate are, and will continue to be difficulties that will trouble us for a long time to come, they are not the challenge that race has been for us over the last four hundred years and will likely be as far into the future as we can see unless…
Unless what? “Unless what?” is a question that I keep asking myself. I am sure that there were abolitionists in the mid-nineteenth century who were optimistic that the problems of race would go away if slavery was abolished. A war that cost hundreds of thousands of lives was fought to end slavery. Slavery ended for less than 20 years before it returned dressed in the disguise of Jim Crow and former slaves found themselves working for their master as sharecroppers. I am sure that over the one hundred years of Jim Crow with its horrific lynchings there were good souls who prayed for a modern-day messiah who would teach everyone that there was a way to live together in harmony and that our politicians would respond to that message and do with new civil rights laws what a bloody war could not achieve. The teacher/preacher/prophet came, the laws were passed, and then the teacher/preacher/prophet was killed as is often the fate of those who call us to live on the higher plane of equity and mutual respect for all people.
The ill will and disrespect toward back Americans have persisted for more than fifty years since the teacher/preacher/prophet gave us a vision of what a better world would look like. Over those years and more than one president has tried to justify systemic oppression by accusing its victims of being lazy and dishonest. All the while, laws and programs that were passed differentially advantaged the majority over impoverished “others” even as civil rights and access to the vote for the minorities were increasingly targeted for disregard at every level of government while the police showed increasing enthusiasm for the use of lethal force against within seconds of stopping a minority person who might have committed a traffic violation, some misdemeanor, or just looked suspicious in their judgment.
A civil war made little difference, laws failed to accomplish their intent when they were disregarded or circumvented. The election of a remarkable minority president was hailed as evidence that the struggle was behind us when in the end it just revealed that distrust and anger were more active than ever. And then in the midst of so many other events of significant concerns a crime that was probably not that unique given the thousands of other wrongful deaths at the hands of authorities in a free nation that espouses respect for human rights was displayed to the world by a seventeen-year-old woman using cell phone video. The video revealed one man who was handcuffed and lying face down on a street pleading for mercy while a police officer who looked bored kneeled on his neck until all life was gone.
The trial of Derek Chauvin rightfully found him guilty of a heinous crime. Charles Blow in his New York Times column this week eloquently described the fear of yet another disappointment for Black Americans that is associated with this verdict in a piece entitled “With the Chauvin Verdict, One Battle Is Won. The War Continues: The fight for equality doesn’t end after a single conviction.”
As James Baldwin once put it, there is embedded in the American Negro the “wise desire not to be betrayed by too much hoping.” The possessor of dashed hopes is in some ways more injured and dangerous than the consistently hopeless. The possessors of dashed hopes spread their wings, which make them vulnerable, and get them clipped. Bitterness is a natural byproduct of such betrayal.
Before Tuesday’s guilty verdict for a former Minneapolis police officer, Derek Chauvin, in the murder of George Floyd, many of us were afraid to hope that justice would be done. It doesn’t matter the strength of the case or the preponderance of evidence; convicting a police officer of killing a Black man is so rare in this country that I can count the recent cases I recall on my fingers — on one hand.
So when the verdicts came down, for me, there was a moment of shock: The justice system had administered justice to a Black man, a Black family, the Black community, the country and the world. We are so used to the system betraying us that it was stunning to see it serve us.
Blow goes on to describe how George Floyd’s death was originally report by the Minneapolis police:
The Minneapolis Police Department’s initial statement on Floyd’s death was headlined, “Man Dies After Medical Incident During Police Interaction,” and it went on to say of Floyd:
“He was ordered to step from his car. After he got out, he physically resisted officers. … Officers called for an ambulance. He was transported to Hennepin County Medical Center by ambulance where he died a short time later.”
That would have been the story, had it not been for witnesses and cellphone video. The truth would have circulated in the community, but the lie would live on in the official record.
This is how many cases live, unresolved, in oral history told from a barber chair or barstool. This is also how hostility, resentment and contempt grow toward policing, criminal justice and politicians. This is why the fundamentals of our criminal justice system must be reshaped in order to restore trust.
Blow is absolutely right with his description of what usually happens. None of us know the absolute number of atrocities that have been obscured and hidden by the powers that be in our society while most of us find it convenient not to ask to many questions or make too much noise about the need for change. Isabel Wilkerson put the problem of race into a much more discussable context this year when she chose to describe our society as a caste system in her book Caste: The Origin of our Discontent. Others have tried to avoid talking directly about racism by flipping the subject and reframing the discussion as one about antiracism. It is a dark secret that it is possible to be complicit with racism while proclaiming to be “antiracist.” Most of us are aware of our position in our “caste” system and would like to think we are antiracist and will defend that self-serving analysis of our own external behavior while denying lifelong biases that influence our interior feelings.
My first memory of any awareness of “race” was when I lived in Miami, Oklahoma between ages three and five, 1948-1950. I did not know of the Black Wall Street Massacre in Tulsa in 1921 which was less than thirty years in the past and 100 miles away from me. In that quickly submerged atrocity, more than three hundred black lives were lost and ten thousand homes were destroyed. A community was abolished and the event was treated like a weather event of only local interest. I did know what had happened in nearby Tulsa but as a young child, I knew that Black people were not welcome in my town. My parents explained that we had a “Native American” housekeeper because Black people were not allowed in town after sundown. Racism was not discussed, but it was universally practiced in all the places I lived as a child. My parents were always polite and respectfully treated the Black people who tangentially touched our lives as “essential workers” in our home and around our community, but our contacts with our Black neighbors were rare. I never had a class with a black student until I went to medical school although five Black students were enrolled at the University of South Carolina when I was a freshman in 1963. The Jim Crow South had no stated apartheid policy, but apartheid existed with the same vigor in the American South that it had in South Africa at the same time.
When I moved to Boston in 1967 to attend medical school I was surprised to discover that Boston did not try very hard to disguise its own racial tensions. There were two Black students in the group of 120 who entered medical school with me in the fall of 1967. One of Dr. Ebert’s achievements was that during his tenure as dean he was able to increase the number of Black students at HMS. The sixties were heady days. There were great expectations for overcoming racism and poverty as we moved toward a Great Society. It would behoove us to ask ourselves as we celebrate the conviction of Derek Chauvin why we are still described as a “caste system” and can be relieved when one injustice is addressed. I do not have the answer but I have some ideas. We have celebrated expectations and possibilities without doing the personal and group work that would create a lasting solution. We talk about healthcare disparities, the terrible impact of poverty on children, the dysfunctional ways that policing is practiced across the land. We know that public services, the tax system, the educational system, employment opportunities, and most aspects of competitive opportunity are not equitably distributed. Ironically, my father used to have a saying that he would use when a job needed to be done but was ignored. He would say, “We decided that George would do it!” We have work of change that needs to occur. In my father’s joke “George” was some other man who would do what no one had the time or desire to do.
As a nation, we have known for a long time that we have a deep-seated problem that will require great work to resolve. Some among us like the problem and want it to persist because they believe that the supremacy of one race, their race, fits their theology or world view. Others of us don’t like it but we are pretty busy and hope that some other George, Martin, Bobby, Abe, Barack, or Joe will do the work for us.
Dr. Ebert tried to initiate change in healthcare but over the years since his efforts, the system has not yet bent much as is demonstrated by an article in the Health Affairs blog that Eve Shapiro shared with me earlier this week. It is entitled Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism And Health. The article was written by Nancy Krieger, Rhea W. Boyd, Fernando De Maio, and Aletha Maybank.
They begin with a statement of fact that deserves deep thought:
Ignorance is neither neutral nor benign, especially when it cloaks evidence of harm. And when ignorance is produced and entrenched by gatekeeper medical institutions, as has been the case with obfuscation of at least 200 years of knowledge about racism and health, the damage is compounded. The racialized inequities exposed this past year—involving COVID-19, police brutality, environmental injustice, attacks on democratic governance, and more—have sparked mainstream awareness of structural racism and heightened scrutiny of the roles of scientific institutions in perpetuating ignorance about how racism harms health.
The authors are being brutally honest about a painful reality. Healthcare as it is taught, managed, delivered, and conducted as an academic or business endeavor has been part of our deep national stain. It is hard to produce real examples of substantive improvements in healthcare disparities, healthcare equity, the social determinant of health, or the extension of coverage for care to every American that has been vigorously pushed by organized healthcare. Within our profession, there are many saints and heroes that we love to celebrate, but their efforts have not inspired real change that has made a difference. We still tolerate huge deficits in the care of minorities, especially children and women.
The authors choose to drive their point home by analyzing the contents of four of the most prestigious medical journals. They write:
In particular, the ways the world’s leading gatekeeper medical journals produce ignorance about racism and health are ripe for review. In our analysis, we build on prior scholarship, including the 2018 study by Hardeman et al that focused on articles published between 2002-2015 in the 50 highest-impact public health journals and found that only 25 named institutionalized racism in their title or abstract. Our novel contribution is three-fold: (1) we extend the analysis to include articles from 1990-2020, thereby expanding the time frame and capturing the past year of increased explicit discourse and action about racism and health; (2) we distinguish between articles that present viewpoints versus empirical scientific investigations; and (3) we deliberately focus on the world’s four leading medical journals, as well as bringing in selected comparators.
Their comment on their findings:
The results are not pretty. As we show, only in the past year have these leading journals begun noticeably increasing publication of articles on this topic, with the vast majority of even these papers solely viewpoints, not evidence-based empirical studies.
But, they see some hope driven by changes in this last difficult year.
And students, scholars, and clinicians across the health sciences are paying attention. Galvanized by the harsh inequities plaguing this nation, they have called for moving beyond declarations condemning racism. They are driving unprecedented steps by major biomedical institutions, health professional organizations, universities, and academic journals to expose and counter harms caused by structural racism.
They do present a long list of recent developments that suggests that we are finally going to see meaningful efforts to address structural racism within our institutions and to recognize “racism a serious public health threat..” But, they argue that the initial efforts should be considered to be just a start:
Yet it is imperative to do more. Harms caused by the gatekeeping culture and practices of major medical journals in publishing—or not publishing—research on racism and health warrant review.
I will leave it to you to read what their analysis reveals and to see for yourself the evidence they present about how trivially the issues of race in healthcare have been treated in our most important journals over the last thirty years. They sum it all up by saying:
Our analysis provides striking evidence of the failure of leading medical journals to publish extant scientific research on racism and health. As we have demonstrated, the problem is not an absence of publishable work. Our intent is to motivate scholarship to investigate the reasons for this production of scientific ignorance about racism and health by leading journals; this research would complement work already underway to address how racism harms not only health but also the culture and practices of medical, public health, research, and academic institutions.
I don’t present the paper as evidence of changes that are about to occur, but rather how resistant we have been to change. Like Charles Blow’s quote of James Baldwin suggests “…[the] wise desire not to be betrayed by too much hoping.” We have hoped before, and we have been disappointed, but perhaps this is the time. What I do believe is that we must fully expose ourselves to the extent of the harm that we have tolerated without seeing a compelling need to change. Maybe George has finally done it for us. Maybe COVID has been a demonstration of how ugly and unfair our system of care is. Maybe a transformation will occur. What I do believe is that we have a lot of history and data to confront. Once we own our own role in what has happened, we can begin to try to do something that will make a real difference this time for a long time.
More Mergansers
I hear that my little town is in the midst of a pandemic-driven transformation. I was on a Zoom call this week that was organized to discuss the critical lack of affordable housing in our community. There is a critical lack of all housing. Even expensive properties are on the market for nanoseconds before there are multiple bidders. A good example of the problem was presented by the new CEO of our local hospital who was on the call. He is concerned because the hospital’s essential employees have a hard time finding somewhere affordable to live within an hour’s drive of work. The problem is so bad that over the almost two years that he has been CEO he and his wife have not been able to find a home that they could afford to buy! They are now getting by in an apartment while building a home which is going to be very expensive not because of elegance but because of the high cost of building materials and labor.
The problem began long before the pandemic. It is worse now that telecommuting has become an increasing reality. Why would a sane person who has the opportunity to move somewhere that is high in four-season natural beauty and low in the anxiety-provoking realities of the activities of daily living in places like New York, Boston, Hartford, or Washington not consider permanently relocating here?
Long ago before the pandemic when we actually went to social engagements, I enjoyed meeting new people and asking them just how they decided to live in the Dartmouth/Sunapee/ Kearsarge area of the Upper Valley of the Connecticut River. Some would tell me that their family had come to the area for summer vacations over the years. Some first experienced the area by going during childhood to one of the many summer camps that once ringed the local lakes. Others were here because they had fallen in love with the area when they had gone to Dartmouth years ago. Some, like me, discovered the area almost by accident while visiting a friend or on a weekend jaunt from some east coast metropolitan area. Whatever the reason for their initial exposure, to be here was a choice that no one regretted.
My wife and I were lucky. We first came to the area in the early 90s to visit a friend and bought an affordable second home in a large recreational community nearer to Hanover in 1995. We began to look for a more appropriate retirement home just as the Great Recession hit in mid-2008. Looking at the data, 2008-2010 was the only time in the last quarter-century that prices fell and that there was much choice in the market. I have always believed that it was much better to be lucky than smart.
There are so many interesting things and places to go nearby that I never seem to run out of surprises. Main Sreet in my little town is on a ridge that is a watershed. Rain falling on the east side of the street flows into Pleasant Lake and then travels east by way of the Blackwater River, The Contoocook River, and the Merrimack River past Concord, Manchester, Nasua, New Hampshire into Massachusetts and then past Lowell and Lawrence to the Atlantic. Water falling on my side of Main Street flows west through my lake, to Lake Sunapee, the Sugar River, and then on to the Connecticut River that flows south through Brattleboro, Vermont to Springfield, Massachusetts, and on to Harford, Connecticut to meet Long Island Sound at New Haven.
I have spent more time on the Connecticut River side of the watershed since that is where I live, but there are some interesting places to be explored heading east. I have fished the Blackwater River near Procter Academy in Andover without much success. I love the covered bridge in Cilleyville which spans Pleasant Brook near where it flows into the Blackwater River in Andover. What I did not know until this last week was that the Blackwater stretches out into a “pond” called “Blackwater Bay” not much further downstream.
My neighbor Peter Bloch graces us with a beautiful video of interesting places a few time a month. Last week he introduced us to Blackwater Bay with a gorgeous video a little less than three minutes long that I hope that you will take the time to view. The focus of the presentation was the red blossoms of the swamp maples that line much of the shore. The swamp maples are beautiful, but what caught my eye was his gorgeous shots of a breeding pair of mergansers. A few weeks ago I tried to share a picture with you that I took of a pair of mergansers on my lake, but as you can see, Peter is a pro and his picture is much better than my effort. If you do look at the video be sure to also check out the turtles.
We had a little snow on Wednesday evening and flurries off and on all day yesterday. It’s been a chilly week, but the prediction for Saturday is for a beautiful spring day. I am hoping to be out in my kayak. I doubt that I will get to Blackwater Bay but I am eager to get in some fishing this weekend because the people from the New Hampshire Fish and Game Department dropped about 1500 rainbow trout fresh from life in the hatchery into the lake earlier this week. These newbies need a welcoming, and I am just the guy who can do it. I catch them, take their picture, give them some brief advice about impulsive behavior, and then throw them back. It may seem like a pointless cycle, but it fits my style.
I hope that wherever you are there will be “out and about” weather this weekend. I would wager that there will be something unique nearby for you to find and enjoy.
Be well,
Gene
Gene, thank you for this penetrating letter. I hope for long needed change but fear an endless stream of words will substitute for action at journals, in medical schools, research institutions, and healthcare organizations. Not to mention in policing and everywhere else. I hope the groundswell of protest in this moment will be the tipping point, but I have my doubts. I hope that I am wrong.
What a beautiful video. Thanks for sharing. I needed that!
Hugs to you, my friend,
Eve