July 23, 2021
Dear Interested Readers,
Can We Use The Desire To Be Anti-Racist To Improve Healthcare?
Even if you are only a casual reader of these notes you know that I am a big fan of many of the columnists who write opinion pieces in The New York Times. Another source of information and entertainment for me that has massaged my moderately left-leaning tendencies has been the podcasts and writing of Ezra Klein. Until recently one would find Klein writing or dispensing podcasts on Vox. He had left the Washington Post to be a co-founder of Vox which made the fact very interesting that earlier this year he left Vox and took his writing and excellent podcast interviews to The New York Times. I am sure there is a story behind that move that I would love to know
If you have not heard one of Klein’s podcasts, I would recommend that you correct that inadvertent omission as soon as possible. Perhaps you might want to begin with Klein’s recent interview with Barack Obama. Klein leans left but many of his best interviews have been with right-of-center thinkers. Last year he published an insightful and well-researched book that examined the origin of our current political polarization. He frequently writes to advocate for abolishing or significantly modifying the filibuster. He cut his teeth in journalism covering the emergence of the ACA and other issues in healthcare over a decade ago. Over the last six months, he has done several interviews with authors and authorities on race. His most recent interview was with Ibram X. Kendi.
If you don’t know who Professor Kendi is, let me introduce him to you. He is a 38-year-old professor of history at Boston University and the founding director of the Boston University Center for Antiracist Research. Prior to coming to BU, he was the founder of American University’s Antiracist Research and Policy Center. He won the National Book Award for non-fiction in 2016 for his book, Stamped from the Beginning: The Definitive History of Racist Ideas in America. In 2019 he published How To Be An Anti-Racist. Since the death of George Floyd, How To Be An Antiracist has been a well-used resource for those of us who are not Black but want a greater understanding of the experience of being Black in America and desire an America that lives up to its founding concept of equity with liberty and justice for all. After listening to the conversation between Klein and Kendi, I have started reading How To Be An Antiracist. In the book and in the interview he frequently references his personal history as a black child and young adult and draws on the history of his family to illustrate his points.
In August 2019, shortly after the publication of How To Be An Anti-Racist Jennifer Schuessler published a review in The New York Times that revealed at least two startling facts: Kendi had been diagnosed with stage four colon cancer at age 36, and that in the How To Be An Anti-Racist he confessed his own racism. Schuessler writes:
But it’s also a book that directs some of its most unstinting criticism at the author himself, and what he sees and is his own racist ideas.
Kendi uses his own feelings about race and the racist self-loathing he sees in the Black community to direct the conversation away from a focus on individual racism because he contends that we all harbor those feelings. His attack is directed at racist policies and institutions. He sees racist policies creating inequities between ingroups and outgroups in every aspect of life including and most distressingly in healthcare as is manifested by the much shorter life expectancies of Black and Latinx Americans. Just this week we have learned that the life expectancy of all Americans has fallen more in the last year than in any year since World War II, but even more alarming is the fact that Black and Latinx Americans have seen a fall in life expectancy that is three times greater than the fall of Whites. In an article written by journalist Mike Stobbe and published by the AP this last Wednesday, July 21, entitled “US life expectancy in 2020 saw biggest drop since WWII” we read:
—Hispanic Americans have longer life expectancy than white or Black Americans, but had the largest decline in 2020. The three-year drop was the largest since the CDC started tracking Hispanic life expectancy 15 years ago.
—Black life expectancy dropped nearly three years, to 71 years, 10 months. It has not been that low since 2000.
—White life expectancy fell by roughly 14 months to about 77 years, 7 months. That was the lowest the lowest life expectancy for that population since 2002.
Kendi would say that the inequity in life expectancy between White and Black and Latinx people in America is the outcome of some of the most heinous examples of racist policy over many years in America. With this latest report, it is obvious that the stress of COVID-19 has pulled back the covers from a problem that we have known about for a very long time and have done very little to mitigate.
Another fact of interest to me is that Kendi and his wife chose their last name. He continues to use the given name, Ibram, which he says his parents chose “daring to name me, their second son, ‘exalted father’ when I arrived in a world not in the practice of exalting Black bodies.” Wikipedia tells the story of his middle and last names and reports on his cancer:
In 2013, Kendi married Sadiqa Kendi, a pediatric emergency medicine physician, in Jamaica in a ceremony officiated by Kendi’s parents. The wedding ceremony ended with a naming ceremony of their new last name, “Kendi”, which means “the loved one” in the language of the Meru people of Kenya. Kendi changed his middle name to Xolani, a Xhosa and Zulu word for “peace”.
In January 2018, a colonoscopy indicated that Kendi had cancer. A further test revealed that he had stage 4 colon cancer that had spread into his liver. After six months of chemotherapy and surgery that summer, Kendi was declared cancer free.
My own speculation about his revelation that he too has racist thoughts and tendencies may stem from a fact that both of his parents have always been religious. They first met at a religious meeting, and his mother was a missionary teacher to Liberia before she married his father who was in love with her before she went to the mission field and had waited patiently for her to return. Much of Kendi’s childhood was spent attending church, and he references the Black church frequently in his book. During his childhood, both of his college-educated parents were employed in middle-class managerial jobs, but now both of them are Methodist ministers. A core Judeo-Christian concept that Kendi was surely exposed to in his youth is that we are all self-interested sinners:
All we like sheep have gone astray; we have turned every one to his own way;
Isaiah 53:6 (KJV)
In the interview with Klein, Kendi talks about why he took the risk of declaring himself to be a racist:
…I can say that there’s been people across different racial groups who’ve come to me and said what allowed them to really reflect on their own racist ideas was reading me do the same, that instead of writing a book in which I lecture to other people about how racist they were, I wrote a book admitting and being vulnerable about the times in which I thought there was something wrong with Black poor people or Black women or Black people or even white people. And I used myself and really my growth and I decided to be vulnerable to do so. And people have responded really well. I didn’t know how people would respond. I’ve also used the stories of history, particularly with white Americans. Because one thing white Americans are not taught, because we don’t teach about race and racism with any specificity or comprehensiveness in schools and even colleges, is about white American history. White Americans don’t know that some studies show that the majority of white Americans were against secession in the South. White Americans don’t know that there were roughly 5 million poor non-slaveholding whites in 1860. White Americans don’t know that white people rioted for food during the Civil War and were fleeing the Confederate army in droves. White people don’t know that white people had to go to court to get some of the Jim Crow voting laws in the South lifted because it was making it harder for white people to vote. There’s so many aspects of white American history that people have not learned…
Teaching the history of race in America is becoming more and more difficult because of the emerging “culture wars” and the laws being passed in many Republican-controlled states that prevent teaching the history of race in America or anything like “critical race theory”(CRT) that might be disturbing to White children. Late in the interview, Klein asked about CRT and Kendi commented:
Ezra Klein
So we’ve been talking about analyses and strategic questions that this brings up for the left, but I want to talk about what’s going on the right. And we’re in the midst of this big anti-critical race theory backlash…when you read a lot of these right-wing critiques of CRT, to some degree, the person they’re arguing with is you. Christopher Rufo, who’s sort of the architect of this push, said you’re a leading figure in the critical theory movement. And he told the New Yorker he only learned about critical race theory in the first place by digging through the footnotes of How To Be An Antiracist. So as somebody who’s, in a weird way, become at the center of this, I’m curious how you read it.
Ibram X. Kendi
I think what’s being described as critical race theory is any analysis, critical analysis, of race or racism in this country that does not position this country as post-racial, any attempt to hold people who are being racist accountable, any attempt to have a clear and complex multivariate approach to American history, whereby we actually document and talk about and teach about the history of racism in this country, and certainly attempts to create outcomes that are more equitable and just. And what I make of this whole fiasco — I was surprised when I learned that I was the father of critical race theory, when critical race theory was born before I was born…
Kendi is a gifted writer and it is fascinating to listen to him expand his ideas. Klein is a great “explainer.” He begins the podcast by summing up Kendi’s work and core idea in less than three hundred words. I have bolded thre core points that sum up Kendi’s position,
I remember reading Ibram X. Kendi’s “How To Be An Antiracist” back when it first came out. So this was, I think, August of 2019. I loved his previous book, “Stamped From The Beginning,” which I still think everyone should read, even if you’ve read, by the way, “How To Be An Antiracist.” But what struck me about “How To Be An Antiracist” was how intensely consequentialist Kendi’s views on racism had become. His argument there was that it doesn’t matter what you intend, it doesn’t matter what you feel, all that matters — the only thing that matters — is outcomes. If a given policy or action reduced racial inequality, it was an antiracist action. If it increased it, it was racist. If you support policies that reduce racial inequality, you are being antiracist. It doesn’t matter why you’re doing it. If you don’t, you are being racist. That’s it. That’s the entire framework. This built on something else that Kendi saw, which had influenced me a lot, that we had the causal arrow of racism backwards. The argument in “Stamped From The Beginning” is that racist policies don’t follow from racist ideas, the way we normally think they do. Racist ideas follow from racist policies.They are created as rationalizations for racial inequality. And I want to repeat that because it is so important to understanding his thought. Racists don’t make racist policies. Racist policies make racists. So if you want to change hearts and minds, change policy, and hearts and minds will follow.
Following Kendi’s formulation, the question for healthcare care is not whether healthcare is racist. The key question is whether or not healthcare is antiracist. Kendi points out that there are many organizations, companies, government agencies, and healthcare institutions that want to view themselves as antiracist or not racist but in fact the inequitable outcomes that they produce argue otherwise. Kendi describes for Klein what it means to be antiracist:
Well, what it means to be antiracist is to first recognize that we live in a society of racial inequities, from wealth to health to criminal justice to education, and to recognize that we’ve been taught that, let’s say, Black people are disproportionately impoverished or incarcerated because there’s something wrong with Black people behaviorally or culturally. And to be antiracist is to say, no, the racial groups, not individuals, but the racial groups are equal, that there’s no group that is inferior or superior. And so therefore, the cause of a disparity or an inequity must be policies or practices that we see or don’t see. And to be antiracist is to identify those and challenge them and to try to rebuild a nation that — policies and practices that create equity and justice for all people.
Kendi does not have much use for a company or say a hospital or medical practice that invests in “diversity training” but continues to produce outcomes that perpetuate inequity. He is outcomes-oriented. His argument feels much like our current thinking about malpractice. Medical errors are usually a systems issue, but we focus on fixing people rather than the system that produces errors in care that lead to bad outcomes. As noted above, this week we had more evidence that American healthcare is not antiracist since the fall in life expectancy for Black and Latinx Americans was three times greater than for White Americans. Those numbers are evidence that despite 25 years of diversity training in healthcare, I had my first diversity training in 1995, our system of care is not antiracist. It is racist. It produces unequal care that allows avoidable deaths that are distributed by race.
What are the mechanisms for decreasing the inequities in medicine that have arisen from racist policies? What changes in healthcare policy and practice would an antiracist healthcare professional support? What would an institution that genuinely wanted to be antiracist do? In his book, Kendi criticizes himself and many of the black leaders of the last half-century for preaching to Black America that the way forward was to work harder, be better parents and be more diligent students, essentially be perfect, productive citizens with the hope that their virtue would be a path to acceptance and equity. Kendi now sees those attitudes among Black leaders as essentially racist accommodations to the racist policies and history that produced the inequities. As it becomes harder for minorities to vote there will be less that the Black community can do alone to correct the racial policies that kill them sooner and in disproportionate numbers other than to emphasize that Black lives do matter. Kendi sees a role for reparations of all sorts including programs of affirmative action until all the inequities in our society are resolved. Kindi references Heather McGhee’s ideas from her book, The Sum of Us, which emphasizes that racist policies damage us all in measurable ways. He expresses solidarity with all groups, women, LGBTQ+, Native Americans, the disabled, and others that suffer inequities. His point in reference to all of them is that they all suffer from bad or unfair policies that create their suffering and that the inequities that they endure on a daily basis persist and are justified by the majority oppressors who differentially benefit from those discriminatory policies.
How might programs to improve health and reduce the inequities in life expectancy and maternal/child death rates look? What are the antiracist healthcare policies that would make healthcare more equitable? Kendi would say that as we propose the strategies to make care equitable we must rigorously measure the outcomes of our policies. A claim of antiracism that is not associated with a change in outcomes is just hypocrisy that leads to cynicism.
Healthcare has a horrible history of racial inequity. There is much work to be done in our communities and in our institutions to improve the social determinants of health and end healthcare disparities. We may want to be antiracists, but so far our outcomes suggest that at best antiracism is still a healthcare aspiration and not a reality because our outcomes are unequal. The pandemic has shown a light on healthcare inequities, and in truth, we may have lost ground over the last year and a half. It is way past time for us to give up denying that we are racist, and high time that we begin to learn how to be antiracists so that we can conceptualize and implement the policies that will abolish the inequities in healthcare and all of life.
Danger Has Blown Our Way
Monday was one of those pretty nice transitional days that I wrote about last week. On Monday evening I enjoyed a few moments of bliss between weather that was warm and muggy, and the overcast wet chill that has been the other end of the cycle this summer. This year, evenings like last Monday evening have been rare. Over previous summers I have enjoyed being out on the lake at sunset almost every day. The hour before sundown is my favorite time of day. The fish are more active in the evening, and in past years I could almost always count on a spectacular sunset, or at least a pretty good one like I enjoyed Monday evening and that you can see in today’s header. Frequently I would see the loon family that seemed to be enjoying the scene as much as I do. Those evenings have been almost non-existent this summer as we cycle between dreary overcast or rainy evenings and hot hazy evenings when looking for a gorgeous sunset is far from the number one activity I have in mind. Mondy felt like a rare gift.
Things changed by Tuesday. We had more rain and then when the rain ended and was followed by a dense haziness that I first thought was fog. It did not take long for me to realize that the haze was smoke. On the evening news, I saw satellite images of the plumes of smoke from the West Coast forest fires that were spreading across the country. New York was as smoky as it would have been if they were burning trash in every street in the big apple. The Statue of Liberty was just a hazy outline in the harbor. People up and down the East Coast were warned that the air was not fit to breathe.
Later on Tuesday, I heard reports that suggested we were at risk from a chemical transformation that occurs as the smoke from forest fires in the West travels across the country. That piece of information got me thinking. What do climate deniers and anti-vaxxers have in common? Obviously, both are oblivious to science. But it is also true that their objections are self-serving and disregard the consequence of their personal attitudes and choices on the health and lives of others. The anti-vaxxer may or may not die of their own ignorance but by facilitating the spread of the “delta variant” they also compromise the health of others. The climate deniers may be seeking to preserve their investments in fossil fuels, protect their job in an industry that produces or is dependent on carbon-based energy products, or just lazy and not wanting to exert the effort or incur the expense of favoring the transition to renewable energy sources. Whatever. in both situations, it appears that there is little recognition of, or interest in, how their personal choices impact others.
I loved my father dearly and respectfully tolerated his combination of evangelical, conservative, and libertarian tendencies and attitudes. He believed in the value of work. He was a big advocate for holding people accountable for the consequences of their activities. He loved to say, “Your liberty ends where my nose begins!” It was certainly not an original idea with him as can be confirmed with a quick Internet search, but he would quote his version of the old saw as if it was holy scripture. I heard it often as he sought to convince me that I needed to consider the consequence of my actions on others, many of whom had no defense against what I might carelessly exercise my “liberty” to do.
I will be blunt. anti-vaxxers and climate deniers are a “danger to themselves and others.” By the way, I heard that reference to “being a danger to oneself or others” from my father long before I heard it in reference to mental health care. Whether you are a left-wing progressive or a conservative that would make Ronald Regan proud, you have considerable responsibility to consider the outcome of your choices even if they occur several thousand miles downwind following an event from which you can deny immediate responsibility, or from the airborne transmission of a virus to someone you don’t know who is unfortunate enough to be behind you as you asymptomatically spew your personal load of coronavirus virus while you stand maskless in the checkout line at the grocery store.
It is a small small world as Jeff Bezos reports based on his observations from the ionosphere. Even if we don’t know our neighbor, or even if we could care less about our neighbor’s health and happiness, it should be increasingly obvious for a totally self-interested person who has “eyes to see or ears to hear” that the world is becoming a smaller place where rational people are motivated, even if only by self-interest, to accept that individual choices have a collective impact.
I hope to be in nature this weekend, haze or no haze, rain or shine. I hope that you will also find some respite from the reminders all around that even in the midst of the beauty and wealth of our nation there are inequities as well as warnings crying out for our attention trying to alert us to the reality that we are all in danger. The air we breathe is blown our way like it or not. The air that blows in is our only air. Air is not like bottled water that can be substituted for the water coming from corroded lead pipes. But enough from me.
Be well. Be wise, Be concerned,
Gene
