June 17, 2022

Dear Interested Readers,

 

Thinking About About Race And Healthcare Disparities

 

A good friend here in New London was a successful Hollywood screenwriter. In retirement, he enjoys substitute teaching at our local middle school where he also sponsors a very popular after-school creative writing experience for a large number of students who flock to his offering like little bear cubs to honey. I enjoy comparing notes with him and always get the better end of the exchange. 

 

During one of our recent encounters, he told me about an interesting book, “A Swim in a Pond in the Rain” which is an analysis of seven famous Russian short stories by Tolstoy, Chekov, and other famous nineteenth-century Russian literary giants written by George Saunders. If you don’t know Saunders and didn’t click on the title to learn more about the book, let me lift a description of Saunders from a review in the New York Times. The reviewer, Parul Sehgal, wrote an interesting description of Saunders:

 

In recent years, the writer has become regarded as a secular saint of American literature, with his Buddhist-inflected beliefs in fiction’s moral, purifying mission. He made his name with his antic short stories — fables, really — thronged with suicides, amputations, broken men: “the malformed detritus of capitalism, the necessary cost of doing business.”

 

The book is the reproduction of a class that Saunders has taught for twenty years to MFA students at Syracuse University. My friend suggested that I get the book plus the audio version which is compelling because the stories are read by notable performers like Nick Offerman and Glenn Close. Each story is followed by an analysis and philosophical thoughts about writing and life read by Saunders. Saunders believes in the power of fiction to underline what is important in life and believes that literature can be a vector of transformation. In the next to the last chapter, after the stories have been told, Saunders wrote about the possibility of communication between a writer and a reader. 

 

The writer and the reader stand at either end of a pond. The writer drops a pebble in and the ripples reach the reader. The writer stands there, imagining the way the reader is receiving those ripples, by way of deciding which pebble to drop in next. 

Meanwhile, the reader receives those ripples and, somehow, they speak to her. 

In other words, they’re in connection.

These days, it’s easy to feel that we’ve fallen out of connection with one another and with the earth and with reason and with love. I mean: we have. But to read, to write, is to say that we still believe in, at least, the possibility of connection. When reading and writing we feel connection happening (or not). That’s the essence of these activities: ascertaining whether connection is happening, and where, and why.

 

That passage spoke to me in my dual identities as a reader and as someone who tries to share his view of the world as a writer. As a child, one of my favorite activities was “skipping” rocks across the still surface of some pond. In my mind’s eye, I can see the ripples on the water as they spread out so Saunder’s metaphor speaks loudly to me. He has achieved a connection with me. 

 

When I write, I do visualize you, dear  “Interested Reader,” as an individual whom I hope is receiving the “ripples” that are coming across the water as I skip my “stones.” There are so many stones to throw. Before Trump disrupted the world in 2016 and while my knowledge of practice and practice management were still relatively fresh, the stones I tossed were more focused on our attempts to achieve universal coverage while reducing the cost of care and simultaneously improving the experience of care for those receiving care and for those providing care. 

 

Things have changed. My days in practice and my time attempting to lead a practice are fast fading in my rearview mirror. Trump, COVID, an economy that is uncertain, our national obsession with guns, the unbelievable destruction and loss of life in Ukraine and the Middle East, the crescendo of violent weather as the planet warms, the apprehensions about our nation after Roe v. Wade is repealed, the rise of illiberalism, our continuing four hundred year battle with racism, and new surprises every week all feel like rocks that I should skip across the pond toward you. I can’t toss each stone every week and I am an authority on nothing but what I feel about each of these challenges. Nothing helps me deal with my own anxieties about what is happening or the meaning of it more than trying to connect with you. As Sauders said, the essence of writing is  “…ascertaining whether connection is happening, and where, and why”

 

One of my greatest challenges each week is deciding which stone to skip. This week there are several logical possibilities. Yesterday’s testimonies and presentations at the hearings of the House Select Committee on January 6th gave us startling revelations, but the situation speaks for itself. Our last president was a crook and should be held to account for his actions. Time will tell if that will happen. The future of our democracy may depend on what happens. In the hearings yesterday J. Michael Luttig, a retired federal appeals court judge who is greatly respected by conservatives, and who had confirmed to Mike Pence that the Constitution did not empower him to block the election of Joe Biden did seem to suggest that our alternatives were to defang Trumpism or lose our democracy. 

 

It is good news that we may get a bipartisan gun control bill. It is bad news that it will still be possible to buy an assault rifle even if it is harder to do for people who are angry or mentally ill. The new law will be a small step forward on a long road. Sometime in the next two weeks, we will get the verdict from the Supreme Court on Roe v. Wade. The outcome, short of a miracle, is a foregone conclusion. The major debate is not whether Roe will be repealed, but whether or not the repeal of Roe will just be an opening gambit for a series of decisions that will greatly limit other personal freedoms that offend the religious right. The floods in Yellowstone and the heat wave that is gripping most of the country suggest that the planet has been pushed to a new weather normal. I could make a longer list because I have not yet mentioned inflation or reviewed the atrocities that Russia is committing in Ukraine. I have many stones that I could toss, and most of them have significant public health ramifications. Our inability to recognize that we woefully undervalue and underfund public health is also a stone that needs tossing. 

 

The stone I am going to toss is about racism in healthcare. Sunday is “Juneteenth” or Emancipation Day. Joe Biden signed legislation last year that made Juneteenth a federal holiday that will be officially celebrated for the first time on Monday. If you are confused thinking that emancipation occurred on January 1, 1863, you are sort of right. Lincoln did sign an executive order freeing the slaves in territory controlled by Union forces on January 1, 1863. It was not until June 19, 1865, before the word got to Texas where June 19 has been celebrated by African American Texans ever since the news of Lincoln’s emancipation decree was announced by General Gordon Granger, the Federal commander in Galveston, that day over two years after the signing. The day has been celebrated by African Americans in Texas ever since as “Juneteenth” and the celebration of Juneteenth as “Emancipation Day” has slowly spread across the country. The sad reality is that “emancipation” has not meant equal rights, color-blind integration, or the abolition of concepts of white supremacy. Even more disturbing is the fact that one hundred and fifty-seven years later there is still substantial evidence of widespread racial bias in healthcare.  

 

A “Perspectives” article in the New England Journal of Medicine this February demonstrated just how confused and biased many medical professional professionals are about race. The authors wrote:

 

In the 20th century, biologic-anthropologic and population-genetic analyses of human variation demonstrated conclusively that anatomically modern humans do not have biologic races. Since human biologic variation is driven by genetic drift (random variation in allele frequency associated with ancestral lineages) and uncorrelated selection pressures, physical traits cannot be used to delineate racial groups. Traits such as skin color, tooth size, bone density, presence of hemoglobin S, and craniofacial measurements do not map to socially defined racial categories.

 

It’s a great article that deserves your attention. It also offers a good bibliography of other papers that give greater depth to this racial bias in medicine that has been fostered by over two centuries of flawed and biased research and observation that are ingrained by making misinformation the correct answer on medical exams. Near the end of the paper they write:

 

Given the long history of racialization of medicine, ongoing training regarding human biologic variation and disease will be necessary to correct generations of misinformation. Symposia and grand-rounds presentations about the cultural determinants of health disparities, the confounding contributions of population admixture, and the potential harm of associating socially defined race with disease entities will help physicians remove the “racial glasses” through which they first see patients and help them focus on finding more meaningful underlying diagnoses. 

 

It is hard to deny that despite the fact that there is no evidence of medically significant characteristics by race, race is a factor in how care is experienced and the outcomes that we can measure. Even when Black Americans have a superior socioeconomic or educational status they experience poorer medical outcomes which suggests that this shameful reality is not a function of genetics, economic status, or educational attainment. We are left to conclude that it is a function of inequality based on cultural concepts, history, and persistent biases even among those who are not aware of their biases.

 

This hidden impact of race on medical outcomes is the subject of a new book by award-winning journalist and 1619 Project contributor, Linda Villarosa. Her book, Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, was published this week and my copy comes in the mail today so perhaps it is premature for me to be writing about it, but I have read the glowing reviews and listened to an interview on “Fresh Air” with Ms. Villarosa discussing her book. You can read the high points of that interview by clicking here if you don’t have forty minutes to listen to the interview.

 

A major interest of Ms. Villarosa has been maternal and child death rates among African Americans. Most of us probably believe that it is a sad fact Black Americans experience a higher maternal and infant death rates and some of us may even believe that the fact that we rank so low among developed nations in this category is because of some failure of Black initiative or character. The more enlightened and charitable observers among us may believe that it is true and relate it to higher poverty rates and the lower educational status of Black women compared to other populations. If you are in either camp, you would be wrong. Ms. Vilarosa reports that:

 

If you’re a Black woman with a master’s degree or more, you are still more likely to die or almost die [in childbirth] than a white woman with an eighth grade education.

 

There are at least two explanations for the poor and disparate medical outcomes that Ms. Villarosa brings to our attention. One factor is the medical biases as referenced above in the NEJM article published last February and in the many other academic papers listed in that article. The second contributing factor is a concept that she calls “weathering.” Weathering is the impact of living a life under the stress of being disadvantaged by race.  As I listened to Ms. Villarosa describe how the stress of racism impacts the health of even educated and financially secure African Americans, I was reminded of what I had read recently in the fourth chapter of Dr. Martin Luther King, Jr.’s last book, Where Do We Go From Here–Chaos or Community. The fourth chapter of the book is titled “The Dilemma of Negro Americans.” Dr. King begins with a powerful statement that was true in 1967 and is most likely true today even though we would like to believe that we have made great progress toward Dr. King’s dream. He writes:

 

…It is impossible for white Americans to grasp the depths and dimensions of the Negro’s dilemma without understanding what it means to be a Negro in America…Over and over it is said in the black ghettos of America that “no white person can ever understand what it means to be a Negro.”…for there is very little in the life and experience of white America that can compare to the curse this society has put on color. And yet, if the present chasm of hostility, fear and distrust is to be bridged, the white man must begin to walk in the pathways of his black brothers and feel some of the pain and hurt that throb without letup in their daily lives.

The central quality in the Negro’s life is pain–pain so old and so deep that it shows in almost every moment of his existence…

 

The rest of the chapter filled me with a sense of guilt. Dr. King goes on to focus on the particularly difficult life of African Americans in the ghettos of our large cities in the North. He moved his family from Atlanta to a Black ghetto in Chicago as an experiment and in a very short period of time realized that he, his wife, and their children were not immune to the environmental stress of life in a big city ghetto. Later in the chapter, he writes in reference to other minorities:

 

If one is rejected because he speaks with an accent, he can at least, if he desires, work to bring his speech in line with the dominant group. If, however, one is rejected because of his color, he must face the anguishing fact that he is being rejected because of something in himself which cannot be changed. All prejudice is evil, but the prejudice that rejects a man because of the color of his skin is the most despicable expression of man’s inhumanity to man.

 

I may discover that I am wrong after I read Ms. Villarosa’s book, but from what I have heard her say I am assuming that like Ibram X. Kendi she is not expecting racism or racial biases in individuals to go away any time soon. What she does call for are institutional policies and enforcement of those policies that mitigate the impact of those inherent biases. Let’s face it, for at least four hundred years, most white Americans have assumed that they possessed a racial superiority even as some sought “to raise Black Americans” out of their poverty and inferior educational and social status. Dr. King chastizes white liberals for their weak commitment and easy fatigue in the struggle for equality. That history and the cultural concerns about “white displacement” make a transformation that eliminates racial bias in society or in medicine something that is unlikely to be accomplished within my lifetime or your lifetime, dear “interested reader.” 

 

We will probably be living with racism for a long time to come. What we can do is institute “anti-racial policies” in healthcare and in our larger society and then measure our progress toward the goal of eliminating bias in medicine and then in society. Ibram X. Kendi is aware of his own racial biases. He implies that we all have racial biases and by some definition could be called racists. I think that St. Paul was right when he wrote in Romans 3:23 KJV “For all have sinned, and come short of the glory of God.” I think he could have just as easily written that we all have had racial biases and come short of the glory of God. I hope that idea has some impact since a slim majority of Americans still believe in a loving creator, and some fraction of that number believe that he created us as equals. Kendi suggests that we give up talking about who is a racist and who isn’t. We should strive to be “antiracists.” By his definition, an antiracist is: 

 

One who is supporting an antiracist policy through their actions or expressing an antiracist idea.

 

Being an antiracist is a choice. Medicine, or more likely individual clinicians, practices, and healthcare systems can introduce and enforce their own antiracist policies and measure their progress toward equality in outcomes. We need leaders to show all of us the way forward. In my mind, introducing and measuring the success of antiracist policies in healthcare would be similar to the small win that hopefully will occur next week in the Senate in reference to some compromise on gun safety. We all know that whatever passes won’t end gun violence, but we hope it will be a start and that there will be measurably less carnage as a result of the weak but bipartisan attempt to begin to make progress after years of doing nothing.

 

People will argue that Black Americans have come a long way since Dr. King described his dream and wrote his books. What he was trying to say was that the distance yet to go was much further than most white Americans could imagine. Ms. Vilarosa’s observations, medical statistics, and the events in the news on many days suggest that in the fifty-five years since Dr. King wrote his book and the fifty-four years since he was assassinated, what he wrote is still true. I suggest that as we celebrate Juneteenth we resolve to move beyond emancipation, beyond incomplete integration, beyond a concern about the social determinants of health that generate little action, and that we make a personal pledge that we will individually try to become antiracist as the first step toward an antiracist system of medical care in an anti-racial society.

 

A Bear Comes To Visit Us, Baby Phoebes, And A Possible Explanation For The Loon Mystery

 

It has been an exciting week at our house. We had guests who are “dog people” from Massachusetts spend the night with us last Saturday. They had plans to leave early on Sunday morning in order to pick up their dogs from the kennel back in Massachusetts by noon. I was just getting up in time to see them off. My wife was enjoying a morning cup of coffee with our guests on our screened porch when they suddenly realized that we had an uninvited guest poking around between the porch and the lake. You can see the young guest in today’s header. He/she is checking out one of my empty bird feeders. 

 

The feeder in question is a heavy iron structure where I can place a plate of seeds during the day and then theoretically remove the plate at sunset if I remember and if the squirrels and birds have not consumed my offering. I will admit that there is some suet hanging over the birdfeeder which is hard to see in the picture. I am not sure the bear noticed it.

 

Our guests and my wife started shouting and banging on pots from the kitchen. The bear turned around and gave them a nonchalant inspection before wandering off into a wooded area on our property. In less than five minutes the bear was back only to retreat again when the banging resumed. By this time I had pulled on my pants and a shirt and joined the festivities. The bear made two or three curtain calls and finally wandered back into the woods not to be seen again on that day. My backyard feeders came down immediately after it was clear that he had given up his quest. 

 

I do have one feeder with seeds and one hummingbird feeder in the front yard just outside the kitchen window. I hope that those feeders are safe from the bear’s discovery because it must cross a wide area of open lawn to find them. I enjoy these feeders most of all because they are easily visible while I am doing my kitchen chores. They are also just a few feet from our side door where an Eastern Phoebe couple has placed a nest under the porch roof over the entrance. We have avoided the side door since we became aware of the nest, but if I stand very quietly inside in the shadows of our entrance hall and look through the lights on the door, I can watch the mother phoebe as you can see in the picture. (It’s not the greatest shot. To prevent her from seeing me or my shadow and flying away, I had to sit on the floor below the windows in the door and after a few minutes when she returned I shot up through the pane where the decal from our security system is displayed.) I don’t know if moma phoebe feeds the babies while popa phoebe supervises from the top of the post which holds the bird feeder or whether parenting duties are equally shared. They both seem interested in their project. Ah, the joys and the questions that nature offers!

 

 

Last week I was bemoaning our lack of evidence that we might have a loon chick. My wife is president of the Little Sunapee Protective Association so it is her responsibility to get to the bottom of the mystery of “Why no chick?” She contacted the area representative of the Loon Preservation Society. We have learned that the male that is on our lake is new. He must have displaced the male who has been on our lake for the last several years. They know that he is a newbie because he is not banded. I do not know where the previous male went. For a while, we had three loons, and now there are only two. I don’t know where rejected loons go, but it seems that when this sort of infidelity occurs there is no nesting and no chick. I guess the new couple is getting to know one another, and I will have to wait until next year to take pictures as I did in other summers. 

 

 

The summer solstice is on Tuesday. We can’t control what is happening in the world around us, but we can be in the natural world where there is much to remind us of what a wonderful place or world is, and that we must protect it to save ourselves. I hope that you will be out and about this weekend having your own adventures and making discoveries that make it easier to put all of the various worries of the world into perspective. I can only toss one stone at a time.

Be well,

Gene