by Curtis Bunn
Hardeman’s article created a buzz—it was discussed, argued, supported, refuted in countless circles—but there was not substantial action in response to it. And therein lies the problem.
“The public health system has not sat down and reckoned with the history of racism in this country and how we do things today,” she said. “And until we do that, we’re not going to change anything. We’ll just retrofit or shove ‘health equity’ into the back of something that was not meant to achieve equity in the first place.”
When George Floyd was killed in Minneapolis, Hardeman was simultaneously incensed and pained. She was also inspired to co-write for the New England Journal of Medicine an article, “Stolen Breaths.”
In it, she wrote:
The truth is Black people cannot breathe because we are currently battling at least two public health emergencies, and that is a conservative estimate. One of every 1,850 Black Americans has lost his life in this global fight against a novel virus that could have harmed anyone. And yet—because of racism and the ways humans use it to hoard resources and power for some, while depriving others—it has killed an enormous number of Black people.
Please—I can’t breathe.
And Black people are three times as likely to be killed by police as white people. Both these realities are acutely threatening Black lives right now. But prevailing gaps in maternal and infant mortality have long threatened our survival beginning before we are even born.
Disturbingly, Hardeman is among a legion of health experts who consider the racial health inequities a result not of a broken system, but rather of a system functioning as it was intended. Altaf Saadi, a Muslim-American physician at Harvard Medical School, sees the inequities and yearns for change. And she believes it should start with doctors.
“We, as physicians and society more generally, must realize that the struggles of one marginalized community are struggles of all of us,” she said. “My fight as a Muslim-American doctor to serve my patients without fear of racism, and the fight of an African American patient to be treated with dignity and respect, should also be your fights.”
Hardeman advocates for a revamped health care system developed by the people it will help the most.
“In order to fix it, we need a new system, and they need to be fixed by the people who are closest to the pain,” she said. “That means we have to desegregate the health care work force. And it’s not just about having more Black physicians, but also thinking about health care systems as the economic drivers of many communities, and there are many opportunities there to employ people and insure they have a livable wage and access to health care that can support the local tax base and counteract gentrification and other social issues.”
Part of that revamping has to be about upgrading the training of young doctors to include education on racism, how it rears its head in the medical profession, why it is pervasive, and how to deal with it.
“We need to make understanding and mastering the health effects of structural racism a professional medical competency,” Hardeman said. “Med students and rising physicians are training without understanding any of this. Just like you wouldn’t allow a student to graduate from medical school without knowing all of the nerves in the body, understanding the impact of structural racism has to be a part of the core competency of medical education.
“Health systems have to mandate and measure equitable outcomes. Hospitals are required to fulfill all sorts of quality indicators to get accredited to serve patients. Part of that has to be quality indicators that are tied to equity.
“Hospitals are there to protect and serve, and sometimes they have to show up for patients and be part of a community that feels safe and trustworthy.”
Hardeman’s optimism on her ideas becoming reality change often, she said, depending on the news of that day, her mood, or what she sees or hears. The impact of the BLM movement has caught people’s notice, making it perhaps the prime time to at least begin the process of implementing new criteria to reverse some of the long-standing concerns around racism in health care.
“There is power in that people are listening in 2020 and, hopefully, willing to learn and put resources behind this work,” she said. “Some of that, though, requires that people decide to see the humanity in someone who does not look like them or have a shared lived experience.
“It’s funny because the people who would shrug their shoulders [seven] years ago, when I said racism was a public health crisis, are now shouting it from the rooftop that we have to do something. That’s cool. But how many jumped on anti-racism because they read a fantastic book and all this other scholarship, and work that has been done is out there and it is the ‘it’ thing to talk about? But will you be there next year involved in the same discussions?”
Those who embrace the “false beliefs about race” make them more likely to possess biases—unconsciously or otherwise, Hardeman contends. And that makes much of this issue about the dignity one person sees in another.
“I don’t think anyone should have to beg for their humanity or to be seen,” she said. “So I’m cynical today. I’m not hopeful today.”
But in her heart, in her core, and in her desire for effective change, hope abounds.
“Other days, I think there are a lot of people across the country doing incredible work and that change is coming slowly, incrementally. We’re looking at new leaders and a whole population of young people who are asking for change and not taking ‘no’ for an answer. But it also should not just be their job. It has to happen on the policy level, too: Having racism listed as a public health crisis, making sure measuring racism is showing up in policy-making. It’s what we do with it in the next year that will determine where we go.”
The core of Hardeman’s work comes down to having racism established as a public health crisis. That acknowledgment would engineer action, she believes.
“Racism is making us sick. It saps the energy and the resources; we all lose when one race is in play. So, from a policy perspective, it’s important to name it,” she said.
“Most people were afraid to say it. You can’t change hearts and minds; that takes a long time. But by putting some sort of policy that creates language that says ‘this is what we are striving for’…we have a chance.”
Hardeman is the mother of eight-year-old Leila, which drives her passion.
“Everything I do is 100 percent all for her,” she said, “because she deserves better. I’m determined to leave things a little better for her.”
The Need For HBCUs and Black Doctors
Four historically Black medical schools have long wanted to be involved—more involved—in the efforts to minimize the health disparities that have plagued Black communities. The coronavirus outbreak was the event that pushed them to the forefront.
Black doctors make up about 5 percent of the physicians in America, meaning there have not been enough doctors of color to treat the Black population, which is all the more problematic when studies show the Black doctor–patient relationship produces better health outcomes.
With the pandemic, many health care entities like the National Institutes of Health and the American Medical Association understood the value of having Black doctors on board in the race to create an antiviral drug and vaccine, to go into communities of color where they would stimulate trust and construct pathways to develop more Black doctors—and solicited their assistance or partnered with them.
The Expanding Medical Education Act of 2020 was proposed on Capitol Hill to commit $1 billion to bridge multiple gaps in the health care system through a grant from the Health Resources and Services Administration. The funds would be split among Meharry Medical College, Morehouse School of Medicine, Howard University College of Medicine, and Charles R. Drew University of Medicine and Science.
The bill, presented by Virginia senator Tim Kaine, was drafted as a vehicle to “tackle the lack of representation of rural students, underserved students, and students of color in th
e physician pipeline,” it said, with the ultimate goal of increasing the Black doctor talent pool. Schools would use the money to make medical school less arduous and more affordable. The rationale: The more Black doctors there are, the more willing they will be to serve underserved communities and help break the established mistrust of medical institutions.
The mere idea of the legislation excited African Americans in medicine, like Donald Alcendor, a microbiologist and associate professor and scientist at Meharry, who said: “There simply are not enough doctors who look like the patients in the underserved communities. And this systemic distrust, the disparity communities have for the medical system, is something that is long-standing and has at least a chance of being overcome with Black doctors’ presence to create a better patient–doctor relationship. So, if this bill would create more Black doctors, then great.”
As exciting as the prospects were for what that bill would do, it had to make it through the new Congress that took office in 2021. A Democratic-advantaged Senate would support the bill, which was one of many reasons the Georgia runoff Senate victories of Democrats Raphael Warnock and Jon Ossoff in January 2021 were so vital.
Meanwhile, Morehouse School of Medicine received a $40 million grant from the Department of Health and Human Services specifically to do work in communities of color around the coronavirus pandemic. It is support that was a long time coming.
Dr. John Maupin, who has the distinction of having served as president of Morehouse School of Medicine and of Meharry Medical College, and who is considered a deity in the medical profession among African Americans, embraced the support, however late.
“This is a huge moment,” Maupin said. “But bigger than that, it’s a huge moment for health care in our communities during a crucial time in our history with this pandemic.”
The program, the National COVID-19 Resiliency Network (NCRN), serves as a ground attack on the coronavirus in the Black, Native American, and Latino communities, with Morehouse School of Medicine personnel teaming with local organizations to make inroads in treatment, care, and other aspects of public health.
“A lot of this comes down to trust,” said Dr. Dominic Mack, professor and director of the National Center for Primary Care at Morehouse School of Medicine. “We have been at the forefront in underserved communities during crisis before, like Hurricane Katrina. It’s our base. So, having a trusted source to treat and educate on testing and vaccinations, etc., can help overcome some of the distrust Blacks have with medical institutions.
“We know the history, and we know the lack of trust is real. But we will partner at the community level to assure we are reaching and helping the people we need to help.”
Maupin considered the grant a tipped hat.
“It speaks loudly to the value of HBCU medical centers and the value of having individuals of science and institutions that come from trusted places,” he said. “We have to have greater engagement of the minority communities in various kinds of scientific studies that give us new knowledge on how to manage and handle things.
“The efficacy of the scientific work is dependent on the people involved so you understand how things impact those in one community versus those in another community, those with one background versus those with another background.
“So, this enables a group of profound scientists and dedicated individuals who have always believed in serving the underserved to do important work where it is needed. So, this speaks highly of the work being done by Dr. Valerie Montgomery Rice [president, Morehouse School of Medicine] and her team. And it speaks loudly about what we really need to happen when we think about the future of health care in America.”
Dr. Mack simplified it. “This gives HBCUs a moment of confidence,” he said.
That confidence was increased when former presidential candidate Michael Bloomberg’s organization, Bloomberg Philanthropies, committed $100 million to the four HBCU medical colleges, with Meharry receiving $35 million.
“Graduates of Meharry overwhelmingly choose to go into primary care so that they can make the largest impact on their communities,” Dr. James Hildreth, president of Meharry, said. “But primary care, particularly in rural areas, does not provide the same level of financial security as other medical specialties. This transformative gift will significantly ease the burden of debt for our students, allowing them to make decisions about where and how they practice based on their passion, not a paycheck.”
For Dr. Pierre Vigilance, adjunct professor of health policy and management at George Washington University School of Public Health and founder and principal at HealthUp Strategic Advisors, the pathway forward is clear. Well, maybe.
“The assertion often made that these Black doctors will go back to the community they serve also makes the assumption that they come from low-income communities,” he said. “That’s true for some, but not all. Sometimes the money to work in specialized training away from these areas is influential in where a Black doctor may work.
“In the end, though, there are two imperatives: to make opportunities for more doctors of color and to build teams that are diverse because teams that are diverse create better solutions to challenges or problems. If you diversify that health care provider group or health system, and if you’re truly about this notion of population health and community wellness…you have no choice but to diversify the provider pool.”
And for good reason. “Teams that are diverse create better results,” Vigilance added. “If you have only one type of demographic in physicians, you will get a certain set of outcomes. But if you have a diverse team that is willing to go into distressed areas, you can address some of these concerns, you can break barriers, and you can improve outcomes.”
According to a National Bureau of Economic Research study, the trust that comes with a Black doctor–patient relationship would exponentially increase preventive screenings of Black men. The researchers calculated that a workforce with more Black doctors could help reduce cardiovascular mortality by 16 deaths per 100,000 per year—resulting in a 19 percent reduction in the Black-white male gap in cardiovascular mortality and an 8 percent decline in the Black-white male life expectancy gap.
Additionally, participants in the study assigned to Black doctors were more likely to have their blood pressure and BMI measured than those who saw non-Black doctors. And for invasive tests, only men who saw a Black doctor agreed to utilize more services than they had initially selected. A participant who saw a Black doctor was 20 percentage points (47 percent) more likely to agree to a diabetes screening and 26 percentage points (72 percent) more likely to accept a cholesterol screening than those who saw a non-Black doctor.
Blacks in the medical field find it frustrating to have to break down this information.
Holloway, the psychiatrist, insisted it is necessary, though.
“This is about structural racism and bias and having more inclusion,” he said. “At Mount Sinai, for example, every time we needed a pathology [the study of cause and effect of disease or injury], it was on a Black body. But every time we needed to humanize someone, it was a white body from the Upper East Side.
“So [white doctors] have this racialized sense that people from rich families who abuse, say, cocaine are given a pass, but it is a completely different mindset when the person who comes in from East Harlem was smoking crack cocaine. That’s a divergence point on the quality of the care you get. So, you have to train doctors in culturally competent care. You have to allow for people who tend to be unemployed compared to the national average to get health care insurance to address those issues. And you need more Black doctors who have built-in sensitivity that eliminates these issues.”
The Eradication of Public Trust
Dawn Baker, a television anchor in Savannah, Georgia, who graduated from Howard University, was the first person in the United States to volunteer to participate in human vaccine trials for the coronavirus. The first.
Many hailed her as courageous. But Black peop
le swiftly and unrelentingly unleashed a barrage of insults and admonishments that left Baker disappointed.
“I was called all kinds of names, and some were downright nasty. It’s one thing to be upset, another to be nasty,” she said. “I was told I wasn’t ‘woke.’ It got to where I couldn’t read the comments anymore. I couldn’t live and die with them. The hurtful part was that the negative comments, the vast majority of them, came from my people.”
Then she showed her dismay by saying: “I am a Black life.”
Baker found the contempt ironic because Black lives mattered to her, and that was the reason she stepped up.
“As a news anchor, I reported every day on the coronavirus and how it devastated Black families,” she explained. “It was so sad, heartbreaking. So, when I learned there was a need for people to participate in the trials, our people, I thought it was the right thing to do.”
Also, her family doctor of thirty years was the chief investigator for Moderna, the pharmaceutical company that ran the trials, she said. “He assured me it was safe,” she said. “I knew that some people would have a problem with me joining the trials and would not understand. But I just wanted to help.
“A lot of thought went into the decision. And I certainly did not discount the horrible things done to us in the past. But you can’t live in the past like that to make for a better tomorrow.”
The past medical malfeasance against Black people is extensive and documented—and the reason why Black people overwhelmingly rejected any notion of trusting medical experiments.
The most widely known is the Tuskegee Study of Untreated Syphilis in the Negro Male. Infected black men were solicited to be a part of a forty-year study (1932 to 1972) to treat the disease with penicillin and were offered free medical exams, free meals, and burial insurance.
