Starting With Curious

A tiny bit of RNA, enclosed in a protein coat.  The entire package is small enough that 8 billion of them would fit in a grain of sand.  The novel coronavirus doesn’t seem nearly large or sentient enough to be a vehicle for racism.  And yet….

While statistics are spotty, it appears that at least in the US, the COVID-19 pandemic is disproportionately affecting people of color, and especially African Americans.  In most places reporting data by race, the toll of this disease is far higher among blacks than others.  In Louisiana, for example, blacks make up 32% of the population but 70% of the COVID-19-related deaths.  Of course, the disease is not evenly distributed within states, but even at the county and city level, the disparities are stark.  In Milwaukee County, blacks are 26% of the population but account for 73% of deaths.  And it isn’t just deaths: blacks get the disease at a higher rate than others.  The disease rate per 1000 population is 3.5-4 times higher in black majority counties than white or Latino majority counties, and the death rate is 6-10 times higher.

Why is this?  Surely it’s not malign intent on the part of the tiny virus.  No, the virus is not racist.  But these disparities are simply the latest manifestation of the kind of structural racism that has affected the health and well-being of blacks for decades if not centuries.  Here are a few of the leading hypotheses for the disparities in COVID-19:

1. Blacks are more likely to suffer from other conditions, especially obesity and hypertension, that put them at higher risk of severe disease or death if they develop COVID-19. While some have been tempted to blame the victim for these disparities, these are the result largely of socioeconomic and health care system factors that have systematically disadvantaged blacks.
2. Blacks and those who are poor are less likely to have jobs that enable them to work from home. They are overrepresented in the kinds of service industries that require closer in-person contact that spreads diseases.  As a report from the Economic Policy Institute pointed out, only 9.2 percent of workers in the lowest quartile of the wage distribution can telework, compared with 61.5 percent of workers in the highest quartile.
3. Blacks and the poor have a harder time complying with social distancing It’s great that child care is considered an essential service, but what if you cannot afford child care and you rely on a network of family members to care for your children while you go to work?  In many places, including Minnesota, blacks are more likely to have no or limited Internet access, further limiting the ability to work or conduct other necessary activities remotely.  And the idea of wearing a mask in public sounds wonderful – if you’re white.  Some black men have expressed a reluctance to do so for fear of racial profiling, and episodes of harassment show this fear is not unfounded.

And here is the human face of this inequity: I grew up in New York, my colleague grew up in Detroit.  These are both disease hot spots.  But my colleague, who is black, knows a heck of a lot more victims than I do.  The point is, these are not statistics.  They are people.

The COVID-19 pandemic has upended almost every aspect of our world.  It has brought out the best in many of us as individuals.  But it has also placed in stark relief some of the less pleasant truths about our society, and about our healthcare system.  I only hope that this virus, when it is done wreaking its havoc on us, by making plain the inequities in front of our eyes, can compel us to begin to correct them.

An irony of the present moment is that while we are forced to remain physically distant, we are in many ways drawing closer together.  I have spent more time on the phone or Zoom with family and friends both near and far than I can ever recall before.  The countless random acts of kindness I see at Children’s Minnesota and that fill the news and social media are nothing short of amazing.  It is a cliché to note that hardship tends to bring out the best in people and draw us closer together.

Except when it doesn’t.  As South African Archbishop Desmond Tutu said, “A time of crisis is not just a time of anxiety and worry. It gives a chance, an opportunity, to choose well or to choose badly.”  Unfortunately, there are those who choose badly.  In the context of COVID-19 in the US, this includes those who hoard supplies, those who choose to put their own interests ahead of the collective good, and those who opt to divide rather than unite.  The ugliest manifestation of this last tendency is the rise in racism and hate crimes targeting Asians and those of Asian descent.  As reported in The Washington Post, a group that tracks hate speech has documented “acute increases in both the vitriol and magnitude of ethnic hate” against Asians on a variety of social media platforms.  Some are as subtle as repeating terms with ethnic slurs that imply the novel coronavirus is uniquely (and even intentionally) Asian in origin, while much is of unrepeatable vulgarity.  There are also reports of harassment and physical attacks on people believed to be Asian.

My thoughts are with the many Asians and Asian Americans in our wonderfully multicultural community.  They are suffering not only the severe disruptions we are all facing, but the additional burden of being targeted by xenophobia.  Dr. Gigi Chawla, my Children’s Minnesota colleague, chief of general pediatrics, and executive sponsor of our Asian Employee Resource Group, puts it this way: “At this time of global crisis, when we so clearly need to fully support one another to get through this, it is even more painful to have Asians and Asian Americans experience the additional trauma of blame, hatred, and social isolation-ism. COVID-19 is not an Asian problem that has become global. It was not propagated by Asian people. It’s just an RNA virus that could infect each and every one of us.”

Such divisiveness is not only hateful, but potentially harmful.  The only way to fight a scourge like the coronavirus is to do it collectively.  It reminds me of many of the science fiction books I read so avidly in the past.  One approach to global crisis was the tribalist “Mad Max” method, which was invariably dystopian and bleak.  The other was for humankind to join together, typically leading to a brighter future.  As Cuban poet and anti-imperialist José Martí said, “In a time of crisis, the peoples of the world must rush to get to know each other.”

Collective challenge calls for collective action.  Collective suffering calls for mutual caring and compassion.  We are truly all in this together.

“Truth makes love possible.  Love makes truth bearable.” – Rt. Rev. Rowan Williams, Archbishop of Canterbury

When I was starting out at a pediatric emergency medicine physician, I could not have told you who the CEO, COO, or CFO of my hospital was.  I knew we had them, of course, but they were an abstraction.  If I thought about them at all, it was as someone to blame when we didn’t have enough nurses, or when I was paying $100 a month (and this was almost 30 years ago!) to park 4 blocks away while just beneath the hospital there were mysterious “reserved” spots.  I didn’t know them, and frankly didn’t trust them.  While in some vague sense I knew we were a “non-profit,” it still felt like all the decisions made by executives were about making money.

And now I am one of those administrative abstractions to many people!  I think a lot about my experience as a clinician, and about what was real and what I just didn’t know about the work and motivation of those in the “C-suite.”  As far as what I didn’t know: I knew medicine was complex, but I didn’t appreciate how complex health care is.  Back then we didn’t talk about “systems-based practice” as a core competency for providers, and so I never really learned about it.  Even now, I think it is one of the harder things for clinicians to embrace.  The Hippocratic Oath compels us to think about the patient in front of us; systems-based practice compels us to think about all those patients and potential patients who are not in front of us.  Neither perspective is better, but both are incomplete.  Regardless of our role, it behooves us to consider how all of us are trying to balance the needs of each patient and of all patients.

As far as what was real that contributed to my lack of confidence in the people in suits, it was that I wasn’t privy to much.  Perhaps they did share information about the hospital’s finances and operations.  If so, I missed it; I suspect it was a combination of both.  But I doubt there was true transparency.  And if I had known then what I know now, I would have had more reason to trust those administrators and their motives.  To paraphrase Rev. Williams, truth makes trust possible.

That trust is always important.  At a time of disruption, uncertainty, and scarcity – like this time of coronavirus – it is absolutely essential.  If the people who work here can’t trust their leaders, if they question their motives, then we can’t possibly do what we need to: make the hard choices and shared sacrifices, to ensure that when the crisis passes we will emerge intact and able to continue our quest to being every family’s essential partner in raising healthier children.

All of us as leaders need to be truthful – open, honest, transparent.  We must share the information we have, even when it is scary.  We must admit when we don’t know, and ask when we don’t understand.  We must explain why we chose A over B, why we believe that choice produces the greatest good, even if the people we are talking with care only about B.  And we must be willing to adjust as new information becomes available, and be willing to admit mistakes.

Being truthful helps build and reinforce trust.  As leaders, we must also care – about our teams, and the organization.  Trust and caring make it easier to hear difficult truths.  Truth, trust, and caring: this is how we will get through this crisis, successfully, together.