Actions and Words

January 18, 2021

What is the first thing that comes to mind when you think of the Rev. Dr. Martin Luther King, Jr.?

I’d be willing to bet a nickel that you were thinking something like “I Have A Dream,” or “speech at the Washington Monument.”  If so, you are not alone.  According to Brittanica on-line, “Martin Luther King, Jr., is known for his contributions to the American civil rights movement in the 1960s. His most famous work is his “I Have a Dream” speech, delivered in 1963, in which he spoke of his dream of a United States that is void of segregation and racism.”

Now don’t get me wrong, that speech is one of the greatest orations in American history.  (I recently learned that the “I Have A Dream” section was not part of his prepared script and was actually delivered extemporaneously, making it all the more impressive.)  But it isn’t the reason Dr. King is important or even famous.  He was already famous by the time of the 1963 March on Washington, which he helped organize.  That speech perhaps solidified his reputation as a speaker.  But he was already known as, and made his greatest impact as, a doer.  I believe Dr. King is wrongly remembered primarily as a man of great words.  More importantly, he was a man of action.

Martin Luther King, Jr., was an organizer, leading people not just in speaking out against injustice but doing something about it.  He led the 1953 Montgomery bus boycott that eventually forced that city’s transit system to desegregate.  He participated in sit-ins at lunch counters in Atlanta and Birmingham, for which he was arrested.  He led the march at Selma to demand voting rights.  And at the time of his assassination, he was in Memphis to march with striking sanitation workers.

Dr. King’s focus on deeds over words was influenced by his mentor at Morehouse College, Benjamin Mays.  Black people couldn’t end oppression by talking about it and waiting for someone else to make it happen; they needed to actively confront it and oppose it themselves.  Dr. King’s brilliance came in how he defined that confrontation.  Motivated by Gandhi’s successes in India, Dr. King recognized that physical power and brute strength were the tools of oppression, and produced transient results. Moral strength and economic power, applied in non-violent resistance, were the best way to counter racism.  But non-violence is not the same as passivity.  He rejected both violence and inaction.

I have re-read “I Have a Dream” many times. The hope expressed there is a beautiful inspiration and aspiration.  But Dr. King was not a dreamer, and he knew that hope is not a plan.  As we honor his legacy today, let’s remember that he called on us to dream, but more importantly to act.  If we want to see change, we must do more than talk about it, we must do the right things.  And as Dr. King famously said, “The time is always right to do the right thing.”

My Brother Bradley

October 5, 2020

As a White person, I do not know what it is like to be Black.  As someone raised Jewish in a largely Christian culture, as a male in a heavily female profession, as a humanist in a profoundly religious society, I have experienced a sense of being different, of alienation, even some degree of oppression.  But it is not the same.  And claiming that because one has experienced alienation or oppression, one knows exactly what someone else’s alienation or oppression is like is inaccurate and even offensive.  Imagine a man telling woman who has just given birth that he knows exactly how she feels because he broke his arm once.  Not going to go over well.

At its worst, focusing on the common elements of our experience can set us up for minimization, for downplaying the unique elements of the experience of those different from us by equating it to our own.  Such minimization gets in the way of true understanding, and can come across as dismissive. This is what can happen when White people, responding to the idea of structural racism, point out their own hardships, which may be enormous, as evidence that all people have obstacles they face.  Yes, we all have obstacles to conquer.  But they are different.  One can call out the unique challenges facing Black people as a result of systemic racism without diminishing the challenges faced by many White people.  It’s not a competition to see whose suffering is worse; there’s plenty to go around.

At its best, however, acknowledging the common human experience of suffering can allow us to achieve sympathy – a sense of caring and concern for another – or even better empathy, the ability to truly recognize and share the feelings of another.  But to do this we have to go beyond “I feel your pain.  I’ve also had pain,” to “I know pain is real, but I don’t know yours.  I want to hear about your pain.”  White people who want to address structural racism can’t just rely on any of their own experiences of difficulty or alienation or oppression.  They have to be willing to listen – really listen – to the experiences of Black people.

So finally to Bradley.  Bradley entered my life about four years ago, via my wife, Lynn. Bradley, a Black man who is incarcerated in Wisconsin, contacted our minister after hearing her speak about Black Lives Matter on local TV.  (I recognize this mention of a minister may be jarring after my reference to Judaism and humanism above – just trust me on this.)  What about my Black life, he asked?  What about my son’s black life?  Do they matter?  What are you doing about those?  That led to the start of a correspondence between Bradley and Lynn, and eventually a deep relationship of which I am privileged to be a part.

Getting to know Bradley has enriched my life, and given me an understanding of racism that I could never get from any number of books or workshops.  Recently, Bradley gave a sermon via telephone from his cell that is the best, or at least the most personal, exposition of the real meaning of Black Lives Matter I have yet encountered.  I urge you to listen here – the sermon starts at around minute 31, with remarks from Lynn following Bradley’s.

Thank you, brother Bradley, for opening my eyes by opening your heart.

Equity Learning Reports

July 31, 2020

I’m going to go out on a limb and surmise that John Lewis would say that we should approach racial justice and equity the same way we approach catheter-associated bloodstream infections.

The connection may seem tenuous, but hear me out.  Traditionally, safety in healthcare was seen as an issue of “medical error.” The focus was on “mistakes” by individuals as the root of the problem, and disciplinary action as the solution.  In that kind of culture, people who had concerns about safety issues in the hospital either kept quiet for fear of being labeled a troublemaker, or they filed an “incident report,” which was used most often to punish someone for making an “error.”

Today, safety is seen as a system issue.  People with concerns are encouraged to file “safety learning reports,” with an effort to identify the system factors that allow harm events to occur, rather than finding bad actors to blame.  Speaking up is no longer frowned upon; reporting is not labeled as troublemaking.  And preventing harm is not a divisive effort to affix blame, but a collective effort to fix the system.

Similarly, racism is being seen not as a personal failing by some individuals, but as a set of customs, practices, and laws that have had the effect of advantaging some groups over others.  Justice then is not an effort to call out and punish guilty individuals, but a collective effort by all to create a system that works for all.

Unfortunately, too often we continue to view racial justice solely through the lens of individual action and accountability.  As a result, calling out examples of inequity is seen as troublemaking and divisive.  Protest is viewed as the equivalent of filing an incident report, rather than an opportunity to learn and improve.

John Lewis, who recently died, was a long-term congressman from Georgia and civil rights icon.  He was also an apostle for non-violence.  Trained and ordained as a Baptist minister, he was a co-founder of the Student Non-Violent Coordinating Committee, one of the original Freedom Riders, and a student of both Gandhi and King.  He was both an advocate for and a practitioner of peaceful protest.

I’ve often wondered about the inherent tension in the phrase “peaceful protest.”  Protest, after all, implies discontent with a state of affairs, opposition to something.  Opposition in turn implies conflict, which seems to be the opposite of peace.  But discontent is the impetus for improvement, for change.  As long as things are less than perfect, there will be discontent – appropriately so.  We know that racial inequity is an important factor affecting the health of the children we serve.  We should be discontent.  And as long as we are discontent with the current state, as long as we seek to improve it, we will have conflict.

The error is in thinking that conflict is the opposite of peace.  As C.T. Butler, founder of Food Not Bombs, says, “peace is not the absence of conflict, but rather, the ability to resolve conflict without violence.”  If discontent is the impetus for change, conflict is the path to achieving that change.  Without conflict, there is no progress.  The trick is in engaging in conflict productively to produce that change.   Any collection of more than one person – a family, an organization, a community – will have conflict, as it seeks to improve and maximize the happiness and well-being of all.  Welcoming the airing of differences and having ways of resolving those differences amicably makes for stronger and healthier families, organizations, and communities.

It has been said you can’t improve what you can’t measure.  It’s at least as true that you can’t improve what you’re not even aware of.  If my spouse doesn’t tell me that something I am doing is annoying or hurtful, I can’t change it. If a nurse doesn’t report a mislabeled medication or a near-miss wrong-site procedure, we can’t design the system better to prevent such events.  If a marginalized group doesn’t make the dominant group aware of the ways the system works against them, we can’t make the system more just and equitable.  Protest is the equivalent of “if you see something, say something.”  It’s the safety learning report for society.

My hope is that we will stop viewing protest as an effort to divide, but rather as an effort to unite us in the journey toward equity and justice.  One of the ways I think the current moment is different is the increased willingness to see such peaceful protest as a necessary constructive step toward equity.  We are starting to listen, really listen, to the concerns of many in our community.  We must then join together to take action.

I don’t know if John Lewis would know a CLABSI from a PIVIE.  But he certainly understood the idea of peaceful protest and loving engagement as a way to help bend that arc of the moral universe a little closer toward justice:

“We must never ever give up, or give in or throw in the towel. We must continue to press on! And be prepared to do what we can to help educate people, to motivate people, to inspire people to stay engaged, to stay involved and to not lose their sense of hope. We must continue to say we’re one people. We’re one family. We all live in the same house. Not just an American house but the world house. As Dr. King said over and over again, ‘We must learn to live together as brothers and sisters. If not, we will perish as fools.’”


Health Care After COVID

May 26, 2020

Just 3 months ago (!), there was a debate raging about the future of the US healthcare “system.”  Should we overturn Obamacare (the position of the Trump administration), improve Obamacare (the position of most of the Democratic presidential candidates), or replace Obamacare with a truly universal single payer plan (Medicare for All).  Very few were arguing for no change at all; despite increases in coverage and some slowing of the rate of growth in healthcare spending following the Affordable Care Act, the US continues to spend more for less results than other industrialized countries.

The global COVID-19 pandemic has led to a temporary pause in this debate.  All attention in healthcare is focused on controlling the spread of the virus, finding a vaccine and effective therapies, and repairing the massive financial damage to the industry.  But we will eventually have to come back to the discussion about what to do with health care in the US, and the pandemic has dramatically shifted the terms of that discussion.  In a few short weeks, a submicroscopic bit of protein-coated RNA has ripped the cover off the US healthcare system and dramatically revealed two of its underlying weaknesses.

The first is the extent to which US healthcare is a massive shell game that is completely supported by cost shifting.  Healthcare providers can accept below-cost reimbursement from government payers (Medicaid, and to a lesser extent Medicare) because they can shift those costs onto private payers.  This particular shift has been under pressure from employers and private insurers for some time; now, in the face of a massive increase in unemployment and an accompanying increase in people who will rely on Medicaid or be uninsured, this scheme will be tested as never before.  Moreover, healthcare providers can accept below-cost reimbursement for many vital services, such as preventive care and mental health care, because they can rely on way-above-cost reimbursement for procedural care.  But now that many of those procedures that may be elective or at least less time-sensitive have been delayed due to a severe shortage of supplies such as personal protective equipment (PPE), hospitals and physician practices are losing massive amounts of money.  And if there is a persistent change in demand for such lucrative procedures, this second cost-shifting wheel that keeps the bicycle of US healthcare going will also go flat.  We’ve never before had this kind of one-two punch before, taking out both means of cross-subsidization that keep the system upright.

The second structural weakness in US healthcare is the shameful lack of investment in public health.  This includes not only the traditional public health infrastructure for epidemiology, but everything from preventive care to well-integrated health records to funding on social determinants of health to a national stockpile of supplies and medications that is actually, well, stocked (that is part of the word, after all).

So when we get back to figuring out how to make the US health care system better and more sustainable, we should ask those proposing any of these – or any other – solutions, how their plan will address these fundamental flaws in our current state.

Lynching in the 21st Century

May 8, 2020

A couple of years ago my wife met someone here in Minneapolis, who mentioned that his father was lynched in Mississippi in the 1950s.  It was hard to believe that we could know someone who was personally touched by that.  After all, much of what we read about lynching, and the accompanying black and white photos, suggest this is something from a distant past.  It is true that lynchings of African Americans in the US peaked in the late 1890s.  But if you go to the Mississippi Civil Rights Museum in Jackson (which I can highly recommend), there are 5 tall columns with the names and dates of the 600 or so people lynched in that state alone; the most recent is in the mid-1960s.  And this only includes those that are known.  Our acquaintance’s father’s cause of death was officially listed as “suicide,” so he is not included among those memorialized at the museum.

So the heyday of lynching actually extended into my childhood, but still I considered it a thing of the past.  Until the other day, when I learned that the most recent lynching was on February 23, 2020.  Ahmaud Arbery, a 25-year old black man, a former high school football athlete in Gwynn County, Georgia, was gunned down by several people as he was jogging.  Jogging.

I realize lynching is a controversial word.  It is fraught with history and emotion.  Some of you will not want to read any more of this because you think I’m being sensationalist and overacting, or being political.  Others may be upset by a white man co-opting a word that is almost synonymous with race hatred against blacks.  My only defense is I don’t mean to offend; I do mean to provoke.

According to Wikipedia, the lynching is “a premeditated extrajudicial killing by a group. It is most often used to characterize informal public executions by a mob in order to punish an alleged transgressor, punish a convicted transgressor, or intimidate a group.”  In this case, two men claimed that Arbery resembled a suspect in a rash of recent burglaries, so it fits the definition.  The alleged crime need not actually have happened (it is unclear whether there were actually any burglaries in the neighborhood in this case).  Since this definition includes killing by a group, the murder of Trayvon Martin would not count as a lynching; he was shot by an individual.  And since lynching is “extrajudicial” killing, deaths at the hands of authorities would also not count.  Matthew Shepard was not accused of a crime, so it’s unclear whether his torture and killing would technically count as a lynching.  Yet it seems his killers intended to “intimidate a group,” and no matter what you call it, it’s a tragedy.  Moreover, while in the US blacks have been the primary victims of lynchings, lynching has historically also targeted Italians, Asians, Jews, and others.

The point is, lynching – targeted killing of people because they belong to some group – is not a relic of history, it is very much alive.  And of course, lynching is merely one type of hate crime.  Physical and verbal attacks on people and property, motivated by hate, have been increasing sharply in recent years.  Since 2016 there have been increased reports of crimes in the US against Latino/a, Muslims, Jews, and most recently Asians.  And this is not only an American phenomenon. Worldwide, one of the leading causes of death appears to be being different.

I don’t know all the reasons for this, and there are many hypotheses.  My aim is not to blame; it is to mourn.  I didn’t know Ahmaud Arbery, but many people did know him and love him.  Every one of these tragic lynching deaths leaves a hole in a family, in a community.  Taken together, they leave a bigger hole, a giant rip in the fabric of society.  I grieve for Ahmaud’s family, and Trayvon’s, and Jamar’s, and Matthew’s.  I grieve for all of us.  Lynching may have made it intact into the 21st century, but my sincere hope is that it ends here.

Equity in the Time of Coronavirus – Part 2

April 16, 2020

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.

Equity in the Time of Coronavirus – Part 1

April 10, 2020

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.

Trust in the Time of Coronavirus

April 3, 2020

“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.

The Blame Game

March 4, 2020

“Congratulations, you’re ready to be a doctor.  You’ve learned how to blame the patient first,” said the attending physician.  He had asked me – a fourth-year medical student – why I thought our patient was not responding to the medication he had been prescribed.  “He may be non-compliant,” I responded.  My intern and resident nodded approvingly.  But George, the attending physician, clearly did not agree.  I was mortified, and I could tell from the awkward silence in the work room that everyone else was as well.  This wasn’t, after all, an indictment of me.  I was merely saying what I had learned, what I had heard these and many other teachers and colleagues say countless times.  George was criticizing our entire system.

We then had a discussion of all the other reasons the patient may not be responding.  It could be the dose was wrong, or there were unacceptable side effects, or we had made an incorrect diagnosis, or the medication was unaffordable.  None of these implied the patient was at fault.  None was nearly as judgmental as that term “non-compliant.”

This was 33 years ago, and as you can tell the lesson was emblazoned in my memory.  We have come a long way as an industry in being more patient-centered – or at least talking that way.  But the healthcare system is still set up largely for the convenience and benefit of the providers.  And we are still too quick to put the onus on patients and families when things don’t work out.  Years later, a medical student was presenting to me when he said the patient’s mother was “a poor historian.”  She was using a phrase that is used very commonly by healthcare providers when a patient’s description of symptoms is difficult to follow.  I paused and pointed out that a historian is one who writes history.  He or she uses a variety of primary sources – documents, artifacts, verbal accounts – to develop a coherent historical narrative of events.  In healthcare, we are the historians, and the patient is the primary source.  It is our job to understand them and make sense of their medical narrative.  If we fail to do so, then we are the ones to blame, the “poor historians.”

That failure can lead to adverse consequences for the patient, and blaming them prevents a resolution.  Take, for instance, “no shows” – when a patient does not come in for a scheduled appointment.  The term itself is somewhat denigrating, and we typically view the consequence only from the provider perspective, such as decreased productivity or wasted resources.  We rarely think of it from the perspective of the patient: a lost opportunity to engage with their provider to address their health needs.  It might mean a delayed diagnosis, or a missed immunization or medication refill.  And our typical approach is to assume it was due to a failure on the part of the patient to remember they had an appointment.  The most common way to address missed appointments is through mail, phone, or text reminders.  Again, it’s blaming the patient, for either having a poor memory or lack of manners.  But what if the issue isn’t that the patient forgot?  What if they tried to take time off from work but couldn’t?  Or their transportation never materialized? Or they didn’t have the money for the co-pay?  Or they didn’t understand the appointment instructions because they were written in a language they don’t read?

Missed appointments are a potential source of health inequities.  National research, as well as our own data, show that a variety of marginalized groups are more likely to miss appointments than whites.  As with other health disparities, we have an obligation to understand and address the reasons behind these differences.  Equity demands that we help patients, not blame them.

It’s Not Personal

February 20, 2020

The new Equity Book Club at Children’s Minnesota is currently reading Robin DiAngelo’s White Fragility.  Written by a white woman, it explores why it is so difficult for white people to talk about racism.  This is true – perhaps especially true – even for many whites who see racism as a problem and want to address it.  While not everything in the book resonated with me, I did have a big “aha!” in reading it.  I have often struggled with the word “racism” because it seems so personal.  Racists are ugly, bigoted, mean-spirited, and often cruel.  This didn’t seem to describe me, or many of the people I know, even when they may be engaging in racist practices.  No wonder no one wants to use the word!

As DiAngelo explains, racism is different from bias, prejudice, bigotry, or discrimination.  The first three describe aspects of how we think, while the last is related to how we act.  These are all characteristics of an individual (though discrimination can be practiced by groups as well).  But they are not racism.  Racism is a system: it’s a set of beliefs, structures, practices, and power relationships that advantage one group over others.  DiAngelo posits that whites have used the term to describe individual thought or action as a way to deflect attention from the systemic aspects, and absolve themselves of blame.  If racists are bad people, then good people can’t be racist.

But racism is a system, the same way capitalism is a system.  By participating in the American economy – working, shopping, etc. – we are, regardless of our individual beliefs, capitalists.  Similarly, by participating in American society – built on a legacy of the white majority establishing advantages over people of color, and especially those of African heritage – we are, regardless of our individual beliefs, racists.  It is not a value judgment, merely a recognition of the current state of our system.  While in many ways less racist than the American society of 100 or even 50 years ago, our structures, practices, policies, and power relationships continue to advantage whites over others.  Only a minority of capitalists are ill-meaning people of the Gordon Gecko “greed is good” variety; similarly, only a minority of racists are of the Bull Connor variety.  Good people can still be racists.

Being able to see racism as a system, and not as a personal attribute, has allowed me to use the term more readily.  And we will not make progress unless we are able to talk openly and candidly about race and racism.

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