Grand Rounds

Published by Congregational Speaker on

Emily Miner

Last week Shelly asked me to share more about my experience presenting on racism in medicine to the anesthesia department at my institution. I thank each of you for the support you offered to me as I prepared for that.

This week as I have been working on finding the words to speak to you all – I cannot help but be heavy with the weight of such egregious brutality this week in Kenosha. A human bypassing the humanity of a cousin, a son, an uncle, a father, a brother. At least seven times attempting to rip the life out of a cousin, a son, an uncle, a father, a brother. Seven deafening shots forever changing the trajectory of not only this cousin, son, uncle, father and brother but also his three young boys in the car, his eight-year-old son celebrating his birthday on Sunday, his family. I can’t but hold this with you today. I can’t but mourn the perpetuation of this violence. The murderer who days later walked right by police cars, an assault rifle still hot from pronouncing death, strapped to his chest. I’m sorry perhaps your week has already been filled with this but I come to Shalom as a community that I know sees the importance of this moment. At first my temptation is to hold this with you all, to feel sorry … but as Latitra said- she doesn’t want our sadness. She wants change. This must be the mantle for each of us. I tried in a small way to take on this mantle as I spoke with my department.

The other reading today was one from Acts, I plan to circle back to that reading at the end of our time together but I want to point you to the voice of what many interpretations call an enslaved woman. This enslaved women keeps calling to Paul to pronounce who he actually is. At some point Paul seems enraged at this constant reminder. What faithfulness are we being called to? Like Latitra said, we must hold our humanity as paramount, we must see the Image of God in one another and have this be our engine for change.

For too long the humanity of our patients has not been front and center in medicine. The perpetuation of violence, of egregious brutality is present in our societies today and as I learn more is present in medicine. The history of medicine is built off the backs of enslaved humans much like the rest of our society. But, as James Baldwin famously said “The great force of history comes from the fact that we carry it within us, are unconsciously controlled by it in many ways, and history is literally present in all that we do.” Learning the racist history of medicine has been and will continue to be one of the most important steps I think I can take as a healthcare provider to recognize what I carry within me.

I carry that history in myself and I saw first hand the ways some of my colleagues carry that history unconsciously and consciously controlling their responses. As I mentioned in sharing last week I met some obstacles as I tried to bring this presentation to life. I thought that I had a mentor who was supportive of the message I wanted to bring to our department but when I finally (albeit late) got the presentation to her she told me that presenting this to our entire department was inappropriate. She assured me that I would have a platform for these messages but the entire department was not the correct context. She encouraged me to greatly change my presentation days before I was scheduled to give it to be more “traditional.” I was warned of professional ramifications for giving this presentation and also that people would

think I was calling them racist. That conversation made me think all the more what change we need in our department.

I was grateful to feel all of you behind me in that moment on that phone call. I felt less alone as I told her I heard from her that it did not seem that she was the right mentor for this presentation. I had already spoken with Deb Rhizal a midwife at our hospital who knows our department and was supportive of the need for this presentation. I reached out to Deb Landis Lewis, also who helped affirm my work as well. I did find a mentor and he told me he thought it would be a powerful presentation that could be more powerful with even more personal responsibility in it (very helpful feedback indeed). And I proceeded.

The presentation was quite long, it was geared to anesthesia professionals and so I won’t present it here today but I do find it quite important to talk about some of the racist history of medicine with you all. And some of the pitfalls I almost fell into as we talk about specific examples like this one. I hope that in talking about the racist history in my own field that is carried forward even today I can motivate each of you to shed the light in your own fields and spheres of influence. So I will discuss some of what I learned about giving a presentation like this to my colleagues.

There were scant guidelines for how I was to format the presentation I had to give to my department; all I knew was that it was intended to be based specifically on a case. But, our department had been talking about diversity, equity and inclusion and I wanted the discussion to go further. I picked a case where a Black woman had an adverse event as I was quite aware of the glaring inequalities in maternal mortality. One pitfall I nearly fell into was focusing only on the inequalities in maternal mortality. I read about other problems where too pointed of a focus on one problem, here what is going wrong with the Black mother/baby pairing, could cause our medically trained minds to make that one focus point an exception – as if there is something that is simply biological that is different in Black mother/baby physiology.

You see, we are taught in medicine to look at individuals and wonder what is going wrong with the individual. When faced with problems much broader than an individual we tend towards turning again back to the individual and wondering what unique genetic predisposition they may have inherited. While in school we are taught whole ethnic groups are more prone to disease this is not explained much further. We fall back on our training to look at an individual and left wondering what must be found in their biology for such a difference to exist. We aren’t trained much in medical school to think on the societal level. I really think this does a disservice to medical professionals as we enter into these conversations about race.

To elaborate more on this subtle but very important difference- As Javan and I were reading “How to be and Antiracist” I remember vividly when he was discussing how there aren’t genetic differences between the races. I recall Javan asking me more about this and my mind hummed with all the diseases and genetic differences we knew had genetic predisposition. Sickle Cell anemia was an example I gave to Javan where we know that African Americans are more prone

to this disease which is protective against malaria but unhelpful in our modern context. As I prepared this presentation I realized that I needed to dig further in to this discussion of what “genetic difference” may or may not exist between races I quoted extensively from the book “Medical Apartheid” in my presentation and I will again here. This quote specifically discusses the Human Genome Project that sequenced the DNA of many individuals. Harriet Washington wrote:

“Analyses found so little variation among the genomes of what have been thought of as separate racial groups and so many genetic characteristics in common that race was found to have no basis in biology… We all know what we mean (or think we do) when we denote someone’s race as “black” or “white.” In our nation, race is inarguably important in discussions of health and disease. However the HGP has erased any lingering doubts: Biological race does not exist, because all humans share the same genes. Although the proportions of genes differ, meaning that genetic differences exist, these variations map very poorly onto what we think of as races. This seems to introduce a logical contradiction: If race is not real, how can we speak of race-based therapeutics? The answer is that race is real, but it is not biological: It is social. What correlates very closely to most “racial” differences in life expectancy, mortality, disease susceptibility and survival is the race to which one is perceived as belonging.”

I told my colleages–>Your brains may be bursting thinking of all the things we “know” to be biologically different in races like Sickle Cell anemia as I discussed above. This too is addressed:

“For there are exceptions and although they are rare, it is important from a medical point of view to recognize them when we see them if we want to devise the best-possible medical treatments. However, many genetic diseases are no respecters of race: As we have seen, sickle- cell disease affects (not just those with African ancestry but also) Mediterranean peoples and South Asians, among others; the autoimmune disorder sarcoidosis afflicts principally African Americans and Scandinavians. Some genetic risk factors for diseases such as heart disease, prostate cancer and low birth weight are present in African Americans but not in Nigerians and West Indians, suggesting that factors other than African heredity are at work.”

You see–> these conceptions have real effects in our work. I don’t think it is too big of a stretch to say that the glaring inequalities in medicine are directly rated to some of these cognitive errors. I also quoted a study that showed evidence that “when we believe in biological difference between the races, we tend towards a greater acceptance of racial disparities.”

So rather than solely putting up the statistics focusing on the Black mother/baby unit showing Black mothers are in general at a 3 times greater risk of dying than white mothers and that college educated mothers are at a 5 times higher risk of dying than their college educated white peers — I tried to also show that broadly across the life span up until age 65 Black people are more likely to die than their white counterparts. I don’t want the field of medicine to get off easy just trying to figure out why Black mothers are dying. We must open our eyes to the disparities at every level. A recent study came out evaluating healthy children in the 30 days

after surgery. It showed that the odds of dying in the 30 days after surgery are 3 times greater for healthy Black children than healthy white children. Granted these risks are low but that is a real disparity.

Clearly healthcare is not equitable, the history behind this is important. I went into more details in my presentation of a particularly gruesome history of the “Father of Gynecology” – James Marion Sims – who has statues built of him. He perfected his surgical techniques on the enslaved women Lucy, Anarcha and Betsey (to name a few) who were forced to undergo up to 30 vaginal surgeries without any anesthesia. After perfecting his techniques he did provide anesthesia to white women undergoing these same procedures. While we can look at this and see the horror. I don’t want him to just be a “bad doctor,” in our minds – so I tried to apply some meaningful vocabulary to his actions thereby allowing us to understand our own actions too.

“How to be an Antiracist” is helpful in giving some clear definitions. He names racism as a powerful collection of racist policies that lead to racial inequities and are substantiated by racist ideas. And antiracism as a powerful collection of antiracist policies that lead to racial equity and are substantiated by antiracist ideas. Notably policies here are written and unwritten laws, rules, procedures, processes, regulations, and guidelines that govern people. He emphasizes that there is no such thing as a nonracist or race neutral policy, he argues every policy in every institution in every community in every nation is producing or sustaining either racial inequity or equity between racial groups. This sounds simple but is powerful in the simplicity.

The “father of gynecology” had a racist policy that black women would not receive anesthesia for his surgeries because he believed the racist idea that black women do not feel pain. Conversely, he believed white women do feel pain and thus would receive anesthesia. This led to inequity in the care for his patients.

It can honestly feel difficult in modern medicine to delve into applying this framework to current issues but I recognize is vitally important.

Many clinics have a ‘no show policy’ where if you don’t show up for an appointment or for multiple appointments you will no longer be seen. I have seen this result in more Black patients being denied further care than White patients, furthering inequity in health outcomes. This is fed by the subtly racist idea that you ought to be timely and if you tried hard enough you could make it to the appointment, and not being on time simply shows disrespect rather than the complex challenges many people of color face. An antiracist approach to this could be to have a policy that if you no show for an appointment or multiple appointments a social worker reaches out to you in order to determine why and offer you the support you may need. This could lead to racial equity with more patients making their appointments.

Another issue is compliance. The general rule is that if patients don’t take their medication they are labeled as “non-compliant.” This is recorded in their chart and essentially leads future health care providers to limit their effort with the assumption that the patient won’t listen

anyway, so don’t waste your time. This can lead to inequitable care where subpar treatment is provided to a patient. This is fed by several racist ideas. The health care providers time is worth more than the patients, so you have to earn their time. Or at its most extreme, that Black people misbehave more than White people, that it’s somehow in their nature to be non- compliant which harkens back to chattel slavery. Of course as healthcare providers we would vehemently deny such a link to the ideas of slaveholders which justified untold brutality, but is there a cultural and historical link that we inherit? Again rather than labelling these patients as non-compliant an antiracist approach would be to ask the why question- perhaps they don’t trust your care team, perhaps they don’t have the resources, perhaps they are scared because a loved one died when this medication was started, perhaps they are more aware of the history of racism within medicine than we are.

In COVID we see great inequities. At first when this pandemic hit we thought, wow this will be the great leveler, COVID is no respecter of race or class, all will be equally affected. However in general Black people are far more likely to get COVID, be hospitalized and die than white people. The guideline that governs people – that you can be in charge of your own COVID risk- is a luxury that not all are able to take part in. I have heard other ideas and even perpetuated them that perhaps biological difference in the ACE receptor is to blame, however I have started to caution myself against this approach as I think the problem is much greater than biological factors could explain. Again, I don’t want to let biological difference make me simply accept these inequalities. An antiracist approach would be to look at these racial inequities and funnel resources to these communities, find out why exposure is happening and support communities to be able to decrease their risk.

So- again that is a fraction of my presentation but the one that seems the most accessible and important to share so that you too can consider these things. To begin to discuss some of the “how” in which I went about this presentation – I want to share the way in which I went about this discussion with my colleagues and also some lessons I learned because I want each of us to be change makers in our field.

I formed my presentation around a disease process that anesthesiologists are familiar with. I used a familiar mental model. Basically as anesthesiologists we are in charge of keeping people comfortable but most importantly alive during surgery. This woman had something go wrong with her baby. When that happened bad things got into the mother’s blood stream coming from baby. Rather than the mom’s blood being good at clotting and stopping bleeding (which saves moms lives after birth), the mom’s blood clotted around the bad things coming from what was happening to baby. This used up all the mom’s ability to clot blood and instead she started bleeding. The temptation can be to see a bleeding mother and try and fix the bleeding. BUT- the only way to solve this problem is to address the bad thing going on with the baby. Without addressing the bad thing going on with baby the mom will keep bleeding even if we as anesthesiologists give her all the things she needs to clot her blood because even those new blood products will keep clotting around the bad things coming from baby.

I used this discussion to say that the racial inequities we are seeing are like seeing the mom bleeding. We can keep trying as hard as we can to pour all the right blood products in and we can try and address racial inequities in similar ways by trying to fix the problem in front of us BUT we MUST address the underlying problem with baby before any of those changes take affect. We MUST address the underlying racist policies and ideas before we can change the inequities. Our normal way of treating bleeding does not work here. I compared this to the “white culture normal” which won’t give us the tools we need to make real change.

Anesthesiologists can think about blood clotting, what are the similar things in your field that you can use to help your colleagues use familiar mental models to address racism? Briefly, some of the other lessons I learned are to find people around you who support you and can be your advocate as you think about taking on these discussions at work. I also encourage you to think about starting first with definitions when you talk with your colleagues – Just like Bonita, Starleisha and Pilisa did at the beginning of their presentation to Shalom, a shared vocabulary can help strip racism of some of its power and these definitions actually ended up shaping the whole rest of the presentation. Finally, when I switched mentors he encouraged me to make the presentation more personal. I used a lot of “we” statements in my initial presentation and instead I made it more “I” statements so that others could then identify it in their own selves. This becomes deeply personal and convicting, presenting in a style of confession is one way to help reduce defensiveness and encourage reflection.

So let’s circle back to the Acts passage. I included verse 9 in our reading because while Paul had many visions featuring a light or the Divine or angels – to my knowledge I think it is one of the only times when a man appears in Paul’s visions. It was a man asking him to come to Macedonia. While the most significant thing noted during Paul’s trip to Macedonia can oftentimes be the imprisonment of Paul and the great earthquake that opened prison doors I think there is more to the story. Not only did a man call Paul to Macedonia, a woman followed him the whole time there calling out who he really was. In this I wondered – what is the call to who I am to be? What if someone followed me day and night calling me to peace, justice and Shalom? Well- Paul eventually got annoyed at this constant call. He somewhat accidentally it seems freed this woman, who other versions of Scripture call a slave. As is often the case, the slave owners in power were frustrated when their exploitative practices were taken away and had Paul imprisoned.

Perhaps these calls from the humans of Macedonia were his main call to Macedonia- I wonder if his job there was to begin to dismantle an exploitative system. When Paul was imprisoned God sent a great earthquake shaking the very foundations of a prison and opening the doors – but it is recorded that Paul stayed in the prison, along with all the others. The title of that section is “The Philippian Jailer Converted” in many versions of Scripture. Paul was very focused on conversion and that was what he did in prison that night- perhaps though Paul was supposed to walk out along with all the prisoners in an act of defeating that system. God seemed to be trying to say something in that and there is a small part of me that wonders if

Paul was missing it! The rest of the chapter records that when Paul was finally told by the authorities to leave prison (as if God shaking the doors open was not enough), Paul insists on the authorities coming to free him themselves insisting with his Roman citizenship (the then white privilege) that they treated him poorly and he was owed an apology. Nothing is recorded of the other prisoners that night but I wonder whatever happened to them, it seems they may have stayed imprisoned. Again, it just makes me wonder if Paul didn’t miss something important here.

So I leave you with a few thoughts. I wonder what things in our lives are constantly nagging reminding us that we are to be addressing exploitation. What big picture things do we miss in our limited focus. Can we tune into these? Not just in annoyance but in earnest? Who are the people calling to us? What is the task we are called to in front of us? How can we see the humanity in one another?

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