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Please use this space to reflect, respond and track main ideas about the readings. Complete your reflections by Friday, the 28th at 5PM. We ask that everyone participates in this activity and brings their thoughts to the session!

Implicit Bias in Medicine

Tuskegee and Vaccine Distrust

About CalFresh Programs

Optional Readings:

Racial Disparities Persist in Maternal Morbidity, Mortality and Infant Health

Amazon Pharmacy

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ok to be *completely* honest, I wasn't aware that Covid had hit the Black community so strongly? I'd like to see more information about that. I remember seeing jokes online that we (black folx) "couldn't get it" because there were reports in the first few months of 2020 that Black people simply weren't getting it. So I guess I'm long overdue for an update lol.

Nonetheless: I thought it was a brilliant suggestion in the U.S. News article to have states require implicit bias training in order for doctor's to receive their license. It's a pipe dream buuut it's a nice thought and something that mightcouldpossibly happen someday lol.

Also the notion that "patients who feel dismissed and stereotyped may be less likely to pursue follow-up care, leading to unmonitored disease progression" touched me somberly. I have been fortunate enough to never have a poor experience with a (medical) doctor and I blindly trust in doctors in general so it struck a chord with me that a negative experience could possibly lead to someone never returning to the doctor again  =/

I loved that the New England Journal piece highlighted that the Tuskeegee Experiment talk is a distraction from the larger conversation around mistrust between Black patients and white doctors. Not to say that Tuskegee isn't the reason a lot of older (late 30s -40s) Black people are skeptical of the vaccine, but for people my age (mid-late twenties), I have yet to hear any skepticism of the vaccine. I do believe that the larger conversation about distrust extends beyond just doctors. I believe that Black people have been so screwed over by multiple systems (judiciary, medical, police/criminal, education, etc) that the mistrust is towards white people and the government as a collective more so than distrusts towards doctors being an isolated event.

I also learned that the Moderna Vaccine was developed by a Black woman, Dr Kizzmekia Corbett in this journal! That was a fun fact and right on brand for Black History Month  :)

This closing point was poignant.
"Though Dr. Fauci's mention that the Moderna Vaccine was created by Kissmekia Corbett, an African American woman, we need more public health messaging coming directly from Black health leaders, a challenge given that only 5% of the U.S. Physicians are Black."  Word.

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                       Donte Franklin      

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                       Donte Franklin      

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I have a peer that is a strong supporter of Trump and a hard right Republican who used the Tuskegee event to stir distrust of the vaccine. In fairness to him, he is also not vaccinated (to my knowledge). He spread misinformation through Newsmax, Fox News, etc. What was dangerous about this is that he did it during a time that Compton, Watts, and surrounding areas were being hit hard by Covid 19.
I do remember one distinct criticism he gave and that was about the public health departments using black public health officials to encourage black communities to get vaccinated. Although, I understand this logic it raises some frustrations for me.

The article on Beyond Tuskegee makes a great point stating, "But attributing distrust primarily to these instances ignores the everyday racism that Black communities face. Every day, Black Americans have their pain denied, their conditions misdiagnosed, and necessary treatment withheld by physicians." My frustration with the article is that it ends with the suggestion that we need more black public health professionals to encourage folx to get vaccinated. This suggestion is a band aid and misses the mark entirely. Candace Owens is black too, and I don't trust her. That is a simplistic way of looking at it because I am aware of the role credibility plays in trust, however the solutions miss the need to address the root of distrust.

I remember Dr. Fauci's comment, “developed by an African American woman,” and I remember the memes and jokes that followed. Although I believe that medical officials that folx can identify with support building trust, I also believe it is half thought through when there if no effort to address the root of mistrust. With that said, I also know Covid 19 called for urgent problem solving, and I'd hope that some practices mentioned in the US News article in addressing implicit bias in the medical field will also continue to build trust.

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I really like the idea of states requiring implicit bias training for doctors (and it seems like a great requirement for lawyers, psychologists, teachers, and just about any professional who requires a license or certificate). That said, I'd also like to see continuing education requirements that focus on specific strategies to curb the documented negative impacts of implicit bias. It seems to me that recognizing the existence of implicit bias is a necessary but insufficient *first* step in addressing this persistent problem.

I appreciated the NEJM article's focus on the everyday racism that Black Americans confront in attempting to receive quality healthcare. During the initial rollout of the vaccine, I felt that media outlets focused extensively on vaccine hesitancy among Black Americans while pretty much ignoring the increased barriers to vaccine access and information faced by Black Americans.  I was curious about where vaccination rates stand currently by race and ethnicity and came across this study, which seems on point and is really interesting: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788286

Explained here: https://www.usnews.com/news/health-news/articles/2022-01-24/black-americans-beat-vaccine-hesitancy-faster-than-whites

I like the structure of this study, because it suggests that there are effective actions that the healthcare system and government actions can take to build trust among Black Americans in spite of the very real racism that Black Americans have faced historically and continue to face today.

Enjoyed the analysis of CalFresh. Very curious (afraid?) to see what SCOTUS has to say about the Public Charge rule that Biden rejected. https://www.nytimes.com/2022/02/23/us/politics/supreme-court-public-charge-rule.html

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Changes in COVID-19 Vaccine Hesitancy Among Black and White People in the US

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This survey study compares changes in COVID-19 vaccine hesitancy between Black and White individuals in the US and examines mechanisms that might help explain the observed differences.

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Admittedly, healthcare policy is such a complicated Goliath to tackle that I often stick to reading articles touching the surface about the need to change the system due to economic burdens. While medical racism is something I have seen through people close to me, I have never read, learned, or considered how it could be addressed through policy initiatives. The U.S. News article’s coverage on Michigan’s Governor Gretchen Whitmer’s executive directive on implicit bias training is the first (and long overdue) type of policy I have seen on addressing medical racism. Needless to say, it’s a shame such a policy should remain an anomaly.

In reading this framework of the Tuskegee medical trials and CalFresh, a dissonance comes to mind. Medical racism in the U.S. operates on two levels. At the first level, the medical system is explicitly and implicitly designed to create barriers for BIPOC communities in receiving medical care at the point when issues arise. At the second, active programs with long-term benefits such as CalFresh certainly has positive impacts, however access to these programs is dependent upon multiple factors: immigration students, certain income thresholds, and understanding how to navigate the complicated system to sign-up. (I had a final project in school on CalFresh policies and programs.) If legislation and funding can be passed to fund programs like CalFresh to catch long-term healthcare issues in communities, then there is no reason why healthcare programs, policies, and clinics can not be place-based to best serve clients.

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My thoughts for this session will be organized around the following quote:

"In these moments, those patients
are probably not historicizing their frustration by recalling Tuskegee, but rather contemplating how an institution sworn to do no harm has failed them." Where I see progressives failing as a political movement is in this particular instance.  Where I have gotten frustrated is that it seems like people use the Black American experience and their awareness of it as more of a political aesthetic/moral high-horse that they are aware of the past, but for those of us living this life in the present, especially those of us who are lower-income we care about what can be done for today.

While I appreciate the historical knowledge and understanding of racism and abuse in the medical field, I don't know too many people (myself included) who view their current world through a historical lens. This is not to say that we should not apply that lens but it seems to me that people either live in their heads (lol) or in the moment.

Which brings me to my next point, how do we (those of us who want a society with equitable outcomes and just treatment) understand that while having the next generation of professionals become more aware of their implicit bias during our training is great, that doesn't address those who are currently in the field?

And I bring that up because for those currently experiencing the current ramifications of racism, abuse, and mistreatment it can be hard to sell a message that is essentially saying "These trainings won't help you now but in 40 years the next generation of your people will POTENTIALLY be okay because biases will be eradicated."

I think in the context of the vaccine, it's a different situation because you have a public health issue that rapidly appeared and needed to be rapidly addressed and there is only so much you can do for trust-building within the timeframe that was and continues to be the virus. Additionally, it would have been nice to know for those who do not trust the virus if it's because of racism or because of not understanding the science behind vaccines/conspiracies?

If your trust-building is focused on addressing historical abuse and harm, but the distrust is actually about being scared of injecting something into your body because you are unaware, then I imagine telling a Black person "We're sorry about the Tuskegee experiments" when someone just wants to know how this was made would not be effective.

This all comes back full circle for me to the progressive movement as I feel the movement constantly pins racism as the source of ills in a way that does not meet the current understanding of racism by society, including those experiencing racism. And without the ability to meet people where they are at, to know when to bring out the textbook and when to leave it home, and what language to use, we risk not moving forward with the needed healthcare and public health policy we need.

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When I think of the ways in which Covid has forced people to really examine the healthcare system in the US, it really frustrates me to know that it took a whole world wide airborne virus for us to start asking basic questions about who gets the most comprehensive care and why.

The most salient piece, in my mind, is the emphasis on every day racism vs historical racism. I think the constant references to Henrietta Lacks and the victims of the Tuskegee experiments are symbols of oppression and white supremacy in and of themselves (the referencing of these horrors, not the individuals). The author puts it so well when they say that it places emphasis squarely on the inane assumption that current issues are just relics of a bygone era, when in actuality racism is alive and well and rampant. I think about my Black friends in medicine and their experiences both with their personal healthcare as well as their experiences in becoming doctors, nurses, and other health practitioners. This isn't something where we say, we just need more representation (though that is definitely a factor) but rather something that we need to address at all levels.

Williams' examples of bias trainings in medical school programs touches on this but I believe we need to have continual and consistent addressing of bias throughout education (and honestly, life). If we understand that skills and knowledge take time to build and become rote, then what does it say when we only devote 4 weeks to understanding implicit bias and the way we personally uphold inequity and white supremacy? What does it say when we fully acknowledge that skills and mastery are gained by repetition and immersion, but we refuse to apply that standard to making spaces safer and more equitable in care?

I often feel like someone who is constantly saying, "NOPE. Not enough." Yet, I think I am at a point in my lived experience where I no longer feel shame or guilt about doing so. It is not enough and we live in a point in history where there is absolutely no reason why we cannot make it so. We live in an era of unparalleled knowledge, technology, and resources. Sure, introduction courses and gentle reach outs are a start but when will we as a collective consider that a good start is not enough? That progress in this area does not need to take decades, but could happen so much sooner?

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This particular topic hits close to home. I'm responsible for attending my parents doctor’s appointments to translate, advocate on their behalf for more thorough treatment and better bedside care, and to help the complexities of insurance (or lack thereof).

Its difficult to conceptualize an equitable, humanist healthcare system that could address implicit bias in a meaningful way over the long term when so much of it is entrenched in bureaucracy and profit. When healthcare is based in profit, there is no incentive for a hospital, practitioner, or insurance company to prioritize the wellbeing of someone who cannot pay for care.

I’m thrilled the State of California has passed Assembly Bill 241 to address implicit bias, anecdotally, it is a problem I notice most in private practices where doctor’s are more insulated from consequences if they’re reported. I'm happy to see that Cal-fresh has such a profound impact in lifting so many people out of poverty.

And while I’m excited to see systemic implicit bias addressed amongst practitioners, I’d like to see similar guardrails placed on health insurance companies who perpetuate inequity by providing better care to those with private, more costly insurances (PPOs), and remain inaccessible to minorities and undocumented immigrants.

If we recognize that we need more public health messaging to come directly from Black health leaders, then we must address their absence in the field.

I’d like to see stronger, government-subsidized pipelines that fast-track first-generation, low-income, minority men and women into this field to address this problem in the long term.

Their addition to this field would help bring in new medical perspectives, address implicit bias, and restore trust in Black and Brown communities.

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I appreciated how the article positioned Tuskegee: “attributing distrust primarily to [Tuskegee] ignores the everyday racism that Black communities face.”

I agree that the reanimation of Tuskegee can be a distraction.

I think that because Tuskegee is historical, white people can discount racism to be something that exists only in the past. Exclusively understanding racism through a historical lens allows white people to disengage from both the current reality of racism and having to confront their role in upholding white supremacy.

Having courses to address implicit bias in medicine could be helpful, but it’s only scaffolding to a much larger problem. America was founded on racism and a 4 week course addressing implicit bias is the equivalent of a reusable grocery bag solving the climate crisis…

Education is powerful, which is why we also need to push for more comprehensive education beginning in grade school. Our youth needs to know the truth from the start. These biases are learned and they’re taught from a young age.

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A theme connecting each of these readings seems to me to be that the health care industry in the U.S. is, as others have noted, explicitly and implicitly designed to deliver care only to some people, and not to others.

One of many passages that drives this point home for me is in the CalFresh article: "CalFresh also serves as a fiscal stimulus to the economy: low-income individuals tend to spend their benefits quickly and use the cash freed up by their benefits on other essentials. A recent national analysis finds that a $1 billion increase in SNAP benefits would raise GDP by $1.54 billion during recessions."

Why is the ability to access life-sustaining food being treated as if it's just a commodity or some abstract economic benefit? Isn't it benefit enough that through SNAP, people can eat? In my opinion, to be effective progressives, we should advocate for our values because they are morally sound, not because they offer "economic benefit." Relying on an economy-wide benefit calculation to justify the provision of food and health care for all ends up reinforcing the neoliberal logic that causes these very disparities because it implies that without that benefit, it might be too costly to implement.

As progressives, we can/should maintain that all people should have access to healthy food and quality health care because they're necessary for human dignity -- not because they're good for the economy. I think maintaining this moral clarity in our values is absolutely critical for building widespread support for health justice policies like the implicit bias legislation/other education programs (like the ones mentioned in the US News article), as well as system-wide transformations like single-payer.

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I'm going to be honest and say I really have no idea what's actually going on with vaccine hesitancy in communities of color. Black and Brown folks are incredibly familiar with racism in healthcare settings and outcomes. It wasn't long ago that white doctors measured and analyzed African skull sizes (phrenology) in the name of Science and Medicine. It also wasn't long ago that many Latinas were sterilized by the U.S. government. And the Tuskegee study remains one of the most racist, ethical violations in biomedicine history.

For me, the difference today is that the COVID vaccine is available* for all* Americans*. Clinical vaccine trials were diverse and inclusive, so no single community -- alone, by itself -- was tested on by the vaccine nor is the vaccine solely available for consumption by only one community (again, caveats). I think Black doctors (depends on who they are) doing PR is important for the community, and I feel like more needs to be done about medical misinformation.

* (terms and conditions may apply)

I believe a lot of hesitancy stems from misinformation and we know that misinformation has significant impact across every community. Many of us POC have Aunties and Uncles who are graduates of Telegram University. I think what ultimately matters is that the pandemic has shown has truly bad "access" to healthcare has been for historically marginalized communities and that we have to continue working on eliminating any racial gaps in healthcare outcomes.

Finally, shout out to food stamps. I didn't have a stable job for an entire year after I was evacuated from the Peace Corps at the start of the pandemic. Food stamps saved me, but the benefits aren't enough. They are supplemental. Not only do we need to expand food stamp access, but we need to increase monthly benefits. Ultimately, we as a society should undo the commodification of something as essential as food by making it healthy, free, and universal.

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I feel the racial bias training for doctors though important is missing the bigger issue of lack of diversity amongst doctors. Given that the article stated that less than 5% of doctors are Black, I would have liked the article to have stated if their are schools and hospitals working to get more Black med students through their program rather then equate the solution with training white people to be less racist.

It also reminded me of a tweet that was to the effect of ‘If you are a doctor or in med school it means you likely have the privilege of not having a chronic disease or have to had to spend a lot of time personally interacting with the medical system.’ Reinforcing that we need to prioritize more diversity of experiences in our med schools, and not to just stop at racial biases training.

Given my work experience on vaccine equity, I thought the New England Journal article was spot on. Folks were usually not responding distrust in the medical system or the government. I hope in the next few years medical institutions can focus on building trust in the communities. In Boston the most effective vaccinating groups were the community health centers that already had regular out reach to the community and already had their trust.

I did not know that Infant morality for Black newborns was halved when cared for a Black physician rather than a white one. The is an astonishing and scary fact.

Reading about Amazon Pharmacy was alarming given how unethical the company is. Amazon has likely collected tons of meta data on all of us and are now adding health data to that. Given how expensive healthcare is and that they are offering to sell discounted meds for folks without insurance, any malpractices by Amazon will disapportionatly affect the most vulnerable. Policies like healthcare for all or regulations on amazon (as a tech company and the tech sector in general) would help to ensure folks using this service are not exploited.

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As many have already mentioned the point that stuck out with me the most was the NEJM's point that fixation on specific historical abuses distracts from the larger narrative of everyday
contributions to distrust". Focusing, yes on Tuskegee and Lacks, AND people's everyday lived experiences get us much closer to understanding medical racism today. The article really helped bring the historical to what actually occurs everyday within medical racism for Black people in the US.

I also found it helpful the examples that the NEJM gave about trusted community messengers and what that looks like on a community based level (ie. the barbershop-based health intervention) and meeting ppl where they are. I enjoyed the example because it meets people where they are rather than a large PR based campaign. I think you need both but i often feel the federal government focuses on the latter and does not actively work to reduce the barriers present.

Regarding CalFresh- the short explainer made me think a lot about undocumented immigrants/immigrants and the healthcare system. And how there's also such a distrust, fear, and intimidation of going to the Dr. within the immigrant community as well. It reminds me of this article I read that finds all Latinos (regardless of immigration status) had lower level of trust in govt as a source of health information during eras of high immigration enforcement policies.

Again it makes me question how active progressive policies are going to find trusted messengers to correct the everyday harms they inflict on Black and brown people within our healthcare framework.