Kendra Outler, MD, MPH

Founder, Uzima Health & Wellness

charge to care in health care

September 2020

We have reason to celebrate as we usher in another administration that won both the popular and electoral votes.

The Supreme Court clapped back at the Republicans’ efforts to dismantle the Affordable Care Act or Obamacare. They ruled on Tuesday, November 10, 2020 that it was not their job to dismantle this important piece of legislation that has allowed for women, children, young workers and persons with preexisting conditions to be able to get access to healthcare.

The Biden and Harris team is tackling the COVID-19 pandemic. They will also examine how to make our healthcare system better and to fortify against so much loss of life should we have another healthcare crisis. Uzima family, I want you all to know that a better medical system is not just about access to buildings or insurance; a better medical system must be void of unequal treatment.

Last February I was invited to be the keynote speaker at a biomedical and technological minority student (BBMT) conference at Cornell University. I was both honored and overwhelmed by the opportunity to address these young Black future scientists and doctors attending an Ivy League institution. If any one of them wanted to test me on a physics formula, I am sure they would outscore me. If any one of them applied to medical school, I am sure their MCAT score would be off the chart. The recommendations to medical school would place any one of these students in the top percentile of the class. Getting into medical school is a numbers game and most premed students play to win. So, what of value could I tell them.

As my fortune would have it, there was a snowstorm and my drive there was halted somewhere between Hershey Pennsylvania and the middle of nowhere. I pulled over to a hotel and thought “let me see what tomorrow will bring. Again, I was intimidated at the prospect of talking before this brilliant group of young hopefuls. Finally, it came to me. I would tell them that the operative word in healthcare is the word “care”. I would tell them that John Hopkins School of Medicine reports that somewhere between 250, 000 to 400,00k people die from medical mistakes. We do not have a number for patients who die because the physician did not care to save the patient. That patient can be your loved one or your friend and until that happens to you personally does it become personal; for me this is personal. If I had given that speech, I would have told them the real test will be caring for a patient that does not look like you, sound like you or come from your neighborhood. What would be your price to make you care about a stranger. I wonder if doctor offices and hospitals can charge an extra fee. Except the only one problem with this is that our healthcare systems would have to publicly advertise what the administrators, doctors and staff know to be true; that patients enter a business arrangement for services when they are sick, and that care is not a guaranteed part of those services.

“Implicit” bias is a construct that social scientists use to describe an attitude we hold towards others or associate stereotypes with them without our conscious knowledge. Implicit or unconscious bias can be dangerous because it automatically seeps into a person’s affect and behavior. This creates a denial process and ultimately interferes with clinical assessment, decision-making and provider-patient relationships. This can be deadly as ultimately health goals are not met, and care for the patient is compromised. As a young doctor in a rural emergency room, I got a pearl of wisdom. One of my colleagues said, “Make sure that when you get home, you can look at yourself in the mirror.”

Howard University Hospital, previously known as Freedmen’s Hospital.

Historically, we discuss the classic case of the Tuskegee Experiment. The study which began at the Tuskegee Institute in 1932 involved 600 black men and it was designed to record the natural history of syphilis. In 1972 they found that even though penicillin was a known treatment for syphilis as early as 1947, the drug was withheld from these black men. These men died, went blind or insane or were crippled by the disease. This was a demonstration of both, willful neglect and a slow kill done in the name of medical research. Most attribute this horrendous 40-year period as the reason that Black Americans mistrust the medical community. Looking through the literature this type of blazon intentional harm to human lives may have stopped but our medical system continues to have unexplained poor outcomes when it comes to Black patients. The ghost of the Tuskegee experiment is not the only skeleton in the closet haunting Black Americans and our medical system.

Noted historian, Jim Downs wrote a revealing book, Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction in 2012. This book caught my attention as I had found myself faced with something medical school did not prepare me for; A healthcare system that would delay the care of my grandmother, rationalized not operating on her and ultimately put on a course for death. My family and I spent seven days, three hospitals later, and no issues with access or money, my grandmother that hugged me when I entered the emergency room and scolded me for talking “biggety’” to the doctors died.

In my many complaints about my grandmother’s care all the way to the head of the Center for Medicaid Services and to the Quality Assurance office for the state of Georgia, I will repeat myself… There was no shortage of doctors nor lack of money; her care was compromised. The reason was not in the medical books; it was in the history books.

Being on the other side of medicine can be sobering. In my quest for answers, I came across Downs’ book, where I started finding the historical blueprint of the American medical system. The United States has always had a fractured medical system. In slave states, medical care was relatively incentivized to keep the slaves healthy (and this is a relative perspective) in order to work or to be bought or sold. There was a plantation doctor, slaves who knew herbs that healed, and slave women who served as midwives. What we refer to today as the “social determinants of health” i.e. food, shelter and place of birth were just as important then as it is now.

Professor Downs writes, “The Emancipation Proclamation officially freed the slaves in the Confederacy, it contained no provisions for how they would survive in the midst of the war (nor its aftermath). Newly freed slaves were desperate and trapped.” According to Downs, President Andrew Johnson thought that providing physicians, medicine, and hospitals for freedpeople would create a system of dependency that even the well-intentioned abolitionist did not support. Eventually, on June 1, 1865 June newly formed Freedmen’s Bureau allowed for the Freedmen’s Hospitals throughout the south. By 1872, there was systematic pressure from Southern Whites to dismantle the funding for the Freedmen’s Bureau; ultimately making it difficult for recently freed slaves to get access to education and healthcare. We should be reminded that Howard University Hospital  was recently was a Freedman’s Hospital. Sick from Freedom helped me understand that for the first time that the ghost of a post-slavery south that viewed black bodies only in relation to the ability to labor for the society or produce labor was walking the halls of this tertiary academic medical center in the state of Georgia. In my many complaints about my grandmother’s care all the way to the head of the Center for Medicaid Services and to the Quality Assurance office for the state of Georgia, I will repeat myself… There was no shortage of doctors nor lack of money; her care was compromised. The reason was not in the medical books; it was in the history books.

Unconscious Bias is a real phenomenon. In the definition it says that it is dangerous, and it prevents a person from caring and creates a way to rationalize the result of the behavior. For families like mine it is synonymous to blind neglect, or a slow kill like in the Tuskegee Experiment.

If our congressmen and lawmakers, physicians and future healthcare providers could just sit and listen to our historians and medical anthropologists we might learn that we are all part of a system that was flawed from the conception that has racial injustice woven throughout it. I know that sounds radical as we cannot go back and dismantle hospitals and call doctors racist one by one. We also cannot deny the data that says systematically black patients are afraid to go to hospitals due to fear of mistreatment and black people whether it is COVID -19 or hypertension are dying more than their white counterparts. Hospitals put VIP on charts to signal that a person is to get a different level of attention and care. They are to get the highest level of care and only the best doctor identified should care for the patient. There are floors that the VIPs are cared for and the nurses are nice and attentive. As for the rest of us and that includes me, we must know how to navigate the medical system. We get unequal treatment.

Unconscious Bias is a real phenomenon. In the definition it says that it is dangerous, and it prevents a person from caring and creates a way to rationalize the result of the behavior. For families like mine it is synonymous to blind neglect, or a slow kill like in the Tuskegee Experiment. Implicit bias is offered as the reason certain police can see a Black person as a threat or a “bad dude”. Since the creation of our complicated medical system Black bodies have been viewed as “other”, “strange”, and “different” when we have the same heart, lungs and brain. The Black Lives Matter cry is also for our hospital care system. As humans we really do not know what we do not know. What I do know is that when you enter medical school you take an oath to practice your craft to the best of your ability and to deliver care.

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