Events & Calendars Presidential Scholar Harriet Washington

Transcript of Harriet Washington Keynote Address

- Good evening, everyone. This is the first time I've introduced an event in Johnson Chapel since March 2020. It's wonderful to be back in here, and I'm really honored that this is the event that comes first in what I hope will be a lot more. I'm honored to introduce special guests, who many of you have already met in a class or at a meeting. She is Harriet Washington writer and bioethicist. Harriet works at the intersection of medical ethics, history, and race. Exploring the history of science always through the lens of the ethics of scientific practices. And in her books, as many of you know, she offers comprehensive social histories that expose crucially important and formerly hidden parts of our history. I was just able to finish Carte Blanche today and really enjoyed just a short conversation with Harriet about what's exposed. Harriet Washington is well-known for her book, Medical Apartheid, the dark history of medical experimentation on Black Americans from colonial times to the present. Medical Apartheid won the 2007 National Book Critics Award for nonfiction. It won many other honors. She's also the author of Deadly Monopolies, the shocking corporate takeover of life itself. Of a terrible thing to waste. A Terrible Thing to Waste, excuse me. Environmental racism and its assault on the American mind. And this year is Carte Blanche, the erosion of informed consent in medical research. Harriet is a writing fellow in bioethics at Harvard Medical School. She's a fellow of the New York Academy of Medicine. She's been a research fellow in medical ethics at Harvard Medical School. A visiting fellow at Harvard's T.H.Chan School of Public Health. A visiting scholar at the National Center for Bioethics at Tuskegee University. She's held fellowships at Stanford. She teaches Bioethics at Columbia university, where she delivered the 2020 commencement speech to Columbia's school of public health graduates. And she also won Columbia's 2020 Mailman School of Public Health, Public Health Leadership Award. Harriet Washington is on campus this week as our inaugural presidential scholar in residence. I know she's met with students, faculty and staff all week. She's visited classes in a range of different disciplines. I also know directly from her how much she's enjoyed our students. She's talked with the bioethics society on campus, and with participants in our Being Human in STEM program. She's generously made herself available and we are all extremely grateful to you, Harriet. Thank you. Tonight's conversation is part of the colloquium on race and racism. It's going to be moderated by Katrina Karkazis, professor of sexuality women's and gender studies at the college, and the senior visiting fellow with the global health justice partnership at Yale. Katrina's not only moderator but a participant in tonight's conversation, and I'm really excited to hear the two of them converse. Professor Karkazis is a cultural anthropologist and herself, also a bioethicist. She works at the intersection of science and technology studies, theories of gender and race, social studies of medicine. She is the author of Fixing Sex. For some reason in the cold, I'm unable to separate my pages. Intersects medical authority and lived experience. And she's co-author with Rebecca Jordan-Young of 2019's Testosterone, an unauthorized biography. Quite a book. Katrina has served as an expert witness on gender discrimination in sport at the court of arbitration for sport. She's been awarded fellowships from the Guggenheim Foundation, the American Council of Learned Societies and the National Science Foundation. And at Amherst she's now teaching courses in feminist science and technology studies, medical anthropology, the body and embodiment. Please join me in welcoming Harriet Washington, our inaugural presidential scholar and Katrina Karkazis.

- Is this on? You can hear me? Lovely. Harriet, I have spent the week reading you, listening to you, thinking with you, and I'm just thrilled to be in conversation once again. I think we were talking maybe two or three years ago. It was pouring rain in the middle of Manhattan. No one wanted to leave, in part because the conversation was lovely, but also it was pouring outside.

- Exactly. You've had a long week and I've been able to listen to some of the talks, but I was trying to write and think through questions and think with you across a really incredible body of work, just impressive around the kinds of topics that you tackle. But always thinking about the way in which the long legacy of chattel slavery persists into this moment in terms of the health of Black Americans. And I wanted to start really with such a profound book, Medical Apartheid. If you've not read it, or if you haven't taught it, I encourage you to dive in because my students have loved this book and enjoy it. And in that book, you chronicle what you call the hidden history of medical experimentation on African-Americans and the long week, if you will, of 18th century scientific racism that lingers to the present day. And I think in tracing that history, which you do so meticulously across such a long period of time using so many examples. You've pushed us to see politically. To see across time the unfinished business of tackling race science. And it makes me think of something that poet Claudia Rankine wrote in her book Citizenship. She said, "the past is a life sentence, a blunt instrument aimed at tomorrow." And I was wondering if you could talk more about the resonances of that history that you write about that you see in contemporary society today.

- Certainly. And thank you for the kind words about my work. That's precisely what I try to do. You know, the history that I detail in the 19th century, where the best scientists in the world convene to describe African-Americans in a way that resonates to the centuries. We're still held captive by their descriptions. And for the first time you had the opinions of people in power cloaked in scientific data to give them the semblance of being scientifically But the truth was they were nothing more than the embodiment of myth. And yet we're still trapped by that. I look at Coronavirus 19 in our attempts to address it. And when it comes to the racial disproportion, a lot of the things that we focus on are direct products of that 19th century belief about African-Americans. That we contribute to our own diseases. That we're not intelligent enough to ask for our own best medical interests. What else was that when we heard about failing to social distance or African-Americans drinking and using alcohol as a risk factor an unproven risk factor. So these things still are with us and Claudia Rankine is exactly right. It's a life sentence, unless we elect to end it.

- Mhm. Keeping along with that idea, I think I'm interested in what you've called the unfortunate habits of thought. That there might be something unique to Black biologies. And I think we saw that with COVID-19. I think we still see it with examples of drugs, like BiDil, right? That there's something that, I mean, I completely see this because we talk about it in my classes. There's even 19th century, 18th century notions of people of different racialized groups being different species, and being connected to different animals. And I'm wondering if you can speak a bit more about the way in which some of this racialized biology. I know you've just addressed it in terms of, you know more broadly, but if there might be an example or something in particular that's on your mind as a specific aspect of biology or the way that that's continuing right now?

- There's so many examples. You're right. But let's talk about intelligence. We're talking about biological dimorphism. The idea that Black people and white people are biologically different and that accounts for their different healthcare and health status. So if you look at intelligence we've long, even the Roman physician Galen said that, "African men had oversized genitalia and undersized brains." The 19th century doctors expanded on that saying that African Americans were a different species than white. Indeed, as you suggest. And that they were unintelligent and they transmitted that intelligence from generation to generation. Today, we have very prominent scientists, like James Watson, echoing the exact same sentent. That African-Americans are genetically less intelligent and will always be, so interventions won't work. So, these statements actually hamper attempts to address any IQ gap or intelligence gap between Blacks and whites by invoking futility.

- Yeah, it makes me think too, like, of some of this recent work that's been happening in neuroscience. Based on this idea of neuroplasticity, where there's a way in which the focus once again is on a racialized biology so that there are ways in which poverty, for example, will affect the brains of Black children. And that in turn hinders their ability, I'm sure IQ is tied into this, but sort of their ability to perform academically. And on the one hand, you know, it's a benevolent gesture in the sense that someone is trying to connect social circumstances to a particular kind of harm, but it does it via biology to suggest that there's a particular kind of damage that's happening in these communities. And that it's a really bio-social deterministic way of thinking that seems, I think in their minds, to be separate from earlier science. It's sort of not that earlier kind of race science, but I actually think it recapitulates some of the same problems of that earlier science.

- I don't try to figure out who's benevolent and not benevolent.

- Mhm. I don't pretend to understand how people think. I don't even know what motivates me all the time. Right?

- Mhm. So instead I look at the foreseeable results of people's claims. The people you're talking about are confusing race and socioeconomics. Poverty is not limited to any ethnic group. But even if they were not, it would be illogical because the fact is there are many things that contribute. The real question is what contributes most heavily and what is worthy of pursuing a remedy based on it? It doesn't make sense to determine that something is one half of 1 percent of the cause and then devote all your resources to exploring the putative genetics of that. In fact environmental racism, COVID-19 gave me an opportunity in March of 2020. When people were talking about different bodily differences, genetic differences between Black and white people to explain why Black people were disproportionately sickening and dying. I thought, why are you worrying about genetic anomalies that may or may not be implicated in a small number of people? When we have very dramatic example of environmental racism. Toxicity is affecting people of color dramatically and causing dramatic increases in risk factors. And yet we're not really looking at that. I wrote an article for Nature magazine in which I posited that. And the most frequent response I got was from people who said, "Well, you're saying that it's race driving environmental toxicity, but isn't it socio-economics?" And I pointed out that, no, it actually is race. That even middle-class affluent African-Americans have more exposure than profoundly poor whites.

- Mhm. So all these mythologies start with bad science and bad assumptions from the 19th century.

- Mhm. And it seems to me what I'm hearing you say too, over and over is that it's a myopia to keep returning to biology, right? As though we can isolate these social determinants, just find that part that is attributable to biology. But the problem is it's only ever responsible for a very, very small amount.

- If any.

- If any, and yet the funding goes into that. In the meantime, the social economic and other factors are very often bracketed off, as if they could be bracketed off.

- Exactly. You said it, summarized it exactly.

- Yeah. Something else that I was thinking about, and you had mentioned COVID and I had some questions about COVID. Maybe one of the places that I'd like to start with that is, I believe you wrote somewhere where talking about the connections between the protests after the murder of George Floyd in 2020, and also, you know, some of the, what was happening around COVID as well, and kind of a convergence around those protests and COVID. And I'm wondering what connections you see between what happened that summer?

- I was talking about that with a class this morning, and it's a very important connection. I think we all sense there's something there, right? This escalation in violence is concomitant with the rise in Coronavirus 19, and we all sense that there's some kind of connection where it's not exactly clear. And some Canadian scientists have gone a long way to providing that clarity, in my opinion. What they have done is, they have a theory that Stranger Infection, infection suffered by strangers to us. We overreacted or react differently. We react differently because we don't have any physical way of determining who's infected, and non-infected. You can look at somebody and maybe if they have pimples or pustules, you could kind of surmise that they might be infected. But we also react that way to people with different skin color, or even people with a different diet. And so we have these very poor cues that trigger us into overreacting to infectious disease. And why do we do that with strangers and not do it with domestic disease? Because being infected by a disease that you have no immunological knowledge of or experience with is especially deadly. Just ask all the European soldiers who died in West Africa, and what they came to call the white man's grave. Of diseases that Europeans had no experience with, had no defense against. For an African exposed to the disease they might get sick for a few weeks and recover, but the European soldier would die. In this country, Native Americans succumb en masse to syphilis strains that they had not encountered before. Influenza, things like that. So stranger violence makes us overreact and we overreact very inaccurately based on things like diet, what kind of pets people keep, but mostly their appearance. And that's exactly what we saw happen in the early days of the coronavirus pandemic here. Remember the point where a hundred Asians a day were being assaulted, physically assaulted. Serious assaults. An entire Asian family was attacked in a supermarket and slashed by an assailant, who put them in the hospital. Every single day Asian people going about their business were being. Oh, I'm sorry. Asian people, Asian Americans, people who even looked Asian were being accosted. Yelled at. Told they were Chinese said, "Don't bring your Coronavirus here." And then finally they began to be assaulted. In New York City, I saw a transition to include African-Americans. When African-American men wore a mask, they were thrown out of stores by security guards, and police said, "You're wearing a mask. You could be a criminal." Disingenuous I know, but that's what they did. But African-Americans in New York City who did not wear masks, were accosted by the police. Given summons. Even arrested. And at the same day, the very same day you had police going through affluent parts of Manhattan, handing out masks to white people with a polite request to put them on. So the ethnic violence was spreading. And I think this theory does account for our overreaction to stranger violence. Unlike some animals, you know, like tadpoles, Caribbean spinal lobsters, they can identify an infected person and avoid them. But we can't do that by looking. We need a laboratory. If we don't have that, we can't tell who's infected and who isn't. So we overreact and American citizens who look Asian to them or have an Asian descent are called Chinese and are assaulted. You know, very stupid, you know, but it's something that happens. So I think this theory goes a long way to explaining the explosion of violence that we're seeing. And I just want to know that, of course it wasn't confined to Asians. I remember the first step that really chilled me cause it was near me. A Black woman in Brooklyn was killed in an emergency department by another patient who said, "she wasn't practicing social distancing. For all I knew she had the coronavirus and would have killed me." So she killed her. So I think that's a connection and we definitely need to examine how we can turn that insight into real solutions.

- I really appreciate that. I remember actually talking to some Black male friends of mine who purposely were choosing masks that had smiley faces and other things because that what you were supposed to do to protect yourself is actually that which endangered them because of how they were perceived, which is an incredibly important piece. Thank you for mentioning that. I was thinking as well about COVID because the way that it's been talked about a lot is it's an epidemic of comorbidities, right? So that people are ostensibly having underlying conditions, and then there's some exposure and that in turn, you know, puts them at risk. And before thinking about that, I was really thinking about how it is that we come to understand and study health inequities, and some of the double binds that that puts us in when it's really about health disparities, about racialized groups. And part of what I was thinking is that, analyzing how structural racism systematically generates health inequities requires a particular kind of scientific theory or hypothesis or data, but when it comes to racialized health inequities, any attempt to analyze any of this actually requires that we engage with the profound challenges of conceptualizing race, right? And operationalizing race and analyzing the very data, which are racialized categories. And I'm just wondering within the U.S. and the histories of, you know, sort of the contested production of racialized data. You've already mentioned some of it already in our conversation. That extends back to, you know, a slave Republic and the racialized science that race science and racist science that you've talked about. That both the non-use and the problematic use of data on racialized groups. And if you have thoughts about how we can use an anti-racist science for health equity? That employs data on racialized groups, like what, how is that done?

- Again, data are weaponized and that weaponization includes mishandling data, misanalysis, using that incorrectly, collecting incorrectly and not controlling for bias are always going to operate in the direction of enforcing some kind of racial stigma or problem. And that's what happens so often. The data can be copious and look convincing on the surface, but often on the way they've been collected or they're categorized means that the bias is going to be reinforced.

- Mhm. And reifying particular racial categories, which can be.

- Exactly. You mentioned BiDil earlier. A very good example of that.

- Mhm. One of the things I wanted to talk about, because I think it's a really wonderful example of the way that you're writing and your engagement actually has brought about really profound changes. In Medical Apartheid, you do a really long discussion of the gynecologist, J. Marion Sims, and the way that his surgical techniques on enslaved Black women that were done excruciatingly repeatedly without anesthesia had sort of, you know. He'd been propelled to this place of a heroic doctor, one to be admired. But one of the things that you talk about is that actually he had contemporary critics in his time and that there were physicians that were both white and Black, who attacked his methods as barbaric. And I wonder, should we pause and have you talk about that? I really want to also have you talk about the statue, but maybe we should pause.

- I can briefly talk about that.

- Yeah.

- You know. What's often said is that James Marion Sims was the father of American gynecology. He was a medical hero and only recently have loud mouth firebrands, like Harriet Washington, began criticizing him. Okay. That's not true. He was criticized in his own time. His white male contemporaries, and the fellow surgeons criticized him. They did not understand why he was giving morphine to the enslaved women, after the surgeries. He didn't give it to them to dull the pain. He gave it to them afterwards. One historian theorized, he did that to make the women more compliant, you know, and to prevent them from protesting too much. That was one theory. But the other thing was he was criticized by other doctors who said what he did was wrong. Most doctors agreed that he should work on enslaved women. They worked on enslaved women, but a few doctors said, "No, it's wrong." One of them was Daniel Hale Williams, a Black surgeon who complained about Sims. But Montague Cobb, a graduate of Amherst by the way, and a very esteemed and brilliant doctor and physiologist He supported Sims. He said, you know, the end justifies the means basically. So there was a very unlively debate about whether Sims was right or wrong in his own time that is ignored by his critics.

- So taking that into account and the fact that there were, you know, people going back historically to his own moment and then there are people such as yourself that are writing this history for newer generations. My sense is that your writings about this were really critical to the statue of J Marion Sims coming down in New York City. And I'm wondering if you can talk about that in terms of whether or not you were involved, but also the importance of that statue coming down.

- Sure. Sure. And that's true. When Medical Apartheid was published, I gave a lecture at the New York Academy of Medicine. The statue is directly across the street from the academy. When I finished my lecture and mentioned Sims, a medical student in the audience jumped up and said, "We have to tear that statue down!" And I said, "If you do don't use my name because I'm already in enough trouble." But it took 10 years. But the women who lived in the area, mostly Black and Hispanic women now and medical students joined together and petitioned the city. Petitioned the parks department. Petitioned everyone trying to get the statue taken down. And they vandalized the statue. At one point, they had like this big white roll that I thought was a diploma put in his hand. And the medical students said, "No, that's a joint." So eventually the statue was taken down in February of 2018. I was so happy to see it taken down. What's interesting is many people were angry about it taken down. And I kept hearing things like, "You're trying to change history." And I said, "Yes, trying to correct it." But the thing is, statues are not historical documents. If you want to learn history, open a book. Don't go to a statue. The statues often are erected not for historical knowledge, but to lionize people and to remind people living in the area, who was in control. That's why Confederate statues are raised and that's why James Marion Sims statue was erected. And I was very happy to see it banned from Central Park.

- I wanted to, I had the fortune of hearing you on Monday talk a bit about this idea of vaccine hesitancy in more generally, but really in the Black community and some of the misconstruing that's happened in the media and in other arenas around that. And B, I want to use that as a beginning to actually ask you a question after that, but can you start with some of your observations about how this has been framed regarding vaccine use in the Black community? I guess the clinical trials, as well as adoption.

- Sure. The 19th century doctors said, as I've mentioned, that African-Americans would not even act intelligently in their own interests and that's why they were sick. And historically, people who have not bothered to learn all of the history and who don't understand that there have been 400 years of medical abuse will always invoke the Tuskegee study to explain this. Okay. So when it came to try this with the COVID vaccine, what I read every day in medical journals and newspapers was that African-Americans were refusing to join the clinical trials. I'm sure you read it too. Every single day. By the end the recounts got kind of nasty. They're saying things like, "If we don't end up with a vaccine, it will be the fault of African-Americans. You know, who don't join clinical trials." When the trials ended, and we were fortunate enough to have two mRNA vaccines that work really well and were safe. I contacted Johns Hopkins and talked to on regional data for the clinical trials. And what did I see? 10 percent of the people in both Moderna and Pfizer BioNTech studies were African-American. 10 percent. African-Americans were 12.3 percent of the population. That means that they were extremely well-represented. They had a very good showing. They were not avoiding the clinical trials, even though we were told every single day that they were. Okay, I found that disturbing. Next, what we read was that now we have a vaccine, but African-Americans are avoiding it. They're avoiding it because of Tuskegee. First of all, the evidence offered was that African-Americans had lower rates of being vaccinated, which is true. That does not mean that they're refusing the vaccine. That means they're not getting the vaccine. We have an established why, and the reason why I think had much less to do with rejecting the vaccine, and more to do with poor policies. One of the policies we adopted was that 85 year olds should be prioritized. Elderly. They're more vulnerable. That makes sense, right? We need to protect our elderly, But what does it mean to prioritize 85 year olds? In this country, Native Americans, Hispanic Americans, African Americans are young populations. If you look at 90 year olds in the U.S. you will find twice the rate of 90 year olds in the white population as the Black population. When we prioritize the elderly, we were effectively limiting access of people of color to the vaccine. Wasn't our intention, but that's what we did. Moreover, how do people access appointments to the vaccine via the internet? In many areas, there isn't a reliable internet access. Many people of color don't have access. And many people of color did not have the luxury of working from home. They had to work at jobs where they had to be there all day long. If they indeed had access, they had to wait until their quote unquote, spare time to go online. I got an appointment by going online several times a day, at least an hour each time. I finally got an appointment at a place 250 miles away from me. And luckily at the last minute I got a local appointment, but most people of color can't do that. Most people can't do that. And so these policies are what really separating people At the same time, we're blaming them as if their rejecting the vaccine is really the problem. It's not. It's inequitable access to the healthcare system.

- Mhm. You know, you made me think of something else. So there's kind of this narrative, I think, happening around vaccine hesitancy that is sort of making caricatures of different populations. I don't think there's one voice that's vaccine hesitant. And, one of those is actually a vaccine hesitant Black population that either because of Tuskegee, or you know, harm from. I mean, it's usually nebulous. It's never very well connected because no one actually talks to anyone. They theorize that maybe they have some knowledge of Tuskegee and that's why. And I was thinking about this because I recently came across two men who were not interested in being vaccinated, but it's not any of the narratives that you typically hear in the media. And I was thinking about it because, I don't know if anyone has seen this, but years ago, Anna Deavere Smith did a play called Let Me Down Easy, where she interviewed people about the healthcare system. And one of the people that she interviewed in that play was a white doctor that was at Charity hospital in New Orleans. And when the flooding from Katrina started to happen. She was a white doctor. The vast majority of the caregivers in that hospital were Black. And she kept saying, "They're going to come and get us." And the Black patients and the Black healthcare workers said, "No, they won't." And as the days go on, there's no food, there's no electricity, they're rationing the vents. And this continues. And she holds out hope. And finally, what she realizes that people around are getting rescued that are at the wealthier hospitals, the white hospitals, but not there. And in her mind, what she said is this is the first time that I really understood what it meant to have your country not be there for you. And it's a long preamble to, to ask what I want to ask. But what I was interested in is that for the people that I had spoken to. There's not a sense that this system is trustworthy, and so to all of the sudden have a country that has not prioritized your health. And in fact has made it very difficult for you to access healthcare, or to get other kinds of things that you need. It's kind of unfathomable and unbelievable that the country at this point would be caring and would want to, you know, and just expect, yes, we want you to be healthy. We want you to have the vaccine, and so come in. But I think I was hearing you say earlier in the week, that's very hard to do when the whole system itself has not been trustworthy. And so why should they, you know, in that way, trust it. When all of the policies of the land have very often worked against them. And I'm just wondering, if that's something that you've come across or you've seen that narrative, or something you could speak to, or maybe it's just the wrong place to be pointing.

- I say this every day, we focus on the reticent and the distrust of African-Americans. But the real problem is that we have an untrustworthy healthcare system. Fix the system. People will flock to it. So we need to focus on both, not just African-American behavior, as if that's a pathology driving. It's not. It's the untrustworthy healthcare system. I want to back up to, and say something about Tuskegee. As I suggested before, it's a lazy, you know, nonintellectual tend to explain behavior. And fortunately, Thomas Loveisck, a professor at Johns Hopkins has written an entire series of articles explaining why Tuskegee syphilis study is not the reason African Americans avoid healthcare and distrust the system. He has pointed out among other things. In one subject study, he pointed out that people who have never heard of Tuskegee are more afraid of medical research than people who have. It is four centuries of abuse in the healthcare system, not one single study that causes people to react. And you know, it's important because if you blame Tuskegee or African-Americans reacting to Tuskegee, what are you saying? You're saying that Black people are overreacting to a single study. That's not what's happening. Black people are appropriately reacting to four years of abuse and falses. Being lied to. So what you said is exactly right, the untrustworthiness of the healthcare system. It's what has brought us to this past. I'm wondering if that makes me think about your latest book on informed consent. And I think those of us that sort of dwell in the land of bioethics, you know, have an understanding from some empirical work that it's a deeply flawed process, whether it's in the clinic or for research. But what you said, I just want to grab your words. That there's another type of erosion of consent that's been lurking. And I'm wondering if you can talk about the kind of egregious violations of consent that you talked about in your latest book, Carte Blanche.

- Most Americans think that they can't be involved in medical research without their consent, right? You have to be able to say yes or no. And generally that has been the truth until 1996. All that changed in September, 1996, when the law was changed. Two addendums were added to the code of federal regulations. One said, if you're a trauma victim, you can be used in research without asking you, without even telling you, without telling anyone in your family. The other is a waiver that said for certain types of research, we no longer need people's permission. One type was generally, using people's data and you could almost see the rationale there. But the other was using research that didn't have more than what they called minimal risk. But their idea of minimal risk does not coincide with my idea of minimal risk. Their idea of minimal risk includes giving ketamine, a very potent anesthetic to people on the street by EMTs who decided they're too agitated and need calming down. 40 percent of being given ketamine that way, wake up the next day in the hospital on a ventilator, and next to them is a form saying, "You've been enrolled in a medical study. Research study. If you don't want to be in it, no problem. You can opt out, just sign the form." Opt out of what? They already have the ketamine. They're already in the hospital on a ventilator. Their objection is not to being infused without their permission. They had to go on a ventilator with nobody asking their permission. These kinds of things have burgeoned now. By my count, at least 900,000 people have been used in research without their consent. That includes soldiers, who were forced to take experimental Anthrax vaccines and people being given ketamine. And it's a huge problem because every day there's new evidence or new studies being used without getting people's consent. And that's unacceptable.

- How are we doing on time? Anybody want to give me a signal?

- Anybody have the time? I have more questions as always, but I want to, what do you think? Maybe one more. Yeah? Okay. I want to ask a big, hard one, but it's one, I think about a lot. So you may not have an answer.

- We'll see.

- Yeah. I was thinking a lot about this during COVID, and white acceptance of Black and brown death is not new, and.

- I'm not sure. I'm sorry, repeat that please.

- White acceptance of Black and brown death is an old thing, in other words, right? It's longstanding acceptance. In the insistent neglect and violence that renders premature death as normative. And I think it risks ongoing indefinite rationalization in some of the ways that you've really, you know, you've detailed tonight in a really lovely way by putting the problem inside individual biologies or lack of trust or other things rather than locating it in systems and histories. And I'm just wondering, how does Black and brown death become as intolerable as white death?

- I think you would have to ask that question of the people who are tolerating Black death. It's a lack of humanity clearly, but the cost of it and the the solution probably varied because we have a spectrum here. We have a spectrum of people who. I'm thinking of something that happened in the 1970s. My father was a military advisor. He was sent to Vietnam in the 1950s, and he and all the other military advisers unanimously said, "We don't need to be in Vietnam, unwinnable war." They continued the war anyway, as you know. He was sent back in 1970, and at this point he was really angry and bitter. This war should have been over 20 years ago. And as a military advisor, he could not carry a weapon, but he could be shot at, right? So it was a really hard time for our family. And I was very upset. My sisters and my brothers were really upset, and my mother would try to comfort us. And one of the things that she often said was, "You have to remember life is very cheap over there, but we're not like that." I think that this utterance about life being cheap, this, you know, vocalization of the lesser quality or value of other people's lives is something people do very often without really admitting it to themselves. And I think we're looking at that here.

- So we're going to open it up. I think anyone is able to ask questions if you have them and I very much hope that you do. There's a mic here. And I think we'll also be fielding some from people online. So please don't be shy.

- Go for it.

- From Richard.

- I appreciate it. Okay. So this is from Richard. "An understanding of race," and this is in quotes, "in medicine" and how the resultant disparities exist does not lead to tangible reductions. How can payment by CMS or commercial insurance plans leverage money to decrease disparities?

- I'm not sure how to answer the question.

- I'm actually not quite sure either, and unfortunately we don't have him here to help us with this.

- Could we possibly have the mic brought to people, who want to ask a question?

- Yeah.

- They might be more comfortable.

- It's like class, I just call on people.

- Okay. You guys can hear me fine?

- Yes.

- A lot of, a lot of the antidotes you listed were also in reference to Johns Hopkins, but after, I took an HDM class over the end of January, and I also know that the institution itself, Johns Hopkins isn't well, it isn't excused from all it's done as well. Do you happen to see any irony? And I guess what they've done in the past and what they've done now?

- I did work when I was at Hopkins, but in terms of the institution itself. Quite frankly, Johns Hopkins fits very neatly

- Mhm.

- They don't really stand out as especially good or bad. We know about episodic abuses. We know about Henrietta Lacks. What people don't know about was that the only documented Burke in this country was people affiliated with Johns Hopkins. A Burke is when you kill somebody to sell their body to the medical school for dissection. The only documented one happened involving Johns Hopkins, but. And then of course the marginalization of medical genius. Something that happens all over the country, and very famously it happened at Johns Hopkins, when Vivian Thomas, you know, who mastered a particularly difficult pediatric surgery was paid as a common laborer and had his work appropriated by surgeons. So, but these things happen at all medical schools in the country. I think it's sometimes a mistake to vilify a particular institution when it's doing things that everybody almost had done. We're looking at American failures from American institutions. And I just rarely see the benefit in singling an institution out unless that institution is either defending its venal actions or refusing to acknowledge them. And that's not the case with Hopkins, they've pretty much owned up to what they had done as far as I can see. Great question.

- Hello.

- Hi.

- I have more of a personal question. My own father has like neglected to get the Corona virus vaccine, and a lot of what you were talking about, this kind of like fear of the medical institutions and also just kind of with the whole masks. He's a laborer, so he's mandated to wear two masks. And we live in New York. So a lot of these pressures start to amount to this resentment to get the vaccine. So I just wanted to know how I could, as a daughter, be impartial and say, you know, "Please get the vaccine. I really want you to be safe." But also come with evidence and not make him feel judged for not having it himself?

- Well, I think. That's a very good question. I think a lot of people probably have the same question, so I'm glad that you asked it. I think one of the most important things you can do for family members and friends is to ally yourself with a part of them that is entertaining fears because those fears are justified, you know, they may not be factual. I don't think people have anything to fear from these vaccines, but I don't blame them for having the fears. It's a logical fear. It's based on history. It's based on known facts. So I think it's really important to let them know that you agree with him. The system is not trustworthy. Certainly researchers are capable of developing a vaccine that could be harmful. We know that unfortunately. Our government has done that. We've disseminated vaccines and treatments that we have known are harmful. That can happen. So let them know that you're not judging them in that sense, and that you actually agree with their fears, but then speak to them about the reality of the present situation. There are factual ways to do that, and there are cynical ways to do that, and I've used them both. I mean, the factual ways are just pointing out. The truth is with this type of vaccine when problems have emerged in the past with vaccines, and they have, but typically they emerge before now. We would've known by now if the, you know, if there were problems. The fact that so many people have taken them, and there have been so few adverse effects is a very powerful argument. And I'd probably amass a little bit of data, and show him that look, you know, it's not hurting people. It's not killing people. It's the best thing you can do. Now, the most cynical thing I have said in the past, don't judge me, is in talking to family members who are dead set against getting the vaccine, you know, and the arguments were the same kind of arguments. Look what they've done in the past. Look what they've, you know, done this to Black people. Done that to Black people. I'm like, yeah, I know something about that. I agree with you, you know. But! But, in the end I said, Look vaccine. At that point, I had this discussion. There were still people who were having a hard time getting appointments, you know, and vying to get it. And there had been an event in New York City where they decided that part of the city was filled with Black and Hispanic people who were not getting the vaccine and who wanted it, So they designated a special site for vaccination. Guess who showed up at eight o'clock the next morning? Rich people from the suburbs, and from upper east side. I showed him, I said, listen, "White people are knocking each other out of the way to get this vaccine." I think it's safe.

- It's true.

- It's the last resort, but it works.

- Yeah. Atlanta as well. It happened all over the place. Oakland, same thing. Yeah. Hi!

- I'm curious if you could talk a little bit, I know for pre-medical students here at Amherst college they have to take, four chemistry courses, two physics classes, a stats class, all of these classes and what we call like maybe hard science and there's no requirement to take, for example, like a feminist science studies class or something about bioethics and or race and medicine. I'm curious if you could talk about kind of how even what we expect out of our doctors as part of the problem, and if how to make changes concretely from that?

- Very good point. Very interesting one too. The talk around affirmative action. Often devolves around test scores, and it's almost laughable. The people who are protesting affirmative action who by the way the lawsuits are being brought not by groups of white students who feel that they've been slighted. They're being brought by Edward Blum. He started several across the country, 65 year old man who is , He wants to end affirmative action and he's instigated a number of lawsuits against it, but he will pretend to be advocating on behalf of Asian American students say for example. Okay. The argument devolves around test scores. You've got a group of students who are whites, who are Asians and their test scores are in the 99 plus percentile. And what are you doing? You're admitting Black people whose test scores are only in the 99th percentile. The differences are so small as to be negligible, but more to the point there's no evidence, in fact, few studies. No evidence showing that having a high MCAT score makes you a good clinician. The things that are being tested do indeed, don't test things that measure your prowess in medicine. There isn't a connection between being a good clinician and many of the things that are being argued with. There's no connection between having an A in a lot of these courses. I talked to doctors who told me the last time I used this particular course was when I was in graduate school. They don't use it. So these are essentially badges of achievement that are used to keep people out. They're not used to judge who is the best future clinician. They're used to narrow the field, so to speak. And many African-Americans. I mean, obviously African-Americans perform extremely well there too, and Hispanic Americans and Native Americans. But when there are very small differences, they've often fit, They often are in favor of whites because white people are more likely to go to the educational institutions where they have that kind of support. A private school, school like this one, or and a school where there's a lot of support who can afford to take thousand dollar MCAT preparation courses, things like that. So the short answer is we're not testing the things that judge, "Would you make a good doctor?" We're not always testing things that make you a good scientist sometimes. And knowing ethics is essential to medical practice. I think it should be, it's right up there. It's probably more important than physics for most physicians and certainly right up there with biochemistry. So we need to rethink some of the credentialing that we do. Great question.

- I'd like to co-sign that quickly because I spent 15 years teaching clinical ethics and research ethics. And I feel very, very strongly that medical school and graduate school is too late. And this is the moment. And so while I have my plug, I decided just about a week ago that in the coming year I'm going to offer a bioethics class because I think this is when we need to bring that kind of thinking in. And what I saw which is not the fault of the students is that the push to get the science is leaving out the social sciences and humanities leaves out the part that medicine is about actually working with humans, right? Not bodies. And that piece is so critical, but if you don't understand yet how to think about race or gender in more complicated ways, and in non-essentializing ways, I think this ends up creating a lot of the problems that Harriet ends up writing about. So to make her writing life easier, I think we should bring that in. But it's imperative that it happen earlier because it's not happening in medical school. By the time I was there, they kept cutting back the hours for ethics to the point where it was very, very minimal and it wasn't taken as seriously. So thank you for that. I didn't see where you went, but thank you for that observation. Yeah. Anyone else? Yeah. Jordan, right? Yeah.

- Hi. I know that there has been a long standing belief that Black people can take more pain or don't feel pain as much as white people. And there's even been attempts to find evidence to support that. And I was wondering, what do you have to say about the effects of that now?

- Sure. Very pertinent question. The 19th century physicians and scientists. Again, we have them to thank for that because one of the tenants that they promulgated was that African-Americans have profoundly primitive neurological systems that don't allow them to feel pain or feel anxiety for that matter. And that belief has persisted for 400 years. If anything, it's gotten stronger and periodically there are studies done to both prove and quantify it. The most recent was 2016 University of Virginia. They found that half of all respondents, medical students and practicing physicians believe that African-Americans do not feel pain the way whites do. They also thought that African-Americans required more radiation than do whites. A lot of beliefs that sound laughable and crude, and I recognize them all as straight out of that 19th century belief promulgated by doctors. So we're still dealing with that. What does it mean when you have doctors practicing who don't believe that Black people don't feel pain? Well, for one thing, what they do is when a Black person appears claiming to be in pain, they're dismissed as drug seeking. So, you know, the assumption is you're just here looking for drugs. Even if you have a disease like sickle cell disease, which is known to be exquisitely painful. Even if it's well-documented, it doesn't matter. You're still going to be turned away. That has a lot of results, you know, that are really poor but it also has a poor result in terms of the way African-Americans are perceived. When you have physicians, assuming that large classes of African-Americans are seeking drugs, that causes them to lack empathy for them. They don't see them as patients who are, you know, worthy of having their health and welfare maximized. They see them as drug addicts. And so it's a huge problem. It's only getting worse with the opioid epidemic because. The cover story in Wired this month, seek it out. It's written by Mya, a friend of mine. And she talks about how the algorithms meant to curb the opioid epidemic are actually quite cruel because they're separating people from drugs that they need, and hoping to categorize these large classes of people like African-Americans as people who are drug seeking. So thank you a very important point. I also have to say, I worry about the things that we're not tracking. We are tracking pain, but a lot of other beliefs I see. I see them in hospitals. I see them being, you know, accepted blindly, and we need to start tracking some of those too. And hopefully crafting solutions.

- I might add one quick thing which was, and maybe you remember this better than I do Harriet. But it was only within the last, definitely within the last five years that there was an empirical study at a teaching hospital in North Carolina, that was a survey about racialized beliefs. And one that I remember was Black people have thicker skin, right. And so, because they have thicker skin, they have a greater resistance to pain, and there were a series of racialized beliefs, and it was.

- There's actually been a lot of those studies.

- Yeah. And there are significant numbers of both medical students and teaching clinicians who subscribed to some of those beliefs, like maybe a quarter, depending upon what it was.

- It's not. It's become a tacit part of medical education. By that I mean you won't find it in a textbook, but it's something that people learn not only from professors who say it, but that's what they've learned when they go on the clinical floors. You go on the clinical floor as a new resident, and what do you see? You see Black people coming in complaining of being in excruciating pain and being dismissed as drug seeking. You know you're told, "Oh, those kinds of patients. they're looking for drugs." You know, you internalize that as part of your training. And so, yeah, it's very common.

- So maybe we'll do one. Oh, sorry. I'm sorry. I didn't see you over there. Yeah, go ahead.

- Yeah. I just had a short follow-up question to your response to Jordan's question, actually. You mentioned at the end of your response there that you think there are a lot of harmful myths outside of this pain one specifically that you were talking about that you think are propagated in medical institutions that we aren't tracking and we aren't talking about. Can you talk some more about what those are?

- Sure, quite a few. Hardly know where to start, but there are diseases that are considered Black diseases. In the past there were things like pellagra, which we now know to be a nutritional deficiency disease that anybody can get. But in the 19th century and earlier we thought it was a Black disease. So Black diseases are one. One good example is Sickle cell disease. Is that a Black disease?

- No.

- No. But is it often described as a Black disease? Do people act like its a Black disease? Do clinicians assume it's a Black disease, in other words if you and say you have sickle cell disease, will there be an assumption that you are Black or have Black organs? Yes. And are Black people with Thalassemia or beta blood deficiencies consistently being misdiagnosed with Sickle cell? Yes. So misdiagnoses because of the belief in Black diseases, and also the link between behavior and disease. Blaming people for their own disorders. That's something that's very, very common and it's very unexamined. So there's fertile ground out there for people who are interested in these questions. We really need people to look into them.

- Maybe I'll ask one more. That came from some where. The inter webs out there. It's a big question, but I think it's an important one. It's from Regina. She said, "You mentioned needing to make the healthcare system more trustworthy. How do we do that?"

- Oh, $64,000 she on that answer. That is a big question. Right? Okay. Many things we can do to make it more trustworthy, but the big change in attitude that I think we need is to begin addressing healthcare disparities as failures of quality of care. We need to stop looking at them as things that we want to do to be moral and to be good to people and kind to people. Look at them as failures to meet our mission of giving everybody the best possible care. Of advancing wellness, as much as we can. And concomitant with that, I think we need to change the way we train people. People always talk about training and education when we hear a big abuse, right? But training and education only take you so far. We need more accountability. We need more policies that are based on quantified research, so that people know exactly what's expected of them in different situations. And when people fail to meet these standards and benchmarks, we need to have punitive responses. We need to not only reward people for doing the right thing. We need to start punishing people and institutions for failing to make benchmarks. If we're talking about quality control, quality control in the hospital. People accept the hospital will be punished. Fined, otherwise stigmatized for not making benchmarks. We need to do the same thing when it comes to racially disparate care. Maybe you shouldn't be able to finish your residency. Maybe you shouldn't be able to get a promotion. Maybe the hospital should not be allowed to get federal funds. We need to Institute penalties. Meaningful consequences for failure to make them, but it should be proceeded and predicated on having quality benchmarks that are very clearly spelled out. Exactly what people should and should not be doing. I think that will get us a long way toward where we want to go.

- Alright. I think we are. Yes. I'm getting the signal. Harriet, it's been an absolute pleasure. On behalf of everyone, thank you for tonight, but also thank you for what was an extraordinary week with us at the college.

- Yes it was. Thank you.

- Very grateful. Yeah.