Sheryl Sandberg recently published a book entitled Lean In: Women, Work, and the Will to Lead that some have touted as a rebirth of the American feminist movement. Others, disagree.

As an African-American pediatrician, I find the idea that women need to lean in to institutional positions of leadership to exert influence, problematic. It ignores the impact girls and women of color, who often exist outside the established order, have in our world. If we are going to assume a new feminist decree, it can’t be follow men to power. In the age of globalization and social media, the table of ideas is wide and growing and includes anyone with the courage to speak their mind. The future of feminism must abandon the constraints of traditional hierarchies, validate positions of influence women already assume in their world, and recognize the power of partnerships across cultural and gender lines. We don’t need to lean in to established hegemony, we need to change the game.

Let me explain.

Women already have power. Comprising 51% of the population, women make or influence 85% of all purchasing decisions in the United States – that’s anything from buying cars and computers to purchasing healthcare. In sum, women generate $6 trillion dollars a year in consumer spending (that’s six times the 2012 federal deficit). With the struggling auto industry, surge in online technology, and new changes in healthcare, women are literally at the center of the markets that are defining the ways we live, move, communicate, and stay healthy, and their influence is growing. In the 31% of marriages where women work, women now out-earn their husbands and it is estimated that in the next decade, women will control two-thirds of the consumer wealth in the United States.

And it’s not just women – girls are also out-performing their male counterparts in age appropriate activities like high school completion and college enrollment; a statistic that holds true despite the girl’s race/ethnicity. If education is the path to increasing earning potential, as the data suggests it is, girls are already on track to follow their predecessors as the primary wage earners and financial decision makers for their families and communities. And if the Girl Scouts are any example, the first cookie was sold in 1917 at a high school bake-sale and is now a $700 million empire, girls already wield power too.

When 1 in 11 women now own their own business and young women of color are progressing to new heights in higher education, it is time to use the power women already possess to create equity across society. And not just gender equity.

I think we need a new kind of feminism, the kind that is not just about women (gasp) and their individual success.

This kind of feminism recognizes that the plight of women to overcome the psychological and institutional barriers to self-actualization, is shared.

This kind of feminism embraces the issues of other marginalized populations, issues like institutional racism, immigration, gay marriage, and growing economic inequality and poverty in the US.

At its core, this kind of feminism is about authenticity and choice – the ability to be oneself (whatever that means) and choose and control one’s destiny, whether that be for control of one’s body, one’s career, or one’s position in society.

It is not about having “women [run] half of our countries and companies and men [run] half of our homes.” It is about building and sustaining institutional constructs where every individual, regardless of race, creed, nationality, sexual orientation, socioeconomic status, or gender, can choose, and work hard to obtain, the life they want, for themselves and their families.

Ultimately, it is not about leaning in, it is about reaching out. In the age of open access technology and social networks, empowered consumers are increasingly defining national conversations that can inform and change the political and cultural agenda – building spheres of influence that are no longer beholden to traditional hierarchies of leadership. Today, collective action matters; and closing the gender gap requires more than a singular vision of what individual women “should” be doing. It is time to harness the power that girls and women already possess to create a new feminist decree: Equality, for all!

The road to be a doctor is fraught with many dangers, toils, and snares (through many of which I’ve already come). Now, 7th months shy of another ending, I feel ready and yet totally unprepared for what lies ahead. It’s not that I feel clinically unprepared (although I know I still have a lot to learn), it’s that I’m still unsure of my path, even as I am starting it. After fighting off the beast of residency, I feel like I just want to pick up the scraps of myself and walk out whole.

And here I am. At a new beginning. A new path. A new start. But as I speculate about leaving academic medicine, essentially all I’ve ever known, and try to forge a way for myself into the world of policy and health innovation and social justice work to get about the business of reshaping and re-envisioning the future for impoverished children and families in our country, I find myself feeling more lost than ever and afraid I won’t find my way.

And so it begins, my blog and my hopefulness – my start to reconciling my passion for justice with my training in clinical medicine, and all the little things that happen along the way. Rhea. MD. This is who I am. And this is what I do.

What does it mean to speak publicly about issues you care about?

If you tweet a link to an article you finding interesting, is that an implicit endorsement?

If I “like” your status update or change my profile picture to a red equal sign, am I a better friend or advocate?

What is the “like” currency and how is it contributing to the economy of change in our society?

Are we all a part of a movement or is the world just getting smaller and we’ve found a new place to put our trash?

What is happening to all the information we’re putting into social spaces? If twitter feeds are a library cataloging everything from congressional politics to scientific theory, is it sacrilege to post what you ate for breakfast? As curators in the age of information, what is our responsibility as architects of truth and reason? Where is the reasonable-check to make sure what we are creating is useful or even mildly entertaining? Are we becoming garbage disposals of recycled ideas, rapid consumers of information that won’t penetrate beyond the limits of the screens we view it on, only to forward the undigested remains along to our “friends”?

How does one go about changing the world anyway? Do you have to own what you feel in a forum of public opinion to be a genuine advocate? Do I have to bleed alongside my comrades in war-torn countries to be a kindred ally, or can I just re-tweet the rally cry? Is it safer to express controversial opinions online or more cowardly? By sharing our intimate thoughts and passions, are we building collective memories or creating new generations of voyeurs? Can social media really bring about social justice?

Should physicians speak publicly about the ways education, housing, environment, and local politics affects their patient’s health? If they do, will it matter?

Social media is the new land of opportunity, democratizing information and offering the promise of connection and synergy – where our collective vision for the future can transcend our individual ability to make it realized. But I am beginning to understand that my words here (in the internet cosmos) mean nothing if I don’t live them here (where I actually live and work and play). Perhaps if we hold ourselves to that standard of engagement as we share our worlds online, the weight of our words really will change the world. As it turns out, the public voice is nothing without public action.

Though much has been said, I feel a need to publicly recognize what has happened. Publicly. For when time has pacified our resolve and memory fails to do justice to the pain we felt, and new problems have filled our consciousness, so in that space, in that unformed future, even there, there is some record, some institutional recognition of what happened to Trayvon and why it mattered. Even if that institution is just the internet. And the memory is just my blog.

It was like the taste of blood in your mouth when you cut your gums with floss. It tastes strange, but familiar. It is less a wound, than a numb reminder of your sensitivity. You know it shouldn’t be there and yet it has always been there, pulsing under the surface.

I am of a generation that had forgotten. A generation whose survival did not depend on the stories of my grandparents or great grandparents or great, great grandparents, ushering me to safety with the shield of their experience. No one had to teach me how to live in a world where black men who upset white sensibilities were killed without reason or retribution or where black women existed as both the object of white men’s desire and their disgust. We were beyond that. I was a classmate, a peer, a colleague, and a friend. Race informed my life. It defined many of my experiences. But it is not my life. I do not wake to escape the burden of my race every day and succeed in spite of it. I am of a generation that with the right dose of education and opportunity have been enriched by my experience of race, emboldened by the history of my people, and empowered to define my own path.

And then there was Trayvon. Well, there was Rodney King and Amadou Diallo and Sean Bell and Oscar Grant…and then there was Trayvon. And those are only the ones who come to the top of my head as I write this and the ones who have been named in the news. What of the others? What of the nameless, young brown lives lost every year in Detroit, Saint Louis, Oakland, Baltimore, and Chicago? What of the more than 50% of African American males aged 10-24 who will die of homicide in the US?

And what of those who live? What of that time Henry Louis Gates Jr. was arrested outside of his own home in Cambridge and when Academy Award-winning actor Forest Whitaker was falsely accused of shoplifting and frisked in a NYC deli? And those are only recent examples of the most famous and prestigious among us. I mean, President Obama even admitted to being the undeserving target of fear and suspicion.

What of my own father who was asked to get out of the car for an impromptu frisking after being stopped by the police, despite our entire family being in the car, being in our own neighborhood, and never being issued a ticket or citation for any wrongdoing. I was only 8. When he returned to the car, I learned a different kind of silence – the silence of shared understanding, fear, confusion, and sadness.

Those are the small slights, the micro-humiliations you suffer when what you want to be melts in front of what you are. They are what Maya Angelou has called the “unnecessary insult.” What Jelani Cobb referred to as “an extended paraphrase” of history, where the unwelcome past lives all too comfortably in our present. The words disappointment or disillusionment don’t nearly explain the feeling. How do you explain realizing you live in a world where you have to remember and you have to teach your children and children’s children to remember for fear of the consequence…Where the struggles of yesterday can instantly be made your struggle of today, if you are wearing the wrong hoodie on the wrong skin tone, in the neighborhood where that threatens your life?

Don’t wonder what the fuss was about. It was about Trayvon and it is about those who have gone before him – carrying the burden of our reminders.

The implicit bias frame does not offer equity. It offers absolution from complicity in systems that harm people. And yet, individuals, organizations, and institutions continue to use the implicit bias frame to make sense of inequity and to address it.

Take police violence, for example. In the face of the devastating and disproportionate toll police violence takes on Black and Brown people in America, policymakers have responded by offering local law enforcement implicit bias training. The underlying assumption is, police violence is an interpersonal problem that takes place between an individual “bad” officer with bias and the civilian on whom their bias is projected. In this framing, the solution then requires an interpersonal remedy to address unconscious racial stereotypes that must drive racial inequity in police violence.

But this limited reading of the problem and solution, rooted in individualized and unconscious judgement, ignores the collective impact of police violence and the explicit choices that structure, authorize and weaponize police-community relations.

Police violence is also, and I would argue, largely, a structural problem, whose effects extend beyond individual civilians to the communities and populations who directly and indirectly suffer the burden of the disproportionate risk of this form of violence. This community and population-level impact is driven by intentional human design.

Police violence must be understood as the predictable by-product of policies that introduce militarized weapons into local precincts and permit use of force in the absence of a lethal threat. Racial inequity in police violence is then incentivized by “tough on crime” and “zero tolerance” politics that penalize poverty and Blackness. This inequity is exacerbated by municipal procedure to use petty offenses to generate city revenue. And it is perpetuated by law enforcement culture that fails to demand officer accountability.

Each of the preceding system-level factors are determined by explicit human choices, not implicit beliefs. Therefore, attending a training on implicit bias or simply substituting a Black or Brown officer for a white one, because they presumably harbor less anti-Black bias, does not address the systems-level choices at the core of police violence or the racial inequities those choices create.

Similarly in medicine, implicit bias training will not help institutions unpack their problematic relationship to entrenched local poverty and racial inequity – both drivers of racial health disparities. Those relationships, between hospitals, poverty and racial inequity, are structured by intentional business models and tax designations, not unconscious preferences or prejudices. And diversifying the physician workforce without disrupting the various manifestations of white hegemony that currently set clinical priorities, research agendas, and promotional criteria, will not magically narrow racial disparities in health outcomes.

One cannot simply change a cog in an assembly line and expect the line to produce a new product. Systems function as they are designed to. To get a new outcome, it requires building a new system or transforming the existing one – each of which relies on humans making different explicit choices, regardless of their implicit leanings.

Advocates, we can no longer afford to use an individual or interpersonal analysis of harm, like that offered by the implicit bias frame, to understand and confront inequity. It fails to capture the collective experience of harm and works to conceal the ways explicit choices encoded in process, reproduce harm, across systems and populations.

While the implicit bias frame may have gained traction because the solutions it offers are relatively simple, like admitting unknowing harm in one on one interactions. The frame ultimately fails where it absolves us from confronting our knowing role in maintaining systems that inequitably distribute harm among populations. That task is more complex and requires us to challenge our individual, organizational, and institutional choices to create and uphold legacies of oppression and privilege. We all must be accountable – to each other and to ourselves, for the systems we create, the systems we protect, and the systems we participate in that harm others. Because ultimately, the goal is not to simply adjust the ratio of good to bad apples, but to change the kinds of trees we are planting.

The torch-bearing, violence-streaked march of white nationalists through Charlottesville, Virginia yesterday, is terrifying. Present tense. Thanks HBO, but turns out we don’t need a fictionalized, revisionist look at the confederacy to imagine an America where Robert E. Lee is a hero, worthy of defense by militias and crowds shouting “blood and soil.” We get it already. It is the America we live in.

But in the wake of yet another iteration of emboldened racism, given platform and legitimacy by the president and his administration, it is important to be clear about the terms and legacy of this public debate.

White supremacy in America isn’t simply a set of informal ideas rooted in the racial superiority of people who call themselves white.

White supremacy is an institutionalized set of ideas founded on the racial superiority of people who call themselves white.

It’s not dangerous because some white people think they are better.

It is dangerous because it re-constitutes and maintains a tangible racial order where white people can become passive beneficiaries of public systems, public goods, public sympathy, and public protection, in ways black and brown people cannot. It is dangerous because this extreme perversion of “the public” excludes black and brown people. And the consequence is deadly.

So while yesterday’s staunch defense of the confederate flag and nostalgia for slavery may appear dated and unfamiliar, the political agenda underlying the protest is not.

In the last month, the Department of Justice, under the leadership of longtime civil rights opponent Jeff Sessions, resurrected white affirmative action to counter “race-based discrimination” in higher education that is costing supposedly deserving white students their so-called rightful place in our nation’s colleges and universities. The Republican-led House and then Senate each questioned and attempted to dismantle the merits of the Affordable Care Act, the only comprehensive national healthcare legislation to narrow deadly insurance and care gaps for black and Latinx patients. And just this past June, the president and Justice Department worked in tandem to request and secure voter data from states, an unprecedented move that has met bipartisan condemnation, and as the former head of the Civil Rights Division noted, is a prelude to voter purges that will disproportionately suppress voters of color.

So while a frequent response to yesterday, and the larger, more violent rally that took place today, is to support local organizations who condemn bigotry and hatred, such charity alone ignores the larger political agenda at stake. What is happening in Charlottesville is emblematic of what is happening to our democracy at large.

This fight is about who deserves the benefits of a shared America.

The answer to that question does not lie in outraged tweets. It lies in organized and sustained resistance to the resurgence of white supremacy that continues to threaten the lives, livelihoods, education, electoral participation, health and survival of people of color. There are only two sides of this and one is wrong.

During the 2016 election, Americans opened a public discourse that sparked new and old fears, evoked unsettling and painful emotions, and surfaced certain real and perceived divides. When elections center solutions in the background to highlight problems in the foreground, it can be distracting and confusing, for adults and kids alike. Post-election, often those intensities fade. But this time, parents may find themselves confronting sustained and sometimes increasing worry, in the emotions and experiences of their children and their children’s classmates. These are the times when parents consider how they will explore complex and potentially charged topics with their children and teens.

As parents examine their values and their hopes for their children in this post-election climate, it may be helpful to consider how to approach a topic that is as oft-used as it is misunderstood – racism.

What are we talking about when we talk to our children about racism?

And how do parents start the conversation? 

When we talk to kids about racism, we are primarily talking about 3 things.

First, we are talking about history – things that happened in the past that are important to understand what is happening now and why it matters.

To illustrate the history of racism in America, some parents may find it helpful to review age-appropriate details. For example, teenagers may have knowledge of historical events like slavery and the civil rights movement. Starting with what they know, consider extending the conversation to other demonstrations of institutional racism like government-sanctioned red-lining practices that decreased the home values of people of color, particularly African Americans, and contributed to current racial wealth disparities in America. Or examine the implications of Japanese internment camps during WWII that used race and nationality to deny Japanese Americans their civil liberties. These events and the history they represent are the embers of old fires still kindling in our present and the more we understand them, the more we are equipped to recognize their reemergence.

Second, we are talking about feelings – the prejudiced assumptions and ideas about others based on race. When stated aloud, as a part of targeted comments or unintentionally as a part of repeated narratives, prejudiced feelings can result in trauma, stress, and anxiety for the people who become the butt of a hurtful joke or the demeaned character in a story. These types of one-on-one interactions highlight episodes of personally-mediated racism.

To help kids identify prejudice and its form of racism, parents may use children’s books to share helpful lessons. Some can be found here and here.

Third, and perhaps most importantly, we are talking about actions – everyday choices, big and small, to treat people differently because of their race. This is called discrimination and it is powerful because it not only hurts people’s feelings, it can also make them sick.

Simply put, racism – like many of the “isms” that have been heightened by this recent election – is about exclusion and harms. That exclusion can happen at the lunch table just as much as it can happen through laws. And the resultant harms can range from emotions like embarrassment, humiliation, and shame to physical violence, psychological stress, poverty, and disease.

As kids come home crying or with troubling stories of what they’ve seen or heard, resist the urge to dismiss their emotions with avoidance or denial. Instead consider these helpful tips:

DON’T tell kids it is unconditionally going to be okay, because for children and families who stand to lose their health insurance, residence, or civil freedoms, it may not be.

DO offer reassurance by discussing and modeling how to unconditionally support and care for classmates and friends who may be facing unique worries and stress at this time.

DON’T avoid conversations about racism, sexism, nationalism, xenophobia, Islamophobia, and intolerance.

DO put those conversations in an age-appropriate context that includes ways children and teens can stand up for peers when they witness their exclusion.

DON’T try to minimize a child’s fears by normalizing distressing language and behavior.

DO listen to their fears and talk about reasons for hope, including their ability to actively express empathy, support, and advocacy for peers whose fears may be different, more acute, imminent, or sustained.

These moments are opportunities to model engagement, tolerance, and compassion for children and teens trying to make sense of a world in which their values may be challenged, demeaned, or disregarded. Ultimately, what we are talking about when we talk to our kids about racism, is the type of person they can actively become.

Each year, as our nation reflects on the life and legacy of Dr. Martin Luther King Jr., I look for contemporary signs of change, examples of how we as a society have evolved in our understanding of race and how and where African-Americans have folded deeper into the American story and been embraced by the country they’ve called home for centuries.

This year, I didn’t have to look any further than my own backyard. Last week, the Sun Reporter, a Bay Area weekly that runs local and national news involving African-Americans, featured a story on Jahi McMath. Jahi was a 13-year-old African-American girl whose untimely death, following a tonsillectomy, lead to weeks of contentious debate between her family, her medical providers, and the national media regarding her diagnosis of brain death. Being a local pediatrician* I was well-aware of the story. But what struck me when reading this particular piece, was the way the periodical characterized the family’s mistrust of the medical system.

Historically, there has been “bad blood” between some African-Americans and the US health care system. In many cases, that tension can be directly linked to documented cases of exploitation and deceit. Like, for example, when the US Public Health Service purposely withheld treatment from African-American men infected with syphilis, allowing them to suffer and sometimes die, to study the effects of untreated disease from 1932-1972.

Or take the case of the Henrietta Lacks, the African-American woman from whom the world’s oldest and most commonly used line of human cells (HeLa cells) were obtained in 1951. Despite being the substrate for some of the greatest advances in medical research, biological science, and pharmaceutical development, neither she nor her family received any financial compensation or recognition. Her cells were obtained without her consent, manipulated and sold without her family’s knowledge, and her genome and her family’s medical records were made public without their approval. In August of 2013, less than a year ago, the National Institutes of Health finally publicly acknowledged Henrietta Lacks’ contribution to science, agreed to protect her family’s private medical information, and allowed her family to be privy to future research utilizing her cells.

Given these egregious missteps in US history, you might not be surprised to know that some African-Americans actually believe the US government introduced crack into their neighborhoods or created AIDS to kill them. The woefully unsuccessful, and I would argue, recklessly enforced, War on Drugs aside, some black folks just don’t trust the core institutions that are created to serve the public good, and chief among them may be our health care system.

In the case of Jahi McMath, I have to wonder if feelings of distrust ran deep and strained the relationship between Jahi’s family and her medical providers, as they sought to find a common ground to discuss an incredibly difficult and distressing reality – a young girl is dead. Add to that discussion the general public’s confusion regarding the medical definition of death and the media-bolstered accusations that everyone, from the family and their lawyer to the hospital and its personnel, mismanaged the situation, and it is easy to see how the private bond between the medical system and the community it serves can fray and break.

Underlying this all has been the hurtful allegation that the hospital wanted to discontinue Jahi’s life support to save money or that the family’s limited resources affected their ability to advocate for her care. The obvious comparison here is the Terri Schiavo case, in which a 26-year-old woman was kept on life support at the insistence (and in part through the financial support) of her parents for 15 years. Although, I must say, that case was very different because the ultimate diagnosis was a coma-like condition called persistent vegetative state where the brain continues to function, albeit at a significant deficit, and in Jahi’s case her brain was determined to no longer be functioning at all.

Ultimately, it seems, despite being cared for at a hospital that local doctors like myself revere as a leader in practicing in and for, communities of color, a disconnect remained. To me, it suggests that perhaps it was the family’s distrust of the system to adequately care for Jahi and the complicated medical language surrounding the diagnosis of death that created an impasse. That impasse gave way to an unnecessarily long period of suffering for Jahi and her family and it must be prevented in the future.

But how? And why is this so important? There are two lessons here.

First, it is just as important now as it has ever been, to elevate the national dialogue about race as we continue to seek to understand each other as human beings.

Second, and most importantly, part of that understanding is rooted in communication and in every area where we miss an opportunity to effectively communicate with each other, we risk alienating people from the very institutions on which our communities rely, including medicine, education, and justice.

It is on this note that the media completely missed the point. Part of our national evolution to understand race involves recognizing and acknowledging the nuanced ways it remains relevant in our lives. One of those ways is in the way we communicate across cultures.

Effective cross-cultural communication (and one can argue that any communication outside one’s area of expertise is cross-cultural), requires identifying the contextual clues – the values, knowledge, and historical roots that contribute to how individuals interpret information and make important decisions. This is key to understanding any human behavior from basic lifestyle choices to the painstaking and charged decisions involved in end of life care.

In America, there is a history there that makes dying while black a particularly contentious issue, one fraught with fear of mistreatment and maligned intention, and one that must be addressed openly, honestly, and with compassion. Whenever we are able, those of us in positions of institutional power, must acknowledge and uphold the dignity of all human life as we practice across centuries of experience and knowledge. If we can do this for the most marginalized, then we have some hope of healing the scars of our past and addressing the ongoing struggles of our present.

I write this post in loving memory of Jahi McMath and Dr. Martin Luther King Jr, beloved members of the African-American community who died challenging all of us to learn to understand each other better.

*Disclaimer: Although I am a pediatrician in the Bay Area I was never involved in Jahi McMath’s medical care and this piece is not intended to discuss any details of her clinical course or treatment. In addition, this post is not meant to speculate on the feelings of the McMath family or the intentions of the medical providers who rendered her care but rather to stimulate a larger discussion about the ways race may remain relevant in each of our lives and how we can confront that reality in a meaningful way.

Update: Thank you to everyone who read, commented on, and shared this post. Given the significant interest it garnered, it was published in the San Francisco Chronicle on Sunday, February 2nd! Check it out here!

Today is Equal Pay Day, or the day that marks how many extra days the average US woman must work into 2014, to earn as much as her average male counterpart in 2013. Given this momentous occasion to spotlight gender wage inequality in America, let’s take a brief look at the wage gap, why it matters, and what our President is doing about it today!

Did you know there is a gap inside the gap?

According to US census statistics, the average, full-time, female worker in America makes 77 cents to the dollar of what the average, full-time, male worker earns. But this statistic only refers to White women. The wage gap is far wider and deeper for women of color in the US, who face both a larger disparity in pay deferential and also fewer opportunities to rectify this great imbalance. The average African-American female worker makes 64 cents to the dollar and the average Latino female worker only makes 53! Part of that deferential is related to lower educational attainment among African-American and Latino women. And yet, “you can’t educate your way out of the gap!” Even as higher education raises everyone’s wage, African-American and Latino women continue to earn less than their White peers with the same educational background. This reveals a racial gap, inside the gender gap that may reflect discriminatory hiring practices, disparate access to meaningful employment by neighborhood or region, and disparate opportunities for upward mobility for professional women of color.

There is also geographic variation in the wage gap. Check out this chart to see how your state compares to Washington, DC or Wyoming, the areas with the smallest and largest gender wage gap in the US!

Why does the gender wage gap matter?

Since 1960, the number of women who are the primary wage-earners for their household has almost quadrupled, such that women now comprise nearly two-thirds of the breadwinners or co-breadwinners in their family. And as it turns out, more than 6 and 10 of the women who are the primary breadwinners in their home, are single mothers.

That means, average American families are increasingly depending on the earning power of women to make ends meet.

So when Mom brings home 23% percent less than her male counterparts (remember, that percentage can be as high as 44% less for Latino women), that is less income for everyday needs including healthcare, less investment in our children’s futures and education, and when added over a lifetime of work, significantly less for retirement.

AND, as a pediatrician, I know that children who live in poverty are more likely to have poor health as adults, including increased risk for cardiovascular disease, high blood pressure, diabetes, arthritis, and depression. What is more, there is evidence to suggest that these risks persist, despite changing social class in adulthood. So in many ways, investing in women is also vital to our country’s health and wellness!

So what is today’s big news?

Today, President Obama continued his commitment to the economic empowerment of women by signing one executive order and one presidential memorandum that take the legislative steps necessary to level the pay-ing field for women, well at least, female federal employees. This week the US Senate is also considering the Paycheck Fairness Act, which would extend the standards put forward by the President’s executive order to all employers covered by the Fair Labor Standards Act. To see President Obama’s complete legislative agenda to address gender income inequality click here!

And finally, any quality discussion of income inequality would be remiss to leave out the debate on minimum wage. Suffice it to say, raise the wage! Doing so, would especially benefit women who are more likely to occupy low-wage sectors of the labor force or to participate in part-time work (given many women’s commitment to their education or their growing family). It is also estimated that increasing the national minimum wage may be essential to lifting more than half of our working poor families out of poverty.

As Martin Luther King Jr said in his 1965 commencement address at Oberlin College, “The time is always right to do right.” And for income inequality in America, that time is now.

Dr. Maya Angelou’s words decorate the walls of our classrooms, fete the ceremonies of presidents, and illuminate the conscience of a nation. By formal account, she was a poet, playwright, memoirist, dancer, singer, stage actress, streetcar conductor, single mother, college professor, civil rights activist, and cultural humanitarian. But, perhaps most importantly, she was ours.

With the rare clarity that comes from lived experience, Maya Angelou captured the curious reality of the American black girl; the girl who awakens to a home she is told, is not hers. The paradox of being born black and female in America is that although you are as quintessential to the American story as the slave trade that brought your ancestors, by virtue of your existence, you are displaced. Despite birthing the generations whose unpaid labor sustained the American economy for more than a century, it is the black woman who lives as a foreigner in her own home. As the social construction of race animates and personifies blackness, the color of her skin eclipses the content of her character. Thus historically, it is the African-American woman’s blackness that shrouds her femininity and obscures her nativity. It renders both her beauty and her personhood, foreign. She is the acquired taste. And as she awaits her palatability, she remains in the shadows.

But as Maya showed us, the shadow is not just a vacuous darkness left in the background. It is the evidence that you exist, that you were here, and that the sun shone down on you. By embracing the lived experience of our blackness, Maya helped us embrace the light in which black women were cast into existence. We were aching to be seen and see us, she did.

The lens with which Dr. Maya Angelou captured the African American experience was transcendent. She humanized us. As she recounted the lives of her mother, brother, father, aunts, uncles, cousins, and friends, she gave living testimony to the pain, humor, love, and tension that pulses beneath the surface of American life. She made survival a virtue and cast black girls as repositories of the national wisdom held in the seemingly insignificant happenings that pepper everyday life. She refused to trivialize the lives of children, the poor, or African-Americans, despite the fact that they so often go unnoticed or uncelebrated. Revealing our inner truths like nursery rhymes, exclaiming our bountiful beauty with exacting wit and unwavering reverence, she told us of a woman, who was once a girl, who was once a black girl in the south, who was once invisible (and mute). Rendering us visible with the audacity of her authenticity, she offered us voice and if you are like me, you took it.

Truly good prose looks into the deepest crannies of human experience, and reveals you, to yourself. By bravely telling her story, Maya told our story. Standing in a line of Sojourner Truth’s, Phillis Wheatley’s, Gwendolyn Brook’s, Rita Dove’s, Audre Lorde’s, Nikki Giovanni’s, Alice Walker’s, and scores of other black female poets, playwrights, and authors, she shone a light onto the very soul of us. I know why the caged bird sings. It sings because Maya lifted its very existence, that it might know it was made to soar.

Maya once said that the greatest thing you can say to another person is thank you because thank you is what you say to God. Where words fail to capture the depth of my sorrow for her loss and the extent of my gratitude for the life she lived and the words she left us to live by, I say, Maya, oh sweet Maya, thank you. You will be missed because you were always ours.

It is no secret that growing income inequality is one of the major issues facing the nation today. Close to 50 million Americans, or 1 in 6, live in poverty and 1 in 3 children are now projected to live in poverty at some point in their lifetime. But did you know, up to 1 in 3 kids in San Francisco may go to bed hungry tonight?

As the price of housing transforms our city into one of the most expensive in the country, the national income gap seems to have landed on our doorstep. And while this topic has garnered robust media attention and local public debate, the focus on poverty remains cursory, at best. Here, the housing crisis is literally changing the face of the city, and yet it is hard to identify who is most affected by the fickle pendulum of the economy and it is easy to make affordable housing the center of the conversation.

But the impact of poverty extends from the most recognizable needs in our community to one of the least – hunger. So let’s talk about it. Who’s hungry in our city?

Meet Lani. Lani’s grandmother originally came to San Francisco from Samoa in the late 1970s and her family has lived and worked in the Bay Area ever since. Like many of us, she dreams of owning a home in the city one day, but like a growing population of San Franciscans, her immediate need is food for her family.

Lani is a 35-year-old working mother of 2 and the only employed adult in her household. Her husband was a construction worker who, because of poor health, is physically unable to work. And after losing her mother in 2008, she and her husband became legal guardians to her younger siblings. That means, it’s all up to Lani to make ends meet.

As a high school graduate, she’s worked in food and cleaning services, but with the downturn in the economy, consistent work has been hard to find. In 2012, she became a certified nursing assistant and found a part-time position that offered $14 an hour but no benefits. She took it.

All 6 members of her household live in a government subsidized apartment in Hunter’s Point and yet because of her new income they recently found out they no longer qualify for food stamps or CalWorks. Struggling to get by without any additional aid, they rely on food from her church to make it to the end of the week. Sometimes, that is only a bag of rice and a can of vegetables. Her kids, aged 6 and 7, are just starting primary school. Without the free breakfast and lunch they receive there, she says she “probably wouldn’t be able to find something nutritious for them to eat at home.”

Hunger is a problem. But the issue here is more complex than the physical sensations of inadequate caloric intake. The more insidious challenge facing family’s like Lani’s is food insecurity, or limited or uncertain access to the resources to buy, store, and prepare the nutritious and culturally appropriate food necessary to support a healthy lifestyle.

According to the 2013 San Francisco Food Security Task Force’s annual report, 1 in 4 San Francisco residents live at or below 200% of the federal poverty level. For a family of 4, that’s about an income $47,100 per year. These low-income families make up a quarter of the city’s residents are the most likely to be food insecure. But the population we seldom recognize, despite having similarly high rates of food insecurity, is our city’s children.

For these communities, food insecurity is literally changing their lives. There is mounting scientific evidence showing that food insecurity is related to poor health outcomes like increased risk of adult chronic disease including diabetes and heart disease, and in children, increased risk of obesity and learning and behavior problems. And recent data from San Francisco General Hospital’s Community to Clinic Linkage Program, indicates almost half of the patients seeking urgent care at our county hospital are food insecure.

This is a public health problem and it sits at the intersection of income inequality and poverty in every city in America, including our own. In December 2013, the San Francisco Board of Supervisors issued a charge to local legislators and community organizations, to eliminate food insecurity in San Francisco by 2020. In collaboration with the San Francisco Food Security Task Force, help address this important issue!

Here are some things you can do today:

• Support your local food bank by making a monetary donation, hosting a food drive, or donating food. The most needed items are: tuna, canned meat, peanut butter, soup, chili, beans, cereal, canned fruit and vegetables, and granola bars. Visit the SF-Marin Food Bank website to learn more.
• Of all the students in the San Francisco Unified School District (SFUSD), 60% qualify for free or reduced priced meals, but less than half of those who are eligible are enrolled to receive this benefit. If you know of a child who may qualify, go the SFUSD website to apply now!
• As summer approaches, even fewer low-come students have access to nutritious food. Know of a child who may need food over the summer? Go to the Department of Children, Youth, and Families website to find out how to enroll them in the After School Snack and Summer Meal Programs.
• If you are a medical provider, start universally screening all of your patients for food insecurity. Here is a quick, validated tool you can use. If they screen positive, call 211 to connect them to food services!
• Contact your state representative to support AB-2385. This bill would create the Market Match Program to provide additional income to recipients of programs like food stamps, to purchase food at farmer’s markets. A similar measure is being considered for San Francisco. Want to learn more? Visit the California Legislature website.
• Join your local pediatricians and the American Academy of Pediatrics at Supervisor John Avalos’ Office in City Hall Room 244 to view a free photo exhibit entitled “Who’s Hungry? You Can’t Tell by Looking!” This exhibit captures the faces of local children to raise awareness of this often invisible need.

National rates of poverty are the highest they have been in decades and they impact our city in unique ways. But when you ask Lani what she wants for her kids, she doesn’t talk about eliminating financial stress or putting food on the table. She simply says, “I want them to become someone.” Healthy food and snacks are the building blocks to “become someone.” If recognizing the problem starts with asking the right questions, perhaps it is time we all asked, “Who’s Hungry?”

Earlier this year, I started teaching a course to first year pediatric residents at Stanford. In it, I challenge the trainees to identify the structural contexts in which patients and families make choices that may impact their health and well-being. Termed structural competency, the goal is to enable young physicians to understand and confront stigma and inequality as key determinants of health. We talk about educational attainment and health literacy, socioeconomic status and health access, social norms and health practices, institutional discrimination and health disparities, and the built environment and health behaviors. Together, we examine the fragile balance between resources and health, recognizing that local forces that manipulate resources effectively legislate health, by structuring choice and opportunity.

To illustrate these fundamental connections, it is often necessary to convert what otherwise exist as invisible forces in society into accessible, clinically-relevant language. This allows us to conceptualize the structural framework in which patients’ live, work, and play, within a medical model. It shrinks what seems like a diffuse and disconnected system of local policies and institutions into tangible drivers of health and disease that require socially-informed, clinical interventions. It transforms inequality, a sociopolitical phenomenon, into a silent but active participant in the clinical encounter. This makes addressing local infrastructure a central component of any community-centered, health promotion strategy.

But as we expand our purview beyond the exam room and encourage young physicians to adopt a global approach to clinical medicine, we must be very careful not to succumb to, what I will call, “the perils of pretending.” Here, there are 3 common pitfalls that warrant discussion.

1. The Poverty Simulator. In any educational endeavor, experience is perhaps, the greatest teacher. Without experiencing poverty first-hand, it may be difficult for residents to understand the challenges families living in poverty face when seeking medical care or selecting medical treatments.

One such simulator offers “players” a chance to live on a low-income budget. Other programs ask residents to navigate public transit to various appointments. At Stanford, I ask the residents to live on the average food stamp budget for a week. These self-reflective exercises are meant to influence learner attitudes about inequality and build empathy among providers as they realize what it takes to survive under certain conditions.

The problem with poverty simulators is that the process of pretending to be poor unfairly and inaccurately reduces the daily struggle of living in poverty to a series of poor choices, no pun intended. The “game” motif insinuates that some choices are superior to others while completely obscuring the larger network of policies and institutions that concentrate disadvantage and manipulate choice in low-income communities.

For example, if you live in a food desert, the choice to eat fresh produce is constrained by the proximity of those resources to your home. This “trade-off” requires bargaining between necessities and results in a loss either way. Buying cheaper food in your neighborhood may have adverse health consequences and expending the time and money to obtain healthy food on a fixed income makes other necessities unaffordable. This zero-sum reality profoundly limits choice.

To avoid this pitfall, it is important to be clear about the purpose of the exercise, which is to acknowledge that resource limitations have health consequences. The lesson is that poverty is not a deficiency of ingenuity or the manifestation of good or bad choices. There are no “right” choices when selecting between food and medicine. So if poverty is the result of eroding urban infrastructure and imbalanced resource allocation and is associated with poor health outcomes, then building infrastructure is a health intervention.

2. The Absence of Clinical Models. While the associations between social determinants of health and poor health outcomes are well-documented, we lack comprehensive, evidenced-based clinical models for addressing complex trauma and chronic stress, physiologically significant exposures that are the downstream sequelae of poverty and inequality. Short of co-locating same-day necessities in medical clinics, like food pantries or legal assistance, there are few models to describe how physicians in particular and the medical system at large, should engage the sociopolitical drivers of health through clinical work.

In the absence of these models, some physicians pretend there is nothing that can be done, or worst yet, that these issues are not “medical.”

The problem is that we are complacent in our current clinical practice. Stagnated by the dearth of evidence and overwhelmed by the magnitude of the issue, we simply avoid it. We fail to universally screen patients for social determinants of health because we don’t know where to refer them. We refuse to inquire about these issues because we essentially lack confidence in our ability or aptitude to address them.

The solution here is to do it any way. Just as all politics are local, so too will be the formation and dissemination of novel clinical models that address these issues. So we must encourage our trainees to identify the most pressing needs in their communities and trial socially-savvy interventions in their continuity clinics. This is quality improvement at its best.

3. The Conflation of Race and Risk. When seeking to address the “cultural” influences in a clinical encounter, it can be easy to minimize “culture,” to the readily identifiable traits in the visit. Here, “culture” becomes a monolithic, static archetype we project onto patients based on our unconscious bias about their physical attributes, like ethnicity, nationality, or language.

When we do this, we are pretending that socially-assigned attributes, like race, are a proxy for risk. We track patterns of disease prevalence by these attributes and over time, come to associate the attribute with the disease. This logical fallacy then informs clinical practice and leads clinicians make inaccurate assumptions about certain patient populations, their relationship with disease, and the efficacy of certain medications to address their complaints (remember BiDil?).

The solution is to replace cultural competence with structural competence and educate young providers to interrogate the local context in which patients live, the resources at their disposal, and the networks they rely on to make medical decisions. We must of course, when doing this, not turn a blind eye to the ways in which local policies and historical discrimination produce predictable patterns of disease in certain communities. These patterns may make it seem as if the risk factor is easily recognized in the exam room (race, nationality) as opposed to the real risk factor that lives in our communities – structural inequality.

As medicine advances to address inequality as an important driver of health, we must be thoughtful about the way we educate our trainees to tackle this new frontier in primary care. While there will be pitfalls along way, if we tread carefully and together, we can transform the future of medicine in powerful and meaningful ways.

The figure is simple. Health care plays, at best, a minor, and at worst, a relatively inconsequential role in reducing early death in America.

That means, where people live and how they function in their local environment, potentially matters more to their long-term survival than what doctor they go to, or what medicines they are prescribed.

That is a powerful statement about a complex phenomenon – what happens in our communities impacts health in profound and lasting ways. So if health is predominantly determined by community-level factors,* perhaps we should re-design the traditional medical model to place community at the center of health care.

This idea isn’t new, and is probably why Dr. Steven Schroeder aptly titled the article from which this graph was taken, We Can Do Better. One look at the data and it is obvious more can and should be done to address the social, economic, and political drivers of health in this country. But the question of who and how somehow remains.

For many physicians, taking on structural inequality may seem overwhelming or outside their job description. Common retorts I hear are, “This is a social workers job.” Or “This sounds good in theory, but how would it work in practice?” To the first point, the evolution I am alluding to is a systems-wide change in the practice of medicine, such that the way we conceptualize medical care draws upon the skills of an interdisciplinary team of practitioners charged with addressing social determinants of health. So while this vision certainly includes social workers (and public health departments, local government, social service agencies, etc) it also necessarily includes physicians.

To the second point, there is a long history of community-oriented primary care (COPC) theory and practice. It dates back to the 1940s, and the work of giants like Sydney Kark, who created a model of government-funded, community-based, preventative care delivery in South Africa; and Jack Geiger who directed 2 exemplary, community health centers in the Mississippi Delta and Boston, MA in the 1960s. Dr. Geiger’s integrated clinics were the first of their kind and used government funding to pay for community-level health issues, like hunger and housing. Today, there are over 1200 such clinics nationwide serving an estimated 20 million Americans, or 5% of the US population, annually. These clinics are the backbone of the national safety net and the front lines of the medical response to growing inequality.

But as the issues of poverty begin to knock on all of our clinic doors, we can no longer afford to ascribe to the notion that this is the niche work of a minority of physicians.

So where do we begin?

The ballot box.

Data suggests physicians have a relatively low rate of civic participation as compared with professional peers like lawyers and the general population. As local policy informs local resources, the ballot box is the space where physicians find voice to address the pressing needs of our communities, needs that have an undeniable impact on this nation’s health.

The future of medicine requires physicians confront the impacts of concentrated poverty, a tiered education system with gaps big enough for entire communities to fall through, immigration and population displacement, and racial and gender discrimination, among other indicators of health. Still, the traditional physician role and our current training paradigms largely ignore these modern threats to health and wellness. So in the absence of a clear system-wide charge, vote in a way that makes a difference.

If community health centers are the backbone of the social safety net, voting is the backbone of physician advocacy.

Civic participation is the new frontier for physicians to combat the effects of poverty and inequality on health in enduring ways. It is how we can reach beyond the limits of our clinical role to engage the issues that matter to our patients and our communities.

Visit Vote411.org to find a polling place near you, trouble shoot election-day problems, and find a state-specific voter guides.

Definitions used in this piece:

* Community-level factors are things like where you live, how safe your neighborhood is, if you have a park within walking distance of your house, or if the property values in your neighborhood are high enough that your local public school is well-funded and thus if you are of school-age, you are more likely to go to college as a result of living in that neighborhood. These community-level factors are intimately related to the choices people make or their “behavioral patterns” (as referred to in the pie chart above). For example, if your neighborhood is relatively safe and there is a park within walking distance of your house, you may be more likely raise your child in a lifestyle that promotes and values physical activity, a known method to prevent obesity. Conversely, if you live in a neighborhood that does not have a grocery store that sells affordable fresh produce, you may be more likely to eat processed food, and more likely to battle obesity and related health conditions.

For more on how community level factors or structural inequality affects health, check out my piece on structural inequality here. If you are an educator thinking about teaching these topics, check out my piece on teaching structural inequality here. This piece also includes the syllabus and reference guide I use when teaching on this topic.

In the post-Affordable Care Act healthcare landscape, sweeping hospital closures have created new barriers to access in a system already criticized for its fragmentation and saturation. Looking back over the past 20 years, urban hospitals, and urban trauma centers in particular, bore the brunt of this impact, closing at the highest rates in the country. Now, evidence suggests the impact of urban hospital closures may disproportionately affect those living in poverty, racial and ethnic minorities, and the uninsured.

This concerning trend begs an important question:

If urban hospitals are a trusted point of access for low-income communities of color, does their closure undermine the national safety net OR does it create opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations?

To answer this question, let’s look at the contentious 2007 closure of Martin Luther King Jr. Harbor Hospital in Los Angeles.

As a bit of background, MLK-Harbor opened in the wake of the 1965 Watts riots and general unrest regarding the lack of sufficient public investment in communities of color in South Central (now termed South LA). The hospital was to provide healthcare in one of the poorest and most violent neighborhoods in LA. At the time of its closure, it remained the only public hospital to serve a large part of South LA, treating more trauma patients than almost all other hospitals in the region. Its closure was prompted by a series of egregious medical errors that eventually threatened the hospital’s accreditation.

Mounting quality concerns aside, what was most notable about its closure, was the staunch community protest. In the face of unquestionably dangerous medical practices, the community rallied to protect their safety net; even garnering the support of Congresswoman Maxine Waters, who rose to the cause’s defense in 2004. Despite their efforts, the trauma center was shut down in 2004 and the general acute care hospital closed thereafter in 2007.

So why would a community fight for the failing care of their discredited hospital? Is the safety net worth protecting when it is offering poor care or is the community’s advocacy tacit admission that poor care is better than no care at all? And ultimately, does “no care” threaten the safety net or does it provide an opportunity for something better?

Let’s dissect these questions piece by piece.

First, it is a basic human instinct to protect what you perceive as yours. Even if what you have is broken. Now superimpose on that instinct, a history of having no say in what is taken from you; a history of abandonment by public institutions charged with investing in your community infrastructure; and a history of displacement driven largely by resource scarcity and discrimination. When viewed in this structural context, the motivations to fight to protect resources become obvious.

Second, let’s explore the idea of fighting for “failing” or “poor” care. Here, the assumption is that low-income communities of color either don’t understand or don’t want, quality. Why else would they protest the closure of a bad hospital, right? In this case, I think we’ve got the assumption wrong. Americans love a deal. We want more for less. Whether it’s super-sizing our french fries or buying into the housing market at the right time, we want quality and we want it at a bargain price. In this way, quality is an American value that translates across the economic spectrum. But sometimes, “the deal” trumps quality. So the real question is, what is the “deal”?

In the case of MLK-Harbor, if there is not another medical facility near your home and public transportation is unreliable, or if you are uninsured and you cannot afford a second opinion, or if the medical specialty you need is only available at your local provider; then the deal is access, the deal is cost-savings, the deal is specialization. This is why low-income populations are vulnerable. Because their lack of resources offers them a bad deal, around which there is little leverage.

So it is not that poor care is better than no care. It is that no care should no longer be an option, but for many, that is the deal they are left with. So as engineers of the system, we have to create something better.

And herein lies the answer to our initial question. It does both.

Because urban hospitals are a trusted point of access for low-income communities of color, their closure undermines the national safety net AND creates opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations.

In attempting to forge a better healthcare system in the midst of our broken one, every failure is an opportunity for improvement.* As the Affordable Care Act re-organizes the medical landscape into regionalized, micro-systems that are accountable for local populations, it provides the opportunity to consider our past failures and the global impact of shifting costs and shifting care on the vulnerable.

The tension between eliminating inefficiency, maintaining quality, and controlling cost while elevating the voice of the community and prioritizing the needs of the under-served, remains. These are the challenges that loom at the forefront of a healthcare system that seeks to cut costs and maximize quality for all. But this is a cause worth fighting for and I’m all in. Are you with me?

* To see how MLK-Harbor (now MLK Community) is improving their system to re-open in 2015, click the link.

There is little to say once you’ve said this before. Although the sadness brings fresh tears, they are also old tears. The grief becomes familiar and so too the inevitable resumption of everyday life. The pain bores to the soul but settles in the subconscious, where it rests, privately born and quietly hidden, lest frustration and bitterness mire the work we do – trying to forget, but ever-reminded. So although there is nothing new to say, perhaps there is something new to do.

Here, I am looking squarely at you, my fellow physicians. We, who deal in health and disease must think critically and act effectively to address the issues raised by the death of Michael Brown and those who came before him. We are the trusted public servants charged with protecting the populations in our care, to promote health and prevent and treat disease. But are not health and disease simply the crude boundaries of life and death? Then, how will we move to protect the lives of black and brown youth that are threatened by violence? How will we confront the reality that the #1 cause of death for black males aged 10-24 is homicide? What are we doing about the death rate for young black males that is the highest among all adolescents in America? Black male teenagers are 37% more likely to die than any of their peers. And according to the CDC, because these deaths are secondary to external injury, they are by definition, preventable.

So I will ask again, what are we doing about it?

Because, despite the vaccines given to ward off the threat of disease, and the medications prescribed to prevent seizures, kill cancer, and treat infections, black males may not make it out of adolescence alive if we don’t address the violence.

In preventative medicine, we talk about risk factors to identify patients who may suffer from an illness in the future, and prevent it, before suffering and/or death could ever occur. In oncology, we talk about getting to the diagnosis and treatment early, so that in cases where it makes a difference, everything that can be done, will be done. And yet, as black youth die in the streets because of where they live, and how they dress, and the volume at which they listen to their music, we are silent. We, as a collective field, say nothing and we do nothing.

Black lives matter because all lives matter and no one gets that more than we do. So as young black bodies line our streets without reason or recourse, we must start asking what that means for all of us. We must start changing the way we teach and practice medicine. Because if we fail to protect these youth, because we don’t understand their music, or we don’t like the way they dress, or we don’t feel comfortable with the way they speak – whatever the because – then we fail ALL of our youth. We fail to do service to the highest honor of our profession, to protect the lives we care for.

Now, this issue is complicated and deeply rooted in the legacy of discrimination that defines American history and continues to inform America’s present. And you may even avoid talking about it in your personal life, let alone your clinical practice. But your, or my, discomfort does not make it any less our responsibility.

So let’s start dealing with it. I’m talking about poverty. I’m talking about racism. I’m talking about structural inequality. I’m talking about the gender wage gap, the academic achievement gap, and the housing equity gap so wide whole generations fell in and got lost. It is time to engage these topics as legitimate and enduring parts of medical education, public health messaging, and clinical prevention strategy.

No excuses.

If you don’t have the faculty to teach this material, call upon our colleagues in the social sciences to share their expertise. If you don’t know how to address community violence, reach out to non-profits who have made this struggle their life’s work. And if you shy away from the institutional failings that underlie the policies that contribute to the disparities, then call on your local, state, and federal policy makers to change the law.

There is literally no time to waste. Every faceless, nameless brown child who drops dead in the streets could have and should have been prevented. Let this issue not settle in the subconscious recess of our field while children suffer. Because in the end, it is not about Ferguson, it is not about Michael Brown, it is not about the countless others who met a similar fate, it is about what we are doing to ensure that all lives matter, regardless of the color of that life’s skin.

The recent killing of Walter Scott was another brutal reminder of the home African-Americans wake to daily. Their America, is one where your father might not come home at night, because his brake light went out and that cost him his life. It’s a place where petty crimes are penalized by life sentences, doled out on the streets by the very men and women charged with their protection. But too often, they don’t find protection. And black men and boys are left lying there, without aid or comfort, in a pool of their own blood, for all to see the boundaries of permissible police conduct.

For there is no crime too small for which black fathers and sons may face imminent death. For some, death may merely be a traffic ticket away. And for others, no crime is even necessary. Simply disobeying social expectations, or committing crimes against the social order, can threaten an African-American’s life, if one encounters the wrong officer or wrong neighbor, wearing the wrong hoodie or playing with the wrong toy. For them, their public presence can be a justifiable cause for homicide and their assailant may not even face trial.

So as the death toll rises, the leading cause of death for black males aged 10-24 fails to shock anyone – it’s homicide. But you might be surprised to know that doctors are doing little to nothing about it.

In the wake of Sandy Hook, the response from physicians, and pediatricians in particular, was astounding. But as boys who could be my sons and men who could be my father, lie in the street, week after week, the medical profession is silent and I’m frankly appalled.

These deaths should weigh on every physician’s professional conscience. They rip into the very fabric of our degree and challenge the meaning of practices essential to modern medicine – harm reduction and disease prevention. If we, as a field, fail to even acknowledge the lives lost, let alone devise systematic interventions, at a certain point, we fail to honor the oath of our practice and to serve the core of our professional obligations.

Targeted police violence against African-Americans is a public health problem and it uniquely affects children. Yet to this date, there has been no public statement on behalf of the American Academy of Pediatrics, or any other professional medical association to my knowledge, recognizing the tragic deaths of African-American men and boys across this nation. So while my lone voice is hardly sufficient, I offer these words as a part of my professional responsibility to care for the lives of all my patients, big and small.

• The toll police killings take on black families, including those not directly involved in the events of violence, matters and the chronic stress it generates may adversely affect family dynamics, community safety, and the mental and physical health of African-Americans of all ages.
• Adolescents, both male and female, commonly participate in risk-taking behaviors as a part of their development as youth. Those same behaviors can have significant and lasting costs for African-Americans, as they may suffer higher rates of arrest, incarceration, and death.
• Efforts should be taken on behalf of physicians caring for black families to discuss the toll police killings have on health. If there is concern for impending danger, appropriate referrals to local authorities and community organizations should be sought on behalf of the physician, nurse, or medical staff.
• Preventative health screening guidelines for children and adults should include risks of gun violence, including police violence.
• Training will be needed for physicians to appropriately discuss these concerns with families, screen youth for risk behaviors, and refer at-risk individuals to further services.
• Funding for clinical interventions to address police killings should also support local organizations that work to decrease community violence.

Too many parents tuck their children into bed, only to worry that tomorrow, their curious 10-year-old may be the victim of police-related violence because the combination of a growth spurt and black skin threatened their life. Too many physicians either don’t know that, or don’t care. Because I’d have to imagine that if we knew and cared, we’d be doing something very different in medicine.

This is my plea for us to do something different. Silence is not okay. This is our responsibility, just as it is for all Americans to re-think what these deaths mean for our society. Because if this legacy of violence isn’t weighing on everyone’s conscience, we are all doing something wrong.

As Baltimore erupts in fiery protest following the death of Freddie Gray, the city joins scores of others who have recently challenged the role of police in community.

With the disproportionate representation of Black males in the correctional system and the videotaped deaths of those approached by police for seemingly petty infractions, the longstanding concern for a criminal justice system that differentially treats communities of color, is finding new relevance in cities across the nation.

But as young and old, gang-affiliated and religious alike take to the streets of Baltimore in unified protest, somehow the public unrest has garnered more attention than the issue itself. It seems, the fight for justice shouldn’t be a fight at all.

Labeled as “looters” and “thugs,” even in the very moment a community mobilizes to denounce their victimization, they are simultaneously recast as criminals, undeserving of the autonomy to freely express public discontent.

Now, my purpose in saying this is not to condone violence but to examine the ways we characterize communities of color, particularly around public displays of anger, and to look deeper at the role policing practices play in the tensions building in cities across America.

First, the idea that African-Americans are strong, aggressive, and prone to violence are antiquated stereotypes that continue to plague the public image of African-Americans today. So despite justified cause for outrage, the media often lazily resurrects these archetypes of blackness instead of investigating the source of community distress. This is both dismissive and misleading. It dismisses the understandable concerns of African-Americans by denying them the humanity of basic emotions and misleads the public by playing into the drama of stereotypes that distract from the issue.

Second, to cast the community as violent miscreants and the police as authorities of order, is to ignore the reality that both groups stand face to face at the line of protest, in confrontation with the other – and that confrontation has been violent, on both sides.

Baltimore has a long history of police misconduct and those abuses have been well-documented in Baltimore local news and recently in national outlets like The New York Times and The Atlantic. So it is problematic to disavow police of any responsibility in the tensions unfolding in Baltimore and beyond, because much of that tension stems from prior police conduct. It is also important to note that when police are outfitted in riot gear to patrol neighborhoods shield-first, it may incite conflict between the authorities and the community demonstrating for respite from police control and violence.

But ultimately policing practices are driven by local and state public policy, and it is that policy that criminalizes poor, communities of color and gives police license to penalize insignificant infractions. Those infractions lead to incarceration rates that cumulatively threaten the cohesion of Black families, the strength of the local economy in Black neighborhoods, the voting power of majority Black districts, and the upward mobility of young Black males seeking to enter the workforce. The mass incarceration of African-Americans may also impact child and community health.

So as we critically look at the role of police in communities, we must also investigate the policy environment that makes that role possible. Because while the police are the front lines of the justice system, they are certainly not the extent of the problem.

And as tensions unfold across the country, we have to shift the conversation to the reasons for protest. Instead of dismissing demonstrators as thugs defiling the sanctity of American business, perhaps we should look beyond stereotypes to uplift the sanctity of their lives and acknowledge the exasperated plea of a community seeking justice. Sometimes that plea is venerable in its non-violent supplication, and sometimes it is marred by the violent frustration of a community long-ignored. But aren’t we all, both the civil and uncivil among us, deserving of justice?

After publishing a few pieces on police violence, public health and safety, I received a number of comments asserting the “real” problem is black on black crime. I get this a lot.

So let’s talk about it.

According to the numbers, the most recent of which come from the FBI’s 2014 crime report, the critics are right. Black victims of homicide were overwhelmingly killed by black offenders. This occurred in almost 90% or 9 out of 10 homicides and includes both male and female victims and offenders.

BUT…

This is also true of white on white crime.

In fact, most victims of homicide are killed by someone of the same race or ethnicity. For white people, more than 8 out of 10 homicide victims die at the hands of another white person. And though Latinos have the highest rates of inter-ethnic homicide, 7 out of 10 victims still succumb to a fellow Latino.

So while it is true that black on black crime accounts for most black homicides in America, racial congruence between homicide victim and offender is hardly unique to African-Americans.

What is unique is the rate at which African-Americans are killed by police.

Let’s review the evidence.

Most data on police-related deaths come from the FBI and Bureau of Justice Statistics. The FBI counts deaths they term “justifiable homicides” or incidents in which the victim was a felon shot in the line of duty. The Bureau of Justice Statistics data is more robust, in that it includes deaths resulting from any use of force while a civilian is in law enforcement custody.

However, these agencies have been criticized for generating unreliable and out-dated data. For example, the exact number of “justifiable homicides” are difficult to pinpoint in any given year, because the tally relies on precinct reporting that is largely voluntary and often incomplete. And the Bureau of Justice Statistics’ most recent metrics are from 2009, and have since been replaced by the Death in Custody Reporting Program, whose latest data is from 2012.

This lack of accurate data clouds the public’s ability to understand the racial context surrounding recently publicized police-related injuries and deaths, and may be leading some to short-sighted conclusions.

The good news is, people are working on it.

Powered largely by news reports, social media announcements, and civilian tips, crowd-sourced databases and other open access portals are keeping public records on incidents of police violence and most importantly, providing real-time, interactive access to the critical numbers necessary to appreciate the size and scope of the problem.

But one database in particular, Mapping Police Violence, is leading the way in illustrating how this issue uniquely affects African-Americans.

These findings are alarming. But what is more disconcerting are assertions that the deaths of some Americans are not “real” problems because those same people face additional threats to health and safety in their communities.

It is certainly easier to indict “cultural” pathologies instead of confronting systems that serve us – systems we pay for and participate in – to demand for our neighbors what we demand for ourselves. But the legacy of racism that results in poor, communities of color suffering heightened risk of violence, displacement, and resource scarcity, continues to structure vital access to justice and safety.

Thus, perhaps the “real” problem is our collective inability to feel empathy on behalf of communities facing complex and compounding traumas, traumas we contribute to through our general apathy for a people and their color.

The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.

The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.

To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.

Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”

But the baffling thing is, that is not what is happening.

Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.

But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.

Thinking outside the “doc in a box”

In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.

The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.

It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.

If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.

There will likely always be a need for physical care of patients with ailments that require  treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.

With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.

In April 2014, Flint transferred its water supply from Lake Huron to the Flint River. It was meant to be a temporizing, cost-saving measure. But what followed was one of the most devastating recent failures of public infrastructure and a heartbreaking example of how social inequity ultimately leads to public health crises.

To quantify just how bad the problem is, here’s a schematic from USA Today.

To add insult to obvious injury, the areas of Flint most affected, were disproportionately poor, communities of color.

Last weekend, I was fortunate to join other activists and Flint community members in an online panel discussion hosted by Black Public Media about the impact of the crisis and what people are doing to address it. This weekend, as the nation prepares to broadcast the latest democratic presidential debate from Flint, Michigan, I wanted to revisit what has and is happening there, who it affects, and what we can do about it.

1. Lead is toxic.

There are no safe levels in the blood and it can affect every organ system. Adults exposed to lead can have high blood pressure, joint or muscle pain, headaches, memory loss or mood changes. In utero exposure can result in miscarriage, premature birth, and low birth weight. Children who are exposed are at risk for learning problems, developmental delay, weight loss, and hearing loss. And the most disturbing data shows maternal exposure may even be transmitted to grandchildren, making the adverse effects of lead, generational.

2. Infants and children are more vulnerable to lead exposure from water contamination.

Infants and children can absorb more water-soluble lead than adults. And infants whose primary nutrition is reconstituted formula mixed with contaminated tap water, likely absorb the most.

3. Low-income, people of color are increasingly vulnerable to lead exposure.

• Aging public infrastructure in urban America means lead may leach into faulty pipes and disproportionately affect areas with concentrated poverty, which are more common in communities of color.
• Neighborhoods with high rates of food insecurity may lack access to foods high in calcium, Vitamin C, and iron, that decrease lead absorption and buffer potential exposures.
• High rates of unemployment and historical housing discrimination may contribute to low-income, communities of color disproportionately inhabiting older homes that increase household exposure to lead in chipping paint, dust, or soil.
• Lack of financial resources to purchase alternative water sources disproportionately expose poor people to contaminated tap water.

4. To fix this, more than clean water is necessary. 

Access to clean water is essential to decrease water-based lead exposures but the magnitude of this exposure (2 years worth!), lead’s potent toxicity, and it’s long-term effects on cognition, behavior, and child development, will require wrap-around social services. That includes access to affordable, healthy food, education supports, behavioral health services, early childhood programs, and sustained investment in local infrastructure to mitigate the short and long-term impacts of these exposures.

Additionally low-income, communities of color should be prioritized to receive these services because they have been disproportionately impacted.

5. For more information about lead exposure for families who are affected or concerned:

• Visit the American Academy of Pediatrics Website OR
• Check out recommendations from Dr. Mona Hanna-Attisha, the pediatrician whose research helped expose the problem.

When things like this happen, and know it is happening all over the country, it’s important to take an honest look at what it means. And I don’t just mean environmentally.

Americans are only as free as the choices at our disposal. And when poor people and brown people have no choice but to take poison because of failures of public systems, systems that dismissed concerns raised time and again, it corrodes the promises on which our democracy is built. From contaminated tap water to neighborhoods that lack fresh produce or communities disproportionately subject to violence or school systems that fail poor, brown youth – it is inequity that is poisoning America and betraying our unalienable rights to life and liberty.

Make no mistake, this is about more than water. And while we can bottle short-term solutions now, it is time to take affirmative steps to close disastrous equity gaps in America that underpin future crises.

A “Health in All Policies” framework has been touted in the past few years as a strategy to illuminate the intersections between public health and other areas of civic life. It’s one way to incorporate health metrics into existing and proposed public policy – from education to transportation. But the question is, will it work?

It seems fairly obvious that health-centric framing may obstruct interdisciplinary collaboration. But at a more fundamental level, will replacing multivariate, silo’d interests with the singularity of health effectively capture the complexity necessary to create shared agendas across public sectors?

The short answer is no. Here’s why and how we got here.

The former structure of medical education and training was rooted in the idea that the greatest knowledge in medicine was best revealed through individual patient inquiry and the greatest challenges in the field were best understood and addressed through individual clinician excellence. So clinicians were evaluated based on their individual aptitude, patients were assessed based on their isolated symptoms, and each sector of the health and human service network operated in silos, training and treating pieces of the problem, without ever quite appreciating the inter-connected whole.

This paradigm of education and practice placed clinicians at the center of care and patients and allied partners at the periphery. Allied learners were taught separately and systems communicated poorly, both of which resulted in fragmentation – in how problems were evaluated and in how care was delivered.

A more recent iteration of this care ecosystem, like the “Health in All Policies” approach, now places patients and health at the center of delivery models and public policy strategies to treat disease and advance wellness. These patient-driven, health-specific metrics ensure that systems are oriented to serve and public policies are structured to mitigate health impacts.

However increased focus on individual patient outcomes may obscure population-level drivers of health disparities and unilateral dependence on health as the primary outcome, may ostracize allied disciplines, institutions, and learners whose work or study contributes to advanced understanding of human behavior and the complex relationships between structural environments and the pathophysiology of disease.

The bottom line is: the intricate problems that threaten child and community health will not be solved by the individual capacity of excellent clinicians or public servants, but rather by the ability of leaders to organize interdisciplinary teams that learn, work, communicate ideas, translate interventions, and are evaluated across shared infrastructures, in the service of shared outcomes.

If identifying health as the primary outcome of interest or individual patients as the primary drivers of systemic priorities, alienate important partners and dilute the input of minority populations, it is time for a new centering principle. In my mind, that principle should be equity.

Placing equity at the center of the care ecosystem ensures each sector of the health and human service network and each provider and recipient of care has a role and contributes to the shared societal realization of public safety, economic security, and wellness.

Shared values, like equity, are important foundations for building integrated public systems. And integrated public systems are important to create parity in resource dissemination and improve productivity through partnership with allied disciplines and institutions. Although the process of integration may generate new financial costs, it will hopefully save money on the back end by aligning incentives and improving efficiency.

In the end, equity will be the framework for the future of care and policy that aims to improve health. So as we move towards the future, let equity be our guide.

* In appreciation for their wisdom: I want to acknowledge Dr Rajiv Bhatia who’s novel work on The Civic Engine, and Dr. Damon Francis whose generously shared expertise, informed the ideas presented in this piece.*

As the screens we carry narrow our proximity to random and targeted acts of violence, many parents and families are rightfully questioning the impact viral violence has on shared perceptions of public safety and child health.

In pediatrics, we have long considered the link between media, violence and health.

We know kids who watch fake violence in movies or play violent characters in video games show signs of increased aggression. But what happens when the violence kids watch is real? Or when the cameraperson is only a teenager?

Today, youth can easily capture and consume real violence, in real-time, as a part of their daily routines – from snapping school violence, live streaming police violence, recording sexual violence, or sharing images of political violence. This is the new normal* and it’s more complex than the simple relationship between simulated exposures and aggression.

A child watching real violence from their cell phone now understands something tangible about the world; and a kid who records or shares violent imagery online can contribute to others understanding of the world. That elevation of the voices and experiences of youth can be extremely valuable. Indeed, in terms of activist’s movements like Black Lives Matter, the perspective of youth, magnified by social media, has become a national catalyst for police reform, criminal justice reform, and racial equity.

Yet, perpetual exposure to viral violence takes its toll – often manifest in feelings of victimization, grief, fear, intimidation, anger and sadness. And kids and teenagers may be most vulnerable to this kind of trauma because they are still developing the emotional and intellectual maturity to process troubling events. What is more, they rely on trusted adult figures to provide safe spaces in their life.

As we face these harrowing challenges, consider two thoughts:

1. While it’s okay to be protective, thoughtful and proactive regarding how youth experience and contribute to violent images online, we, as parents, caregivers, or providers, cannot simply turn a blind eye. While distressing, some images of violence advance our collective understanding, compassion, and empathy for the suffering that exists outside the walls of our private communities or our segregated social groups, and the privileges those spaces confer. In this way, confronting the visual of violence with a particular effort to center the interpretation of the events around the marginalized populations disproportionately affected, is the first step towards collective healing. And that healing begins with rigorous and vigilant public exploration of the ways systemic racism, sexism, Islamophobia, homophobia, xenophobia and intolerance threaten public safety.

2. As we live-stream our lives, we open windows to the neighborhoods we live in, the spaces where our kids learn and play, and the ways we perceive and are perceived in the world. When we don’t like what we see on the other side of that window, it can be easy to hide discomfort or insecurity with blame or shame or to create narratives that distort the humanity we witness. But each time one of us resists the opportunity to understand the burdens or experiences of another, we all move further from the co-existence necessary to bring peace.

*This is a piece I wrote with my friend and colleague, Dr. Wendy Sue Swanson, that was published in the July 2016 Pediatrics. It is available for free online for the first week of publication.

What does it mean to understand police violence from a public health lens?

It starts with understanding how police behaviors can result in harm and who is most affected.

In the Cure Violence podcast link below, I introduce what I term adverse police exposures, or a conceptual framework to understand how harmful police behaviors can impact health and public safety. I then explore ways public health leaders, providers, clinicians, advocates, community activists, and students can advance our understanding and commitment to addressing adverse police exposures as important threats to public health and safety.

Cure Violence Podcast: Police Violence Through a Public Health Lens

For more resources on the topics and data discussed in the podcast, see the frequently asked questions below.

Have professional medical associations addressed police violence in the past?

Yes. Here are the American Public Health Association’s 1998 Impact of Police Violence on Public Health policy statement, the National Association of City and County Health Officials’ 2015 policy statement on Public Health, Racism, and Police Violence, the American Academy of Family Practice’s 2015 resolution declaring Discriminatory Policing is a Public Health Concern, and the American Academy of Pediatrics’ 2016 Initiative to Confront Violence in Children’s Lives.

Was Stop-and-Frisk only employed in NYC?

No. While the phrase “stop-and-frisk” is derived from a tactic utilized by New York police departments (and was ruled unconstitutional in 2013) similar tactics have been and are being used in many other cities. For example, in 2015 and 2016, the Department of Justice released scathing reports detailing similar discriminatory tactics utilized by both the Ferguson and Baltimore Police Department. Notably, these tactics are also ineffective, as noted here,

What does “ban-the-box” mean?

This is a national campaign to provide a fair opportunity for employment to those who are formerly incarcerated. In 2015, President Obama took an important step to do this for federal workers.

What do pediatricians know about how stress affects health?

While some stress can be good, too much stress can be toxic, particularly to the developing brain and body. For babies and young children aged 0-5, exposure to toxic levels of stress can have longstanding impacts on adult health. Having an incarcerated parent or caregiver is considered an adverse childhood experience that can contribute to toxic stress.

What’s problematic about police in schools?

For some children, their police contact is structured by their school’s disciplinary policies. According to the Department of Education, across public schools nationally, students of color are more likely to encounter police in this way. Specifically, black male and female students are disproportionately more likely to be referred to law enforcement and have school-related arrests, than all other students. These early exposures criminalize children of color in places where they should be safe to explore, learn, and grow and can contribute to barriers to higher education, employment, and successful participation in community.

What can doctors and health departments do?

We can collect data that captures the magnitude of police violence by counting injuries, morbidities, and deaths related to police encounters. Here is one way to start, authored by Nancy Krieger, a public health champion for this work, and colleagues at Harvard’s School of Public Health.

We can support community organizations that are seeking to redefine what safety means to communities of color. Here, the Ella Baker Center for Human Rights’ Justice Teams stand out as incredible leaders for their work to deploy community-led crisis response networks in California. Here is a list of other organizations working at the intersections of police accountability and racial justice from Funders For Justice, the member organizations representing The Movement for Black Lives, and Blackout for Human Rights, a collective of filmmakers, artists, activists, musicians, lawyers, tastemakers, religious leaders, and concerned citizens lifting the voices of the movement through media engagement.

And we can mobilize communities to go to the polls this November and speak up for public safety and health. Confused on the issues? Check out Campaign Zero, which lists comprehensive federal, state, and local policy agendas and a side-by-side comparison of where each presidential candidate stands on these important issues.

Although I write a blog that centers people of color in exploring the connections between the medical system and race  – an activity that has always been fundamentally personal – I rarely discuss how it personally affects me.

The occasions in which I have, were driven by my need to make sense of Trayvon and Walter, Tamir and Freddie and to reconcile their lives with how I move in my life, as a black physician. But there is no sense to be made of state-sanctioned murder and each time I left the task weary with emotion.

I used those emotions to power 6 months of writing and editing my first submission to Pediatrics, the most important academic journal in my field, on police violence; both begging and demanding this type of violence be considered a devastating threat to public health and safety for children of color. The first comment my co-authors (also black women) and I were asked to address was what the editors called our “anger” and the last was to “say something nice about the police.”

Here I was, asking to be seen; asking for black children and families to be seen; but having to respond to why I don’t see police and why what a white man perceives as my emotion, is a problem to be addressed, in writing. My emotion. That they named anger.

To be labeled angry and asked to publicly disavow said emotion for professional legitimacy was nothing new, for me, my co-authors, or centuries of black women accosted by the limited public characterizations of our person-hood. But when they named my emotions anger, did they also name my tears? Did they name the deep humiliation I processed to explain, to a pediatric medical journal, why the deaths of black parents and children should be a priority?

Did they furiously, nauseatingly, mind-numbingly, cry over the public executions of their people? Did they choke and swallow those emotions back everyday just to function as a productive adult in the world? Did they wake to bury the devastation that allows them to hold academic conversations about the threats, challenges, and disparities that may amount to the extinction of their people?

In medicine, if we talk about racism at all, we talk about how it is unfair – but no ones fault really. Short of bias training that validates a generalized lack of explicit accountability – we primarily do nothing. It is as if medicine thinks the solution to centuries of systematic racism and racial inequality that continues to poison black bodies, young and old alike – through public divestment, disease and varying degrees of despondency – is self-reflection.

But it is killing us.

Racism. Is. Killing. Black. People.

Sometimes I feel the poison in me. Squeezing my chest in anxiety, fear, or fury as I navigate the complex terrain of my public female black-ness, trying to wear my emotional and intellectual complexity in a way that at best, allows me to be seen but at least, prevents me from being dismissed altogether. The daily work of avoiding the silencing that accompanies being mistaken as simply an “angry black female” while also finding safe spaces to be a black female who can hold anger and the emotional complexity inherent to full humanity – is an extra job, that I do, at my regular job and on vacation.

Sometimes I see the poison in my family, as they do the work of making space for their whole self in a world that can easily, effortlessly limit them to an assumed identity. I watch them negotiating other people’s comfort in an exhausting performance of excellence and I understand the raw pain blackness chafes on their humanity.

Racism excludes black people from public goods and private sympathies. It is the root cause of health disparities, the education gap, the wealth gap, the gender wage gap for black women, and the unconscionable incidence of institutional violence against black bodies.

And in so much that medicine ignores that root cause, it is and will remain complicit in the maintenance of institutional racism, both inside our walls and out.

So just in case you have wondered or are wondering, yes, I am angry.

I feel intense and unapologetic anger. But know, my anger isn’t the poison, racism is.

2 weeks ago, my family and I visited the National Museum of African American History.

It is said the museum was a century in the making.

When you walk in the doors, you know exactly what that means.

We happened to enter behind a black family of four. Two parents, who appeared in their mid-late 30s, and two young boys, both of whom could not have been more than 5. It was raining that day and they were all bundled up – hats, vests, scarfs, boots. Despite the aggressive gear, as soon as we got inside, off those boys ran, like they were in their own playground. While a lot of kids run everywhere they go, to see these little black boys, brothers, running free and unencumbered in this building, their building, on the National Mall, erected to honor their ancestors, standing in honor of them, was the perfect prelude to what lay before us.

The whole day, we saw babies and watched children, crawling, running, sitting, climbing. Like the little one, maybe 3, who walked up, alone, and sat next to me on a bench. Together, in silence, we watched a short video about the contributions of African American athletes. Shortly afterwards, his father and brother arrived, obviously happy to have found him. But there he was, drawn to the images, sitting still and watching intently, as people who look like him did great things. I can’t imagine what the moment felt like to him. Perhaps it was simply another age-appropriate act of independence and environmental curiosity. But sitting next to him, the moment felt full and hopeful.

But it wasn’t just the young who captured the moment, it was also the elderly. Those who entered the museum with canes and walkers, who moved with the support of their family or church or neighbors. Those draped in t-shirts commemorating their visit, who traveled across states just to be there.

I think of one woman in particular.

She walked slowly, with her weight heavily upon a cane, her white hair curled, her lips peach with pigment. A women who seemed like her daughter walked at her side, supporting her, and a young woman, maybe age 20 or so, walked in front of them guiding them towards an exhibit on Greenwood in Tulsa, OK. The walls were flanked with images of a town that looked ravaged by a natural disaster. The air in the small exhibit felt thin and heavy. You stood, surrounded, by a town decimated in ash. Only the actor was not an unruly Mother Nature, but rather the destructive, unpredictable, and irrepressible swell of White Supremacy that leveled, literally burned, an entire neighborhood, notably one of the wealthiest black neighborhoods in the country at that time, to the ground. As I stood, solemnly confronting the wall-sized photos and recovered personal items, next to what appeared to be a family of women, I watched as the elder asked the youngest to read the inscriptions to her. I don’t know if it was the photos, the women, or the collective recognition of what black people have endured, suffered, and lost in this country they have called home – but I cried openly there. Left my tears, my heart, my gratitude, to those women, to that place, to the grit that rose from those ashes to trouble and inspire me.

My experience of the newest Smithosonian museum was captured in small moments and big. Moments when I stood shoulder to shoulder with history and watched as the future crawled along the floor, with a certain mix of joy and pride I can only remember having felt so vividly the morning after Barack Hussein Obama became President of the United States. There was a palpable shift in the world as this black girl turned black woman saw and was seen. Standing with my family only added to the consequence of the moment.

As science, history, literature, the arts, and public consciousness inch towards full acknowledgement, engagement, inclusion, and elevation of our presence, our personhood, our importance, and our centrality in the American experiment, this building will stand in tribute and truth. The gift is our ability to return to it, in reverence and expectation, to share that truth with our future generations.