Children’s Hospital Grand Rounds: The Fierce Urgency of Now: Health, Education, and Democracy

February 12, 2020

Five years ago, I delivered the Alvin Poussaint lecture at Harvard Medical School on the topic of health as the unfinished work of the civil rights movement.

The occasion was near the 50th anniversary of the founding of the community health center movement—a historic and ongoing effort to bring health care services to low-income residents in the United States.

The very first of these centers was established in the Dorchester neighborhood, right here in Boston. It was called the Columbia Point Health Center and opened in 1965, founded by Dr. Jack Geiger and Dr. Count Gibson of Tufts University.

The same grant would also fund what is now known as the Delta Health Center Inc. in the all African-American town of Mound Bayou, Mississippi, at a time when health care was virtually nonexistent for the vast majority of Black Mississippians.

Over the past half century, we’ve seen progress—but not nearly enough. And today, even the gains we’ve made feel increasingly precarious.

As we come together for Black History Month, at the start of a new decade, I want to share some thoughts on how we can move forward. On how we can “bend the arc of health” toward equity and justice.

As health care providers, many of us tend to focus on individual patients. This is as it should be. But our work also has impact on a far larger scale. It will go far to shape the future of our nation—and I would go as far as to say shape the future of democracy.

This is true for the health care professions as a whole, but it is especially true for those of you who serve families and children. A healthy, vibrant citizenry—one where all voices are lifted and heard—starts with healthy babies. And to go a bit further upstream, it starts with healthy mothers.

You no doubt know how far we have to go here.

In recent years, maternal mortality among Black women is again getting some long-overdue attention, this time much more in the public eye in the wake of harrowing first-person stories from celebrities such as Serena Williams and Beyoncé.

To be sure, this is part of a broader problem. Maternal mortality in the U.S. has been rising across the board, with American women 50 percent more likely to die in childbirth than their own mothers. The United States has the unfortunate distinction of charting the highest maternal morbidity and mortality rate of all the world’s high-income countries. But for Black women the situation is especially dire.

The numbers are quite simply stunning. Black women are three to four times more likely to die in childbirth than their white peers, irrespective of income or education. (Source: Dr. Neel Shah on HMS website.)

And of course, it’s not just here that we see vast health disparities between African-American and white patients.

Health economist Austin Frakt summed it up like this in the New York Times: “Put simply, people of color receive less care—and often worse care—than white Americans. Reasons include lower rates of health coverage; communications barriers; and racial stereotyping based on false beliefs.”

We know that life expectancy for whites in the U.S. has consistently exceeded that of Blacks, an inequity rooted in the darkest chapters of our national history. The New York Times explored this history last year as part of the 1619 Project, commemorating the 400th anniversary of the start of American slavery. “There has never been any period in American history where the health of Blacks was equal to that of whites,” Harvard’s Evelynn Hammonds observed. “Disparity is built into the system.”

Disparity is built into the system.

Today, our task is nothing less than to dismantle this system. Only then can we replace it with something better. Only then can we complete the unfinished work of the civil rights movement.                                                                                             

So often, our focus is on what we want to eliminate, from diseases to racism. But we also need to stay focused on what we are working for. That’s where the joy is. That’s what keeps me going.

We must not lose sight of our North Star—a just and healthy world. A world where everyone has an equal chance to thrive. I am sustained by these words of the World Health Organization: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” That definition has been on the books since 1948, and it’s every bit as inspirational today as it was then.

When I left the Connors Center for Women’s Health, the organization that I’d founded and to which I’d dedicated more than 15 years, some were quite surprised. They saw my move to Wellesley College as an abrupt shift. But for me, the move to women’s education could not have been more natural. Throughout my career, I’d been spurred on by a number of powerful questions. Yet, ultimately, all were facets of a single inquiry: How do we create the conditions for women to flourish and reach their full potential—both in service to them and in service to the world?

So, I want to turn now to some of the important factors that support these outcomes.

I’ll turn first to the importance of role models.

I’ve been fortunate to have many in my life—and the fact that I am here today is a testament to their power.

One of the earliest was someone I never met.

I was 9 years old when Shirley Chisholm ran for Congress in my Brooklyn district. My mother took me with her into the voting booth to cast that historic vote. I still recall the jubilation we shared on learning of her victory—that for the first time ever a Black woman would serve in the U.S. Congress.

In that moment, my sense of possibility blasted wide open. Someone who looked like me could aspire to anything.

This childhood experience was a critical one. As a college freshman, I would study with the legendary Ruth Hubbard—the first female biology professor to be awarded tenure at Harvard and a powerful feminist voice in and for science. In so many ways, she set me on the course that’s brought me here today.

And yet, it didn’t start with Ruth Hubbard. First I needed to find my way into that Harvard classroom. Shirley Chisholm’s example, and my mother, who fostered what would now be called a “growth mindset,” were instrumental in that.

Role models are powerful—especially when we are young.

That’s one reason that I was intrigued to learn about the animated children’s show Doc McStuffins. I would imagine that many of you are familiar with it, but for those of you who may not be: The main character is a 6-year-old African-American girl who plans to follow in the footsteps of her Black pediatrician mother and become a physician. In the meantime, she’s bent on diagnosing and curing her toys of diseases—such as the “can’tpopitis” that afflicts her Jack-in-the-Box.

The series—I think it ran for five seasons—was widely praised. It won a prestigious Peabody Award, and Michelle Obama even guest-starred in an episode. It was hugely popular with children.

Kids absolutely loved this show. And when I say kids, I mean all kids, white kids as well as children of color.

It also caught the attention of the Artemis Medical Society, an international group of women physicians of color with several thousand members. The group deployed Doc McStuffins in its campaign “to normalize brown-skinned women as doctors” and get more of them into medicine.

The show’s impact was very real, according to Artemis co-founder Dr. Myiesha Taylor, an emergency medicine physician in suburban Dallas-Fort Worth.

As she told an interviewer: “You’d be surprised at the number of children I now hear say ‘She looks like Doc McStuffins’ when I walk in.”

And before Doc McStuffins? “It was often assumed I was not a physician.”

I thought of Doc McStuffins again Sunday night while watching the Oscars. The award for best animated short went to Hair Love, about a father who learns to style his young daughter’s beautifully rambunctious, kinky, curly hair. In accepting the award, co-producer Karen Rupert Toliver said: “We have a firm belief that representation matters deeply. Especially in cartoons, because in cartoons, that’s where we first see our movies and it’s how we shape our lives and think about how we see the world.” 

Of course, that job is far from done—and it will take far more than cartoons, potent as they may be. I recently watched the documentary Black Women in Medicine. At one point, a Black surgeon recounted a story where, just in the recent past, she’d been at a conference and it was assumed that she couldn’t possibly be the surgeon.

“Who’s going to be doing the operation,” someone asks.

“That would be me.”

“You’re the surgeon?

“Yes, I am.”

Really?!”

“Honest to goodness.”

As she told this story, she laughed—though it’s not funny. Yet, until there are many more of us, it will be all too common.

For all the effort made in recent decades, African-American enrollment in medical school still is not what it should be. Some of you will remember 3,000 by 2000, a national campaign to matriculate 3,000 underrepresented minority students into medical school each year by the year 2000. Launched in 1991, the campaign was spearheaded by the late Dr. Herbert Nickens. Sadly, that campaign failed to meet its goal, and even now—20 years later—it looks like we’re just barely there. Going off the website of the Association of American Medical Colleges, I tallied 3,189 under-represented minority matriculants for this academic year.

I could be a bit off on the numbers; in some cases, it’s a bit unclear if a category should be counted. But regardless, we are nowhere near where we should be.

To the physicians of color among you—especially those of you who care for kids—you are real-life Doc McStuffinses, now all grown up. With every office visit, every conversation, you help to expand minds and possibilities.

And our need for role models hardly ends with childhood. Throughout our lives, we need to see people who look like us doing things we want to do.

I know this from personal experience.

As you may know from my bio, I was the first African-American to serve as chief resident in medicine at Brigham and Women’s. I can still feel the exhilaration, anxiety, and—perhaps most of all—sense of responsibility I felt as I embarked on this role. It extended beyond my fellow residents and patients to all those who might come after me—who might be judged by the example I had set. Fair? Certainly not. Likely? Very.

Enter Dr. Michael Shannon.

As many of you know, Dr. Shannon was the first African-American full professor of pediatrics in Harvard Medical School’s history.

He trained in pediatrics at Boston City Hospital and here at Children’s, where he also received his fellowship training in general pediatrics, clinical pharmacology and toxicology, and pediatric emergency medicine.

I remember how excited we were, my co-chief resident and I, when he’d review our cases at our morbidity and mortality rounds. He could dissect absolutely any case that had to do with toxicology. All of us residents benefited from his consummate skills and talents. But for a young Black physician, the power was something more. Here was an African-American physician at the pinnacle of our profession. If you see it, you can do it. That was the message.

Michael Shannon was a true renaissance man—an internationally recognized investigator and teacher with a lengthy record of leadership roles and authorship. A deeply engaged family man who also made time to hone and share his great talents as a dancer, earning the moniker the Dancing Doctor.

At the time of his sudden, unexpected death at the age of 55, many believed that his best work still lay ahead—which was really saying something given all he’d achieved. By the way, his son, Evan, trained at both Children’s and BWH in med peds.

I still recall the devastation I felt on learning Michael had died—a feeling so widely shared. Not only because of who Michael was, but because of the place he filled. Today, just 4 percent of U.S. doctors are Black, compared with being 13 percent of the overall population.

At Harvard Medical School, 6.2 percent of full-time faculty fall under the rubric of “under-represented minority” as of last year, a category that includes Blacks, Latinx, and Native Americans. This is up from about 3 percent in 1980. To put a positive spin on things, I guess we can say that the percentage has doubled. But the numbers remain so very small. (Source: https://fa.hms.harvard.edu/faculty-demographics; but also see: https://faculty.harvard.edu/faculty-demographics.)

Clearly, something is wrong here. For all the considerable efforts toward diversity, we are still woefully behind. And I say “we” because HMS is both my alma mater and my former academic home. This will always be my community, and I feel an abundant sense of concern and responsibility.

On a more positive note, I know how many wonderful people are working to change this at the institutional level. Under Sandi Fenwick and Kevin Churchwell’s leadership, the ideal of diversity is getting the kind of investment essential to meaningful change. Dr. Valerie Ward, who so kindly helped me prepare for this event, now holds the new post of medical director of the Office of Health Equity and Inclusion. The new roles of chief culture officer and chief experience officer will help further shift hospital culture for patients, family, faculty, and staff from many angles.

I must take a moment to also recognize Dr. Jessica Daniel, who for years created a pamphlet each February recognizing all Black senior faculty, and I’m also thrilled that my dear friend Dr. Tina Poussaint will soon be receiving an endowed chair, a well-deserved honor. The chair will be named after her beloved father, Dr. Lionel Young! Tina was promoted to professor at HMS a year before I was, and she is an inspiring role model.

But here’s the thing—and I suspect you’ll agree with me here: We need to do better.

The only way to create a robust pipeline is having more people move through the system and advance to the highest levels.

We need more Michael Shannons, more Tina Poussaints, more Kevin Churchwells, more of all of you.

I’ve talked about the importance of role models for the rising generation. I want to turn now to why diversity is critical throughout the health care system.

From clinical care to medical research, excellence and diversity go hand in hand. Indeed, you simply can’t have excellence without diversity.

At one level, this is just common sense. All of us have blind spots. Who we are informs what we see—and what questions we ask.

Here’s a great example from clinical care: In his book How Doctors Think, HMS professor Jerome Groopman recounts a story about my dear friend and former colleague Dr. Judy Bigby, a longtime primary care physician and former secretary of health and human services for the state of Massachusetts. Judy is former faculty at HMS and Brigham and Women’s Hospital and she is also, I am proud to say, an alumna of Wellesley College.

Like me, Judy is an African-American woman who grew up in modest circumstances. Her father was an airline mechanic, her mother a homemaker who late in life went on to earn a high school equivalency degree.

The story Dr. Groopman tells took place at the Brigham. A 74-year-old African-American woman had been admitted to the hospital, with a number of conditions that included diabetes, hypertension, coronary artery disease, and advanced rheumatoid arthritis. Despite an array of medications prescribed, she continued to decline. During a previous admission, she’d been labeled “noncompliant.”

Under these circumstances, a physician might have reasonably assumed that the problem lay with the patient’s failure to take medications as prescribed.

There might have been a certain exasperation, however well concealed, as she once again stressed to the patient the importance of following the treatment regime.

But that’s not where Judy went—at least not at first. Instead, she had an insight, something entirely overlooked by previous physicians. This elderly Black woman had come of age in Jim Crow Mississippi. There was a good chance she simply couldn’t read her medication labels.

As a result, Judy connected with the patient’s daughter, who worked as a manager in a local corporation. She made sure that the daughter was present for discharge and presentation of the outpatient plan. Things quickly looked up.

Is it a coincidence that Dr. Bigby—herself an African-American woman—was the one who had this insight? I don’t believe so.

Any more than it’s a coincidence that my own lifelong passion for women’s health followed the misdiagnosis of a grandmother I deeply loved.

Any more than it’s a coincidence that I myself often think of health as the unfinished work of the civil rights movement.

We are not only scientists and physicians. We are also people. Each of us brings our whole selves to the work we do. I suspect this goes far to explain why Black patients do better across many measures when paired with Black doctors, a robust research finding.

This certainly isn’t to say that you must be a person of color to have insights that relate to race and health. Indeed, some of the most important work being done today is that of my college classmate Nancy Krieger, now a professor at the Harvard T.H. Chan School of Public Health.

That said—as I know Nancy would agree—who we are matters.

Just as this is true for clinical care, it’s true for academic medicine.

That’s one reason I was so disheartened to see a recent headline that read “Why Black doctors like me are leaving faculty positions in academic medical centers.”

The piece was published just last month on the website STAT. The author is Dr. Uché Blackstock, a board-certified emergency medicine physician and, until recently, a professor at NYU’s School of Medicine.

Some of you may know her. Uché Blackstock and her twin sister, Oni, both graduated from Harvard Medical School, following in the footsteps of Dr. Dale Blackstock, their physician mother. In so doing, they made history as Harvard Medical School’s first Black mother-daughter legacies.

Today, Dr. Oni Blackstock serves as assistant commissioner for the Bureau of HIV/AIDS Prevention and Control with New York City’s Department of Health and Mental Hygiene.

Uché Blackstock has also built a stellar career. For nine years, she worked at NYU’s School of Medicine, serving as an assistant, then associate professor. From 2017 to 2019, she served as faculty director for recruitment, retention, and inclusion for NYU Langone’s Office of Diversity Affairs. 

Then last year, she made a change.

As she explains in her STAT op-ed, she’d never planned to leave; indeed, she’d been deeply invested in her work with patients, students, and colleagues. But finally, it became too much: The “toxic and oppressive” work environment. The fear of retaliation “for being vocal about racism and sexism within the institution.”

“I could no longer stand the lack of mentorship, denial of promotion, and work environments embedded in racism and sexism,” she wrote.

Fueled by a need to “speak truth to power” and have “a larger impact,” Dr. Blackstock created and now serves as CEO of Advancing Health Equity (AHE), a company that seeks “to equip health care organizations with the tools to support a diverse workforce and to provide equitable care to each and every patient.”

Now, this sounds like a wonderful venture—a silver lining to be sure. That said, it can’t make up for all that came before. Nor can it compensate for what such losses mean for academic medicine and research.

We have a vicious circle here, a phenomenon explored by the University of San Francisco’s Dr. Michelle Albert, a former colleague of mine from Brigham and Women’s, in a piece titled “#Me_Who Anatomy of Scholastic, Leadership, and Social Isolation of Underrepresented Minority Women in Academic Medicine.” As Dr. Albert describes it, the lack of critical mass serves to compound feelings of isolation, feelings further exacerbated by factors such as discrimination, bias, stereotype threat, and tokenism. Then add long hours and long years of training, not to mention the financial stressors so common for people of color. What you have is nothing less than a recipe for attrition.  

Clearly, change is called for. What we need instead, Michelle says, is “an inclusive ecosystem,” a truly “authentic approach to diversity and inclusion, one that extends from childhood to senior leadership.” She offers a set of suggestions that deserve our consideration, all aimed at nurturing a diverse and outstanding health care workforce.

This is a topic close to my heart. When voices go missing, vital questions go unasked and unanswered. In essence, we don’t know what we don’t know. And the impact is profound.

My own field of women’s health provides a cautionary tale here.

Let’s take a trip back in time. When I began my medical career, women were rarely included in clinical trials—and in most of medical research for that matter. Investigators operated on the assumption that what was true for men would hold true for women for most conditions. That male biology was typical and women’s was, well, not.

There was just one problem with this approach: It was wrong, at odds with science. We now know that women and men are different down to the cellular and molecular levels. It is not just our sex organs, but our brains, hearts, lungs, and joints that are different. Simply put, to quote a 2001 report from the Institute of Medicine, “Every cell has a sex.”

The implications are enormous—all-encompassing. Men and women differ genetically, and these genetic differences are compounded by hormonal and reproductive changes across a woman’s lifespan.

We now know that the circumstances of women’s lives impact their health in unique ways— ways that the field of epigenetics has elucidated. We know that the same disease often looks different in a man than it does in a woman. We know that violence experienced by women in their early years is the single most powerful predictor of chronic disease as they age. When we fail to take such realities into account, we leave women’s health to chance. This is dangerous, unfair, and all too often deadly.

So how did this come to pass?

How could we ignore over 50 percent of the population?

Why on earth would we assume that their symptoms are atypical—and make those of the other near 50 percent the universal norm?

These are simple and obvious questions, and yet, for the most part, they went unasked until the 1990s.

This finally started to change after the elections of 1992, which led to an influx of women into the Senate in the wake of the Clarence Thomas/Anita Hill hearings.

This was known as “The Year of the Woman” and was, in many ways, a time not unlike our own, a moment where women were waking up to injustices and demanding action.

A turning point came the following year, when Congress passed a historic measure mandating the inclusion of women and minorities in phase 3 clinical trials conducted by the National Institutes of Health. Slowly, the medical research community began to shift.

So why did this take so long? Much of it has to do with who was asking the questions and making the decisions, with who was at the table. Or at the lab bench.

Back in the 1990s, Rep. Patricia Schroeder summed it up this way: “You fund what you fear. When you have a male-dominated group of researchers, they are more worried about prostate cancer than breast cancer.”

Now, of course, prostate cancer is important! And so is breast cancer.

Which brings me again to a critical point: Diversity is essential if we’re to have excellence.

Diversity is not a PC add-on—trendy window dressing. Rather, it goes to the core of where our commitments lie. It shapes the questions that we ask and how we move forward.

It’s no coincidence that the push to require that federally funded studies take sex into account was spearheaded by women—notably Rep. Schroeder and senators Olympia Snowe and Barbara Mikulski—and women researchers and physicians, among whom I’m proud to count myself.

For all the progress made, we are still far from where we should be. Consider that the majority of federally funded studies still do not report sex-specific findings, even if women were included in the research population. And if we don’t do this, results stratified by race/sex groups is even more unlikely!

Think about what that means: When you give an average as a result, that’s not really good for women or men or for racial and ethnic subpopulations. It doesn’t give the right answer for either of them. I’m reminded of this quip from the 4-foot-11-inch former Labor Secretary Robert Reich: “Shaquille O’Neal and I have average height of 6 feet 2 inches.” You get the picture!

There’s an irony here: Even though we are on the cusp of the personalized medicine revolution, there is astonishingly little awareness of the impact of sex and how it combines with race and ethnicity.

Once again, there’s reason to think that gender matters.

In an article published in the recent Lancet issue devoted to advancing women in science, medicine, and global health, Vincent Larivière and colleagues analyzed some 115 million scientific publications covering public health, clinical medicine, and biological research by the authors’ gender over 30 years.

Their findings showed that:

  • Studies with a female first or last author were more likely to report research findings by sex.
  • The effect was strongest when both first and last authors were women.

Such studies highlight yet another danger posed by medicine’s leaky pipelines: how science pays the price when voices and perspectives go missing. We are losing too many women. We are losing too many people of color. And we are losing far, far too many women of color.

Today, just 2 percent of physicians are African-American women. When the numbers are so small, any single loss has a disproportionate impact—an argument we had at HMS many years ago. Which is why stories like Dr. Blackwell’s are so troubling for me. And why I am so heartened by those of you committed to creating environments where all patients, and all physicians and staff, have what they need to flourish.

To repair medicine’s leaky pipeline, we must be holistic and go far upstream. What happens in families matters—the messages sent and received about what is possible, the range of available opportunities and options.

It’s not enough simply to have access to education. Students and trainees at all levels also need to feel seen, supported, and respected—they need to have a sense of belonging. Take this away, and your pipeline will predictably spring leaks.

Here, I want to flag an issue of special concern to me: sexual harassment.

I recently co-chaired a study to assess the impacts of sexual harassment in academia of women in STEM fields. This was a joint effort of the National Academies of Sciences, Engineering and Medicine. You may have read about it a bit over a year ago; it got a lot of media coverage on its release.

What we found was alarming. Academic workplaces are second only to the military in the rate of sexual harassment. This includes gender harassment (put-downs rather than the “come-ons”), sexual coercion, and unwanted sexual attention, including sexual assault. This was especially disturbing given the place academia holds in the STEM pipeline. At a point when talented women are poised to reap the benefits of their efforts, they are all too often derailed. We concluded that wholesale change was needed—nothing less than, and I quote: “systemwide change to the culture and climate in academic STEM.”

There is strong evidence that women of color are uniquely vulnerable here—targeted at even higher rates than their white peers. All of us share the responsibility for changing this, for creating that systemwide change in climate and culture.

* * *

On March 28, 1963, the Rev. Dr. Martin Luther King Jr. spoke from the Lincoln Memorial about “the fierce urgency of now.”

Speaking to some 250,000 civil rights supporters gathered for the historic March on Washington for Jobs and Freedom, he called for an end to racism, violence, and discrimination, saying: “Now is the time to make real the promises of democracy.”

The same is true today.

The rallying cry “Time’s Up” emerged from our own era’s outrage over oppression and abuse. In fact, it reprises a cry for justice that dates back more than 50 years.

The time for change is now. Not only for sexual harassment, but for every form of injustice that thwarts the right of all people to grow into their full potential. Every injustice that cuts against the physical, mental, and social well-being of every person.

On the cusp of a historic election, it’s impossible to overstate how much is at stake.

  • The future of the Affordable Care Act and Roe v. Wade—indeed, the future of health care itself: Who pays for it? Who receives it? What services are provided?
  • The future of scientific and medical research: Who decides what work is prioritized? What funding is available?
  • The future of health, both for people and the planet. These are bound up in profound and enduring ways with the future of democracy.

At the heart of the civil rights movement was the right to vote. Today, victories won during that era are again under fire, with massive efforts at voter suppression and partisan gerrymandering that dilutes even votes that are cast. For so many reasons, we must recommit to assuring that all voices are heard at the ballot box.

This is the essence of democracy: a political system that itself has been linked to better health.

The Nobel Prize-winning economist Amartya Sen famously pointed out that famines tend not to happen in democracies.

More recently, and concretely, a landmark study published in the Lancet last year made a compelling case that a nation’s health improves with free and fair elections.

Voting and other forms of civic action may also foster health and well-being at the individual level, for those who participate—so important at a time when depression and feelings of alienation are disturbingly prevalent. A number of intriguing studies point in this direction, and as a college president, I’m eager to learn more.

You are citizens as well as scientists, physicians, and health care experts. Please, always remember that—and be engaged! So much is at risk!

* * *

Three years after the March on Washington, Dr. King spoke at the second convention of the Medical Committee for Human Rights. At a press conference, he had this to say:

“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”

You’ve probably heard these words before, or at least you’ve heard a version of them. As Wellesley [Associate] Professor Emerita Charlene Galarneau has pointed out, they are quite often misquoted, with the words “health care” replacing the single word “health.”

In pursuit of these goals, we will need to work far beyond the official health care system to extend our focus far upstream, to the social determinants of health.

Of these, two of the most important are democracy and education.

A culture of health is also a culture of democracy, one that fosters civic engagement, community building and voting.

A culture of health is also a culture of education, one where every person has the chance to learn and grow into their full potential.

Today, with renewed awareness of all that is at stake, let’s commit to joining forces to create this culture of health.

Let’s strive to create a world where all people can flourish.

Let’s complete the unfinished work of the civil rights movement.

Thank you.