Racism and Medicine

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Narrative Matters

DOI: 10.1377/HLTHAFF.2020.01311

This, Too, Is What Racism Feels Like After George Floyd’s killing, a physician reflects on how the health effects of racism become embodied for her and other Black Americans. BY BROOKE A. CUNNINGHAM

I t was 9 a.m. on May 26, 2020, in Minneapolis, Minnesota. I logged into my first Zoom meet- ing of the day, a gathering of my community advisory board. I

opened the meeting, as I typically do, with check-ins, particularly important during a pandemic. I mentioned some upsides of staying at home—probably in an effort to mitigate what came next. I shared that my cousin, a nurse who worked in a New Jersey nursing home, had recently died from coronavirus dis- ease 2019 (COVID-19). His employer had failed to provide him with sufficient

personal protective equipment. I felt the tears well up in my eyes but quickly com- posed myself, relieved that we were still in the first few minutes of the call. Peo- ple were still signing on, so only a few caught a glimpse of my emotion. One or two others gave their intros

and updates, and then another joined. She explained that she was late joining the call because she had been on the phone with her distressed son. No wor- ries. Family first. Totally understand- able. She continued, “I am angry this morning. ... The police killed another unarmed Black man.”

My mind swirled. I had not heard the news. I often listen to NPR in the morn- ings, but I had not done so that day. The woman’s words began to blur together after she said, “The police killed anoth- er….” I felt like I’d been struck with a body blow for which I had not braced, like the punch that leaves a boxer dazed and teetering on his feet. I needed a moment, but I did not say

that to the group. Physicians learn early to compartmentalize. Displaying emo- tion at work can be a liability, particu- larly in biomedicine, especially as a Black woman, and especially as a re- searcher. So I tried to press on, to speak with the controlled language and self- presentation that is normative, even when it’s off the mark. My community advisory board meets only every month or so, and we had items to attend to on the agenda. I briefly expressed my anger and sad-

ness, and I mentioned the obvious tie to our work on racism as a health risk fac- tor. While that was accurate, I immedi- ately knew that it did not make anyone feel the slightest bit better. I found no solace in it myself, and perhaps that was what cracked the veneer. The tears came full on this time. I covered my eyes with my hands to prevent the tears from fall- ing, pursed my lips tight to hold in what wouldhave been ascream if Iwerealone, and took a deep breath as I let the mo- ment set in, instead of pushing it away. And the community advisory board,

which is predominantly Black, did what it always does. It shored me up. Black board members unapologetically ex- pressed their anger and frustration, not only with the police, but with business, and in this case research, as usual. As the meeting ended, I realized that for other board members, the conversation may have been as up close to Black pain as they had ever been.

Witnessing At 11 a.m. our meeting ended. I paused before I opened my search engine. The board’s love and support had helped me regain my footing, but as I thought

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about watching the video recorded by a Black teenager who bore witness, all I felt was dread. At that point I did not know the details. I did not know George Floyd’s name, nor how he died. I just knew the police killed him. “When will they stop killing us?” I

asked myself, fully knowing no answer would be forthcoming. Another question followed: “Am I

ready to turn up?” It was actually two questions in one. First, I was trying to figure out if I could handle witnessing a Black man being murdered again. The question wasn’t whether I would watch, but whether I should watch right then, knowing the potentially damaging phys- ical and psychological effects of witness- ing.Was I ready to watch the police kill a stranger who was still family? Witnessing is important because the

police often do not tell the truth, and it’s harder to be lied to if you have seen murder with your own eyes. Witnessing is important because even a masterful storyteller might fail to fully capture the horror. Witnessing is important be- cause to bear witness is to honor Mr. Floyd’s life. For the people on the scene, witnessing is an attempt to protect be- cause “maybe this time the police will stop when they see us watching.” Wit- nessingis holdingMr.Floydaswe would a loved one on their deathbed, to let them know that they are not alone. Just thinking about watching the vid-

eo, I could feel my chest tighten. My pulse probably quickened. I know that Ibegan breathing deeperand moreslow- ly to get rid of my nervous energy and in an attempt to counter my activated sym- pathetic nervous system. I knew that when I watched, I would feel a threat to self, knowing that I and my loved ones (my extended self) were always also at risk. Of course, I would not go into full fight or flight. The threat of police vio- lence was real but not immediate. I was in my apartment after all…but so was Breonna Taylor. Black people have talked about race-

related stress and its effects on the body for decades.We know that microaggres- sions, microassaults, and frustrating interactions with White-controlled insti- tutions can “get your pressure up” and lead to “racial battle fatigue.” Even an- ticipating exposure to racism is associ- ated with hypertension, obesity, and

delaying care in order to avoid experiencing discrimination. Newer re- search on vicarious racism—learning about or witnessing others experience anti-Black racism (such as via dashcam or cell phone videos)—finds this form of racism to be harmful to your health as well. Academics often call exposure to racism “race-based trauma” or “race- related stress” and refer to the body’s pathophysiological responses to that chronic toxic stress as “weathering” or “racism becoming embodied.” Acute ac- tivation of the stress response can save your life, but chronic activation contrib- utes to allostatic load (that is, wear and tear), which leads to diabetes, hyperten- sion, depression, dementia, and other adverse health conditions. Fully aware of the potential

consequences, I watched the video. I cried hard, and I did scream. I wanted to break something. The question “Am I ready to turn up?” now took on its sec- ond meaning—what was I ready to do? My attention turned briefly to Martin, then quickly pivoted to Malcolm, and then to NWA. Their words and images came forth from memory, colliding as I struggled to figure out what I could do and who I should be in this moment.

Remembering I finished work because, like most of us who still have jobs, I had to work. I’ve seen one YouTube post by the internet personality Evelyn Ngugi about “Calling in Black” to work, sickened from the latest news of yet another police killing of an unarmed Black person, but that was not an option I had. There has been

a good amount of talk about resiliency and ways to work productively while coping with the uncertainties of the COVID-19 pandemic. In contrast, few have addressed how unreasonable it is to expect Black people to show up ready to work after repeatedly witnessing their owndeath. The responsefrommanagers and organizational leaders to police bru- tality varies. So often the response is too late, too measured, too neutral, and, as such, too familiar. I remember Philando Castile. He was

killed on Wednesday, July 6, 2016, by a St. Anthony, Minnesota, policeman (who was charged but subsequently ac- quitted), one day after Alton Sterling was killed by Baton Rouge, Louisiana, police officers (no charges were ever brought). I remember walking into the physician workroom at the end of that long week quiet, trying to hold it togeth- er, avoiding eye contact, not sure if I wanted to talk to my White colleagues that day. I was relatively new on staff. We were associates, not friends, and I wasn’t sure what they were going to ask of me that day. I knew my colleagues well enough to know that they, too, would have heavy hearts. However, I also knew how easily Black people’s needs fade into the background when White people are “in their feelings.” I teach about racism and health, but I did not want to be (and to their credit, they did not ask me to be) their teacher or counselor that day. During the evening of the day after

George Floyd’s death, I texted my friend, who like me is a new mom and Minne- apolis resident.We had gone on a social- ly distant walk with our toddlers (to the extent that is possible) the day before. Her picture of our not-yet-two-year-olds hugging in their matching pink pants was the last message in the text chain. “I am so tired and sad,” I wrote to her.

“Our children are so beautiful and they are Brown in America.” My friend is not Black, but she is

Brown, and Black and Brown mothers have concerns that White mothers do not. We stand watch over our children as this world tries to deny their beauty, thwart their genius, dim their light, and too quickly take their innocence. We know the day will soon come when we will have to dry their tears and remind them that they are everything. We hold

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Narrative Matters

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them tight, because we know there will be other days when we will not be there to comfort them. When George Floyd called out

“Mama” as he died, I heard my own child’s voice in his. His call for “Mama” sounded like her call for me, when she is scared in the middle of the night and yet knows, even in the darkness, I am there.

Sleepless Because I am the mother of a toddler, I am always exhausted. Most nights I am asleep by 9:30 p.m. But that night I could not turn off my brain. I was still awake at 10:45, and at midnight, and at 2 a.m. We know how important sleep is for

health. Yet a growing literature shows

that racism keeps Black people up at night. Blacks sleep fewer hours and ex- perience more sleep disruptions than Whites, for many of the reasons that kept me awake. That night was filled with the noise of helicopters and sirens. Though I tried to still my mind, I re- played Mr. Floyd’s death over and over again. His murder was the worst type of “everyday racism.” Though the phrase typically refers to the ordinary experi- ences of unfair treatment to which Black people are routinely subjected (such as disrespect), given the regularity with which Black people are killed by the po- lice, “everyday racism” seems a fitting description. In whatever form or intensity, chronic

exposure to interpersonal racism is

maddening. If you are like me, you are angry that it happened again, that you didn’t expect it when you should have, and that the perpetrator is unlikely to be held accountable and probably went about their day unbothered, with no (though sometimes with full) awareness of what they had done. And here you are still thinking about it. I decided to try to write that night as

a means to process and hopefully quiet my thoughts. Rebroadcasts of news pro- grams played in the background. The hosts all commented on the city’s action to swiftly fire the four policemen. I was not sure if I detected one commentator insinuate undue haste. I sighed. Then they showed the protests and a press conference with the mayor—“Being Black should not be a death sentence”— and the attorney general—“This is a na- tional historic problem. People are out- raged by it. They’re sick of it, and they want government to be responsive.” Maybe this time it will be different.

Hope feels foolish and necessary at the same time.

Restructuring In the past, calls to eliminate racism have largely gone unanswered. Many or- ganizations, including the Minneapolis Police Department, have implemented implicit bias training, often as “one- off” sessions, despite the research that shows that interventions to reduce im- plicit bias generally have only short- term effects and are unlikely to lead to behavior change. The effects of these trainings are small because anti-Black racial bias is deep seated in our brains and deeply rooted in the fabric of Amer- ica. Anti-Black racial bias and animus persist because dominant American culture persistently denigrates Black people, even as it has made room to he- roize a few Black individuals. Too many Whites fail to interact with Blacks as equals. Rather, they keep Black people at a distance, support policies that re- produce the racial status quo, and elect people who clearly act against Black in- terests. I commend leaders who have used im-

plicit bias trainings to start new conver- sations about racism in their organiza- tions. However, I, like many others, fear their promulgation. There is a real risk

Policy Checklist

The issue: In this moment of “racial reckoning,” highly visible Black deaths—George Floyd’s and those from COV e increased awareness and acknowledgment of structural racism. By “leaning in” consistently over the long haul, in solidarity with our fellow community members, health care professionals can address the profound, complex, and painful path- ways through which racism adversely aff ects health.

Related reading:

Bleich SN, Findling MG, Casey LS, Blendon RJ, Benson JM, SteelFisher GK, et al. Discrimination in the United States: e

Brondolo E, Love EE, Pencille M, Schoenthaler A, Ogedegbe G. Racism and hypertension: a review of the empirical evidence and implications for clinical practice. Am J Hypertens.

Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patt erns of allostatic load scores among blacks and whites in the United States. Am J P

Heard-Garris NJ, Cale M, Camaj L, Hamati MC, Dominguez TP. Transmitt ing trauma: a systematic review of vicarious r

Hicken MT, Lee H, Hing AK. The weight of racism: vigilance and racial inequalities in weight-relat-

Lai CK, Skinner AL, Cooley E, Murrar S, Brauer M, Devos T, et al. Reducing implicit racial prefer- ences: II. Intervention eff ectiveness across time. J Exp P

Pritlove C, Juando-Prats C, Ala-leppilampi K, Parsons JA. The good, the bad, and the ugly of

Rodriquez EJ, Kim EN, Sumner AE, Nápoles AM, Pérez-Stable EJ. Allostatic load: importance, markers, and score determination in minority and disparity populations. J Urban Health.

Sawyer PJ, Major B, Casad BJ, Townsend SS, Mendes WB. Discrimination and the stress re- sponse: psychological and physiological consequences of anticipating prejudice in intereth- nic interactions. Am J P

Smith WA, Allen WR, Danley LL. “Assume the position...you fi t the description”: psychosocial experiences and racial batt le fatigue among African American male college students. Am

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that organizational leaders will stop there, confusing an “opening act” for the main event, and the hard work of eliminating systemic racism will not get done. In her consummate June 5 tweet, writer Lisa Ko noted: “The revo- lution will not be diversity and inclusion trainings.” I’d add implicit bias train- ings to that list.We cannot simply tinker around the edges as these trainings of- ten do. Instead, we must radically restructure

society. As we take back power from the police, we must upend other systems as well.As a physician, I know thatincludes health care. Thus far, in efforts to elimi- nate racial disparities in patient access, experience, and outcomes, we, too, have been tinkering around the edges. Incre- mentalism, or health care as usual, is harmful to millions of Black people, whose symptoms are not taken serious- ly; who struggle against more powerful clinicians, researchers, and policy mak- ers who construct their cultures and bodies as problems; whose access to care hinges on their employment, in a coun- try that systematically undereducates and therefore underemploys Black peo- ple; and who develop chronic conditions because they live in a racialized society and therefore have greater exposure to morbidity-inducing environments. As a country, we now face a choice:

substantively address racism head-on or, at our peril, discourage antiracism

discourse and action. Health care lead- ers have similar choices: downplay calls to change the status quo or address the ways in which racism inhibits our ability to achieve the Triple Aim to optimize the experience of care, improve population health, and reduce costs. If we are seri- ous about the Triple Aim, we must tackle the ways in which racism negatively impacts mental and physical well-being, increases costs, impedes quality, and undermines population health goals. Many health systems, especially safety- net systems and clinics, attempt to bridge the gaps that structural racism creates. However, even biomedicine’s more holistic biopsychosocial explana- tory models often fail to account for rac- ism’s impact. Furthermore, consider the Quadruple Aim, which adds the goal of improving the experience of providing care. Black providers, nurses, and staff and other members of racialized minor- ity groups often face a number of race-related stressors, coming from in-

dividuals (including patients); the institutions in which they work (as dis- cussions about the minority tax demon- strate); and living while Black in the broader culture. While we must develop systems to de-

tect and address bias at the point of care, it is more important to change the con- ditions that cut Black lives short. We must push for antipoverty policies, such as universal health care, that would go a long way to reduce the economic ram- ifications of systemic racism, and we must seriously consider, rather than summarily dismiss, reparations as a means to deal with racially stratified so- cial determinants of health. We are well positioned today to re-

articulate our commitment to optimal health for all and to reimagine health care operations and clinical teams so that others have less reason to doubt us. Leaders in clinical medicine, research, and medical education can choose to powerfully champion change, or they can stand in the way. Like defunding the police, divesting from our current system will generate fear and discom- fort. But this is what we must do if Black Lives really Matter. ▪

Brooke A. Cunningham ([email protected]) is a general internist, a sociologist, and an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota, in Minneapolis, Minnesota.

Like defunding the police, divesting from our current system will generate fear and discomfort. But this is what we must do if Black Lives really Matter.

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Narrative Matters

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