Beyond the White Coat

Diagnosing our National Disease

Episode Summary

Academic medicine is taking a hard look at its role in the long-standing systemic and institutional racism that Black Americans have faced when engaging with teaching hospitals, medical schools, and research programs — an experience that historically has fostered distrust of medicine and health care within the Black community. David J. Skorton, MD, AAMC president and CEO, talks with Lonnie G. Bunch III, secretary of the Smithsonian Institution, about how the history of racism in medical schools, clinical care, and research has impacted academic medicine’s relationship with the Black community. They discuss what can be done to regain trust and become allies and partners in their health and wellness.

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Episode Transcription

[Audio introduction]

Narrator:  Their deaths define a global movement. What started as a hashtag back in 2013 by three Black women — Alicia Garza, Patrisse Cullors, and Opal Tometi — in response to the acquittal of the man accused in Trayvon Martin’s murder, George Zimmerman, is now one of the largest movements in U.S History according to the New York Times.

Amid the protests and civil unrest, the Black Lives Matter movement is gaining broader acceptance. The question now is what does this mean? What does it mean in health care?  Where do we go from here? 

The current pandemic has also exposed the stark reality many Black Americans face in getting basic medical treatment in light of racial health disparities.

Every time a state or county releases racial data, those numbers reveal a sizable racial disparity where black Americans are overrepresented among the infected and dead. A concern Dr. Malika Fair raised in a previous “Beyond the White Coat” podcast interview.

 

Malika Fair:  “As a Black woman, I'm particularly concerned about how it's affecting my community. We represent 13% of the nation's population but 24% of the COVID-19-related deaths. Here in the District, we represent about 47% of the District population but over 80% of the deaths related to COVID-19. “

 

Narrator: As the movement’s messages become more mainstream, so do new and important conversations about racial injustice. To dig deeper we’ve invited Lonnie Bunch, the 14th Secretary of the Smithsonian Institution, to talk with us. He’s the first African American and Historian to lead the Institution. Bunch has written on topics ranging from the black military experience, the American presidency and all-black towns in the American West to diversity in museum management and the impact of funding and politics on American museums. 

His most recent book, A Fool’s Errand: Creating the National Museum of African American History and Culture in the Age of Bush, Obama, and Trump, chronicles the making of the museum that would become one of the most popular destinations in Washington, D.C.

This is our conversation with Secretary Lonnie Bunch on “Beyond the White Coat.”

 

[End of music]

 

David Skorton:           Greetings to our listeners and welcome back for another season of “Beyond the White Coat.” I’m David Skorton, president and CEO of the Association of American Medical Colleges. This season, we’re focusing on issues of racism and public health in America, and I’m really looking forward to all the inspiring guests we’ll be speaking with and learning from during this season.

Today, I’m here with Dr. Lonnie Bunch III, the 14th secretary of the Smithsonian Institution, a position that some of our listeners might recall that I held before coming to the AAMC. In his role, Dr. Bunch oversees 19 museums, 21 libraries, the National Zoo, numerous research centers, and several education units and centers. And Dr. Bunch was the founding director of the Smithsonian’s National Museum of African American History and Culture. 

This museum, which I believe is one of the jewels in the crown of America’s cultural institutions, is something wonderful to visit. But if you can’t get there, especially in the current times, you might enjoy Dr. Bunch’s recently released book, A Fool’s Errand, Creating the National Museum of African American History and Culture in the Age of Bush, Obama, and Trump. This book chronicles the making of the museum that would become one of the most popular destinations in Washington.

On Juneteenth of this year in an interview with PBS, Dr. Bunch made a statement that many of us are starting to reconcile with the fact that “if you look at the history of this country, you realize that everything from foreign policy to economic considerations to culture to education was shaped by the institution of slavery.” Today, I want to dig into this history and the intersection of racism and public health specifically. To set the stage for season two of our podcast, we will certainly have many tough conversations, confront our own personal and institutional biases, and hopefully come out the other side better prepared to lead, serve, and be actively anti-racist.

Thank you very much for being here, Dr. Bunch. Lonnie, it’s great to see you.

 

Lonnie Bunch:            It’s always a great treat to be with you. I learn so much. 

 

David Skorton:           Well, thank you. Well, with the amplified conversations on race and racism in America, is the shift that we are seeing across the country in the American mindset today any different from the shift that took place after Congressman John Lewis helped lead the Civil Rights protesters across the Edmund Pettus Bridge in 1965? Is there anything new under the sun?

 

Lonnie Bunch:            I think it’s first important to recognize that we’ve been in this place before. We’ve been in moments where Black bodies were broken. We’ve had moments where people have said that’s wrong and they’ve protested in the streets. What’s different now, however, though is — I think, first of all, because of social media, you begin to see that this is not just a localized activity but a national and international activity.

You’re also seeing something that gives me great comfort — which is, traditionally when African Americans struggle for fairness, they have allies, but it’s mainly an African American movement. Here, you see a greater diversity of people owning this, because I think one of the great challenges and where I’m optimistic about this moment is, traditionally these are issues that say, “How do we improve the status of African Americans?” Today, you’re hearing people say, “How do we improve the status of Americans?” — because if we do this, this is something that we all have to own. So that gives me a bit of hope.

 

David Skorton:           I really couldn’t agree with you more, Dr. Bunch, and I think the idea of looking into our own souls, looking in a mirror not only personally but looking at our institutions, is really critical to get to the place that you are talking about.

 

Lonnie Bunch:             And can I say, I mean, the thing that really hits me, and I want to applaud what you’re doing by looking at the intersection of race and public health, because in many ways as a country, we now understand the role that violence, the role that police brutality has played. But I’m not convinced we understand the role that racism has played in public health, the role racism has played in our medical system. And in some ways, that we need to illuminate that challenge because that challenge we’re now seeing in terms of the impact of the pandemic, that challenge is not something that just happened yesterday. This is hundreds of years of discrimination, a hundred years of choices, hundreds of years of preventing people from entering into the medical profession. All of that led us to where we are today, so I applaud very much the conversations you’re having.

 

David Skorton:           Well, we have so far to go. I’ll share with you one statistic I’m not proud of. In 1980, when I accepted my first faculty position, that year 3.4% of the matriculants in American medical schools were Black males. Last year, 39 years later, 3.4% . So, we have a long way to go on having people of color and other underrepresented groups, most particularly Black men, see themselves possibly in the medical profession, dream about it, achieve it, be successful, and grow into leadership positions. So very important point that you are making.

Lonnie Bunch:            Well, I think for me, as you know, having a daughter that’s gone through medical school, finished her residency and is now an attendee in emergency medicine, what I’m struck by is listening to her talk about both the challenges of the paucity of African Americans, especially African American males in her medical school class or in her residency. But also, what that really means in terms of how a profession interacts with African American patients or patients of a lower status. So I think it’s really important that we’re really saying that this is a moment not to sort of rest but a moment to really push forward and try to make the changes that will lead us to a more equitable health care system.

 

David Skorton:           Yes, absolutely agree with you a thousand percent.

Now looking back through history at how Black Americans have engaged with the medical community, racism, as you mentioned, was prevalent in medical care and, as we’re discussing, in how physicians were trained. Seven medical schools were established between 1868 and 1904 specifically to educate Black physicians. Today, there are four. What is the difference in how society supports historically Black medical education today versus during the late 1800s or early 1900s?

 

Lonnie Bunch:            In the 19th century, what you see is how difficult it was for African Americans to get medical training. The medical schools were segregated. They weren’t accepted. There were very few people who have actually gotten through the American medical system in the late 19th century, early 20th century.

But there was really a need to say how do we address the health issues within our community. So, the goal was that education was always seen as the key coming out of slavery to the future of the Black community. So, part of that was tied to, “How do we have the medical education?” So, you have these amazing medical schools at places like Shaw College in North Carolina, and all of these are generating sort of the profession that allows African Americans to become members and to really help serve their community. 

The challenge is that the prevailing society made it more difficult. Issues of accreditation, issues of, “Even after you graduated from these medical schools, did you get the opportunity to have the right to do work in hospitals? Did you have the right to sort of grow as a physician? And did you even have a right to join in what was the precursor, the American Medical Association?”

So, in many ways, it was a conscious decision in a way that the racism of the time-limited even great opportunities for many people. And as you’ve said, today we have only a limited number of medical schools that are geared to training African Americans. That’s a real challenge for you as a profession.

Education has always been at the heart of what the African American community wants and expects. Coming out of slavery, there were very few ways for African Americans to be educated. Instead, they forced the creation of public schools, they led to the creation of historically Black colleges. So, education has always been at the center of African Americans’ belief that they can find a freer and fairer America.

So I think what’s important now is to recognize that there is a great interest in the educational opportunities if they’re there, and there’s a great interest in saying, “At this moment, how do we help our community deal with the next pandemic?” And I think there’s great interest in people learning more about science, about health care, about medicine. I think the challenge is to, as you’ve said earlier, to reach back into the earlier periods and to allow younger people to understand these are career paths for them, to make sure that they are seeing role models.

I have been struck talking to my daughter as she talks about encouraging other people of color to go to medical school, how important it is for them to see people like them who have survived the challenges of medical school because people have to believe that that is possible.

So, ultimately, I think the education is crucial for the future of the profession. But I think it’s also crucial for the future health of the African American community.

 

David Skorton:           Very, very good points. And obvious as you’re mentioning, this is a much bigger issue than just medical education. Could you extrapolate and share your thoughts on perhaps underinvestment in historically Black colleges and universities, really in general?

 

Lonnie Bunch:            Well, I’m always struck that because my grandfather was able to go to an HBCU in 1910, that it transformed the trajectory of my entire family. My daughters are now the fourth generation of our family to graduate college, and I think in a way it’s because of having the opportunity at HBCUs.

And what has really been clear is that with notable exceptions, the education of African Americans had never been a priority. It had never been a priority of local communities; it had never been a priority of the national government. And so, in some ways, we’re reaping that policy which has underinvested not just in HBCUs but underinvested in the kinds of programs that allowed me to go to graduate school. Those programs, special opportunity, fellowships, and the like — those are gone. 

And so in a way, what we’re really seeing is, at the very time we need a diverse leadership in the medical profession, we need to understand how diversity is crucial to understanding the public health system; at the very time we need that, we don’t have the mechanisms to produce the generations of leaders that you need.

So, I think that the challenge is to find out, “How do we empower those medical schools that are really geared to creating a diverse workforce, and how do we make sure that medical schools around the country and inclusive?” And to create the opportunities for all people who want to go to medical school to get the opportunities that so many people have always had.

 

David Skorton:            Very, very good and very important points and very timely points.

I want to switch gears a little bit and talk about health care itself beyond education. So, this pandemic obviously has laid bare the tremendous, maddening inequalities in the health and health care of African Americans. As you mentioned, it didn’t start with the pandemic by any means; it was generations and generations and generations. But it certainly has been laid bare and shown in bold relief. What are some of the historical factors that have led to these kind of disparities, and how did African American patients fare during earlier pandemics — for example, the Spanish Flu in 1918?

 

Lonnie Bunch:            Well, what you really have historically is the health of African Americans has always been undervalued. In some ways during the period of slavery, African Americans were worked excessively; there was limited health care to them, a lot of it tended to come out of traditional health care coming back from Africa. What you also have is then a racism that says some of the diseases that Blacks succumb to were because they were inherently inferior, because their bodies were different. So that even when medical science could have improved a lot of African Americans, they didn’t.

And what you see then is, not only is there the lack of treatment for African Americans, but African Americans then become used. They are used in test cases, they are experimented on. In essence, their worth is seen as, “How do they improve the White community?”

So, in a way, what we have is the lack of historic treatment on many of the illnesses that African Americans have. So then when diseases hit, whether it’s tuberculosis in New York in the 19th century, whether it’s the Spanish Flu in the early 20th century, African Americans are both weakened because they’ve had a history of not having fair health care. But also, they’re the last to be paid attention to in these moments. So, they got the tail end of the treatment and they ended up having larger number of losses than others.

And so what I think we see is that hundreds of years of neglect, hundreds of years of not prioritizing Black heath care has led us to the moment where we are now where, when we look at the numbers of African Americans who die or Latinos who are dying versus other communities, the only answer is it’s because we didn’t care enough as a country to invest in their health.

 

David Skorton:           Well, you’ve brought up such very important points, and points to really a failure for the society at large for a very long time.

 I’d like to move on to a discussion about how we come up with new knowledge. You’ve already commented on the history — very checkered history — of experimentation related to the African American community. Well even today, Dr. Bunch, as you probably know, only about 10% of participants in National Institutes of Health clinical trials are African American. And as medical researchers move, for example, to develop a vaccine to dampen and eradicate the spread of this particular virus, what are the dynamics that have led to the Black community’s tenuous relationship with the medical research community?

 

Lonnie Bunch:            I think that, in some ways, that’s one of the most important things to shed the light on, right? To say that rather than being seen as patients, African Americans were also seen as guinea pigs. They were the test case. When you look at the early history of gynecology and the study of OB/GYNs, they experimented on enslaved women. When you think about, “How do you handle certain diseases?” you realize that things like the bad blood experiment, where in the 1930s, Black men with syphilis were told they were being treated, but they were really part of a longitudinal study that lasted almost 40 years that wanted to trace the impact of this disease. So, what you have are Black men who thought they were being given something to make them better, and instead they were given placebos and they suffered great pain and death in order to make it better for the White community.

And so what you have is, historically, as the Black community looks at this, you begin to think, “Where’s the trust?” When you look at even more recent issues like the cells from Henrietta Lacks, that amazing woman who died in Baltimore and how those cells were crucial — and continue to be crucial — in terms of our battle against various forms of cancer.

So, what you have is a group of people who feel that they can’t trust the medical research establishment, that they are really seen as guinea pigs rather than as people who will reap the benefits of that experimentation.

So, I think that in some ways, you add to that candidly that so much of the staff and the research personnel is not African American, so there is not the other ways to build bridges to have trust.

So, I think part of what you’re seeing is — I hate to say it this way — but the chickens have come home to roost. What you’re seeing is a lack of trust, a fear — and that prevents many people from being engaged in this research.

The other side of it is, it’s also incumbent upon researchers. Who are they reaching out to? Who are they looking to work with? So, it really is a two-sided coin. And I think this pandemic tells us how crucial it is to make sure that we have a diverse array of people in these trials to make sure that the very communities that are suffering the most reap the benefit from the vaccine when it comes.

 

David Skorton:           You know, you brought up eloquently the Tuskegee Study and the situation with Henrietta Lacks’ cells harvested without her knowledge and then used for the greater good without her knowing about it. Let’s drill down a little bit more.

What’s your advice? How can academic medicine today reconcile these events in a way that expands the perspective of those leading institutions and improves our relationship with communities of color? Because I really believe that this lack of trust will get in the way of many, many things happening, even when people attempt in good faith to do it. For example, the current leadership of the National Institutes of Health, Dr. Francis Collins, is really devoting himself to a much broader view of the critical scientific importance of diversity in trials. But what can our colleagues listening to this podcast who are leading these institutions or aspiring leaders, what can they do to expand the perspective and improve our relationship with these very important communities?

 

Lonnie Bunch:            Well, I think, first of all, you’ve got to understand your own history, that you’ve got to really be clear about how your institution, how your medical school, how you’ve treated historically people of color. And that knowledge then gives you a way not to just apologize but gives you a way to build on that foundation of trust.

I think it’s crucially important to look at, “What are some of the things that would give people confidence? What’s the percentage of African Americans that are entering into medical school? What are the percentage of African Americans that become attending physicians? What are the percentage of African Americans who really get to provide leadership in a variety of places?”

So, I think it’s partly sort of demonstrating that, and it’s also partly a need to really think about what’s the strategy to communicate to communities to say that it is a new day. And one of the things would be if we really see that the African American needs are taking real consideration as you craft a virus or a treatment for this pandemic, suddenly you’re building good will. But it’s going to take more than just saying we were once flawed. People are going to look for concrete examples of where change is possible.

 

David Skorton:           You know, it’s very interesting that you bring that up. Traditionally in academic medicine, we’ve talked about the so-called tripartite mission of education, patient care, and research. And we’re getting the idea at the AAMC this year that we have to add a fourth leg to that stool, if you will, that we’re calling community collaborations. Just to put a fine point on the wording, not calling it a community engagement but community collaborations. In other words, we need to hear the voices and accept the leadership from the community itself where there are trusted voices, because they’re the voices of neighbors and members of the community. Is that a robust approach? Do you think that might possibly work?

 

Lonnie Bunch:            That is so powerful because what you’re really saying is two things. One, that the medical profession, you can’t be community centers but you can be at the center of the community. And that in essence, what we’ve learned in so many other areas is how better we are when we collaborate with the people we’re trying to serve. And to really think about beyond engagement, which is sort of a top-down way, but to really say, “How do we partner, how do we understand better what the needs are? How do we understand better what the possibilities are?” And I think in a way what you’ve done is tap a powerful way, and you’ve tapped something that I would argue the country needs to explore, which is the way to make sure that we’ve got true relationships, not just simply engagement.

So I’m very excited about what you’re doing. Of course, any way I can help I would beat the drum.

 

David Skorton:           Well, that would be unbelievably helpful. I’d like to focus a little earlier in the educational pathway. One of the things that I have worked on, and not been very successful over the years, is trying to interest African American men and others underrepresented in medicine — those from the Latinx community, Native Americans, and so on — who are already college students to think about a medical career. And my own experience in higher education, and you’re very experienced in higher education, has led me to believe that while helpful to some extent, that that’s pretty late in the entire sort of life cycle of one’s thinking. 

One of the ideas that we’ve been kicking around is that in order to hopefully encourage more and more young people from underrepresented groups, and let’s talk about the African Americans today, to see themselves in a medical career, that we have to go way back, maybe to middle school. Maybe even earlier. That’s always a little daunting because any given leader is not going to see that result in their professional lifetime.

But I continue to come back to the idea that although it’s very important to work with colleges and admission counselors and so on, that sometimes the battle is already lost because people just don’t see themselves in the profession, particularly those who are first-generation college students.

So what’s your thought about that idea of going way, way back in the educational pathway?

 

Lonnie Bunch:            I think there are examples where that has worked dramatically. You think about — there are some programs I have seen where middle school kids get engaged in engineering or middle school kids get engaged in aviation. And they become people that are interested in recognizing that that could be a pathway for them.

I think the challenge is you also need to have a variety of role models that people can see. So, I think that if one has, and I know many of the doctors of color want to engage, so if there are ways that we can make sure that these kids see what’s possible. Because isn’t that the real challenge? The real challenge is they don’t see this as a possibility. They don’t see other people who look like them. They don’t see the role models.

So when you can tap the people who are already working in the profession, who have done important work or who are even graduates or even students, that will engage people and make them believe what’s possible because that’s the biggest challenge. Not just to engage, but to help people believe it’s possible that you can have this as a career.

And I think one of the things that would be so powerful about reaching back now is these younger kids now understand the world has changed. Wearing masks. This pandemic has changed things, and I think it’s going to turn more people’s attention to health care, to medicine, because they’re seeing the lack of it in some of their communities.

So, I think this is the exact moment to reach back further and create a pipeline that may be a generation before we see its impact, but we know we’ll have that impact.

 

David Skorton:            Now it’s interesting, we’re sitting here recording a podcast called “Beyond the White Coat,” very much oriented towards the medical community, but we’re taking advice and learning lessons from a humanist and social scientist, not a doc. So the question I have — given your profound and enormously successful career in history and all the things that have gone into that, the social sciences perspective, the humanistic perspective and so on — what’s the place of these kinds of dialogues between those in the science community on the one hand and those in the arts, humanities, and social sciences communities on the others. After all, you’re running an organization where you’re doing everything from art history to astrophysics. So, tell us what you think in this particular dilemma about the perhaps robustness of bringing these communities together?

 

Lonnie Bunch:            I mean, I think some of the work that you did when you were secretary has really been about, “How do you cross these lines? How do you cross these boundaries? How do you recognize that medicine is not just scientific; it’s cultural, it’s educational, it’s shaped by history?”

So I think these kinds of conversations are crucially important because they’re conversations that allow us to have a different perspective, allow us to understand that there are a variety of tools we have to grapple with these questions, and if we expand the tool case, talk to the people in the humanities, talk to social scientists but get them involved in these questions, I think we bring more resources to fixing what are some of the grand challenges we face.

So, I think that in all professions, the opportunity to recognize how much we’re made better when we understand our field, but when we look beyond that and give guidance and learning. So, I think this is a really important opportunity. And I would agree that in some ways, this is a moment for historians. This is self-serving. But this is a moment for historians to basically say, “Let me help you by contextualizing the world we’re in today, by helping to understand, ‘What are some of the pitfalls that we have?’” And by understanding that today, I think it points us towards a better future.

 

David Skorton:            So, as we come to the end of our discussion today, I would love to get your advice on a call to action of those who are listening to your wisdom today. This is a broad audience that includes leaders and aspiring leaders and those very much committed to the best things that academic medicine can do for society at large. Any advice on a call to action to our colleagues would be greatly appreciated.

 

Lonnie Bunch:            Well, I think in some ways you framed some of the things that are crucially important. To recognize that at this moment it is important to increase the pipeline of people going into medicine, going into health care. That’s really going to be key moving forward. And this is an opportunity, as more people are turning their attention to that, to do that.

This is also an opportunity to really come to grips with your profession’s own tortured racial past. I think in some ways without doing that, you don’t understand the depths of the challenges you face. Without doing that, you don’t understand why there is concern within African American communities to work more effectively with the research community. So, I want people to sort of understand their own paths.

But then to recognize that what this moment has said to us is that we can no longer allow racial attitudes to prevent us from providing adequate health care across the board. We are now seeing in a way that we’ve rarely seen before the impact of discrimination and poor health care. So, I think more than anything else, I want to see a commitment to saying never again will we allow this moment to pass without trying to make fundamental change.

 

David Skorton:          Well, I want to thank Dr. Lonnie Bunch for joining me today. It’s been wonderful to hear from you and to learn more about how Black people have experienced racism from the medical community and what we can learn from history and continue to learn. The AAMC stands against racism and hate in all its forms, and we are committed to harnessing all of our resources in the academic medicine community to catalyze meaningful and lasting solutions.

Thanks again very much, Dr. Bunch, for joining “Beyond the White Coat.”

 

Lonnie Bunch:            It is my pleasure. And thank you for your leadership because this is the moment that we can make our country better.

 

David Skorton:           For those attending Learn Serve Lead, the AAMC’s annual meeting, virtually this November, I want to share that we’ll also be joined by Nikole Hannah-Jones, the New York Times Pulitzer Prize-winning investigative journalist and creator of the 1619 Project. I hope to see many of you for what I hope will be a powerful meeting with an all-star line up of speakers.

Thank you very much and we’ll see you again soon on “Beyond the White Coat.”

 

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