The Clinical Problem Solvers

Jack, Sharmin, Lindsey, and Dan discuss a case of Jaundice and Lung Nodules.

 Jaundice schema

Lung Nodules schema

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CPSolvers: Anti-Racism in Medicine Series

Episode 11: Racism, Redlining, and the Path Towards Reconciliation

Show Notes by Sud Krishnamurthy, Michelle Ogunwole, Chioma Onuoha

October 12th, 2021

Summary: This episode is part of a 3-part series on Race, Place, and Health. In this episode, we invite Mr. Richard Rothstein, distinguished Fellow of the Economic Policy Institute and acclaimed author of the book, The Color of Law: A Forgotten History of How Our Government Segregated America, and Professor Fernando De Maio, PhD director of research and data use at the AMA’s Center for Health Equity, professor of sociology at DePaul University, and co-editor of the recently published book, Unequal Cities: Structural Racism and the Death Gap in America’s Largest Cities, to share their expertise on structural racism, neighborhood segregation, and health inequities.

Episode Learning Objectives:

After listening to this episode learners will be able to…

1. Explain the differences between de jure and de facto segregation
2. Explore the historical and present-day implications of neighborhood redlining and housing segregation on health disparities
3. Explain the importance of precise definitions when discussing structural racism  
4. Explore short and long term remedies to segregation

Credits

• Written and produced by: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
• Hosts: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Sudarshan Krishnamurthy, Michelle Ogunwole, Chioma Onuoha
• Guests: Richard Rothstein, Fernando De Maio, PhD

Time Stamps

00:00               Introduction

02:29               De Jure and De Facto Segregation: The Color of Law

06:45               Health Inequities and Segregation: Unequal Cities

12:07               Defining Structural Racism

18:05               Federal Policy and Suburbanization

24:50               The Racial Wealth Gap and its Consequences

30:27               The Role of Health Equity Promoting Policy

32:00               Potential Remedies for Past Harms

39:45               Segregation of Medical Care

41:20               What Can Listeners Do Going Forward?

Episode Takeaways:

   1. Terminology and Definitions of de jure and de facto segregation: The myth that segregation in modern societies has to do with private activities (e.g individual bias or bigotry that leads to a failure to sell a home to a person of color)  and personal choices ( e.g. Black people prefer to live among other Black people) is referred to as de facto segregation. Adopting this worldview removes any obligation to remedy the consequences of segregation. In contrast, de jure segregation refers to the involvement of federal, state, and local governments in creating, structuring, designing, reinforcing, and perpetuating segregation. This reality of de jure segregation helps us understand that we have an obligation to remedy this constitutional violation.

  2. Segregation relates to crucial public health outcomes that ultimately have an effect on life expectancy: The average life expectancy across the United States is 78.6 years; however, there exists a 10 year gap in life expectancy among the 30 largest cities in the US, from 72.9 years in Baltimore to 82.9 years in San Francisco and San Jose. Across the country, we see a 4 year gap in life expectancy between Black and White Americans; and this gap between and Black and White individuals ranges from 12 years in Washington DC, more than 8 years in Chicago, to no gap in El Paso. These gaps are not a product of lifestyle choices, biology or individual behaviors. They are a product of deep-rooted man-made policies that extend to many sectors (healthcare, education, criminal justice etc). These policies have systematically disadvantaged some groups, and have advantaged others. These policies are woven deeply into the fabric of the United States, and are intimately related to residential segregation, life expectancy, and mortality.

 3. Unconstitutional housing policy in the mid-20th century led to the present day wealth gap and has implications for disparities: Discriminatory policies prohibited African Americans from being homeowners, while allowing White Americans to purchase homes and accumulate generational wealth. These policies established the wealth gap between Black and White Americans that persists today. Nationally, African Americans’ income is 60% of that of White Americans. Although one would think this leads to a 60% wealth gap as well, household wealth of African Americans is 5% (95% wealth gap)  of that of White Americans. This extreme disparity between the 60% income ratio and the 5% wealth ratio is attributable to consequences of federal housing policy practiced in the mid-20th century. You can draw a line from these discriminatory housing policies, to the wealth gap, to disparities in education, health, and police brutality.

Pearls

 On the importance of considering place based inequities

Variability of health inequities between communities in a single city or across different cities is critical to consider when discussing health inequity.

“We tend to think of health inequities as big, monolithic, deeply entrenched patterns, and they are, but their variability is really important. It gives us a sense of how different things can be.”-Professor Fernando De Maio

On language and the use of the term ‘structural racism’

Structural racism  is a word that is used often, however many people do not know what it really means. Professor DeMaio notes that confusion around terminology is not a reason to shy away from discussions around it. He declares that one of our greatest challenges, and also one of our obligations, is to address structural racism head on.

“It’s our collective responsibility to explain it, to define it, to communicate it in effective ways to physicians, to healthcare systems, to the public at large and in detail, with data and with narratives, all the ways through which racism impacts our health.” -Professor Fernando De Maio  

On Remedies to segregation

Mr. Rothstein shares two examples of potential remedies to segregation. The first would specifically address the constitutional violation that prohibited African Americans from becoming homeowners. The remedy would be for  the government to buy up homes at market value in neighborhoods where African Americans were not allowed to buy homes, and sell them back to qualified African American buyers at deeply discounted rates. 

The second remedy would correct a policy– the low-income housing tax credit– that reinforces segregation. Currently, low-income housing tax credit is a federal program distributed to housing developers who build housing for low-income families. However, this program reinforces segregation as developers are more inclined to build low-income housing in low-income neighborhoods. This can be reversed by placing a priority on use of these tax credits in higher-opportunity communities and prohibiting the use of this credit for creating more segregated communities.      

Mr. Rothstein notes that the challenge is not in thinking of ideas or potential remedies…

“ We know what the policies are to create equality, a more equal society and a non-segregated society. What’s missing is not policy ideas. What’s missing is a new civil rights movement that’s going to create the political environment where those policies have to be implemented.”-Mr. Richard Rothstein

On being a citizen and the collective effort needed to change the status quo

Mr. Rothstein leaves us with these wise words to consider as we head back into our professional roles in medicine.

“In addition to being a physician, you’re a citizen. And I think the most important thing you can do is align yourself with other citizens in whatever profession they are, because this is going to take a community effort” -Mr. Richard Rothstein

References

1. Rothstein, R. (2017). The Color of Law: A Forgotten History of How Our Government Segregated America.
2. Benjamins MR, De Maio F. Unequal Cities: Structural Racism and the Death Gap in America’s 30 Largest Cities. Baltimore: Johns Hopkins University Press; 2021.
3. De Maio F, Ansell D. “As Natural as the Air Around Us”: On the Origin and Development of the Concept of Structural Violence in Health Research. Int J Health Serv. 2018;48(4):749-759. doi:10.1177/0020731418792825
4. Benjamins MR, Silva A, Saiyed NS, De Maio FG. Comparison of All-Cause Mortality Rates and Inequities Between Black and White Populations Across the 30 Most Populous US Cities. JAMA Netw Open. 2021;4(1):e2032086. doi:10.1001/jamanetworkopen.2020.32086
5. Metzl JM, Maybank A, De Maio F. Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System. JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289
6. Liao TF, De Maio F. Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties. JAMA Netw Open. 2021;4(1):e2034578. doi:10.1001/jamanetworkopen.2020.34578
7. Krieger M, Boyd R, De Maio F, Maybank A. “Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism And Health, ” Health Affairs Blog, April 20, 2021. doi: 10.1377/hblog20210415.305480
8. Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality. London: Routledge; 2005.
9. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133. doi:10.1016/j.socscimed.2013.06.032
10. The “Redress Project,”, i.e. the New Movement to Redress Racial Segregation, will launch early next year. For anyone who wants to receive more information about the launch of the New Movement to Redress Racial Segregation, please click here NMRRS. 
11. For a brief 8 minute summary of talks about how segregation happened, see this: https://www.facebook.com/NowThisPolitics/videos/270363507375249/
12. See the 17-minute animated film, “Segregated by Design” https://www.segregatedbydesign.com/
13.  For a high school curriculum unit to teach this history: https://www.zinnedproject.org/materials/how-red-lines-built-white-wealth-color-of-law-lesson
14. Rothstein, R. (2020, February 3). Opinion | The Neighborhoods We Will Not Share. The New York Times. https://www.nytimes.com/2020/01/20/opinion/fair-housing-act-trump.html
15. Rothstein, R. (2020b, April 21). The Coronavirus Will Explode Achievement Gaps in Education. Shelterforce. https://shelterforce.org/2020/04/13/the-coronavirus-will-explode-achievement-gaps-in-education/
16. Rothstein, R. (2020c, August 14). Opinion | The Black Lives Next Door. The New York Times. https://www.nytimes.com/2020/08/14/opinion/sunday/blm-residential-segregation.html

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

De Maio F, Rothstein R, Khazanchi R, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR. “Episode 11: Racism, Redlining, and the Path Towards Reconciliation.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. October 12, 2021.

Show  Transcript

We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Gabriela presents a case of impairment of speech to Gabriel and Valeria. 

Neurology DDx Schema

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Gabriela Pucci

Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).

Gabriel Talledo

Gabriel is a MS2 student from Cayetano Heredia University. When it comes to medicine, he enjoys dermatology, infectiology, and LGBTQ+ health. He fell in love with his career when he understood medicine not just as a concept of knowledge but a combination of knowledge and social justice pursuit. He loves cooking Peruvian cuisine (one of the best in the world), eating, jogging and watching TV series. Recently he is doing a transgender education program at his university and a volunteering of sexual education in Lima schools.

Valeria Roldan

Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.

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Alec presents a case of abdominal pain and hematochezia to Laura, Stef, and Jack.

Laura Geiszler

Laura Geiszler is a third-year Internal Medicine resident at Lankenau Medical Center in Wynnewood, Pennsylvania. 

Laura completed her medical school at Philadelphia College of Osteopathic Medicine.
She has a passion for humanizing medicine and promoting health and wellness to prevent disease. 

Outside of work she is a proud cat mom, fitness lover, fiction book enthusiast, and fashion addict.

Stefanie Gallagher

Stefanie is a PGY-3 internal medicine resident at Lankenau Medical Center, located in Wynnewood, PA. 

She earned her medical degree from the Philadelphia College of Osteopathic Medicine, with a dual-degree in Bioethics from the University of Pennsylvania. 

She is an aspiring gastroenterologist and has a passion for disorders of the gut-brain axis. 

Outside of medicine, she enjoys her English bulldog (Boomer), cycling, and reading non-fiction.

Alec Rezigh

Alec Rezigh is an academic hospitalist at Baylor College of Medicine in Houston, TX. 

He completed medical school at McGovern Medical School in Houston and his residency at The University of
Colorado. 

His clinical interests include medical education and clinical reasoning. 

He loves all things basketball, CPSolvers, and playing with his human and doggy daughters.

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Dr. Titer, Dr. Williams, Maani and Lindsey discuss macro/microaggressions in the clinical setting. 

Dr. KeAndrea Titer

Dr. KeAndrea Titer is an Assistant Professor in the Division of General Internal Medicine at University of Alabama at Birmingham. She was born and raised in Tampa, Florida. She received her Bachelor of Science in Biology from Oakwood University in Huntsville, Alabama. She went on to earn her medical degree from Loma Linda University School of Medicine in Loma Linda, California. She completed her residency and chief residency at the University of Alabama at Birmingham Tinsley Harrison Internal Medicine Residency Program. Her academic interests include physical exam-focused medical education where she co-directs the Enhanced Clinical Skills Residency Track and serves as Investigator for the AMA Reimagining Residency Grant awarded to John Hopkins, Stanford, and UAB focused on studying clinical skills as it relates to resident wellness. She is also passionate about diversity, equity, and inclusion and serves as the Assistant Director of Diversity and Inclusion for the Tinsley Harrison Internal Medicine Residency Program where she works to design initiatives and curriculum focused on recruitment, education, and building community. 

Dr. Karla Williams

Dr. Karla Williams is an assistant professor in the Division of General Internal Medicine and Hospital Medicine at UAB in Birmingham, AL. She serves as an assistant program director and the director of diversity and inclusion for the Tinsley Harrison Internal Medicine Residency Program. She has a passion for advancing diversity, equity and inclusion in graduate medical education and care delivery and was recognized as a recipient of the 2020 Dean’s Excellence Award in Diversity. She has recently worked with colleagues to develop a formal curriculum, Supporting Trainees by Addressing Inappropriate Behaviors by Patients, to address microaggressions and other inappropriate behaviors in the medical environment. This initiative has created a platform to have safe and honest discussions about the presence and effect of bias, including racial and gender derogations, in the medical environment and has been presented and implemented at numerous academic institutions at the UME and GME levels. The ultimate goal is to bring awareness to our implicit and explicit biases in an effort to cultivated more inclusive learning and clinical environments for trainees, faculty and patients.

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 Anna presents a case of metabolic acidosis, pulmonary nodules, and fevers to Smitha and Simone

Schema 1

 Schema 2

 Schema 3

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RLR are recording an episode with author of the New York Time Diagnosis column, Dr. Lisa Sanders

Subscribe to our Join Live tier to join us on Zoom in real time on Monday August 30 at 9:30 AM PST/12:30 PM PST.

A few weeks later, we will release this episode to all our Patreon tiers. 

Link to our Patreon

RLR are back on the podcast with a fascinating case. Over the summer, they’ve been releasing a lot of cool content on Patreon. Check it out here for much more RLR content. 

Schema One

Schema Two

More about the RLR series here.

 Lindsey presents a case of polyuria to Dan, Jack, and Sharmin

Hypernatremia schema 

Polyuria schema 

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz.

This time, Gabriela presents a case of impairment of speech to Maria and Kirtan.

Neurology DDx Schema

Want to test your learning?

Take our Episode Quiz

Gabriela Pucci

Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).

Maria Jimena Aleman

Maria Jimena Aleman was born and raised in Guatemala where she currently is a medical student in Universidad Francisco Marroquin. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field.  She also looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Louis Armstrong. Outside of medicine she enjoys modern art, 21st century literature and having hour long conversations over a nice hot cup of coffee or tequila.

Kirtan Patolia

Kirtan is a final year medical student from B.J. Medical College, Ahmedabad, Gujarat, India. He is looking forward to joining Internal Medicine Residency in the USA by applying through this year’s Match Cycle.

He loves to solve clinical cases and was delighted when he got the opportunity to join the CPSolvers team. He is so grateful to Dr. Geha and Dr. Manesh for this opportunity. Clinical reasoning is his biggest passion and he strives to enhance his diagnostic skills every day. Discussing and sharing clinical cases with his friends gives him distinct pleasure. Outside of medicine, I like to read Agatha Christie and Nancy Drew novels. He also loves kite-flying, as he finds the various techniques and maneuvers to fly kites fascinating.