A panel convened by the Cancer History Project for Black History Month started with a discussion of mentorship, and concluded with a big underlying concept—justice.
The panel, which met Feb. 23 at 7 p.m., included:
- Robert A. Winn, MD
Guest editor, Cancer History Project;
Director and Lipman Chair in Oncology, VCU Massey Cancer Center;
Senior associate dean for cancer innovation and professor of pulmonary disease and critical care medicine, VCU School of Medicine
- Otis W. Brawley, MD
Co-editor, Cancer History Project;
Bloomberg Distinguished Professor of Oncology and Epidemiology, Johns Hopkins University
- Edith P. Mitchell, MD
Member, President’s Cancer Panel;
Clinical professor of medicine and medical oncology,
Department of Medical Oncology;
Director, Center to Eliminate Cancer Disparities;
Associate director, diversity affairs;
Sidney Kimmel Cancer Center at Jefferson, Thomas Jefferson University
- John H. Stewart, MD, MBA
Professor of surgery, Section of Surgical Oncology;
Founding director, LSU Health/LCMC Health Cancer Center
Words matter, Mitchell said, focusing on the oft-used euphemistic expression “implicit bias.”
“There’s no such thing as ‘implicit bias.’ If somebody can look at you and based on your color or your gender or some other aspect—that’s not implicit. That’s racism,” Mitchell said.
“It is well recognized that Black patients in a majority situation receive fewer minutes during a clinical consultation than white patients. That’s not implicit. That is a person making a decision based on other attributes of the patient’s physique—the color, maybe even what they’re wearing, how they speak, and other facets that are related to the individual patient,” she said.
The expression “health disparities” also merits unpacking, Stewart said.
“Let’s think about what the definition of disparities really is. We understand it’s access—or lack of access—to really good care, but the double edged sword of that is that it is also exposure to less effective care. So, more ineffective care, less effective care,” Stewart said. “We have to address both of those issues if we’re really going to understand health equity and how we move forward with health equity.”
Tackling health disparities means addressing the many factors —structural, social, and even epigenetic—that create them.
“I think that where we go often is the biology, thinking that African Americans are just more predisposed by their biology to having cancer, as opposed to the structures that have created many of those disparities,” Winn said. “We can’t talk about the treatment and the biological differences without understanding the structural issues. I’ve been going around talking about the ZNA or the znome, the ZIP code of association, and how that ZNA actually impacts the DNA and your ultimate biology.”
The panelists said mentorship was crucial to their career development.
“I remember when I started at the University of Chicago in 1981, they had one Black full professor in the medical school. It happened to be Jim Bowman, who is now famous as Valerie Jarrett’s father,” Brawley said. “He was the only Black full professor in the medical school at the University of Chicago in the early 1980s.”
Howard University was the first place Stewart found mentors who looked like him.
“That made all of the difference in the world, because I actually was at an institution where people looked like me and we emulated excellence,” Stewart said. “When I say emulate excellence, LaSalle D. Leffall was the chair of surgery there. We all wanted to be like LaSalle D. Leffall. I think that many of his habits still resonate with me today.”
The panelists said the communities they grew up in have informed their careers in oncology, driving them to focus on underserved populations.
“It was clear to me that the reality is that I wasn’t just going to school for me to become a doctor, I was not just going to school for me just to graduate, but I was going to school for me to have a purpose,” Winn said. “The focus on the health disparities and the focus on trying to reduce that gap was by John and Hannah Darden, my grandparents, who ultimately told me, ‘Don’t go to school and start learning all the books and then become stupid enough not to know that you need to go back to your community and help.’”
Stewart, too, said his background better informs his approach to medicine.
“A year ago, when I had the opportunity to come back to my home state to found a cancer center in New Orleans, it was an opportunity that I could not pass up, because as you know, in Louisiana, we have such disparate outcomes in cancer, if you look at racial and ethnic differences, if you look at rural and urban differences in outcomes, if you look at outcomes in the Delta—we’ve got a real opportunity to affect change,” Stewart said. “So, not only giving back to my community, but also giving back to the spirit of those who have poured so much in me over my career has been a singular professional honor.
“Multi-level interventions based upon improving implicit bias, multi-level interventions based upon understanding some of the structural barriers to care, are even more evident in surgery. So, that’s really what has driven me, and I still live to this day to think that, A, you have to help the community, B, you have to ask the right question, but that right question needs to be informed by the community so that your findings are relevant to their everyday lives.”
The conversation is available as a video and podcast.
A transcript of the discussion between Brawley, Mitchell, Winn, and Stewart follows.
Otis Brawley: Good evening. I’m Otis Brawley, co-editor of the Cancer History Project and Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University.
Welcome to this program. In celebration of Black History Month, we have a panel to discuss the evolution of the health equity movement.
It’s my privilege tonight to introduce to you Dr. Edith Mitchell, professor of medicine and oncology at the Kimmel Cancer Center at Jefferson Medical Center. Dr. Mitchell is also a retired U.S. Air Force Reserve General. She’s also a member of the President’s Cancer Panel.
Dr. John Stewart is professor of surgery at Louisiana State University. He’s also director of the LSU Cancer Center.
Dr. Robert Winn is professor of pulmonary and critical care medicine at the Virginia Commonwealth University. He is also guest editor of the Cancer History Project for this month. And, he’s director of the Massey Cancer Center. I want to welcome all of you.
I want to start out with just a little bit of history, because it’s important to remember where we came from. In the 1960s and early 1970s, there was increasing interest in differences in health status among Blacks and whites.
This grew naturally out of the Civil Rights Movement. The 1960s were a time when we still had segregated schools, including segregated medical schools. Yale Medical School, for example, only allowed two Blacks per class. Others didn’t allow any. There were segregated hospitals for patients and for doctors. Literally, Black doctors were not allowed to practice medicine in many hospitals; interest in minority health grew and became an academic discipline in the 1970s and 80s.
The field was catalyzed by the Secretary of Health—it was called Health, Education, and Welfare at the time. Patricia Roberts Harris, Secretary Harris. really stimulated a great deal of work looking at differences in outcome between Blacks and whites. Later on, Margaret Heckler, Secretary of Health, Education, and Welfare in the Reagan administration, would take this on.
She would literally commission what became known as the Heckler Report.
The Heckler Report of 1986 demonstrated a lot of problems, Black versus white, in terms of outcome. Louis Sullivan, Dr. Louis Sullivan, at that time was on the National Cancer Advisory Board and he would stimulate a lot of this as well. He would later help to further stimulate it when he was Secretary of Health and Human Services under then George H. W. Bush, 1988 to 1992.
It’s at this time that the Health and Human Services Office of Minority Health was formed. The NIH Office of Minority Health was also formed in several offices in CDC and HRSA and elsewhere. In the 1980s, outcomes research at the same time was maturing. We’re very fortunate that Richard Nixon signed the National Cancer Act in 1972. This created the SEER program, the Surveillance, Epidemiology, and End Results program, which documented cancer incidents and cancer mortality in first nine and later 17 sites across the United States.
This gave us, over time, data showing differences in incidence, differences in mortality, between Black versus white. By executive order, Ronald Reagan mandated that we start collecting and publishing data for Hispanics, Asians, and Native Americans as well. And this data began being published in 1990 and has been published since.
So, there you have the evolution of a discipline, first called minority health, then called special populations research; then, later, under David Satcher, a Surgeon General, called health disparities. Today, we tend to call it health equity. It is studying the differences in outcome and studying interventions to try to reduce those differences in outcome.
I thank my distinguished panel. All of you have contributed tremendously to the discipline of medicine, as well as the discipline of health disparities. I’m going to start out with a question.
What was it like as a young Black in medicine? What were your challenges and who helped you with those challenges? I’ll start with Dr. Edith Mitchell. Number one, she’s one of the few doctors who as an Air Force reservist or military reservist has ever attained the rank of general.
She is now a retired, two star Air Force Reserve General. So, number one, she deserves the respect. Number two, I have known Dr. Edith Mitchell all of my life, and I’m so proud of her. And number three, I’m even more proud because I’m a veteran too, but I didn’t get to be a general. So, General Mitchell.
Edith Mitchell: So thank you so much, Dr. Brawley, Colonel Brawley.
OB: It’s an O-6 in the Navy.
EM: Yes. And that I know. Thank you so much for that introduction. And yes, we have known each other and our families connected for many, many years. Thank you for the opportunity to join this great panel tonight.
I think there are several things that influenced my growth in medicine. I always tried to keep my ears open to meet with people, to get advice. I actually had some of the best mentors, both in my work as an oncologist and as my work in the Air Force. Certainly one of the people who influenced me over many, many years in training was Dr. Phillip Schein. Dr. Schein was chair of oncology at Georgetown and my training program.
He was just a person who you could talk to at any time, you could tell at any time, you could call at any time. He taught me that you don’t expect positions. You don’t expect things to just happen, you make them happen. And therefore, working with patients, working with research, was just a part of what we did every day. So, it was interesting that when we were ready to take the oncology boards, we were finishing up fellowship and someone in our program asked in a group session one day, when was he going to give us an oncology review? And he says, “What? Since you’ve been with me for the last three years, you’ve had your review.” It was very nice that all of us passed the boards on the first taking.
So, having mentors, having people you can trust and communicate with, and doing your best at every step of the way, that has been a model that I’ve followed. Dr. Schein was the one who really pushed me. And by the way, I was the second woman to finish that training program and the first African American. So, finding those people who not only can mentor you, but who can open doors for you.
OB: Dr. Winn?
Robert Winn: You know, mine is a different story. This is one in which I didn’t find medicine—it found me somehow. That pathway became the story of why I’m committed to this day to pipeline programs and to making sure that I give young people the opportunity as I have.
The reality is, my path started trying to be essentially the youngest GM for General Motors. Actually, they made money. That’s how that happened. That’s what I wanted to be. It was a fortunate set of circumstances of winding up at the University of Notre Dame where my freshman counselor at the time, Father McNeill, said, “Well, what do you want to do?” I was like, “Well, I can’t play football and I want to work for GM.” True story.
After several renditions of trying to figure out, well, what did that mean, I said, “Listen, I don’t really care, they pay well.” Fast forward to a couple years in. Father Walter, Father Austin—Father Walter has unfortunately subsequently passed, but Father Austin is still here—saw something in me that I didn’t. And in fact, only probably at Notre Dame could two priests who were in the pre-med program come to me and say, we are going to actually sign you up for pre-med classes. We think you’re going to be a better doctor than you would ever make an engineer. And so, my story begins.
The wonderful part about that is that getting to have mentors—or, I would say, models—like Francis Collins, when he had just discovered the cystic fibrosis gene at Michigan, helped me recognize that I actually may have had a love for science, I just didn’t know what it was. But that ultimately opened doors and opportunities. I was able to take that.
Why is that important? It’s important for me, because I actually had never been so enamored with science because when I would go back to my neighborhoods, I didn’t see what it did.
My whole entire course, once that light bulb went on, was, how could I bring what I’m learning from these institutions like Michigan and Notre Dame and all these places and where I wound up doing fellowship at—or pulmonary critical care with the Dr. Petty, the Thomas Petty, the giant in the field of pulmonary and critical care and also focusing on cancer. Little did I know that as a pulmonologist, I would have the most unusual experience of being a kitten among a pack of puppies. I had no idea that pulmonologists weren’t as fascinated with cancer as oncology.
I mean, we all, from Paul Bunn to many, many others—I thought about, dreamt about, and researched nothing but cancer. So, I tell you that story to say that the bottom line is that I really think that as we are pushing ahead, one of the things you said Dr. Brawley that really resonated with me, was that there was initial studies of the differences in outcomes, because prior to that, we may have assumed things, but once you put the data in place, it actually added clarity.
What I didn’t know or didn’t know how to articulate—I think in my neighborhood, I really knew these things, and I went to college and medical school to learn how to put tags on them—and now that I’ve gone through the process, I’ve learned how to actually better use data, to really frame the questions that I ultimately hope will have impact in communities in reducing the cancer burden. So, that’s a little bit of my story.
OB: Great. Dr. Stewart?
John Stewart: Growing up in the Northern part of Louisiana, I think that there were a lot of opportunities that I had, that were afforded to me by the hard work of my parents, by the support of the neighborhood, and by the hard work of my relatives.
And so, the thing that was missing, I think, in my journey, is that I had very few African American role models in medicine. We had five big factories where I grew up, but not really a lot of influence in medicine. And so, fast forward to going to undergraduate at Louisiana Tech and finishing early and going to work in a lab and trying to decide where I was going to go to medical school—I received some very good advice from Shirley Robison, who worked at LSU, and she said, “Listen, you should go to Howard.”
That made all of the difference in the world, because I actually was at an institution where people looked like me and we emulated excellence. When I say emulate excellence, LaSalle D. Leffall was the chair of surgery there. We all wanted to be like LaSalle D. Leffall. I think that many of his habits still resonate with me today.
I’m typically the first one up in the morning, because you get ahead of your day, but you also solely focused on your patient, and you never lose hope in that equation. I had the fortune to meet Lucile Adams-Campbell, and she took me under her wing. I did my first cancer research project with her. And subsequent to that, I went and did three years of training and went to the National Cancer Institute where I was fortunate to work as immunotherapy fellow with Dr. Steve Rosenberg for the first year, and really be under his influence for the subsequent three years.
During that time that sparked an interest in investigation for me, but I also understood the disparities in cancer outcome that were so prevalent. Fast forward, during my time at the National Cancer Institute, Dr. Harold Freeman was there, and he actually invited me to a President’s Cancer Council meeting when he was the chair. I think that at those steps along the way that I’ve seen excellence, I’ve benefited from the mentorship of people who are legendary in the field of cancer.
That really helped me to aspire to do what I do today. A year ago, when I had the opportunity to come back to my home state to found a cancer center in New Orleans, it was an opportunity that I could not pass up, because as you know, in Louisiana, we have such disparate outcomes in cancer, if you look at racial and ethnic differences, if you look at rural and urban differences in outcomes, if you look at outcomes in the Delta—we’ve got a real opportunity to affect change. So, not only giving back to my community, but also giving back to the spirit of those who have poured so much in me over my career has been a singular professional honor.
OB: It’s interesting—all of us can tell stories about mentorship. For me, Robert, it was the Jesuit priests in Detroit in high school. And then, at the University to Chicago Oncology, it was an infectious disease doc named Elliott Kieth. Then, once I went to medical school, it was John Altman. John Stewart, when you talk about not having any Black faces, I can identify with that.
I remember when I started at the University of Chicago in 1981, they had one Black full professor in the medical school. It happened to be Jim Bowman, who is now famous as Valerie Jarrett’s father. He was the only Black full professor in the medical school at the University of Chicago in the early 1980s.
Let’s move on. How did you decide to do what you do? Tell me a bit about how it’s woven into paying back to the Black community, the minority community. Each of you does something very special in terms of minority health or health disparities, health equity, but each of you does something very different in terms of medical oncology. Dr. Mitchell, how did you become a GI medical oncologist? Tell us a little about the work you’ve done even beyond GI medical oncology and health disparities.
EM: Certainly. So, I’ll weave it all together. My great grandparents were in their 80s and reaching a stage where they were not doing as well as they had previously, and my father worked out some details with his grandparents and bought part of their farm, which actually was given to my great-grandfather from his mother, who was a slave. So, I grew up near my great-grandparents, and they were my babysitters while my parents worked and my older four siblings went to school.
So, he became ill. I heard the family and others talking about how they could not take him to the hospital because they didn’t take care of Black patients well at that hospital. They were making a list of who was going to be with him. And a Black physician came to the house for a house visit, a home visit. I was three years old.
When the doctor left, I said to my great-grandfather “Pa, when I grow up, I’m going to be a doctor and I’ll make sure you get good healthcare.” Obviously, I didn’t recognize time, but he encouraged me to become a doctor. So, literally, we did not have kindergarten in our area, but I went to first grade and told the teacher, “I’m going to school to be a doctor.” That’s what I stuck with. I spent some time at St. Jude in the summer after my sophomore year of high school. That really interested me in oncology. St. Jude at that time was one building.
As I proceeded through my career in education, it was GI that I was very interested in and that encouraged me to seek a fellowship with Dr. Schein. So, that’s how I became interested in GI. He is a noted GI physician as well as researcher. He did his own endoscopies. So, I became interested in GI research, both in the laboratory with him, as well as a clinical oncologist. For disparities, I have been on the path to getting my great-grandfather that good care that he needed from when I was three years old. I’ve been working on this most of my life, Otis.
OB: Dr. Winn?
RW: I don’t think I even had a choice in the matter. Bottom line is, when I wound up leaving Michigan Medical School, I happened to go to a program in Chicago Rush Presbyterian. There was a gentleman there, a doctor named Roger Bone, incredibly famous for what he did as a pulmonologist and critical care specialist, but also his attention to cancer. Turns out that Roger Bone, Dr. Bone, and Dr. Tom Petty had known one another.
I think it was right the year before I became a chief resident had he actually made a decision for me, that I was on the path to becoming a pulmonologist. The interesting part about the cancer thing is that, I think, that even since my residency, the issues of what we were doing with cancer and disparities between Blacks and whites, in particular around lung cancer, was really stark. So for me, as I wound up going to University of Colorado National Jewish, there was this really amazing opportunity to be around people like York Miller, Paul Bunn, and many, many others who were just focused on lung cancer.
So, it was easy to actually get in the lab with people like Raphael Nemenoff and others. I found my way around the basic science, basic translational science, the sciences, and was able to weave that into a career in which I’ve been focused on lung cancer.
The interesting thing is, though, the health disparities. People say, “Well, how did you fall in the health disparities?” Well, that happened from when I was 10 years old and was part of the last group of folks that were forced busing. It was clear to me that the reality is that I wasn’t just going to school for me to become a doctor, I was not just going to school for me just to graduate, but I was going to school for me to have a purpose. At least my grandfather would say so. And the purpose was to come back and help out my community.
I mean, that I heard from the time I left Notre Dame until even today, from my grandmother. So, for me, this path of being a doc that’s focused on lung cancer, I think was in part set up by the places I had seen and some of the people I was most impressed by. But the focus on the health disparities and the focus on trying to reduce that gap was by John and Hannah Darden, my grandparents, who ultimately told me, “Don’t go to school and start learning all the books and then become stupid enough not to know that you need to go back to your community and help.” So, that lesson stuck with me.
OB: Dr. Stewart.
JS: And so, again, doctors Mitchell and Winn gave great examples of why it’s important for us to give back to the community, and the message is clear. It is something that you were born with, but this is also shaped by the fact that we recognize what’s going on around us. And so, again, recognizing, at least for me, the opportunity to improve care. The second opportunity is for us to understand why we have disparate participation in clinical trials, and that is what really drives what I do today.
As I mentioned before, I spent four years at the NCI—and you generally don’t go to the NCI, as you know, Dr. Brawley, for standard of care. You go for participation in clinical trials. One thing that I did note early is that, irrespective of what happened with the 1993 NIH Revitalization Act, is that we had differences in participation in oncology trials.
As a surgical oncologist, I asked the question—I believe the year was 2005—what does participation in surgical oncology trials look like? I found that we still have those differences, and those differences are probably more stark based on a number of different factors. These different factors include things like implicit bias.
Multi-level interventions based upon improving implicit bias, multi-level interventions based upon understanding some of the structural barriers to care, are even more evident in surgery. So, that’s really what has driven me, and I still live to this day to think that, A, you have to help the community, B, you have to ask the right question, but that right question needs to be informed by the community so that your findings are relevant to their everyday lives.
OB: You brought up the NIH Revitalization in ‘93, which, for the audience, is a legislation that I have worried about a lot publicly, because it says that when we design a phase III clinical trial, we have to look at the result of that trial to see if the result is the same in Blacks as it is in whites, as it is in Asians, or Native Americans, or Hispanics, as if those define biology.
Don’t you think—this is a question for all three of you—don’t you think the bigger problem right now is that Blacks especially, and let’s bring Harold Freeman in here, poor people, don’t get the treatment? Not that the treatment doesn’t work if they got it, but that they’re not getting the treatment.
RW: What is Dick Worthy’s example of actually calling disparities? That is the definition, where if everyone had access to the therapy and appropriate therapies, there would be no differences in their outcome. That to me is the inherent disparity. We’re still looking right now at Black men having a 6% higher incidence of cancer than their Caucasian counterparts, and almost a 20% higher death rate. We’re looking at African American women and seeing that—this is surprising—that there is, I believe, off the top of my head, an 8% lower incidence in cancer and a 12% higher death rate.
OB: Oh, I agree with that.
RW: The reality is, I think that where we go often is the biology, thinking that African Americans are just more predisposed by their biology to having cancer, as opposed to the structures that have created many of those disparities. We can’t talk about the treatment and the biological differences without understanding the structural issues. I’ve been going around talking about the ZNA or the znome, the ZIP code of association, and how that ZNA actually impacts the DNA and your ultimate biology. I think we’re at a much more sophisticated level of understanding these disparities than we were, say, 30 years ago.
OB: What’s your line, ZIP code being more important than your genetic code?
RW: DNA is definitely 80% of what’s going on, more than the 20% of the contribution of the DNA.
OB: I’m sorry, Edith, I stepped on it.
EM: But there’s also the genetics that we inherit, and the effect of the environment on the gene milieu, and that’s something that really has not come out in our clinical trials. Therefore, we need to do more genomics on these clinical trials so that everybody has access. There are influences from the time you’re born, until the development of cancer, that can impact the gene environment.
There is also, after the 1993 [NIH Revitalization Act], one thing that we have initiated and adopted, and that is the word “implicit bias.” There’s no such thing as implicit bias. If somebody can look at you and based on your color or your gender or some other aspect—that’s not implicit. That’s racism.
If you can see a person and make a decision regarding their care, regarding whether they might participate in a clinical trial, even with the time spent with them—it is well recognized that Black patients in a majority situation receive fewer minutes during a clinical consultation than white patients. That’s not implicit. That is a person making a decision based on other attributes of the patient’s physique—the color, maybe even what they’re wearing, how they speak, and other facets that are related to the individual patient.
So, we need to make sure that we are getting our Black patients into the appropriate clinical care trials. We need to revise the healthcare system so that those differences are not allowed in the practice of medicine.
OB: Don’t get me wrong. I am in favor of minorities going into clinical trials, because I’ve got studies, Dick Warneke did some of them, Bob Robert, that show that doctors who participate in clinical trials take better care of their patients, of all of their patients, compared to doctors who don’t.
If a doctor puts two or 3% of his or her patients on clinical trials, they provide care. And the reason I’ve been really into this—let’s talk about clinical trials, but let’s also talk about adequate care. Because studies have been done. We’ve got six states in the United States where Black and white women have the same death rate for breast cancer. I’ll flip it around.
We’ve got 12 states in the United States where white women have a higher death rate from breast cancer than Black women in Massachusetts.
RW: This goes back to what John said, though. If you actually can have all of the teams and the pieces to put together a clinical trial, by definition, that means you have institutional, organizational capabilities that would allow you not only to put together those trials that will take care of better care of your patients—but I was going to turn this over to John.
OB: Go ahead.
JS: So, let’s think about what the definition of disparities really is. We understand it’s access—or lack of access—to really good care, but the double edged sword of that is that it is also exposure to less effective care. So, more ineffective care, less effective care. That’s the double edged sword of disparities that we are facing. We have to address both of those issues if we’re really going to understand health equity and how we move forward with health equity. Let’s say the second part of this is that—Dr. Mitchell made a very important point—we’ve now got the emerging field of social epigenomics.
To be honest, it’s not something I thought about until I started working with Robert Winn in Chicago. We know that based upon environmental exposures, you have imprinting of the genome. That just doesn’t affect our cancer incidence. It also affects our rates of hypertension. I mean, you look at studies of Black men who have “made it,” but we still have high incidence of hypertension relative to our white counterparts. There’s something there to speak about the exposure of not just our environment, but our ancestors’ environment, and the way that it’s affected genomic imprinting and epigenomics moving forward.
EM: Absolutely—allosteric oncology, where we are evaluating enzymes, hormones, based on stress and where one lives, with redlining and other methods of disparities. So, we’ve got to consider that. It’s also been weaved into the healthcare system.
So, when you think about the 1910 Flexner Report, through that report, seven medical schools, Black medical school were closed, with only Howard and Meharry surviving. But, in the Flexner Report is also information that Blacks should be trained in medicine as sanitarians, and their explicit job should be to teach the Black folks how to keep themselves clean and not to allow diseases like tuberculosis enter the white community. So, it’s saving white folks from disease processes. Can you imagine the four of us only being what, sanitarians?
That set the culture until the Johnson administration, former President Johnson. So, during this time from 1910 to the late ‘60s, most majority medical schools did not admit many Black doctors, Black medical students. So, the number of Black practicing clinicians in this country decreased significantly after 1910 and did not begin to rise again until the 1967 Great Society of former President Johnson. So, the 1910 Flexner Report set the culture for medical school education in this country and it disallowed the education of Black individuals in medicine and opportunities to become clinicians.
OB: I should point out that Flexner was a noted segregationist from the University of Louisville, who was asked to study medical education in the United States. And the end result was, as Dr. Mitchell said, most of the Black medical schools got shut down. John.
JS: I think the Flexner Report is informative. Because, I mean, he was a eugenicist. Let’s just be simple about it. I mean, he was a strong proponent of eugenics. So, Dr. Mitchell makes the point of saying, “Hey, African Americans should be trained to work on African Americans.” But more importantly, they wanted to keep the diseases that they thought were associated with us from spreading into the white populations.
So, all of that’s important, but in the rear view mirror, we have to understand, we have to understand who’s telling our story. We have to understand who’s telling the history. And if we would allow somebody like Flexner to report the history and take down seven Black medical schools at the time—we’ve got to just be careful of that.
RW: That whole soft science, this is why we are at a crossroads right now, where we have many people who—listen, I don’t think that there’s a problem, all of us on this Zoom know that we will continue to make amazing strides in science, we’ll make amazing strides with scientific miracle drugs and with technologies. What I fear most is that we will lose public trust.
I will tell you that running throughout this whole conversation was the soft science of eugenics. It’s the same science that allowed Flexner to do what he did. But fast forward from 1910 to 1934, it’s the same science that allowed a guy like Homer Hoyt to come up with a Fair Housing Act or the Federal Housing Act of the 1930s, which established redlining based on the soft science of eugenics that white people would be smarter and therefore more able to pay back a loan than someone who was Black.
It’s interesting that, in an age of TikTok and all this other stuff, that people are not putting the pieces together, that science does matter whether you want to do it or not. COVID and cancer don’t really care. The science of what we are trying to get out to the public, I think is that is something that particularly as African Americans, we are having to take up that challenge of how do we better communicate these things within the 21st century.
Many people may actually be available to some access to these things, but if they don’t know it’s accessible and don’t know what it’s for—and it’s not just African Americans. There are more and more people who, again, the miracle cure or the miracle vaccine or the mRNA vaccine, the COVID-19 vaccine, refused to take it, because why? Because again, the communication is being challenged with a lot more clutter, with mistrust and distrust.
So, I think one of the other challenges we have—as not only people of color, but thinking about rural areas and all the rest of the stuff—is how do we maintain the move forward of our love for science and the progress that science needs to make? How are we actually going to pragmatically break down that science so that we really do have impact within our communities? Just like in the ‘30s, the eugenic movement puts everything from Flexner to Homer Hoyt, who came up with the red line programs. We have, again, misinformation that’s actually coming out there that will, if we’re not careful, undermine the progress that we’re making in our science even today.
EM: Oh, absolutely. I think it’s so important that we look at history and how, despite being recommended as sanitarians in the Flexner Report, we have survived. We have worked together with others, and I think it’s so important to recognize the fact that—I tell everybody the Tuskegee Airmen integrated America and made opportunities for all of us.
So, when you think about the fact when funds from the Congress to build Tuskegee—the same thing as sanitarians. It is in the federal register, I’m told, I’ve never looked it up myself, that there was a Congressman who stood in the Capitol when there were discussions of funding the Tuskegee Airmen, that it was said, give those N-words the money and show them that they can’t fly planes. And we all know the history of the Tuskegee Airmen.
And then later, former President Truman—who I think was one of the greatest presidents, don’t put that against me—but what he said was he was going to introduce the bill into Congress to desegregate the military, based on the record of the Tuskegee Airman, and another Senator from South Carolina said he would never let it out of table and that this was not an issue. He would not let it go to the congressional floor.
What happened was former President Truman said—I won’t say what they say he said—but he then wrote the bill 9981 that integrated the services. That was presidential order, 9981. So, Congress had nothing to do with it. And later, the state department was integrated after the military services were integrated. Now everything is integrated such that we had the opportunities not to become sanitarians based on the Flexner Report, and to go to really good schools and get training in those really good schools. So, it’s how we’ve collaborated with all of the efforts that despite those setbacks, we’ve survived—and not only have we survived, but we are in a situation where we are leading the effort to end disparities in multiple healthcare settings, multiple disease processes.
OB: Well, I would actually make the argument that the military, especially since the Civil War, has always led the country a little bit in some of these issues. It was the Black soldiers of the civil war who fought—
OB: And then, going even into the Veterans Administration in the last 30, 40 years, much of my career has been writing papers on how equal treatment yields equal outcome, and there is not equal treatment. Where we’ve frequently gone to look at that and show that is in the Veterans Administration. Black men who have stage II prostate cancer, treated in the VA, have the same outcome as white men with stage II. But in the United States as a whole, Black men with stage II are one and a half times more likely to die from prostate cancer.
I’ll even say, having run a large organization, as chief medical officer of the American Cancer Society for 12 years, as a Black man, I was more accepted as a leader because Colin Powell did it 30 years before me. I can give a number of examples of where Black people were leaders in the military before we were allowed to be leaders in the—I was going to say in the real world, but outside the military.
JS: The civilian world.
OB: The civilian world. Thank you, Dr. Stewart.
JS: Got you, man.
OB: The surgeons always got to clean up for us.
EM: But also, Otis, General Davis.
OB: Oh yes.
EM: With the Tuskegee Airman, when there was the plan to raid over Germany, the general in charge, as they were planning, asked, “Where are the Red Tails in this?” They had not included the Red Tails. And he said, “Leave, don’t come back until you come back with a plan that includes the Red Tails.”
So, when General Davis briefed his men about where they were flying to, he said, “Usually we get orders to go places, but this time we’re going by request.” When he finished, when the raid was over, General Davis had painted on the front of his plane, “by request.” So, the generals in the military, certainly General Powell, but General B.O. Davis, I think was one of those also. I have a picture in my office of his plane with “by request” painted on the nose.
OB: His side course went on to become a very distinguished general as well.
RW: I want to pick up on that though, and say, if we actually maintain that same spirit, of understanding that when called to the task, that we’ve had multiple opportunities throughout history, which African Americans rose to the occasion and exceeded. If that same “by request” were done with continuing the programs of getting more minorities into medical school throughout the ‘70s, and you said post ‘67, and we actually maintained that and maintained the steam through the ‘80s and ‘90s—but instead, the interesting thing, and again, I’m speaking as an older emissions team, when I was at University of Colorado, the numbers have slipped.
The focus has actually also slipped. So, one of the things that I really love about the story you just talked about, Dr. Mitchell, is that this isn’t going to happen just because it’s going to happen. It happens because people have the will and they put things in place—and in programs that ultimately say, “I know you may be uncomfortable with these folks being here, but we going to get them here. They’re going to show you what they can do.” And I think that less of that has happened over time, where we have not had the opportunities, I think, to shine, because the numbers don’t lie. They’re going, in some cases, I think a few years ago, we had less African American medical students than we had in the ‘70s.
OB: We’ve got a bunch of questions here. I want to try to get some of these in real quick, lightning round, because we’ve got about six minutes left. What was the most challenging portion of your medical journey and how did you overcome it? Maybe, do you have advice for the next generation, Dr. Stewart?
JS: So, this allows me to use a quote that I love to use from Dr. Charles Andrew, former chair of the Department of Surgery at Howard. It said, “Excellence of performance transcends artificial barriers created by man. Go to work every day and be excellent.” Now, I can’t tell you that every day is going to be great when you walk in. Just by the nature of being human, every day’s not going to be great, but you have to harvest those opportunities to be great. A lot of times, you have to look past circumstances and understand that you’re beginning that day with the end in mind, and that’s to be better than you were when the day started.
OB: Good idea. Dr. Winn.
RW: I think the best advice I have is, ultimately, have grace, humility, and know your North Star. The bottom line is, once you know your North Star, it doesn’t matter what turmoil or turbulence comes you way, you are committed to—ultimately you’re committing to your community, the folks around you, to being the best you can. And again, I would echo what Dr. Stewart just said, that just do you and you are usually enough.
OB: Dr. Mitchell.
EM: I would echo the same, be the best that you can be every day. Another topic I picked up recently from Admiral McRaven, who was over at the Navy SEALs, who were in charge of ending the Bin Laden. And what he said to me one day, and he has said it multiple times, it’s all over TV and everywhere, is that with the Navy SEALs, they were taught some days are not going to be good. You might not feel good about what you’ve done, but if you make up your bed every morning and that’s the first thing that you do, you can always come back home, or to wherever you’re staying to see that you’ve done something good every day. So, make up your bed first thing in the morning and do good, do your very best every single day.
OB: Great. Now, we’ve got a few more minutes, we’re going to end with one more question from the audience and I’m going to slightly modify it. This is somebody who was concerned that patients don’t have enough time to talk to doctors and to get information. And I’m going to ask you, do you think that Medicaid especially, which doesn’t pay nearly as well as Medicare, which doesn’t pay as well as private insurances, actually causes some disparities because it forces us to talk and see patients in a shorter period of time?
RW: One word answer to that would be yes. I mean, the truth of the matter is, the program by the ACS and ACS CAN and NCNN just showed that oncologists, when you took a large swath of them, 62% thought that we were doing a worse job with people of color than we were with our white patients, and that the outcomes were worse. Part of that is multifactorial, including what you just talked about, but there are many other things that are at play.
JS: So, I would say that if we look at the Medicaid expansion and what did from 2013 to 2018, we saw that it allowed people who were previously uninsured to become insured. So, for instance, if you look at the Black-white gap, that dropped by about 50%. So, I think that access is something that we really have to work on.
Now, what happens when you get through the door, and you’ve got that compressed time? I think that’s really where we have to do our work. We have to do our work and understand how we can have those valuable communications with our patients to make sure that they understand all of the options and that they’re comfortable with proceeding with whatever treatment plan they decide to pursue.
OB: Dr. Mitchell, I know you’ve got to leave in a second. You want to say something about that?
EM: Absolutely. Access to care is very important. And for us, we’ve got to lead the way to make sure that patients, number one, have access. And with that access, can in the healthcare system, get the proper care, the best care, the opportunities for clinical trials, opportunities for genomic information, so that we can say our Black patients are getting access and they’re getting the best of the best.
OB: If you have time for one more, Dr. Mitchell, what is the current role of minority medical schools?
EM: So, there are now four medical schools that are based on African Americans, but understand there are other medical schools, for example, the school in South Texas that has almost all Hispanic and LatinX students. I think we’ve got to think about all minorities now. For many years, we only collected information on Blacks, but now we’ve got to look at all of the processes, all of the access to care, so that everyone in America is a part of the system, has access to the system, has equal care in the system.
And therefore, we are talking about all of America. We’ve got to look at the whole situation and therefore make recommendations that affect everybody. So, all socioeconomic, all social determinants of health, so that we are providing good care to all individuals of America, despite their socioeconomic status, where they live, rural areas, and all others. We’ve got to make sure that we have not only equity in America for medicine and healthcare, but justice.
RW: Dr. Mitchell had the word of the night.
OB: Justice, justice. I think that’s the appropriate point to leave. I mean, this is really a justice issue. We went from minority health with the Heckler Report to special populations health, to—David Satcher actually challenged some Congressman and said, “Let’s call it what it is. Health disparities.” He literally said that. By the way, that’s where the phrase came from, in a conversation with staff. He literally said, “I want to see, and I won’t say the name of the Congressman, I am against programs to reduce health disparities.” That’s where the phrase health disparities came from. Then we started talking about health equity. I think Dr. Mitchell is right. We need to talk about justice. Thank you so much.
EM: Oh, thank you.
OB: We had a wonderful talk. I really appreciate it. Dr. Stewart from Louisiana State University, Dr. Winn from the Virginia Commonwealth University, and Dr. Edith Mitchell, General, United States Air Force, retired from the Kimmel Cancer Center at Jefferson Medical College. And I’m Otis Brawley, Bloomberg Distinguished Professor at Johns Hopkins University. Have a good evening.