Failure to Act is a Violent Action
How the Body Politic and the Human Body Carry History | An Interview About Health with Dr. Ronald Wyatt, MD, MHA by Kimberly J. Soenen | January 21, 2022
(Crown Fountain in Millennium Park, Chicago. Designed by Spanish artist Jaume Plensa. All photos by Kimberly J. Soenen)
In the April of 2020, I co-authored an OpEd for the Washington Post with Dr. Ronald Wyatt about the language of marginalization and oppression across the United States healthcare scape.
Wyatt is an internationally-recognized Patient Safety advocate. We were first introduced by the editor of Please See Me literary journal. Dr. Wyatt attended a guest lecture by me that was cosponsored by The MedStar Institute for Quality and Patient Safety during the world premiere run of the “SOME PEOPLE” (Every)Body exhibition in Chicago.
As the event was closing down and attendees were leaving, he approached me quietly and said, “This. This exhibition and project is everything. Have you ever read The Tragedy of the Commons?”
Dr. Wyatt is a graduate of the University of Alabama Birmingham School of Medicine, and was the Chief Resident in Internal Medicine at St. Louis University School of Medicine. He holds an executive program master’s degree in health administration from the University of Alabama Birmingham School of Health Professions. He was a 2009-2010 Merck Fellow at Institute of Healthcare Improvement. He speaks frequently on harm reduction, trauma prevention and Healthcare Justice.
I contacted Dr. Wyatt to get his take on the current state of Public Health.
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This week, the administration of United States President Joe Biden announced they are preparing to send 400 million tax-financed N95 masks to health centers and pharmacies across the country. Earlier this week, taxpayer-financed Over-the-Counter Home Covid Tests were also made available directly to households across the United States.
The United States is now in its third year of executing a wartime Single Payer National Health Program policy. Taxpayers are financing the deployment of the United States Military and National Guard to assist with medical support at buckling hospitals and distressed schools; Taxpayers are supporting federal subsidies to prop up privately-managed hospitals and health systems that were on the brink of bankruptcy; and they are also financing ongoing private pharmaceutical research on Covid-19 vaccines and boosters. United States taxpayers are also financing assistance with the global vaccine roll out through the World Health Organization, COVAX, Gavi and other partners around the world.
In your opinion as a physician, and also as a citizen and a father, how are we doing?
I am hopeful.
Let’s talk equality and the role healthcare access plays in achieving equality and economic empowerment. Every year, a quote attributed to Dr. Martin Luther King circulates on social media on Martin Luther King Day about health and healthcare. It’s often quoted inaccurately. Can you address that quote?
In 1966, The Reverend Dr. Martin Luther King, Jr. spoke in Chicago. He is often quoted as saying, “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane."
However, although this quote makes the social media rounds annually during the week of Martin Luther King Day, these words have been whitewashed. Many who witnessed that speech recall him saying “inhuman,” not “inhumane.”
We are now in the third year of the SARS-Cov-2 virus pandemic response globally. How has the response impacted historically marginalized and oppressed populations across the United States specifically?
The historic devaluation of Black and Brown people is causing a tsunami of adverse childhood experiences, trauma, under-appreciated workers, preventable healthcare-related harm and premature death.
It is true that poverty is scientifically correlated to exposures to environmental toxins, over policing, and other Public Health threats, but structural and institutionalized racism within the healthcare industries are causing ongoing preventable adult chronic disease, the unnecessary spread of Covid, and preventable harm and death.
Have we become numb to the global health crisis because of fatigue?
This week alone, January 16, 2022, data shows that almost 2,000 people died from COVID-19. For reference: That number is the equivalent to four large airliners crashing in one day. When we analyze the mortality and morbidity data, however, it become obvious that the suffering of marginalized and under-resourced people and communities preceded COVID-19 by more than 400 years.
Health Inequity, Health Disparity and unaffordable healthcare in the United States are at the epicenter of inequality and poverty. Is this a new conversation that has arisen from the pandemic response?
In the late 1800’s, W.E.B. DuBois published the scientific paper “The Philadelphia Negro,” and concluded that there is a “peculiar indifference” to the health and healthcare of Black people.
The words of DuBois continue to ring true today—especially in the United States— as demonstrated by the violent inactions of the United States of America healthcare approach and model. From the time of slavery, a condition described as “Drapetomenia” was applied to runaway slaves.
Drapetomania was considered a mental health disorder by the white-dominated medical establishment. Dr. Samuel Cartwright posited: “Why would a “happy slave” want to be free?” His recommended cure was too was to whip the devil out of the slave.
Peonage—also called “debt slavery” or “debt servitude,”— is a system where an employer compels a worker to pay off a debt with work. This term supplanted slavery and resulted in a death sentence for many Black men who were unjustly incarcerated and forced to provide manual labor for coal mines and other industries in the southern United States.
The system of peonage was supported by the Black Codes that were designed to oppress and disable former slaves. As a system of healthcare, racism evolved, and the Jim Crow era emerged. Jim Crow laws negatively impacted the lives of Black people by legalizing racial discrimination in the Southern United States. These laws created segregated, low-quality healthcare for Black persons.
Trauma impacts memory, emotional intelligence and physical function in many ways. Can you explain, as a physician, how we, as human beings, carry trauma, marginalization, violence, vicarious trauma and oppression bio physiologically? Can we separate the history of enslavement and violence from our individual health and the current state of Public Health in the United States? Another way of asking the question: Does the body politic have muscle memory in the same way the human body has muscle memory?
Based on research by Nancy Krieger, a professor at Harvard T.H. Chan School of Public Health, Jim Crow laws directly contributed to increasing a Black women’s risk of breast cancer and a worse prognosis. Dr. Krieger states it well: The truth is “You carry your history with you in your body.”
So, knowingly or unknowingly, we carry history and trauma within our bodies subconciously?
Look to the United States. We have the largest number of incarcerated, and formerly incarcerated, Black people. “The New Jim Crow,” per the exceptional author Michele Alexander, finds more Black men under the control of the Prison Industrial Complex than were enslaved in 1861.
Let me say that again: More Black men are now under the control of the United States Prison Industrial Complex than were enslaved in 1861.
The result of Mass Incarceration directly impacts the health and well-being of millions of Black families and has a cross-generational impact. It also impacts society negatively on the whole. It’s called Vicarious Trauma. For every one incarcerated person—or, analogously, for every person who is unable to afford or access healthcare—many people in their circles are effected economically, socially and physically. Mass Incarceration is not just poor social and economic policy, it is failed Public Health policy. We cannot separate that triangular impact.
From your perspective as a Patient Safety expert internationally, how do we amplify the conversation about Health Equity, Health Literacy and Healthcare Access to widen the definition of health and Public Health more expansively?
As a Patient Safety expert, I feel it is critical to understand the root causes of harm and preventable death in the context of Public Health and healthcare. It is essential to identify risk and then implement measures that will mitigate the risk with the intent of Zero-Harm and a more reliable, trusted, health and healthcare system.
A key tenet of root cause analysis is to ask “why” inequality persists in order to better understand the root causes of ongoing harm.
The inequities in United States healthcare have been designed into the system intentionally since there was a healthcare “system.” The United States Managed Care healthcare model is perfectly designed to uphold inequity and disparity because it is unaffordable, inaccessible and prioritizes profiteering by shareholders rather than The Patient and The Common Good.
The root causes of poor Public Health in the United States include failures in leadership—from the executive level and the board of directors’ level across corporate health systems and commercial health insurance companies—to commit to Zero-Harm and prioritize Public Health over record-breaking profiteering and self-interest.
Just this week, an arresting short film produced by Jonah M. Kessel and Lucy King was released by The New York Times about violence toward nurses. For decades, budget cuts by corporate health systems have led to dangerously low staffing numbers, violence directed at medical professionals in hospitals, and moral injury.
Another riveting film, The First Wave, underscores the distress United States medical professionals are subjected to in the workplace.
The questions the rest of the world watching from afar is: How does the wealthiest country in the history of humankind have so many distressed hospitals? Long before the pandemic, why is such a wealthy country distressing its own medical labor force? Why are so many hospitals going bankrupt? And, how is it that so many Americans cannot afford healthcare?
You and I are aware of the root causes of these horrific realities, but how do we move forward to transform the United States Health Philosophy, approach, and delivery model?
Health Inequities and Health Disparity are the expression of leaders who are over reliant on technology and policy, want to hear only “good news,” favor blame over justice, and do not address unprofessional behaviors, thereby sustaining toxic cultures that lack psychological safety for all people.
Corporate Health System “leaders” continue to align the efforts of the system with perverse incentives like rankings, ratings, and grades, as opposed to addressing the data that demonstrates clear inequities that are unfair, unjust, and gives an advantage to one population over another population.
All too often, it becomes apparent that marginalized and under-resourced communities were not allocated the essential resources they needed to mitigate risk. The result of this ahistorical approach? The devaluation of certain populations and communities has caused—and continues to cause—premature death.
In 2021, you and I co-authored an OpEd in the Washington Post about Racism in Healthcare and the harm it imposes across our Public Health infrastructure. It also harms The Patient. Can you talk about your work in Patient Safety, Bias in Healthcare, and Systemic Disparity based on health outcome data and other weekly evidence-based indicators? Is judgment and prejudice in medicine invisible, or is it a metric that is traceable?
As I continue to review the root causes of harm and preventable death in the United States, it is clear that structural and institutional racism are root causes. The most expensive healthcare model in the history of the world favors one population over all others, persons who identify and are perceived to be “white.”
Embedded in the United States healthcare model—from medical school education to research and clinical practice—race, ethnicity and language continue to be a factor in poor health outcomes and unhealthy communities.
In the United States, healthcare access is another extension of the caste system here. Health Inequity and Health Disparity are embedded in our language.
Americans use terms like “Cadillac Plan,” “Concierge Healthcare,” and “Platinum Care,” to identify who can afford access to quality healthcare and who cannot. The level of access to healthcare has become another socioeconomic status tier.
If a citizen has Affordable Care Act Medicaid—despite working more than 40 hours a week in some cases—they are considered “working poor.” If a citizen has an expensive commercial health insurance plan with UnitedHealth or Cigna, or access to Mayo Clinic’s corporate concierge offerings, they are considered wealthy and accomplished.
In other instances, Americans are permitted to bump up friends and family in surgery queues through nepotism and connections rather than formal protocols. Frequently we hear Americans calling their surgeon “The Best,” as if only one surgeon is capable of cardiac, cancer, knee or hip replacement surgery.
Apart from fetal surgery, transplants, and other rare, rare specialization, is there a “Best" in healthcare?
There is no “best.”
Clearly, healthcare has become a commodity. For decades wealthy countries and wealthy people were medical tourists. Now these same countries are attempting to build their own capacity and capability. That part makes sense from a business perspective and from the perspective of a wealthy country that wants to improve the health status of its citizens.
A bigger question is what are these big United States-based health systems—all whom are registered federally as “nonprofit” for tax purposes—spending the community investment money on? Is the money allocated fairly and justly? How are these behemoth corporate health systems being held accountable? Can Good Will be expected, or does it need to be legislated?
The tax and accounting protections for these so called “nonprofit healthcare systems” needs much closer scrutiny and oversight.
For ethical healthcare professionals, financially-distressed patients and struggling business owners, what are some solutions to strive toward as we look to the aftermath of the SARS-CoV-2 pandemic?
It is long past time to strategize, organize and act. I support and endorse the following recommendations:
1. Establish a Single Payer National Healthcare Program
Currently, House Resolution 1976 in the United States outlines National Improved Medicare for All, how it will be financed, executed and sustained. Universal Healthcare is the only way to avoid another crisis like the one we are in now. (Blood shortages, medical staff shortages, medical supply chain shortages, financially distressed hospitals, bankrupted rural hospitals, shuttered psychiatric hospitals, violence in hospitals, moral distress of burned-out medical professionals, poor health literacy education, and so on…)
2. All healthcare systems must commit to becoming Anti-racist Multicultural Transformative Systems
This can be embedded in contracts, bylaws, board governance structures, employee handbooks and published transparently as Open-Source document policies online by every institution.
3. Structural Humility and Structural Competence should be required of all care givers
Keep the bar raised ethically.
4. Regulatory agencies and accreditation organizations must establish measurable standards that are linked with reimbursement
Specifically, establishing a National Patient Safety Goals oversight regulatory commission on Health Equity is essential.
5. Affordable Medical School Education must be required to increase the numbers of Black physicians and administrators
We had a nurse and Primary Care physician shortage long before the pandemic. It’s a crisis. Who can afford to be saddled with debt for decades after medical school? The cost prohibitive tuition is a deterrent. New York University and Kaiser are experimenting with philanthropically-supported tuition-free medical school. But medical school should not be a private sector charity model, it needs to be implemented as a cultural, social, economic and ethical value to which American society assigns fiscal priority.
Our current approach to medical school education is unsustainable.
6. Corporate Healthcare should be required to demonstrate community participation and engagement in designing an equitable system
Hospitals that are managed by persons who live in their local communities have better health outcomes than hospitals that are managed by senior management five states away. The greater the distance from the people you serve, the bigger the moat is for harm and death.
7. Stratify data by race, ethnicity and language
Act on the data where disparity is validated and can be used to improve the outcomes of all people always.
8. Identify sources of distrust in healthcare and Public Health
Vigorously work to Repair, Restore and Reconcile the loss of Public Trust through integrity, honesty and ethical standards.
9. Build and support cultures that are Fear of Reprisal free
If medical students, nurses and physicians need to report risk and harm, they should be free to do so without fearing the loss of their job. Becoming a “Whistleblower” needs to be regarded as an honorable action, rather than a life-threatening, career-ending choice.
Unchecked greed in United States healthcare is notorious worldwide. Just a few examples: Pharmaceutical industry CEOs make deals with the United States government to purchase vaccines and roll that money into investment portfolios, salaries and personal wealth at taxpayer expense. Commercial Health Insurance industry executives implement Denial of Care as a business model to enrich shareholders while delaying and denying care to premium-paying Americans.
You have witnessed and worked within several international health systems. In the United States, The Pursuit of Liberty (individualism) is baked into our founding. The argument can be made by Americans that The Hustle—making a buck any way possible at any cosst—is in our DNA.
It’s uniquely American to believe that shareholders should be able to profit from injury, illness, disability and death like any other commodity. That’s Capitalism. That said, what is the argument against the record-breaking historic profits made by the Commercial Health Insurance, pharmaceutical, biotech and corporate health system industries in the United States? They are simply benefitting, legally, from our American model, aren’t they?
Well, this question is the Zero-Sum question.
Healthcare is a Common Pool resource. In the end, if the prime objective is to perfect being a free rider, in order to maximize monetary returns, then most certainly the destination is the exhaustion of resources resulting in either maintaining the status quo, or worsening and weakening “the system.” Here is where robust rules, regulations and other forcing functions are necessary to protect The Patient and Public Trust.
You have witnessed a lot of pain and strife in your own life. Are you hopeful about this opportunity in our midst to transform thinking around health and healthcare in the United States and beyond?
“Hope is not a plan, soon is not a time, and some is not a number…” therefore, the failure to act is a violent action.
The world can change, and the starting place is the ground that we stand on.
There is The Fierce Urgency of Now that calls upon visionary Public Health leaders with courage who are committed to the heart work of eliminating inequity in Public Health to speak up and act.
The road ahead is paved with structural and institutional racism in healthcare that must be called out and eliminated in the United States. Achieving Health Equity and equality requires love, respect, empathy, humility and compassion for all people.
We are in a crisis. Suffering and preventable death is prevalent. As healthcare leaders we must make the vision plan, show courage, and recognize that redesigning the system will be slow. But we must, therefore, progress with urgency and commitment and keep moving forward.
Thank you Dr. Wyatt.
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Recommended Reading
Slavery by Another Name: The Re-Enslavement of Black Americans from the Civil War to World War II by Douglas A. Blackmon (Double Day) t
The New Jim Crow: Mass Incarceration in the Age of Colorblindness by Michelle Alexander (The New Press)
Recommended Viewing
The Long Shadow of Incarceration’s Stigma , co-produced by VII Photo Agency, Kimberly J. Soenen and Sheila Rule with photojournalists Jessica Dimmock, Ashley Gilbertson, Ed Kashi and Ron Haviv.
America, directed and produced by Garrett Bradley, now streaming at Field of Vision.
Not Going Quietly, directed and produced by Nicholas Bruckman and PeoplesTv. Available to stream beginning January 22 on POV / PBS.
Current Relevant Exhibitions
It’s Where It’s At at Anthony Gallery, Chicago >
Is where it’s at! derives its title from Nina Simone’s Young, Gifted and Black performance of the song at the 1969 Harlem Cultural Festival, a song that celebrates the beauty of Black people and youth as the future. Is where it’s at!, is an ode to Black people who continue to enrich the culture of the world, urging us to never forget the power that we possess.
Engagement
White Coats Black Doctors Foundation
Business Leaders for Health Care Transformation
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