Monday, August 31, 2020

Hospitals compete for money, not the people's health. We need to stop this.

For decades, Santa Fe, NM, had only one hospital. St. Vincent’s was founded 155 years ago by the Sisters of Charity, but was taken over by the national Catholic corporation CHRISTUS in 2008. It’s a pretty good hospital with about 200 beds, for a small city of 85,000. A couple of years ago, the largest health system in New Mexico, Presbyterian, opened another hospital. It is a big building, but has only 30 beds, so its additional contribution is not primarily general inpatient care. Interestingly, while the hospital is on the far southwest side of Santa Fe, its main medical center building is directly across the street from St. Vincent’s. This is obviously not a coincidence, as it is now firmly in the center of the area in which people are accustomed to coming for medical care, establishing itself, at least for outpatient care, as a competitor.

The point that I want to talk about is not hospitals in Santa Fe specifically but rather competition among hospitals in general. This is not a problem in rural areas and small towns where the struggle is, rather, to hang on to their hospitals at all (often with just a very few inpatient beds, and almost invariably losing money). It may not be a big issue for mid-size cities like Santa Fe. It is a huge issue in the major metropolitan areas where most hospitals and doctors are, and where there are the greatest concentrations of patients (the medical term for what in English we call “people”).

In these areas, you will find that almost every big hospital (or “medical center” or “health system”) has a Cancer Center. And a Heart Center. Centers for Orthopedic Surgery and Sports Medicine are also big. And in the last decade Neuroscience centers have joined the ranks of “must-haves” for each of these centers. Of course, if they deliver babies, they certainly will have a Neonatal Intensive Care Unit. What is wrong with this? Are these not important, serious diseases that can and do kill a lot of people and need treatment? Am I advocating against treating, say, cancer?

Not at all. But while there are a lot of people with cancer, it is a finite number. Was the new Cancer Center just opened to a lot of hoopla at St. Elsewhere necessary because there were many cancer patients for whom there was not room in the Cancer Center at Downtown General, opened a few years ago, and now would have an opportunity to receive treatment? Or, just perhaps, is St. E’s hoping to attract many of the patients, and perhaps the doctors, who currently use DG to instead use their new, glitzy, state-of-the-art facility? Is it a simple matter of competition for a limited market?

If we had a medical care system that was based on the health care needs of the population, we wouldn’t have such redundancy of facilities; we would have enough for all the people who need care and not unnecessarily duplicate services. Downtown General might have centers of excellence in cancer and orthopedic sports medicine, while St. Elsewhere might be great for heart and neonatal care. And, since we are fantasizing about a system in which the driving force is the health of the people, let’s throw in primary care and mental health. But that doesn’t happen. And, in our hypothetical city, even with both cancer centers (and perhaps yet another at Doctors Medical Center), there will still be bunch of people who cannot receive care because they have no insurance or their insurance is poor (i.e., they are “underinsured”).

So, in addition to creating excess capacity, which creates major excess cost, competition in medical care services doesn’t meet the needs of all the people. The true driver of the health system, making money, creates at least three major sources of inequity:

  1. The services are only for the well-insured. Entire groups of poorly-insured people are excluded. The services offered by these special centers may be highly-profitable, but only if they get paid. They don’t make money providing care to poor or uninsured or underinsured people. 
  2. The services offered are those that are highly profitable, and most often this is for particular procedures. Yes, cancer is bad. So is heart disease. But the real reason for these centers is that these conditions are very well reimbursed by insurers, so the hospitals (and doctors) make a lot of money (provided the patients meet criterion #1, of course). For example, while chemotherapy drugs are ridiculously expensive, of course, making money for the pharmaceutical industry, the hospital makes money on the “administration fees” which are far in excess of the actual cost of administration. In addition, the creation of new “centers” are often driven by a single procedure. No one had big “Neuroscience” centers until the procedure for inserting a catheter into a brain artery to pull out a clot was developed. THAT is reimbursed incredibly well! All of a sudden every big hospital needed a “Stroke Center” and started competing (and paying a lot of money for) “stroke doctors” (who might be neurologists, neurosurgeons, or invasive radiologists) who could do this procedure. But poorly reimbursed services? No matter how much the people need them, don’t expect lots of new centers for primary care. Or mental health. Or even general surgery. Essentially, we discriminate not only against those who are poor or uninsured, we discriminate against those who are unlucky enough to have poorly-reimbursed diseases!
  3. The third great inequity is obviously geographic. If you live in a major metropolitan area, and are well-insured, you can have your choice of which hospital is the best for your problem. You consult US News, ask your friends, read the ads. But if you are in a small town or rural area far from such a city, it’s a long trip. And not worth making if you don’t have the money.

What can and should we do? In the long term, we need to eliminate the motivation of hospitals to compete for profitable services by putting them on a global budget, which is what is done in Canada as part of their single-payer health care system, called (interestingly) Medicare. And, of course, we need to cover everyone so there are no people left out because they are poor and uninsured, a universal health insurance system, not “cover more” but “cover everybody”. And by long term, I mean as soon as possible.

In the mid-term, we must change policies to much less dramatically favor certain procedures at the expense of others. Pay more for mental health and primary care. Pay less for cancer drug administration and sucking clots out of brain arteries. Stop making it so much more profitable to do knee surgery than gall bladder surgery. The availability for any kind of procedure should be based on the need for it, not how well it is highly reimbursed. That is a totally backward motivation, and dangerous to our health. This can actually be done by federal policy simply by changing how (US) Medicare values and pays for services. Because Medicare is the largest payer, it sets the market rate. Private insurers may pay more, but it is always “multiples of Medicare”; the ratio of what is paid for one medical service relative to another is set by the federal government.

And while we’re at it, let’s eliminate the universal tax-breaks “non-profit” hospitals get for anything that they do, which are mostly things that will make them money! As evil in many other ways as for-profit hospitals are, they are at least required to pay taxes, and go to the capital markets for capital expansion. No donations to a hospital should be tax-deductible if they are going to be used for a money-making scheme. Again, in Canada capital budgets are separate from operating costs. A hospital is not motivated to increase its operating profit so it can expand and build, to better compete with others. It must apply for additional capital funds, which will only be available if they serve a health need.

In fact, this is something we can do in the near term. As citizens and donors, we can demand that the next opulent fund-raising gala for our local hospital is not for the purpose of expanding money-making services, but rather to expand those services to those who cannot currently access them. The money raised should be earmarked only for, say, providing cancer care at our great cancer center to uninsured people. That would be something for which tax-deductibility is justified.

It is outrageous that our health system in the US is structured to maximize money-making and not health. But as in so much else in our society, those making the money have a lot of it to use to exert their clout. It is going to take a massive national effort by the people to make the changes that we need to have.



Monday, August 17, 2020

How the left is losing the COVID “war”

Guest post by Edgar Blaustein.  Originally posted at

Can the left already be losing the political war regarding the COVID pandemic?

A look at the political impact of the current coronavirus crisis in the United States, the United Kingdom and France, and what it might portend for the left.

Hail to the chief! Pandemic as legitimization

Donald Trump’s, Boris Johnson’s and Emmanuel Macron’s rise to power share key similarities: lack of legitimacy, and, for Trump and Johnson, appeal to nationalist sentiments (MAGA, Brexit). Trump through lies, luck, and electoral math won the Presidency with less than a majority of voters. Johnson won through lies on Brexit (no hard borders, more money for health services). Macron won with less than a quarter of votes in the first electoral round. Nevertheless, the winner takes all systems in all three countries gave the victor complete control of the legislative and executive branches of their respective governments. Though lacking legitimacy, all three wanted to think of themselves, as great war leaders such as Churchill, Roosevelt or De Gaulle.

Unlike the World War II leaders, our modern day chiefs have had the leisure over the last several years to choose their wars. Trump’s initial attempts failed, as he was outmanoeuvred by Xi Jinping and Kim Jong-un. Trump and Pompeo sounded the drums of war with Iran, but Iran, notably through attacks on oil tankers and a Saudi refinery, stopped US escalation.

Johnson’s chosen enemy was the European Union, framed as a faceless foreign oppressor, trying to grind down the plucky English. But “getting Brexit done” ran up against barriers: no hard frontier” between the Ireland and Northern Ireland, and the impossibility of assuring economically vital free trade with Europe without membership in the European Union.

Macron’s struggle was against “recalcitrant” sectors that opposed his vision of the “modernisation” of France, clinging to “outdated” notions such as progressive taxation, unions, worker’s rights, public services, or a public retirement system. Macron had won most battles, but the ceaseless conflict — with the gilets jaunes, trade unions, students — had taken its toll, and at the end of 2019, Macron’s government was visibly suffering from wear and tear.

At the end of 2019, all three leaders were in difficulty. And then came the coronavirus.

The birth of the war against a virus.

German President Frank-Walter Steinmeier said “This pandemic is not a war. It does not pit nations against nations, or soldiers against soldiers. Rather, it is a test of our humanity.”

And yet, the three leaders wound up framing their reaction to a health emergency as a war. But the path that led them to the war paradigm was far from direct. Indeed, in a first phase, all three initially downplayed the risk of the pandemic. In a second phase, they for a short while followed the “herd immunity” strategy, letting the infection run its course. And then in a third phase, all declared war on the coronavirus.

The three leaders hesitated, contradicted themselves, changed discourse, lied about the lack of personnel protective equipment, were contradictory on the subject of tests, all in frantic efforts to avoid assuming responsibility for massive unemployment and tens of thousands of unnecessary deaths. Trump’s “I take no responsibility” will certainly go down in history.

The three tried to frame their failures as responsible action to find balance between the health and economic impacts. As the double health and economic crisis deepened, they pivoted to “communicating”, a difficult task, since several countries — South Korea, Taiwan, New Zealand, Germany, Viet Nam, the Kerala state in India, among others — have demonstrated that rapid effective action on health, combined with a strong safety net for workers, leads to optimal economic as well as health results.

There appears to be no simple left/right divide that explains which countries have been most successful in meeting the crisis. Some rightist or extreme right governments — Poland, Germany, Austria, Australia or Japan — have done better in dealing with COVID, than the Social Democratic governments of Spain or Sweden. It does seem that women leaders, whatever their politics — New Zealand, Taiwan, Germany, Iceland, Finland — do better than men.

The countries that did not act rapidly have had to impose lockdowns, a blunt medieval pandemic control instrument that dates back to the time when humanity knew very little about the science of disease. Lockdowns are in no way progressive, although progressives must respect them when there is no better alternative, as in the case of our 3 countries.

The combined health and economic crisis in these three countries represents a severe threat to the legitimacy of their leaders. The depth of the crisis and the loss of legitimacy of the governments has led many leftists to imagine that we are on the brink of radical change, even the end of capitalism. The remainder of this article will argue that this is not the case, and that whatever our long term goals are, in the short term we should focus on more immediate achievable victories.

COVID is worse for the left than the subprime crash.

The 2007–2010 financial crisis was triggered by the collapse of Bear Stearns and Lehman Brothers, in the very heart of the capitalist financial system. The “shadow bankers”, who engineered the 1999 repeal of the Glass-Steagall Act walked away with hundreds of billions in profits made during the decade of the expanding bubble, while the general public paid for the crisis when the bubble burst. At the time of the subprime crisis, many people (author included) thought that the bankruptcy of the capitalist system had been made evident to the majority, and that the way was open for radical change. The crisis gave rise to the occupy movements, their European variants such as “indignados”, and in part to the Arab Spring and “Nuit debout”.

The actual results over the last decade were the opposite of radical progressive change. Economic inequality increased, the hold of bankers on public policy expanded, the influence of the right wing press increased. Authoritarian regimes have come to power over half the globe. Democracy, trade unions, free press … all declined. As Naomi Klein has argued (“The Shock Doctrine: The Rise of Disaster Capitalism”), capitalists are generally better equipped than progressive forces to take advantage of a major shock. Furthermore, the specific nature of the COVID crisis makes a radical change even less likely than was the case in 2008.

  • Capitalism did not cause COVID. Indeed, the modern capitalist system has contributed to the coronavirus pandemic, through globalisation-driven increases in travel, through accelerated exploitation of natural resources that increase interactions between wild animal populations and human activity, and through the neo-liberal sabotage of public health systems. Nevertheless, it is false, and harmful for progressive forces, to argue that capitalism caused COVID. Viruses, animal to human transmission, and long range trade all existed long before the emergence of capitalism.
  • COVID weakens intergenerational solidarity. The lockdowns strike most heavily on the finances of the youngest, whose professional and economic situation is often fragile. In contrast, older people, a majority of whom have a stable retirement income, suffer most from the health risk of the double crisis. This divide in material interests, coupled with the lack of close links between generations, has led to a political divide.
  • Weaken class solidarity. COVID divides workers by race, by class, and by type of work. The most obvious cleavage is between white collar workers who can telecommute, and essential blue collar workers who are exposed to sickness. Furthermore, since many of the essential workers are from minorities, this distinction is also of a racial nature: Black people are 4 times more likely to die than the general population in the UK, and 3 times more likely in the US.
  • Increase oppression of women. In normal times, many two income families “outsource” the principal domestic tasks: childcare, cooking, cleaning. This has ended under lockdown. Furthermore, with schools closed, home schooling is a new domestic task. It is no surprise that women have assumed a major share of this increased workload.
  • Physical distancing degrades the tissue of society. Staying 1 or 2 meters away from other people is a physical measure to prevent the spread of the corona virus. Breaking down social links is an unfortunate, and perhaps partially unavoidable, consequence. This frazzling of the tissue of society is harmful for progressives, since our main tools for collective action — demonstrations, public meetings, civil disobedience, strikes — are difficult or impossible for the moment. The rise of telecommuting will most likely make it even harder for unions to penetrate into tech related industries. Naomi Klein, in “How big tech plans to profit from the pandemic”, shows how the “tech bros” plans to make use of the crisis.
  • Justify the permanent surveillance State. “Test, trace, isolate”, while essential to fight COVID, nevertheless involve public intervention into the private lives of citizens. Successful programs in China, South Korea, Taiwan and Hong Kong all involved massive privacy intrusions. China, in particular, has woven the COVID tools into already existing, widespread programmes of surveillance of citizens lives. We can expect that these surveillance tools and powers will be used against progressives.
  • War on truth. Rightists have made a scale change in their war on truth. The chloroquine controversy, built on the basis of nothing, is just one example. Rightists no longer attempt to counter the truth, they simply bury it under a constantly growing pile of rumours, factoids and lies. Hannah Arendt, in “Lying in Politics: Reflections on The Pentagon Papers”, explains that the fog of lies aims to make both thinking and action impossible.
  • Democracy, pollution, climate. It is clear that different strands of progressive movements will have lost ground and lost momentum during the pandemic. For instance, President Donald Trump signed an executive order to ease up on businesses that make so called “good-faith” attempts to follow regulations during the coronavirus pandemic. This text will not detail the many other cases of using the crisis to weaken democracy, and to sabotage regulations on the environment.

It thus appears that the specific nature of the COVID crisis will leave the left in a weaker position than was the case after the subprime crisis.

We are not in a pre-revolutionary period

Six months ago, the UK, France and the United States were led by men who, even if they were stumbling, were strongly supported by at least a substantial minority that was enthused by their nationalistic, racist, xenophobic fear mongering. Certainly — as shown by Bernie Sanders, Jeremy Corbyn or Jean-Luc Mélanchon — there were also substantial minorities of mostly young people that give enthusiastic support to reformist candidates critical of capitalism. Nevertheless, the three radical reformists have all lost elections to more conservative politicians: Sanders lost to Biden, Corbyn to Johnson and then Keir Starmer, and Mélanchon to Macron and Le Pen. From these results, we conclude that the support for substantial reforms stems from perhaps 20% of the population, far from the overwhelming large majority that could be the basis for a mass movement for radical, post capitalist change.

The COVID crisis paradoxically weakened the political support for the three Presidents, while at the same time — for reasons outlined above — weakening the tactical capacity for action by the anti-capitalist left. In this context, the killing of George Floyd and the BLM and related movements swept across all three countries. From the point of view of the author, the BLM movements are radical in character, but reformist in their demands, mostly seeking limited reforms of a democratic nature: the right for people of color to live without fear of being harassed, beaten or killed by police. The achievements of the ’60s civil rights movement shows that this and related BLM demands are hugely important, and nevertheless achievable within the current political and economic system.

Since the end of decolonisation and the wars in South East Asia almost half a century ago, the left, with the exception of victories on women’s and LGBTQ rights, has lost more struggles than it has won. Today, over half of our planet’s inhabitants live in countries controlled by different types of authoritarian, xenophobic and racist regimes.

The left desperately needs short term victories to reverse the drift towards authoritarianism. While the current situation is not in general favourable for progressives, the specific nature of the COVID crisis in the three countries could lead to victories on specific objectives, such as the following.

  • Rebuild public health systems, and public hospitals.
  • Universal health care. Millions of Americans lost their health care when they lost their jobs. The spread of the virus in poor communities shows that health care must include undocumented workers and families.
  • Vastly increase international cooperation on preventive health issues. We cannot avoid a future pandemic unless all countries, even the poorest, have the capacity to rapidly identify and isolate new diseases. We need a strengthened WHO. Even the most closed minded of capitalists can understand that spending a few tens of billions per year to build up world health systems would cost much less than the next pandemic.
  • Increase protection of workers in times of unemployment, both through financial support, and effective retraining to allow workers to adjust to inevitable economic change. Again, a portion of capitalists would support such action.

The BLM movements show support exists for another category of actions, focusing on policing, and more broadly on systemic racism. Two types of measures should be within our reach:

  • Measures to limit police violence in poor communities, such as always-on body cams, new rules for use of firearms, end of choke holds, effective surveillance of deaths of people in police custody, some kind of control on abusive stop and frisk, or transferring some police functions to unarmed civilians. These measures broadly correspond to the slogan “defund police”.
  • Measures to reduce discrimination against minorities in employment and in the media. The actions of several large enterprises (for instance in the Facebook boycott) show that large parts of the capitalist class will support some measures.

Three other measures might be within reach.

  • a guaranteed of a job or of a basic income. This would be cheaper than the current hodgepodge of measures, and would be a more effective countercyclical Keynesian economic shock absorber. Unfortunately, opposition might come as much from some workers as from capitalists.
  • deepening of democracy, or at the least limiting of corruption.
  • perhaps a more progressive tax system. Possibly a one time special COVID wealth tax on multi-billionaires, to repay the public borrowing during COVID. Spain may create such a a wealth tax. Perhaps some kind of reparations for slavery.

We should use the opportunity of the weakness of our rulers to fight for significant and achievable short term goals. We need victories to strengthen progressive movements, to improve our capacity to win future battles. We must at the same time keep in mind our long term goals, and use the experience we gain in short term struggles to develop common ideas on our vision for the future, our strategies, our alliances, our tools and modes of action.

This text benefited from the generous help of Robert van Buskirk and Jérôme Santolini, who kindly contributed, even though they disagree with major portions of the text.

Sunday, August 2, 2020

Institutionalized racism and violence and the impact on people's health

I recently wrote about the confluence of the COVID-19 pandemic and its greatly disproportionate impact upon poor and minority communities, and the increasing awareness of the overall oppression of minority communities that has come to a head in the aftermath of the murder of George Floyd by the police in Minneapolis, along with the huge protests (and police repression of those protests) around the country (‘Structural racism, structural violence and COVID-19: We must fight both epidemics’). This incredibly important and deserves not only further discussion here but ceaseless discussion in all venues until the US really changes.

Minority communities in the US (and for the rest of this piece, “in the US” will be implicit) have always suffered a much great burden of chronic disease, much more limited treatment options, and worse health outcomes. It is not new with COVID-19. In addition, minorities have always suffered more police brutality, more incarceration and involvement in the criminal “justice” system, and more violent death. We live in a nation and a society that was built upon and perpetuates not just racist bias but a structure in which repression of minority people, especially people of color, and most especially African-Americans, is an intrinsic component. Police violence against Black people is not (solely) a result of the individual racism of the police officers inflicting it; it is the purposeful enforcement mechanism of institutional racism, which has always existed in the US: slavery, Jim Crow, mass incarceration. The White-run police state in apartheid South Africa was odious and obvious, and most Americans correctly identified its purpose, but our own similar structures seem to have been harder for many to see. This is partly because they have been less clearly stated in law (for at least a few decades), and in part because in South Africa, Whites are a small minority whereas here they are the majority (so far). But, if perhaps less obvious and to some degree less severely violent, our own society has always had racism built into its fabric.

Facts that must be acknowledged: Black people are victims of police violence, and are killed by police way out of proportion to their percentage of the population. Black men are involved in the “criminal justice” system at, at least, 3x the rate of White men. Black families have a net wealth of about 10% of White families. For years, decades, centuries, official policies, laws and de facto practices have relegated Black people to the back of the line, kept them from good jobs, housing, and education. Black men, even if they have money, or are doctors, or are off-duty police officers, are more likely to be stopped, harassed, arrested, injured or killed.[1]

Racism can take many forms; Dr. Camara Jones, a professor at the Morehouse School of Medicine and former President of the American Public Health Association (APHA), describes three broad types: institutionalized (which is what I am mainly discussing here), personalized (that expressed by individuals toward others), and internalized (the “self-hate” that victims of racism may begin to believe about themselves, in part at least)[2]. They are all important, and all affect the health of the victims, and all need to be addressed. We have increasingly seen campaigns aimed at raising (White) people’s awareness of unconscious (as well as conscious) bias.  This is good, and important, but our analysis needs to go far beyond the idea of individual bias, and understand WHY people have grown up with and maintain such bias.

The US was built upon the free labor provided by chattel slavery of African-Americans. Many of our “Founding Fathers” (e.g., Washington, Jefferson, Madison) were not only slaveholders, but plantation owners with huge numbers of slaves. Thomas Jefferson’s “agrarian ideal”, that our nation would be best off if its people were farmers, was either ironic or hypocritical; it was not Jefferson but his slaves who did the farming at Monticello. Compromises with slaveowners led to a Constitution whose flaws are now obvious; that each state has two senators, regardless of population, was intended to help the South. Thus today small states are overrepresented in the Electoral College (e.g., Wyoming has one congressional district and thus 3 electors, 5.5% of California’s 55, but its entire population is less than any of California’s 53 congressional districts). Indeed, the South wanted to count each slave as a person for the sake of the census, although they had no intention of letting them vote; the ‘3/5’ rule was a compromise. Of course, today it is the “conservatives”(really, racists) who say no to counting everyone, especially undocumented immigrants (a category that did not exist at the time of the Constitution).

The “race” (pardon the pun) is fixed; we do not all start from the same place; Blacks start with one hand tied behind their back (or one leg shackled?). It is not just in health or in police violence; the story of government-sponsored racism in housing is amazing and scary (as portrayed in this video). What is amazing is how persistent this has been.  On the death of John Lewis, a true American hero, some have discussed the role that the violence perpetrated by police on nonviolent protestors in Selma, AL, had on helping push the Voting Rights Act of 1965 into law. Signing it, President Johnson noted that it had been over a century since the Emancipation Proclamation, but that in the South many Blacks still could not vote. Today, in 2020, it is more than half again as long and in the US – not only in the South – strategies continue to be implemented to keep minorities from voting.

The negative impact of our racist infrastructure on the health of minority people is tremendous. Woolf and colleagues estimated that in the decade 1991-2000, all medical advances averted 176,000 death, but if African-Americans had the same death rate as Whites, over 686,000 deaths would have been averted![3] Park and colleagues demonstrated that Leukocyte Telomere Length, a marker of cellular aging indicating cumulative biologic stress, which equates to shorter lives, is indeed shorter in those who perceive the neighborhood they live in as poor quality, compared to those who perceived their neighborhoods as good quality.[4]

Our medical schools, on the front lines of training new physicians, rarely overtly address the pervasive, not occasional or individually-mediated, racism of our health care system. We still train students to start presentations including race (and gender) -- “A 53-year old Black male” – although in the US “race” is a social construct and the genetic variation within any “racial group” is far greater than that between different groups. A recent article in the New England Journal of Medicine by medical student LaShrya Nolen uses the metaphor of the bulls-eye lesion of erythema migrans that characterizes early Lyme disease – in people with white skin. Because it is not as obvious in people with dark skin, the diagnosis is made later and complications are more common. She observes that we are “missing the bulls-eye” in addressing systemic racism in medical education.[5] In a New York Times Op-Ed, “Medical Schools Have Historically Been Wrong on Race” Dr. Damon Tweedy comments on the pervasive racism in patient care and education of physicians that is current as well as historical.

If we are to approach a system where there is truly health equity, we need to work simultaneously on many fronts. The health care delivery system, and its educational components, need to restructure from the ground up. Much more significantly, we need to address the Social Determinants of Health: access to safe housing, enough food, good jobs? Opportunity for a good education, not tied to the income of one’s parents through local school funding; all the things that make health worse and telomeres and lives shorter. We need to dismantle the police state that addresses protests against police brutality with more police brutality; to recognize that the police do not protect everyone equally, but primarily have the role of repression in some of our communities, and stop incarcerating such a high percent of Black males.

We are in a war for the soul of our nation. Will the racism of our history continue to dominate the reality of our lives, and continue to create and maintain inequity and poor health and death, or will we, finally, more than 150 years after the Emancipation Proclamation, really begin to address structural racism and its impact upon our health?


[1] Derrick CB, “Sirens: 4 decades of harassment by the police”, Guernica, July 27, 2020

[2] Jones CP, “Levels of Racism: A Theoretic Framework and a Gardener’s Tale”, Am J Public Health. 2000;90:1212–1215.

[3] Woolf SH, Johnson RE,Fryer GE, Rust G, Satcher D, ‘The Health Impact of Resolving Racial Disparities: An Analysis

of US Mortality Data’,  American Journal of Public Health | December 2004, Vol 94, No. 12,2078-81.

[5] Nolen, L, “How medical education is missing the bulls-eye”, N Engl J Med 382;26 June 25, 2020


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