Racism is making us sick. How can equity in medicine help us heal? A community conversation with Sahan Journal.

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The most powerful theme so far in the ongoing murder trial of former police officer Derek Chauvin is trauma. 

Last week, three teenagers and one nine-year-old testified in the trial as witnesses to George Floyd’s death, and the angst they felt about being unable to intervene and protect him. This type of trauma may live with them for the rest of their lives.

Sahan Journal’s panel discussion this week centers on how structural racism plays a role in health outcomes for people of color. We spoke with three medical professionals about their personal responses to pervasive graphic images like the video of Floyd’s death. They shared their experiences about opening up discussions with their patients on how structural racism affects them. And they spoke incisively about why the medical field is moving too slowly in the direction of health equity. 

Our panelists are,

Ramla Kasozi, MD, MPH, a third-year resident at the University of Minnesota in family medicine. Having lived in Uganda, Canada, and the United States, Dr. Kasozi has embraced advocacy work. She also conducts research to examine racism in medical education and as a cause of health inequities. She has presented her work in several conferences, podcasts, and social media platforms. Dr. Kasozi helped lead a petition last summer to push the dean of the University of Minnesota Medical School to take action against systemic racism.

Bryan Leyva, MD, a third-year resident at the University of Minnesota in pediatrics and internal medicine. Leyva has been published in prominent journals like The New England Journal of Medicine, JAMA, Ethnicity & Disease, and Journal of Healthcare for the Poor and Underserved. He is active in advocacy against systemic racism in health care. 

J’Mag Karbeah, MPH. A fourth-year Ph.D. candidate in the Health Services Research Policy and Administration program at the University of Minnesota. Karbeah works in the Center for Antiracism Research for Health Equity and the MORHE lab under Dr. Rachel Hardeman. There she studies police brutality as a form of structural racism and its impact on adolescent health outcomes.

The following conversation has been edited for length and clarity. 

We all saw the viral video of Floyd. It was a very graphic video. What kind of impact does that have on peoples’ mental health?

Ramla Kasozi: Individuals who identify as Black, Idigenous, and people of color, we’ve just been traumatized on a daily basis. Personally, I felt that when you reach a tipping point, you’re just exhausted and don’t know how to respond anymore. For me personally, there was a point where I just became numb. Because how much more of this can I take? And realizing that I’m a physician, and I’m trying to also function at work and take care of my patients. 

I think for white individuals, it’s really hard for them to understand what we go through mentally. How it takes so much energy for us just to even function when you’re seeing daily trauma. When I think of my mental health, that time was really unsteady. And when I started speaking to other people, they felt the same thing. There were many reactions that I thought were very valid. There was anger, there was frustration, there was just literally paralyzation and feeling numb.

J’Mag Karbeah: We started 2020 with a very traumatic murder of another unarmed Black man, Ahmaud Arbery in Georgia. He was killed not by law enforcement but by white men who thought he was suspicious.

Then we had the pandemic start, and we know that Black and brown communities were hit hardest. For a second, we were all so busy adjusting to the new reality of living in this pandemic world. And then to be hit with this again, this very unfortunate reminder that even when the world is changing irreparably around us, we’re still Black and brown. Despite whatever is going on in the world, being Black and being seen as a threat is still something you have to worry about. 

It’s not only, “I have to make sure I have my keys and my mask,” or “I’m working from home and that’s very difficult.” It’s also, “When I go outside, will I be killed by law enforcement?” I think the mental strain of that is quite a lot to deal with, and we don’t talk enough about that. 

Bryan Leyva: We know not only community violence but also other kinds of trauma—earthquakes, for example—have impacts on peoples’ wellbeing and mental health, even if they’re not directly involved in the incident. I did some work in Boston looking at the mental health impacts of the 2010 earthquake in Haiti. Even people in Boston were having increases in anxiety, depression, and feeling angst as a result of the earthquake.

When we look at community violence, particularly those that are racial in nature, we have to understand these events impact everyone in the community. Some of those effects are passed down from generation to generation and result in increased perceptions of untrustworthiness of institutions. It even changes the life course of a person. 

I remember one patient, a teenage boy, originally wanted to be a police officer. But after what happened with George Floyd, he said, “I don’t think I want to do that anymore.”

So we’re seeing how events like this can change a person’s life. The effects of one kind of incident like this has repercussions for years to come, especially if there’s a lack of justice involved in the case. 

Since George Floyd’s death, have your patients been more willing to discuss how these issues impact them?

Kasozi: My Black and brown patients would talk about it even before George Floyd. Maybe it’s because they see me as a Black physician. They know, “She understands my experiences and why I might be hesitant with the health system.” 

Most of my clinic visits during that time of George Floyd was just talking about George Floyd. And rightly so, because people were just trying to grapple with, “How is this still happening?” 

But with my white patients, I’ll have to admit, I can’t seem to remember one single white patient talk about George Floyd. Instead what I would hear, sadly, “Why are they rioting? They’re looting the streets, they’re destroying the area.” 

It just took me aback because it’s just a different narrative. Even from colleagues, people who I work with. What was so disheartening is that my fellow white colleagues just talked about the lake house. “Oh, what are you doing this weekend?” And I’m like, “A black man just died, and there’s just no conversation.” People thought it was just a normal business day and didn’t want to talk about it.

I reached a point where I was just like, “No, you cannot ignore this.” And it was unfortunate because the burden was upon me to bring it up.

Leyva: I actually try to normalize the conversation with my patients. Usually when a patient comes in, I’ll ask, “How are you how are you doing?” Then most patients will say, “I’m OK.” And then I’ll say, “Wow, I’m very surprised you are doing okay, given the event that just took place, given the COVID pandemic.” 

As soon as I normalize the fact that it is OK not to be OK, people disclose to me how they are actually feeling.

I try to create my patient encounters in a way where there is room for that. Sometimes when doing primary care, we feel that there’s so many things we have to get done in that one visit that this takes the backburner. 

On the institutional level, are we seeing more change or a greater push for racial equity in health care?

Kasozi: After George Floyd, there was energy, there was the will, there was the want, even in my program. But then, for some reason, I feel like things kind of faded. There was the creation of a diversity, equity, inclusion office. There’ve been so many task forces. But I find that the work is now under the timetable of mostly white people. 

They are sort of in their journey of trying to understand this whole situation, where I found myself and other Back and brown individuals that we’re already saying, this exists! There’s no need to contemplate and reflect: We need action now. 

I struggle with it right now, whether or not we’re moving forward. We’re kind of moving, but I feel like it’s at such a slow pace that’s only comfortable for whiteness, but not necessarily comfortable for what we see. I think what a lot of white individuals are struggling with is probably trying to give up that power, because they have to realize there’s an element where they need to give back. 

I think a lot of them don’t realize through trying to address racism in medicine, you really have to reflect upon yourself. The power you have, the power that allows you to get in that position, and then acknowledge that maybe I need to use my power to step back and allow somebody of color to come through. I think a lot of people are not allowing that to happen. 

I feel some of the innovation that’s needed in our training is white individuals or, even more, predominantly white institutions acknowledging that they need to step back. When you call them out, you are vilified. You lose your job. I don’t know if institutions are ready yet, because they still want to hold on to that power. So I’m a bit hesitant to feel like things are moving in the right direction. But that’s just my perspective, based on what I’ve seen. 

Karbeah: I’m working in public health, and being adjacent to medicine, I think the problem is twofold. As a country, we came to this moment of racial reckoning under false pretenses. It’s been very comfortable for institutions to say, “Policing is the problem.” 

In June of last year, I saw some medical students at a protest with a sign that said something along the lines of “What if doctors treated black people the way that the police treat Black people?” Which is an interesting and thought-provoking statement. But if you talk to Black patients, a lot of them would say, I already feel like I’m treated similarly by physicians. I already feel equally unsafe with a medical institution. 

Especially when you talk to Black women who are alarmingly aware of the fact that they are three to four times more likely to die due to pregnancy-related complications, or if you talk to any Black person that knows what the mortality gap in our country is, and how Black patients often report not receiving the same quality of care from white providers.

There’s this huge disconnect that institutions still have to reckon with: The idea that racism isn’t blood in the water, racism is the water. This is not an isolated incident. It is good to be vocal against the criminal legal system and its injustices against Black and brown communities. But you should also turn inward and really analyze how your institution is equally complicit. 

That’s the piece that’s really missing about medical education. This reluctance to acknowledge the harms that we’ve caused within our own institutions. It’s really easy and really comfortable to say, “Hey, we’re committed to antiracism, because we see how bad it is out there.” 

Myself and some colleagues wrote a piece about how a lot in the Twin Cities organizations like Allina, M Health Fairview, and everyone else put out these statements about how horrible the George Floyd incident was. ut they didn’t say how are these same systems of anti-blackness and white supremacy reflected within our organizations?

That’s where it gets sticky, and I think that is the future we need and that is the leadership that creates this alternate future that we want. It has to be people in positions of power who are willing to say, “I’m not just handing the mic off momentarily. I need to give what I have towards this better future that I say I’m committed to.”

Leyva: When we think about fun activism, it’s so easy to look externally. To say blanket statements like Black Lives Matter, but then to not specifically say what you mean. We see this a lot of times when people say, “Black Lives Matter, but I don’t believe in defunding the police.” 

Like, what do you mean by that? By acknowledging that there’s police brutality, by acknowledging mass incarceration, by listening to Black people, we say we know how critical it is to invest in community resources. We know how dysfunctional our police system is right. 

And so, yes, it might mean that your uncle who’s a cop might lose their job. And it’s not because we want him to be unemployed but because we think that the system in which he works is harmful to Black people, as a community, as a population. I think a lot of times it’s very easy to join in on a movement without really understanding what that really entails.

I also think we absolutely as an institution need to look inward. Am I happy with some of the changes that are happening at the University of Minnesota? Absolutely. Do I think we’re moving too slow? A hundred percent. Would I like there to be more rapid progress? A hundred percent. Do I think we need to make space for leaders who represent the community? A hundred percent. 

Part of that work involves giving spaces to Black and brown people. Hiring them, getting more Black and brown and indigenous medical students into your medical schools. Promoting Black and brown people in the faculty. It isn’t enough just to state, “Black Lives Matter.” You really have to move out of the way and give space for these individuals.

What we’re seeing, too, is institutions, denying that this is even real. We have JAMA, an established medical journal, releasing podcasts that structural racism isn’t real. Gaslighting the experience of an entire population of people, denying the history of the United States. That is what we’re up against. 

There are well-meaning efforts. But there are also efforts that to me feel outwardly aggressive and destructive, and are entirely self-serving. There’s certainly this incremental push, and I think initially there was a lot of energy. I want that same energy back, and it needs to be sustainable, and people of color need to be leading that effort.

What does it take to bring that energy back? 

Karbeah: The creation of institutions like the Center for Antiracism Research for Health Equity. That is something that, through the gift that Blue Cross Blue Shield, made for the development of that center, says in order to keep this momentum going, we understand that this requires financial investment. And going back to the difficult part of addressing structural racism: The energy is needed. Committing to leadership by people of color by people who are from these communities means one thing, supporting this community-engaged work, I think is really important. The National Institutes for Health is releasing a request for proposals about studying structural racism, but for an institution that has historically underfunded proposals like this, how does it think it’s now situated to make this transition to fund this work in a way that’s antiracist? 

And the answer is, it can’t be if it’s the same people who did the last round of grant funding. So, we keep the momentum going by bringing in people of color but I think a huge part of this work is—as we say in our national conversations, if you want Black women to save you, you have to pay Black women. We need to make these solid investments for the future that we want to see. That means funding more Black researchers and putting more Black people in leadership positions.

Leyva: Part of it, too is, we need to get out of our academic bubble. I actually used to work at a funding agency. I worked at the NIH and then the National Cancer Institute and I helped to draft funding announcements. This is before working in academia, I was a health services and public health researcher. You can study it all you want, but is that trickling down to the people who racism most affects? 

Even right now in this reckoning on race, even in my own clinic where services are predominantly Black and Asian populations, providers tell me they don’t feel equipped to have conversations about race with their patients. My own supervisors say this. There is this disconnect about what we know in the academic literature and what people know in real life. 

What providers know in real life and how they can utilize and mobilize their knowledge to have encounters that help to address these issues. That help to combat the disparities that people of color are experiencing as a result of events like what happened to George Floyd. It’s not just research, but we need investments and infrastructure. This has become apparent through the COVID vaccine rollout.

Kasozi: A few weeks ago, there was a really great conference called diversity in medicine, and there was one speaker. Dr. Feranmi Okanlami, who mentioned if you really want to look at the commitment of diversity, equity and inclusion, or antiracist work in an institution, look at their budget. See how much has been invested.

What I’ve also called to task, just within the University of Minnesota and Graduate Medical Education and whatnot, is understanding how much public money is really going into this work. And it isn’t really a priority. When it comes to something like this, I feel the funding and space is not there. At the end of the day, a lot of institutions will put energy where there’s money. 

Or sometimes they like to do it because it’s a new fad and people wanted to kind of just do a hashtag so they look like they were part of it. Those are the things I think we need to be mindful of. Is there funding? Are there resources? 

This story is the third in our series of community conversations, occasioned by the trial of former Minneapolis police officer Derek Chauvin. In our previous panels, we asked “Who gets to decide if Derek Chauvin is guilty of murder? And who belongs on a jury of his peers?” and “What would ‘Justice for George Floyd’ actually look like?”