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Eric J. Topol, MD: Hello. I'm Eric Topol, here with Abraham Verghese, and this is a new edition of the Medicine and the Machine podcast. We are especially delighted to welcome Dr Uché Blackstock, who is joining us today with a lot of perspective on the pandemic, structural racism, and medicine. Welcome, Uché.
Uché A. Blackstock, MD: Thank you so much for having me.
Topol: It's a delight. I want to start things off with your background. Could you tell us a bit about your parents and the beginning of how you got started in medicine?
Blackstock: I am a second-generation physician. My mother was the original Dr Blackstock, but she grew up in very different circumstances than I did. She grew up here in Brooklyn, where I'm currently located, but she grew up in poverty with a single mother. She really didn't have any role models, but she had a love of science and a love of community service. She went to college and ended up with a chemistry professor who encouraged her to apply to medical school. That was something that she had never thought about.
She applied and was accepted into all of her medical schools, and ended up matriculating at Harvard Medical School. Obviously, that was a huge deal for her. After Harvard, she came back to New York City and practiced in the same neighborhood where she grew up. She was an incredible role model for my twin sister, Oni, who's also a physician, and myself, especially in terms of thinking about the work that we do — feeling passionately about it but also about giving back.
Obviously, she was my influence, and my mom, Oni, and I were the first Black mother-daughter legacy from Harvard Medical School, which I think is a testament to my mother's hard work.
Abraham Verghese, MD: Wow, amazing.
Topol: That is amazing. Is your mother still alive?
Blackstock: No. That didn't make it into the Lancet profile, but our mom died from acute myelogenous leukemia at the age of 47. We were only 19 years old. She was an avid runner, and we had run a race the summer before in Central Park. Even at 47, our mom would come in before us in these road races, even though we were 19 years old. She just slowed down and we said, "Mom, are you okay?" A few months later, she was diagnosed.
Topol: Oh my gosh. She had to be enormously proud of you and your sister. That's phenomenal.
Blackstock: Yes, and at the time, she knew we were premed and our plan was to go to medical school. So, when she died, she did know that that was in the future.
Topol: Is your sister also in emergency medicine?
Blackstock: No, my sister is a primary care physician. She did an HIV fellowship and, as of recently, she is the assistant commissioner for the Bureau of HIV here in New York City with the Department of Public Health.
Verghese: Amazing story, truly.
Topol: It really is. You worked 10 years at New York University (NYU) in emergency medicine, right?
Blackstock: Yes, I was 10 years at NYU. I did work around emergency ultrasound and a lot of medical education work. Then I transitioned into diversity and inclusion work, which was really my passion — thinking about how to create environments that can support a diverse workforce in medicine, because we know that's very important to addressing the inequities that we have in care.
Topol: Then you had this really bold move that you were going to leave academic medicine, and you found a new entity, Advancing Health Equity. What was going on in your mind at that time?
Blackstock: I thought, How do I do the work that is authentic to me, and how do I do it in a way where I can be bold and brave? Because these are issues that truly need to be addressed. I had just been promoted to associate professor and people were looking at me like I was crazy. "What? You're leaving this to start your own organization?" And I said, "I just feel like this is the time that organizations are going to be more open to doing this work." I would have never imagined the events of the past few months, but it just showed me that the decision I made was a correct one for me. And much needed.
Experiencing the Pandemic in NYC
Verghese: And yet, you continued to work in emergency medicine and urgent care while doing this, and happened to be at the epicenter of the New York epidemic. Talk a little bit about how that first manifested for you.
Blackstock: It was interesting, because when I left emergency medicine in December to work in urgent care, I thought it would be a little bit slower so I could focus on my organization. I didn't realize that I would essentially be seeing the walking wounded of the pandemic in urgent care. I saw some very, very sick patients. I sent a number of patients to the emergency department. Someone actually walked into urgent care with an oxygen saturation of 64% — that was the lowest one I saw.
It was a very difficult experience, seeing that level of human suffering. And at the time, we were limited. Initially, we couldn't test everybody, and so I was having to have that conversation with patients about why I couldn't test them. We were limited to two tests over a 12-hour shift, so I had to choose two patients to test. I felt like I was letting them down.
Verghese: I think you made the observation then that it was very likely that people with more affluence, with more agency, and with more willingness to push were probably getting tested much more often than the frontline workers, like the bus drivers who really needed to be tested and get back to work.
Blackstock: Yes. I noticed at the beginning that with the criteria we were using, you had to have visited one of the countries in which coronavirus was endemic. That wasn't typical of the patients I was caring for. The ones that were essential workers and service workers hadn't traveled out of central Brooklyn, yet we found out that they were still being infected.
Minorities Bear the Brunt of the Pandemic
Topol: It's been so striking that those who have borne the brunt of this pandemic have been the underrepresented minorities — Blacks, Hispanics, the indigenous — and it actually even took a while for that to be recognized. The Centers for Disease Control and Prevention (CDC) wasn't on top of it. Can you give us your view as to what's going on here?
Blackstock: The CDC put out a piece recently showing that about 80% of the children who had died from coronavirus in this one study were Black, Latinx, or indigenous. In March, when I first started seeing coronavirus patients and I noticed this rapid shift in the composition of patients I was caring for, something went off in my mind and I said, "This is going to be very bad for our communities."
I knew that Black and Latinx communities carry a higher burden of chronic disease. We know that diabetes, high blood pressure, asthma, and obesity are more common, and we know that's for reasons connected to social determinants of health. There's nothing biological about that. That's because of environment. But also, there were all of these other factors — like living in overcrowded housing, being more likely to take public transportation, being more likely to have jobs where you are essentially on the front lines of the pandemic and always interacting with the public — that also place these communities more at risk.
Of course, we saw that borne out in the numbers that we've seen so far. And what's interesting is that even for the month of August, the mortality rates associated with the pandemic actually went up for Black and Latinx communities. We're 6 months in but are still not seeing any action by this administration to focus and address these inequities.
Topol: Wow. So striking. You went over several of the reasons for this, but as you have pointed out, the pandemic in the United States exposed the miserable situation of the inequities. There are blatant inequities. This is the only developed country that doesn't provide healthcare for all. This was laid bare. Do you think this was predictable?
Blackstock: I absolutely think it was predictable. In recent years we've heard more about the Black maternal mortality crisis. We've seen that in the news and we've seen some Congress people take up legislation around that. We've seen some famous people like Serena Williams and Beyoncé talk about their own experiences of being pregnant and feeling like they were not listened to because they are Black women.
Black women are more likely to die around pregnancy in the United States than even women in Mexico, where a larger percentage of the population live in poverty. We're seeing these trends even across socioeconomic background and professional education. Even I, as a Black woman with a professional degree, am more likely to die around pregnancy than a White woman with an eighth-grade education.
When we see that data, we know that this is not just about socioeconomics. This is about the kind of environment that structural racism, through practices and policies, creates. And we know that your professional level of attainment doesn't protect you.
Time for Change
Verghese: I want to focus on your leaving academia. I think many people in academia, well before this, have been trying to make efforts to bring about equity of both color and gender. But there's so much more work to do, and there's a new life infused into these efforts now because of COVID-19. What do you see as the common threads that keep all of us back from doing the best we can in this area?
Blackstock: I thought I would stay in academics for my career. I love the stimulating environment. I love working with trainees and I love learning from my colleagues. But I also recognized, over time, especially doing diversity and inclusion work, that sometimes institutions — because they've been the way they are for so long — are embedded with certain cultural aspects that make change very difficult.
When I was at my previous institution and I wanted to push the envelope, there was a lot of resistance. There was a lot of resistance to just speaking the truth and saying, "This is what's going on; how are we going to address it?" Or "This is how our Black students are feeling. This police killing happened, but no one's talking about it in school, and they have to go in the wards and take care of patients."
What I think organizations can do better is to have leadership that cares deeply about these issues, and to see how not addressing these issues divides us. And how even within medicine, it compromises the care that we provide to our patients. It trickles down from institutional leadership to the care we provide to patient outcomes. It's all interconnected, and I think once institutions realize that and really appreciate that, then we can talk about what change looks like. It's embedding change in your strategic plan and not just giving one person, like a chief diversity officer, the complete responsibility for doing all of the work. That work should rest on the shoulders of every person in leadership in that organization.
Topol: There is a paucity of activism among physicians. As I mentioned earlier, it was pretty bold for you to say, "I'm going to go out and do this." When did you make that decision, and what was going on in your mind at that time?
Blackstock: I was involved with TIME'S UP Healthcare, which is a branch of TIME'S UP, to address gender equity and sexual harassment in healthcare. And I found out that my involvement in the organization was a problem for my institution. They thought it was political. I said, "I can't imagine being in an environment where I'm doing this important work that everyone should care deeply about and you're saying it's political. That being treated like a human being is political."
That really rubbed me the wrong way. And there was also a fear around speaking out. There was a fear from faculty and students that you couldn't really talk about what you were experiencing. I think a lot of institutions have that culture of fear. People in leadership may not realize that, but it's there.
I thought that maybe I could do this work from the outside. And so I've partnered with all different types of healthcare-related organizations — not just medical schools but departments of health and healthcare startups — that are thinking about racism and how we've almost let these inequities exist without even actively addressing them. We're letting people die. So I do keynote talks, facilitate trainings, give recommendations, and do consulting services and organizational assessments around racial equity and health equity. I was recently involved in a CEO search to help an organization choose a CEO who would prioritize this kind of work. It's really exciting.
Topol: Yes, no question.
Verghese: Clearly, if we wanted to bring about change, I think people have to see leaders who are of the color or the gender embodying the diversity. Your mother and you had this remarkable journey to Harvard Medical School. I had a chance to chat with the dean of Morehouse at one point, also a Harvard grad. It was an incredible story. She's concentrating her efforts on early middle school and before, because we're losing folks in that pipeline — narrow as it is, shrinking as it is — well before high school and college. What are your thoughts? How do we meaningfully increase the Black physician workforce?
Blackstock: It's interesting that you bring that up. I was speaking to an older Black woman physician earlier today just about this issue, and we were saying that the pipeline has to start as early as possible, even kindergarten and first grade, because to address the lack of Black physicians in the workforce, it's not just about medical school. You have to get to students before medical school. But the problem is, we have an educational system in this country that's overall very underfunded, and we see the results of that. It's very segregated as well. I think we're going to have to see public-private partnerships come together, where we are exposing students to what physicians and other healthcare professionals look like very early in their education, and also giving them resources, tutoring, and mentoring from kindergarten all the way up. High school is too late. College is too late.
Is Now the Time That Racial Injustices Can Be Changed?
Topol: The systemic part of this is important to emphasize, because when you think about this pandemic, it was unprecedented 101 years ago. And then you see how the racial injustice story has played out. We haven't seen anything like this since the 1960s, even though it's been smoldering and continual all this time. Do you think that this is the time that we could finally make a difference? Are you optimistic about this?
Blackstock: I hope so. Honestly, I've been saying, if not now, then when?
Topol: Right. This runs so deep. You've touched on a few things, and Abraham brought up the need to start at the earliest time. But we need a systematic strategy that has never been launched. You have a lot of great ideas for this. What are some of the things, beyond what you're capable of, that we should be doing on the grand scale?
Blackstock: In June, I testified in front of the US House Select Subcommittee on the Coronavirus Crisis on the racial health inequities, and as part of it, I had to give some recommendations. My recommendations weren't just about the short term, in terms of targeted testing and personal protective equipment (PPE) for our communities; it was long term, thinking about how to invest in communities that have been disinvested in for centuries.
We know that a lot of the disinvestment is related to home ownership, so it's even thinking about how we can encourage opportunities for home ownership and opportunities for employment. If we're talking about this moment right now, I think it's a great moment to talk about reparations for Black communities, because I feel like we got into this situation because of practices and policies coming out of the New Deal, like redlining.
Redlining is this process where you graded neighborhoods based on who lived there, and the grading reflected your ability to receive a federally funded mortgage. What we've seen over time is that those redlined neighborhoods that received the lowest ratings correlate today with the neighborhoods that have the most severe and profound health inequities. We know that's all linked, so we need policy to get us out of this situation. I think policy that addresses the social determinants of health will be incredibly helpful for our communities.
Topol: One of the things that strikes me, Uché, is the fact that we don't have universal healthcare, but at the same time we're putting trillions of dollars into this Paycheck Protection Program. I have no idea where it's going and there are all these call-outs of, "We don't have funds to do this." We could have funded decades worth of care for everyone with the amount of money that's being wasted in this pandemic rescue, right?
Blackstock: Absolutely. I also think that this moment is the time to talk about what single-payer universal healthcare would look like. At the very least, we should have that for this country. I think it's inexcusable that we have people who don't have insurance, and we know that directly impacts the health of communities. And that leads, down the road, to spending more money on care. It doesn't make sense.
New York Recovery
Verghese: How is New York doing, in your view, in this sort of post-COVID-19, posttraumatic phase of recovery? I think you actually used "PTSD" to describe what it's like to come out of it.
Blackstock: I think we're all still shaken by it and I think that's why we've been able to keep our infection rates low. I think people are still understanding what we need to do to get out of this and that it requires collective effort. People are wearing their masks, we're practicing social distancing, we're doing what we need to do to keep those numbers down.
New Yorkers are very resilient and I think we're going to get through this. Obviously, it's going to take longer than we had hoped, but lessons were learned this spring. As we go into the cooler weather and into the fall and winter, I'm hoping that we won't have to go back to that horrible place ever again, where we heard ambulance sirens literally every 12 minutes.
Verghese: I know you have a new health commissioner for New York. Have any changes been implemented to address the sort of inequities that made these conflagrations so bad in certain neighborhoods?
Blackstock: There is a Center for Health Equity that's part of the Department of Health here in New York City. They have been trying very hard to address some efforts, like contacting physician offices in these neighborhoods and ensuring that they have adequate staff to reach out to patients who haven't been seen in a while but may have underlying medical problems. They have used social media advertisements, as well as community health workers, to do outreach and education. I think that it was a priority of the Department of Health, and hopefully it will continue to be one.
Topol: While we're on New York and the Department of Health, can you give us your comments about sending a child to school there?
Blackstock: That's interesting. I think that my opinion is unique, but I try to be the voice of reason. As we've discussed, New York City is doing great in terms of our infection rates, so that obviously is a key indicator to determining whether or not schools should open. I do think that the school piece, in terms of ensuring adequate PPE, ventilation, a plan for if someone tests positive, and an adequate testing infrastructure, are very important. And I think the Department of Education and our mayor could do better at ensuring the transparency of those conversations and those discussions. A lot of teachers and educators are feeling very worried about going back. I think what they need to realize is that we're not in a situation where we have zero risk. We won't have zero risk for a very, very long time, but yes, we do understand that we need to make you as safe as possible, and I agree with them on that.
I have two children. They are 3 and 5 years old, and as of now, they will be going back to school next Monday, 5 days a week, in person. I'm very proud of their school's leadership. They have kept us incredibly informed, and we'll see what happens.
Lack of Diversity, Lack of Trust
Topol: That's terrific. I want to switch a little bit to the science side of things. We've talked about how our government hasn't done a very good job at all. Also, all this work in genomics and sequencing and these genome-wide association studies, there was very little in the way of people of color represented in these studies.
We're now seeing terrible underrepresentation in the vaccine trials. I saw the data yesterday for the Pfizer trial, which was even worse than Moderna, which was not at all representative. We have problems in the clinical trials, with genomics. One of the notable science papers from last year was the one about Optum, with this biased algorithm that was basically, again, embedded bias. Can you just give us your sense about this pervasive problem in the medical and life science community?
Blackstock: We think of technology as helping people, but if we have technology that's biased, it can harm people, as we saw with the Optum case. Whoever is designing software and whoever is designing clinical trials for whatever study needs to do it using a lens of equity.
There are equity tools that help you go through that process of thinking about who is going to be advantaged, who is going to be disadvantaged from that. Do we have all of the information we need to make an educated decision? How are we going to measure outcomes in how different communities and populations are impacted? We need to be more measured and more intentional and methodical when we are thinking about how we use technology in these ways that can be incredibly advantageous but, conversely, can be incredibly detrimental to health.
Verghese: How do you overcome the problem of long-standing suspicion among the Black community, which is there for good reason, about entering clinical trials?
Blackstock: That's a great question. I've been working with some pharmaceutical companies recently around these issues. I've been telling them that it is really important to form relationships with communities — community-based organizations with trusted leaders — because to come in and say, "Hey, we have this trial and we need you to enroll" is not going to be enough. You need to explain why this trial is useful, how it will help you, and how it will help your community.
I think people also need to realize that when you're in a trial, everything is monitored. You sometimes receive better clinical care being part of a trial than not being in a trial, especially if you don't have health insurance. There are a lot of very positive attributes that community members can be educated about, but I also think that history should be acknowledged, like the Tuskegee syphilis study and Henrietta Lacks. It's important to keep that as part of the conversation, but also to emphasize the greater good. The greater good of this clinical trial is that it will help our communities, and that's most important.
Topol: Although in the All of Us research program, one really positive feature is that out of 350,000 people in that cohort, more than half are from underrepresented minorities. So it can be done, but as you say, Uché, it takes real, dedicated commitment.
I wanted to get your comments about something that I read about yesterday that I am so outraged about and is related to this topic: Immigration and Customs Enforcement (ICE) and hysterectomies being performed.
This seems to be one of the most heinous things that you could imagine. It has not even gotten that much national attention. Can you comment about that?
Blackstock: When I read about it, I started thinking about the content I talk about when I do my talks and trainings. I think what people don't know is that eugenics programs are a part of US American history. Even from the 1900s to 1970s, we had federally funded eugenics programs.
We even had ob/gyns in the South who were performing these hysterectomies without patients realizing it, called the "Mississippi appendectomy." Many of these patients didn't realize it until after the fact. So this is part and parcel of US history, and you would think that by now we would all know better. It is such an injustice; I agree with you. I think, What doctor would ever do this?
Topol: I just cannot believe this is happening in this country, in 2020. Haven't we learned?
Activism and Optimism
Topol: You're one of the true experts in social media, which, obviously, is a way to get your message out there.
Blackstock: Not intentionally, though. It was totally by accident.
Topol: Tell us about that.
Blackstock: I was finishing up my time at NYU and I was getting really frustrated with my experiences, so I would just share it. I think I was very transparent. People started following me, and I said, "Wow, now I have a platform to talk about issues that mean a lot to me, like racial health inequities."
Topol: It's highly informative. I learn a lot from you on a daily basis, and I know others will as well.
Verghese: We're in such a unique moment in time. I don't think we've had more opportunity, but also more of a threat to suppression of the very things that we're trying to bring about. What is your crystal ball? What is your sense of where we're headed and what the future will look like for your daughters?
Blackstock: I'm an optimist and I feel like the good will prevail. I think if people like us who believe in science and justice keep pushing forward and doing good work, then we will see positive outcomes. I'm hopeful.
Topol: One of the things to reflect on in our conversation is this culture of fear. In part, that motivation of you leaving allowed you to do what you're doing now. We're seeing even in the top governmental agencies, like the Food and Drug Administration and CDC, people not standing up, becoming subservient to the White House and the current administration, and seemingly complicit. What you are doing is so notable.
One of the most important things TIME'S UP Healthcare ever did was to stimulate you to do what you're doing, and I think you are one of the great young activists in medicine. We are going to be following you very closely because you are a born leader and you're an inspiration to all of us. Thank you so much, Uché, for joining us. Abraham and I are very grateful. I know that all of the people listening will be as well.
Verghese: Truly honored. Thank you.
Blackstock: Thank you so much for having me. I'm honored and humbled. Thank you.
Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.
Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.
Uché A. Blackstock, MD, is a board-certified emergency medicine physician. She recently left her academic post to launch Advancing Health Equity, which partners with organizations to address inequity and systemic racism within the healthcare system. Follow her on Twitter
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Cite this: Uché Blackstock, One of the Great Young Activists in Medicine - Medscape - Sep 24, 2020.