Dr Ebony Hilton Wants to Talk Herself Out of a Job

She Won't Be Silent Until Racial Justice Is the Norm in Medicine

; Abraham Verghese, MD; Ebony Hilton, MD

Disclosures

October 20, 2021

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol for Medscape, with my co-host, Abraham Verghese, for our podcast, Medicine and the Machine. Today we're privileged to have Dr Ebony Hilton with us. She is an anesthesiologist and on the critical care medicine faculty of the University of Virginia. Dr Hilton comes from a town in South Carolina called Little Africa. She's one of three girls. She had her training at the Medical University of South Carolina, where she became the first female African American anesthesiologist since its opening in 1824. She recently won an award from the National Newspaper Publishers Association, writes children's books, and focuses on health disparities. She is medical director for GOODSTOCK Consulting and a contributor on MSNBC. Welcome.

Ebony Hilton, MD: Thank you all for having me.

Topol: You recently tweeted, "I wish I had an interview where I'm allowed to just ramble." So we're going to give you full range.

Hilton: I think a lot about the intersection of health and all of the social determinants of health. You have to think about the intersection of every facet of society — education, housing, transportation, poverty, privilege — because right now with this pandemic, we're literally seeing how privilege and racial injustice are two ends of the same stick. And both of those ends, when overworked, have a cost to life. We're seeing how privilege is leading some to make decisions that aren't necessarily favorable for public health measures. I can ramble on for days talking about it.

Abraham Verghese, MD: It's a great pleasure to meet you. I have been reading some of your key papers about critical care workforce, and I must confess that the word "intersectionality" is new to me, and I have a new understanding of it. A woman faces certain inequities, but then a woman who is an immigrant and is also a woman of color or is gender fluid, for example, faces further levels of complexity. You wrote about that very beautifully. But maybe you could talk about the critical care workforce; I was, first of all, astounded to read that up to 40% of critical care specialists are women. That was a larger number than I expected. But these women are not in leadership roles. Talk about those choices and where we go from there.

Hilton: Medicine in many ways is a business like any other business. The persons in positions of power typically are men and typically are White. That stretches across the board. Studies show that when there is concordance — racial concordance and gender concordance — outcomes can actually be better for those populations we serve. So it behooves the medical community to move in the direction toward our patient demographic, which has always been and will continue to be more and more diverse. We're seeing that in our medical school classes with gender diversity. We know that more women are coming into the medical field.

But when we're talking about intersectionality, we often miss the intersection of gender and race. Black women are often left out and we become invisible. And it's not only in the workplace model when we think about affirmative action; the greatest beneficiary of affirmative action is White women. They really did gain a foothold in society. But Black women, in totality, still have the lowest unemployment rates and income earned. We unfortunately have worse health outcomes, even compared with men. I tweeted an example of the intersectionality of gender and race and COVID outcomes. Over and over again, we hear that men have worse outcomes than women, but the truth of the matter is that Black women are three times more likely to die than either White or Asian men.

We have higher death rates at younger ages for both males and females across the board for any race except Black men. Black men and Black women are left out of this discussion. Without naming us specifically and naming race specifically, we need to figure out why it is that race trumps socioeconomic status. Why is it that race trumps educational attainment? Even if you are more compliant with your medical regimens and you're trying to do what's best, why does race still trump this as far as having negative outcomes?

Topol: What you're emphasizing is so critical: the idea that when you look at just one variable, like gender, you can be misled. What are the remedies for this? What if the United States had universal healthcare? We have the worst inequities here. Do you think that if you could flip a switch and get universal healthcare, would that change anything? How can we get this right?

Hilton: I would love to say yes, but Twitter has been a great resource for me this past year in getting to meet other people of different backgrounds, such as a physician from the United Kingdom. After one of my Twitter rants about racial inequities, he wrote and said that they, too, are seeing this in their BAME (Black and minority ethnicity) population. They found that they have racial and ethnic disparities despite having universal healthcare. So it's not just an issue of access. Not that I don't think we need access. Don't get me wrong, I'm all about universal healthcare. I believe the passing of Medicaid and the push for that by the NMA (National Medical Association) back in the 1960s, which said, Hey, if federal dollars are tied to this insurance, then you can't deny Black people coming into this hospital. That's one of the reasons we have this in the first place.

We also have to have accountability in medicine, and this is where we can learn from the intersection of protest and pandemic. The George Floyd protests brought to the forefront how we need police reform — not because all police officers are bad; we know that the majority of police officers are very good and they try to do their best. But there has to be some form of accountability when there is that outlier, when we know something wrong has happened. The same thing needs to happen in medicine.

To give you an example, I'm a double board-certified anesthesiologist and yet my child is two times more likely to die before their first birthday than if I were a White woman with a third-grade education. There is a two-tier system. Why is it that when Black women in preterm labor go into the hospital seeking care, they are less likely to get steroids, knowing that our babies will fare worse in their lung development? But studies show that Black and Hispanic women are less likely to get that intervention.

Studies also show that if I, as a Black woman, have a Black physician, the likelihood that my child will die is cut in half because I have race concordance. That shouldn't be the case. We do implicit and explicit bias training all the time, but do we get a report card that reflects back to us, that tells you what your outcomes are along the lines of race, gender, or the primary language spoken by your patients? We have the ability to do that, but we simply don't do it.

Verghese: The discussion around gender too often focuses on the pipeline, the glass ceiling, and achieving numbers. But you make a great point that this is also more about the patient. There are extraordinary data that suggest that surgical outcomes, including cardiac outcomes, are better when women perform these surgeries rather than men. No one has quite explained the differences, but they are real. Nevertheless, it raises the question of whether that should be our motivation, if this is better for patient care, because focusing too narrowly on numbers misses the point completely.

Hilton: It completely misses the point. At bare minimum, everyone is someone's son or daughter. And they deserve to know that when they pass away, someone actually cares enough to investigate the why behind it. We have morbidity and mortality conferences in medicine, where we sit in our small groups to try to figure this out. But collectively, we as a medical community need to reflect back and say, why is it that racial disparities in particular have not changed since Civil War times, despite the advances in health, diagnostic capabilities, and therapeutics? Why is it that since the beginning of time, Black men are not even reaching the life expectancy that White men were reaching back in the 1970s and 1980s?

We know how much we have gained, but this pandemic has pushed to the forefront what Black people have been screaming: Why are we dying, and no one's looking and no one cares? But it happened so fast that you can't ignore it. With the pandemic, during the first 6 months of 2020, Black men lost 3 years of life expectancy; their life expectancy in Virginia was only 72 years before COVID. We are literally looking at Black men and saying, don't expect to see 70. Live your full life because 60, 65, that may be the end of the road for you. And that is just absolutely gut wrenching for me, and it should be something that keeps every physician up at night to figure out why.

Topol: Your point here is especially astute, because if you look at the data, there's been a 2-year loss of life overall for Americans from the pandemic, but it's much higher for people of color. One of the things I wanted to get to was maternal mortality, especially among mothers and newborns. This has been an area of neglect long before the pandemic. It's been atrocious, and we have the worst in the United States of all the 37 OECD (Organization for Economic Co-operation and Development) countries. Our statistics for maternal mortality are outrageous and nothing seems to be getting done about it. We mounted a study to try to get as many pregnant women engaged so we can get to the roots of this. What's your sense here about why the United States is such an outlier in such an important group of people?

Hilton: You can literally see the health of a nation based on the health of their mothers and children. It is usually young, healthy women who are getting pregnant, and we should not be dying at the rates that we are. You can tell where a country puts its priorities based on where it puts its money. No one wants to die, and definitely no one wants to bury their child. There's an intention to try to get the best of care.

When I think about disparities, I think about it in three different buckets, or a Venn diagram with overlapping circles. We have the individual component. Do you smoke? Do you drink? What are what are some things you can change and influence for yourself? Are you medication-compliant? Those sorts of things. Then we have the community component that literally is your zip code and your genetic code. What are the impacts of environmental racism? We can think about industrialization of certain communities and the toxins spewed into the air and water. What does that do to you? We can think about the insults of poverty within that community, the availability of healthcare resources, and the fact that Black and brown communities are twice as likely to not have a hospital and four times as likely not to have a grocery store within their communities. What does that contribute to outcomes? The third component or bucket is the healthcare system itself. What happens at the capillary level when someone walks into the hospital? Do I treat you the same? What are the impacts of implicit and explicit bias for the individual provider? What are the interjections of racism into the medical policies we put in place, and how do they contribute to outcomes?

We can definitely talk about that as it is linked to COVID outcomes. But that's what I think of with a Black mother; we have so much that is outside our ability to control that determines how our fetus is allowed to develop and what are the stressors. We can talk about the intersections of all these things — the impact of generational wealth and the lack thereof; the influence of the Homestead Act and the GI Bill and all these welfare programs that were beneficial for predominantly White Americans, and how they don't trickle down to Black people. The influence of poverty within that community and the stressors that it causes are huge factors for why Black women are 50% more likely to go into preterm labor, just based on the community they live in, and the insults of those racist policies that still structure our communities today.

Then you take that insult and put yourself inside the hospital where, again, studies show that you're less likely to get steroids for your child, and we know those steroids can help your baby breathe better. We know about the lower likelihood that you will get pain management, and pain is not something that you can just brush off because pain is linked to other problems, including placental abruption, which is more likely to be missed with Black women. And there are other complicating factors, like what Serena Williams experienced, where you're having complications like blood clots and no one's listening to you. All these things tie into reasons why we die and reasons why, unfortunately, our children are twice as likely to die too.

Verghese: Many of our listeners are probably in administration and are well intentioned but may not necessarily know quite how to go about bringing change to a big organization. I know you have a consultancy where you give advice about this. Can you share some general principles of what organizations need to do? How do you bring that about and how do you measure it?

Hilton: First, we have to listen more than we speak. I tell people all the time that my diplomas, my degrees, they mean nothing to me in comparison to my life experience. I come from a single-parent home, and with that, I had to watch my mom navigate the system. I understand when you say that vaccines are available from 9 to 5, that's the time she works. And if she doesn't go to work, she cannot feed us. So a vaccination is not accessible. You can say it and say it, and I say it all the time: We center privilege with our actions and then we claim equity in theory but what we're doing doesn't work.

I would tell administrations and the leadership of organizations that the person you believe is the most vulnerable should be the very person that's at your table speaking the loudest, and you need to listen. You need to make it a situation where they can be vulnerable with you and they don't feel judged. If that means you leaving the room, then so be it. But you have to have an authentic conversation because that's where you can get to the root.

I can give you an example here at the University of Virginia. We try to do a fantastic job at being equitable in our approach to COVID-19. But from the very beginning of the pandemic, I started tweeting that we are going to see racial health disparities, and I would tweet it over and over again. And a couple journalists finally said, why do you keep saying this? There are no numbers. What do you mean? And I said, I mean Black people. We die at higher rates from nine of the 15 leading causes of death, and this should be no different. I don't want to get to the point where we're reporting the numbers, if we can possibly stop it.

One of the things I started asking at the University of Virginia was, what are our outcomes and what are we doing right now? The pulmonary group created a COVID clinic where, if you have COVID, you can get tested and initiate treatment. And I said, okay, can you tell me the process, how this works? And they said, well, if you have symptoms, you call your primary care physician, and they can refer you to our clinic. I said, whoa, let's stop, because that's racist. And they said, no, no, no, wait, wait, wait until we tell you what happens. I said, yeah, but you can't tell me what happens next because the first step is flawed; we know millions of people are now unemployed, and if I have to choose between paying a copay or feeding my children, I have to feed my children. Not only that, but we know that before the pandemic, many of the most vulnerable persons did not have a primary care physician because they don't have insurance. So that first step is already going to be skewed toward being pro privilege.

To prove the point, I said, let's run the numbers; tell me who we're seeing in clinic. And 76% were White, 11% were African American. I said, well, they're not going to the clinic, they're going to the emergency department (ED). Let's run those numbers. And we found, through the screening process, that even with those persons in the ED, White people who screened negative, who did not have signs and symptoms of COVID, were still more likely to be tested for COVID; and Black people, even if they screened positive, were less likely to be tested for COVID. The test positivity for Black people was 21% and test positivity for poor White people was 3%.

The suggestion I made there was to have an alert that pops up so that if someone screens positive and you do not test them, you have to enter a reason as to why. And if someone screens negative and you still decide to test them, you need to enter a reason why. That ties some accountability to our actions because otherwise there is no checkpoint between the patient and physician.

Topol: All along the way, you've shown yourself to be a gifted communicator, and obviously it's not just on Twitter. You are now increasingly having a voice on cable television and you've written children's books. Tell us about your path because it's vital that your voice has become manifest — not just in the pandemic, but in general in medicine. A lot of doctors are reluctant to speak out. You know, everyone has a chance, but what has gotten you into this mode of voicing your opinions in such an articulate way and not being afraid of the repercussions? All of us who post things, we get a backlash, we get all sorts of undesirable messages that make our days more complicated. Tell us about that.

Hilton: One of those things I say all the time is that I want to talk myself out of a job. I say, as bluntly as possible, if you want me to shut up, then fix the system and I will. I came from a single-parent home. I have two sisters on either side of me, and when I was 8 years old, my little sister asked my mom, "Could we have a brother?" And my mom all of a sudden just started breaking down crying. This woman was the strongest woman I've ever met in my life. She does not cry easily. Then she began to tell us that my parents' first child was a little boy. They were in high school when she became pregnant. She was going to a clinic for prenatal care. They ran some tests, she still doesn't know what type of tests, but she felt a sharp pain, and when she went home, she started leaking fluid. She called the clinic and said, "Hey, my underwear is wet; is this okay?" And they said, "Yes, everything is fine. You'll be okay. We'll see you back at your next visit." But unfortunately, she went into labor within 2 days. My brother, who would have been 43 years old this year, lived for 3 days and passed away.

That was my introduction to medicine. I decided in that moment, as an 8 year-old, I'm going to be a doctor so other mothers don't have to cry like this. As naive as that sounds and as crazy as it sounds, I never had a plan B. That was it. I grew up in a very low socioeconomic situation — I got free lunch in school. And growing up in medicine, and I do mean that I grew up in medicine, to learn that those same inequities exist today really bothered me; to learn that the way we have medical training speaks nothing about the racial injustices that have happened — not only in Tuskegee, because Tuskegee was a big part of it — but there are many injustices that continue to happen, and policies are put out that we know have a negative impact on certain communities. And yet we remain silent.

In my naive state as an 8-year-old, I believed doctors were the greatest minds available. So how can we be silent? How are we silent in our positions and not influencing what happens outside our community walls and within the walls of the hospital? We know right from wrong, but along the way, we have lost that confidence in our voices. So I am unapologetic in speaking truth because everything I say is tied to the fact that my brother would have been able to speak if he had been allowed to live. He can't, so I will.

Topol: There are so few activists in medicine. You are the prototype of the young physician activist. Abraham and I are the old dogs. Do you think we can promote more people like you in the years ahead? Most physicians just keep their heads down. They don't want to get out there and start to rally and change things that desperately need to change.

Hilton: There is a cost to it. I tell people that all the time. I don't know what it's going to cost me in my life, but I know what chronic stress costs, and I know stress is linked to cancers and hypertension and diabetes. I have to watch myself very closely. The study I mentioned, about the fact that as a double board-certified anesthesiologist, my child is twice as likely to die than the child of a White woman with a third-grade education, was done by Keisha Bentley-Edwards at Duke University. She has said that when you're the only [person of color] in a room, when you're in this circle of elites, there's a toll to pay. Being in this position to go against the grain, to literally tweet out at the CDC — we have a call set up where we can talk to the White House COVID Task Force every now and then. I know I'm going to see them face to face. And I tell them after every meeting, I'm going to tweet and I'm going to go directly at you because the way you have rolled out these phased groupings — phase 1a, phase 1b, phase 1c — are literally pro-White in design. When you enact policies that are race-neutral in a racial health disparity–laden disease process, then it's pro-privilege, it's pro-White in design.

That's what we saw with the vaccine rollout: phase 1a with healthcare workers and nursing home residents; healthcare workers are 60% White. Nursing home residents — it costs money to put your family members there; 77% are White. For phase 1b, initially they said people 75 and older and then they dropped the age to 65 and older. But we know there's a paucity of life for African Americans, and in the United States of America, 76% of people over age 65 are White. Then came the essential workers. Again, by April 2020, less than 50% of all Black adults actually had a job; they were the first ones fired. So you're tying this lifesaving intervention for an illness with higher infection rates, higher hospitalization rates, and higher death rates for Black and brown communities to age, but they die at younger ages; and to occupation, but they are less likely to actually have a job. The only qualifier that encompassed the Black community at large was having a preexisting condition.

So, what the CDC basically said to Black people in their policy formulation was, even though you're dying at higher rates and at younger ages, and although we see that you've lost 3 years of life expectancy, in order for you to qualify to be an early recipient of this lifesaving intervention, you need to come into 2021 with at least one of your organs dead and gone. You need to have heart failure, kidney failure, cancer, or diabetes. You need to have something wrong with you. Whereas White Americans, if you lived a nice life to see the age of 75, come on in. You can be in a 3000–square foot home with only yourself living there, where you're able to socially distance and work via Zoom. But you come on in and get this shot. And Black people, we'll see you in April. If you look at how the vaccines were rolled out, in January there was only 5% African American vaccine uptake to April, when it was 9%, and then past April, that's when the Black percentage of uptake began to match that of White Americans. It wasn't that we were hesitant; we were denied.

Verghese: Talking about vaccine denial and hesitancy, you've been brave about speaking out about that and countering the myths within the African American community. My limited experience here is that there are a lot of reservations but it's not politically based. It's based on general suspicions of this kind of work. How do you overcome that in your community? What do you say? What do you do to increase vaccine rates?

Hilton: I try to lead by example. I was the first person to be vaccinated at the University of Virginia, and I wanted to lead by that — to say, if I'm going to tell you to do it to your body, I'll do it to mine. I want you to trust me. Also, the narrative about vaccine hesitancy was pushed out even before the vaccines were approved. They started this rhetoric back in November and early December, and I was like, stop saying that. Don't just label it for the Black community. I think in terms of buckets — my mind does that — but I think of four large buckets of vaccine hesitancy. The African American community is one, because it's rooted in suspicions of the government. We can go to Tuskegee, and that whistle was blown only 10 years before I was born. So that tells you that my grandmother and my mother were very much alive when those reports were coming out. But we don't have to stop there. We can talk about the Flint, Michigan, water crisis, where they still don't have clean water. And you're sitting there seeing brown water come out and you're telling me that it's okay, as if I'm stupid, right? That is still an injustice we're dealing with. So that's the African American community. We also had the Hispanic community and the fear, especially in our undocumented brothers and sisters, that if I come in to get this vaccine, will I get deported?

Then you had these other two buckets that weren't mentioned. I used to tweet about this all the time. You have the anti-vaxxers who have been anti-vaxxers for decades and are largely White, college-educated women. Then the fourth bucket are the COVID hoaxers, the GOP, heavy Trump followers. That bucket was 74 million people who voted for President Trump.

Those two large buckets of White Americans barely got mentioned. I wrote an op-ed piece that no one would publish, but where I said, "Dear White America, you're in danger. Vaccine hesitancy is going to be an issue and a very big problem for you," because if we look at racial health disparities, it used to be that Black and brown people were six to eight times more likely to die from COVID. Now that number has been cut down to two, which is still bad, but it's not because Black people are dying less but because White people are dying more. If you look at the death count from September/October 2020 for White Americans, it was right around 12,000-15,000 each month. But then after Thanksgiving, it went to 27,000. After Christmas, it went to 42,000. After New Year's in January, it went to 47,000, and between February 2 and March 2, 58,000 White Americans died from COVID19.

These are two ends of the same stick: racial injustice and privilege. They are both deadly and we concentrate messaging to the Black community. We constantly tell them, oh, you're vaccine hesitant. Meanwhile, Black people are saying, we will wrap ourselves around this building waiting in line just like we have to when we vote. We will wrap around this building waiting to try to get this vaccine at this mobile clinic because we got the plan B option of healthcare. Instead of a hospital being in our community, we have to go to our church parking lot. We will show you that we're not so hesitant. We're curious. We want you to tell us the truth about the vaccine.

But we will show up because we're tired of dying and we've been screaming this for generations. Stop blaming us for being noncompliant when we can't afford our medication, because we don't have jobs that pay us the same amount, even if we have the same skill level. Stop blaming us for hypertension and diabetes when you know we don't have a grocery store within our community, but all we see are McDonald's, Taco Bell, and Burger King, which the city deems safe to be placed in our community. Stop blaming us for asthma when you know you put an industry that spews toxins in our air for our children to breathe in our community. Stop blaming us for things when we, as tax-paying citizens, are giving our money to the government and saying, can it trickle back to us? So we can have great ventilation systems in our schools in the middle of COVID, so our children don't have higher rates of infection and literally be three times more likely to die if they are Black vs if they were White?

Topol: And it goes deeper. We've talked mainly about healthcare, of course, Ebony, but our democracy is on the brink. Voter suppression. The recent Lancet report on the racial injustice with arrests and imprisonment. I want to get to something we mentioned at the outset: Charlottesville. Had you already joined the faculty at UVA?

Hilton: I literally moved here on the 1-year anniversary, and I did not even realize it was the 1-year anniversary day until the chairman wrote me and said, hey, don't go downtown. And I was like, why? Just don't go downtown.

Topol: Do you have any reflections? Even though you weren't there, obviously, it became a focal point of this country. And it bespeaks the depths of the lesion, the disease, if you will, and Charlottesville will go down in history for that. What are your thoughts?

Hilton: Yes, and it's not just Charlottesville, unfortunately. I moved here from Charleston, South Carolina, where we had Dylann Roof shoot up a church and unfortunately killed nine people as they were praying for him. We had Walter Scott a few years back. It's the chronic stress of living in a society where you're constantly told you're devalued. What does that do to the activation of your HPA axis — to your hypothalamus, to your pituitary gland, to your adrenal gland, if not increase your cortisol, increase your glucagon, and lead to insulin resistance? All the things that we talk about as far as chronic conditions. But one thing I can say about the city of Charlottesville is there's a lot of intentional work to talk about it. And I was really shocked, actually, at the amount of ongoing conversation. You can't drive down the street without seeing some sign that says "Love Lives Here" or "Black Lives Matter." I am the only Black person in my neighborhood, and literally there's like three signs.

But it has to go a step past conversation and more toward action and accountability. And like I said with the CDC, when I tweet you and I've been tweeting you about your initial vaccine rollout, when you come down to the booster and I see that it's the same thing that is still tied to age and employment... Right. And you specifically list out that the independent risk factors for this are race and age, then how is it that you choose one and neglect the other? Look me in the eye and tell me that Black lives don't matter, because that's what your actions are saying. And then in the words of James Baldwin, I can't believe what you say because I see what you do. You know, he also said — I'm a huge fan of his work — I love America more than any other country in this world. And exactly for that reason, I insist on the right to criticize her perpetually because this is my country and I do know how great we actually can be, but we will never be as great as our potential until we take care of the least of those. And right now, we're not doing that.

Topol: Ebony, this has been a memorable conversation. I mean, you're extraordinary and we're going to be seeing a lot of you in the years ahead. Your career is in the early stages; I just imagine where you're headed. We hope that you will inspire others to become activists like you are and help change medicine, help change our country to be a better place where it isn't now. But it can be, as you emphasized. So we really appreciate your taking the time to visit with us and have this conversation, and all that you do each day because this is hard work. We're just so thrilled to have the chance to see the beginning of what you're going to be, the impact that we know is going to be profound in the decades ahead. Thank you.

Verghese: Thank you.

Hilton: Thank you both.

This podcast is intended for US healthcare professionals only.

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