Tell Me More: Fixing Institutional Racism in Health Care
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In this episode of Tufts’ podcast Tell Me More, professor and author John Rich talks about applying a systems approach to tackling the consequences of trauma in the lives of young African-American men. Rich is the author of Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men. Now a professor at the Drexel University School of Public Health, Rich previously served as medical director of the Boston Public Health Commission, and as a primary-care physician at Boston Medical Center.
HOST: Welcome to Tell Me More, a podcast series featuring distinguished visitors to Tufts University who share their ideas, discuss their work, and shed light on important topics of the day.
In this episode, professor and author Dr. John Rich visits with Tufts University’s Jen Greer-Morrissey to talk about applying a systems approach to tackling the consequences of trauma in the lives of young African-American men. Dr. Rich is the author of Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men. Now a professor at the Drexel University School of Public Health, Dr. Rich previously served as medical director of the Boston Public Health Commission, and as a primary care physician at Boston Medical Center. Let’s listen in.
JEN GREER-MORRISSEY: Thank you for joining us, Dr. Rich. In your book, Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men, you address the frequent violence that African-American men in urban environments face and sometimes perpetrate, as well as a system that overlooks this cycle. Can you tell us about this system and how this cycle is overlooked?
JOHN RICH: When we talk about young African-American men who live in cities, we’re often talking about young people who live in poor communities, and therefore there’s the intersection between race and class and masculinity that often, when these young people come into systems, those systems don’t recognize them as young people who have any agency or young people who even understand what’s happened to them. So, we know that health-care systems, for example, have lots of health disparities. People of color in health-care systems are often treated worse than white people in those same systems. It’s doubly so for these young people.
When they come in as victims of violence, regardless of the circumstances under which they got hurt, it’s often assumed implicitly that it was something they did to get themselves injured. That has the impact of making the trauma—the psychological trauma—even worse, and also means that the people in those systems don’t see much change as possible. They may simply decide “Well, until this person gets their life together, I’m not going to help them.”
I think recently there has been a shift and a transformation in this space. Across the country, hospitals are beginning to think about “What is our responsibility to treat the trauma that young people are experiencing as a way to also treat the trauma that is rampant within communities?” I think we’re seeing a shift now in those systems, but we would be naïve not to think about the fact that, from a systems perspective, we know it isn’t just about an individual hospital or an individual provider. It really is about the levels of racial bias and racism—institutional racism—that play out in all these institutions.
Those of us who are really interested in affecting this issue and reducing violence are thinking about, “How do we better serve young people who are victims? How do we treat the consequences of trauma? But also, how do we change the whole conversation away from one that is about badness and a criminal justice approach, and rather toward one that’s about trauma that also acknowledges things like segregation, racism, and how they’re playing out in the lives of these young people in their communities?”
GREER-MORRISSEY: What is the single-most important thing that needs to be done to break this cycle? Is it changing the mentality and addressing these underlying issues?
RICH: It’s a tough one, but I would start by saying the single most important thing is to realize that there is no single thing that we can do to make this go away. There’s been a tendency to think about “Well, this program will reduce violence, and this is the magical thing that we need to do.” Often in the short term, political leadership is looking for something that will have an effect in the next four or eight years, but those of us who are in this for the long haul—and I would really say that those are people in communities—realize that it isn’t only about a program or an intervention.
It is about how do we change the systems and the infrastructure. How do we address residential segregation and racism as it plays out in communities? How do we address the historical racism that has kept people out of meaningful employment that has landed people in communities where the schools don’t work for them?
We ought to be spending more money on the education of poor children. Instead, what we do is spend more money on the education of well-to-do children and neglect the health and the education of young people who in these settings. Again, this shift in perspective that we can have, we do have to do the short-term programs, but we have to take a longer-term perspective that looks at systemic issues.
GREER-MORRISSEY: Is there progress in certain cities or places across the nation? Where might there be cause for hope?
RICH: There’s always reason for hope. Our reason for hope is that we know the incredible potential that these young people hold, which has been somewhat overlooked and ignored. If we’re able to engage the young people who are closest to the problem as the change agents for the solution, I believe that’s our greatest hope.
Now, having said that, there are lots of other systems approaches that are happening. For example, in New York, they’ve made moves to close Rikers Island. That is a huge step forward to thinking about how we stop using incarceration as our only strategy to reduce crime in communities. Across the country, in Oakland, they are having different systems, different interventions work together. So, hospital-based violence intervention programs are working together with community-based interruption programs, creating something they call the Healing Justice Alliance. They’re really beginning to think across health care, public health, and criminal justice in order to make a difference.
I think we can see examples of progressive approaches, but almost all of those that will be successful are not only focused on one system. They’re focused on community development, economic development, education, law enforcement and criminal justice reform, and health care as a broad strategy that really engages the community as true partners in these efforts.
GREER-MORRISSEY: In your book, you share a number of stories of young black men whose lives were violently disrupted by trauma and violence. These stories are all deeply compelling in their own way, but is there one story though that stays with you more than another?
RICH: You’re right. All of them stay with me in one way or another. That’s why they—that’s what led to the book, sort of holding all of these human stories and realizing that it was an opportunity, though imperfect, to tell the stories of these young people was important.
There is one young man in the book, he is named David. He stuck with me because he was shot in an incident where his cousin was killed. I had known about him before that incident happened, but I hadn’t met him until after. I remember going to his home in Roxbury and sitting with him and talking about it. He really laid out the way that the loss of his cousin had changed his life through a trauma-informed lens.
For example, he had lost the ability to feel fear. That is not uncommon, but not much talked about in post-traumatic stress. It’s thought about as emotional numbing, but he’d lost the ability to feel fear, and he had lost the ability to feel love. It is often said that the emotions that the person was feeling at the time of the trauma become walled off to them.
So, you can imagine that here was in an incident where he and his cousin were in a car, someone shot at the car, his cousin was killed, and in that moment, he was feeling both the fear of what would happen and the loss of his cousin, the love for his cousin. So that distress which would manifest itself in anger and frustration, it was easy to see how that could be misread in another circumstance where you didn’t know his story.
So, it stands out to me as a human example about not only the loss of life or the loss of physical function, but how deep these wounds can be. It also stands as an example, though we don’t get to see it in the book, of David’s own process of recovery and his own process to come to grips with this, to reestablish loving relationships in his life and to be able to move on. That, for me, is an inspiration.
GREER-MORRISSEY: What has this work taught you?
RICH: There’s a lot. I would say this work has taught me mostly how little I knew and how much I have to learn by engaging with young people who’ve been affected not only by violence but by structural violence.
Within organizations, one-on-one is critical, but at the same time that we’re doing this direct service work, we have to continually look at systems. What are the systems that not only affect this client, but are affecting clients like him or her? When you take a systems approach, we think “Well, this is an event. What are the patterns that it represents?” If we look at those patterns and then think “What are the underlying structures that produce those patterns and the mental models underlying them, and then the cultural and institutional values?”—that’s kind of the systems approach we use in public health.
We try and continue to keep that in our heads even as we’re dealing with the event or the patterns. How do we change the structures and the mental models? Really, how do we reframe the narrative about young people away from one that’s about predator or perpetrator and toward one that’s about how we understand the impact of trauma over the lifespan?
GREER-MORRISSEY: What advice would you have for students who are looking to also dedicate their lives to working to solve these issues?
RICH: I would advise that students really take the time to set aside their assumptions and their notions and look at problems in a little bit different way—or perhaps a dramatically different way. So, the opportunity, for example, that students have here [at Tufts University] to engage with community, to have an experiential learning experience where they go in with the assumption that everyone in that environment is going to be a teacher to them and that they’re not only looking at what’s happening, but they’re looking at the structures—to me, that is the ultimate learning.
It’s challenging for physicians who are often early on in their medical education placed on something of a pedestal that convinces us that we pretty much know the underlying problem. That becomes a lifelong barrier to learning for us as physicians, and I would say that’s something we as a profession need to take on.
At the end of the day, being in community not as a spectator, not as a tourist, but as a really engaged and listening learner is more than worth the cost of the tuition that students are paying, and perhaps a better value in the long run.
GREER-MORRISSEY: What’s one more thing you can share with us either about yourself or your life’s work that people don’t already know?
RICH: Most of my life, I guess, people don’t already know. I would say that I grew up in Queens, New York. I grew up in a home with a mom who was a teacher and a dad who was a dentist. I would say—maybe this was apparent from the book—that I got a lot of what I now have from my parents and my community, and I never really take that for granted. The opportunity to be in a family where there’s an understanding of inequality and an understanding that we have an opportunity.
For example, my dad was a dentist in an area of New York that a lot of people thought he shouldn’t be practicing in. It was East Elmhurst-Corona, where most of the folks were poor. So, I think that those kinds of influences were important. I hope that there’s an opportunity more and more to let young people, even as they’re growing up, understand there aren’t two worlds, but there’s one world where we have an opportunity to have an impact across these somewhat artificial boundaries.
GREER-MORRISSEY: Thank you.
RICH: Thank you. It’s been my pleasure.
HOST: Thanks for listening to this episode of Tell Me More. Be sure to take a minute to rate and review us wherever you get your podcasts. We’d also welcome your thoughts on the series. You can reach us at firstname.lastname@example.org. That’s T-U-F-T-S dot E-D-U. Tell Me More is produced by Katie McLeod Strollo, Steffan Hacker, and Dave Nuscher. Web production and editing support provided by Taylor McNeil. Production support provided by 5 to 9 Media. Special thanks to the Jonathan M. Tisch College of Civic Life, the Tufts University Africana Center, and the Department of Community Health. Our theme music is sourced from De Wolfe Music. And my name is Patrick Collins. Until next time—be well.