Reforming Health Care Isn't Enough. We Need a Transformation

Douglas Brooks served as the head of the White House Office of National AIDS Policy during the Obama Administration as the first openly gay, HIV-positive African American to hold the job. He focused on addressing the health needs of those at higher risk of HIV infection, and is now executive director of community engagement at the biopharmaceutical company Gilead Sciences. Dr. Otis Brawley was chief medical and scientific officer of the American Cancer Society before becoming a professor of oncology at Johns Hopkins, where he oversees a research effort exploring disparities in cancer rates and outcomes. Over a Zoom call, the two discussed the systemic factors behind racial inequities in health and how COVID-19 may serve as a catalyst for addressing them.

Dr. Otis Brawley: It’s a combination of racism as well as socio-economic deprivation that causes people to not do as well. It starts out at birth and involves what we eat, what our habits are, what our living conditions are, and involves prevention of disease, which I think is not stressed enough, as well as access to care to get treated once diagnosed. We have a lot of data to show that people who are poor are going to have more high-calorie diets, and it causes increased amounts of obesity. People who are poor are not going to be able to have access to doctors for counseling about prevention of disease.

If you look at the major chronic diseases, cancer, cardiovascular disease, diabetes, they’re all caused by a combination of smoking, consuming too many calories, not enough exercise and obesity. Those are the causes of cancer, diabetes and cardiovascular disease, which are the major chronic diseases and habits that come along with poverty and with the deprivation due to racism.

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Douglas Brooks: Otis, you mentioned racism. Often when we hear racism, we think of this as an act of one person or a group toward another. But I think we have to think about what you just described in the context of structural racism, and the way the systems are designed and affect how people have to live, work, play and pray. I read a great piece from a woman from Harvard, who was talking about, yes, the comorbidities that exacerbate COVID-19 serious illness and death are real.

But what we also have to look at is that many of these people, especially Black people, are living in overly crowded homes and buildings. They leave those overly crowded homes and buildings and get on overly crowded public transportation, go to overly crowded workplaces. We can’t ignore those systemic issues that also exacerbate COVID-19 and other health disparities.

OB: When I was at the National Cancer Institute in the 1990s, we started a campaign trying to encourage people to eat five to nine servings of fruits and vegetables per day. The chain grocery stores that were located in the inner city carry very few fresh fruits and vegetables. They thought that people in the inner city wouldn’t want to buy them—but they didn’t even try to encourage people to buy fresh fruits and vegetables. To me, it’s a form of systemic racism. The people who made that decision weren’t thinking, “I’m going to go hurt Blacks and Latinx people.” They weren’t thinking that way.

But the end result was people were hurt.

DB: Leadership is important. But it’s defining leadership in ways that make sense for the community. So what do I mean by that? In some places, it may absolutely be that the leader in the community is the guy who owns the barbershop, or the leader in the community is the woman who is looking out for everybody’s kids if they’re going to and from school. We have to be flexible enough in our thinking to understand how we make investments in those communities in ways that are both sustainable and that are realistic.

OB: I agree with you. I think the long-term investment should also be in good schools. We need more educated people who can get engaged in the community. We don’t need to reform health care. We need to transform health care. We need to change how we provide it. We need to change how we consume it.

DB: Back in April, Tony Fauci said that some of the data [on COVID-19] had started coming in around the significant disparities among Black and Latinx members of our country. And he said, Look, we’re going to find a cure. We’re going to end coronavirus. But once we’ve done that, we have to come back and look at these disparities that continue to impact the African-American community. It felt like a call to action, quite frankly. [I] reach[ed] out to Daniel Dawes, who is the new director of the Satcher Health Leadership Institute at Morehouse School of Medicine. So with Morehouse we are building a platform to, in real time, capture not only the COVID-19 disparities, but disparities around mental health, behavioral health, diabetes and asthma. We want to overlay these on the COVID-19 data, and then use the data with partners like academic institutions, policymakers and folks like us in the private sector, to see how we can make a difference and change the laws and policies in our country to address structural racism.

I’m a social worker by training, and the very painful aspect of subtle racism is that childhood should be spent dreaming about what one can be with zero barriers in one’s mind. When a child is in a home, in a family, where people are having to struggle and fight barriers every single day, that opportunity to dream is just not as available. You can’t get change made without being able to both tell the story and show the data to make a difference.

OB: If I were health care czar, what I would try to do is make sure that every person in the United States has a health coach. This will be someone who they would meet with perhaps three or four times a year, from birth all the way through the rest of life, and be an adviser on how to stay healthy and discuss what things you need to be doing, and what habits you are starting to get into that are not good for your health. We could prevent a lot of disease.

I’m always a little bit optimistic. That’s why I get up out of bed every day and keep doing this. I do think that ultimately we will get people to realize there is a problem. It may not be fixed in the next generation. But I do think we’re going to get better and better.

In my field of cancer, I actually get to see the mortality rates for Blacks. For prostate, breast, lung, colorectal—all the major cancers, the mortality rates are actually going down. So I can tell you I’ve got data to prove we are doing good, and the disparities are lessening. But the disparities are going to be here for a long, long time.

DB: If I didn’t think we could make a difference—truly make a difference—I probably couldn’t pull myself out of bed. What I think is different about now is the intersection of COVID-19 that has us all at home, and watching TV. The horrific murders that everyone witnessed—good people in our country saw those movements, those actions and marches across the country. And that energy, I think it’s all coming together to see these disparities. I feel more hopeful about our country writ large, but more hopeful about health care and about the economy, about racism and injustice, inequity, than I have in a very, very long time. Because I think good people just didn’t know. They’re not evil, hateful people. They are just people who are going about their lives and didn’t know. Now they do.

Moderated by Alice Park

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