publication date: Jun. 12, 2020

#WhiteCoats4BlackLives aims to lead to real change in oncology

“I’ve never been more hopeful in my entire life”

By Alexandria Carolan

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

A movement that began with a fatal chokehold on a Minneapolis street grew into demands for police reform, but outrage didn’t stop there. Amplifying, reverberating, it became a call for racial justice in medicine, in oncology.

The COVID-19 pandemic focused America’s attention on health disparities. The murder of George Floyd led them into the streets, and they kept going, people from all walks of life, including thousands of doctors young and old, out there, taking aim at racism in medicine.

“White Coats for Black Lives extends much further than the knowledge of the violence, a knowledge of the killing of young men and women by police, a knowledge of the police brutality against blacks. Consequently, all of this affects health care,” Edith P. Mitchell, a member of the President’s Cancer Panel, clinical professor of medicine and medical oncology in the Department of Medical Oncology, director of the Center to Eliminate Cancer Disparities, and associate director of Diversity Affairs at Sidney Kimmel Cancer Center at Jefferson, said to The Cancer Letter.

Some say this is the turning point, that clear changes will be made to increase diversity in leadership positions, that work will get done to narrow health disparities, that black patients will get the same care as white patients.

“I am more than cautiously optimistic that this is our first step to healing, that this is our first step to really getting real change,” Robert Winn, director of Virginia Commonwealth University Massey Cancer Center, said to The Cancer Letter. “I’ve never been more hopeful in my entire life. I think people are waking up from their slumber, and as a country, we are embracing and becoming our best selves.”

There are no shortcuts.

“I’m thrilled that doctors are concerned about health disparities, but we need to get at the social root of the cause. And we need to tackle all aspects of the health disparities problem—including, why is it that American society has created this ‘thing?’” Otis Brawley, Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, said to The Cancer Letter.

 

Something is different

Perhaps the reason this movement feels so different, is the words “Black Lives Matter” have permeated the mainstream.

“I would say, even as recently as a few months ago, to talk about police brutality—to even say the words ‘Black Lives Matter’ was something that was felt to be political or controversial,” Malika Siker, associate dean of student inclusion and diversity in the Office of Academic Affairs, associate professor in the Department of Radiation Oncology, student pillar faculty member, at the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, said to The Cancer Letter.

“I feel like that conversation has changed now, and people are no longer afraid to say those words, and not just say the words, but understand what they mean—and show a commitment to social justice and anti-racism,” said Siker, who is also academic vice chair of the Community Advisory Board at MCW Cancer Center, Medical College of Wisconsin. 

In oncology, these doctors say staying silent about racism is no longer an option. If a physician’s goal is to alleviate human suffering, how can the quest for racial justice be overlooked?

“If you don’t step out, there is no middle ground. We’ve got to be anti-racist, and every person in their position, in the medical field, needs to speak out, step out and do what we need to do so that we are removing the knee from the neck in all areas,” Mitchell, a former president the National Medical Association, said. “We can therefore face a world of equity, health care equity, for all. It’s not only ethically the right thing to do, but for this country—for health care, for all, it’s the best instance.”

At the start of Mitchell’s career, in the year 1972, she recalls being fitted for her white coat as a sophomore. The seamstress asked: “Are you going to like working in the kitchen at the hospital?”

Physicians “have a responsibility to address racism,” Christina Chapman, assistant professor in the Department of Radiation Oncology, University of Michigan School of Medicine, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, said to The Cancer Letter.

“It’s also the recognition that the physician does take a white coat off at the end of the day, but still has that responsibility, even in other sectors of their lives, to take a stand on racism, as one of the very critical roles in the healthcare system,” Chapman said. “It’s to unite, and to not give physicians a pass on their responsibility in addressing racism.”

Until recent events, doctors whose work isn’t focused on disparities could simply not think about injustice. If they didn’t live it, or actively engage with it, they didn’t have to talk about it.

“On the end of health disparities and our day-to-day lives as oncologists, it’s easy to just sort of ignore, or be very casual about the health disparities that we see and we encounter,” Curtiland Deville, associate professor of radiation oncology and molecular radiation sciences at Johns Hopkins University School of Medicine, said to The Cancer Letter.

“I hope that this time it helps people take it to the next level—really trying to solve the cancer disparities that they see in the communities they serve, or even just at the individual level of the patient, or the immediate patient that they have,” Deville, who is also clinical director of JH Sibley Radiation Oncology, and co-director, of JH Sibley Prostate Cancer Multidisciplinary Clinic at The Kimmel Cancer Center Sibley Memorial Hospital, said.

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Protesting in the era of COVID

The decision to come out into the public square is never trivial.

Police have tear gas, a chemical weapon, no less. They have rubber bullets, which hurt like hell and can put your eye out. They have pepper spray, which adds injury to humiliation. They slug you with their truncheons, knock you to the ground, bind your hands with a zip tie behind your back, cart you off, and maybe tell your employer, whose views on racial justice might differ from yours.

The risk of COVID-19 makes the threat bigger.

“If you need to protest, there is something that is a threat to your safety and your security and your livelihood—and you have deemed that that threat is greater than the immediate threat of the coronavirus,” Deville said.

If you’ve been schooled in public health issues, you might find it hard to argue that racism is anything other than a public health issue. You would also see the overlap of COVID-19 and police brutality. George Floyd survived the former, but was killed by the latter.

“There are two pandemics, there are two infectious diseases. There’s COVID-19, and there’s racism. Racism hasn’t gone anywhere, and racism is of paramount importance,” Chapman said.

“The impact of racism extends beyond just the risk of police brutality and murder—people aren’t simply out there protesting because of what happened to George Floyd. They’re protesting because they know that the system that allowed that police officer to do what he did is the same system that creates residential segregation, and poverty, and health inequities that black people die from,” she said.

On June 1, in Washington, D.C., in Lafayette Square, a park across Pennsylvania Avenue from the White House, police used tear gas, rubber bullets, flash bangs, horses, and a helicopter on peaceful protesters to make it possible for President Donald Trump to hold up a Bible, using St. John’s Episcopal Church as a backdrop.

Deville marched down the same street less than one week later, on June 6. The temperature was in the 90s that day, as tens of thousands of demonstrators took to the streets to let it be known that Black Lives Matter. Protesters marched peacefully to the White House from all directions—the Lincoln Memorial, the U.S. Capitol, the National Mall. Chances are that if you were anywhere near downtown D.C. that day and you weren’t already in a protest, you would have become a part of one.

By then, D.C. Mayor Muriel Bowser had ordered that two blocks of 16th Street NW leading to Lafayette Park be renamed Black Lives Matter Plaza.

The words BLACK LIVES MATTER are emblazoned in yellow on the asphalt—impossible to miss.

“It was a shift in what was becoming a very negative and hostile kind of situation, into a more positive direction forward,” Deville said. “Being able to be there for an hour or two was a very positive feeling.”

The chants were unforgettable:

“Say her name: Breonna Taylor. Say his name: George Floyd.”

It’s a call and response.

“It’s not just black people, marching, it’s all kinds of backgrounds who are, equally as enthusiastically shouting,” Deville said. “You really do feel it that they are just upset, and agitated, and not holding back. And they’re shouting—these black people that were killed—they’re shouting their names out. It was very powerful.”

The marches by the White Coats for Black Lives movement were held in multiple cities. Students, faculty, and staff showed up on June 5 at Johns Hopkins University campuses. Deville was there, taking a knee alongside other protesters.

Institutions participated, too. On the same day, Memorial Sloan Kettering Cancer Center, like other hospitals across the U.S., held a moment of solidarity. Hundreds of MSK employees joined in. At Chapman’s University of Michigan School of Medicine, more than 1,000 students, staff, and faculty called in to a virtual protest organized by the University of Michigan Black Medical Association. Chapman was one of the virtual attendees.

The decision to protest is complicated for oncologists, who took the risk of being exposed to SARS-CoV-2.

The risk was worth it for Allison Betof Warner, assistant attending physician in the Melanoma Service and Early Drug Development Service at MSK. She stood with nearly 3,000 other health care workers in the East Meadow of Central Park.

“Living in New York City and having worked on the front lines of COVID, I am very wary of any groups of people. That being said, I think it’s critical to have the voices of healthcare workers heard. Both COVID and cancer disproportionately affect people of color,” Betof Warner said to The Cancer Letter. “Racial disparities in access to health care profoundly affect our patients.”

Betof Warner wore an N95 mask. She maintained her distance from other participants, who were primarily healthcare workers in New York. Masks were distributed to anyone who didn’t have one.

“I firmly believe that racial disparities are a public health issue, and therefore, it’s critical that we hear from doctors, nurses, and other healthcare workers that the time for change is now,” she said.

Protesting is a personal matter. Siker doesn’t judge those who choose to, or who choose not to.

“At the end of the day, it comes down to an individual choice. For me, as an advocate, as somebody who’s committed to social justice—and an oncologist still actively treating cancer patients—this has been a really tough decision,” MCW’s Siker said. “Because I know that if one of my cancer patients were to see me at an event, they might be disappointed that I would be putting myself at risk of contracting the virus, and therefore putting them at risk when they come to the clinic.”

Chapman agrees. “I treat head and neck and lung cancer, and my patients tend to be not only immunocompromised—because most of my patients are receiving concurrent chemotherapy—and given that I treat lung cancer and I work at the VA, a lot of my patients have bad lung function,” Chapman said. “So, for me, I decided, given the risks to my patients, I haven’t gone out there.”

The role of the physician is to provide guidance, to educate protesters on how to protect themselves, Deville said.

“As a physician, I think you can educate people. If you’re going to go out there, maybe there is no 100% safe way, but certainly, there are things you can do to try to minimize your risk. I mean, we tell people that all the time, right?” Deville said.

Fred Hutchinson Cancer Research Center and Seattle Cancer Care Alliance released a guidance for employees protesting in the time of COVID-19:

  • Wear a mask or face covering that fully covers your nose and mouth.

  • Strongly consider wearing or having ready access to goggles or eye protection for added protection (avoid wearing contacts).

  • Bring hand sanitizer and use it frequently.

  • Avoid sharing drinks, carrying other’s signs or touching objects that others have touched.

  • Attempt to limit your group size and maintain six feet of physical distance whenever possible during the activity.

  • Try to avoid crowded activities that involve shouting or singing in close proximity to others, and avoid those who are not wearing masks or face coverings if possible.

  • Bring your own water, food, or other personal items.

“The epidemiological principles of pandemic containment have not changed—it has always been to limit exposure, wear a mask and practice other precautions,” Ishwaria Subbiah, palliative care physician and medical oncologist in the Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, at MD Anderson Cancer Center, said to The Cancer Letter.

“Assuming no legislative mandates on gatherings are in place, the decision to engage in a peaceful assembly is the individual’s to make. Patients with health concerns can engage their medical team to assist through a discussion of the risks to self and others of person-to-person COVID-19 transmission,” Subbiah said.

Risk-taking is subjective. A pandemic makes the downside steeper.

“If you have the luxury of having the conversation around, ‘Should I weigh this versus that,’ then, you know, that’s a privilege in itself that you should be aware of,” Deville said. “I don’t know that a protest occurs for convenience. If you look throughout history, when did people protest when it was convenient?”

While Hopkins’s Brawley is hopeful that this movement will spark real change, he is concerned that COVID-19 will spread as a result of these protests—and African Americans have already been the hardest hit population in the U.S. African Americans make up 13% of the U.S. population, but comprise greater than 33% of all COVID-19 deaths.

“We keep talking about this as if it’s a tidal wave. I think there’s going to be a series of big waves—not one big tidal wave. I think we’re going to see it in the fall, August, September,” Brawley said. “I cannot say that people ought to protest and not worry about the coronavirus. Every protester needs to understand the risks that they are putting themselves in.”

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Diversifying the workforce

While the oncology workforce is growing increasingly diverse, the leadership still appears to be predominantly white and male.

There are a total of 71 NCI-designated cancer centers. VCU Massey’s Winn is the only black director. No data exist on self-identification by other directors. There are nine women directors (The Cancer Letter, June 5, 2020).

Senior leaders at cancer centers are “finally starting to really grapple with the issues around diversity within their own ranks, or the lack thereof,” Winn said. “In fact, I think that it’s probably been the first time in my life time that I’ve seen CEOs and deans and people not just reflect, but look at their own institutions and say, ‘How can I be wanting to aspire to actually have diversity and not have any in my own ranks?’”

Leaders of many institutions have used the words “Black Lives Matter” in their public statements.

“People need to take a critical look at their lives, their circles of influence and power, and be intentional about wielding that power in a way that includes voices that may not be at the table,” MCW’s Siker said. “How that looks for each individual may be different.”

Mitchell agrees. “How many deans do we see are African Americans? How many professors are at the highest ranks and are African American? How many hospital directors, and how many cancer center directors are African-Americans?” Mitchell said.

And what about funding?

“NIH is evaluating how many individuals of African American or other underrepresented minority descent receive top grant funding from NIH. NIH is therefore contributing resources to study this and to improve the number of individuals receiving grants, and who become grantees for NIH funding,” Mitchell said. “This goes farther than police brutality, it’s involved with equity, and diversity, and inclusion.”

For Deville, workplace diversity is a prerequisite to addressing health disparities and health equity.

“In the area—I went into prostate cancer, the reason I was drawn to it was because I was going through my rotations and saw a lot of black men with prostate cancer. The fact that their outcomes were worse—they have death rates twice as high—I was feeling like, why aren’t people as wound up about this as I’m feeling?” Deville said.

“It says to me that, what a shame that patients often do not have providers that look like them. They often don’t have that option in a large proportion of healthcare settings throughout the U.S. It’s just sad.”

 

“The gravity of racism”

NCI requires that its designated cancer centers have Community Outreach and Engagement programs focused on addressing health disparities.

“Doctors are realizing that they have a social obligation. I actually wish they would push it a little further, because even amongst doctors—the thought is always the racism, getting rid of the racism when the patient has a diagnosis and is being treated,” Brawley said. “And that, certainly, is an important part of it. But the thing to realize is that the police issue, the health disparities issue—they are all part of one thing. They’re held together by this gravity of racism.”

This gravity of racism is entrenched in an almost endless array of health inequities that affects the black cancer population. There are multiple barriers to treatment: cost, travel, inferior quality and delivery of care, and distrust.

African Americans have higher incidence of hypertension, diabetes, lung disease, prostate cancer, and now, COVID-19. To pull patients out of peril requires concerted effort by leaders in health care.

“Therefore, we really must increase insurance for individuals. Again, it’s been recognized that those individuals who live in states where there has been expansion of Medicaid have better oncological outcomes,” Mitchell said (The Cancer Letter, June 5, 2020; June 21, 2019). “So, we can say that African Americans and other underrepresented minorities, whether racial or ethnic, have access to the best health care and that we can, in a few years, show that there were no differences in individuals based on their ZIP code and where they live, and the color of their skin.”

Often, African Americans can’t afford and don’t have access to the latest and greatest drugs and technologies.

“You get a system where, by innovating in a way that doesn’t account for racism and doesn’t account for other forms of discrimination, you actually perpetuate and exacerbate disparities,” Chapman said.

“It’s not surprising that when we come out with the next targeted agent, and that when those agents initially are only available in the context of clinical trials, we know that minorities—and especially black people—are less likely to go to hospitals that have expensive technologies, have these drugs available, have clinical trials available,” Chapman said.

New treatments should be designed in a way that allows for access, Chapman said—“in ways that can be disseminated to hospitals that are not academic, that have a payer mix that is primarily Medicaid or for the uninsured.”

Disparities remain—and grow—in part because people have learned to accept them.

“In other words, we have not only come, as a society, to accept that disparities will occur (as a law), but we can always explain them away by the differential distribution of individual risk factors (as the theory),” Winn wrote in an editorial about the very subject in COVID-19 (The Cancer Letter, May 11, 2019). “Thus, the ‘individual risk factor theory’ becomes a unifying, acceptable explanation and a refrain that is absolving from our collective, societal responsibility.”

“To put it even more simply, underserved communities, are underserved, because they are underserved (as stated by Dr. Otis Brawley), and this has been made abundantly clear during the recent COVID-19 crisis.”

People are paying attention because of the gruesome murder of George Floyd.

“I think we’ve gone through a radical transformation with the recent events. And I think that there’s a better understanding from our university administration about what this movement means to our black community and our students,” Siker said. “It’s been great to see our administration step up and acknowledge that black lives matter in a public way, as well as support the students during this time.”

Brawley is hopeful, too.

“You go to Missoula, Montana—where there are no blacks—but there’s a Black Lives Matter protest. There were 300 people out for a Black Lives protest in Missoula, Montana, and they were all white,” Brawley said. “The majority of people under the age of 50, who are white, actually are starting to get it, and not be threatened by it. Caring about other people, and not feeling threatened, can get us very far in this movement.”

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