On May 25, 2020, George Floyd said “I can’t breathe” more than 20 times before he suffocated on a street in Minneapolis. On Jan. 7, 2023, Tyre Nichols repeatedly screamed, “Mom, mom, mom” as he was beaten to death on a street in Memphis.
Both were Black men. Both died at the hands of police officers wielding the power of life and death.
“This is like déjà vu all over again. That’s only two years ago,” said Robert Winn, director and Lipman Chair in Oncology at the Virginia Commonwealth University Massey Cancer Center, a professor of pulmonary disease and critical care medicine at the VCU School of Medicine, and the guest editor of The Cancer Letter during February, Black History Month.
“It’s a cultural problem. It’s some kind of bias. It’s a disrespect,” said Otis Brawley, Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, and co-editor of the Cancer History Project.
Both physicians have had life-threatening encounters with police—Brawley was thrown to the ground and held at gunpoint for standing in the garage of his own home; Winn was thrown to the ground and held at gunpoint for walking toward his own car.
“We both happen to be Black men. With the events in the last several weeks involving Tyre Nichols in Memphis, we thought we should have a chat, because both of us have in the past talked about our experiences with police, our experiences in society growing up,” Brawley said.
The Cancer Letter invited Winn and Brawley to discuss the structural biases and racism in law enforcement as well as in health care.
This conversation is also available as a video and podcast.
It’s important for physicians and public health professionals, as individuals in positions of power, to reflect on the problems in policing in America, and identify areas where these problems are also present in health care, Brawley and Winn said.
“Someone had said the other day, ‘The Tyre thing is very different than the thing from George Floyd, because, well, with George Floyd, the policemen that were doing that were predominantly white, and in this case, the policemen were all African American,’” Winn said.
For me, the only time I’ve had guns pulled out on me has been when I was encountering law enforcement. It wasn’t by a gang or anything like that.
Robert Winn
“And I essentially said that that is actually incorrect,” Winn said. “Policemen still see, even whether they’re Black, Asian, or white, based on the way sometimes that unit is taught or the culture of that unit, that they would treat an African American different than they would treat a white person for the same traffic stop violation. It’s a power dynamic.”
“And I worry about that power dynamic in medicine as well,” Brawley said.
Race is one dimension of that power dynamic.
“We have a medical system that is segregated by socioeconomics, and separate cannot be equal. Separate is not equal,” Brawley said.
Class is another dimension, albeit less talked about, Winn said.
“Class does not protect, whether it’s in law enforcement nor, actually, in medicine,” Winn said. “But I guarantee you this: if you’re Black and you’re poor, that becomes an issue.
“I hope that with Tyre’s death that one of the good things that could come out of this would be for us to take a pause and be all recommitted, as many of us were at the time that George Floyd actually was also murdered in front of all of our eyes.”
The conversation between Brawley and Winn follows:
Otis Brawley: Hello. I’m Otis Brawley, and I’m a medical oncologist. I’m here with my good friend Rob Winn, who is director of the Massey Cancer Center at Virginia Commonwealth University. And we are two major players in oncology. We both happen to be Black men.
With the events in the last several weeks involving Tyre Nichols in Memphis, TN, we thought we should have a chat, because both of us have in the past talked about our experiences with police, our experiences in society growing up.
I’ll start out by simply saying, I personally think that there is a problem in the United States with police and policing, and it’s a cultural problem. It has to do with biases and disrespect. We can talk about whether it’s biases and disrespect because of race or because of social positioning.
There is a problem in policing, and unfortunately, the police are not ready to deal with it.
Now, we are in medicine, and I think it’s a good time to actually think if some of these problems that we see in policing that actually do go into the rest of society, actually transcend into medicine. And that’s an area where we actually can do something about it and can be leaders in bringing about change.
So, Brother Winn, thank you for joining me in this conversation. It’s been two years since George Floyd, and now we’ve seen Tyre Nichols. And along the way, we’ve had Breonna Taylor and so many others who have been abused by police.
My first question for you is why do you think it’s important that we, as physicians and public health professionals, have an understanding of these issues in depth and think about them broadly?
Robert Winn: Dr. Brawley, I want to thank you for all that you have and continue to do, particularly in bringing light to these issues that really impact our communities and our patients.
I was thinking, as you were talking, about a line—and just for transparency’s sake, my brother just retired from the police force as a state trooper—I remember when we had been talking at some point it came up, the saying that “When you’re Black in America, there is no such thing as a routine traffic stop.”
That extends to when you are Black in America and you wind up going to an ER for certain problems; that many things that should be routine are not; that are really impacted by historical things that have happened long before us and continue to impact both, not only policing.
But I still think what we do in making sometimes unconscious, biased decisions about, for example, the lack of African Americans wanting to be on clinical trials.
I think that is a myth. I still think, to this day, that if you were to ask first and be able to communicate effectively, we’d have many more people from African American and many other communities, including rural communities, wanting to be on clinical trials.
So, I’ll start there by saying that it did make me think this weekend that 32 years after Rodney King, two years after George Floyd, that this is like déjà vu all over again, except for I think this time it may be a little different.
OB: Now, some of the folks who are listening to this or reading this may not be aware, but two years ago, you and I both wrote pieces for The Cancer Letter, talking about our negative experiences with the police throughout our years.
I, in particular, was an aide to the Surgeon General and a tenured researcher at the NIH, but I found myself face down in my driveway handcuffed for opening my garage door.
Yes. And then, when they saw that I had a military ID, one of the police—and by the way, one was Black, one was white—actually challenged my military ID’s validity, because they decided that I was too young to be the rank on my ID.
Some of these things get really, really stupid that the police do. And unfortunately, we see a lot of these things. And it’s some kind of bias. It’s a disrespect.
And it’s not all police. There’s three kinds of police. There’s the police who do this, the police who let it happen, and the police who are ignorant to the fact that it’s happening. I’m worried about that in medicine… We’ve recently had an article that medical students at a major university—I’ll tell you, it was the University of Virginia—thought that Black people don’t feel pain the way white people feel.
Black people do it, too. I hear about Black breast cancer as if it’s a proud thing among Black women. They’re talking about triple-negative disease. Last time I looked at it, 20% of Black women have it, and 12% of white women have it. Now, we’re going to claim it as Black breast cancer.
Help me out here. We’ve got to get away from some of these labels, and the bias, and we need to start respecting each other, and being concerned about each other.
RW: I absolutely couldn’t agree with you more. Going back to your first point, it was senseless. The use of appropriate policing is always in order.
In fact, my brother would say that the people who dislike that kind of bad policing are good police.
For me, the only time I’ve had guns pulled out on me has been when I was encountering law enforcement. It wasn’t by a gang or anything like that.
And Henry Louis Gates, remember, when [he was] trying to get into his own house? I only say that to say that class does not protect, whether it’s in law enforcement nor, actually, in medicine.
You and I have talked about that sometimes we have these feelings like African Americans do less well from things like multiple myeloma, until we actually have studies like the ones out of the University of Wisconsin-Madison, and others that are looking at multiple myeloma.
They actually show that if you give the appropriate access to care, it may not be-all-end-all, but it certainly reduces the disparities.
It’s not so much that biology is a major driver, but those things around the biology. I hope that not only will we grow as a society in being much more thoughtful around policing, but I also think that we will take this moment of Tyre’s death to figure out how many of us in the medical community said, or at least stated, that we wanted to be better; that we wanted to do things better after George Floyd’s death. That’s only two years ago.
The reality is, I hope that with Tyre’s death that one of the good things that could come out of this would be for us to take a pause and be all recommitted, as many of us were at the time that George Floyd was also murdered in front of all of our eyes.
And that extends to health care. I think many of us in the cancer world said, “How could we make access to care better? And how can we address these issues?”
Because sometimes, there’s the DWB—driving while Black—but I think that there’s also these same phenomena when we’re talking about our patients. That just simply being Black means that you, in some cases, say, “It’s our biology,” and don’t look at other issues that happen in the context of the ZNA, or the ZIP code-neighborhood association.
Other factors also play a role.
OB: You and I are great believers that the ZNA, or the ZIP code, is far more important than the DNA in many of these issues. And indeed, there are studies going back to the 1990s that show that equal treatment yields equal outcome amongst equal people, but there is not equal treatment.
Let me just go into my disease. Black men who have stage 3 prostate cancer are twice as likely to die as white men in the United States. When they’re treated in American College of Surgeons-certified hospitals that have a cancer program, they’re only one and a half times as likely to die.
When they’re treated in some of the premier hospitals in the United States, equal treatment yields equal outcomes. It’s Black and white one-to-one in terms of outcome.
And so, here we have in prostate cancer, clearly, a problem that a large number of Black men, actually some white men too, don’t get good treatment.
I suspect the same is true in breast cancer. I suspect the same is true in a myriad of cancers. I think the way to overcome implicit bias—and all of us have it—is to realize that these disparities exist, number one.
And two, try to do your best, to give your best care to every patient in front of you. Get back to basic principles. Who was it? Was it [Francis] Peabody who said, “The secret in caring for the patient is caring for the patient?”
RW: Is caring for the patient. Yes.
Otis, you bring up a good point. And you bring up a good point that I think is, as we started this conversation, the broad range of how we can address this issue. Number one, it turns out that just sensitivity training alone for policemen and “sensitivity” or diversity equity modules that get just taught about unconscious bias may not be enough.
What we really ought to get to is what you just said. And some of that can’t be policed, and some of that can’t be driven by law. Some of that’s going to have to be instilled in a culture, of medicine and hopefully, in policing, that every person does count, and that the truth of the matter is to see the person in front of you, not your image of what you think about them.
Now, someone had said the other day, “The Tyre thing is very different than the thing from George Floyd, because, well, with George Floyd, the policemen that were doing that were predominantly white, and in this case, the policemen were all African American.”
And I essentially said that that is actually incorrect. Policemen still see, even whether they’re Black, Asian, or white, based on the way sometimes that unit is taught or the culture of that unit, that they would treat an African American differently than they would treat a white person for the same traffic stop violation. It’s a power dynamic.
OB: And I worry about that power dynamic in medicine as well.
RW: Exactly. And these tags of Black men just come out, “they do worse from prostate cancer,” as if it’s a gospel truth, without understanding that it probably takes more data.
Or that we do worse in lung cancer. We have the data to show it, but the question is, what’s the why? And the why is not frequently as easy as “Well, because I’m Black.”
We usually are fascinated, and we push lots of dollars towards really getting down to the molecular and submolecular levels of science, and molecular therapies. We’re always asking the additional why question.
But it turns out, when it comes to issues around population health, health delivery, implementation sciences, sometimes we don’t have the same patience, and particularly when it comes to health systems—and they’re dealing with collecting data, using data in appropriate ways, and making sure that all people have the access to the same care, in the same manner—those are actually also important questions. I’m not sure that we do that as well as we could.
OB: I’m also concerned that in medicine we are letting the perception of biological differences amongst the races—keep in mind, I think race is a sociopolitical categorization.
Area of geographic origin, there’s some biological differences there, but when we started talking about area of geographic origin, when we talk about Black people or people of dark skin, there’s well over 100 of those in Africa.
When we talk about areas of geographic origin amongst Caucasians, there’s more than 600 of those that have been identified in Europe and Eurasia. So, I think race is just too big a thing, and it’s really sociopolitical.
But getting back to my original point, I think we worry too much about racial differences in biology and not the true racial issue, which is getting all people adequate care.
RW: Recognizing that structure matters. And as we get adequate care, we also have to account for the structures that are sometimes even creating and contributing to the disease.
I am so happy that what you just said is that when we now talk about ancestry and we talk about African Americans with ancestry, we don’t recognize that everyone has ancestry.
If you trace some of this back to ancestral markers as opposed to just Black—for example, I thought that the work from Lisa Newman and Melissa Davis were actually important about women.
African Americans who were considered African Americans with triple-negative breast cancer. What they said about having more Eastern African descent or ancestry as opposed to Western African ancestry, there was a difference in outcome.
I actually think that goes beyond just people who were “Black,” which is a social construct to fit everyone, whether you’re Asian, Latino, or Caucasian.
An awakening and an awareness of that idea will be helpful as we try to come up with new therapies as opposed to using the shorthand Black and using the shorthand white for everything.
As we progress, those tags hopefully will become relics of the past.
OB: I wanted to talk about this later on in this talk, but since you brought up two extraordinary scientists… I personally am very pleased with the young folks coming up and their absolutely amazing contributions in this area to help us understand it better.
I’m especially fond of Lisa because I’ve been able to watch her grow over the last 25 to 30 years.
But what do you think senior leaders in health care, Black and white, need to be doing in this area? And tell me a little about what you think about the next generation of health care. Then I’m going to go back to what I was originally going to talk to you about or ask you about.
RW: Thank you for asking that question. I think that I’m going to make a parallel to what’s happening in law enforcement to medicine.
The first is the reality that more diverse voices at the table do matter, and ultimately, understanding that you’re picking the best and the brightest to be able to fill the jobs matters.
I think in law enforcement, it’s becoming clearer that what happened in Memphis, and the speed in which it happened—of getting the information out, of being able to deal with things—in large part, was because there was a different type of leader at the helm.
I would say that when I think about Massey Cancer Center and I think about the next generation of leaders, having the first woman of color now be the cancer center director at University of New Mexico doesn’t guarantee, but allows for a different voice to be at the table and different perspectives.
Humility, caring about the patient, and awareness that we all have these prejudices—we need to overcome them. I think that’s the solution to giving good high-quality care
Otis Brawley
It doesn’t mean that, as I told someone as a cancer center director here at VCU Massey, that just because I’m an African American doesn’t mean that all I’m focused on is African Americans.
As if I were the governor of the state, I have multiple constituencies to be concerned about, including white rural, and people who are well off.
My number one goal is to make sure that anybody with cancer certainly benefits from having our cancer center. But I don’t want to pretend that I come in different than some of my colleagues—from not just being an African American, but from a class perspective—with also understanding some of the structural issues that are contributing to disease.
Maybe in a more nuanced way than others.
Having said that, I think our future is bright. You have folks like John Carpten. You have, like I said, Melissa Davis, Lisa Newman, Brian Rivers, Chanita Hughes-Halbert. There is a host of new and up-and-coming researchers in the basic science, translational, clinical, and data field.
And I’m feeling very comfortable that if you look at cancer center directors in 1971 and you now look at 2023, we have women, we have people from underrepresented groups.
And as a result of that, I think we’ve made over the last several years significant strides in progress in “normalizing” the concept that while people may look different on the outside, there are some core things that we all have to do to deliver the best, the highest care, and our research matters for all of them.
OB: Getting back to where I was going to go first, tell me what you think of this: I worry about people who mean well, but don’t understand the entire situation. We have people who are pro-life, but once the child is born, they don’t care about the child’s upbringing, and education, and grooming, and health care.
You might say, in so being pro-life, they should say they’re “pro-birth,” because they’re not really pro-life, because life is taking care of the person after they’re born.
We have people who are nowadays going to very resource-poor hospitals that take care of a lot of people who are from socioeconomically deprived backgrounds, and they’re pushing programs on these resource-poor programs to try to help poor people.
For example, I was director of the cancer center at Grady Hospital, which is an inner-city, county facility. It’s a safety net hospital. It’s common now for people to try to go and get places like Grady to do lung cancer screening.
Lung cancer screening is wonderful. It saves lives. It does have some drawbacks that we don’t talk about enough, but it does save lives.
I like to point out the study that shows that it works was done in 30 of the finest hospitals in the country. It showed that for every 5.4 lives you save, you kill one person; so, benefits and harms.
But if you go down to Grady, and you start doing lung cancer screening, you make the line for those four CT scanners at Grady longer. You actually create disparities and worsen the care of people who need that CT scanner by making the line longer.
And by the way, the current director of the cancer center at Grady constantly has folks saying, “Why aren’t you doing lung cancer screening?” I just told you why. That’s just one example. We have a medical system that is segregated by socioeconomics, and separate cannot be equal. Separate is not equal.
People who are poor who go to these resource-strapped hospitals and clinics do not get the same quality of care as people who go to the places that accept the private insurances. And I’ve been preaching, you can respond to that.
RW: Your point is well made. 85% of the people don’t wind up in NCI-designated cancer centers and academic centers. They’re being treated in the community setting.
And yet, these folks in the community setting frequently are under-resourced. As you just said, we’re layering on top what they should be doing without layering on additional resources for them to get the job done. Dr. Brawley, you know this.
We first met when I was in Chicago at University of Illinois where I had a dual role of being a cancer center director there. I was director of the University of Illinois Cancer Center, but I was also the associate vice president at that time of community-based practice, which is a fancy title.
I ran the network of Federally Qualified Health Centers, which came to be as part of the act on making sure in the 1960s that people had access to care, poor people in particular. There would be well-intentioned scientists who wanted to do studies within the FQHC settings.
When they would come in, well-meaning, well-intentioned, they would never-ever come with additional resources that wouldn’t disrupt my team.
Once I remember famously saying to someone, “I love your research. I’m sure it’s going to be of value, but the reality is the number one job of my team in this FQHC, at this site is to see patients that are, by the way, lined up in the hallway to be seen. If they’re not seen here, then they wind up in the emergency room. So, if you want to do research, what additional resources are you going to bring to the table so that you don’t disrupt?”
I would actually say the same thing is true with most of our community hospitals. The ACCC is doing a wonderful job in shedding light that there are community hospitals that have resources, but there are other community hospitals that do not. We are fooling ourselves that we’re giving the same care. It’s not even separate and equal. It’s separate and unequal in most cases.
And we have to do a better job from policy perspectives on how the academic centers can partner better, how there will be better policies, how we can get more resources that are used appropriately to do those things that we know can help.
But until we bring resources to the table, I think it’s unrealistic to have our community hospitals be mini, if you will, NCI-designated cancer centers. It just will not work.
OB: We’ve covered a couple of issues here, Dr. Winn. There’s a bunch of folks who are out there and who say we must get more minorities in the clinical trials.
But they ignore the fact that 97% of Americans don’t go on the cancer trials, by the way, Black or white, 95% plus don’t. And those who don’t go on the trials, frequently, if they’re a minority, or poor white as well, don’t get adequate care.
They push clinical trials, but forget about the fact that a lot of folks aren’t getting adequate care. They push screening programs that are of low yield.
Yes, they do save lives, but they’re of low yield when you look at the community as a whole. They tie up resources like CT scanners and pathologists and so forth and bog down the system and make care for other diseases worse. And we got to think about all of these things.
And then, of course, there’s the folks who are heavily into the biological differences amongst the races, which we’ve just talked about. All of these things to me—and I’m linking this to Tyre Nichols—those -isms that caused those police officers to beat that poor man.
We have our own version of those -isms in medicine, a lot of them—a lot of them that lead to biases that lead to misapplication of science.
Keep in mind, sometimes it’s the willing who do the wrong thing even; I mean good people who want to do the right thing, and they just don’t understand.
RW: Or, it’s attributed to Mark Twain. “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”
And frequently, we go in without the flexibility, the curiosity, the humility of being able to set these programs up. For example, I still think that there is a role for not only screening, but prevention—the resources and the voices needed to garner the resources.
We need to employ not just prevention in well-to-do places, but prevention all over is a good strategy.
Second, we do have to think about the reality that there are a bunch of -isms. We have -isms for “This person won’t go on trial. Well, because they’re Black.”
We have the -ism of, “Well, even if we screen this person, what are we going to do,” without actually saying, “If you’re going to screen, you ought to actually have the arc of screening that leads to the diagnostic screen, then to the therapy, and the treatment already in place.”
These -isms are frequently in the way of why—as we know through history and literature—people are offered certain therapies and others are not.
Not because they could or couldn’t, but because they were never asked.
And by the way, at the end of the day, in addition to race issues, there are class issues.
And what’s not being talked about with Tyre as well, is not only his African American status, but class.
When you start looking at both of those intersectionalities of being Black in America as well as being poor, whether you’re talking about the hollers of Beattyville, Kentucky, or you’re talking about the South Side of Chicago, there are more similarities in those two groups. And yet, we fail frequently to speak about that.
When it comes to policing—the data’s there to vet it out—African Americans certainly got pulled over more and treated more harshly, whether they have money or don’t have money.
But I guarantee that if you’re Black and you’re poor, that becomes an issue. The structural issues that we go in with our pre-biases, that extends well beyond law enforcement into what we do also in medicine.
The way to fight it is to first be cognizant of it, and then be able to hopefully develop these conversations where policies will help us get through this that don’t exist today. Hopefully with some thoughtfulness and some action, we can do better.
OB: Wrapping this up, you said a word that I just want to reemphasize, and that was humility.
I should point out, I don’t think you have to be Black to take care of Blacks.
As a matter of fact, my uncle, who was not a very educated man, but had some experiences in the health care system, used to always talk about how Jewish doctors understood him and took care of him well, because they cared.
He would talk about the history of what Jews have gone through in terms of persecution and so forth as one of the reasons why they cared, understood, and felt what the patient in front of him felt.
Now, that may be a little racist in itself, what he was doing, but I actually do think the point about humility, the point about caring about people, or just giving a damn, and the awareness that you might have some of these prejudices, and we all have them, is really important.
Humility, caring about the patient, and awareness that we all have these prejudices—we need to overcome them. I think that’s the solution to giving good high-quality care, no matter if you are a physician, a surgeon, a nurse, a medical student, a respiratory therapist, or a lab tech. Humility, caring about the patient, and then having awareness that we have these problems and trying to tamp them down.
I’m going to let you have the last word, Dr. Winn.
RW: Thank you for that. I’ll add only one thing, and that is having diversity at the table. I think when you can see your neighbor, whether they look like you or they don’t, and you can see their humanity, we tend to be much better off than when we don’t see each other’s humanity.
The only way to do that is by being mindful that access, not only to care, but access to becoming physicians, access to becoming directors of cancer centers, access to becoming deans, all that put together matter. We can disagree, but if you’re my neighbor, and I see you, and I get to hear you and your unique different viewpoints, I’m more likely to hear you and your differences. I’m more likely to hear a counter-argument from someone who I know and have humility and respect for than from someone who I don’t.
Michelle Obama said it better: “We have to do a better job of getting to know our neighbors, even those that we don’t actually agree with.”
We need to hear counterpoints so that we may actually be able to sharpen even our own ideals about why we think the way we do.
So, thank you for the opportunity, Dr. Brawley, to talk about this. The last word for me is not only may Tyre rest in peace, but hopefully, this déjà vu will be different. We will, hopefully, at a minimum, come out of this with some reasonable, practical laws that should have been put in place after George Floyd’s death.
We can only hope that it not only stimulates a change in law, but we can learn that there are also areas in health care that we need to work on so we can be our best selves for the patients we serve.
OB: Thank you. This has been a discussion about health care and lessons for health care from the unfortunate events of the last several weeks involving the beating of Tyre Nichols.
I want to thank Dr. Robert Winn, the director of the Massey Cancer Center at Virginia Commonwealth University and professor in the medical school at Virginia Commonwealth University, and February’s guest editor of The Cancer Letter.
I’m Otis Brawley. I’m the Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins, and I am the co-founder of the Cancer History Project. Thank you.
