Recognizing and addressing disparities in health care with Camara Phyllis Jones, MD, MPH, PhD [Podcast]

. 16 MIN READ

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AMA Update

Recognizing and addressing disparities in health care with Camara Phyllis Jones, MD, MPH, PhD

Mar 2, 2023

Camara Phyllis Jones, MD, MPH, PhD, a family physician, epidemiologist and anti-racism thought leader, is well-known for her allegories on race and racism. In this AMA Update episode, she joins AMA Chief Experience Officer Todd Unger to discuss specific ways physicians and medical students can advance health equity and address systemic disparities in medicine.

Speaker

  • Camara Phyllis Jones, MD, MPH, PhD, a family physician, epidemiologist and anti-racism thought leader

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Unger: Hello and welcome to the AMA Update video and podcast. Today, we're discussing specific tools that medical students and physicians can use to help advance equity in medicine. I'm really pleased today to be joined by Dr. Camara Phyllis Jones, a family physician, epidemiologist and antiracism thought leader.

I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Jones, how great it is to have you here today.

Dr. Jones: Oh, thank you for inviting me to join you.

Unger: At a recent AMA-hosted event with a large group of medical students, you discuss tools to help these students navigate valuing and prioritizing social justice work as they make their way through medical schools—and medical school and on their way to clinical practice. Let's just start with a question, why are students so pivotal to addressing current barriers? And what tools are at their disposal at this point in their career?

Dr. Jones: Well, I would say that all of us are pivotal, so I wouldn't elevate students above everybody else. I think we all need to become social justice warriors. But the opportunity to influence students while they are still forming their professional identities is the most important thing, and we don't want them to learn bad relationships or bad assumptions.

We want them, as young and open as they are, to value all individuals and populations equally, to recognize and rectify historical injustices, to understand the importance of providing resources according to need. So I'll speak to anybody. I'll speak to old folks, babies. And so it was my opportunity to speak to these medical students recently.

Unger: Well, to your point, whether you're a student, physician, wherever you are in your medical career, all individuals can be part of the solution, but I think what you've said many times is this—it's really a system level issue. How do we go about addressing system-level problems like this?

Dr. Jones: It's, first of all, to understand that we as individuals have tools that we can use. We can advocate for a patient. We can stay longer, ask deeper questions, check the labs twice, that kind of thing. But the real power is in collective action, and in this country, we have been so inculcated with this narrow focus on the individual that sometimes we don't recognize that collective action informs us, inspires us, propels us, protects us.

So the first thing is understanding that you don't have to take on the system by yourself. The second thing is you need to name a problem before you can even get started on the solution. So we have to name racism. My work is on naming, measuring and addressing the impacts of racism on the health and well-being of the nation and the world.

And so we have to be prepared to say the whole word, but as necessary as it is to name racism, it's necessary but insufficient. We have to take that second step, which is, really, to your question, we have to ask the question, how is racism operating here? That's how you start understanding the mechanisms of the system that would be most amenable to immediate action or targeting or levers for intervention.

So how do you answer that question? By looking at structures, policies, practices, norms and values. And I gave most medical students and physicians a big headache right there. Until we recognize that all of those are the mechanisms of the elements, I would say, of decision making—so structures who, what, when, and where of decision making, especially who's at the table and who's not, what's on the agenda, what's not.

Policies are the written how of decision making. Practices and norms are both the unwritten how of decision making. But practices are unwritten but you just watch me. You'll see how we do things here whereas norms are much more deeply embedded and how we've always done things, and how we expect you to do things, going forward. And values are the why of decision making.

So in order to address structures, you just ask those questions of who, what, when, where, how and why of decision making. And in five, 10 minutes you can identify some promising levers for intervention targets for action. And then the third step, after naming racism and asking how is racism operating here, is to organize and strategize to act because, yes, we do have individual power.

We have wheel houses. We can speak up. We can put things on agendas. We can advocate.

But when we come together, that's when we start sharing leadership, but we don't have to always be that goose in the front of the V that's breaking the wind for everybody. But when we get tired, somebody else can take that place. That's when we can have a long, sustained effort, the kind of long, sustained effort we need when we're addressing racism.

Unger: Now, one of your particular techniques to help people understand what you just kind of referred to, these system-level examples that identify racism, is through your unique brand of storytelling. Talk to us a little bit about what your approach is and why that's so effective.

Dr. Jones: Thank you for that opening. I love my allegories, so I first started using allegory many years ago before medical students were born. So I won't even say. But when I was teaching at the Harvard School of Public Health—and these allegories are basically sparked by images that I've seen with my own real eyes that left me going, hmm.

So they weren't about racism. It's just images that I had, but then when I—I developed the Harvard School of Public Health's first course on race and racism, way back in 1994 to 2000 is when I was there. And as I was trying to help people understand—for example, three levels of racism with my "Gardener's Tale" I found myself pulling these images out just because I am a teacher.

Honestly, it's just a teaching tool, and I'm trying to make things that seem complex or inaccessible to people very real with things that they would have also seen with their own real eyes. So that's how it started. It was just because I'm a teacher and I was trying to talk to people about racism. And I had all these images. Anytime I see anything, I might have 100 weird images floating around in my head, but then when I'm called to explain something, then I can use one of those.

Then I went to a meeting that was about storytelling in medicine and I realized that everybody else's storytelling was narrative storytelling, which is also a very powerful kind of storytelling. But I realized that the difference between narrative and allegory is that, if a narrative feels too distant from the listener, they may discount that narrative. If it's out of their experience, they may say, oh, that's an exaggeration, or that didn't really happen, or you have a chip on your shoulder or whatever.

But when I'm using images that all of us can see, a two-sided sign, flowerpots, one with rich, fertile soil and one with poor, rocky soil and flowers, for the seed for the same kind of flowers, ending up in the different kinds of soil and what we see with that, or on and on and on. People can remember those and they can relate back to them. And they can share them forward, which is really my goal.

Unger: Let's talk about one specific one that you've talked often about, which is called dual reality—a restaurant saga, which came from an experience that you had when you were in medical school. It sounds like this might have been a little bit of an aha moment for you, but tell us more about it.

Dr. Jones: So basically, it was late one Saturday. I had been all day studying with friends. We were hungry. I had no food in the apartment. We go into town to find something to eat.

We walk, and we sit down. The menu is presented. We order our food. Food's served. We're sitting there.

Not a remarkable story about racism until I just happened to look up across the room and I noticed a sign that said open. But that was a startling revelation to me because I knew something about the two-sided nature of those signs and recognized that the restaurant was not open, even though I was sitting inside the restaurant at the table of opportunity, eating.

And all indications, the sign declared open to me and if I hadn't thought more about it, I would have just assumed somebody else could walk in, sit down, order their food and eat. But because I knew that these were two-sided signs, I recognized that now, because of the hour, the restaurant was, indeed, closed and that other hungry people, just like me but just a few feet away from me on the other side of the sign, would not be able to come and sit down, order their food and eat.

And that's when I recognized that racism structures, open-close signs in our society. And so then I go off on that. And in fact, I've embellished it very recently to also use that image of a dual reality to talk about the distance between those who value comfort and those who value social justice.

I know we don't have time in this setting to go into that, but it's—so the other thing about allegory is, I will say, is that, once I put them out, they're ours. So it's not my story.

I'd like to be credited with my stories. People have been taking different pieces of my stuff without my permission or my voice. And so that happens, and it's not good. So stop.

But once I put it out in a room, then all of us can poke at it, embellish it, elevate it, bring new insights, which is also why my oldest allegories are the ones that are the longest in the telling because I have learned so much over the years in the telling from the questions and insights. And I like to share those on.

So the dual reality used to be five minutes and now it might take me 10. "Gardener's Tale" started with five or six minutes, and now it takes 20. So anyway, there's a lot of learning to be done in the allegory and the story is ours.

Unger: So let me just ask you a question. First of all, somebody has to know what an allegory is. I had to look that up. I'm embarrassed, but ...

Dr. Jones: It's a teaching story, like—

Unger: I got it now.

Dr. Jones: --like a parable or teaching story, yes.

Unger: I guess they have a universality about them, kind of to the point that you were making before. Some people might have a harder time making the connection necessarily to, let's just say, medicine today. So talk to us a little bit about how that particular allegory that we were just talking about is relevant to medicine today and if you have any kind of specific examples.

Dr. Jones: Well, the allegory that I was talking about helps us understand that it is difficult for anyone to recognize a system of inequity that privileges them. So those who are sitting in the restaurant at the table of opportunity, eating, and look up and they see a sign that says open may not—they may be in staunch denial that there's a two-sided sign going on.

Or they may have a hint that there's a two-sided sign going on, but they are passing laws all over the country to not even look at the other side of the sign—does it really say closed—because it might make their children uncomfortable. But anyway, so that's true for all different kinds of systems of structured inequity—racism, sexism, heterosexism, and the like. So the first thing is to recognize that we need to actively look for evidence of two-sided signs.

Even if a sign proclaims open to us, think about it. There would not need to be assigned proclaiming open unless it were a two-sided sign and it were closed to others. If you walk out into the wilderness, we don't have signs that say open unless you can't go on the other side and it's trespassing.

So the very proclamation strongly that this is an open society already tells us that it is not so for everyone. But when we're seeing patients or whatever, we need to be careful to not underestimate the closed signs that our patients or our colleagues might have encountered which are open to us. People only notice the highest level of closed sign that they encounter and all the open signs they basically ignore as irrelevant.

Unger: Dr. Jones, why right now in this time when we're emerging from at least the acute phase of the pandemic? Is it the right opportunity to prioritize this work? And from your standpoint, what's the urgency that's driving this? And where do you see the greatest opportunity for change?

Dr. Jones: You ask three questions, so I will—

Unger: I did.

Dr. Jones: So first of all, there has always been an urgency to name, measure and address the impacts of racism on the health and well-being of our nation and the world. But some people have been beguiled—I will say that racism denial is so staunchly held by so many in this nation, even though racism is foundational in our nation's history and in its wealth and development.

So it is no more urgent now than it has been for the last 400, 600 years since people came and took the land, and did near genocide on Indigenous North Americans, and then the kidnapping of West African people and our importation across the Atlantic with tremendous loss of life in the Middle Passage, and then for centuries for the survivors and their progeny, what I describe as the coerced usury of our unpaid labor for centuries to build this country.

So it has always been an urgency. So it's—I am actually not amused, actually dismayed, that it took COVID and the disproportionate impact of COVID-19 on communities of color to have some people wake up. And then other people woke up with a very brutal public murder of Mr. George Floyd in May of 2020 and COVID sweeping through, starting in March of 2020, and people recognizing the disproportionate impact starting in April.

So why does that kind of irk me? Because the infant mortality disparities that we've been documenting for centuries are the same thing. The maternal mortality rates, the differences in asthma prevalence, and the like, these are all signals of differential life experiences, life chances of racism, which is a system of structuring opportunity and assigning value based on so-called race.

All of these things have been signals, but we have become so inured to that—we have become so used to documenting these race associated differences without vigorously investigating the root causes of the differences that we have either biologized them in our minds or felt that we couldn't touch them.

But then here comes a new infection. We know nobody on the planet has been exposed to it before and we see the same thing. And then we're like, oh, something's going on here. But that same thing is going on for all of the race-associated health—differences in health outcomes that we have been documenting for centuries.

So it is no more urgent, but I'm glad that more people are paying attention. And perhaps, when I talk about racism, there are three impacts that I describe. Racism unfairly disadvantages some individuals and communities, but every unfair disadvantage has its reciprocal unfair advantage. So it also unfairly advantages other individuals and communities.

But the third impact, how racism saps the strength of the whole society through the waste of human resources, that is the one that might—once people recognize that, once we have more media stories about that, once we have more data collection evidencing that, once we have more conversations around our boardroom tables and dining room tables, that fact that racism does sap the strength of the whole society may sustain the urgency that was piqued a little bit in 2020.

Unger: Dr. Jones, just last question, are there any key messages that people really should take away in regard to racism?

Dr. Jones: Yes, actually, I would say there are four key messages when we're naming racism, when we're confronting racism denial. And they are that racism exists. Racism is a system. Racism saps the strength of the whole society. And yes, we can act to dismantle racism.

Unger: Well, thank you so much. That is a great way to end today's episode. Hey, thank you so much for sharing your wisdom and your allegories, which I now know exactly what that means, and what a great approach for really shining a light on this problem and really appreciate you being here today.

That's it for today's AMA Update. We'll be back with another episode soon. In the meantime, you can see all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today and please take care.


Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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