Below is the text of an abridged version of my talk for the opening plenary session of the Association of American Colleges’ first national summit on Inspiring Intersections. You can also watch a video of the talk here.
I have many fond childhood memories although I concede I have none without the presence of my younger sister, Rubab. Rubab joined me in voicing our reluctance to wearing matching bright yellow or polka dot sundresses yet again. And she joined me when we easily succumbed to our mom’s pleas who had lovingly sewn the dresses using fabric bought at the flea market nearby. Rubab was also there, anxiously watching when I brazenly pushed out the furniture from our dad’s “office”. I was determined to claim all fifty square feet as our first bedroom and I’m sure my sister was also excited to no longer wake up in the middle of the night on the living room sofa bed with my feet suddenly two inches from her face. Upon entering the apartment and seeing the desk, chair and piles of cardboard boxes strewn across the floor, my mom looked utterly shocked and my dad’s eyes surprisingly betrayed only amusement before agreeing to take Rubab and me out the next day to buy a bunk bed.
The following morning, my sister and I giddily skipped down the sidewalk ahead of our dad towards the furniture store. We abruptly stopped when hearing the screamed words, “Go back to where you came from!” followed by the four-letter F word that no ten-year old should ever hear being hurled at her father. The year was 2001 and the tragic events of 9/11 had just taken place a few weeks ago. Several days later my mom, with sunken eyes, told me that someone had broken the windows and spray painted “Terrorist” on my dad’s small perfume store in Manhattan. After years of saving up while working as a NYC Yellow Cab driver, my dad was forced to close down the store after his business partner, very shaken up by the incident, suddenly moved back to Pakistan.
In the months that ensued, I was warned to no longer walk outside in the neighborhood wearing shalwar kameez or to go to the mosque nearby for my weekly Quran classes wearing a hijab or to openly discuss politics of any kind with other people. The constant threat to safety lingered in my mind while at the same time I grew particularly conscious of my identity as an “Other”.
Growing up, I saw firsthand how one’s race, religion, gender, or socioeconomic class could render one disproportionately vulnerable to assaults on one’s well-being and health. Whether its having your body be in a state of “perpetual crisis”, or not being able to adequately nourish yourself through food and exercise because of financial constraints or safety concerns, or more simply, not having the luxury to take time off from work for a doctor’s appointment, your identities inevitably intersect in a manner that uniquely shapes your lived experience. And as the intersection of marginalized identities magnifies the risk of exposure to structural and physical violence, it’s crucial that we engage in relationships of healing individuals or advocacy with communities at large in a truly intersectional manner.
Both personal and academic experiences eventually led me to choose the field of medicine as my future profession. I learned how poor health can adversely impact every facet of one’s life and how one’s health is actually largely shaped by forces outside of the walls of the hospital. Yet, I was eager to join a profession that gave one the unique privilege to directly alleviate physical and mental suffering while elevating the human story—imbued with complexity and beautiful nuance—in the process.
When I first enrolled into medical school fall of 2013, I was disheartened by the dearth of instruction on domestic health inequities. In response, a fellow classmate Robert Rock, who was born to Haitian immigrants and also hailed from Queens, NY (coincidence?) joined me as we spent months meeting with faculty members, administrators, and, more importantly, local community leaders, to muster support for a course on US Health Justice. That summer we developed the curriculum for an eleven session pilot course with the aim of providing students from not just the medical school, but also from the nursing school and the physician associate program, with the critical knowledge and skills to provide equitable patient care and to engage in meaningful advocacy to ensure that structural determinants of health are appropriately addressed both within and outside the clinical setting.
Since the pilot, the course has grown tremendously in size and impact, with less than half of applicants now accepted due to resource constraints and ten student leaders who have agreed to spearhead the continuous revamping of the curriculum to make it ever more rigorous and relevant. However, despite this success, we still have a lot of work to do. Only less than a quarter of the pilot curriculum has been integrated into the main curriculum for all medical students so far and, hence, only a self-selected group of students are getting this crucial training on how to effectively practice medicine with the understanding that factors like race, gender, or class significantly inform the lived experiences, and consequently, health of our patients.
We already know that the continued lack of such training contributes to the incongruence between people’s expectations of the practice of medicine and the reality of the practice of medicine. This incongruence has been shown to play a role in the rising rates of physician burnout. And, sadly this gap in knowledge and skills, frustrating for physicians and dangerous for patients, will continue to persist unless medical schools institutionalize the curricular reform on issues related to social justice and health inequities that is still, to a large degree, led by medical students across the country.
But, if we really want to be successful in addressing the multifactorial causes of health inequities, we need to address bias. And I don’t mean just acknowledging that we as humans all have implicit or unconscious biases but recognizing that in the context of policies and structures that have institutionalized racism, sexism, religious bigotry, and so forth, our biases wield immense power and harm to the very people whose well-being we are entrusted with. In response to some painful experiences I myself had with encountering bias during the medical school interview process, I felt compelled to co-found Systemic Disease. Systemic Disease is an initiative seeking to promote dialogue and healing around issues related to bias in medicine while pushing for all health care providers and those in-training to actively work towards countering biases in patient care and beyond so that we don’t continue to have health injustices such as stark racial disparities in treatment of pain or gender gaps in post-MI rates of mortality and morbidity.
Yet, in order to effectively counter the impact of bias in our clinical interactions, it’s imperative to also counter the impact of bias in our learning and training environments. Ensuring that the makeup of our patient populations is appropriately reflected in the physician workforce and, in particular, the leadership of those entrusted with training the future workforce, is vital. There were reportedly fewer Black men in medical school in 2014 than in 1978. Meanwhile, while approximately 60 percent of medical students come from families with incomes in the top twenty percent of the nation, only three percent come from families with incomes in the lowest 20 percent. And women are still less likely to get full professorship or get paid equally to their male counterparts in academic medicine even after adjusting for factors like age, experience, specialty, and research productivity.
That is why the time is now for equity in medicine. As physicians, we freely get access to people’s most intimate and vulnerable moments while being treated with great respect in not only clinical encounters, but also in other social and political spaces. With that privilege comes great responsibility and we can no longer afford to remain silent in the face of heightened vulnerability for many in this country.
When we have 3.4 million undocumented homeowners who are struggling to look into who can replace their names on their leases and take custody of their children in case they are deported amidst the recent onslaught of ICE raids. When we have reports of increased anxiety, depression and PTSD among Muslims, immigrants and members of other groups targeted with violence and intimidation that escalated under the current President’s election campaign and further worsened under the Muslim Ban. When the incidents of anti-black hate crimes and black lives lost to police brutality are actually higher this year than they were two years ago. When there are ongoing threats to federal funding for basic reproductive health services for women and to welfare programs such as Meals on Wheels that strives to prevent the elderly in our country from going hungry. And when 24 million Americans are at risk of losing health care if the GOP health care bill is passed.
If not now, then when?
Pictured from left to right are Dr. John Sanchez (Assistant Dean, for Diversity and Inclusion at Rutgers NJMS), me, Dr. Feranmi Okanlami (incoming physician at Michigan Medicine), Dr. Michelle Guy (Professor and GME Director of Diversity at UCSF School of Medicine), and Dr. Darrell Kirch (President and CEO of the Association of American Medical Colleges)
Tehreem Rehman, MD MPH 