|The Doctor of Prejudice|
|The Doctor of Prejudice|
|By Beth Schwartzapfel '01|
When Augustus A. White III arrived at Brown in 1953, he joined a student body as whitewashed and WASPy as a beach house in Kennebunkport, Maine. Hillel House wouldn't open for another decade. The first woman, the first African American, and the first Jew on the Corporation's Board of Fellows would have to wait until 1969. White was one of only five African Americans in his class.White was not the sort of young man to complain, though. "We, Brown's African American students, didn't feel affronted by this plain discrimination," he says. "Quite the opposite. We felt happy to be at a place so liberal that it accepted Negroes at all."
Almost sixty years later, the University has an Office for Institutional Diversity. The students and, to a lesser extent, the faculty members walking across the College Green on any given day hail from all over the world and have parents and ancestors from every imaginable race, background, and religion. Students arrived on College Hill this fall from more than 100 countries. Thirty percent of undergraduates are nonwhites.
And we have Gus White to thank for that.
The influence White'57 has had on Brown's racial and ethnic diversity reflects the steady, deliberate effort of an unlikely pioneer. A groundbreaking orthopedic surgeon, he was the first African American medical student at Stanford, the first black surgical resident at Yale, the first black professor of medicine at Yale, and the first black department chief at a Harvard teaching hospital. One of the nation's preeminent experts on the biomechanics of the spine, White has coauthored textbooks that remain seminal references for surgeons and clinicians. When his book for a popular audience, Your Aching Back: A Doctor's Guide to Relief, appeared in 1990, the New England Journal of Medicine decreed that it "should be read by every person afflicted with low back pain, and perhaps everybody."
Despite these accomplishments, it would be difficult to find a more modest man than Gus White. His perpetual optimism and quiet good cheer have been key to his acceptance in places normally inhospitable to African Americans. Yet he has never for a second forgotten how lucky he has been to be in such places, or how essential it is that he use his position to make more space at the table for all victims of prejudice.
For Gen Xers and Gen Yers who were raised on Martin Luther King Day assemblies and class projects about Harriet Tubman and the Underground Railroad, diversity is sort of like puppies and rainbows. We take for granted that it's desirable, good, even quaint—with all the jadedness that last word implies. But Gus White wants you to know that despite the huge strides we've made—including the first black president, both at Brown and in the White House—we still have a long way to go. In fact, White argues in his latest book that our ongoing lack of both diversity and good cross-cultural communication is making us sick. Literally.
Since his retirement from the operating room in 2001, White has taken on a medical issue that he says is far more difficult to solve than even the most complicated spinal problem. A combination memoir and manifesto, White's new book, Seeing Patients: Unconscious Bias in Health Care, lays bare the troubling and insidious ways that prejudice gets in the way of good medicine.
If you want good medical care in the United States, White asserts in Seeing Patients, your best bet is to be a young, fit, straight, white, and middle-class male. He means this as a wry joke—and, when he repeated it at a lecture this summer at Boston's Brigham and women's Hospital, the audience chuckled on cue—but it's also true. The time it takes for EMTs to transport women to a hospital after a heart attack, he told the audience, is longer than it is for men. Hispanics receive fewer bypass surgeries for heart disease than other patients and fewer basic health-care measures such as flu vaccines. Similarly, African Americans receive fewer kidney and liver transplants than other patients, and more castrations when they have prostate cancer. African American diabetics undergo more amputations than other groups, White says, and Native American, immigrant, obese, and homosexual patients all receive inferior care simply because of who they are. And this remains true even after researchers control for such complicating factors as education, economic class, and insurance status.What's going on here? How is it possible that a country with one of the most advanced health-care systems in the world is failing such a large proportion of its patients?
The answer, Gus White says, lies in our nation's history, and also within ourselves.
Gus White's grandparents were born into slavery. In the segregated Memphis, Tennessee, where he grew up, the legacy of that recent past was everywhere. The city had its black middle class, White recalls in Seeing Patients, but "the white world did not mix with the black and the black did not mix with the white." Although White grew up as an only child in that middle class—his physician father graduated from the all-black Meharry Medical College and was a house physician at the local black hospital—his family had to use colored bathrooms and colored water fountains. White and his friends watched their favorite Westerns at all-black movie theaters so they could avoid having to sit in the balcony at the segregated ones. At the hospital where White's father worked, even the blood at the blood bank was segregated. As a young boy delivering the black newspaper the Pittsburgh Courier, White occasionally saw front-page photos of the lynchings that were still commonplace. On those days, he writes in Seeing Patients, "I didn't want to take the newspaper around. I didn't even want to handle it."
Still, the middle-class black community in Memphis was committed to "advancing the race." Teachers at the black schools stressed that "education was going to drive forward our right to equality that we had been struggling for so long to achieve." White's mother, Vivian, and his Aunt Addie were proud women who refused to be belittled or underestimated.
As a teenager working at a drive-in movie theater, White and his friends clashed with white workers who took to calling them "darkies." When they retaliated by calling the white workers "Nabisco Boys," the workers followed White and his friends home one night in their car, shooting BBs and shouting curses.
After White's group was attacked, "Mom and Aunt Addie practically had a fit," White recalls. "Vivian White and Addie Jones were not going to take this kind of thing, and after some discussion they made it clear that I was not going to take it either." The next day they drove White to work and gave a stern talk to the manager of the drive-in, who ensured White's safety for the rest of that season and the one after it. "I didn't know at the time that this incident would stay with me for the rest of my life, but what a lesson it was," White notes.
When White was eight years old, his father died suddenly, and he and his mother were forced to move from their two-bedroom house into the home of Aunt Addie and her husband, Uncle Doc, a pharmacist. The family doubled up on couches and cots, and White's college-educated mother got a job as a secretary at a high school, where she eventually became a teacher. Still, as White writes in the book, "My father's death when I was so young meant that most of my relationship with him ended up being my relationship with his reputation," and the question he heard more often than any other was, "You going to be a doctor like your dad? Your dad was a fine man, a great doctor."
A bright and a diligent student, White at thirteen left Memphis for the Mount Hermon School for Boys, an exclusive New England prep school (now Northfield Mount Hermon). Students earned tuition money by waiting tables and sweeping floors. Although he suffered from culture shock at this tiny northwestern Massachusetts enclave, he thrived at Mt. Hermon, singing in the choir, excelling academically, and earning varsity letters in football, wrestling, and lacrosse.
In 1953 White opted for college at Brown. "Brown had good athletics, highly regarded premed studies, and, my grapevine informed me, they not only took Negroes, they treated them well," he writes in Seeing Patients. "Four or five each year. Never more, but never fewer, either."
At the University, White worked grueling hours in order to play football—he was a varsity offensive and defensive end—while simultaneously earning high grades in his premed studies. When psychology professor Anthony Davis helped White research and write an honors thesis, it "increased my level of confidence by several magnitudes," White writes.
He also became the first African American fraternity brother at Brown when he rushed Delta Upsilon. And it was because of White's designation as the Brown DU chapter's delegate to the 1956 national convention, to be held in Vermont, that he and his fraternity brothers received the following telegram: "the middlebury chapter regrets that due to circumstances beyond its control... it is necessary to postpone the delta upsilon convention... until 1957." (Thirty years later, the fraternity formally apologized to White. "I can tell you that the delivery and celebration of justice does feel good to all concerned," White writes. "No matter how long you might have to stick around to see it.")After graduation and medical school at Stanford, White did an internship at the University of Michigan Medical Center and an orthopedic residency at Yale. But soon he was forced to confront yet another foreign world.
In August 1966, White arrived in Vietnam as a combat surgeon. Subject to a special doctors' draft, he could have found alternative service but opted not to. He wanted to "jump over there and do what I could," he writes in Seeing Patients. While he was in Vietnam, he couldn't help but notice that he was "seeing more wounded black soldiers than I might have expected. . . . What I heard from the black troopers was that they were more likely than not to be chosen as point men when they went out on patrol."
As a respite from the brutality, White volunteered at a nearby leprosarium, performing surgeries to help patients regain some mobility in their crippled hands and feet. "For me, the St. Francis Leprosarium was an oasis," he wrote. "After all the blood and gore, it seemed almost a place of meditation. . . . In many cultures leprosy is regarded with such horror that if anybody just makes eye contact and looks at lepers and acknowledges them as human beings, they are profoundly grateful. And if you help them? You fix them up? . . . The feedback is incomparable. . . . I didn't know who was helped most at that leper colony—the helpers or the helpees."
On the bumpy jeep ride out to the leprosarium, White writes, he would reflect that "at the hospital I was seeing the worst that man can do to man, then I go down the road to see the worst that nature can do. Man's inhumanity to man and nature's cruelty to man—both of them an absolute bitch."
The "equal opportunity employers"—pain and death—that White saw in Vietnam helped crystallize one of his most resonant realizations about race and humanity. He writes, "Our humanness supersedes our cultural issues, our difference in status or rank, our racial selves. A superior officer, a trooper, black, white—under the knife they're all the same. . . . In the final analysis, that's all we are—human."
After his surgical residency, White spent eighteen months earning a PhD in orthopedic biomechanics at the Karolinska Institute in Sweden. It was there he met his wife, Anita, a Swede, and it was also there, he realizes in retrospect, that he made a formal commitment to promoting diversity in medicine. In Sweden, he says, race was simply not an issue.
"Nobody cared," White recalls. "When people said hello, it was just hello. Not hello—I see by the color of your skin that you are a white person; what kind of white baggage might you be carrying toward me? Or, hello—I see by the color of yours that you're black; wonder what kind of baggage you might be carrying toward me?"
White knew that one of the reasons race isn't an issue in Sweden is that there is essentially only one race there—something neither possible nor desirable in the United States. But Sweden gave him a glimpse of true equal opportunity for African Americans, and he resolved to make medicine a more welcoming profession for blacks. He joined the admissions committee at Yale Medical School, where he was about to become a faculty member, and began advocating on behalf of qualified black applicants who might otherwise have been overlooked.
To this day, White notices that too many black students play down their accomplishments, underestimate their own worth, and try to blend in and be as inoffensive as possible, with the result that they are hesitant to speak up and share their ideas. When he meets such students, White invariably asks them a favorite question: "Do you know that you're a national treasure?"
Some years later he and a handful of his peers founded the J. Robert Gladden Orthopedic Society, a group of African American orthopedists who saw the need for "an effective platform for sharing concerns and research both among ourselves and with the larger orthopedic community."
"I'm aware of only one or two organizations that are similar," says former Secretary of Health and Human Services Dr. Louis Sullivan, "and none that I believe is as viable or active as the Gladden society."
After White became a Brown trustee in 1971—he later served on the Board of Fellows from 1981 to 1992—he began to realize that "diversity was a black question, yes, but not only a black question." Increasing the number of underrepresented minorities in a given community, he argued, not only benefitted those minorities; it also enriched the community as a whole. All people, he writes in Seeing Patients, "should be willing to share knowledge with each other and learn from one another and teach one another, to achieve better understanding of cultural differences and the implications of them, and to appreciate the importance of working together and getting beyond the isolation of cultures from each other."
Seeing Patients is full of stories—some funny, some not so funny—of things people have said and done before realizing Gus White is black. (A woman he once dated assumed he was Puerto Rican. When he told her he was black, she slumped down in her chair in tears and asked, "Are you absolutely sure?")
In addition to being fair-skinned, White is tall and lanky, usually at least a head taller than anyone else in a room. There's an inherent gentleness and elegance about him, and his calm, unflappable demeanor puts people at ease. "He was an athlete in his younger days," says David Chanoff, the coauthor of Seeing Patients, "and he still has that kind of presence. He's a combination of congeniality, collegiality, and drive."
Thinking positively is something of a reflex for White. In a notebook he kept during the 1960s, he jotted down the phrase "Black brother, don't hate. Calculate." Where others might get angry, White is unflappable. "Hate doesn't help," he says. "It only pushes you down. It depresses you." His daughter Atina White '98 says, "He has this ability to be strategic about letting yourself cool off and finding other ways to accomplish what it is you're trying to do. He is very logical—almost to a fault sometimes." His favorite bit of fatherly encouragement to his three daughters, Atina says, is to be "strong in the head, strong in the heart, strong in the whole body."
At his talk at Brigham and women's, White ran through slide after slide of dispiriting, frustrating evidence of unequal treatment in medicine. As an orthopedist, he said, he was particularly upset by the fact that blacks and Hispanics are less likely than whites to get adequate pain medication after a long-bone break or fracture. Pain is pain, he said; it has nothing to do with culture or race. This fact, White says, "is not presented to abuse anybody or accuse anybody or make anybody feel guilty. It's not your fault. It's not my fault. But it is your responsibility and my responsibility to do something about it."
"In surveys," White writes in Seeing Patients, physicians say they do not discriminate on the basis of sex. And yet in 2008, when researchers sent a male and a female patient with identical osteoarthritis in their knees to seventy-one family practitioners and orthopedic surgeons, 67 percent recommended knee replacement for the man, while only 33 percent did so for the woman.
"I think this is not conscious bias," White argues, quoting Mayo Clinic orthopedist Mary O'Connor, the past chair of the Ruth Jackson Society, which tries to correct health disparities affecting women. "I don't believe these physicians had the female patient in their office and thought, 'I'm going to withhold a recommendation for surgery.'"
O'Connor continues: "But there's still something going on. . . . There's the stereotypic—Oh, she's going to be a whiner. . . . The most difficult thing to realize is that, yes, you may be the one doing it. You may be guilty of giving different care to people who don't resemble you."
White admits his own bias against obese patients. But, he says, "If you can be aware, let that be a yellow light." That yellow light forces you to pause and remind yourself about what the evidence says you should do with this particular patient, and make sure you do it.
Three decades after graduating from Brown, White was serving on Brown's Board of Fellows, watching with dismay as the hundreds of black students now at Brown voiced their discontent.
"They felt they weren't being treated properly, that their needs weren't being addressed," White writes in Seeing Patients. "From what I could see, the school cared about its minority students—it just did not know what to do about them." So White approached then-President Howard Swearer with an idea. Rather than "responding to brushfires," why didn't the University convene a committee to study what might help improve relationships among students of all races at Brown?
Swearer asked White to lead the effort. White and his colleagues spoke to hundreds of students, faculty, and staff about diversity at Brown, and compiled, synthesized, and analyzed what they heard. The resulting report, The American University and the Pluralist Ideal, was released in 1986. It made seventeen recommendations, including broadened course offerings on race- and ethnicity-related subjects (the ethnic studies concentration was born as a result) and increased support for minority clubs and organizations. At its heart, the report asked the University to move past diversity and aim for the broader goal of pluralism.
"Diversity meant that the University community would include people of different races, religions, and so on," White writes. "To a certain extent Brown had achieved diversity. Pluralism moved beyond diversity in that it conceived of a community where minorities were not simply present, but where they were welcomed, where their cultures were acknowledged and valued. . . . We were asking Brown to make diversity into one of the pillars of its fundamental identity." (Brown awarded White an honorary degree in 1997. He also worked on a follow-up report, which was released in 2001.)
Now that White is looking to make culturally competent care one of the pillars of medicine's fundamental identity, he thinks he knows intuitively what will help. Doctors must be honest with themselves about their biases, for example, and medical schools must increase the number of medical students from underrepresented minorities. But will it make a difference, really?
"I'm sorry to say," White says, "that we did a review of the literature and we said, 'Culturally competent care education pedagogy: what works? What are the teaching methods that work?' So far, there's not anything that has been demonstrated experimentally, on an evidence basis, that says, if you teach these things, you can get these better outcomes in patients that are getting disparate care."
After White retired at age sixty-five from performing surgery—"I wanted to exit at the peak of my skills, while I was still providing the highest level of care I could," he writes—he founded Harvard's Culturally Competent Care Education Program to try to address the problem. The program consists of White, his assistant, and piles of papers, books, and sticky notes. It is fueled by White's unfailing optimism. Each day he puts on a jacket and tie—even on days when he has no appointments or meetings—and goes into his office to do research, write papers, give lectures, collaborate with others in the field, and mentor students.
In medicine, evidence is king. Without a clinical trial demonstrating the effectiveness of one type of intervention versus the other—without data to prove that, say, teaching medical students one way versus another results in better outcomes for minority patients—White is, he admits, "just flailing away at things that ought to make sense, that ought to work." He adds, "Hopefully at some point we'll show that they can work."
White has always drawn great pleasure and comfort from music, and several of the chapters in Seeing Patients begin with quotes from the blues great Memphis Slim. One of the chapters, "A Man Ain't Nothing But a Man," draws its title from "John Henry," that quintessential American folk song about the man who beats the steam engine and dies trying.
When great bluesmen like Lead Belly and Mississippi John Hurt sing about what John Henry told his captain, the words are layered with meaning. John Henry, a former slave in some accounts, says that he is only a man—there is only so much he can do to beat the steam engine—but he promises to die trying. At the same time, he is making a simple yet deeply profound statement that he, like his captain, is a human being. And yet, because of who he is, he, like his ancestors, is going to die with his master's tools in his hands.
As important as our cultural identities are, White notes in Seeing Patients, "In the final analysis, we are all so much more similar than different. Once you make the incision, once you look inside, everybody is the same. Open up that skin and underneath it's all one. The reality of the body tells this to you. . . . A man, in John Henry's enduring words, ain't nothin' but a man."
When White was invited to lecture at Brigham and women's in June, he was the keynote speaker at a function celebrating the achievements of underrepresented minority faculty and fellows at Harvard Medical School. From behind the lectern, White took a quick tally in his head: about twenty of the fifty doctors, medical students, and other health-care professionals gathered before him that day were from racial or ethnic minorities. There were medical students from programs aimed at recruiting underrepresented minorities into medicine. There were doctors, now mentors, who had previously been mentees in these programs. White felt deeply gratified, even as he prepared to talk about how racism and other "isms" were getting in the way of good medical care.
He smiled. "Good afternoon, my fellow humans," he began.
Beth Schwartzapfel is a contributing editor.