Monday, June 29, 2020

A graduation address for the COVID-19 era

If you watched your child graduate this year, as I did my older son's junior high school ceremony at the end of May, you most likely did so online. The same for my participation in the virtual graduation ceremony for Georgetown University School of Medicine's Class of 2020, which included 17 family physicians who start their internships in July. Two years ago, I was inspired to write about Dr. Atul Gawande's moving graduation address to UCLA's newest physicians. This year, I turn the clock back to 2012, when Dr. Don Berwick addressed Harvard Medical School's graduating students; his speech later appeared as an essay in JAMA's A Piece of My Mind.

Dr. Berwick, as longtime readers of Common Sense Family Doctor know, is one of my heroes. I finally had the opportunity to meet him in person in early March, when he delivered the Georgetown University School of Nursing & Health Studies Values Based Lecture. He recently captured the essence of that talk about the "Moral Determinants of Health" in another JAMA essay that is well worth reading, but in this post I will focus on "To Isaiah," his Harvard graduation address from eight years ago.

Isaiah is the name of one of Dr. Berwick's past patients, a Black teenager from the Roxbury neighborhood of Boston who developed acute lymphoblastic leukemia and received the "the best of care ... the glory of biomedical science," including chemotherapy and a curative bone marrow transplant. But biomedical science - then and now - proved to be no match for poverty and despair:

Isaiah smoked his first dope at age 5. He got his first gun before 10, and, by 12, he had committed his first armed robbery; he was on crack at 14. Even on chemotherapy, he was in and out of police custody. For months after his transplant he tricked me into extra prescriptions for narcotics, which he hoarded and probably sold. Two of his five brothers were in jail—one for murder; and, two years into Isaiah's treatment, a third brother was shot dead—a gun blast through the front door—in a drug dispute. ...

His world was the street corner and his horizon was only one day away. He hated it, but he saw no way out. He once told me that he thought his leukemia was a blessing, because at least while he was in the hospital, he couldn't be on the streets. And Isaiah died. One night, 18 years after his leukemia was cured, at 37 years of age, they found him on a street corner, breathing but brain-dead from a prolonged convulsion from uncontrolled diabetes and even more uncontrolled despair. ...

Isaiah, my patient. Cured of leukemia. Killed by hopelessness.

Dr. Berwick went on to tell HMS's Class of 2012 that Isaiah's story demonstrated that they had two duties as new physicians. One, to "go to the mat" for their patients, always putting their needs first and advocating for health care to be recognized as a human right in the United States. The second duty was "more subtle - but no less important":

Maybe this second is not a duty that you meant to embrace; you may not welcome it. It is to cure, not only the killer leukemia; it is to cure the killer injustice. ... One million American children are homeless. More people are poor in the United States today than at any other time in our nation's history; 1.5 million American households, with 2.8 million children, live here on less than $2 per person per day.

I am not blind to Isaiah's responsibilities; nor was he. He was embarrassed by his failures; he fought against his addictions, his disorganization, and his temptations. He tried. I know that he tried. To say that the cards were stacked against him is too glib; others might have been able to play his hand better. I know that; and he knew that.

But to ignore Isaiah's condition not of his choosing, the harvest of racism, the frailty of the safety net, the vulnerability of the poor, is simply wrong. His survival depended not just on proper chemotherapy, but, equally, on a compassionate society. ... Isaiah, in his legions, needs those in power—you—to say to others in power that a nation that fails to attend to the needs of those less fortunate among us risks its soul. That is your duty too.

Our nation's health care professionals have been "going to the mat" to treat patients with COVID-19 for the past four months. In doing so, hundreds have already lost their lives. To their credit, the Congress and the President rapidly enacted legislation to reduce obstacles to coronavirus testing and care created by our patchwork health care system, where at least 27 million are uninsured and tens of millions with insurance still cannot afford to see a doctor or pay for essential medications. Thus far, there has been no similar national initiative to eradicate injustice, even as millions have peacefully protested incidents of police violence and people of all races, from all places, have signaled support for the Black Lives Matter movement.

Doctors have participated in many protests, leading some to label them hypocrites because of the real possibility that the protests could accelerate COVID-19 community spread (though early findings from Washington State suggest that their contribution has been minor as compared to indoor social gatherings without masks). Thus far, the Washington, DC metro area is one of few in the country that has seen a sustained decline in cases despite large protests and tear gassing of protestors. But as imposing a public health problem COVID-19 remains, it pales in comparison to the morbidity and mortality toll of racism, social injustice, institutionalized inequality, and poverty - all factors which have fed the pandemic and contributed to the disproportionate devastation the virus has caused in communities of color. To respond to Dr. Berwick's "second duty," it is absolutely right and appropriate for all physicians to take a knee against injustice, and to use the power of our medical degrees to make our political representatives "go to the mat" for the most vulnerable Americans.