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  • Writer's pictureDr A Bashir

17 Equity

To celebrate Black History Month, I decided to share my interview with Dr Stella Safo, a Harvard-educated Physician and Assistant Professor of Medicine who is currently writing her own page in our history books. On February 11th 2021, the day we recorded our conversation for Her Royal Science, Dr Safo and fellow advocates at Equity Now at Mount Sinai, along with Councilmember Helen K Rosenthal, proposed a new bill titled ‘Creation of an advisory board for gender and racial equity in hospitals’, in the hopes of addressing discrimination within medical centres in New York City. During our conversation, we discussed why this important bill was first created, and what she hopes comes out of it in the near future. She also shared her journey into medicine with me, choosing to follow in her mother’s footsteps from a very young age. Sharing her thoughts on the inaccessibility of the COVID vaccine within many communities of colour, we discuss the ways in which the healthcare system needs to be re-designed in order to get the best outcomes possible for all patients, especially the most vulnerable among us.

You'll find the audio version of this episode on our website, Spotify, Google Podcasts, and Soundcloud.

The transcription of our conversation has been prepared for accessibility purposes, with minor edits for clarity and brevity.

Her Royal Science jingle

Dr Asma Bashir: Hello world and welcome to Her Royal Science. Thank you so much for joining us for today's episode. Today, we'll be chatting with Dr Stella Safo, a Physician and Assistant Professor of Medicine at the Icahn School of Medicine at Mount Sinai. She completed her MD at Harvard Medical School, and her MPH at the Harvard School of Public Health. Dr Safo is extremely passionate about population health delivery, gender and racial health equity, HIV care, as well as voter engagement. I hope to speak with her today about the pervasive effects of racial and ethnic inequities in health care, and I'd also like for us to talk about COVID-19, specifically, how we responded to the pandemic as a society, and the challenges of the COVID vaccine rollout. But let’s start from the very beginning: Dr Safo, what’s your story?

Dr Stella Safo: I'm so glad to be here! My story really begins with my mom, who is a paediatrician from Ghana, and she trained in Ghana and Nigeria. For reasons of giving our family the best future we could have, [we] came to the US and [she] always told us, ‘you know it hurt me to leave my home country behind, and it's important for me that you guys, my kids, do as much as you can to give back to your community.’ I knew from an early age that I wanted to do medicine, because I wanted to basically be my mom.

I trained in HIV primary care. I went to Harvard for undergrad, med school, and public health school, with a real focus on global health. Then, I went to Montefiore Medical Center in the Bronx because I was really interested in this idea of medicine as a way to address societal ills. In Montefiore, we had a program in internal medicine, called the ‘Primary Care and Social Medicine Program’, that really thought about how the social determinants of health could be addressed from within the medical paradigm. With that training, when I finished my medical residency, I went and I got an HIV fellowship with HIVMA [HIV Medical Association], and then ended up at Sinai working on this hard question of ‘How do we manage the changes that have had to happen in healthcare with this new move towards value-based medicine and population health management? How do we manage those changes in a way that would be most helpful for our patients, and also, in a way that would protect our frontline staff?’

I worked at Sinai for years, served as the Senior Medical Director for Clinical Transformation, and in that role got to work with some really amazing people, and do what I think is really amazing work. Since then, I've been thinking about this question of, ‘how do we make our health systems the best for our patients and our providers and really speak to the issues of racial, gender, and health equity?’ throughout all the work that I’ve been engaged to so far.

AB: That's incredibly valuable work. Now, as a physician you've obviously experienced and continue to experience the COVID pandemic on the front lines. What do you think are some of the things we did wrong as a society, especially on the eve of the news that New Zealand is basically COVID-free and is venturing back into normalcy—and the United States is nowhere near that—what do you think we did wrong?

SS: I think the thing that we did wrong—and it's the thing that you do wrong whenever you meet a big challenge or a big enemy—is we underestimated it. We underestimated it because we are the 21st century generation of innovators. We have medicines that have eradicated diseases that decimated societies before. We have technologies that take us to the moon and back. We, as humans, and certainly as Americans at least—I'll speak for us on this side and in parts of the Western world—have felt so invincible, that there hasn't been a challenge that we haven't been able to meet. And it's good that we haven't had a world war for decades, and it's good that we haven't had a pandemic for almost 100 years, but I think what it ended up doing is it made all of us underestimate the challenge that we were facing. You know what's funny about that? We had some warning signs, right? We know we have this battle with climate change and we're underestimating it now. We had to face Ebola a few years ago. It was something that was kind across the world, in the Global South, and so we didn't really think about it.

We had some warning signs and yet somehow when the test came, we all failed the test. We can put the blame on our federal government, our local government, but ultimately, I think all of us were a bit complicit in thinking, ‘Well, this will be done in a month, two months. Okay, maybe three months. How about this will be done in six months?’ And we just kept doing that, and I think it speaks to our sense of hubris that we can just handle anything—and I think we can and we will—but I think we have to really appreciate the enemy that is COVID.

AB: Do you think that, at this point, because of the scale that COVID really affected all of us, that will change the way we handle situations in the future? With respect to climate change, as you mentioned, will there be a little bit of humility that people might feel with handling this very looming problem?

SS: It's such a great point. I think absolutely! I think the humility that we've all learned with COVID will carry through. There's a story that's told that the Obama Administration left a playbook—a pandemic playbook—for the Trump Administration, and the Trump Administration essentially put it in the cupboard somewhere and didn't even bother to read it. It's essentially what we're doing now with climate change: these scientists and these at activists are telling us, ‘This is happening, this is happening, this is happening!’ and we're all putting that message in a cupboard and saying, ‘we'll get to when we get to it’ or ‘it's not so important’, and I think when we're not fighting for our lives with COVID quite so acutely, we're going to stop and say, ‘what other problems are dead in our face, that we are ignoring that are going to explode and force us to face it?’

I think climate change is a perfect example of that.

AB: Mhmm. I also wanted to talk a little bit about how COVID and racial/ethnic inequity have come together. There's no doubt that the medical establishment has had a tumultuous relationship with Black and Brown individuals in the general public, and now with COVID, with all of the results coming out with respect to the number of COVID cases, the number of COVID deaths, and now, even the number of individuals who are getting the COVID vaccine, there are definitely some disparities. Could you speak to that a little bit, as you were, and continue to be, on those front lines?

SS: Yeah, I think the thing that's really been hard for me as a provider is I see my patients in clinics, so I do outpatient medicine, and when the pandemic first started—because my patients, many of them have HIV—they talked about their fears with going outside and how if they got sick, what would happened to them, and so we counselled them through that, and we got them through that. Then, we got to this point where we could talk about the vaccine being present and coming, and many of my patients were so excited that I got vaccinated, and they were just they were happy that I was safe, and I want to be able to do that to them. One of the things that I’m finding, as a provider in New York, is that there are some structural barriers to getting patients vaccinated, even those that are eligible.

The way that we sign up is online, and not all the patients can get online. There isn't enough supply and so, by word of mouth, sometimes it gets filled really quickly and other people who are waiting can't get to it, so there's a lot of issues around access. You know, what matters around access so much is that whenever you have an issue with access, you have to think about who's going to benefit and who's going to lose.

Access says that something is hard to get into, so if you have time, resources, connection, and money, you'll probably be able to get into it. If you don't have those things—time, resources, connection, and money—you probably won't get access to that thing.

If you think about COVID—the COVID vaccine is a restricted item that requires access—you can see the ways in which it's going to continue to re-emphasize already present inequities within our society, so those individuals who may have more components to be able to have access, like time—they're older, they’re retired, they have children who can get on the websites for them—or they have money—they can hire someone to help them out—all those folks will be the ones who will be able to go, and go first. Those who are working two or three jobs, those who are not literate in the primary language that these resources are being offered in, they won't get as much access. So, what you see, and what we are seeing are these crazy maps by zip code where COVID is the highest, and then you overlay that with the same zip codes of where the COVID vaccine is being given the most, and it is flipped! The places where COVID is the highest are getting the lowest [number of vaccines]. And before we throw our hands up and say, ‘The system is rigged; it's broken,’ anyone who's doing COVID vaccine rollout—the public health folks and others—they're wonderful individuals. They want to do the best that they can do. It's not because of malice. It's because of the ways the systems are designed, and it's part of the reason why I'm so passionate about health-system design, because the way that we design our health systems, give us the outcomes that we get.

What's needed now is an equity lens: it's saying, ‘Maybe we send more vaccines to zip codes that are harder hit, so they have more supply. Maybe we hold some [time] for people who are walk-ins who may get off work and can only come in without an appointment.’ But we have to think in a different way, otherwise exactly as you said—the inequities that we already have, COVID disproportionately affecting communities of colour—we're going to see it in those communities of colour not getting vaccinated, in the rates and in the ways that they need to get vaccinated.

AB: Absolutely, and I love that term, 'equity lens', because it speaks to the way in which we need to look at our world—love that! I'm wondering now, because of everything that transpired in 2020 with the Black Lives Matter movement—I think people almost exclusively thought about the BLM movement with respect to police brutality, but Black lives matter in so many other contexts as well, including here, in the healthcare space—do you think anything of what transpired in 2020 will have a direct effect on that equity lens and how [healthcare providers] receive people of colour in the healthcare space? think, absolutely. We ended up feeling as though we were in two pandemics, the pandemic that has plagued the world, really, and certainly the United States for hundreds of years: the pandemic of racism, and the pandemic of COVID. And what COVID did, and what diseases often do—we saw this with HIV showing us the stigma against individuals who were part of the LGBTQ community, foreigners, initially Haitians— they put our societies under a microscope and they show us the ways in which, quite frankly, we suck, right? We've always kind of sucked at being equitable in our societies when it comes to the race, and COVID came along and really showed us, yes, you guys really suck.

There were places where African Americans make up about 20% of the population and in the early months of COVID, Black people were making up, in those same areas, almost 80% of the deaths. I mean, these numbers were so stark and so horrifying that it forced you to say, ‘this thing is here.’

So, I think, absolutely. There's a way in which these things coming together and the murder on screen of George Floyd and the protests that followed from it, converged with this global pandemic to say, ‘the very things that are driving the higher rates of infection, hospitalization, and mortality for BIPOC communities—Black, Indigenous, and People of Color communities—those very things are the same things that have been structurally and institutionally implemented into our racist environment or our racist system.’ I think that it was a lesson that certainly many of us live, and so we know, but it was a lesson that we as a country, and we as a group of countries have to really look at, understand, and really reckon with.

AB: Absolutely! [Since], as you said, there were so many of us who had that lived experience, what were the conversations that you had with your non-BIPOC individuals within the healthcare space like? Was there an element of disbelief? If you were to relay those really horrifying statistics that we knew were pervasive—not necessarily with respect to COVID, but other diseases, and other reasons why individuals from within the BIPOC community might need to seek out medical care, or might die—what was the reception?

SS: One thing that I was inspired by is that a lot of the reception that I got was anger. I don't know if most people remember this, but right before George Floyd was murdered, about a week before, there was a woman in Central Park who called the police.

AB: Yup, Amy Cooper.

SS: Exactly, and she did that because she was basically mad at him and wanted to find a way to get back at him—and she was a liberal, she lived in New York—people were really shocked and disbelieving of that. And then, a week later, George Floyd happened, and it's uncovered all the things that had been happening with Breonna Taylor and Ahmaud Arbery. [It] had gone from a week of, ‘well, that Central Park story was interesting,’ to a few weeks after, when we were really in the thick of the Black Lives Matter protests, many of them were outraged. Many of them were really, really upset [alongside] me and us about how individuals are treated.

I don't want to make it sound simplistic as though they didn't know, but I think having it so clearly in your face, that response of anger and rage was refreshing for me to see because, as a Black woman in America, that's something that I carry all the time. I'm always afraid that something may happen. I'm always afraid that something could happen to my three brothers, to my loved ones, to me, to my patients, you know? It was a nice moment to say, ‘Oh, hi! Welcome—welcome to the side of the world where we have to look at racism; we have to face it.’ And the only response, honestly, when you see just how bad it is, is one of rage. Why is it that someone can have their neck pressed on for eight minutes until they die, and people just stand there and do nothing? How? In what world?

You know, I think that there can be such a thing as eloquent rage where you channel it in a way that is helpful; it can lead to action. I had a lot of conversations where they were really angry with what they saw and how things were. And, you know, it felt a little bit like, ‘Oh, it took you this long to see how bad it is?’ But you know what? We get there when we get there.

AB: True. Post-rage, what do you think non-BIPOC members of the medical profession can do to be better allies to us? I consider myself [to be] on the patient side, but also to someone like you, who's within the medical profession, what can they do to be an ally to you and an ally to me?

SS: I cannot overemphasize the importance of being a bystander and a true ally. People love the word ‘ally’.

AB: Oh, yes.

SS: And it doesn't have any meaning if all your allyship is a performance. You post a ‘Black Lives Matter’ poster, but then you don't actually speak up when you see your minoritised co-worker get degraded or spoken down to. I actually once worked with a person who was always so ready, when it was just one-on-one conversations, to tell me all the ways that I had been talked down to, disparaged, dismissed, kind of as a way of showing that this person got it and was allied with me. Yet when it was time for her to really speak up and say what she had seen, it was crickets. I often think about that, because I think it takes a lot of bravery to use your voice, it takes a lot of, you know, overcoming your own fears— you're afraid you could be disciplined, or challenged, or lose in some way, but no one's asking you to lie, or over-tell something, or stick your nose somewhere. All that is often asked of individuals who want to help is to bear witness, to say, ‘I saw this person speak down to this other person and that's not okay,’ and ‘I'm going to say something.’ It starts to change the culture and the environment, and also, it lets these perpetrators feel less emboldened. Silence is complicity in almost every single situation, and so I would say one of the easiest ways to help is to be active in the way that you present yourself as an ally.

AB: Absolutely, I was nodding so vigorously, because I’ve had that exact experience happened to me. I talked about this in my last episode where if that happens to me, and it has happened—where I am either spoken down to or berated in some way—I get a text afterwards from someone saying, ‘Oh, that was awful.’ No, no, no. Don't send the text. I don't want the text. I don't want it because if it really bothered you to your core, you wouldn't have been able to stop yourself from saying something in that moment.

SS: I love that! And I want to say that part of the reason why you get the text is that that person needs to absolve themselves.

AB: Yes!

SS: And what I want in this world is that I want none of us to feel okay until we're all okay. The thing that you do to make yourself feel okay: I re-tweeted that Black Lives Matter post, you feel okay. Oh, I donated to whatever, you feel okay. Think about how you translate that into real action, because when you placate yourself and you tell yourself that some of the performative action is action, what it does is it just slows us down, and what it does for the people who are experiencing these abuses is it's a re-enforcing of the gaslighting, right? They start to think, ‘Did I experience what I experienced? I'm not sure...’ And then they can silence themselves, they can make themselves smaller, and they can exit that space, so the talent and the collective brilliance that we all bring also gets affected.

I really agree with that—save that post-analysis text, no one needs it. If you can’t speak up in the moment, don't come and tell me how you ride with me. No, you don't, because you would have been there in the moment.

AB: Precisely. When I saw how vocal and active—again we're talking about active measures of changing the world that we live in—you are on Twitter and what you do with your life's work, [I found it] so admirable. My question now is, how you think your background played into who you are today, and what is important to you, and why you ride so hard for us and other people who need to be represented, all of us minoritised individuals?

SS: You know, it's something that I struggle with sometimes because I'm not actually someone who loves the spotlight. I often call it minding my own business. I really love minding my own business, just doing the work. But I, like many people were, was really inspired in 2016 when I watched eight years of the Obama Presidency come to an end, and someone who I thought was not fit for office take over and determine so much of our lives—from our healthcare, our reproductive rights, our ability to exhibit and be ourselves in the workplace, our sexual orientation—everything was impacted by that decision and I thought, I can no longer be someone who is quiet in this world. It's really important that each of us uses our voice in the spaces that we are in. I think the other thing that happened to me personally, is that I experienced a really horrific, toxic workplace culture that led me to lose a lot at the time. I lost very dear professional and personal relationships with that experience. I lost career opportunities that I was really invested in. Sometimes what happens with loss is that you look at it and you say, ‘Do I want to be the kind of person that looks and experiences this loss and reacts from that, or do I want to make it better, so that others don't have to experience the same thing?’

And between looking at the larger political environment, and then what I experienced at my workplace, it really brought me to a place of saying, ‘I want to be the kind of person that makes this world even just a little bit better, so the next person that comes after me can walk in that path,’ and that's really what's led me to do a lot of the work that I've done.

AB: Thank you. I can't thank you enough for what you do. I know what it feels like to feel that discomfort because for so long, it was easier to be the representation, right? So, you enter these spaces—these academic spaces, these medical spaces—and you go, ‘So long as I'm here, I'm doing my people right, and I'm representing us well, that is my fight. That's how I do my part.’

SS: Yes!

I went through a very similar experience, where I just thought, I don't think that's enough anymore, in 2016. The minute you said 2016, I knew exactly where you were going because I [thought], we all felt it, did we?

SS: Yeah, we did!

AB: We could feel a seismic shift; the world was forever different and I don't think a lot of people understood why it felt like an attack on the self. It felt personal.

In the last couple of minutes, can you tell us about the lawsuit that you're currently working on and the bill that hopefully will be passed?! I and eight other individuals who are employees at the Mount Sinai Health System in New York suffered race, age, and gender discrimination, including being called names in the workplace, being demeaned in other ways, having our work undermined, in some cases having our pay differentiated by gender with others who are in the institution, [and] being retaliated against. There's a whole bunch of things that we experienced as eight collectives that we outlined in a lawsuit, a federal lawsuit that's being evaluated now. You know, once you're in a lawsuit, you're in a world of pain that no one ever wants to be in, but we chose to do this because we thought it was important to help our institution to get better. I still see patients at Mount Sinai; I feel dearly for my colleagues there, and my patients there—I have such affection for them, because it's a great and wonderful institution that does really important work. I just think that our leadership could lead us better when it comes to the issues of addressing racism and sexism within the workplace.

As part of our advocacy, we worked with Councilmember Rosenthal—Helen Rosenthal in New York City—and are hopeful that we'll be able to pass a bill that addresses gender- and race-based discrimination at academic medical centres and all medical centres within New York City, by having a separate advisory board that would work with these hospitals, and work with individuals who’ve experienced these types of discriminatory experiences, to really ensure that there is accountability.

That bill is being decided on today, and something pretty terrible happened this morning in our press conference. Individuals who didn't want to see that bill passed, and wanted to essentially silence us, came onto the virtual Zoom press conference and porn-bombed us with images and sounds of disgusting porn on the call. It was so much—it was just non-stop, continuous for about two minutes straight that the call had to end. But what these fools don't know is you can't stop the truth. You can't silence people who are working for justice, so we got back on another call we kept going. The bill will hopefully be voted on, decided on, this afternoon, and if it passes it will be because of the advocacy of our group, Equity Now at Mount Sinai, [and] it will also be because of brave lawmakers, who have been fearless in saying we're not going to let this happen to our citizens.

So, to those who targeted us in the press conference, too bad. We're going to move forward and we're always going to move forward.

AB: I'm so sorry that it happened. I've said it before, but I can't say it enough. It's so disturbing and disgusting that people would try to do that, but people are emboldened now more than ever to do these kinds of awful things, to stand in the path of justice, but like you said, they can try all they want, but you have some amazing individuals at Equity Now at Mount Sinai and people in politics who care about equity, who care about fairness, who care about justice, and I'm so excited to see what happens this afternoon. Fingers crossed, it's all going to be very, very positive. Thank you so much, Dr Safo.

SS: Thank you so much! Thank you so much for having me; it was a true pleasure.

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