Archive December 31, 2020

Giving Voice to the Speechless

It’s been a long year. For the last couple months I’ve fallen silent, no small feat for me. Nothing I had to say seemed equal to the task of the chaos around me.

I think I’ve found my tongue again. The Nishmat prayer that paves the way into the main section of Shabbat morning services refers to Hashem as mekitz nirdamim, mesiah ilemim – the One who wakes the dreamers and gives voice to the speechless. I’m feeling more awake than I have in a long time, and plan to be sharing a lot more material over the coming months here on this website and over my social media channels, where most of you will probably be reading this, starting with my newest installment of my Times of Israel blog, which is actually about mekitz nirdamim, waking the dreamers. That should post by tomorrow.

I haven’t been completely idle; aside from my day job I’ve actually had a few speaking engagements lately. Check out the Events page to see what I’ve been up to despite the pandemic, and “where” I’ll be next. There are at least two talks coming up in February and March, and I’m always open to discussing new virtual events (and eventually in-person ones) if you’re interested. Tag me on one of the social media platforms and we’ll talk, or email [email protected].

Where did this return of energy come from? Who knows. Maybe Hashem decided to give me a reprieve – or maybe it was the new puppy.

Open Your Mouth and Say…

A dozen years ago I stood on the bowling green in Frick Park with a group of Jewish teachers from my community to listen to Gabe Goldman, an educator with a strong passion for the environment who had recently arrived in town.  He pointed out some poison ivy to us, and then reminded us that often, in nature, the antidote to a poisonous or noxious plant is found in the immediate vicinity of the offending species.  The solution is embedded in the same environment that produced the problem.

A well-known Mishna in Pirke Avot (5:6) asserts that God works the same way.  At dusk on the sixth day of creation, just before the twilight that would usher in the first Shabbat, God created 10 things that would seem later to be miracles.  The Mishna, however, asserts that these were no miracles in the sense of violating the order of the universe, but rather things that were built into the fabric of that universe from the beginning, to serve a single purpose.

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Listen, Self…

My wife tells me that as a child, she often caught her grandfather talking to himself.  “I’m talking to a very important person,” he would reply.

Self-talk has become a lifeline for me in the turmoil of the last few years.  The turns of phrase that anchor my published writings often originate as grounding statements I employ to haul myself back from the brink, or to call my own attention to God’s presence in the world when I have been missing it.

Prayer is self-talk at its most refined, a vocabulary of these phrases woven into a daily drama in three acts if you’re Jewish, five if you’re Muslim, and so on.  The dialogue of this drama is purportedly between the worshipper and God, but the Hebrew word for prayer, l’hitpalel, comes from a root meaning “to accuse” or “to interrogate,” as if in a courtroom.  Since it is a reflective verb, where the actor is doing the action to themselves, l’hitpalel means, “to accuse or interrogate oneself.”  Don’t bother me when I’m praying – I’m prosecuting a very important person.

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Both Hands On The Wheel

“Both hands on the wheel.”

I can’t tell you how many times I heard that from my father when learning to drive, or how many I said it to my son when teaching him recently.  But I can tell you that every one of those times, it was said in relation to where hands belong while driving.

Not once did it occur to my father, nor to me, to say, “Both hands on the wheel if you get pulled over by the cops.

Last September, I was stopped at the traffic light in front of the Carnegie Museum of Natural History, on my way home from rounds in the nursery.  As soon as the light changed and I started to move, I saw the lights in my rear-view mirror.  It was evening on Labor Day, and I was the only car for a block.  No one had blown by us at 80 mph, or made an illegal left turn.  Those lights were for me.  I pulled over just past the intersection, before the bridge over the ravine with the railroad tracks, put my car in park, flashers on, and rolled down my window.  While I waited for the officer to approach, I instinctively reached first for my wallet, then the glove compartment, to collect my license, registration, and insurance card.

When the officer arrived at my window he immediately apprised me of what my father had failed to tell me, and what I had failed to tell my son.  “Both hands on the steering wheel until I tell you otherwise, sir,” he said very sternly.  “Keep them where I can see them.”  My pocket or glovebox, after all, might contain a weapon.

Over the next few minutes it became clear I hadn’t actively done anything wrong.  My crime was one of omission; I had let my registration expire, and fallen prey to a practice of officers running plate numbers whenever they stopped behind someone at a traffic light, in order to opportunistically catch people who couldn’t keep themselves organized.  Had we arrived at the light in reverse order, with me behind him, I’d never have been stopped.

My procrastination cost me a couple hundred dollars.  My ignorance about keeping my hands on the wheel, however, could have cost me my life, except for one crucial fact: as Ashkenazi Jews, my father, my son and I all code white, at least until someone spots the crocheted kippah sitting on the crown of my head.  Otherwise there’s a good chance my ill-advised move to the glovebox wouldn’t have resulted in a humorless reminder of “both hands on the wheel.”  It could have gotten me shot and killed by an officer who felt “threatened.”

This phenomenon is often called white privilege, but it occurs to me that “privilege” is a word that means something that is gifted to you that you don’t necessarily deserve, that can be revoked whenever the giver decides you’ve had it long enough.  It seems to me that not getting shot by a police officer who pulls you over for being bad at finishing your paperwork shouldn’t be a privilege, of any color, but a right.  Not a white right, or a black right, but a civil right, a human right – an inalienable right, at the intersection of life, liberty and the pursuit of happiness (and Forbes Avenue and Craig Street).

Calling it privilege suggests that the fathers and mothers of color who do tell their sons, “Both hands on the wheel if the cops pull you over” are doing the normal thing, the reasonable thing, and that people who don’t live that way are getting the bonus prize.  That’s ludicrous, or should be, in what is supposed to be a free country.  Living in fear of the authorities might have been normal in Nazi Germany, or the Soviet Union, or in repressive monarchies in the 19th century.  Getting stopped “to check your papers,” which is essentially what happened to me, is the stuff of authoritarian regimes.  And having to worry you might die as a result of these random stops is not normal.

Over the past two weeks the streets of America have been filled with protestors pointing out this exact truth: the degree to which people of color in the US have to teach their children to fear police is not normal.  Feeling safe around the people whose cars say “To Serve and Protect” is a right, not a privilege.  And it is a right without a color or a qualifier.

I was not out on the streets the other night, when police helicopters circled overhead less than a mile away, monitoring the activity of a couple dozen reckless individuals who broke off from a much larger, peaceful march (or so the news said at the time; the real story appears to be murkier).  I was holed up in my room, still awaiting results of a very slow COVID-19 test, and marveling at the irony that there were no helicopters overhead when George Floyd was suffocating, nor when Brianna Taylor was killed in her home, nor when Atwaan Rose was shot in the back not much further away from my home than those helicopters were.  There were helicopters to stop the broken windows, not the broken souls.

But truthfully, I’m not much of a marcher, and definitely not a brick-thrower.  This is a moment in history, and that history is long and painful.  Changing it wasn’t going to be achieved last Monday night, or even all last week.  When the marches are over, and some other kerfuffle seizes the news cycle, the system that enabled these deaths is still going to exist.  It is still going to put decent white people – and for that matter, decent people of color – in the position of following rules and procedures that, by their very nature, will eventually lead another one of those decent people, by virtue of how they were trained, to shoot and kill an unarmed black person.  They will be pronounced innocent by a review board, or by a court of law, because they will be able to show that all protocols were followed to the letter.  And that unarmed person will still be dead.

The marches and the trials, and the marches that follow the trials when the shooter walks free, won’t change the situation, because it is the protocols that should be on trial.  And not in a courtroom either – but in each of our own daily lives.

A lot of our institutions have roots in a system that was explicitly designed to keep the races separate and unequal, from transportation to schools to prisons and even to my own turf, healthcare.  Otis Brawley, an oncologist, author and former Chief Medical and Scientific Officer at the American Cancer Society, once worked at Emory University, whose flagship, H-shaped hospital is commonly known as “the Gradys,” because the two sides of the “H” were originally segregated facilities for Black and White Atlantans.  Had Brawley come of age a few decades earlier he couldn’t have gotten care in one-half of the hospital.  Likewise his colleague, my social media favorite Kimberly Manning, MD (@gradydoc), one of the leading voices on how to educate medical trainees by personal example.

I mention Dr. Manning because she is a master of owning her mistakes and being openly self-critical when she catches herself making unfounded assumptions, talking down to people, or not being her best doctor, no excuses.  I won’t try to tell her stories; I wouldn’t do them justice.  Suffice it to say that a woman willing to post a picture of her feet to a Twitter account with thousands of followers when she discovers she’s gone to work wearing mismatched shoes is not afraid to admit she’s wrong.

I mention Kim Manning as well because the kind of wrongs she often talks about are not obvious ones, like explicit segregation, or a person being murdered by the police.  They are the subtle errors of racism, classist elitism, gender bias and the policies that implicitly establish these biases as the rules of the road.

Take pain management.  Those who have read my book, Healing People, Not Patients, or heard me speak publicly, may remember a story about a Black woman with trigeminal neuralgia, an incredibly painful condition that is uniformly treated with antiepileptic medication, because that’s what works.  It is not a condition treated with narcotics.  Yet when I did not offer an opioid to this patient, she automatically assumed me to be dismissing her pain because of her color.

In the book, the lesson I took from that story was how hard it would be for me to earn back the trust of people who had lost faith in the system.  But if I’m honest with myself, I have to ask whether I have, in fact, perpetuated the undertreatment of pain in people of color.  In 2013 and 2014 we essentially zeroed out our prescribing of schedule II and III opioids for chronic pain and referred everyone to pain management practices.  It wasn’t easy, and the people who follow #CPP on Twitter probably think I’m evil for participating in putting up this barrier to treating chronic pain, but that’s a different essay for a different day.  What I remember most is that out of a population of a couple dozen patients who I asked to transition, a handful were African-American.  Each of them encountered resistance, suspicion and ultimately refusal from the pain management physicians I sent them to, in two cases on the first visit.  The coded language in the notes I got back wasn’t hard to spot. 

What’s telling is that none of them turned to heroin or street fentanyl – they had chronic pain but not opioid use disorders.  They might occasionally “borrow a pill” from mom or neighbor, but once in a blue moon to treat excruciating pain, not daily to avoid withdrawal.  But while some of my white and white-passing patients who had far more troubling patterns of use managed to establish with clinics, these three did not.

Or consider anger.  White patients, especially well-dressed ones, who become angry or irritated with the reception staff, unit clerks or nursing staff in a clinic or hospital end up calling a “condition H(elp)” or speaking with the office manager or nursing supervisor.  Black patients who do the same thing are more likely to find themselves with a sitter in their room; their angry visitors are likely to be removed by security.

Or turn your attention to telehealth.  When it was a way to prevent poorer people from needing to take three buses and spend six hours getting to the office and back for a fifteen minute visit, telehealth was an inadequate and non-covered substitute for in-person care.  Physicians wouldn’t get paid for it, so they wouldn’t do it.  Now that wealthy people need to see the doctor and not catch COVID19, telehealth has gone from zero to 95% of my practice, with the full blessing of CMS and all the insurance companies. 

Ironically, while it might be an equalizer in some ways, telehealth also exacerbates the disparities in others, for patients who cannot find a private spot for a visit, do not have enough bandwidth to accommodate the amount of data that goes into a telehealth visit, or can only to telephone without video, taking away the possibility of doing an exam.  Not to mention the possibility of not having a phone available at all, due to punitive or restrictive policies of the phone carriers or even simply having an accident that could happen to any of us, but not being able to replace the phone right away.  Before the pandemic, people could just show up at the office and hope we’d figure something out.  Now they don’t have that option.

These types of policies are “reactive” – responses to crises and challenges that are conditioned by biases.  But there are pro-active tasks we engage in as healers that also fall prey to bias.  What we teach, and what we ask in our visits, is often blind to issues faced by the people of color we’ve promised to help.

Last night I got an email from another faculty member at one of the training programs where I teach, alerting me to a textbook of dermatology in skin of color that we have access to.  We have known for years that this is an issue; open any standard dermatology textbook and you will see pages and pages of white, pink, and maybe pale olive skin.  But just like being safe around the police shouldn’t be a privilege, seeing pictures of dark skin when studying dermatology shouldn’t be “special.”  I wrote back to suggest that in order to really make change, we should be leading with that book.  “This is what pityriasis rosea looks like.  Now, in a patient who happens to have a paler complexion, it might look a little different (slide of white person with same condition).”  Instead of dark skin being “unusual” or “atypical,” it is the first thing we see.  It becomes normal, accepted, expected.  At least until we get a “standard” book diverse enough that we don’t need the “special” one anymore.

The questions we ask also need to be asked with open eyes.  Just as we have added questions acknowledging non-binary gender, non-heterosexual orientations, and non-neurotypical ways of learning and understanding the world, our social histories need to acknowledge the reality of being a person of color in America.  I ask teens all the time about behaviors they engage in that might cause them harm, like vaping or unsafe sex.  Why am I not asking if they are ever afraid they will be shot or beaten up by law enforcement – or vigilante civilians with guns?  Why am I not screening for the effects of implicit bias on their mental health – or indeed on their physical well-being?  We know these things happen, but we won’t know they are happening to our patients until we ask.  And asking will show we care far more clearly than carrying signs down Penn Avenue.

Of course, asking isn’t enough.  Trauma-informed care expert Megan Gerber cautions providers that they shouldn’t screen for trauma if they aren’t prepared to deal with the consequences.  What do we do when an honors student tells us he is afraid to wear hoodies when he walks home from school because it makes him a target for law enforcement?  How do we respond to a girl who tells us she wanted to be a physicist but gave it up because of repeated belittling comments from her guidance counselor?

If we are going to be allies, we have to make allies – out of the same people who are perpetuating the system, so we can influence them to stop defaulting to the old ways.  Over the last 12 years I’ve made useful contacts in non-profits, local government, the US immigration office, schools and a host of other places in order to be a faithful advocate for my patients for all sorts of reasons.  This situation calls for more of that same outreach.  Imagine what a pediatrician, or a group of pediatricians, could do in earnest dialogue with a local police department, or a school, for the safety and wellness of children and teens of color in those locales.

Once I look at my behavior under this self-critical lens, I see all sorts of “rules” that I follow, many without thinking about it, that tip the scales against people of color, even when I think I’m being helpful.  The pattern of referrals to child protective services.  The incredible lack of ethnic diversity, and particularly representation of African Americans, in many of our health-professions training programs, even when supposedly open-minded folks like me are in charge.  The establishment of norms for healthy body measurements and eating habits to represent what wealthy white folks value and shame others for how they don’t measure up.  And the chronic under-funding and under-resourcing of the health services in majority black neighborhoods, even to the point of closing and demolishing the hospitals that serve them to put new, shiny replacements in a nearby white suburb.

We do these things with such facility, such effortlessness, that it seems we are on cruise control – that we do not actually have both hands on the wheel.  We – and by this I mean me, first, and then encouraging my peers to join me – need to take full responsibility for what we’re doing. 

Those protestors down the hill Monday night were engaging in something Thoreau called “civil disobedience.”  But not all civil disobedience happens in the streets with signs and megaphones.  My cousin Jed Diamond shared a different definition, one that I’ve spoken and written on before.  Civil disobedience is when someone tasked with enforcing a rule or regulation recognizes that it is an unjust rule, or that it cannot justly be applied in this case, and refuses to default to just going along with things.

In the Exodus story, Moshe, at the time still an Egyptian prince, a person of privilege, happens upon a taskmaster mercilessly beating a Hebrew slave.  The text tells us vayifen koh va’khoh, vayar she ein ish – “He looked this way and that, and saw that there was no one around,” and then struck the taskmaster dead[i].  It seems like Moshe is checking to see if the coast is clear so no one will see him do this, but the commentator HaKtav V’HaKabbalah observes that Moshe is actually looking around to see if any of the other Hebrews is going to step up to protect this slave.  More than a thousand years later, Hillel would say, Bamakom she ein ish, hishtadel lihy’yot ish – “In a place where there are no humans, try to be a human.”[ii]  What Moshe was looking for wasn’t a person who would catch him in the act – he was looking for a human being to rise to the occasion.  Seeing no one was going to do so, he does it himself

This is what we’re being called to do right now – to be the humans in a place where it seems humanity has disappeared.  But Moses’ example is problematic – we are not looking to trade blood for blood, life for life.  A better example of civil disobedience in the previous chapter of Exodus is that of Shifra and Puah.   These two midwives are asked to commit infanticide whenever they deliver a male Hebrew baby.  They don’t argue, or protest – they simply don’t carry out the task and allow the babies to live, telling a lie that the Egyptian establishment is only too ready to believe to cover for their actions.[iii]  Of course the ultimate goal is to strike down the system itself and replace it with a just one, and of course we want to see justice done on an individual level to those who are directly responsible for murder, but that type of justice moves slowly.  People have been waiting too long for us to ask for more patience.  Jed’s subversive form of civil disobedience, the Shifra and Puah variety, can happen right now, even as the Moshes of the world fight the long fight for systemic change.  And the actual midwives, along with the doctors, nurses, physician assistants, nurse practitioners, technicians, therapists, receptionists, patient transporters and hospital administrators, are the ones who will be called upon to do it.

The “it” is calling out the physician who uses coded language and forcing them to own their stereotype.  It means exemplifying tolerance and compassion to someone that hospital security is about to drag out unceremoniously because their legitimate needs weren’t being heard over the volume of the staff’s unconscious bias.  And it involves challenging – and refusing to enforce – policies that disproportionately burden patients of color in the name of efficiency, convenience, accountability, or some other corporate concept.

I can point to a few times when I’ve done each of these things, but I can’t take much pride in that, not when I hang my head in shame for far more times when I failed to do so, when I let words come out of my mouth that let it be known that I was still helping to prop up a system that was failing people, that was “privileging” some people with treatment that should be a right for all people.  I was on “cruise control” – I did not have both hands on the wheel, and it was not my life in danger, but the lives of the people I was supposed to be caring for who were getting less care than they were entitled to.  So when the protests are over, and every day for the rest of my career, it’s time to be better.

Drive safely.  And keep both hands on the wheel.

[i] Exodus 2:12

[ii] Pirke Avot 2:5

[iii] Exodus 1:15-19

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