50 years ago, it was discovered that the United States Public Health Service and the CDC–the federal government–had left nearly 400 Black men with syphilis untreated for 30 years to study the long term consequences of the disease. They told these men, mainly sharecroppers, that they were providing them free healthcare. The consequences of this inhumane, disgusting study still echoes among Black Americans today–leaving many deeply mistrustful of the healthcare institutions that are supposed to provide treatment. Worse still, the same attitudes about Black people continue to shape medical and public health interactions. Abdul sits down with Dr. Rueben C. Warren, Director of the National Center for Bioethics in Research and Healthcare at Tuskegee University and former Associate Director of Minority Health at the CDC, to talk about the history of the study and its lasting implications for health inequities.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: The president suffered a post-Paxlovid rebound, testing positive again after several negative tests. The surge in COVID cases resulting from BA.5 appears to have slowed over the past few weeks. The Biden administration pushes pause on another round of boosters for those under 50 holding out for an updated booster in the fall. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Trust the science we’d hear it at all the time during the height of the pandemic lockdowns in 2020, it became one of liberal America’s favorite catchphrases. But that phrase always made me wince just a little bit when I’d hear it. First, as I’ve discussed a bunch of times on the show, it’s implicit in science to be mistrusted. Science moves because people don’t trust it. You replicate experiments to verify them and then test alternative hypotheses. But that’s not the main reason that phrase always got to me. Because science isn’t just a process or even the outcomes of a process. It’s whether we like to admit it or not, a whole set of institutions. Institutions are collections of people. And as much as scientists wish they were totally objective, evidence driven characters we aspire to be. We are part and parcel of a culture and we are susceptible to the same biases. We’re still in thinking that we are objective, scientists are sometimes the most blind to the ways our biases shape us. It’s not that science isn’t the incredible tool for understanding the world around us. It is. Make no mistake about that. It’s just that we as scientists are imperfect, sometimes terribly so. Terrible things have been done in the name of science. And one of the worst is the subject of our discussion today. When I served the city of Detroit, which is 85% black, we often struggled to get parents to vaccinate their children. We struggled to get parents to test their children for lead. We struggled to engage families on a number of issues we tried to tackle. Well-meaning folks from outside the city, usually White, would say things like, I can’t understand why these people won’t just take care of themselves. I’d wince even more, just like trust the science. The inevitable retort was, Why don’t they trust us to help? Why don’t they trust us to help? That’s because the very institutions, institutions like the one I ran, like the state health department, like the CDC, have betrayed that trust in profound, indelible ways so many times before. The U.S. Public Health Syphilis Study at Tuskegee, the Tuskegee Syphilis Study for short, is a big part of that painful legacy. In 1932, the U.S. Public Health Service enrolled 600 black men into a study intended to understand the quote “natural history of untreated syphilis in Macon County, Alabama.” 399 of them were known to have syphilis, and 200 were recruited as controls. To enroll these men, mostly poor, the USPHS promised free health care. Though they did receive that health care, none of the infected men were ever told they had syphilis and instead were offered sham treatments for what they were told was, quote unquote, “bad blood”. Though they were initially told the experiment was supposed to last six months, it extended for 40 years. 40 years, four decades. Here’s the thing, syphilis is treatable by penicillin, which was widely available by 1947. And yet these men went untreated for an additional 25 years. 28 died of syphilis itself, and over 100 died of syphilis related complications. 40 of their wives were infected and 19 children were born with congenital syphilis, which is extremely serious. In 1966, a whistleblower named Peter Buxton, who studied STIs, wrote a letter to the director of what was then called the Division of Venereal Diseases, demanding an end to the study. But the CDC refused, arguing that the study could only end after all the subjects had died, had died, and were autopsied. Several others tried, including William Carter Jenkins, a Black statistician working at the Public Health Service. It ended finally after Buxton took the story to the press, where Jean Heller, an AP reporter, broke the story in The Washington Star. Senator Ted Kennedy called a congressional hearing, which prompted the CDC to appoint an ad hoc committee which ultimately elected to end the study. The NAACP sued on behalf of the study participants and their descendants, winning the equivalent of $51.8 million dollars on their behalf. And the fallout of the study has created the system of institutional review boards that govern biomedical research today. And yet the legacy of the study remains. Imagine knowing that your government health department knowingly left people who looked like you untreated for a deadly infectious disease in the name of science and then being told to trust the science. It’s not just legacy. It’s also the present. It’s the fact that Black mothers still die at 3 to 4 times the rate as their White counterparts in childbirth, that their babies die at 1 to 2 times the rate. It’s the fact that Black patients are less likely to be treated for their pain and more likely to have their complaints dismissed in the hospital. It’s the fact that Black life expectancy remains several years shorter than White life expectancy. It’s the fact that nearly two thirds of Black children are on Medicaid compared to just a third of White kids. That reimbursement rates literally value their bodies at half the rate, because they’re poor. One of the lasting consequences of Tuskegee was this: 

[clip of unnamed speaker] To the survivors, to the wives and family members, the children and the grandchildren. I say what you know. No power on earth can give you back the lives lost. The pain suffered. The years of internal torment and anguish. What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look at you in the eye and finally say, on behalf of the American people, what the United States government did was shameful and I am sorry. 

Dr. Abdul El-Sayed: As part of that apology, the federal government helped establish the National Center for Bioethics and Research in Health Care at Tuskegee, which opened in 1999. My guest today is Professor Reuben Warren, the director of that center and previously the associate director of Minority Health at CDC. I sat down with him to understand the implications of the study, inequities in health care today, and what it will take to address them. Here’s my conversation with Professor Reuben C. Warren. Let’s jump right in. 

Reuben C. Warren: All right. My pleasure. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Reuben C. Warren: Yes. I’m Reuben Warren. I’m the professor about ethics and director of the National Center for Bioethics and Research and Health Care at Tuskegee University in Tuskegee, Alabama. 

Dr. Abdul El-Sayed: Professor Warren, thank you so much for taking the time uh to join us today. We wanted on this episode to mark the 50th anniversary of the story of the United States Public Health Service study on syphilis in Tuskegee to mark the discovery of that for the general public. It’s been 50 years since then. That study has had huge implications for health equity in our country, for the trust that people can put into the federal, biomedical and public health industry. And we wanted to invite you to to share your perspective and educate us about it. And so just to start from the top. Can you tell us a bit about what happened at Tuskegee? 

Reuben C. Warren: Yes. I guess starting from the beginning, we need to start back to the 1930, around 1930, and the Rosenwald Foundation. Currently, the former Sears and Roebuck Rosenwald Foundation. I had been working, Rosenwald had been working with the president of Tuskegee Institute, Booker T. Washington for many years, and trying to improve the conditions of particularly Black children. They establish Rosenwald schools throughout several states in the south. So when the issue of the syphilis study came, it was clear that Rosenwald and Booker T. Washington had a relationship not around help but around really improving the human condition. So when they decided it started off as a treatment program to provide treatment for syphilis because that was really horrendous at that time. The treatment was worse than the disease and it was funded by Rosenwald and two years later around Depression time and the funds left. So there was no more money to do the treatment program. So the federal government, the Public Health Service, decided to continue the uh the work and they called it a study, but it was non-therapeutic. And to see what the history of syphilis, the disease would evolve untreated. And that’s why it became the Tuskegee Study of Untreated Syphilis in the Negro male in Macon County, Alabama. So it started off as a treatment program targeting Black people. It evolved into a non-therapeutic program, specifically targeting Black males. So that the question was, was that was it appropriate at any time? And I would argue that from the onset that it became a non-therapeutic program, it became unethical. 

Dr. Abdul El-Sayed: Mm hmm. And what was the rationale that the United States Public Health Service had for doing the study? What what did they tell themselves at least to justify what they were doing? 

Reuben C. Warren: They were trying to trace the natural history of syphilis in organ systems, that was their thing, the natural history of the disease in organ systems. And they thought they could only do that by not providing treatment. So the natural disease history would unfold, was the articulation, that’s what they said. We want to see what the dis– what happened with the disease, untreated. 

Dr. Abdul El-Sayed: So they took over a program that was foundation funded to provide low income sharecroppers in Macon County, Georgia, access to health care, and then justified it and the lack of treatment for these folks, for the particular disease on which they were recruiting. By saying that this was a scientific study to understand the long term natural history of syphilis. This is, it is so counterintuitive. And yet the study lasted for decades. Can you tell us a little bit about the people in the study? Who were they? What was their circumstance? What did they think was happening? 

Reuben C. Warren: Yeah, first off, they weren’t, quote unquote, all farmers or sharecroppers. These men cross-sectioned the economic uh circumstance in Macon County. 

Dr. Abdul El-Sayed: Mmm. 

Reuben C. Warren: So the misperception was they were low income or uneducated men, and therefore they could be easily deceived into participating in something that was not appropriate. 

Dr. Abdul El-Sayed: Hmm. 

Reuben C. Warren: That– the wrong perception these men were, some were low income, some were had farmed and had animals. So that perception that they were ignorant is not, is not correct. But they were trusting people. They were trusting Black men in the community and trusted the federal government, more than the state government. And that, you know, back in the forties, that’s the survival for Black people particularly in the South was the federal, not the state government. So they trusted these scientists to do the right thing. More importantly, the scientists went to the faith community, went to the Black church, which is a trusted institute. So trusting the Black church, trusting Tuskegee Institute, which had at that time a regional hospital treated Black people, was the, was the logical thing to do. They never discussed it being a study. It was a continuation of a treatment program. And, but they stopped treatment. 

Dr. Abdul El-Sayed: So the user experience for these men was that they had already been in a in a in a treatment program. They uh were being told by a series of trusted institutions, whether it’s the federal government and the federal government’s public health service, the Black church, the Tuskegee Institute, that this is just a continuation of the program. And they were never really told that they were being studied actively for the long term history. The natural history, as we call it, in science of a deadly disease. 

Reuben C. Warren: Absolutely. Matter of fact, they said they were treating them for bad blood. That was the term that they used, bad blood, which covered a plethora of disease, but never talked about a study. We were treating them for for bad blood. So the notion of study never came up. 

Dr. Abdul El-Sayed: And for the first several years, first ten years or so, the study, the treatment that that is still currently in use for syphilis, penicillin hadn’t yet been discovered. But by 1947, it was widely used, it was the de facto treatment. It fundamentally changed the experience of syphilis because it’s a very, very effective treatment. And do we understand what went through the the minds of the study administrators when there was an available treatment and they chose to withhold it from these men whom whom they told that they were providing health care? 

Reuben C. Warren: I can’t imagine what was in their mind. But my my perception is that, first off, there was not the recognition that these human beings were human. 

Dr. Abdul El-Sayed: Hmm. 

Reuben C. Warren: You know, and then the framework that you’ve heard many times is for the sake of science. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: And I think that overrides sometimes people’s perception of the sake of humanity. So I think that with more grounding in their perception of were these human beings worthy of treatment and as some of the scientists in this this so-called study would say, that they didn’t have anything. So we didn’t take anything. They weren’t getting here, so we didn’t do any harm. And Cutler was one of the major scientists in this study. So called study said, well, if I had to do it again, I would do it. So there was never a recognition by the scientists, by the federal government that it was wrong. It was not exposed by the federal government. It was exposed by the New York Times. Associated Press. 

Dr. Abdul El-Sayed: Mm hmm. 

Reuben C. Warren: So if if it was not exposed, one could imagine it would still be going on. 

Dr. Abdul El-Sayed: Hmm. And walk us through what ultimately ended the study. What was the the series of events that ultimately led it to be exposed? And what was the reaction both among the local community and the broader national public? 

Reuben C. Warren: Several things occurred early in the episode, probably in the late sixties, early epidemiologists and African-American Bill Jenkins tried to express some concerns about the methodology, and it was ignored. And, you know, Peter Buxton later on expressed similar concerns, but he left CDC and assumed a position in San Francisco. And at that time, he made public his concerns about the unethical so-called study. And that’s when the reporter and The New York Times Associated Press exposed the study in 72. So it was never acknowledged by the federal government. It was exposed by non-scientists and the popular and the public press. So that was the dilemma. It’s not that we not we made a mistake and we want to acknowledge the mistake. 1972. No, no, it was exposed. And we had to stop it because of the exposure. 

Dr. Abdul El-Sayed: And what was the public reaction to this when it was discovered that there was this ongoing 40 year long study of, by that point, a disease that would have been treatable for a quarter of a century. What was the public response? 

Reuben C. Warren: I guess from my perspective. We’d have to talk about what public you’re talking about. The general public was one of uh shock and embarrassment I believe. The Black public, particularly in the South, was one of of horror and fear and I believe feel of humiliation. I think it was a very different reaction. One was, oh, why would you do this? General public. And the other. I think in the Black community in the South was, you did it again. 

Dr. Abdul El-Sayed: Mhm. 

Reuben C. Warren: But we thought we could trust you, federal government, and that’s what really, really was important and we thought we could trust you, Tuskegee Institute. But you weren’t in charge. Tuskegee Institute and Federal Government, you were not in charge in terms of a a body that recognizing a wrongdoing and and intendeding to stop. And the other thing that’s really important, the study was stopped. We say, we think, we believe, but whatever happened to the data? There was samples. There was blood taken. But it, where is the data? 

Dr. Abdul El-Sayed: Hmm. 

Reuben C. Warren: So that’s a question that has yet to be an answer. So I always say with with with full confidence, the best that we know that what happened stopped. But, you know, as you know, as as as a scientist, what do you do with data? You don’t throw it away. 

Dr. Abdul El-Sayed: No, that’s. Yeah. 

Reuben C. Warren: What do you do with data? You don’t throw it away. So it is stopped, but what did we learn and uh about the science? And more importantly, what did we learn about the ethics? It started, quote unquote, “in 1932, and by 1936, they had answered all the questions about the relationship between the surface and its impact on organ systems.” By 36, they knew that. So what is the real issue? What are they trying to find out? Why they didn’t continue? If we, what went went published and the, quote unquote, “leading journalists by 36, they knew they answered the questions about the relationship between syphilis, the disease and organ systems.”

Dr. Abdul El-Sayed: Hmm. I didn’t realize that that data is unaccounted for. 

Reuben C. Warren: Yeah. Yeah, but then nobody brings it up because. What were you trying to do? And how do you follow the natural history of disease in human beings? And you do that by when the human beings die, you autopsy them. And that’s what the strategy was. And so they uh the so the men who was in the study there was after the apology was acknowledged, they were given uh. Before it was announced they were given um uh pay for insurance as well as their health care, and they paid for for, for burials. Which resulted, also included autopsies. So that was the way they could track the men until they died. We’re going to pay for your your funeral and we’re going to do autopsies. 

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Dr. Abdul El-Sayed: So by 1936, they’d they’d achieved the ostensible outcomes of the study, despite the fact that there was no institutional review, there was no, no no effort to to take any sort of permission and consent from any of the study participants. And yet, after 36, this continued for another 34 years. 36 years? 

Reuben C. Warren: Yes. 

Dr. Abdul El-Sayed: What was the response to people in the study? What how did they feel? Do we have any recorded outcomes from from folks who had been in this study? What did they think when it was discovered? What was happening? 

Reuben C. Warren: Well, you may recall that when it was published in The New York Times, one of the men, Pollard, went to attorney Fred Gray and said, I’ve just read about this this this study, this Tuskegee study. And what can you do to help us? 

Dr. Abdul El-Sayed: Mm hmm. 

Reuben C. Warren: And Attorney Fred Gray said, I think I can do something to help you. Because it was clear that they were violated. And Fred Gray senior, attorney Fred Gray, took on to try to help the men. And that’s how the study became. That’s when the lawsuit began. 

Dr. Abdul El-Sayed: Yeah. And what was the outcome of the lawsuit? 

Reuben C. Warren: A settlement. It was a young black lawyer took on the federal government. And so there was a settlement, out-of-court settlement, and there was payment. And how do you pay for death? But there was some payment to the men individually, and their their first generation family members. And their health care was supposed to be guaranteed for the rest of their lives. That was the settlement. And then a part of that was to find all the men who were in the study. 

Dr. Abdul El-Sayed: Mm hmm. 

Reuben C. Warren: And right now, to date, they still can’t find all the men who were in the study, they were in and out. The science was horrible. There was never a written protocol for the research that was done for the so-called study. Unwritten. So how do you even call that a study? That’s why we we we comfortably talk about so-called study, nor written protocol. 

Dr. Abdul El-Sayed: Yeah. And just for listeners, you know, when you do science, you write a proposal. You say, here is our study question. Here is our study hypothesis. Here are our study methods. Science is not about the outcome. Science is about the process. And then the outcomes are what you yield from that process and you rinse and repeat. And so the idea that there was never really a protocol for the study, that they didn’t really track all of the participants through and through, that they didn’t actually capture all of their data is exactly what what Professor Warren is talking about. And, you know, the thing about it that makes it so just so [?] is that it just continued to go on and on. And for 25 years after this was a treatable illness, they allowed it to persist. And, you know, regardless of what the settlement came to, regardless of how many millions of dollars it was, you cannot bring back the people who unnecessarily died of a disease that was treatable. You can’t undo the infectiousness of syphilis and the people who then got it from them. And you certainly can’t undo the the broad impact of this study as, as you put it, Professor Warren, that they did, again, on the perception and the trust among the Black community of health and health care institutions. And that’s where I want to turn our attention. Now, what is today’s impact of this so-called study on the trust of the Black community for public health officials and institutions? 

Reuben C. Warren: Yeah, I think the risk, the impact and response varies, but I would argue it was a continuation of of violations both by ethics violations and public ethics violations. For example, there was some fluidity between who was in the study, who was out, control group, treatment group. And they said in the protocol that this was tertiary syphilis, not infectious, but yet some of the children of the men were born with disease. So how could it be in it’s tertiary stage and still, in fact, women and the children born with syphilis. And that’s well documented. So the issue of who was in it and how they’d stay in it, did they get out, is still unanswered. Some of the men were treated and some were not. And so it’s very difficult, for to call this a study of any scientific or ethical consistency. So the impact is tremendous. And so that what was left, and a colleague of mine, Ralph Katz, did some work in the nineties that really asked what was the reaction by the Black community and other communities? Because the notion was that because of this quote unquote “Tuskegee syphilis study”, Black people in particular refused to participate in human subject research. That was the excuse that the research committee was using because we couldn’t get Black people involved in clinical trials and other parts of research, but that that just was not the case. There was an hesitancy based upon legitimate concerns, and those concerns still exist. And it’s not about the giving or not giving treatment. It’s about trust. And the trust was violated and it repeatedly happens over and over again. So we have to use that history as a a window. But if it had stopped, they could say, oh, that was then. But this is continual abuse and violations in human subject research. So we don’t have to go back to 1932. We don’t have to go back to 1942. We can talk about some of the shortcomings today. So the issue is history as a context, but current circumstances as, how do we respond today? 

Dr. Abdul El-Sayed: So in some respects, the continued mistreatment, maltreatment among Black folks at the hands of health and public health, health care and public health professionals validates a lot of it’s part of a broader continuum of the way that racism shapes both the structures and the individual interactions in health care. And, you know, I think in my experience as a health director, I served a predominantly Black city, in fact, America’s largest predominately Black city in Detroit. And the degree to which the the fallout of a persistence of mistreatment, maltreatment, downright abuse and neglect on the part of health and health care changed the way that people interacted with our department and changed the way that they thought about what it was that we were trying to do was really quite profound. And this is the thing about it is that a lot of times, you know, when when folks outside of the city of Detroit or somewhat ignorant or not thinking about this history, the way that they would talk about what people chose to participate in was as if people were making decisions that were antithetical to their own well-being. Right. If only they got tested. If only they got vaccinated. If only they chose to come in, we could help them. They’re making these bad decisions for themselves. And in some respects, it’s, you know, just so, so much privilege to assume that the institutions around you are there for your own well-being. And I think for a lot of folks in communities across the country, this history, this present even fundamentally shapes that question. Are you actually there for me? And, you know, this this came to a head in the pandemic where, you know, it was common where people would say, well, trust the science. And those words carry barbs for people for whom science and scientific institutions have fundamentally been untrustworthy. I want to ask you, how has the legacy of Tuskegee from past to present shaped the way that the Black community has engaged with this pandemic, the push to vaccinate and to test, etc.? 

Reuben C. Warren: Importantly, it fits within a continuation of violation. One incident, maybe it was a mistake, the continuation of those incidents, not a mistake, but a pattern. And we don’t start in in 1932. We can start with Marion Sims and the father of gynecology. We can start in 1619. And so the continuation of not recognizing the humanity of Black people and other vulnerable populations continues. So don’t ask me to trust you. Prove yourself trustworthy. And that takes long and consistent engagement. So I have a history of of being abused by your system. And then you ask me to ignore that history and then blame me when I don’t comply with the things that you said you were going to do, when I know in the past you have done it. So I think it’s very wise to raise the empowering question. Hesitancy, that’s the common word. But reluctance is not the same as denial. Reluctance is, I think, a wise approach. And then we have to engage in those kinds of conversations and assurances that speak to what happens, what do we do to prevent what has happened in the past from happening in the future? So I think that the pause is an appropriate one, is the wise one by the Black community and other populations who have been abused. So let’s talk about how do we assure, how do we protect and assure? And those are not the kind of conversations we’re even having right now. 

Dr. Abdul El-Sayed: Hmm. 

Reuben C. Warren: And so and when when that assurance is come forth, then I think the willingness to engage in those kinds of healthful circumstances, be it research, be it health care delivery, uh change. But don’t ask me to ignore the past, particularly when you repeat it time after time after time and the data are clear. 

Dr. Abdul El-Sayed: Yeah. 

Reuben C. Warren: See and I always say, you know, we talk about the Black community does not trust the science. I can’t speak for the Black community, but my perception, my experience says, at times we don’t trust the scientists, different paradigm. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: Let’s talk about the scientists and ways to hold them accountable, regardless of who they say they are, regardless of who they say that what they’re doing. But how do we hold the scientists accountable in addition to trusting the science? 

Dr. Abdul El-Sayed: I really appreciate that point, because one of the things that we’ve come to understand about bias is that it’s the most dangerous when you’re unwilling to acknowledge that it exists. 

Reuben C. Warren: Exactly. 

Dr. Abdul El-Sayed: The thing about scientists is that we sometimes think that we think so comprehensively that there is no way that we could be biased, that biases for other people. And it renders a lot of our scientific institutions among the most biased, whether it’s who gets entry into doing science or the kind of science that we do, or the kind of answers we look for, the kind of questions that we ask, science can be biased systematically, specifically when you’re asking the wrong questions and you’re interpreting all of your questions or answers to those questions within a very, very, very fine set of calipers around the answers that you can even admit exist. And, you know, one of the things that I find really intriguing about you is that you worked in in the CDC and you spent um your career thinking about uplifting and empowering vulnerable and marginalized communities when it comes to health. What did it feel like working inside of an institution that had perpetrated so much of this to try and correct that? And what how should we be thinking about positing solutions to exactly the problem that we’re talking about here? 

Reuben C. Warren: Yeah, I think we’ve got to to do engage in a different kind of relationship with the science community and with the academy. I think what we’ve got to begin to rely on those things that have served us in the past, those people, those institutions and that have proven himself trustworthy over time. You’ve heard the notion of the helicopter scientists, come in, get what you want and helicopter out. So I think we got a major shift. And I think it’s a shift from thinking about trust to thinking about trustworthiness as a major way of thinking that holds the scientists accountable in opposed to trying to convince those who we want to perceive, want to work with, hold them accountable. It’s a very different way of thinking. So I think we’ve got a lot of work to do and it starts with asking the question in opposed to posing the answer and we all oftentimes go in with the right answers. And in fact those answers are not only scientifically incorrect, but they’re ethically inappropriate. 

Dr. Abdul El-Sayed: Mmm. 

Reuben C. Warren: We’ve got some different way of thinking and I would talk about a ethical conversation in opposed to a scientific one. I don’t believe you can be an unethical person and be an ethical scientist. Inconsistent. And I think communities who have been experiencing this over years know that. And they and and as researchers, as scientists, as health care providers, they have to be real thoughtful about our limitations and don’t promise something that you can’t deliver. 

Dr. Abdul El-Sayed: Mmm. 

Reuben C. Warren: Work within your locus of control and admit to what that locus of control is and where the limitations are. And we oftentimes don’t do it. I represent this university. I represent. No, no, no. I represent myself in the context that here’s my role in this university, in this science endeavor. Very different way of looking at the world. 

Dr. Abdul El-Sayed: Mmm. 

Reuben C. Warren: Um, your much smaller than you think you are. So think about really your level of influence around issues that impact upon large populations. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that nugget of wisdom. Another big challenge that we have is who are the scientists? There’s just very little representation of marginalized folks in the halls of science. And part of that is that, you know, people people are aware of the stories that they come from, that they inhabit. And oftentimes there is a either surface level or uh disconnect from a lot of this history because people care the privilege of being able to do that. And we don’t often think about what it means to have scientists who come from communities that have been impacted by this kind of I’ll just call it institutional um uh violence and what does it look like to build the pipeline? And, you know, people talk about that in some, I think sometimes surface level ways. But but what does it mean to actually invest in a community of Black and otherwise marginalized scientists so that the folks who are doing the research in these communities are doing it in a way that is educated by the experience of the communities themselves? 

Reuben C. Warren: I think fundamentally it’s not. We said it in a nice way. You can’t operate in a racist society and not understand you’re operating in a racist society. 

Dr. Abdul El-Sayed: Mmm. 

Reuben C. Warren: The system demands much of what you do. I’m a dentist by primary training, and I recognize what dental education is designed to do and in another life I was the dean of adults who at Meharry in Nashville. And I was frustrated because I was training young people, educating young people to do something that the system would not allow them to do. 

Dr. Abdul El-Sayed: Mmm. 

Reuben C. Warren: It was frustrating to them. How can you go through medical school and dental school and oh and $300,000 dollars and be expected, almost required to go in communities that have no resources? 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: It’s inconsistent. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: So you have to be very thoughtful about what the system that that’s impacting on you. And until we really design some system changes in terms of how we educate young people and who we bring into the system. I don’t think things are going to change in any major way. I was trained to look for disease, no question. And I don’t look for health. I look for disease and bypass the health issues that really enhance communities’ well-being. So we’ve got more than just changing the people in the system. We got some system changes and those who are teaching students to socialize by their professors, and you come in there with high expectations and you leave feeling less confident about what you want to do. Even the system that has compromised, what you think you can do. So I’m really reluctant, matter of fact one of the reasons I left Meharry as as the dean was because I was I was feeling torn between telling young folk to go to places where they could not even pay back their student loans. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: That was inconsistent. So it, we had to talk about a rethinking and relooking on who we bringing in and what systems that we provide. For example, you shouldn’t be having to pay $300,000 to get education to serve. Nope. 

Reuben C. Warren: It’s absurd to me. 

Dr. Abdul El-Sayed: It is. 

Reuben C. Warren: But that’s the way it is. It doesn’t have to be that way. 

Dr. Abdul El-Sayed: I really appreciate you saying that. So I. You know, I went to medical school really focused on the question of health inequalities. My family’s from Egypt and I spent a lot of my childhood summers there. My grandmother lost two of her infants of eight to whom she gave birth. So the personal infant mortality rate of 25%. And I grew up right outside Detroit. And the crazy thing I didn’t have to go 15 hours to to Egypt. I could go 15 minutes to Detroit. 

Reuben C. Warren: Right. [laugh]

Dr. Abdul El-Sayed: To see the same inequities. 

Reuben C. Warren: Exactly. 

Dr. Abdul El-Sayed: I wanted to do something about that. And I thought being a clinic- clinician would allow me to do that until I realized that, you know, in the end, I was I was working one part of a pipeline, and the pipeline was consistently, consistently failing to deliver right access to the services. I was learning how to provide inside the medical system and realize that at the end of the day, you know, you can be a cog working in a system that fundamentally is created to to profiteer off of to monetize sick people’s bodies. Or you can work on that system to try and make sure that actually it matches the resources that that it has to the need that exists rather than the size of the wallet that exists. And um and you see that that mismatch and the injury, frankly, that it causes to people in the system who have good goals. And what happens is folks stay in these systems and then get jaded out of even thinking that they can solve a problem. And so they say, you know what, I graduated with $250,000 in loans. I might as well go and make as much money as I possibly can. And maybe somehow I’ll donate and try and take that on. And that’s not not I’m not I’m not inditing anyone. But I am saying that if you cannot address the antecedents inside the system trying to work against what the system is trying to produce in the end, right? In the end, will, will fail. And so the system question of what our system is supposed to do, why it’s supposed to do that, I think is is a is a profound one. And unfortunately, right when you decide that you are going to monetize sick people’s bodies, which you’re also deciding is that you are going to cement persisting inequalities. And if you live in a world where racism has robbed people systematically of opportunity, rendering the the most marginalized people also the poorest, what you are saying is you are going to work in a system that exists to perpetuate the same kind of health inequalities that, you know, that that we talk about. In the research system, I hate to say it, is not that much better. It hasn’t really been until 2020 that researchers who work on inequities uh could get funded by the NIH. Before the kinds of questions that would get you tenure, that would get you the NIH grants were the questions that were methodological questions or focused on disease pathways, as if the biggest disease path pathway wasn’t the structural failure in our society that systematically renders Black and Brown people sicker and poorer for having been sick. So I really appreciate that point. 

Reuben C. Warren: Yeah. And you will do the research that NIH funds, right? Which may not be the research that, you know, needs to be done. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: So you can’t separate, I can’t separate the health delivery system from the research system, though it’s all one system and it’s part of a greater yield, greater challenge. And we have to address that greater challenge. And I think if you don’t understand that before you get in the system as a health care professional student, then you become compromised by trying to be the best doctor you can be. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: And that becomes a real challenge. And as I know, I don’t know about your school, but my least taught subject and our at least appreciated department in medical education, dental education was community health. 

Dr. Abdul El-Sayed: Right. 

Reuben C. Warren: You know you can do that when you can’t do anything else. 

Dr. Abdul El-Sayed: Yep. 

Reuben C. Warren: They say, uh because there’s a way of avoiding the real issues. So you bring babies in to medical school and then you graduate baby doctors four years later. 

Dr. Abdul El-Sayed: Hmm. You know, I was I was told by one of my attendings that when I said that I wanted to work in public health, he’s like, well, you know, why would want to do something like that. You’re smart. 

Reuben C. Warren: [laughing] Right. Right. And the same thing as a dentist. You- Your hands are not good. So you’re doing public health. 

Dr. Abdul El-Sayed: Right. Mm hmm. 

Reuben C. Warren: Yeah. I think there’s a group of young people who are coming in to help refreshen schools with a more grounded, more well-rounded education. And so they see the issues, and so they’re better able to combat them. I was a biology major, and I learned biology and the world did not function around biology. So a broader array of students who know how to think and willing to challenge systems is going to make it better. So I’m confident that we’ll have another cadre of people with the [?] That if the the [?] Of them, in terms of time and tenure will admit to the mistakes that they made. And few of us are willing to do that. 

Dr. Abdul El-Sayed: That is uh that is a profound point. And I will tell you that the energy, enthusiasm and focus of young people these days, you know, frankly, who have grown up in a world where a lot of the mistruths that our systems have taught us have manifest, I think they’re done with it and they’re coming up asking the fundamental questions. And uh and so, you know, I hate to say that, you know, we’ve had to leave it to the next generation, but but hopefully we can all continue to walk in the work. And Professor Warren, we appreciate that you’ve you’ve made this path easier to walk for so, so many others. And I’m grateful to you for joining us and sharing your perspective, your insights on the United States Public Health Service Syphilis study, or so-called study at Tuskegee. Your perspective on what the implications and the impact of that have been even 50 years, 90 years really on and um and uh what we can do to to take on the persisting inequalities in our system. Thank you so much for joining us today. 

Reuben C. Warren: Yeah, and I heard about your tenure in Detroit as in the public health department, it was good. 

Dr. Abdul El-Sayed: Aw, I appreciate that. 

Reuben C. Warren: Now I didn’t hear that to tell you that I heard that because I heard it was true. So I appreciate your work and continue to do the work. And I know things will be better because we will make them better. 

Dr. Abdul El-Sayed: I appreciate that. That’s kind of you. And we will. And it’s going to take all of us. So, you know, thank you again for for continuing to do this work. And we look up to you, we’re grateful for you. And we hope that we get to cross paths again soon. Okay. 

Reuben C. Warren: Okay. Let’s stay in touch and I appreciate the conversation. 

Dr. Abdul El-Sayed: I’ll look forward to that. As usual. Here’s what I’m watching right now. The BA.5 surge appears to be ebbing after nearly four months of steadily rising cases. Cases only increased by about 3% over the past two weeks. And case positivity, the proportion of tests that were positive was steady. That suggests that we may have hit the height of the BA surge. But make no mistake, this doesn’t spell the end of the pandemic. The reality, unfortunately, is that we’ve seen a fall surge every single year since the pandemic started. I don’t know how many times I have to tell you all that, but that’s the thing I want you to understand. That’s mainly driven by changing behavior. School starts back up. People spend more time indoors, but it’s also driven by the virus’s own evolution. Right now, BA.5 is bending what we understood about how immune invasive and transmissible SARS-CoV-2 could be. But the next surge could come from another variant altogether. Toward that end, the Biden administration held off on recommending a second round of boosters for those under 50, electing instead to update its vaccine arsenal with Omicron specific boosters in the fall. But here’s the worry I have. How many people will actually take them? A measly 2.8% of children under five have been vaccinated, less than 3%. And the rates of vaccination are now decreasing, with fewer people lining up to get them every single week. The zeitgeist that COVID is over has well driven the sense that COVID is over. I wish it were true. For his part, President Biden was one of the upwards of 10% of those on Paxlovid who suffered a so-called rebound infection, meaning he tested positive again after several negative tests. He’s back in isolation but is expected to make a full recovery. Paxlovid is a combination of a protein shredding medication and one that stops your body from metabolizing it quickly. Rebound infections occur because, well, sometimes it fails to fully destroy all the virus. But even though it doesn’t deal a knockout blow, it still gives your body a level up over the virus, allowing your body to finish the virus off once and for all. But it’s less than ideal. And this has prompted calls from scientists and physicians to run trials of longer courses of Paxlovid treatment to avoid rebound. In other vaccine news, the FDA has signed off on another 786,000 doses of monkey pox vaccine. The holdup came over the sluggish certification of vaccine manufacturer Bavarian Nordic’s factory in Denmark. The key thing now is that they get to where they actually need to go. Considering that vaccine efforts in highly affected communities like New York and San Francisco have lacked the necessary doses to protect their communities. Meanwhile, mega corporation Amazon made another foray into health care, this time into direct primary care itself, purchasing one medical and online primary health care provider for $3.9 billion dollars, in cash in cold, hard cash. Big capital purchasing health care companies is nothing new. But this isn’t just any private equity firm. This is one of the biggest corporations on earth. It tells us something about where health care is going in this country. Amazon has grown as big and powerful as it has by being strategic about growing either vertically or horizontally, trying to consolidate as much of the supply chain for consumer products as it can, and then using that consolidation to take over sector after sector. Remember when the company started they were an online bookseller. My have they grown. If I had to put myself into the shoes of an Amazon executive I’d be thinking that this would be a great way to drive patients into the other parts of my business. Online pharmacy, over-the-counter products and data data data. For the rest of us. It is a scary consolidation of power in a market that is rife with risk for upselling and data exploitation, as they say. Watch this space. Before we go, I want to remember someone special today. Zahra Abbas was a local progressive activist and organizer in metro Detroit. I met her when I ran for governor. She lived with epilepsy, a debilitating disease characterized by seizures that can strike at any time. The only thing that helped her was cannabis. She became one of Michigan’s most outspoken activists for universal, affordable, equitable, accessible health care and for legalizing cannabis. She passed away last week. I wanted to lift up Zara’s memory today because she reminds me both of how urgent the effort to guarantee health care in this country is and the courageous people who are fighting for it. That’s it for today. On your way out. Don’t forget, please rate and review the show. It does go a long way and I’d like to think that we have some meaningful information that you would like to share with friends, family, and random people on the internet. Also, if you love the show and want to rep us, help drop by the Crooked store for some America Dissected merch, we’ve got logo mugs and t-shirts, our science always wins sweatshirts and dad caps are available on sale and our safe and effective tees are on sale for $20 off while supplies last. 

Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Tara Terpstra. Veronica Simonetti mixes and masters the show. Production support from Ari Schwartz, Inez Maza and Ella Price. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez and me. Dr. Abdul El-Sayed, your host. Thanks for listening.