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Becoming a doctor is hard. Becoming a doctor when you face discrimination because of your race AND gender? Twice as hard. Abdul reflects on the obstacles that hold back promising future healthcare providers. He interviews Jasmine Brown, a medical student and author of a new book, Twice as Hard, detailing the history of America’s pioneering Black women doctors.

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Dr. Abdul El-Sayed, narrating: A train carrying toxic chemicals derailed in East Palestine, Ohio, raising questions about who’s left holding the bag when it comes to resident’s public health. A new survey found that 70% of providers are using waivers that rely on the pandemic state of emergency that’s set to expire in a few months. The Biden administration approves using Medicaid for food. And a shooter murdered three students and injured five more on the campus of Michigan State University last week. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Chances are most of you listening to this podcast haven’t gone to medical school. In case you wondered, med school is not fun. I can safely say that the four years I spent in med school were probably the worst four of my life. Well, today we’re going to talk about those years, not just mine, but the years countless people entering the medical profession have to endure to obtain their degree and become practicing physicians. And the reason why is because as painful as the experience is, it confers the opportunity, the rare skill to heal people, and that, that’s an incredible gift. And as tough as I found medical school, the obstacles that so many others face make becoming a doctor not just hard, but nigh on impossible. And who gets to be a doctor matters because that has profound implications on the health of the people they treat. Before we get into that, here’s a bit about medical school. For the first two years, your job is basically to memorize PowerPoint slides. That’s right. The day starts with 3 to 5 hour long lectures, the slides from which you’ll be examined on. By the time I got to medical school in the aughts, we had enough tech to allow you to watch the recordings of those lectures. And since you were going to have to memorize the lectures anyway, you might as well watch them as fast as possible. My poison, 3 to 4 times speed. At that speed, you’re not listening to anything. You’re osmosing material. The upside? Well, you can listen to podcasts at two and a half times speed with no problem for the rest of your life. After you memorize enough material, pass your exams, you get to cosplay a doctor like a really bad entry level doctor for the next two years as you vie for the approval of actual doctors, none of whom really have time for you. See, most of the people overseeing you when you’re a medical student are called residents. The term harkens back to a time when quote, “residents” actually lived in the hospital. Today, they just spend, what, 80 hours a week there? During those years, your job is to learn as much as you can and stay out of the way. And hopefully, maybe, maybe, just maybe, be helpful. The good news is that most of your day when you’re not doing the scut, the absolute most menial part of the job for residents, you can spend time with patients, and that’s the best part. Beyond rote memorization of PowerPoint, you actually get to learn about real people, about their illnesses, sure, but about who they are, what makes them tick, and what illness means to them. I credit patients that I got to meet in medical school with motivating so much of the content of this podcast. But most of the time my days in medical school were, well, miserable. But I can’t help but admit I had it easy. See, let’s start from the very beginning, though. Though I didn’t grow up in a house of doctors, both of my parents went to grad school. And among our family friends were many doctors. They say you can’t be what you don’t see. But I had plenty of people I could see. I attended medical school on an NIH funded program. They didn’t just pay for my medical education. They even gave me a stipend and health insurance on top of it. That means I dodged the $170,000 in student debt that the average graduating doctor carried when I graduated. That was 2014. It’s even higher now. And on top of all that, I didn’t have to worry about caring for children or elderly parents. I could focus on my education. And even with all that privilege, med school still sucked. In 2019, only 6% of med school graduates identified as Black. Less than half the proportion of the population of this country who do. As of 2021, only 5% of practicing physicians identify as Black, and that’s in large part to the way that structural racism makes the pipeline so much harder to get through. Everything from the way we criminally underfund public schools and Black communities to the fact that Black students face significantly more debt to go to medical school. The fact that there are so few Black doctors to begin with. All of these things conspire to make it way harder to become a doctor if you’re Black in this country. For Black women, the odds are even tougher. Twice as hard, according to our guest today. In 2016, less than 3%, 3% of practicing physicians were Black women. Misogyny and racism are a toxic brew after all. To understand why that matters so much, consider the fact that Black women die in childbirth at 3 to 4 times the rate as their white counterparts. When you consider the fact that only 3% of doctors are Black women, you come to understand why our system systematically dismisses them. Maybe our system would focus a bit harder on it if more doctors understood firsthand the experiences that victims of this inequity face. Provider diversity isn’t just nice to have, it’s life or death. Today’s guest is future doctor Jasmine Brown. While a Rhodes scholar at Oxford, she began researching all the ways that Black women have been denied entry into the profession. And while becoming a doctor herself, she’s turned her research into a book called Twice As Hard. The stories of Black women who fought to become physicians from the Civil War to the 21st century. Here’s our conversation about the path breakers and the obstacles they faced. 

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

Jasmine Brown: Yes. So I’m Jasmin Brown. I’m a third year medical student at UPenn. A Rhodes Scholar and the author of Twice As Hard The Stories of Black Women who sought to become physicians from the Civil War to the 21st Century. 

Dr. Abdul El-Sayed: So, Jasmine, your book just came out, and I’m really excited that it that it did. And um I want to step back. Uh. Obviously, you’re a third year medical student. You are a Black woman in medicine. And so much of the book, I mean, in the nature of the title, Twice As Hard is about how our systems have consistently gate kept against Black women. And so much of that has had real consequences for the health of Black women and Black people more generally. I want to ask you, um why did you write this book? What motivated this book for you? 

Jasmine Brown: So my journey to writing this book began in undergrad when I was involved in a lot of biomedical research and was the target of prejudice, and then also saw many other Black students experiencing prejudice around the country. And I didn’t understand why this was so prevalent within the research medical space. So when I got the Rhodes Scholarship, I found out about this History of Medicine program, and I thought that would be a great opportunity for me to look back in time and see how these barriers were constructed and put in place. And as I was investigating for my dissertation, I realized there is very limited literature looking at the intersection of being Black and a woman within medicine. A lot of literature on Black physicians and women physicians focuses on Black men and white women. And so I felt like it was really important to look at this intersecting identity because I do not believe that it’s just the addition of those two identities. So that’s what I was studying at Oxford. Uh. My dissertation specifically looked at the social and structural barriers put in place to prevent Black women from entering medicine in the U.S.. And as I got deeper into the project, a few months in, I started to learn more about individual Black women physician’s lives, and I was struck that this was the first time I was learning about it. And then later on, that was the first time that I actually met a Black woman physician. Despite being pre-med and starting the process of applying to medical school. So I felt like it was really important to share those stories. And writing the book seemed like the best way to do that. Because I had so much research, I couldn’t even fit in to my dissertation. 

Dr. Abdul El-Sayed: Hmm. I want to um step back, right, because there is something um profound about something that you said is is that so much of the pathbreaking history that we learn about about medicine is about white women or Black men. Right. But we don’t really hear about Black women. And it’s an important point because the degrees to which both being Black and being a woman, throw additional barriers up in terms of the way the systems are built. It’s not just additive. Right. You have a supra additive uh interaction, so, so to speak, but it’s um profoundly more difficult. Um. But you write about this pathbreaking physician, the first Black woman to get a medical degree in the United States, Rebecca Lee Crumpler, born Rebecca Davis. Can you tell us a little bit about her story and some of the barriers that were in her way and what the implications for her experience as a physician uh continue to be today? 

Jasmine Brown: Yeah. So Rebecca Crumpler, she started medical school in 1860. So this was before the Emancipation Proclamation was signed. She studied at the New England Female Medical College, which was prior to that, she was the first Black woman to attend that women’s medical college and actually the only Black woman in its entire history to attend there. And I was really struck by her journey where as tensions really started to build between the north and the south and the Civil War started to begin, she actually had to stop medical school mid-way through because it wasn’t safe in Boston. There were a lot of people, white Americans, who were against abolition, who started to target the Black neighborhoods in Boston and terrorize them. People were beaten. People were killed. One of the major neighborhoods was only about two miles from her school. And so she had to stop and after the Emancipation Proclamation was signed, she came back to school and they actually tried to take away her scholarship, saying that her reason for leaving school was illegitimate, that the risk to her well being, her safety was not a good enough reason to stop medical school and–

Dr. Abdul El-Sayed: –so, like a whole ass war uh fought largely over the premise of race based slavery was not a good enough reason to to stop? Okay. 

Jasmine Brown: Exactly. And I guess, like, if there’s looking at the perspective of the majority of their students, white women, that wasn’t an issue for them. They kept going. Um. But I think that speaks to one of those challenges of having that intersecting identity, of being Black and a woman that, like it was already hard enough for the women of overcoming people’s expectations of how a woman should behave at that time, that she shouldn’t be pursuing higher education or a profession such as medicine, and that even considering investigating the body oftentimes within medicine that’s naked is unwomanly. So already overcoming those barriers, then she had to worry that people would literally try to kill her because she was going against this system of who was above and who was below. And so eventually she did graduate from medical school. This was 1864. So 14 months after the Emancipation Proclamation was signed. And then she went south to provide medical care for Black people who had recently been freed from slavery. This space was largely male, and I don’t know the demographics, so I can’t say how many were Black, how many were white or otherwise, but they went there on the premise of supporting slaves. All of these people or newly freed slaves, all of these physicians went there to provide medical care to these people. But she, as the only Black woman physician there, was alienated in that space, told that her M.D. just stood for mule driver. The uh pharmacist did not accept her prescriptions that she gave to the patients, the other doctors didn’t work with her. And so she had to continue to fight to exist within that space, um even though there were people that shared at least some part of her identity and they still just didn’t accept her. 

Dr. Abdul El-Sayed: This is an interesting time in medicine, right? Because post-Civil War, this is the first sort of large scale test of the beginnings of science based medicine. And medicine really has a renaissance in the late 1800s, early 1900s, when um we start to formalize a lot of the fundamental scientific principles upon which evidence driven medicine is now based. And with that, there was a series of efforts to professionalize um the practice of medicine, right, in the past uh before this time, there were a number of schools that would pop up with varying degrees of rigor in terms of, you know, whether or not you could you would you would graduate. And over time, there was an effort to say, listen, you have to be accredited. You have to demonstrate a particular adherence to certain principles. And actually, a lot of that was done earlier um in Europe. Um. And that was also a place where a lot of Black male physicians got trained. What were the challenges facing Black um women, aspiring physicians to get their training abroad? Was that an option? And then beyond that, once you had this sort of professionalization of medical practice, did that make it easier or harder for Black women uh to achieve this kind of training? 

Jasmine Brown: Yeah so to your first question about barriers that the Black women face to training abroad, because you’re right, a lot of Black male physicians in the mid 1800s went abroad to get training because those schools were actually more open to Black people going into medical school than in the U.S.. One of the most notable is Dr. James McCune Smith, who was the first African American to get a medical degree. And he went to school in Edinburgh um to medical school there. And it’s actually really interesting. So he went there in 1837, they accepted a Black man, but they did not accept any women for more than 50 years after that. White, Black like they didn’t care, if they’re a woman they were not allowed to study there. Um. So then that is a very like clear barrier. So because one thing that I was initially thinking was back to the community based, what is the expected role of the woman and the man? The man is the one who is allowed to go and pursue a job and a profession while as the woman is supposed to stay at home. Because for Dr. McCune Smith, he actually got a lot of support from the Black elite community in the US to get funding to go abroad. And so I was thinking like they probably wouldn’t have done that for a Black woman because they’re expecting her to stay home and have family and take care of the kids. But beyond that financial barrier, these schools were just not even accepting any women because of this global uh gender roles that were forced on women at the time. 

Dr. Abdul El-Sayed: You know with the publication of the Flexner Report, right this this canonical report that professionalizes medicine and calls out these sort of like wahoo medical schools in the middle of nowhere, teaching all kinds of you know crazy inherited wisdom– 

Jasmine Brown: Yeah. 

Dr. Abdul El-Sayed: –uh types of treatments. Um, did the institutionalization of medicine, did that benefit the training of Black women uh in medicine, or did that make it more difficult? 

Jasmine Brown: Oh yeah, that definitely made it more difficult. And that was actually a really fascinating time that when I was learning about that, just seeing how much medicine was evolving. And then as a medical student, seeing how these structures that were put in place in the early 1900s. So the Flexner report of 1910, how that laid the groundwork for my training today, the premise was that they were trying to distinguish what were the legitimate medical schools and what were the illegitimate. But the most interesting example that kind of counters that is actually my alma mater, Washington University, that initially on the Flexner report, they deemed it illegitimate and they were going to say that they didn’t, it didn’t deserve accreditation. It should be closed. But then the school was able to provide some money to take a second look. And then they decided, oh, Wash U actually it’s a pretty good school. We’ll keep them on the list. And today is is now considered one of the best medical schools in the country. So then that in itself kind of questions the legitimacy of this report in that, while there was probably um some truth to some of the schools that were closed. There is also some like money dealing under the table and then also racism that Flexner actually admitted himself when in his report, he said that Black physicians should only be providing care to Black patients. And the fewer Black physicians, the better. And, you know, it makes sense, like we think of these things in a bubble sometimes, but he lived in the early 1900s, in the late 1800s. So he was seeing these Black people come out of slavery and still upholding this white supremacy that who should be on top? And so he embedded that within his report. And that report actually led to the closing of countless Black medical schools. So in the late 1800s, there were as many as 14 medical Black medical schools. But after the Flexner Report, there were only two left, Howard and Meharry. And then a few years after. I’m pretty sure it was the AMA. The American Medical Association was trying to get Meharry closed. But then the Carnegie Mellon Foundation had to jump in and say, no, like we’re still going to keep this school open. And they supported them. And so now there are four Black medical schools in the U.S., Howard, Meharry, Morehouse and Charles Drew, which is connected to UCLA. And those four institutions trained the vast majority of Black physicians across the country, even though there are over a hundred medical schools. But then when we look at how that policy affected Black women. So I mentioned Dr. Crumpler, who trained at a women’s medical college, and there were multiple other Black women in the late 1800s who also trained at women’s medical colleges. But then after this report, all women’s medical colleges were closed. They had to be joined with the other medical schools that were suddenly coed. But then there was a quota limiting the amount of women that were accepted. Some of the um physicians during that time said that there is maybe three or four women as the quota for how many female students were allowed to enter the medical school class. But then if you’re thinking about a predominantly white institution, or maybe there had not been any Black students to date and you’re only leaving three spots for women, you’re going to give those spots to white women. And then if you look at the Black medical schools well, I saw some research on it and then I lost the citation. So I can’t say this with certainty, but there seemed to be also a preference for Black men in the Black medical schools as well. Going back to this, gender norms of who should be pursuing a profession and who should be supporting the family. Um. So then that made even fewer options for Black women to entry into medical school. 

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Jasmine Brown after this break. 

[AD BREAK] 

Dr. Abdul El-Sayed: In medicine we’re always taught that the Flexner Report was this critical uh report. In some ways it was it definitively established a set of standards. But what we’re never taught is how it ported over a set of uh biases and prejudices around both misogyny and racism in ways that fell hardest on both medical schools that serviced uh women generally, and the medical schools that serviced Black folk generally, which then meant that the people who are uh left out the most tended to be Black women, right? Because it eliminated spots in Black medical schools for women and in uh in medical schools that accepted women for Black folk. And so we don’t really think about the impact of that in the way that you know racism was specifically used in that report, specifically by Abraham Flexner, um to do exactly that. And, you know, it’s tough to go back to history and have to look at it um and recognize the degree to which it it ported through so much of the the the animus of the day that built institutions around that animus that still continues to affect our present and um and even those pieces of history that people universally applaud, there have to be big asterisks around them because of misogyny and racism. Can you tell us a little bit about Dr. May Chinn? Who was she and um what role did she play in the evolution of the Black female physician in America? 

Jasmine Brown: Yeah. So Dr. May Chinn, she was born around 1900, and she went to medical school at NYU. This was also around the time when, as you’re saying, medicine is evolving. We’re learning more about microbiology. We’re learning more about germ theory. And she was involved in research while she was in college to help just support herself financially. That ended up positioning herself to get into medical school. Um. And so she went to medical school at NYU. And then afterwards, she was refused entry into residency programs. And this was not just her experience. This was common for Black women that they were excluded because they were both Black and women. And so for her, then she ended up training under some physicians as an apprentice model, which is actually similar to the way that residency and medical school is but in a more in an unofficial way, she was an apprentice for a set of physicians and their practice. And then after a few years, she left them because they continued to exclude her. This was a group of male physicians, and they wouldn’t acknowledge her in public. They forced her to pay rent to stay in their medical space, even though there is a physician who was required to stay there in order to have this practice. And they continued to raise her rent without increasing her pay to the point where she couldn’t afford it anymore. So then she left, opened her own practice. And because at that time, so this was in the around the 1940s, there were segregation around the country, right? So then that bled into the medical system. So Black physicians were not allowed to work at many hospitals and Black patients were either not treated at all or given substandard care, told to be on the lower floors, etc.. And so then Dr. Chinn counteracted this by basically doing house calls to these Black patients, providing an array of medical care. And one of the most interesting services that she provided uh was surgery actually for these patients, because regardless of if you can get into a hospital or not, somebody is bound to need surgery. And so she actually partnered with Dr. Peter Marshall Murray, who was a Black male surgeon, trained at Howard, and they performed surgeries in these patients homes. And it was it was incredible to me to hear about it like they were using the patient’s bedroom, the bed or the ironing board as the O.R. table. 

Dr. Abdul El-Sayed: Wow. 

Jasmine Brown: They were sterilizing their equipment in the ovens and the steamers. And then they were on call from pre induction of the surgery until the patient was able to get up and when I wrote about this, um I was working on this chapter during pre-clerkship, but I didn’t truly appreciate what being on call for that long meant until my clerkship year and then during my surgery rotation as well like just the complexity that is necessary to safely bring a patient through surgery, to do anesthesia correctly, to have the tools necessary if something goes wrong, such as she was able to provide blood transfusions for those patients if she needed if they needed it. Um. And then the physical demand of, like I said, being on call for that long, like I don’t know how physicians do it now, being on call for some of the long hours that I’ve heard, I think recently heard like 48 hours is maybe the highest I’ve heard so far. But um for those two physicians to take turns being on call just them, to make sure this the patient was okay is really incredible to me, and that they did this over and over again because these patients didn’t have access to a hospital to get the surgery that they needed. Um. And so, yeah, I think just her resilience and persistence and ingenuity to find a way to provide care for these patients and also to continue her medical practice despite people trying to block that path for her. It was just really incredible for me to learn about. 

Dr. Abdul El-Sayed: And you see in that story the impact of the existence of Black female physicians in terms of people who would not have gotten health care, but for the commitment of these physicians who understood what it meant to be excluded from institutions of power and institutions of healing. And so they built their own institutions um and used what they had to provide care for people who also on the demand side of health care um would not have gotten health care, but for their engagement. Um. You also write about about some of the trailblazing uh Black women physicians in the mid 20th century, um folks like Dr. Lena Edwards and Dr. Dorothy Ferebee, folks who um through their careers, uh were able to really climb um into the upper echelon of of health care and medicine uh in our country. I’d love to hear a little bit about their experiences and what they tell us about how, um you know, even if it comes too slow uh and certainly not fully, um some of the ways that these pathbreaking physicians have forced institutions uh to change. 

Jasmine Brown: Yeah. So Dr. Ferebee, who was also born around the same time as Dr. Chinn, around 1900, she went to medical school in the 1920s at Tufts Medical School. And with her, there were a few other women. She’s one of the women who spoke to the um quotas that she saw that her understanding that at least at Tufts at the time there was a quota, maybe three women that were allowed. And then in her year, there were some acceptances made because one of the women was really wealthy, and then the other one had a father who was a part of the institution. And so I think there were five women in her class, four white women, and then her. Um. And during that time, they found that they were excluded significantly within their class and to the point where professors would not teach them, they would send them to wards more akin to like nursing teaching um as opposed to the surgery ward or the internal medicine ward. Um. And then in classes, they were just not selected to go through cases to practice the skills that they had been learning and so then they teamed up together and decided that they would make sure that they got through their medical education, even if their professors and their classmates wouldn’t support them. They created this study group and they would meet at least weekly to study the material that they had learned and prepare in case they were eventually selected um to go through a case in class. And there was a point where they finally were this professor, he gave them a hard case, assuming that it would basically embarrass them. But they had been studying so long that they knew it and they went through the case, they went through the differential diagnosis, they went through their treatment plan, and they were completely spot on. And the professor was so upset that afterwards he stormed out of the room, [laughing] which is just it’s just incredible to think about. Um. But they basically, through the support of each other, found a way to excel in school. Eventually, their male classmates grew to respect them because they realized how much they knew. But they still had challenges with some of the professors. Um. But Dr. Ferebee, she spoke about how they all graduated, those five women at the top of their class like top ten out of the rank of over 100 students. And then she told a story of how later on in her life she would give speeches and one of the other women from her class would be attending the speech and and Dorothy or Dr. Ferebee would say, how yeah, the us five were all in the top ten of the class, and the woman would speak up and say, well, Dorothy is not telling the whole story like yes we were all at the top. But she was actually number one, um this Black woman, number one in her class. And despite that incredible achievement in the midst of her professors really trying to deprive her of educational opportunities, she was still excluded from residency programs. Um. Her and the other women submitted their residency applications along with their male classmates. And despite being at the top of the class, the year went on were that final year where none of them had heard back from residency programs while the men had gotten accepted into residency programs and some of the eventually by towards the end of the year, some of the responses would come back of, oh, uh there are no spots left or you were not competitive enough, which is incredible if you compare the male classmates who were ranked below them and them like, what more does she have to do besides being number one in her class to be competitive enough to get into a residency program? Um. But eventually, through support of her brother, she was able to go to her residency program at Freedsman Hospital, which is affiliated with Howard University, and hers is one of the stories of how important those historically Black medical schools and medical training institutions were. Um. So that’s where she went. And she actually stayed there for many years, rising through the ranks, going into faculty position. Um. And then in addition to that, she was very involved socially. Um. So one of the big projects that she was involved in was the Mississippi Health Project, which was she did through Alpha Kappa Alpha sorority, which is the sorority that she was involved in. 

Dr. Abdul El-Sayed: Mm hmm. 

Jasmine Brown: Through this initiative, she went to Mississippi with other Black women health care providers, some physicians, some nurses, etc.. And their initial plan was to set up clinics in Mississippi so that the Black um sharecropping families could go to and get health care. But the white landowners said that they would not allow those families to leave the land in order to, the plantations, in order to go get health care. And so they decided that they were going to get all the medical equipment back into their cars and drive plantation to plantation to provide health care. And this actually became the first mobile clinic, mobile health clinic in the U.S. Um. So they were providing vaccines, they were giving medication. Um. And just again, that resilience and persistence to provide medical care regardless of what the they’re faced up against. And and she continued to have a, a really prosperous career, even to the point of participating in global health initiatives in Africa, Asia, Europe, etc.. Um. And she served on President Kennedy’s health committee. So, yeah, it took a long road for her. And there were many points where if she didn’t have the support that she needed, whether it be through family or through these Black institutions or just with other champions who were willing to support her, um she might not have made it that far. And it even begs the question of how much farther would she have gone if she didn’t have those barriers? But it was still really incredible to learn about how much that she had achieved. 

Dr. Abdul El-Sayed: You, again, I mean, here are highlighting the kind of health care that uh Black women physicians are offering, the way that they’re innovating health care to move beyond, um to move around a lot of the institutions that have excluded people who look like them uh throughout history. And um, you know, it’s it’s it’s incredible to think but, you know, we can’t forget that the book is called Twice as Hard. And in some respects um, I I feel in the tone of the book and in in uh your telling of these stories, there’s a bit of being torn about it. On the one hand, we have to celebrate the incredible ingenuity, hard work, um capacity, talent, um commitment that these Black women physicians brought to this work, in opening doors. And then we also have to lament the fact that the doors were closed in the first place. And um I want to ask you, as you as you think about this moment, you profile a number of physicians doing incredible work uh right now, Black women physicians who are leading major institutions, the Robert Wood Johnson Foundation, for example, um their past president was Dr. Risa Lavizzo-Mourey, um a Black woman physician. And there are Black women leaders uh across medicine right now doing incredible work. Um. You are a third year medical student. And, um you know, obviously, your uh your pathway through medicine has been paved by the women you write about. What was the experience of researching and reporting these stories for you um about what it means for your work and the kind of career you want to build? 

Jasmine Brown: Yeah. Um. So first, I want to speak to the kind of conflicted nature that you read that it is true and actually is the root of two key goals that I have with the book. On the first hand, my goal of by highlighting these stories that have not been recognized enough, at least in my opinion, hoping to inspire other students of color, Black girls, but really more broadly underrepresented minorities to pursue medicine. But then on the other hand, I want these institutions to look at, okay, this is when this barrier was created. This is when this barrier was created um to work, to better remove those barriers and make medicine more accessible. And then as it involves my own career and my journey researching these women, it was a really fulfilling, inspirational. It was a really wonderful journey for me. Um. I know some of the barriers that exist because I have lived through it, and that was the impetus for me starting this research in the first place, but just to see how much they had overcome. And how much they were able to achieve really gave me hope about what I could do, because that was a worry. Like, I’m ambitious, I have these goals. I have all this that I want to do, but will society prevent me from achieving that because I’m Black and I’m a woman? And while there may be some things that the path may be slower, or maybe that I could reach even higher if I didn’t have those identities or I didn’t have at least the society’s oppression of me due to those identities. Seeing what they had done, it made me believe that there there wasn’t as much of a glass ceiling to my career as I had initially believed, and that I could have these ambitions and in seeing that, what they had done. Um. One of the women, Dr. Joycelyn Elders, she said, you can’t be what you don’t see um or what you can’t see. And those women were seeing from me. So by seeing all that they accomplished, it’s like, okay, maybe I can do that or maybe I can do this thing instead. Um. And while I believe a key part of my career will be continuing to work to dismantle these barriers and to increasing diversity within medicine, they also gave me hope that just more broadly, my impact in medicine doesn’t have to be as hindered as it feels when I look around and I do not see those women in leadership positions. Like it took a lot of work to find them. Um. And so prior to finding them, I wondered if that was possible. But I see them now, so it definitely gave me hope. 

Dr. Abdul El-Sayed: One of the things that um that I think when we talk about history, there’s sort of a there’s a rose tint about, you know, it’s always a progress moving forward and that we look at it and say, well, we’ve gotten to where we need to go. And certainly when it comes to representation in medicine, we have not gotten anywhere near where we need to go. What are some of the barriers that exist for Black uh female physicians and aspiring physicians today? 

Jasmine Brown: Yeah. So I think some of those barriers which we’ve actually um touched on that were established back in history, the Flexner report is really one of those key barriers. So back in 1900, there were about 160 Black female physicians. And that to me was like, that’s an awesome number in 1900. But then if you look at the bigger picture, what else is happening? 1600 Black male physicians, 3500 white female physicians and 88,000 white male physicians. Okay, maybe it’s not as great, um but there still was some progress. And then in 1920, ten years after the Flexner Report, the number of Black women physicians had dropped to 65. So more than half– 

Dr. Abdul El-Sayed: –Wow. 

Jasmine Brown: –because this Flexner report decided that these Black institutions were illegitimate and thus so many of them were closed. So and and still today, so back in 1910, there were about 2.5% of Black physicians generally um within the medical um community. And then in 2006, there was 2.2% Black physicians. 

Dr. Abdul El-Sayed: Wow. 

Jasmine Brown: So almost 100 years later– 

Dr. Abdul El-Sayed: Wow. 

Jasmine Brown: –and the number is the same or slightly lower. Um. And that is the most clear example of policy change that affected that dynamic that we saw immediately ten years after and that then persisted almost 100 years later. And so I think one of those big barriers is just who can get in, in the first place. So if we have these limitations on the number of Black medical students that can enter a PWI and then only so many Black medical schools, then that’s going to prevent there being more Black physicians, Black women, Black men, Black people um going into medicine. So I think that’s one of the, the big barriers. Um. So there are a lot of medical schools, um predominately white medical schools that could do much better in terms of their representation. Um. I know some schools where there’s maybe three Black medical students out of almost 200 students. Um. I do think there’s kind of an unsaid cap that as long as it is the national demographics, so around 13%, then that’s good enough. Um. Without speaking to the historical exclusion that still contributes to the lack of diversity. But I think that would be hard. A lot of schools would be hard pressed going much higher than that 13% of Black students generally. Which to me then goes to we need more Black medical schools because it’s still not good enough. If if more than half of Black trainees are trained at only four Black medical schools around the country, then we need more and we need more support of the institutions that exist. If we want to increase diversity within medicine and then within the PWI’s, they need to be supporting more Black students in entry and then retention, because that’s another issue of, okay, we let them in and we say we got all the numbers and then we see one drop off this year, one drop off this year. Um. Till by the end of the training, there is maybe half that are left. 

Dr. Abdul El-Sayed: Can you tell us, a PWI, I’m not familiar with that term. 

Jasmine Brown: Sorry, predominantly white institution. 

Dr. Abdul El-Sayed: Predominantly white institution. Got it. 

Jasmine Brown: Yeah. 

Dr. Abdul El-Sayed: Thank you. Um. I want to ask you, right because it’s not just about I think sometimes when we think about diversity, it’s sort of thought of as a nice to have. Right. Wouldn’t it be nice if uh these institutions look like the people they serve? But there is a much greater urgency and frankly, I would argue an ethical um failure when you consider the fact that across almost any outcome from the beginning to the end of life, Black patients generally uh suffer worse, suffer earlier, uh and suffer faster than white patients. And nowhere is that more urgent than at the beginning of life. You think about the handoff of life, maternal and infant mortality. And we also know that um Black patients who see Black doctors tend to have better outcomes. And in so many ways, if you think about the way that institutions have discriminated both against doctors and patients, it makes sense that if you are a Black person, you’re seeking care in a predominantly white institution, that when you have a Black doctor, uh your perception of the kind of care that you’re going to get, your trust in the care that you’re going to get is that much better, particularly when you think about all of the history of these kinds of institutions actively discriminating and the present of your own experience being discriminated against in these institutions. And so it’s not just a nice to have issue. It is a fundamental question of whether or not we are serious about taking on health disparities. But then so much of that also is um baked into the nature of our health care system. And I thought you did a great job writing about that. On the one hand, we need more diversity when it comes to our clinicians. But on the other, we continue to rely on a health care system that itself patterns access to care, and then access to be able to provide care on income uh and on wealth. And um it’s it’s hard to imagine a system whose incentives are so built around marginalizing uh folks who have already been marginalized because of institutional and systemic racism actually solving the problem. So what would it look like in our country to take this problem as seriously as it is, as urgently as it needs to be treated? And how deep does rethinking the nature of our health care system have to go? 

Jasmine Brown: Well, I agree with you. I think this problem is multi-dimensional and extremely complex from the beginning of economics, as you mentioned, we live in a society where health care is largely based off of if you can pay for it. Maybe if you go to the emergency room and if you don’t get this pill, you will die in two days then they’ll give it to you, even if you can’t pay for it. But in terms of primary care and preventive care, which has a significant impact on lifespan and quality of life, that is very much based off of your income and is seen within society because of this historical exclusion, oppression, discrimination. Black Americans average income is significantly lower than other Americans. If you can’t afford health insurance, then you’re not going to go to the doctor for primary care. Um. And then it’s going to be until the disease has progressed to a point where it’s much harder to treat, when you finally go into care and that’s something that I’ve actually seen in the hospital where, okay, I go to a medical school in Philadelphia, we’re more likely to see some disease presentations that are uncommon because they’ve progressed to a point where if this person had gotten treated after year one or year two, then it wouldn’t have manifested in the same way whereby ten years later it looks terrible. And like somebody like one person, their foot was literally like there was gangrene, like it was dying um and had to get an amputation. And it was like years before they sought care. But okay, if you don’t have health insurance, you don’t realize what’s going on. You start to get used to it, and then you’re worrying about providing food for your family, the paying for rent, then you might never go to get care. And if we think back to Dr. Ferebee and providing care to those sharecropping families, while I don’t think it’s as explicit as the white um plantation owners there. If somebody is poor and they’re constantly waiting to get um opportunity to work, how much time is that job giving them to go get health care? So there are those financial boundaries and and the beginning of like just entry of getting care. And then as you spoke to on trust and just the repeated assaults that Black patients have experienced through the medical system, whether it be themselves or collective history, consciousness of what’s happened to their people, um then it becomes more difficult to trust what the physician is saying. If the physician goes too quick in their visit, they don’t explain things which, I have more empathy now on the other side of like learning about how much the patient burden that physicians have, etc. but if you’re not able to connect with your patients and you’re not able to establish that trust, then it’s much harder for them to believe that they should take this medication that causes them pain for a disease that they don’t have any symptoms for yet. And then that leads to catastrophic outcomes in the long term. Um. So it’s it’s very complicated and I think that they’re just societally like doing something to address this economic disparity, whether it be addressing wage gap um inequality or um more support for Black Americans, to having more Black physicians that are able to maybe connect with their patients more quickly so that they can establish that trust and they can explain why it’s so important for them to take X blood pressure medication, even though they’re not having any symptoms or X diabetes medication. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that perspective. And I think, you know they say health is wealth, you sort of think about prolonged disease burden and the way that a disease can develop and manifest over time if it’s untreated. The point that you’re making is it highlights exactly the same set of mechanisms, which is to say if this system is set up to keep you from accumulating wealth um and financial security. Then over time, you are you are always uh in a situation where you are insecure to the bumps and uh bruises along the pathway. And when those bumps and bruises get that much worse um and you are uh you are gate kept from the institutions that can support you um what do you think is going to happen? And this is like the physical manifestation of exactly that. And it’s the same racism that keeps Black physicians, Black female physicians from being able to um train and become doctors. That uh exposes Black folks in our country um to the kinds of physical insults and mental insults that yield disease and then keep them from getting those diseases treated. And um and so we’re failing on this front to take on that same singular factor and feature um that ends up in more people being more sick um and fewer people uh who are focused and and um committed to treating them. And I really appreciate you just telling these stories in this book and highlighting it and I do hope that folks um will pick it up because the stories are really quite inspiring but they also lay out exactly how many hurdles uh there are in front of Black women choosing this career path and the consequences that that faces. Um. Our guest today was future foctor Jasmine Brown, and the book uh is Twice As Hard: The Stories of Black Women who fought to become physicians from the Civil War to the 21st century. Jasmine, thank you so much for taking the time to join us today. 

Jasmine Brown: Thanks so much for having me. 

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. 

[unspecified news reporter] Tonight, outrage growing less than two weeks after that massive train derailment and the controlled burn of hazardous chemicals sent up a toxic plume of black smoke in East Palestine, Ohio. 

[unspecified residen of East Palestine, Ohio] It doesn’t smell safe. I’m taking my things and I’m out of here. 

[unspecified news reporter] Residents demanding answers, complaining of burning eyes, nausea, headaches and a pungent odor. 

Dr. Abdul El-Sayed, narrating: A few weeks back, a train carrying hazardous chemicals, including vinyl chloride, isobutylene, and several other chemicals, all used in bulk synthesis of materials like PVC piping and rubber, derailed in a massive accident in a small Ohio town called East Palestine. Vinyl chloride is highly flammable, and authorities feared that the derailed train could cause a major explosion. So they ordered a, quote, “controlled burn of the materials”. Locals were evacuated and the EPA and the Ohio Emergency Management Agency have been conducting assessments for safety, including samples of the community’s air and water quality. While authorities have since told residents that they can come back to their homes and the testing has shown no evidence of contamination of the city’s water supply. Nearly 3500 fish have turned up dead following the derailment. And on top of that, there have been several reports of sick and dying animals. Locals have reported headaches, rashes, difficulty breathing, painful coughs and eye irritation. So here’s the challenge. Most of what we know about how these chemicals actually affect people is through acute workplace exposure, like spilling some on your hands, not the kind of long term chronic exposure that could occur if some of this spilled in soil or groundwater. And so the situation is unprecedented, and that’s just the science part. Then there’s the economics and the politics. Norfolk Southern, the train operator, loaded their train to the hilt before it left the station in Illinois a few days earlier, causing it to break down even before it ever derailed in Ohio. Employees report concerns over the sheer size of the thing. 151 cars long, weighing in at 18,000 tons. To put it in perspective, 80 cars is considered long. This one was 151. Now, why would the operators load the train up so much? Greed. Loading up a train means you can put more cargo into each journey and make more money. But it stresses the capacity of workers who have to inspect trains that are far longer, increasing the probability that they might miss something. And don’t forget, this is the same train industry where operators had to strike simply to get some paid time off, to go see a doctor or their kid’s baseball game. And as bad as this derailment is, right wing pundits and politicians have actively used it to spread misinformation for political gain. These are, by the way, the very same people who wanted to pretend that a pandemic that killed over a million people wasn’t anything to be worried about. But they’re now spreading conspiracy theories about this derailment. Oh, and don’t forget, these are the same politicians who want to bust the unions that are advocating for safer train transit. You can’t make this up. All of this is a reminder that health is that place where science and society meet. And when we ignore the truth and put greed ahead of safety, these are the kinds of disasters that can happen. We’ll keep an eye out on this for you as it unfolds. Now, in case you got sick of me talking about the public health emergency over COVID, I’m sorry, but this is the third week I’m going to talk about it. Abdul, what gives? You might ask. Well, look, it’s a big deal, and as I’ve tried to emphasize before, and I’m going to say it again, so much of what the state of emergency enabled should be well, regular policy. In today’s version of things that it shouldn’t require an emergency to do in American health care, a new survey found that 69%, nearly seven in ten doctors, are regularly using waivers that only exist as a function of the COVID emergency. Why? Because despite the Internet having been a thing now for more than two decades, before COVID, you couldn’t use telemedicine to do a lot of things like, say, treat someone with opioid use disorder. The pandemic forced regulators to change the rules to enable telehealth, and it turns out that both patients and clinicians really like it. Now that the state of emergency is ending, nearly 50% of doctors using these waivers are worried that they won’t have enough time to readjust. But should they though? Given that the Internet uh has allowed Fortune 500 CEOs to run their companies from the kitchen table at an Airbnb in Wyoming, shouldn’t doctors be able to treat their patients that way, too? I mean, it’s been nearly three years and it’s working out just fine, guys. Can we just make these things permanent already? In good news, the Biden administration began approving requests for some states to use Medicaid funds to help beneficiaries buy groceries or get nutrition consultations. First, some background on Medicaid. It’s the federally funded insurance program for low income Americans that’s operated through the states. Unlike Medicare, the program for seniors, which is both federally funded and federally operated, there are a lot of differences across states. Like in Florida or Texas, where their governors have blocked expansion of the program. But I digress. Given the fact that food well matters for your health, some state Medicaid programs have wanted to use Medicaid to tackle food insecurity as an add on to programs like SNAP. Considering the fact that millions of Americans on Medicaid struggle to afford healthy food, these programs would allow more families to access food benefits. Right now, SNAP is restricted to families earning less than 130% of the federal poverty line. But Medicaid, at minimum, includes people earning less than 138% of poverty and includes even more folks in states with more generous Medicaid programs. This is a critical step toward taking a more holistic view on health. This week, tragedy struck close to home for me. 

[clip of Jordan Kovach] We shouldn’t have to live in this anymore. Things need to change now. Thank you so much. And go green. [crowd noise]

Dr. Abdul El-Sayed, narrating: Michigan State is an hour from where I live, and this week everyone in Michigan is a Spartan. A gunman killed three and injured five on Monday night. While his motivations aren’t quite clear, what is is that he used a gun he shouldn’t have had. In fact, his father had previously asked him to get rid of the gun he used in the murders. The survivors at MSU, they include several students who survived the shooting at Oxford High School just 14 months earlier, and at least one who survived Sandy Hook more than a decade ago. I wish I could say how terrible or tragic this is, and it is. But this is so normal in America today that to call it tragic would be to claim that it’s somehow out of the ordinary, which I cannot in any honest sense of the word do. Instead, this is the America our lawmakers have chosen for us, where some children don’t just survive one school shooting, but many. And the gun manufacturers who lobby them, schmooze with them and fund their campaigns. They understand that the aftermath of these shootings is actually just good for business. Gun sales spike after mass shootings. As in the absence of any real action, people turn to the very thing they’re afraid of. In Michigan, we just elected the first Democratic trifecta in my lifetime. This is where they have to show what all that campaigning was good for. Because if we can’t pass real durable gun reform legislation after two school shootings in just 14 months, what can we do? That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. And if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. We’ve got our logo mugs and t-shirts, and our Science always wins sweatshirts and dad caps. [music break] America Dissected is a product of Crooked Media. Our producers are Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz and Ines Maza. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer Sandy Girard, Michael Martinez, and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.