I’m sure I’m not alone when I admit that anxiety is a familiar companion. I’ve woken up at 3:00 a.m. on more occasions than I can count in a cold sweat about a patient, about a grant, about a pending decision. (I’ve also spent far, far too much time worrying about things over which I have no control: our electoral system, the weather, the past.) For those issues where I might assert some reasonable amount of control, the balm for anxiety is often action. I get up, make a cup of coffee and start work on the grant, or I scour PubMed to see if I can find additional clues about my patient’s condition. Sometimes I make a plus/minus list. For those situations where I have no control, I try everything I can just to get back to sleep.
The last several months have brought to front of mind something that has been percolating in our country for decades. The current pandemic has brought into sharp relief the health inequities that we might have tried to ignore in the past. It’s not only that African American and Latinx patients have higher death rates or infection rates from the novel coronavirus or that the poor are more likely to live in situations where containment is nearly impossible. It’s that every other downstream effect seems to amplify damages to the poor of our country. Unemployment disproportionately hurts the economically vulnerable. Restrictions on school openings disadvantage the poor educationally and nutritionally. Even telehealth is not a solution for so many individuals. How are you supposed to set up a virtual visit with a patient who doesn’t have the resources for a data plan?
If the brutality of George Floyd’s death spotlighted racism in the way our nation’s laws are enforced, this pandemic has illuminated long-present disparities in our health care system and limitations in the way we’ve deployed the fruits of scientific progress. This is, sadly, no surprise. We hematologists should know this in our bones. Ask anyone who regularly cares for patients with hemoglobinopathies. Ask anyone who looks at clinical trial recruitment patterns. Ask anyone who understands prostate cancer risks, myeloma deaths, and insurance coverage. It’s enough to make even the most optimistic person feel not just anxiety, but despair. What can a hematologist reasonably do to counteract wrongs?
I was discussing these feelings of despair with my sister recently. As she often does, she turned things on their head. “Laura, doesn’t your work constantly ask you to deal with impossible situations? Seems like you would have a lot of experience in this.”
It was a great reminder. Hematologists are practiced in facing daunting odds. We are constantly asked to solve problems — whether an obstacle in the lab or a problem with a drug interaction or a challenge with getting a patient support for a transplant. While we often keep our focus on those small victories — in reality, achievements like this can spiral into bigger change. Done well, science and medicine can impact social inequity. Perhaps an understanding of a drug’s molecular activity illuminates important pharmacogenomic considerations in non-white populations? Maybe the clinical trial you design reveals that mild or moderate renal dysfunction need not be a barrier to treatment? Perhaps the next time you negotiate for a pharmaceutical study, you build in travel funding for patients who live a distance away, without access to local trial options. Perhaps, we find true cures for sickle cell disease (SCD), for myeloma, for hemoglobinopathies that can be fairly and safely deployed.
And so, yet again, we go to work. For my part, I am trying to actively reflect on how my research, the clinical care I provide, and any teaching I do can somehow better aid the marginalized communities of this city. I’m trying to listen to my patients more, to ask about barriers they face that I might not have even imagined, and I’m bugging my institution to stay on track with their efforts at diversification and change. The focus needs to be constant. How can we keep the spotlight on those who have been in the shade?
I don’t have anything to report yet except a recognition that I have work to do. I have also tried, whenever I am giving feedback to residents or fellows, to ask them to also pivot a bit: “Is there a way that you see your career helping to alter disparities in care?” “Can Medical College of Wisconsin assist you in any way in the effort?” And there are other approaches as well, at the scale of the institution. Can we find a way to support minority-owned businesses or contractors? Are we actively engaging local community members in research? Can I better support ASH’s advocacy efforts in SCD or under-represented minority education?
Certainly, despair over poverty and inequity is real. And yet, as physicians and researchers, our talents can contribute to remediating some of these problems, with scientific discovery, with translational diligence, and with a sharp eye and dogged effort toward ensuring that we deliver outcomes to everyone. This is not the time to go back to sleep. The balm for this anxiety is work.
