In order to be anti-racist, we need to understand the levels of racism, how they impact public health and identify racism when we see it. Nathan Chomilo, MD, a HealthPartners pediatrician and internist and the medical director of Minnesota Medicaid, shares how to apply anti-racism to our everyday lives.
In order to be anti-racist, we need to understand the levels of racism, how they impact public health and identify racism when we see it.
Nathan Chomilo, MD, a HealthPartners pediatrician and internist and the medical director of Minnesota Medicaid, shares how to apply anti-racism to our everyday lives.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Nathan Chomilo, MD
Dr. Chomilo on Twitter: @ChomiloMD
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together, we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is Off the Charts.
Steven Jackson:
Welcome to the show. In this episode, we spoke with Dr. Nathan Chomilo, who is a HealthPartners' adult and pediatric physician. And he also serves as the Minnesota Medicaid medical director.
Kari Haley:
We had a great conversation about what it means to be an anti-racist.
Steven Jackson:
Being an anti-racist or being an anti-racist organization, I think requires us to kind of go back to the basics. What is racism? Dr. Chomilo does a great job of really talking about what most people envision when they think of racism and what it is to be racist, so to speak. And a lot of times we have it all wrong because racism works and manifests in just so many different levels, but once you name it, then you have to talk about, well, what do we do about it?
Nathan Chomilo:
You have to start with terms that most people are likely familiar with, or have some type of understanding around and the first one being racist. Right? And so when you hear that term and the way we've kind of were grown up to think about that term for most of us, I should say myself included, is that racist is a person who is filled with hate. And does these acts of overt explicit bigotry, or you think about the folks who are over at Charlottesville marching with torches. You think about the folks in the capital insurrection, walking through the halls with the Confederate flag, and that's really clear to you what racism is, and so that's racist. But I think what I've learned and what I think more and more of people are understanding is that racism works on many different levels, right?
Nathan Chomilo:
And so I like Dr. Camara Jones definition of racism. So Dr. Jones is a family physician. She's a PhD epidemiologist and former president of the American Public Health Association. And over 20 years ago, she'd published paper on a framework around the levels of racism and how they impact public health. And so she has the levels of racism being institutional racism, personally mediated racism, and internalized racism. And she defines racism as a system of structuring opportunity based on how someone looks, what we call race that systematically favors or advantages one community. And the coin or the opposite of that coin, I should say is that it disadvantages other communities and overall zaps the strength and wastes human resources. Right? And so if you have that understanding of what racism is that it's not just these one-off acts or these individuals that are filled with hate and animus, but it's actually a system.
Nathan Chomilo:
Then when you talk about being anti-racist, then it is talking about what are actions and what's a belief or system that kind of works to dismantle the racist outcomes of these racist systems. And what are, as Dr. Ibram Kendi talks about, he says anti-racist policy, for example, is any policy that actually promotes racial equity, right? And so anti-racist is really about kind of identifying racism when you see it, and then moving actively to address it where you're at. And so that's, I think, a good starting place for any individual. That's a good starting place for any organization. If you're really thinking about diving into anti-racism and becoming anti-racist is to first know what your definitions are, and then kind of that helps you go from there.
Kari Haley:
And I think too, kind of re thinking about how he talked a lot about that traditional thinking of racism, the bigotry acts, these are the bad things. You're a bad person when you're a racist. Removing some of that and thinking more about the ways and racism can manifest itself and removing that connotation of bad person with it, I think really opens us up to about two naming it, and then acting on it.
Nathan Chomilo:
You're going to tell in this conversation that I'm a big Dr. Camara Jones fan, because I'm going to cite her several times. And one thing she says when she talks about how do you start addressing it is first, you got to identify it and kind of see where is racism acting, where I'm at, right? And then once you're able, so you name it. So we know this is structural racism, you identify and see how it's acting, where you're at. And then you work together with the communities that are impacted by it to actively dismantle it and its impacts. And so physicians have lots of different ways that they can or any health care provider, because our health care systems really depend on so many different people and professions have lots of different ways that they can identify it.
Nathan Chomilo:
And so the different kind of levers that you think of that pop to mind first are just in education, right? And how do we educate the current and future physicians and trainees and other health care providers? There's a lot in our medical education right now that bakes in ideas of racial, biological racism, and biological basis of race. Right? And so the idea that someone walks into my clinic, I look at their skin color. I think I know their race and therefore I can tell them that their kidneys operate differently than someone else's is flawed science. And we need to kind of challenge that. But that's something that is duplicated across lots of different specialties and how we're even trained to kind of think about race and health. And so there's been studies that have showed that white medical students and white residents in 2015 and in one study about 25% of residents who graduated medical school believed that Black skin was thicker than white skin.
Nathan Chomilo:
Right. And that's a consequence of the ways that were taught race in our education. And then that study also showed that if you believed any difference of biological difference of race, that that actually impacted your assessment for pain and your creation of a treatment plan. And so there are real impacts of kind of some of the ways that we're taught about race. And so being anti-racist is really first understanding that, dismantling it. I think it really starts with having a more systematic approach and understanding the systematic determinants of care in health. And then how someone's ability to have intergenerational wealth is to tied to structural racism, how that intergenerational wealth can impact where they live in their housing situation, the education they get, the food they have access to, the environments they grow up in, and the environmental toxins that impact their health.
Nathan Chomilo:
And so if we focus just on what happens in between the doors of our hospitals and clinics, we're going to kind of miss an opportunity to be truly anti-racist. And some of that is actually working with our community. Some of that's informing our policy makers and helping them understand that when they build a highway here or zone a certain neighborhood this way, it actually has health impacts that we will end up seeing on the back end. But they need to be informed upfront, and physicians, I think have a unique place. Health care in general has a unique place to do it. And I'll kind of frame one other report that I helped work on was what health care can do to address health inequities in Minnesota. It was done by the Wilder Foundation and United States of Care published January of last year.
Nathan Chomilo:
And it really kind of had this kind of systems framework of the different levers that health care can really look at. And they talked about organizational level, the community level, and the policy level. And when it comes to being, anti-racist, there's kind of like four main tenants that we can think of. One is, we are health care providers. And so what can we do. And that kind of gets to kind of the training part, what can we do to be more anti-racist ourselves? We are also employers, right? And so how can we make our systems more welcoming to all? And so that there's equal opportunity the way we pay people, benefits, like paid family, medical leave, and other things are equitably distributed across our organizations.
Nathan Chomilo:
We're a community partner, right. And so how do we engage with community and actually bring them in at the beginning and say, what are the problems you're seeing? And what are some solutions that you're working on that you just need to help scale up for versus saying, oh, we have the solution for you. You should do this. And then that last part, like I talked about a little bit earlier, how do we talk about health in all policy? Health care systems are at a lot of tables. We have our own lobbyists and how can we use that to kind of actually have conversations around policy focused on health inequity?
Kari Haley:
I think one of the things that Dr. Chomilo really spoke to is, as we're thinking about dismantling racism, we first need to kind of figure out where we are in it and then work on that next step, which is dismantling it. And then as he says, doing that over and over and over.
Steven Jackson:
Rinse and repeat.
Nathan Chomilo:
Identify where you see it, where you are at. And that can start with your clinic or hospital. It can start with your interactions with your colleagues or your staff or superiors. It can start in your community and kind of working within your professional groups, whether you're part of a physician specialty organization or not. Name it, and then find where it working in your life, and then work together to dismantle it. And that's really the key. And we talked about multiple different ways you could start to dismantle it. Even if it's talking about a book club to kind of get the same language, if it's talking about how you can use tools to help inform choices on investments and policies, how you can work to educate and put together resources for patients and families, but work together to dismantle. And then do it all again, right?
Nathan Chomilo:
It's an iterative process. Again, like to point out that these things have been built up over 400-plus years, it's not going to get fixed in one era, one budget cycle, one election cycle. We need to kind of have that long game and know that we're kind of helping move it so that hopefully my grandkids don't have to have these same conversations and fighting these same battles. But I think we can definitely use this moment to catalyze and take a much bigger step than we've taken in the last 20, 30, 40 years.
Steven Jackson:
We know that people make up organizations, and people/organizations make up societies. And it's important that when we talk about dismantling racism, we have to first dismantle the racism in us or the racism that we operate in. But then when we look from a bigger standpoint, we have to be able to identify, meaning look and have an honest look in the mirror as to what are our policies say? What messages do they send? Are they racist in nature? Do they benefit all or some? But these are difficult questions that we have to answer in order to "dismantle" racism as an organization and a society.
Nathan Chomilo:
Having the conversation, yes. I think there's been a lot of sincere movement to have conversations, to create spaces, to where folks before can't get away with saying, I don't want to talk about structural racism and walking out of the room and that type of thing. And even in some spaces that are predominantly white and male, and historically have not been open or interested in that conversation. I think I'm still struggling to see the next step, which is then the action, right? So we can talk about it. We can name it and say we are committed to this, but then how are we fundamentally changing what we are doing to be anti-racist? And that's what anti-racist is, right. It's how do you actually change the systems and structures that have been built up over 400-plus years through slavery and land seizure and Jim Crow and disproportionate incarceration that we've seen?
Nathan Chomilo:
How do you actually change policies and systems to correct those? And I think, one thing to watch closely is like COVID vaccination, COVID 19 vaccination. What are we doing fundamentally in how we allocate it? And what are we doing fundamentally in how we help folks overcome barriers and not make excuses like they're more hesitant. And so that's why the numbers are lower. I think that will be the first big challenge. And then I think there's a lot of conversations around how do we actually intentionally be actively anti-racist with our policies beyond just hiring more Black folks or doing implicit bias trainings? How are we paying folks? What are the benefits we offer that we know help lift people out of not only poverty, but help overcome some of these barriers?
Nathan Chomilo:
How do we look at how we structure schools and things like that? So I think there's a lot ahead of us to see if this is truly another moment, or if it kind of fades back into the background again, and folks get back to kind of things as they were beforehand and say that was a really tragic occurrence, but we're better now. And I've even recently kind of tweeted out, I don't think we can use the words, racial reckoning, because reckoning means a settlement of accounts. And we have not done any settlement. There's maybe like a racial awakening or reawakening to issues, but there's been no settlement yet.
Steven Jackson:
As we closed out this conversation, Dr. Chomilo really challenges us to move to action. It's easy to make big statements as an organization about how we're committed to being anti-racist or how we're going to treat our Black and brown people better going forward. But now that the statements have been made and the promises have been made, now we have to really think about how do we honor that? How do we make good on these promises? And so, as we move forward, and as we attempt to be an anti-racist organization and society, we have to turn our words into action and commit to it.
Kari Haley:
And I love that it's that commitment and that we end with that because it is a commitment. And it's not something that we've talked about you changing overnight. This is something, a promise that you have to continue to show up for and continue to do the work for.
Nathan Chomilo:
This idea of actually sharing power and resources and decision making. And so, I think that starts with really truth and reconciliation. So let's have a conversation about where we've gone wrong as a medical institution and a medical practice. Let's talk and acknowledge that we haven't treated Black and brown people the same throughout our history. And in fact, it's not just not treating the same, there's been straight-up abuse, straight-up violation of that trust. And so I think that truth and reconciliation is really key to part of this. And so, I'm enheartened by the American Medical Association, which has in the last year or so, put out a couple statements and even the American Academy of Pediatrics put out a statement about we years ago didn't allow Black physicians into our organization, or we have lionized people who are blatantly racist in their past.
Nathan Chomilo:
Right. And we need to do better moving forward. And so I think part of that first step is key. And so thinking and hearing so maybe we don't again know our blind spots and think, oh, no, we've never treated anyone poorly. So maybe it's getting community together and hearing where we've gone wrong and acknowledging that and processing that. And then, yeah, the hard work of how do you build trust going forward after you have that truth laid out? And I think that having community at the table to help design and take part and have control over some of the resources that we have at our fingertips to address these problems and create these solutions is key. And I think consistently doing it because easy to come and say, oh, we solved this one problem, and now we're going to go help this other community.
Nathan Chomilo:
But when you built that relationship and you were successful, like why do you leave? And then allow people start having ideas of other things they could work with and how they could continue to help their community. And so how do you create that ongoing investment in the community? How do you create this ongoing, shared power? Which I keep saying over and over, but that's what I haven't quite seen in many places. It's a lot of a model, you need to create your own 501(c)(3). You need to show us the data that your intervention works, and then we'll fund you, right. Instead of let's work together, and let's actually fund people who are doing the work and move from there in a more iterative process. And so I think that would go along way towards helping, but I think you're right.
Nathan Chomilo:
It's going to take a while to repair the trust that's been violated. I'm hopeful that we continue to find ways through COVID-19 vaccination to kind of show that we mean different this time. And this is just the start. We're not going to create all these infrastructures to deliver a vaccine. And then once, the pandemic's done, it's like, all right, we don't need to keep engaging anymore. Close up that mobile vaccination unit, we don't need to keep going on communities and offering education and resources. No, let's keep using these kind of infrastructures that we're building right now to continue to invest in kind of a more just health care system.
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy with creative by Peggy Arnson, Tina Long, Tim Myers, and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.