What questions are you trying to answer with your research?
How do we build systems that optimize medical treatment and health while mitigating or obliterating racial disparities? These systems include disseminating and implementing new evidence, using informatics tools to provide transparency, building workflows that include humans using the tools, and, in an ideal world, including methods of outreach to support people in the community.
If you could collaborate with anyone, who would it be?
Geni Eng and I have worked together with the Greensboro Health Disparities Collaborative since 2003. It’s been a complementary experience in that I’m a science/technical/medicine guy, and she’s the community/participatory research person. Putting those skills together, we’ve gone a long way in getting things done. So I wouldn’t choose anyone else.
What research accomplishment are you most proud of?
The first would be the ACCURE (Accountability for Cancer Care Through Undoing Racism and Equity) study and companion lung cancer study where Geni Eng and I partnered with the Greensboro Health Disparities Collaborative to design and implement an intervention that totally closed the gap in black-white treatment disparities in early-stage lung and breast cancer.
In 2003, a community organizer in Greensboro, Nettie Coad, received a grant to partner with academics to look at health disparities. Out of that grant, the Greensboro Health Disparities Collaborative got started. At the time, I was working in Greensboro, mostly in medical care, although I had started doing disparities research in 2000. As part of the collaborative, we all attended a two-day training with the Racial Equity Institute, and we just started talking about where we should start with our work. It was the community that wanted to start with cancer treatment, and they knew that if we really wanted to make a difference, we needed new data that was transparent. They came up with the concepts that were needed to improve cancer care: transparency, accountability, and better communication. As the scientists, we had to figure out how to do that.
I’m also proud of Heart Health Now. Through the NC Area Health Education Center (AHEC) practice support program, we worked with over 200 small primary care practices across North Carolina, about half of which were in the stroke belt region of the state. We came up with a tool using data from electronic medical records to stratify all the patients according to their cardiovascular disease risk. AHEC practice support coaches came into the practice and said “Now you have these data. What kind of system do you want to design to engage and re-engage these high-risk patients and rapidly reduce their risk?”
After one year, the baseline risk score went down from 23.6% to 17.1% in the high risk cohort. It was a huge drop from using statins, controlling blood pressure better, and using aspirin in some people where it was indicated. The study showed that with informatics and practice coaches, you can rapidly implement new recommendations in small practices, especially in rural areas, with the dedication of the practices.
We touched nearly 150,000 high-risk patients to reduce cardiovascular risk. If we could couple this work with community activism—for example, working with community health workers on lifestyle change like we did in the CHANGE study—and a living wage, we could really push the needle.
When you were a kid, what did you want to be when you grew up?
When I was growing up, I couldn’t decide between medicine and being a teacher and a coach. I ended up swinging toward medicine, but as it turned out, I got to do both. I got to coach youth baseball teams and youth basketball teams. And I coach and teach every day with medical students and research mentorship. So, I got to do it all.
Who or what inspires you?
A vision of fairness and true democracy. My dad spent 6 years in concentration camps in World War II and came here dedicated to equity, problem-solving, and work. He was taken prisoner in Poland and was in two different concentration camps between 1939 and 1945 and somehow survived. He came out of that as a person who cared about fairness and democracy rather than being embittered or angry. And he passed those values to my brother and me.
And Nettie Coad, a community organizer in Greensboro who was instrumental in starting the Greensboro Health Disparities Collaborative helped me put meat on the bones of that vision. She taught lessons as a community organizer about how you have to be to start working on those values and make them real.
She taught about the way that different systems are organized and diffused responsibility to allow systems-based racism to flourish. In cancer care, a patient might have pain or nausea and vomiting. The system is set up so that a primary care doctor might say “I’m not taking care of your cancer treatment. Why don’t you talk to the oncologist?” And the oncologist could say “Well, I’m not using chemotherapy yet, so this is a surgical problem.”
The surgeon might say “Well, the nausea and pain has nothing to do with your surgery. Why don’t you talk to your primary care doctor?” The system allows people to diffuse responsibility and not aggressively say, “I’m going to be specifically responsible for my white and my black patients, my rich and my poor patients, and answer their concerns the same comprehensive way. Most of what happens is not intentional; it’s a product of implicit bias and systems that reward doing things fast rather than well.
But that diffusion of nobody taking leadership or responsibility allows racial inequity to exist because nobody will combat it. Everybody is saying “No, it’s not me.”
Another concept Nettie Coad taught was that conflict is okay. When you’re trying to solve a problem, especially sticky problems associated with racism, it’s okay to fight about the solutions and fight about the causes. Not confronting things and sticking to “Everything is okay, and we’ll just go forward from here” doesn’t help. So, conflict is okay.