The Truths We Hold

by Kamala Harris

  My mother’s circumstance could feel overwhelming. Chemotherapy is depleting; oftentimes my mother was too wiped out to do anything but sleep. Meanwhile, there were so many medications, possible side effects, counterindications, and things to keep track of. What if she had a bad reaction to a new medicine, as happened more than once? I had to coordinate her care, make sure her doctors were talking to one another, and ensure that she was getting the proper treatment. I often wondered how my mother would have fared if we hadn’t been there to speak up on her behalf.

  I came away believing that we should mandate patient advocates with medical expertise so that anyone dealing with an acute illness has a trustworthy, capable champion by their side. After all, we have decided that when their liberty is at stake, people are entitled to an attorney. We do this because we understand that most people don’t speak the language of the courtroom, and even if they do, in high-pressure situations it’s difficult to make objective judgments. The same is true in a hospital. Emotions are running high. People are placed into a new environment where a specialized language is being spoken, with complex, unfamiliar terms and phrases. And they may have to make decisions while they are frightened or in pain or heavily medicated—or all three. They’re expected to be strong enough to monitor themselves at a moment when they feel deeply vulnerable. We should have expert advocates to shoulder that burden so that patients and their families can focus on healing.

  We should also speak truth about the racial disparities in our health care system. In 1985, then–Secretary of Health and Human Services Margaret Heckler released a pathbreaking Report of the Secretary’s Task Force on Black and Minority Health. As she wrote at the time, despite significant progress in the American health picture overall, “there was a continuing disparity in the burden of death and illness experienced by blacks and other minority Americans as compared with our nation’s population as a whole.” In her words, this disparity was “an affront both to our ideals and to the ongoing genius of American medicine.”

  I was in college when she commissioned this study. What have we seen in the three decades since then? The gaps have narrowed, but they are pervasive—and communities of color pay the price. According to the 2015 Kelly Report on Health Disparities in America, black Americans have higher mortality rates than any other group in eight of the top ten causes of death.

  In segregated cities like Baltimore, there are twenty-year gaps in the life expectancy of those living in poor black American neighborhoods and those living in wealthier and whiter areas. “A baby born in Cheswolde, in Baltimore’s far northwest corner, can expect to live until age eighty-seven,” writes Olga Khazan in The Atlantic. “Nine miles away in Clifton-Berea, near where The Wire was filmed, the life expectancy is sixty-seven, roughly the same as that of Rwanda, and twelve years shorter than the American average.”

  These disparities begin in the delivery room. Black babies are twice as likely as white babies to die in infancy, a stunning disparity that is wider than in 1850, when slavery was still legal. In fact, infant mortality rates for black babies today are higher than they were for white infants at the time of the Heckler Report. In other words, today, black infants are less likely to survive their first year than white babies were in the early 1980s.

  Black women are also at least three times as likely to die due to complications relating to pregnancy than white women—a shocking gulf that transcends socioeconomic status. A major five-year study in New York City found that college-educated black women are more likely to face severe complications in pregnancy or childbirth than white women who never made it through high school.

  There are a number of factors that put black men, women, and children at a disadvantage. Hundreds of years of institutionalized discrimination in housing, employment, and educational opportunity have left black Americans more likely to lack access to health care, to live in poor neighborhoods with limited healthy food options, and to have fewer community health care resources.

  And because black Americans are more likely than their white counterparts to be born and raised in low-income, high-crime neighborhoods, they are more likely to experience a phenomenon known as toxic stress, the result of trauma caused by things ranging from witnessing violence to experiencing it. This causes not just psychological anguish, but also physical changes. To borrow the words of toxic stress expert Dr. Nadine Burke Harris, founder of the Center for Youth Wellness, in Bayview–Hunters Point, “child adversity literally gets under our skin and has the potential to change our health.”

  One study found that children who go through at least six adverse childhood experiences could see their life expectancy reduced by more than twenty years. Physiological stress leads to hypertension, which results in higher rates of infant and maternal mortality, among other conditions. Research has even found that certain levels of stress shorten our telomeres, which are structures that hold our chromosomes together. As we age, our telomeres naturally get shorter until cells start dying, which leads to disease. A study at the University of Michigan measured the telomere length in hundreds of women and found that black women were biologically more than seven years older than white women their age.

  But environmental circumstances alone cannot explain health care disparities.

  It’s also the case that black Americans experience poorer care when they go to the doctor. White patients are 10 percent more likely to get screened for high cholesterol than black Americans, even though rates of heart disease and stroke are higher among black Americans. Black patients are also less likely to be treated using procedures to repair blocked arteries. White women are more likely to get breast cancer screenings than black women and Latinas. And women of color are more likely to have their symptoms dismissed by their doctor, regardless of their economic status.

  When tennis star Serena Williams, one of the greatest athletes of all time, delivered her baby, she had serious complications. The day after an emergency C-section, Williams started having trouble breathing. She had a history of pulmonary embolisms, or blood clots, and, having experienced them before, she suspected she was having another. She told Vogue magazine that she walked out of her hospital room so that her mom wouldn’t worry and told her nurse that she needed a CT scan and an IV blood thinner right away. But the nurse was skeptical. She thought Williams must have been confused because of her pain medication. Williams persisted. Rather than give her the CT scan and IV drip, the doctor arrived with an ultrasound machine.

  “I was like, a Doppler?” Williams recalled. “I told you, I need a CT scan and a heparin drip,” she stressed to the medical team. When they finally sent her for a CT, they discovered that she was right after all. “I was like, listen to Dr. Williams!” she told Vogue. There were further complications that required surgery and left her bedridden for six weeks. If someone like Serena Williams can go through such an ordeal, imagine what happens to other patients who articulate symptoms and are ignored.

  What accounts for these inequities in the care of our fellow citizens? A growing body of research suggests that part of the problem is unconscious, implicit bias—similar to what we see in police departments. All of us absorb social stereotypes and assumptions, often without ever realizing it. But left unexamined, they risk leading us to behave in discriminatory ways, which can have profound consequences in fields like law enforcement, criminal justice, education, and health.

  Some enlightened members of the medical profession are working to address this problem. At UC San Francisco, all first-year medical students take a class on the discriminatory effect of these biases. Before they begin, they are given an implicit bias association test that measures their unconscious attitudes, not just about race but about gender, weight, and age. Research has found that 75 percent of those who take the test—no matter their race—show an unconscious preference for white people.

  How do we close the divide? It starts by speaking the uncomfortable truth that it exists, and then
we can break the problem into parts we can tackle one by one. First and foremost, we need every medical school in the country to require implicit bias training for their students. When people are given the knowledge that implicit bias is real, and that we all have it, it gives them room to think about it in their daily actions and make better decisions.

  We also need medical schools to focus proactively on bringing more diversity into the field. As of 2013, only about 9 percent of our country’s physicians are nonwhite, and only 4 percent are black. This is the first gap we need to close if we intend to close the others. It won’t be easy. It’ll be a generational challenge. But it’s time we get started.

  Most critically, however, improving health outcomes across the board demands that we transform the health care system itself. I believe that health care should be a right, but in a system where the quality of your care does indeed depend on your station in life, the reality is that health care is still a privilege in this country. And we need that to change. It’s why we need Medicare for All.

  Imagine if U.S. health care coverage was based not on how much you can pay but instead on your health needs. The purpose of the system would be to maximize good health care outcomes rather than maximizing profits. That, in itself, would be revolutionary. Getting sick would no longer mean risking bankruptcy. Employers would no longer have to spend so much to provide health insurance to their employees. And the system itself would run far more efficiently, as we see when we compare the high administrative costs of private health insurance companies with the lower costs of Medicare.

  But even if we could snap our fingers and make Medicare for All a reality, this alone would not alleviate all of the problems in the system.

  For starters, we need to dramatically increase funding to the National Institutes of Health to step in and fill the innovation gap that pharmaceutical companies have left. I remember how proud my mother was to work with the NIH as a peer reviewer and collaborator with other experts in her field. She would speak of her time there with such reverence that when I was a girl, I imagined Bethesda, Maryland, where the agency is located, to be a place filled with castles and spires. I might have been wrong about the architecture, but not about the beauty of scientific collaboration—and certainly not about the fact that the NIH is a national treasure. If we want our children to have cures for humanity’s most terrible diseases, we should invest in our national medical researchers, instead of relying on companies that would rather funnel money to their shareholders.

  We also need to protect patients and taxpayers from fraud. And that means putting bad actors under a microscope. Consider for-profit dialysis companies, which offer one of the worst examples of bad practices.

  Dialysis is a process by which a machine cleans the blood of patients who are in kidney failure. Kidney disease remains the ninth leading cause of death in America, but for a person in kidney failure, dialysis is a lifesaving treatment and an important bridge between loss of kidney function and getting a kidney transplant (which is a cheaper alternative with a much better prognosis). Across the country, nearly 500,000 patients are on dialysis, going three times a week to have their blood circulated out of their body through a multi-hour process that mimics a healthy kidney’s function.

  Who are these patients? Disproportionately, they come from low-income communities. People living in certain zip codes are far more likely to end up with kidney failure, which is most commonly the result of diabetes and high blood pressure. Black Americans develop kidney failure at 3.5 times the rate of white Americans, and they constitute nearly one-third of all U.S. patients who receive dialysis.

  The two largest dialysis companies, DaVita Inc. and Fresenius Medical Care, have both found themselves in legal hot water. In 2016, Fresenius agreed to pay $250 million to settle thousands of lawsuits. According to The New York Times, “Fresenius’s own medical office sent an internal memo to doctors in the company’s dialysis centers saying that failure to properly use one of the company’s products appeared to be causing a sharp increase in sudden deaths from cardiac arrest.” Yet the company chose not to warn doctors in non-Fresenius clinics who were using the product until after the memo had been leaked to the Food and Drug Administration.

  In 2014, DaVita agreed to pay $350 million to resolve claims of illegal kickbacks, in a scheme where it allegedly sold an interest in its clinics to physicians and physician groups in exchange for their driving patients to those clinics. In 2015, the company agreed to pay $495 million to settle a whistle-blower case in which it was accused of fraudulently overcharging Medicare. DaVita was sued in 2017 for keeping its clinics so understaffed and requiring such high-speed care and turnover that patients’ lives were endangered. It’s time to crack down on this kind of behavior.

  Finally, we will need to overhaul public health policy so that it does a better job of providing mental health care to all Americans. That effort will have to begin by ensuring that more mental health professionals contract with Medicare in the first place. There’s only one way to solve this problem: We need to raise Medicare reimbursement rates. As the largest single payer of health care services, the federal government must lead the way to ensure we pay all mental health professionals what they deserve.

  We also need to encourage a new generation of Americans to go into the mental health care field. Let’s create a model similar to Teach for America or the Peace Corps—an apprenticeship system that has as its core mission the goal of getting people to serve their country through mental health training.

  Let’s also do away with laws that strip funding from mental health care services. There’s an old law known as the IMD exclusion, for example, that prohibits Medicaid from paying for treatment in mental health facilities with more than sixteen beds. This rule has hollowed out mental health care hospitals and left most people with severe mental health conditions to fend for themselves.

  Ultimately, I believe we should provide mental health care on demand. And when I say “on demand,” I mean that whoever you are and wherever you are, mental health treatment is available if you need it. In addition to requiring far more practitioners, meeting this goal will require investment in and expansion of telemedicine so patients can access mental health care no matter where they live. This is especially important for people in rural areas, where nearly 100 hospitals have closed over the past several years. So far, studies have shown that telemedicine is generally as effective as in-person treatment. But further research and development can surely improve its value.

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  In the days before being sworn in as senator, I read a newspaper profile of Chillicothe, Ohio, a small city in southeastern Ohio’s Ross County. It’s located in the foothills of the Appalachian Mountains, with sprawling fields of soybeans and corn and a skyline marked by the smokestacks of a paper mill that has operated continually for more than a hundred years. Kenworth has its largest truck-manufacturing plant in Chillicothe and pays middle-class wages. The local hospital is one of the county’s largest employers. But the grand history and pride that once defined this classically American town have been replaced by a sense of despair.

  Seventy-seven thousand people call Ross County home. In 2015 alone, doctors in the county prescribed 1.6 million opioid pills. That same year, thirty-eight people died from accidental overdose. The following year, another forty lost their lives. “Now you can get heroin quicker in these communities than you can get pizza,” Teri Minney, head of Ross County’s Heroin Partnership Project, told The Washington Post. “They’re delivering.” According to the Post, addicts in Ross County often shoot up in public places, hoping that if they overdose, paramedics or police officers will revive them. “One day in September, police and paramedics responded to thirteen separate overdose calls, including one fatality: a man who died in an apartment right on Main Street. Meanwhile, a woman overdosed in her car as it idled at a Valero gas station with her two-year-old daughter
in the back seat.”

  As has happened in other areas with heavy opioid use, the violent crime rate has gone up, as have incidents of theft. So have the numbers of opioid-addicted babies born, and of children requiring foster care. According to local officials, two hundred children were placed into state care in 2016, 75 percent of whom had parents with opioid addictions. The surge has required that the county nearly double its child services budget, which now makes up more than 10 percent of the total county budget. What was once one of the happiest places in Ohio is now clouded by a fog of hopelessness.

  Similar stories are repeating themselves in every state in America. The human toll has rocked the nation to its core. Entire communities have been destroyed. And the opioid epidemic does not discriminate. It has hit people across every demographic, and infected rural, suburban, and urban areas alike. For so many people, what began as a legitimate desire to reduce pain became an overpowering addiction. Now the pain they feel isn’t from the original back injury or post-surgery healing; it is the pain that comes from quitting. “It’s like having the flu and laying in the street while people run over you while you’re puking,” one Chillicothe addict described to The Washington Post.

  The opioid epidemic has killed more than 350,000 Americans in the past two decades. But the national health crisis we face today is itself the result of a failure of public health intervention, from the moment OxyContin was approved to be sold. It is a different story than the one we witnessed during the crack cocaine epidemic—now, instead of people dealing drugs on the corner, people in suits and ties and white coats are dealing a drug while drugmakers cover up the dangers.