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Introduction
On a spring morning in 1997, Jim Harper, a young man from Durham, North Carolina, woke up in his two-bedroom apartment with no clue that he would soon become gravely ill.
The first signs of trouble seemed innocent enough: some numbness on the right side of his face and in his right arm and hand, easily chalked up to having slept on that side of his body. He stumbled as he got out of bed, but figured he was simply tired from the previous day’s shift managing angry teens at a group home. His fiancée, Regina, asked if he needed to see a doctor; he smiled and told her that she worried too much. Her anxiety ebbed as she went off to her job at Kmart, only to resurface when he didn’t answer the phone during her lunch break.
When Regina rushed home a few hours later at the end of her shift, she found Jim sprawled across their bathroom tile. His eyes were wide open and he clearly recognized her, but his words were garbled. He couldn’t tell her what was wrong or how long he’d been that way. She frantically dialed 911. Within a half-hour of his arrival at the emergency department, after a neurological exam and rapid CT scan of his brain, it was clear what had transpired: Jim, just a few weeks shy of forty, had suffered a massive stroke.
The doctors learned that Jim had high blood pressure that had been poorly treated, but found nothing else to account for his tragic fate. He had no heart problems. No clotting disorders. No aneurysms. No diabetes or high cholesterol. He didn’t smoke, rarely drank, and avoided street drugs. Ultimately, as best they could tell, Jim mostly had a lot of bad luck.
* * *
About two weeks later, I stood at the foot of Jim’s bed at Duke Hospital. Along with another first-year medical student, I was shadowing Dr. Wilson, a faculty neurologist, as part of a weekly seminar that introduced us to clinical medicine. This class was the highlight of our week, as it gave us a brief break from the lecture hall and laboratory, where we memorized biochemical pathways and microorganism names, and provided a peek at our future lives on the hospital wards. We wore perfectly knotted ties and crisp white coats for the occasion, trying hard to look like the doctors we would one day become.
Jim’s future seemed far less promising than ours did. A big man, he had once been a football player. Now he could not move the right side of his body. His face drooped as saliva dribbled out of the corner of his mouth. His words came out choppy, like those of a toddler; when frustrated, he cried like a child in the midst of his “terrible twos.” Given his lack of improvement, the doctors had begun to doubt that he could make any significant recovery. They were preparing to send him to a rehabilitation facility. This place also had a long-term care unit, where, if he made no real progress, Jim might spend the rest of his life. According to the nurses, Regina’s visits were already becoming shorter and less frequent.
“It’s a very sad case,” Dr. Wilson said, as we left the room and walked to a nearby conference area to discuss our patient and his illness.
He started by telling us that stroke was consistently one of the top five causes of disability and death in America. Then he drilled us about the major risk factors, going back and forth between us in a competition of sorts. In eager medical student fashion, we rattled off the usual suspects: diabetes, hypertension, heart disease, advanced age, smoking, and high cholesterol. When it was my turn again, Dr. Wilson indicated that there was one important risk factor we had yet to mention. He looked at me with a worried frown. Come on, his look said, for you of all people, this should be easy. I sighed. I’d hoped it wouldn’t come to this, but, as I was quickly learning, it always did.
“Race,” I said, looking down at my dark hand against my pristine white coat. “Our patient is black.”
“Exactly,” Dr. Wilson responded, as if I’d now earned a top score on my exam. “Some would say that this is the most important variable of all.”
He rattled off damning statistics about race and stroke: “The risk is twice as high for blacks compared to whites for those over sixty-five. And in younger groups, such as with our patient here, the ratio is more like three-to-one or even four-to-one.”
I’d seen the impact of stroke on both sides of my family. When I was fourteen, my dad’s brother—who would often drive five hours each way on a Saturday to visit us for a few hours—died within days of collapsing at his home, putting an abrupt end to his unexpected and always enthusiastic visits that I so enjoyed. A few years later, my maternal grandmother—Grandma Flossie—developed dementia from a series of minor strokes that slowly stole her mind and, eventually, her body. Like Jim, both had high blood pressure.
“Our patient’s other major risk factor is hypertension,” Dr. Wilson continued. “This also is much more prevalent in blacks—nearly twice as common. No matter how you slice it, race is a very big deal when it comes to stroke.”
Dr. Wilson had hammered home something I would learn time and again, both at Duke and beyond: Being black can be bad for your health.
* * *
“Of all the forms of inequality,” Martin Luther King Jr. told a gathering of the Medical Committee for Human Rights in 1966, “injustice in health is the most shocking and the most inhumane.”
At the time of his remarks, the United States had begun to take several formal steps to end its century-long practice of state-sponsored segregation that had followed the end of slavery. In medicine, this meant that black people could begin to receive treatment side by side with whites rather than being relegated to separate and unequal facilities or sectioned off in run-down areas of white hospitals. Such practices had undoubtedly contributed to their poorer health, especially in the Deep South of Dr. King’s time, where black people on average had a life expectancy nearly nine years less than whites. While the civil rights movement ultimately stirred remarkable racial progress in various areas of American life, many of King’s concerns about health and health care remain valid to this day.
From cradle to grave, these health differences, often called health disparities, are found virtually anywhere one might choose to look. Whether it is premature birth, infant mortality, homicide, childhood obesity, or HIV infection, black children and young adults disproportionately bear the brunt of these medical and social ills. By middle age, heart disease, diabetes, stroke, kidney failure, and cancer have a suffocating grip on the health of black people and maintain this stranglehold on them well into their senior years.
Thus, it is no surprise that the life expectancy among black people, despite real progress over the last twenty-five years, still significantly lags behind whites. In suffering a crippling stroke at age thirty-nine, Jim had become another casualty of inequality, a fresh case that Dr. Wilson could use to illustrate the health burden of being black.
* * *
Three decades after Dr. King’s 1966 remarks, I entered Duke University School of Medicine as one of a half-dozen black students on scholarship. With the scholarships, Duke sought to cast aside its
history of racial exclusion and become a national leader in producing a new generation of black physicians who could change the face of medicine. My goal as I headed for Durham was much less ambitious and civic-minded. I simply wanted to make my parents proud of me and set myself up to earn a good living. Race-based concerns ranked low on my list of priorities.
But my professors couldn’t stop talking about race. During my early months, as they taught us about diseases both common and rare, they inevitably cited the demographics, explaining which disorders were more common in the young or old, women or men, and one racial group or another. When they spoke about race, they would sometimes mention Asians, Hispanics, and Native Americans. Yet invariably, as it always seems to in America, their analysis came down to comparing blacks and whites.
It seemed that no matter the body part or organ system affected, the lecturers would sound a familiar refrain: “It’s more common in blacks than in whites.”
Each time the demographics of a new disease came up in a lecture, my stomach twisted. I knew where this was heading. Seated in a sea of mostly white and Asian faces, I wondered how this information affected their views of black people, whether they already had biases against us, and whether any of this impacted the way they saw me. This racial health data intensified my already uneasy feelings about my place at Duke. My classmates largely hailed from well-to-do suburbs and had attended prestigious, brand-name schools; I came from a working-class neighborhood and had attended a state university with little name recognition. Their parents all seemed to be doctors, lawyers, or professors. My dad didn’t finish high school and worked as a meatcutter in a grocery store; my mom attended segregated inner-city public schools before embarking on a forty-year career in the federal government. From the moment I walked along Duke’s manicured lawns and inside its Gothic buildings, I worried that I was at a stark disadvantage, both socially and academically.
Constantly hearing about the medical frailties of black people picked at the scab of my insecurity. Over time, I came to dread this racial aspect of the lectures so much that I felt intense, perverse relief whenever a professor mentioned that a disease was more common among white people. But this list was short and the refrain that accompanied it proved equally painful. For example, while breast cancer got diagnosed more often in white women, “black women who get this disease do much worse,” the professors would say.
While I was learning about the health woes of my race, my own body began to betray me. The first sign occurred not long after I’d met Jim, the young stroke victim. As part of that same introductory course, my classmates and I learned basic medical skills by practicing on each other. One day, we measured blood pressures. My classmate frowned as she took mine. The reading was 150/95. Our supervisor, a family physician, rechecked and confirmed the reading. The doctor I saw soon afterward gave even worse news: My kidneys were showing early signs of failure.
To a twenty-three-year-old first-year medical student, high blood pressure and kidney disease sounded like a death sentence. Worst-case scenarios flashed through my mind: Dialysis. Kidney transplant. Transplant rejection. More dialysis. Infection. Death. Was I destined for a similar fate as my uncle and grandmother? Or something worse? Would I even reach fifty?
The image of Jim flashed through my mind. A few weeks after leaving the hospital and moving into the rehab facility, he died from a massive blood clot that lodged in his lungs. He had just turned forty. I drove home from the clinic picturing Jim in an open casket. But instead of a stirring eulogy and traditional funeral hymnals, I heard Dr. Wilson’s voice reciting statistics on race and stroke.
* * *
As I struggled to make sense of the prospect of facing chronic illness in my twenties, I became consumed by the broader health problems of my race. Along with the many patients I saw who gave life to my professors’ statistics came reports of prominent black men who had met similar fates. Harvard Law graduate and billionaire CEO Reginald Lewis died at age fifty from cancer, while football legends Walter Payton and Reggie White died in their mid-forties from rare disorders, just a few years before 60 Minutes mainstay Ed Bradley succumbed in his mid-sixties to cancer. Journalist Ron Howell chronicled the premature deaths of his black classmates from Yale in a 2011 article for the university’s alumni magazine that generated national interest. A large bank account, Ivy League schooling, Hall of Fame busts, and a quarter-century run on America’s most-watched program stood no match against early death for these black men.
Why do black people suffer more health problems than other groups? What do these challenges mean in their everyday lives? How do their struggles play out before a largely white medical community? How can we begin to solve these seemingly intractable problems? Do I have a special role to play as a black physician? Confronting these questions has led me on an intellectual and emotional journey, one that I’ve tried to capture in the pages that follow.
I’ve divided the book into three sections, corresponding to the different phases of my medical life. Part I surveys my medical school years. Part II explores my grueling twelve months of medical internship as a newly minted doctor. Part III examines my subsequent years in psychiatry training and in early clinical practice. Throughout each stage, race played a recurrent role, at turns predictable and unexpected, often annoying, sometimes disheartening, and occasionally uplifting. By sharing my story, as well as the stories of some of the patients I’ve met over the past fifteen years, I hope to humanize the dire statistics and bitter racial debates and paint a fuller picture of the experiences of black patients, as well as that of the black doctors who navigate between the black community and the predominately white medical world.
In tracing my journey along the intersection of race and medicine at the end of the twentieth century and the dawn of the twenty-first, I make no claim to speak for all black physicians or black patients, yet I am confident that much of what I have written will ring true to their varied experiences. By putting human faces on these serious dilemmas, I hope to contribute to a much-needed public dialogue on improving the health of black people. Jim’s fate—a young black person robbed of his future—is one that far too many of us suffer.
PART I
Disparities
1
People Like Us
It was a hot late-summer morning, a month into my first year as a Duke medical student. The classroom of nearly one hundred students buzzed with energy. After a few weeks of mostly tedious lectures that seemed no different from the science classes we’d taken in college, our professor had just finished the first half of his presentation on the case of a young boy with a rare childhood disease. A short film had brought the complex scientific data in our textbook to life in the words and actions of the boy and his parents. Following the video, the professor talked about promising therapies for this disorder. Finally, we were getting glimpses of the clinical knowledge that we’d come to medical school to learn. I could hardly wait for the second part.
But that wasn’t the only reason that I suddenly felt better. My first few weeks at Duke had been an exercise in expanding insecurity as I learned more about my classmates. As one of a handful of black students, I naturally stood out, but race was just part of the story. In those early days, it seemed that all of my classmates came from professional, well-to-do families. My mom never entered a college lecture hall; my dad did not finish high school. While my brother, Bryan, had been the trailblazer of our immediate family in graduating from college, medical school was a different league. The majority of my classmates graduated from high-prestige colleges like Duke, Harvard, Yale, or Stanford. I’d gone to the University of Maryland–Baltimore County (UMBC), a young school with a limited national profile. Could I hack it at Duke? Determined to use this fear as a buoy rather than a deadweight that could sink me, I probably spent as many hours studying in that first month at Duke as I had my entire senior year of college.
The effort paid off. Our midterm scores had just come back, and, to my immense relief,
I had done well, firmly within the top half of the class on each exam. As I stood to stretch during the break before the professor resumed his lecture, I was finally starting to feel comfortable, or at least what qualified as such for a first-year medical student.
The mid-class break offered time to use the bathroom, grab coffee, or simply remain in place and gossip. I preferred to move about, as the lecture hall, with its folding seats, dim lighting, and sticky floor, had the uncomfortable ambience of an old movie theater. On my way out, I chatted with a few people and overheard one group discuss plans to camp out for Duke men’s basketball tickets.
When I reentered the lecture hall a few minutes later, Dr. Gale, our professor, headed in my direction. Ordinarily, he didn’t socialize with students, so I expected him to walk past without acknowledgment. Instead, he stopped directly in front of me.
“Are you here to fix the lights?” he asked.
The sounds of the classroom seemed to vanish. So did my peripheral vision. Calm down, I told myself, maybe he was talking to someone else and only seemed to be looking at me. I glanced behind me. Nobody there. A few classmates were within hearing distance, but they seemed too engaged in conversation to notice us. Maybe with all the background noise, I had misheard him.
“Did … did you ask me about fixing the lights?” I said.
“Yes,” he replied, irritation creeping into his voice. “You can see how dim it is over on that side of the room,” he said, gesturing with his index finger. “I called about this last week.”
Reflexively, I stroked my chin and looked down at my clothing to check if I seemed out of place. Clean-shaven, and dressed in a polo shirt and khaki slacks, I thought that I’d done a decent job of looking the part of the preppy first-year medical student. Obviously I had failed.
“No,” I said, stumbling to come up with a reply. “I don’t have anything to do with that.”
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