Closing the Gap: Improving Health Outcomes for Black Americans

Major funding for The Pulse is provided by a leadership gift from the Sutherland family. The Sutherlands support WHYY and its commitment to the production of programs that improve our quality of life. This is Closing the Gap, a special production from The Pulse at WHYY. I'm Mike and Scott. Fatima Cody-Stanford is kind of a big deal. As a physician scientist, she's changing the way we think about obesity and treat it. She's the subject of a PBS documentary on breakthrough women in science and medicine, and she's been on Oprah. There is not a target number. I will not give you a target number. Should we give ourselves a target number? We should not give ourselves a number. It's not the number on the scale. So you can probably imagine how busy her practice at Massachusetts General Hospital in Boston is. One day, her office got a call from an older woman requesting an appointment. This patient actually lived in the community that I grew up in in Atlanta and moved to the Boston area. and happened to see me on television and called up to my office and told the office that she knew me and I used to ride my bike with my sister past her house when I was a little girl and told the office that she wanted to be my patient. And they said, well, you know what? Dr. Stanford doesn't have any new patient slots. And she said, no, you need to tell her who I am and have her call me. So I get this note after I'd seen patients that day. And of course, I knew exactly who she was. So of course, I found a way to make it fit. Fatima has been treating her for several years now. And just recently, she was invited to the patient's 90th birthday party. It was in one of the fancy hotels here in downtown Boston. I get to the hotel where she's having this fancy birthday party with assigned seats. And I get there and I'm like, I wonder where they're going to put me. So many family members were present. Kids, grandkids, great grandkids. And so I'm going to ask you, where do you think they put me in the seating situation for this party? Where do you think I was? I'm kind of thinking you were sitting at her table. I was seated directly next to her. Her kids weren't next to her, her grandkids. And so I was like, wow, how did I get the prize seat of honor? And they were like, oh, because you're the one keeping her alive. And so I said, OK, fair point. That seat meant a lot to Fatima. She saw me as an ally, someone who could be there as someone to support her through her experience. She says that connection with her patients is why she went into obesity medicine in the first place. Right now, we are seeing staggering levels of obesity, particularly in the Black community, disproportionately affecting Black women who have the highest rates of obesity of all groups here in the United States. I didn't see growing up individuals that cared for this population that looked like me as a Black woman. And so I wanted to be part of the solution, someone that wasn't just at the bedside, but also someone that was involved in clinical trials and the studies to be really an advocate for those individuals, but also to understand what was causing the high rates within this community. For the most serious illnesses, from obesity to heart disease and cancer, Black Americans have higher rates and worse outcomes than most other groups in the country. And now, initiatives to close gaps in care face major headwinds. Federal funding cuts to research and programs like Medicaid and pressure on diversity, equity and inclusion efforts threaten to roll back progress. But in the face of these challenges, people are doubling down on providing care that builds trust and delivers better health outcomes. On this episode, we'll find out what those efforts look like on the ground. To get started, let's hear more from Fatima Cody-Stanford. She says obesity is a complex disease with several contributing factors. When we look at obesity, a lot of people think it's just what we're eating and the fact that maybe we're not engaging in enough exercise. And while those are contributors to this issue, I really want to look at the vast number of causes. Number one, genetics plays a large role in the high rates of obesity. 40 to 70% or 40 to 80%, depending upon what study you look at, plays a role in the likelihood of a patient having obesity. So if you're born to parents that have obesity, unfortunately, that raises your likelihood. Let's talk about behavior. We talked about behavior in terms of just not eating and exercise. Those are important contributors. But I want to point out something that's really, really important, particularly as we look at study after study that talk about stress and stress sores and how that contributes to storage of fat mass. And when we have increased stress and stress sores in our life, we accumulate more fat mass. The black community, unfortunately, particularly here in the U.S., particularly as descendants of the enslaved here in our country, we have stress and stressors that have been generational. And when you have these chronic stress, your body ends up storing more fat due to issues like discrimination, racism, and what we call allostatic load, this accumulation of stress over generations that's passed down. This contributes to energy storage or fat mass storage. And so this is really important. If you're a night shift worker, believe it or not, just that dysregulation of the timing in which you go to work can cause weight and weight gain. So sleep dysregulation. There are a variety of factors that you can hear that are contributing to weight and weight gain that disproportionately impact the black community. There are lots of things that we all get wrong about obesity. What does the medical profession get wrong when it comes to this issue? I think the medical profession gets a lot wrong about this disease. I think that, first of all, there's still a high degree of weight bias and stigma that exists in not only the lay population, but in the medical community. I still think that we have this idea of just eat less and move more, and that will solve obesity. This is highly pervasive in the medical community, despite the fact that we know that obesity is a complex, multifactorial, multi-sector disease. We still preach this mantra very often within our doctor's offices, our nurse's offices, our dietician offices. And so when patients consistently hear this messaging, they may not seek care because they don't see our offices as inviting. They don't see this as a safe haven or a place that they can get compassionate care for their disease process. And so if you don't see the doctor's office as a safe place, where can you go to get compassionate care? Fatima says her patients are going to get a lot more than the standard health advice. They know that I'm not going to tell them just to eat less and move more and assume that that's going to fix their disease process. They know that I'm going to likely present them with a variety of options, which include lifestyle, behavior, medication, surgical options, depending upon where we are. They know that I'm going to support them over the life course. Most of my patients have been with me for 15 plus years. They know this is not going to be a quick fix. And so they realize that I am going to be a partner, an ally in their care, and this is going to be a relationship that will be sustained over time. You mentioned that you want to be an ally for people. And I'm assuming that also means that you want to provide care that speaks to people, that meets people where they are. And, you know, a lot of how we feel about food and what we eat and so on depends on where and how we grew up. So how does that come into your practice? Absolutely. I'm so glad you brought that up, particularly as we see the recent dietary guidelines that came out that actually deviated from the work that my colleagues worked on with the Dietary Guidelines Advisory Committee that was released under the previous administration. We actually wrote a whole chapter on culturally tailored dietary interventions, which spoke to the need to recognize that when a person comes through my door, I want them to have optimal nutrition that meets them where they are. So if I'm speaking to a family that's Haitian, or if I'm speaking to a family that's from Zimbabwe, or I'm speaking to a family that grew up where I grew up in Atlanta, Georgia, I'm going to need to meet them where they are with a plate that represents what they value, but with the most optimal nutrition. And if I want to assume that a plate that's from Japan would fit them, then I'm going to be flawed in assuming that that would be something that they would consume on a daily basis that would meet their palate. So I'm very thoughtful about listening to what is it that they enjoy and making sure that I help ensure that the dietary considerations that I give to them are most optimized to fit what they enjoy and what fits their cultural needs. Fatima Cody-Stanford is an obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School. This is Closing the Gap, a special production from The Pulse. We're talking about Black health. When it comes to nutrition, many people believe that healthy means you have to stay away from lots of dishes you love or grew up with. But food is a source of joy and connection. It's part of who we are. Nicole Curry has this story about navigating culinary traditions with your health in mind. For as long as I can remember, my aunt, Gladys McLean, has been the best cook in the family. I grew up in a small rural town in North Carolina. Our family is huge, and honestly, most of us know how to make a decent meal. But there is something special and effortless about a dish from my Aunt Gladys. Even to this day, when I call home for guidance on a traditional Southern dish, my own mother directs me to call my aunt. And that's because my aunt has been cooking for a long time. And I started cooking really because mom and dad was going to work and we were at home. We refers to my aunt, my mom, and their siblings. In the summertime, my grandfather would come home during his lunch break to cook. They didn't really like his specialties. So I decided to go in the kitchen and experiment myself. But there was a learning curve. Like the time she made spaghetti with meat sauce. My aunt had observed her mother washing all of the meat products she had used. Chicken, pork, beef. So I decided to wash the ground beef. No. I was nine. I was nine. So I did try to rinse it but coming through the colander and going down the sink and all that kind of stuff it was a mess Since then my aunt has definitely learned her way around the kitchen She makes some of the best southern staples for our family and holiday dinners. Collard greens, cabbage, barbecue pig feet. She's also an amazing baker. But a few years ago, I started noticing that my aunt began to cook other things, dishes that seemed to be straight out of a healthy eating cookbook. She says the shift began after a few doctor's visits. I've had some issues with my blood pressure. I have been on the borderline a couple of times when I got my blood sugars done. But I stopped and I said, no, I don't want to be sick. She decided to look more closely at the food she was eating and what kinds of changes she could make. Now she experiments with kale and colorful salads, sautéed with garlic and onions. She creates dishes with plant-based protein, like this black bean salad she showed me how to make. All right, so we have cilantro, bell peppers. Oh, we also have grape tomatoes. Yeah. And a red onion. After making these changes, my aunt is the healthiest she's ever been. Her blood pressure and blood sugar are in normal ranges. But when my aunt and I were cooking, she said something that surprised me. She still eats the other stuff. Traditional Southern dishes that often get tagged as being unhealthy. Barbecue, pig feet, collard greens with meats like smoked ham hogs. So it's not about replacing our food. Not really, no. My first thought was, oh, she's eating it in moderation. But as I dug deeper, my aunt laid it out for me. When she thinks of unhealthy food, she doesn't necessarily picture dishes that are staples in our culture. Instead, she pictures fast food. My aunt says she got acquainted with fast food decades ago when she first left home to go to college. And that period that came when we went to college, moved to other areas and worked. So we started fast food. It was quick. I had a busy life. She was very busy. She paid her tuition herself by working two jobs. So, yes, I took a lot of shortcuts. But when life settled, those easy options didn't just disappear. Sure, she cooked, but fast food was always available. So now in her healthier approach to food, she doesn't eat much fast food. But then I wondered, why the kale? Why the plant-based protein? Why these new things? She says, why not? My aunt says to think of it like an extension of the food we already know and love. an extension that's been stretching far and wide since slavery. Because at first, most Black people in America didn't have control over what they ate. At one time, there were no choices. You just ate what they gave you or what came out of the master's house or whatever. But after the abolishment of slavery... Then we came to a point where the community started understanding our own garden, our own cows, our own pigs. So that transition was going into the healthy part. The family garden played a big role in what my aunt ate as a kid. Gardening was so important to us because people sometimes ask, did you grow up on a farm? I said, no. I said, but I think our garden was a farm because the garden was so big. And at that time, not only our family, but the neighborhood had gardens. The garden was how we were fed with additions from the stores or whatever. But we had practically any kind of vegetable that the South was growing. My aunt says that simply being fed and feeling full from food that your family grew or raised meant that you were healthy, even if they didn't name it explicitly. And at that time, they knew that that was good food. It was good for you. They just knew this was healthy for us. And today, healthy food is just taking on more meaning for her. My aunt has now returned to gardening, along with incorporating new vegetables into her diet and finding new ways to prepare them. She's navigating healthy eating without losing our culture. So is it about just expanding the type of food you eat this time around? That's it. And I feel good that I can share it with my family because I want my family healthy. And when we come together, we want to be having a good time and tasting different things. And, you know, they get excited too. So I really feel good about it. That was Nicole Curry reporting. Physician and obesity researcher Fatima Cody-Stanford says giving advice that fits into people's lifestyles and cultures is really important when it comes to moving the needle on obesity. Oh, absolutely. And I want to take you back to a project I was involved with back in the late 90s, early 2000s, which will date me a little bit, but that's okay. I want to call out Dr. Ken Resnikau, who's now based at the University of Michigan. And he did a project called Healthy Body, Healthy Spirit in black churches. This project at the time was based in Atlanta. What I really appreciated about this project was that he looked at what was traditionally soul food, which can be possibly villainized. This is heavy food. It's laden with oils and things that are not healthy for you. But he then worked with individuals and dieticians to prepare this food in a very healthy way. And I thought that this was brilliant because instead of just saying, okay, this is bad food, why not prepare food that people enjoy? Let's modify the recipes so that it's optimized to provide the best health benefit. And this was received very well by the communities in which we implemented this particular project. And so I think this is meeting people where they are. How do you talk through goals with patients? Because when it comes to, you know, discussing obesity, a lot of times we focus on numbers on the scale or this number or that number. So how do you define a healthy goal for your patients? So I actually never give them target weights. I say my goal is to get them to the happiest, healthiest weight for them. So it often is defined by what number for them allows them to have the best blood pressure, the best cholesterol, the ability to move through space and time. And by that, I mean, are they able to navigate space without having their knees hurt and their hips hurt? Like all of these things, putting the whole picture together. And so what is that number? We don't know. until we get to that number. And once we get to that number, can we sustain that number? And so that number is going to be different for each person. Fatima Cody-Stanford is an obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School. This is Closing the Gap, a special production from The Pulse. We're talking about Black health and expanding access to quality care. Coming up, A physician talks about her journey through med school and paving the way for future doctors. Today is tough, but it's bringing you closer to your goal. Closer to your goal. That's next. This is Closing the Gap, a special production from The Pulse. I'm Maiken Scott. Physician Ayla Stanford is a recognized national leader on issues of health equity. During the pandemic, she founded the Black Doctors Consortium to provide COVID testing and later vaccines to communities that didn't have access. She then left her role as a pediatric surgeon to double down on creating better access to care. And now she's also running for office in Pennsylvania's third congressional district. She says too many Americans have to make choices between taking care of their health and paying their bills. People are worried about the basic necessities of life. It's a struggle she can relate to. I grew up in one of the poorest parts of Philadelphia, PA. As a child, Ayla's family relied on public assistance for food and housing. My parents seemed to be working all the time, but sometimes we had heat, sometimes we didn't. Sometimes we had food, sometimes we didn't. When Ayla was sick, her mom took her to a local clinic. I was a health center number 13 kid, which in most cities are sort of nondescript city or federally run clinics, which can be kind of sterile. They're cement. It's not warm. It's not inviting. And that's where we received our care. But getting there for routine checkups was often challenging. When my mom was working a lot, we sometimes had to go to the ER to get our forms filled out for school. Stuff like vaccine records, height, weight, general health. She remembers the ER physician seeming annoyed that they had come there for something that was not an emergency. The doctors looked at you like, oh, another one abusing the system. But it was really the doctor's office closes at five o'clock. You're not open on weekends. My mom is working two and three jobs taking public transportation because we didn't have a car. And this is the only place that's open that she could bring us to get our immunizations, to get our physicals for school. But so often the health care system would look at that person as you're not living up to your responsibilities as a parent. But that's furthest from the truth. Ayla says these experiences shaped her as a doctor and an advocate. She sees lack of access to quality care, especially primary care, as one of the main issues that contributes to worse health outcomes for black Americans who have higher rates of issues like heart disease, stroke, diabetes, or cancer. What that means is when they present, they're sicker. That chest pain, they couldn't get it checked out. So now they're presenting to the ER an extremist, and that's how we're seeing more stroke and more heart attack and whichever. The same is true for cancer, where you see more prostate cancer in Black men. You see more colon cancer in Black men and Black women. You see more gynecologic cancers because of the screening. You got to go in and get the pap smear, get the fit test or the colonoscopy. If you don't have a primary care doctor, you're not getting those things. In 2021, she opened the Dr. Ayla Stanford Center for Health Equity in North Philadelphia. There's access. It's culturally appropriate and aware for the people that we see. She says the center treats everybody. If you have insurance, we see you. If you have no insurance or you uninsurable we see you And if you have private insurance we take that too But your care is not different Now granted the reimbursements we get back for Medicaid versus private insurance are strikingly different which is part of the problem but how we treat our patients does not change And what equity looks like in health care is that you get exactly what you need as an individual. She says the work at the health center is built on trust. Trust is everything. And it's a continuation of Ayla's efforts during the early part of the pandemic with the Black Doctors Consortium. They offered COVID testing before it was widely available. As a private citizen, I sat on my couch and being from this area, everyone was calling saying, Ayla, I can't get a test or I was getting turned away. And it was not my job nor my responsibility. But as a surgeon, I happened to have gloves, gowns and masks in my office. And I went to the communities where the positivity rate and the death rate was highest for COVID. it. Most of the city didn't know who I was then, but I knew that Black people trusted the church and they trusted a mosque and their faith-based leaders. So my pastor was my surrogate to reach out to all the faith-based leaders and say, all she needs is your parking lot, your electricity, and your restroom for her staff. She will build a triage hospital in your parking lot. So that was my olive branch, if you will, of trust to get into the communities where the disease was most prevalent. And then you have to keep showing up. You have to go to the people. It was being present, being persistent. So they keep seeing you come up in their communities. And that's how the trust was built. When the COVID vaccines came out, Ayla and her team were very successful in getting people vaccinated. Talk a bit about the vaccination rates that were a result of your work and all of the work you had put in previously with the testing. Because I think if you hadn't done the testing, if you hadn't showed up, people wouldn't have lined up for the vaccines for you. You're absolutely right. You're absolutely right. And one day we were doing the COVID testing and we introduced a questionnaire. And as people came to get their COVID test, we said, if there were a vaccine available, what would make you more likely to get it? In your neighborhood, administered by your doctor? Do you trust the vaccine? So we had data, if you will, to use as we prepared for the vaccine. At the time, a lot of experts believed that Black people would not trust the vaccine. And I said, it depends on who's giving it and where. Because of the trust that we had built, because we got vaccinated on TV in front of everyone to see, they said to me, many, Dr. Stanford, when you get the vaccine and you roll up your sleeve, we'll know that it's time for us to show up. And so Bloomberg News reported we vaccinated more black Americans in Philadelphia than any other major city in the United States. And it felt good to be a part of that, knowing that what we did saved lives. And we touched over 100,000 people during that. Ayla believes another pillar of providing better care is to increase the number of black physicians. and her own journey through medical school showed her why representation matters. Med school, if there was a class, the class was about 150 students and there were about 10 black students. And it was tough because none of us came from parents who were doctors or families of physicians. so we didn't have that sort of mentorship that you might just get in the family. So we had each other, and we had to figure a lot of things out on our own. In med school, women didn't. We might become doctors. There were fewer Black women, and you definitely didn't become surgeon because a surgeon was the hardest specialty of all. And I definitely remember being on rounds and the attending or the head surgeon asking a question and then looking at me and saying, oh, never mind. The girls never know anyway, you know, kind of thing. Like that was commonplace. That was commonplace. After med school, she started her training to become a pediatric surgeon. I can remember being across the table from a surgeon and we're operating on a small surgical field and the whole time whispering. So why would you choose something so hard? You know, there are lots of other specialties you could have gotten into. I don't know how good you think you're going to be. There's still time to change. And there's a person asleep and I'm like crying and I can't see through my glasses. And that was one of those aha moments that I said, never again will you bring me that I feel that I need to cry in front of you. And it's not to say I never cried again, but I never did it publicly again. And I was resolute that I did not come this far to not achieve what I was striving for. And in that moment when you decided never again will somebody make me cry like this, what did you have to change? You know, it seems like sometimes we have to just harden ourselves or we have to be so gung ho and it takes a lot of energy. Well, I did have to sort of put on a harder shell. I was determined to look people directly in the eye. And when they said something, say something, that's interesting. Can you expound on that a bit? and then they would have to hear the maliciousness of what they were saying. And so I became very determined to look someone straight in the eye. And when I heard something that didn't feel right and made my heart race and the hair on my arms stand up, I confronted it head on. It was that and then also prayer, reminding myself that my training was finite, that this was just a hurdle that I needed to clear to get to the next step. But it sounds exhausting. Oh, my gosh. Totally exhausting. But I had a good support group of other residents that were trying to achieve what I was achieving. And I just, even now, you know, I give grand rounds at universities sometimes, and I see the students, and they're so excited to see me, especially the ones that can identify culturally with me or have a similar upbringing. And I just reassure them, today is tough, but it's bringing you closer to your goal, closer to your goal. And it's kind of like everyone has to go through these hard knocks to get it. As my mother would say, if it was easy, everyone would do it. Just remember that. Ayla Stanford is a physician, a pediatric surgeon, and a health equity advocate. She's the founder of the Black Doctors Consortium and also a political candidate. She's running for office in Pennsylvania's 3rd Congressional District. This is Closing the Gap, a special production from The Pulse. Coming up, in the mid-1960s, federal policy, combined with the efforts of a few dedicated individuals, brought about the integration of hospitals. The administrator told them to go to hell, that they would never integrate. So the physician said, OK, but you just lost $5 million in funding for next year for your hospital. That's next. This is Closing the Gap, a special production from The Pulse. I'm Mike and Scott. We're talking about the forces shaping black health outcomes in the U.S. Right now, a lot of federal policies could be diminishing access to health care, cuts to Medicaid, or cuts to research funding. But federal policy has also often played a role in expanding access. One case in point is what happened in the mid-1960s when federal policy brought about the desegregation of hospitals. Before these changes, segregated hospitals were the norm, or hospitals had different wings for black patients. There was a colored entrance and there was an entrance for whites. There were colored waiting rooms and white waiting rooms. The children's wards were segregated. That's the voice of Brenda Armstrong, a pioneering Black physician who passed away in 2018. A few months before her death, reporter Alana Gordon spoke with Brenda Armstrong and other key figures who were deeply affected by segregated care and pushed for change. Let's listen back to this story. Brenda Armstrong grew up in Rocky Mount, a rural town in North Carolina. She remembers how Black patients were treated unequally in hospitals. They waited a longer time in the emergency room to be seen. They were addressed in demeaning ways. When she was just a little girl, she had an experience that she could not shake, that would fuel her passion and her lifelong work. She was six or so, and her mom was pregnant with her baby brother. Brenda's dad was a doctor and knew her mom and the baby were in danger, that mom needed a C-section, because she was a petite woman and the baby was big. Dad reached out to the town's hospital that could handle this, but that hospital was for whites only. My dad, he was a very proud man. And he asked, you know, if they would make an exception, and they said no. In 1956, Brenda's baby brother Wiley was born, at home, without a C-section. and I remember my dad coming to pick me up at school to tell me what had happened and it was difficult he could not tell me I thought he was gonna tell me that my mom had died and she hadn't died, but my brother was in trouble. And we just didn't know what was going to happen. Wiley had had a stroke. His left side is permanently damaged. I was angry. I still am. That stroke, she says, probably could have been prevented had her mother not been turned away from the nearby local hospital, the white one, for a C-section. This denial of care was standard practice back then. But by the 50s, a movement was growing to challenge the status quo, to fight back against the segregation. From restaurant sit-ins to bus boycotts, the civil rights movement was gaining momentum. And in Greensboro, North Carolina, a group of black doctors and patients set the foundation for the changes in health care. Gwen Blount Adolph is the daughter of one of those doctors, Alvin Blount. I know that one of the things that just bothered my dad and his peers was that they could not treat patients in the hospital that had the better facilities Those facilities were for white people. It wasn't about the better quality of the doctors, but it was about equal access to quality facilities. When the patient of one of Alvin's colleagues needed to be hospitalized for an abscessed molar and was refused to be seen at the White Hospital, they'd had enough. The group reached out to the Legal Defense Fund, a really important part of the civil rights movement. Michael Meltzner took up their complaint. I was the one lawyer at the Legal Defense Fund who handled health cases. What they did was challenge the federal status quo and a law that actually allowed hospitals to get federal funding even if they were for whites only. The case went through the legal ringer, but it came on the heels of the landmark Brown v. Board of Education ruling that overturned the notion that separate was equal in schools. The black doctors from Greensboro argued the same thing for publicly funded hospitals. They won. This principle that separate is unequal was then adopted into the Civil Rights Act. It clarified, plain and simple, that hospitals could not discriminate if they wanted federal money. Which, on the face of it, should have ended the racial policies of about 6,000 southern health facilities, hospitals, clinics, and the like. That was the theory. But really, almost nothing happened. At that time, those southern hospitals didn't heavily rely on federal money. And without any major penalties, they didn't have any big motivation to change, to let black patients or doctors through their doors. Until? No longer will older Americans be denied the healing miracle of modern medicine. And then along came a gift. And the gift was Medicare. No longer will illness crush... President Lyndon Johnson signed Medicare into law on July 30, 1965. So that they might enjoy dignity in their later years. This was the new health care program that would cover seniors, those with disabilities, millions of people the government would now generously pay hospitals to care for. This new Medicare funding had the potential to change everything, to tear down hospital segregation. But that would require more than just a rule on the books. A tiny unit took on that responsibility. It was going to be a David versus Goliath fight. My name is Peter Labasi, Frank Peter Labasi, but everyone knows me as Peter Labasi. Peter Lavassie led that unit inside the Department of Health, Education and Welfare, or HEW. I was then hired. I talked to him by phone from his retirement home in Connecticut. Peter's little civil rights unit of just six people was tasked with creating and enforcing the rules that hospitals would need to follow to be eligible for these lucrative new Medicare funds. And I'm talking about 25 percent of their income they were hoping to get from HEW that year. The core rule was that no hospital would get any funding until they were completely integrated. No ifs, ands or buts. But let black patients be treated in the same way and in the same rooms as the white patients. Early on, Peter remembers reporting the pushback to one of the higher ups in his office. He said, Pete, tell me, what's up? How are you doing? And I said, oh, we're doing fine, Joe. And he said, what do you mean? Well, I said, you should know that there isn't a hospital in the South that's desegregated, so no one will be eligible for any of the HEW new money. He said, why did you say you're out of your mind? But the government got behind Peter's efforts. It was a game changer. When the federal government decides to act and there's urgency about it, gosh, it's fantastic. People all around the country began to organize visitation teams. Peter's unit, remember, was small, just six people. They needed help, and help they got. People from all over the government stepped up. Doctors from the public health service, bench scientists, men and women, black and white, who wanted to see these changes in health care through. They were divided into teams of three, made up of someone who specialized in medicine, a government worker from the local community, and someone who knew the law. These teams went out to investigate the hospitals in person, on the ground, to ensure that hospitals would not get any money, not a dime, until they were actually fully integrated. This was going to require 18-hour days, threats on their lives. David Smith is a professor who's written a book about this called The Power to Heal. He's interviewed some of those team members. They would be chased by the Klan. Windshields would be shot out. Crosses would be burned on their lawns. And most of the people that volunteered knew. David says everybody had a story. One black doctor went in as part of a three-person team to Marshall County, Texas, to see if he could put pressure on the local hospital. The administrator told them to go to hell, that they would never integrate. So the physician said, OK, but you just lost $5 million in funding for next year for your hospital and left. And three days later, that physician is called by the chairman of the board, who says, we just fired the administrator. Tell us what we have to do to get the money. Sometimes they tried to cheat, and they tried to fool us, and they tried, it was ridiculous. But the three pepper teams said, wait a minute, this is not desegregation when you put one black person in one bed up here. We mean to desegregate the whole hospital, don't you understand? The whole place has to be desegregated or you're not going to get the money. Local constituents complained and word got up to their congressmen. So while those teams were on the ground, Peter spent a lot of his time testifying and defending their efforts in D.C. But within a few months, they'd more or less succeeded. 98% of hospitals had integrated. In July of 1966, one year after Medicare passed, the program was ready to go. The money was ready to flow. So my grandmother was one of the first people to get a Medicare card because you could apply for it in January if you had already passed your 65th birthday. Edith Mitchell grew up in Brownsville, Tennessee. She saw this transition when her grandmother needed help. She got admitted to the hospital. Had she been to the hospital before? No, that was her first time ever in a hospital. How old was she? She was 65. It was a good experience. A few years later, Edith was on her way to becoming a doctor herself. She's an oncologist now, leading efforts to reduce racial disparities in cancer. And as a young med student in Virginia, she got to see the changes from the inside. Nursing staffs were integrated so that nurses could work on any floors. Black doctors were given medical privileges so that they could admit and take care of their patients in those hospitals. It was just amazing. She says in the years right after Medicare took effect, fewer black babies died. Health improved. Which brings us back to North Carolina, where we started this whole story. It wasn't until I came back to Duke in the 70s to do my residency and fellowship training that I could tell a big change. We met Brenda Armstrong at the beginning. Her baby brother had a likely preventable stroke when he was born because he was refused care at the local hospital, the whites-only hospital. Brenda has kept that experience close to her heart. She became a pediatric cardiologist and a dean at Duke's medical school. Being dean of admissions for the medical school gave me a chance to challenge Duke to do the right thing. When Brenda first started out decades ago, she says too many really smart and qualified African-American students got turned away. That's been changing. Duke has done better than almost everybody in the country in the recruitment of women and students of color. Now, Black students make up nearly one-fifth of the med school. For The Pulse, I'm Alana Gordon. Alana Gordon reported that story in 2018. Since then, several of the people who were interviewed have passed away. Physician Brenda Armstrong in 2018, attorney Peter Labassi in 2022, and oncologist Edith Mitchell in 2024. As for the enrollment of black medical students at Duke University that we just heard about, it's now at about 12%. Following the 2023 U.S. Supreme Court decision on affirmative action, Duke has faced scrutiny and investigations regarding, quote, race-conscious admissions policies. Since then, the university has also seen pressure from the Trump administration for their diversity, equity, and inclusion efforts. Surgeon and congressional candidate Ayla Stanford says while this is a very challenging time, she's a big believer in providing opportunities and mentorship to black physicians in training. I don't just talk about it, but I see where they are in their journey. Are they undergrads? Are they post-bac students? What do we need to make you a solid candidate? And also writing those letters of recommendation and putting them in touch with folks who will continue to nurture them the way that I have. And so we can't just talk about, well, there's no more funding for that. And oh, admission rates are down. I don't own a medical school, but the medical school still exists. And so how do I make you the most competitive candidate so that you will be accepted? And I'm not the only one doing that. It takes a lot of effort and intentionality, but I feel like I have to for the next generation. You've been listening to Closing the Gap, a special production from The Pulse. We're a weekly health and science show. You can find us wherever you get your podcasts. Our reporters are Alan Yu and Liz Tong. Charlie Kyer is our engineer. Our producers are Nicole Curry and Lindsay Lazarski. I'm Mike and Scott. Thank you for listening. Behavioral Health Reporting on The Pulse is supported by the Thomas Scattergood Behavioral Health Foundation, an organization that is committed to thinking, doing, and supporting innovative approaches in integrated health care.