We Belong to One Another: A Lesson from Dr. Martin Luther King, Jr.

From the January 21, 2022 issue of the Transformational Times (Urban and Community Helath)

We Belong to One Another: A Lesson from Dr. Martin Luther King, Jr.

Cassie Ferguson, MD

In his letter he wrote from a Birmingham jail—the letter that began in the margins of a smuggled newspaper and on found scraps of paper—Dr. Martin Luther King, Jr. shared this:

“Whatever affects one directly affects all indirectly. For some strange reason I can never be what I ought to be until you are what you ought to be. And you can never be what you ought to be until I am what I ought to be—this is the interrelatedness of life.”

The very same stardust

Dr. King suggests that if we would see how inextricably connected we are to one another—if we would see that we belong to one another not only by virtue of being born on the same planet, but also by virtue of the scientific and spiritual reality that we were made from the very same stardust—that then all of us could see how the systems that uphold and protect racism, health and wealth disparities, educational inequalities, and residential segregation dehumanize us all.

That if we understood our interdependence, we would move beyond empathy for those who are suffering the most under the weight of these systems and know in our hearts that when one teenager is murdered, we are all killed. That when a pregnant woman delivers a stillborn baby because her health concerns are dismissed, that we all lose a child. That when one of our students must repeat their first year of medical school because of inequities in medical education and in our learning environment that disproportionately impact students underrepresented in medicine (URiM), that we all fail.

Dangerous unselfishness

This kind of radical compassion is not for the faint of heart. Dr. King understood this. In his very last speech delivered in support of the striking sanitation workers in Memphis, Tennessee, Dr. King rallied the crowd declaring, “either we go up together, or we go down together. Let us develop a kind of dangerous unselfishness.”

At the Kern Institute, our mission has been to inspire and support this kind of unselfishness and this kind of compassion in our learners and educators, such that we might transform the system of medical education to ensure that every one of our patients feels seen and deeply cared for; such that every one of our patients is given the opportunity to flourish. This kind of systemic transformation requires tremendous courage, sacrifice, and love. It demands that we understand compassion not “as a relationship between the healer and the wounded…but as a relationship between equals.” (Pema Chödrön).

Despite these challenges, there are examples of how the MCW community is “showing up.” Here is one example. In the spring of 2020, student doctors British Fields, Jamal Jarrett, Morgan Lockhart, Enrique Avila, and Adriana Perez learned that the Apprenticeship in Medicine (AIM) enrichment program they had been chosen to lead that summer would not be funded because of the pandemic. Led by the incomparable Jean Mallet and supported by the Kern Institute, these students advocated for their program, pivoted, and in three weeks designed and stood up the Virtual Health Sciences (VHS) program. Over Zoom, they provided forty Milwaukee-area high school students from backgrounds historically underrepresented in medicine a meaningful and engaging look at careers in health care and showed them that there is a place in the profession of medicine for them. Our student doctors saw themselves in these high school students and this motivated and empowered them to take direct action.

“The Path of Joy is Connection”

What I have come to realize as a physician and, as someone who teaches medical students about well-being, is that when we become aware of our interrelatedness, we not only wake up to how we might design and redesign systems that assume the humanity of all peoples, but we also feel less alone, less fragile, less anxious; and, like these student doctors, we are empowered to become our best and truest selves. As the late South African anti-apartheid leader and Nobel Peace Prize Laureate Archbishop Desmond Tutu reminded us frequently, the path of sorrow is separation, and the path of joy is connection.

This week, as we celebrate the Reverend Dr. Martin Luther King, Jr., may we cultivate the awareness of our interrelatedness in our hearts, and find the courage to unselfishly redesign our world such that all of us may flourish. 

Catherine (Cassie) Ferguson, MD, is an Associate Professor in the  Department of Pediatrics (Emergency Medicine) at MCW. She is the innovator of the REACH Curriculum, and the Associate Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

To be understood and appreciated: A trip to Lac du Flambeau

From the September 22, 2023 issue of the Transformational Times

"To be understood and appreciated": A trip to Lac du Flambeau

Bruce H. Campbell, MD, FACS

In July 2023, Dr. Campbell joined a group of Medical College of Wisconsin (MCW) researchers, clinicians, faculty and staff for Lac du Flambeau Family Circles Professional Development Training with the Ojibwe Community in Lac du Flambeau, WI. Despite many visits to Wisconsin’s Northwoods, this was his first effort to learn about the historical trauma the region’s Indigenous peoples have experienced ...

 

All human beings want to be understood and appreciated.

— Family Circles Traditional Parenting Program

Native writer Sherman Alexie, in his short story, “War Dances,” tells of an Indigenous son whose father has just come out of surgery. The father is shivering and, when the thin, white hospital-issue blanket is insufficient, the son sets off on a quest through the hospital—with its “white sheets in a white hallway under white lights”—looking for a “particular kind of patient and family.” He eventually locates a Native man who has an extra Pendleton wool blanket. After a blessing (“It doesn’t matter if you believe in the healing song ... it only matters that the blanket heard”), the son returns to his father and wraps him. The father begins to sing. The son joins in. “The sick and the healthy stopped to listen.” I have always viewed this as nothing more than a heartwarming story.

The roots of my own misunderstanding

As a white American male growing up in the 1960s, I read books that included Native stereotypes, learned the Eurocentric stories of Christopher Columbus, Plymouth Rock, and Thanksgiving, and watched TV Westerns and The Lone Ranger. In school, I dutifully learned about the Oregon Trail and a whitewashed version of America’s Manifest Destiny. I colored maps depicting the Treaty of Paris of 1763 and the Louisiana Purchase of 1803, never recognizing that these lands never belonged to the French in the first place. I studied versions of history written by the dominant culture.

As I moved toward adulthood, I learned about the forced removal of the Cherokee people via the Trail of Tears, the deaths of hundreds of Anishinaabe people in the Sandy Lake Tragedy of 1850, the 1890 Massacre at Wounded Knee, the American Indian Movement’s Wounded Knee occupation in 1973, and the Wisconsin Walleye War of the late 1980s. I read about rural poverty, domestic violence, meth, and alcohol abuse on reservations. The injustices, brutality, and cultural loss that Native peoples had suffered stood in stark contrast to the mythology I had studied as a child.

These competing narratives offered hard lessons, yet the depictions of injustice seemed distant from me and difficult to comprehend. I sensed there was much that I would never understand.

A brief, meaningful experience in understanding and appreciation

In July 2023, eighteen MCW people were graciously welcomed by Ojibwe trainers onto the Lac du Flambeau Reservation in northern Wisconsin.

Brian Jackson, MS, EdD, (spiritual name: Chi Ayaabe or “Big Buck”), led the training. He is an Anishinaabe educator and Assistant Professor in the MCW Institute for Health and Equity’s Division of Epidemiology and Social Sciences.

Dr. Jackson reviewed the development of the 24-session Lac du Flambeau Family Circles AODA Traditional Parenting Program, originally conceived and co-authored by tribal elders Dr. Alton “Sonny” Smart and Ernest St. Germaine. The program builds on traditional Anishinaabe values to enhance physical, emotional, spiritual, and intellectual resilience, awareness, and self- understanding. It guides parents and children to develop new skills while strengthening families and communities.

Educators Melissa Doud and Doreen Wawronowicz walked participants through stories depicting the toll real people have suffered because of historical trauma. They highlighted the role of cultural resilience. Dr. Jackson also shared the history behind Wisconsin Act 31, a 1989 law that requires all Wisconsin public schools to provide instruction on the history, culture and tribal sovereignty of Wisconsin’s eleven nations and tribal communities.

A visit to the Boarding School

We visited a building from the Lac du Flambeau Government Boarding School. It operated from 1895 to 1932 before being converted to a day school. Eventually, the school that was widely reviled by Natives closed. Most of the buildings were demolished. The remaining boy’s dormitory serves as tribal office space and houses a museum.

In the era when the school opened, official U.S. government policy empowered Indian Agents to ensure that Native peoples would be trained to farm successfully and sustainably, be prohibited from using liquor, have their children instructed in English and industrial training, and be restricted to the reservation unless they had travel permits. The school was supposedly designed to accomplish these tasks.

Indian Agents and police patrolled the reservations, looking for children ages five to fifteen. Once they were seized and taken to the school, the students were given English names, their hair was cut, their toys and clothes were confiscated, and they were given uniforms and assigned to a Christian church. They were separated from their siblings.

Speaking Ojibwe was forbidden. Schedules were highly regimented, with bells ringing over twenty times each day to mark different assignments and activities. The goal of the school—and other Indian schools—was to Americanize and “civilize” the students through re-education. The graduates, having been separated from their families for years, emerged prepared for neither the Native nor the non-Native world. They were often lost.

Students, according to the Great Lakes Inter-Tribal Council’s Amy Poupart, program director for the Great Lakes Native American Research Center for Health (GLNARCH), were “processed not parented.” The effects of the stress and trauma suffered by these children has lasted for decades. Melissa Doud quoted Anishinaabe activist, Winona LaDuke, who wrote, “What our Seventh Generation will have is a consequence of our actions today.” The community’s intergenerational pain is best addressed by the Ojibwe people.

MCW researchers, such as Tim Meister and Matthew Dellinger, PhD, were recognized for their long, productive collaborations and respectful partnerships. Projects must be approved by tribal elders, are overseen by NIH-funded NARCH Centers, and adhere to the caveat that policies and practices reflect, “nothing about us without us.”

Moving forward

It will take time for me to revisit and correct the lessons I learned throughout my life. In contrast to the myths I learned about America’s Western expansion, Ojibwe scholar, novelist, and writer, David Treuer, writes, “American did not conquer the West through superior technology, nor did it demonstrate the advantages of democracy. American ‘won’ the West by blood, brutality, and terror.”

Although some have asserted Indian culture was destroyed in the late-1800s, Treuer writes with “the simple, fierce conviction that our cultures are not dead and our civilizations have not been destroyed.”

Each tribe is different from the others and, as non-Natives, we are challenged to not romanticize Natives and Native culture. Native history is complex and multilayered. The communities are active, vibrant, evolving, and resilient. These, too, are hard lessons that I barely understand.

Back to Sherman Alexie’s short story

I started this essay with a feel-good story about a blanket. On further reflection, though, I see the story is also about the father’s impending, premature death from his life choices and his alcoholism, the alienation between the narrator and the dominant culture’s healthcare system, and the very short-lived nature of whatever comfort his father would receive from the wool blanket.

The story ends with a crowd of nonNatives standing in the hallway listening to the father and son sing the healing song. I now see that not one of the hospital employees joined in, celebrated, or offered any form of comfort to the man. Still, one of the nurses—one who had been unresponsive to the man’s suffering earlier in the story—takes a few steps toward the singing. The narrator tells us, “She sighed and smiled. I smiled back. I knew what she was thinking. Sometimes, even after all these years, she could still be surprised by her work. She still marveled at the infinite and ridiculous faith of other people.”

So, to the Ojibwe trainers and people I met, I say Chi Miigwech for the training that has allowed me to take a few steps closer. I hope I have a better understanding and appreciation for the people I met and for the hard work in which they are engaged.

I am grateful to the members of the Lac du Flambeau community who reviewed this essay prior to publication. Special thanks to Carol Amour who told me that many Indigenous and non-Indigenous people have significant issues with Sherman Alexie.

For further reading:

A summary of the visit to Lac du Flambeau:

A summary created by participants Cindy Mann and Tifany Frazer for the MCW Office of Global Health can be found here.

An in-depth journalistic examination of the Native American boarding school system: 

Since the visit to Lac du Flambeau, the New York Times published an investigative study exploring the lasting damage inflicted by the 523 Native American Boarding Schools in the US. This remarkable article, 'War Against the Children," has horrific stories, photos, old documents, historical information, and data. It can be found here.

Upcoming observations:

Sept. 30, 2023 - National Day of Remembrance for Indian Boarding Schools in the United States

Oct. 9, 2023 - Indigenous Peoples’ Day

 

Bruce H. Campbell, MD, FACS, is a retired Professor of Otolaryngology and Communication Sciences at MCW. He is on the editorial board of the Transformational Times.

What Does a Medical Student Look Like? Social Determinants of Medical Education

From the May 5, 2023 issue of the Transformational Times

What Does a Medical Student Look Like? Social Determinants of Medical Education

Adina Kalet, MD, MPH

In this week’s Director’s Corner, Dr. Kalet muses on what it means that not all, but most, medical students come from high-income households and how this may be the cause of unnecessary struggle and suffering ...

*While this is a true story as I experienced it, I have changed my friend’s name and some of the details to respect her privacy.

It was late on a wintery night when the car’s brakes failed. As we rolled down the steep Upper Manhattan hill the driver, my classmate, Laura, pumped the hand break until we came to a stop by gently bumping the rear of the vintage Mercedes Benz paused at the traffic light. “Shit,” she muttered.

Following Laura’s lead, I got out of the car and gingerly approached the older tuxedoed man who had emerged from the driver’s seat and was now carefully inspecting the rear bumper. No harm done. A moment later, a woman emerging from the passenger seat, wrapping her fur coat tightly around her shoulders as she strode over. She looked us up and down, no doubt taking in our matching server uniforms, poorly fitting black skirts, and polyester white button downs, bow ties askew. She then eyed the rusted 10-year-old baby blue Buick from which we had emerged and screeched, “How can you have this piece of junk on the road? You could have killed us...and my husband is a surgeon!?”

It was chilling. To his credit, the man looked chagrined. Using my best communication skills, intending to diffuse the tension, I said softly, “Ma’am, we are sorry for frightening you. We hope no one is hurt. We are medical students on our way home from a catering job.”

The woman’s tirade revved up. She accused me of lying about being medical students and us of being dangerous menaces, among other things. She was rattled and had cell phones been available in the 1980s, no doubt, she would have called the police. The man coaxed his wife back to the car and waved us on.

Luckily, no one asked for Laura’s insurance information because she didn’t have any.

Clearly, we did not fit this wife-of-a-surgeon’s image of medical students. She could not imagine medical students driving run-down jalopies or being employed in the “service industry.” I was perplexed, aggravated, and embarrassed. But Laura was nonplussed. She was used to this sort of dismissive treatment. After all, she was regular catering waitstaff at NYC gala fundraisers. She was used to being invisible to people like this couple.

Laura’s story

In retrospect, I realize Laura grew up poor. Compared to most of us who had taken loans to pay our tuition and were otherwise fully supported by our parents (I lived with my family in a two- bedroom apartment and commuted to school by subway), she needed the car to get to school and her service jobs from her working-class neighborhood on Staten Island. Public transportation was not an affordable nor easily available option. Both Laura and her mom, who had a serious chronic disease, needed to work to pay the family’s basic expenses. Her car was a mess, clearly in need of repairs, and probably dangerous, but it was all she could afford. While a handful of us occasionally joined her on a catering job to make some extra cash, she had no choice but to work nearly full time. To be clear, medical school is a more than full time endeavor and most medical students do not need to hold down jobs.

Laura’s family likely went hungry or were marginally-housed during the time we were in school together. Maybe they were on public assistance. She might have told me if I had asked. But I didn’t. I hope she asked for—and received—help from the office of financial aid. But I am not certain, knowing her, that she would have.

Even in our highly competitive city university program, dedicated to recruiting a diverse class of local students able and committed to becoming inner city primary care physicians, Laura’s level of financial need was rare. Laura had a few friends and was an excellent school project partner, but she rarely showed up for social outings or joined us when we went out for meals. She couldn’t afford the time or money. I never quite figured out when she studied, but she survived academically, repeating a year of school along the way.

I lost touch with her after we graduated. I know she trained as a surgeon, worked in the community from which she came, and had a child. A few years ago, I learned that Laura died young of cancer.

When we all went off to traditional medical schools to finish our training I was, for the first time in my life, introduced to the fact that most medical students came from relatively wealthy families. Naive as it sounds, I was stunned when a new medical school classmate picked me up in his vintage Aston Martin to drive out to his family’s suburban home, replete with private

swimming pool and tennis court for a weekend barbeque, bringing his laundry along to be done by the maid. I felt like Dorothy in Oz, “Toto, we are not in Kansas anymore.”

The COVID-19 pandemic reveals the Social Determinants of Education

Much has already been written about how the pandemic revealed the stark health and economic disparities in our society. It should not surprise anyone that medical schools were also challenged to recognize and be responsive to the needs of students with fewer resources. It became crystal clear that like Social Determinants of Health that create negative consequences for patients, Social Determinants of Education (SDOE) create disparities among learners. There is a myriad of ways that some student’s lives have been shaped by factors such as socioeconomic stress; bias and oppression; food and housing insecurity; poor access to health care; and unsafe neighborhoods. These challenges put otherwise highly motivated ambitious, capable students at a significant educational disadvantage compared with their peers in terms of access to and success in the health professions.

Because society desperately needs a robustly diverse and excellently prepared pool of future health professionals, the 2022 Josiah Macy Jr. Foundation Consensus Conference on COVID-19 and the Impact on Medical and Nursing Education recommended (among many other things) that, “Health Professions Education (HPE) leaders, educators, and learners—together—must examine and eliminate the detrimental effects of the SDOEs on HPE learners and build equitable learning environments for everyone.” But this is often difficult to do because it is traditionally a hidden problem.

Medical students disproportionately come from high-income households

In 2022, data from an AAMC-Medical Student Questionnaire revealed that 50.5% of all Allopathic medical students come from the top quintile of household income, with 24.0% from the top 5% and less than 6% come from the bottom quintile. This overrepresentation of higher income and underrepresentation of low-income groups—consistent across race and ethnicity— is a manifestation of the fact that access to the profession has been persistently out of reach for those from the lowest socioeconomic strata. This is being addressed in many ways. Long-term upstream targeted investments in the student pipeline through community partnerships can get more students like Laura to feel prepared to apply to health professions programs. Medical schools can, and do, assess socioeconomic disadvantage during the admissions process using essays and the parental education and occupation indicator. And grade point average and Medical College Admission Test scores, can be adjusted for socioeconomic disadvantage.

But more needs to be done. To reduce the unequitable circumstances while in medical school, students from low-income households could be monitored for the accumulation of unexpected expenses and provided with what they need to thrive (e.g., food, clothing, computers and internet access, emergency housing) given that they do not have nearly the same level of family support as most of their peers.

The pandemic worsened every social determinant of education and negatively impacted current and future students. Students from poorer families are much more likely than their peers to have experienced the devastating impact of the pandemic, the death of family members and loss of livelihoods, the serious economic deprivation while having fewer resources to recover from these challenges. In addition to providing concrete support and wellness and financial counseling, schools should monitor policies that inadvertently disadvantage some students like required travel and housing for training and fees not included in financial aid packages (aka “hidden tuition”). Medical schools like ours have restructured large classes into smaller learning communities to build better communal resilience both academically and socially and to enhance our opportunity to look out for each other.

For those of us working for transformation of a medical education that is built around a core of character and caring, the pandemic has “catalyzed a strategic inflection point” (Lucey, 2022) where we now have an opportunity to better address the health care needs of both our patients and students. While Laura’s “journey traveled” from poor kid to surgeon is inspiring, her almost invisible struggles to persevere in the face of hardship makes me wish we had been more compassionate and kinder. We could have done better.

For more reading:

Lucey CR, Davis JA, Green MM. We have no choice but to transform: The future of medical education after the COVID-19 pandemic. Acad Med. 2022(suppl 3);97:S71–S81.

Muller D, Hurtado A, Cunningham T, Soriano RP, Palermo AS, Hess L, Willis MS, Linkowski L, Forsyth B, Parkas V. Social Determinants, Risk Factors, and Needs: A New Paradigm for Medical Education. Acad Med. 2022 Mar 1;97(3S):S12-S18. doi: 10.1097/ACM.0000000000004539. PMID: 34817406; PMCID: PMC8855756

Shahriar AA, Puram VV, Miller JM, et al. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017-2019. JAMA Netw Open. 2022;5(3):e222621. doi:10.1001/jamanetworkopen.2022.2621

Josiah Macy Jr. Foundation Conference on COVID-19 and the Impact on Medical and Nursing Education: Conference Recommendations Report. Acad Med. 2022 Mar 1;97(3S):S3-S11. doi: 10.1097/ACM.0000000000004506. PMID: 34736279.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.