In 2015, Dr. Bram P. Wispelwey worked with Dr. Michelle Morse and other colleagues at Brigham and Women’s Hospital (BWH) in Boston, who found that over a 10-year period, Black and Hispanic patients diagnosed with heart failure in the emergency department were less likely than White patients to be admitted to the hospital’s specialty cardiology unit, where patients had better outcomes. Dr. Wispelwey helped create the Healing ARC, a race-conscious framework based on the reparations work of William Darity and E. Kirsten Mullen, that aims to redress racial inequities in medicine, improve patient outcomes and enhance accountability. Today, under a pilot program at BWH, when the emergency room treats a person of color with heart failure, a new, more equitable, process is in place. When physicians select admission to the general medicine service for a patient, rather than the specialty cardiology service, they receive a “best practice advisory” from the electronic health record system. The physician can either change their decision and admit to cardiology or override the best practice advisory and continue admission to general medicine. Implementation of the Healing ARC stirred a backlash among critics. Dr. Wispelwey, Dr. Morse and others were the targets of threats and a neo-Nazi protest at the hospital. Dr. Wispelwey recently talked with the Healing ARC Newsletter about this experience and his commitment to racial justice and health equity.
Where did you complete your medical training and what led you to a health equity focus?
I attended medical school at Ben Gurion-University of the Negev. I learned about the program through my master’s advisor at Columbia University who was a co-founder. The design was focused on global health and social medicine. It’s in the desert in the south of Israel. I moved to Boston to complete my internship in residency at Brigham and Women’s. During my residency in Global Health Equity, I met Dr. Michelle Morse, and we began working together.
What did you learn from being in Israel?
Israel is a country the size of New Jersey established in the wake of rampant antisemitism in Europe. Yet the creation of the state was a disaster for the Palestinian population living on the same land, displaced either to nearby areas like refugee camps in Gaza or the West Bank, or in surrounding countries. I became acutely aware of this situation in July 2010. In the desert, Palestinian communities were being displaced and I came to know the people in one community. The village was demolished in the summer of 2010. Two families kept rebuilding it. It’s been demolished like 200 times. In this time, I gained a real sense of the pain and suffering of that community. That experience and those relationships allowed me to better understand the impact of racism and displacement in the US, once I returned.
My interest in going into medicine was always focused on global health and social medicine and helping solve big problems. Some people are getting sicker and dying younger than others, and we have the tools, we have the resources, to stop that. Palestinians in Gaza and in the West Bank live 10 years shorter than Israeli Jews. I’m less interested in the newest, latest technology that might help a few well-off people. I am more interested in trying to eliminate disparities in care and outcomes.
Is there anyone who sparked your passion for health equity?
Marshall Ganz is a long-time organizer currently at the Harvard Kennedy School. He began organizing in the 1960s working in the deep south during the Civil Rights movement. He later went to work with Cesar Chavez in his home state of California. In this work, he saw injustices in a new light, and what he had normalized growing up there no longer seemed normal at all. He called it looking through his “Mississippi eyes” because of the racism he had seen and experienced working in the Civil Rights movement. I use a similar analogy. I have what I call my ‘Palestinian eyes.’ Now I see racism and injustices more clearly in my home context, which I was socialized to miss or ignore as a white person growing up in the US. Returning to the US after four years of medical school, I observed elements in our society differently. Injustices became much more apparent. This was part of how I noticed the initial heart failure inequities; It was apparent Black and Hispanic patients were receiving different care than white patients right in the hospital where I worked.
How did you recognize an inequity in heart failure care?
Brigham and Women’s has two clinical services where patients with heart failure are admitted: general medicine and specialty cardiology. The attending doctors work in silos by service, so they each only see one set of patients. Residents work in two-week rotations with each service. I had just been in cardiology and saw all the resources at their disposal to help patients. I noticed they were predominantly white patients and they received the best cardiology care possible. Over in general medicine, we would have patients with heart failure—some cases were severe forms of heart failure – and even though we had a specialty cardiology service specifically for patients with these problems, they were treated in general medicine. I observed that they were predominantly patients of color, mostly Black and Hispanic. That is what set off the Healing ARC research and initiative.
What steps did you take to address the disparity?
I discussed my observations with other residents including those in the Division of Global Health Equity and presented my observations to faculty at the Harvard TH Chan School of Public Health where I was completing my masters. Among faculty some of the responses were, “Even if we are segregating care, it doesn’t really matter because the outcomes are what matter.” This thinking sounded to me like “separate but equal is ok, right?” And it didn’t sit well. So, we then worked with Jen Goldsmith, the program director in the Division of Global Health Equity, who helped to get data on admission and discharge patterns. This was a real departure in use of patient data and required working with hospital administrators to understand our question was not theoretical, it had meaningful immediate impact on patient care.
When we finally analyzed the data, it essentially confirmed that this segregation of patients had been impacting care for at least ten years. This led myself and fellow residents to open the conversation with other departments. Predictably, these conversations with emergency medicine and cardiology became quite tense. We learned a lesson from not having worked together across departments earlier in our analysis. From there, we shared the data with everyone involved: clinicians and statisticians alike. Dr. Morse had studied organizing strategies and began building a coalition movement internally. Eventually, that included department chairs who emerged as big champions of the work. A large part of the work over the years was winning people over to the urgency of this issue. That took time, but it paid off. We were able to build a shared understanding of what the data showed and commit to making changes in care.
Has the hospital committed to the Healing ARC for the long-term?
Our pilot program has been funded by the highest level at the hospital and has significant institutional support. There is also a broader campaign within the Mass General Brigham Health System to address racism. Yet our race conscious approach has required building critical consciousness of past harm and commitment to redress. That’s an evolving process.
How did BWH handle the potential legal issues Healing ARC presented?
We first published our research in 2018 and the Department of Medicine funded several health equity improvement pilots before we launched Healing ARC. Yet, many people were not aware of the inequities in care until the attacks against implementing the Healing ARC as an intervention. We had conversations with the interim president of the hospital as well as working with the hospital’s general counsel recognizing real risks and backlash the institution could face [related to implementing Healing ARC]. A number of conservative organizations threatened to sue the hospital if we went forward with it. Some claimed that Healing ARC was essentially racism against Whites, and that it violated the 1964 Civil Rights Act.
I am not a lawyer, but my interpretation is that, increasingly, in order to prove discrimination, intent matters. You must prove there was an intention to discriminate. Once we documented the disparities, it wasn’t like there was some smoking gun where you could say, ‘Oh, there is this bad actor or this bad part of the system.’ It’s built into the system. So where we landed was that because we had documented the disparities so thoroughly, we had the legal argument to say that we had to do something about it. Even if we didn’t intend to have this racial inequity in care for heart failure, we knew about it because of our research, and if we didn’t attempt to fix it, we could be liable. But most important to us was finding a new way to way to address examples like this, something reparative.
How did the backlash affect you personally?
It was a frightening time beginning in the spring of 2021. I received numerous threatening emails. Dr. Morse received messages that were full of cruel, racist, and gendered slurs. The backlash wasn’t aimed just towards us, it was also aimed at the hospital. It created questions like, “Is this the right thing?” “What are we doing?”
Is the Healing ARC approach being used in other institutions?
The University of Virginia Medical Center is implementing a Healing ARC model to address racial disparity in the heart failure patients assigned to general medicine versus the cardiology unit, much like we did at BWH. Also, the Institute for Healthcare Improvement has launched a campaign called Rise to Health, which will include the Healing ARC as one of the remedies they will cite in their health equity campaign.
Can the Healing ARC approach be used more broadly to address other inequities in health care?
That’s an important question. We haven’t yet fully explored the scale up from Healing ARC in the treatment of heart failure patients to broader Healing ARC interventions applied to a wide range of scenarios to address racism.
Our commitment is to reparative and restorative justice for harms that have been perpetrated. Clearly, this framework can be utilized to address many inequities that are discovered and documented. The goal is to engage communities and patients during the process of repair.
Disparities are pervasive across our health care system. For example a race-based modifier applied to kidney function showing that Black people are less likely to be put on kidney transplant lists. That is a direct harm. There are other well-documented race based algorithms in pulmonary function and bone density testing, for example. And there are other documented disparities in patient care like around access to pain management and hospital security responses. The Healing ARC process could be adopted to find ways to redress these inequities and others. We hope to share this model to right past harms where they exist. I hope as a clinician to sustain my commitment and work with communities who have long been misserved by engaging models like Healing ARC that offer these essential elements of acknowledgment, redress and closure of past harm.