Dr. Stella Safo, MD, MPH is a Harvard-trained, board-certified HIV primary care physician, an innovator in designing health care delivery models, and an advocate committed to gender and racial equity and civic engagement in healthcare. She is a founding member of Equity Now at Mount Sinai, VoteHealth 2020 and the Coalition to Advance Antiracism in Medicine. Dr. Safo, she has emerged as a national voice on how to address racism and sexism in medicine, and her activism led to the NYC Council passing legislation in 2021 to create a Gender and Racial Equity Advisory Committee. She has continued these efforts with ongoing advocacy to ensure antiracist policies are enacted on the federal level, through her efforts with the Coalition to Advance Antiracism in Medicine. Dr. Safo recently conducted a wide-ranging interview the Healing ARC Newsletter.
Where did you grow up?
The first six years of my life we were in West Africa. My mom is a doctor and my dad did taxes. A lot of times when immigrants come to the United States they have to retrain and get their medical degrees again. My mom had to do that, and it made for a very hectic childhood. I lived in Amherst, Massachusetts and Brooklyn before moving to Long Island, New York.
Why did you become a doctor?
I decided on medicine because I knew that I wanted to be close to people. And I thought that the way that I could do that was either by doing journalism or medicine. I chose the medicine route because I thought that when I learn about people’s stories, I’ll also be able to help them. My mom is a pediatrician. And so I was also thinking I can be like my mom.
Where did you go to college and medical school?
I went to Harvard for undergraduate. And then for medical school I also went to Harvard. Boston is an incredibly racist city. I was so surprised by this because, as I mentioned, I spent a few years in Amherst. We had a pleasant experience there. I grew up there and in New York. In my mind the Northeast was always someplace that I thought didn’t have the problems of the South. I thought Boston was one of the most racist cities I have ever lived in. I experienced it usually in social settings. People just tended to congregate with their own group. It was rare that you would see diverse groups really mixing. So, when we went out, I would make sure that I went out with my friends because I wasn’t sure where I would be, and who would be there. The thing that stands out the most to me was the experience of trying to get transportation at night, and having cab drivers pass us by because we were Black. I know it was because we were Black because the nights where we were smart enough, we would bring along a White friend. And have that person get us the cab. The nights that we did not do it, I remember walking home from downtown all the way back to the Longwood campus. This was before Ubers and so it was a real experience of seeing what it meant when people assumed something about you. And oftentimes some were Black cab drivers as well.
How was your time in medical school?
We were at one of the top medical schools in the country and in the world and it was an incredible experience. You would hear about a certain disease and then have a lecture from the person that founded the disease. We knew that we were getting an elite education. One thing that really stayed with me though was that the patients who came to the medical facilities at the Harvard hospitals were not the people who lived next to me in Dorchester and Roxbury. They went to Boston Medical Center. And that was always interesting to me. When I did my trauma surgery rotation, one of the things that confused me was that I did not see gunshot wounds. I didn’t see stabbing wounds. We used to see old people who fell down. That would be our trauma training. When I asked what was happening with all the other individuals, I was told they go to Boston Medical Center. ‘The police and ambulances do not bring traumas over here.’ That stayed with me tremendously. This idea that we have one of the best healthcare facilities in the world and the people who look like me didn’t come there. They did not come for lots of reasons. Sometimes it’s the insurance or they didn’t want to come because they didn’t have a good feeling about our hospital. Or everyone who they knew went to Boston Medical Center. This was not one directional. But it was fascinating that one of the best health systems in the world was not accessed by populations that are historically marginalized and literally live two miles down the road.
Do you think that’s still the case today?
I think it is. Fortunately, the hospitals are trying to address it. At the time that I was there in the early 2010s, there wasn’t much of an effort. There’s been somewhat of a reckoning in the last three to four years. And I think institutions are looking at it quite seriously. That is why the work of leaders like Dr. Michelle Morse is so important. It starts to get at the heart of the question of why there are inequities in medicine. It has not been rectified. But I think we are on the right path.
How does America address the racism and sexism in medicine?
The first step is to acknowledge it. We have a backlash now, the idea of anti-wokeness, anti- critical race theory where people are pushing back against racial equity. Most people don’t even understand what critical race theory is. Where there is denial, there’s a lack of a desire to see the problems, and you can’t fix what you can’t see. In some ways, I feel like we’re back to the first steps of acknowledging what is happening within the wider population. Many of us laugh and joke about these studies that are just reproduced again and again and again, telling us what we know to be true: there is discrimination, there are disparities in medicine. That life outcomes for Black and Brown patients aren’t as good. It’s frustrating to see study after study. At the same time, we’re asking the broader public to have these real conversations and acknowledge what’s happening to Black and Brown people. People in medicine must stop being satisfied with finding and identifying inequities and get to the place of developing the solutions. By that I mean the people who are in decision-making capacities, like the leaders at Brigham and Women’s Hospital and Mass General Hospital, should be having conversations about why racial and ethnic disparities exist, and not be stuck on identifying the disparities. We are past that at this point. The discussion and work need to be centered on how healthcare systems are addressing these problems. Some institutions can be leaders. People can look at Brigham and say they tried to address the problem this way, and we can try it as well. And that is how we make progress. The general public needs to catch up and understand that these problems really do exist. We live with the potential for backlash and people disbelieving that racism and sexism even exists. It forces us to work to get the general public to understand. I think those in positions of power within medicine must start implementing solutions to move things forward.
A Medscape survey found that only 22% of all physicians see disparities in patient care. What, what does that say about the doctors in America today?
Doctors are part of the larger population. We all swim in the same water. I think this comes from the desire that everyone tries to believe that they are not racist, they’re not discriminating. It’s just a natural thing where you might understand that racism happened somewhere else, but you don’t believe that it could happen in your practice. It’s why physicians and policy makers are talking seriously about having health equity report cards that allow physicians to see their own data, looking at their own patients, and compare their patient data with others. People can understand this a little bit better if you think about what happened in South Africa after apartheid ended, or if you think about what happened in Germany at the end of World War II. Because these events were so egregious, so bad that there were public reconciliations and public acknowledgement of the atrocities. With the history of enslaved people in this country, with the history of the genocide of native peoples, we’ve never really had a come to Jesus moment. There needs to be an acknowledgement that these are the groups that did it and these are the groups that suffered from it. America has never had that. So, the history and the narratives are not definitive. The history is loose. Some people think they can change the narrative if they wish. It’s not by accident that many clinicians come from the highest socioeconomic groups. They tend to be White. We have done a better job of getting women into medicine so that gender disparity has improved. But largely physicians are rich White people. It’s a natural place of privilege and we don’t always do the work to interrogate those areas of privilege. So, it’s not surprising that 22% of physicians don’t see disparities. We are not a reflective society. We have never acknowledged the ways this society has damaged various groups and continue to do damage to these groups.
Could medical schools play a bigger role in helping future physicians understand the disparities?
Absolutely. And there’s a real fight within the medical schools over curriculum to make sure that the very limited amount of hours are used for biomedical sciences in addition to the kind of social sciences that relate to what we just described. Every time we talk about teaching more about cultural and competence, and teach about social determinants of health, there is pushback from those asking, ‘Where will the time come from?’ But it is happening in a lot of different places. For instance, when we talk about a disease state, instead of talking about how asthma affects Blacks more, there should be a conversation about the environment where they live – closer to highways, near hazardous waste, et cetera. I think more of this is being done, but missing is the application. If you sit in a lecture and hear about these things, it sounds remote and removed from you. It just isn’t the same as experiencing it and understanding it that way. And that’s sometimes hard to recreate, especially in places that are not racially diverse. Lucky for us, a lot of health facilities, medical schools, and definitely residency programs are located in places, good or bad, where there are more historically disadvantaged populations. I would argue that it isn’t just the medical schools that need to expand their curriculums, but also the residency programs. ‘Do you understand that the patients that you’re seeing come with the social drivers of health disparities?’ We need for physicians to learn how to create the experiential part of this education so they can really feel it, not just intellectually, but in their souls when they look into a patient’s eyes and really see, ‘This is the way the country’s history is impacting this person who is suffering and dying in front of me.’ We can do a better job of getting that to be emphasized.
What tactics and interventions are working in this movement to remove racism from medicine?
One of the things that I do with my work with Just Equity for Health is bringing the end users to the table. We are often looking for magic solutions to problems in healthcare, in medicine and in our society at large. But these problems are so intricate, complicated, and layered. We may find solutions that work for the moment, but circumstances change. Often, we are not able to factor in the whole picture. We only get a tiny part of it that leads to imperfect solutions. My argument is that if we can get the patient/end user perspectives at all times, it will improve the way that we develop and implement solutions. For example, if you are in a health system creating a hypertension model. From the beginning of their engagement, patients are treated by their primary care doctor, and an array of registered nurses, doctors, and other health associates within the health system. These are all physicians and health workers who tend to be White and socioeconomically privileged and most don’t have a full understanding of what it’s like to be Black or Hispanic or have to confront health disparities. But these are the people who most often are sitting at the table determining the care model for a population that lives in a world very different from theirs, with different everyday challenges. Thus, a care model may be created that has the best intentions, is well thought out and super smart. Yet it may not have the needed impact because the patients weren’t engaged enough in creating the solution. At every step of the progress toward solutions, we must include individuals from the community and it is just not happening at the level it needs to happen. Too often, the community is invited to the final meeting that takes place in the middle of the workday when they can’t come, and we use medical jargon and don’t pay them for their time. How do we create powerful co-learning, co-collaboration when designing solutions? That is what we need to better understand. We need a process where there is a partnership with the end users. Another thing that’s important is the work that people like Dr. Michelle Morse are doing. She is creating solutions and they become models for others to replicate or build on. When someone creates a radical solution, something that is vastly different from the norm, maybe others can’t implement the exact same thing in their health systems, but it still plays the critical role of opening up a vision of what’s possible. I encourage people in leadership positions to be bold, push yourself, think about something that is different and try it because, frankly, we’re already failing. We may as well fail and learn from it. It is needed for us to be successful in the future.
What isn’t working right now in the fight for health equity? What are the public and private sectors wasting money on?
A couple of things. One is continuing to fund studies that tell us a problem exists. What is happening is people get so inundated with the problem, they stop listening. So, there’s a big push in the health equity world that people doing this work need to be trained so they’re not just adding to the problem. Another thing that isn’t working is putting faith in the idea that technology will save us. We know there’s a desire especially in Silicon Valley, Amazon, Google, and other places to believe that by engaging in healthcare delivery they can be the savior, that there’s a belief that technology will solve our healthcare issues. But we’ve seen this act before with Big Data and all that it was supposed to improve. The reality is garbage in, garbage out. It will take more than just advanced technology to produce health equity. We must acknowledge that these systems are inherently inequitable, and when you add a technological solution to it, you are just replicating the inequities because the technology usually has a discriminatory lens.
Are you in favor of race-conscious interventions?
I think so, depending on how they are used. I think there’s a lot of potential. My caution on race-conscious interventions is to be very mindful of how the language may inadvertently weaken the buy-in. My concern is that we do not become over focused on the role of race and give less attention to the actual solution. There may be different ways to acknowledge that race is a central factor without making it the obvious focus. Maybe by looking at socioeconomics. There must be ways we can move forward without the backlash that comes when race is centered. Down the road, yes. Race can be centered. We should shout from the mountaintops that we are adopting a specific equity program because Black people deserve and need reparations. At some point, we will be able to say that. What is challenging is when we try to push certain things now, the level of intractability and resistance is extremely high and so nothing is really working. There are people who are afraid to say the word race in board rooms in 2023. When two years ago these same people were focusing on how to be anti-racist and were empowered to achieve equity in our society. But something happened, and we have gone backwards. Things have shifted. And that’s the reality, I think that we have to be smart. This is a long game.
What are your thoughts on the Healing ARC framework?
I think it is absolutely tremendous. It is a real highlight. I teach it in my lectures and I do so because people cannot imagine what it looks like to really implement anti-racist policies within medicine. And this is an important example. The reason why it is so robust, rich, and important is honestly because it was at The Brigham. This is a hospital that everyone knows has a certain gravitas. And for them to do it there with everything that is in their history. It creates a sense of what is possible. I teach about the backlash that occurred when Healing ARC was implemented because it explains what we must be ready for. The Healing ARC work is well grounded. I think the theoretical framework that they use was an excellent one. Their use of community partnership is exactly what I was talking about. You must partner with the community and make sure they support what you are doing.
Can racism be eliminated from medicine and patient care?
It can be, but I think it will take an incredibly long time for it to happen. The biggest problem is not racism in medical care. It is racism in our larger society. And until that is addressed, and that’s addressed substantially, we won’t see substantial change in medicine. It will take something tremendous for us as a society to address the insidious role of race within every institution and every system in our society. When it does happen, then we can eradicate racism from medicine and patient care. It can be addressed in sports, it can be addressed in corporate America. It can be addressed everywhere.