“I Can’t Breathe”: A Tale of Health Inequity and State-Sanctioned Violence

By Khaalisha Ajala, MD, MBA |  June 12, 2020 | 

One might immediately think of the murders of Eric Garner, George Floyd or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, Do the Right Thing, when they hear the words “I can’t breathe.” These words are a cry for help. The murder of these unarmed black men is devastating and has led to a state of rage, palpable pain and protest across the world.

However, in this moment, I’m talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19 or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have pre-existing conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh produce store was interested enough to set up shop in their neighborhoods. So they have been eating fast food since early childhood. A fast food burger is still cheaper than a salad. The result, obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke and end-stage renal disease.

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the affects of high sugar diets in our patients. This colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, White Fragility. Why It’s So Hard for White People to Talk About Racism, I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It’s that same systemic racism that could create two America’s where my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we all know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain? Hoffman et al. reported in their groundbreaking April 2016 research article, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites,” that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of that provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency rooms and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.”  It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 PCR? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one-dimensional is always dangerous – and even more so during this pandemic. That person we can relate to secondary to a cool pop culture moment, a TikTok song or a negative stereotype is not one-dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the chokehold that slowly removes the light and life from a person who has a story, who has a family and who has been an essential worker that can’t work from home. That person is telling us that they can’t breathe, and sometimes the only things seen are comorbidities through a misinformed or biased lens that bare assumed lack of personal responsibility. In their May 2020 New England Journal of Medicine perspective, “Racial Health Disparities and Covid-19,” Chowkwanyun and Reed caution us against creating race based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman or non-binary person is telling you “I can’t breathe. I’m tired. I’m short of breath… I have a cough… I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower income black and Hispanic patients already saw local hospitals and front line workers fight to save their lives while loosing their own to COVID-19. We all witnessed the battle for scarce resources and PPE. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading Medical Apartheid by Harriet A. Washington. Let us examine that painful legacy, which, although has moments of good intention, still carries the stain of indifference, racism, neglect and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.

4 Comments

  1. Avatar
    Jeff Cooper June 13, 2020 at 11:49 am - Reply

    Well put my friend. We’re all too guilty of seeing what we assume to be and not providing each human the respect and basic rights they deserve. We’ve got lost of work to do and I’m here to help, thank you for sharing!

  2. Avatar
    Maria June 13, 2020 at 1:08 pm - Reply

    Very thoughtful post! Current and continuous Quality Measurements are so vitally important. Thanks for your astute insight and diligence to finding much needed solutions.

  3. Avatar
    I. Michael Goonewardene June 16, 2020 at 8:58 am - Reply

    I challenge myself to speak up on behalf others when I hear or witness racist comments. Not just the obvious ones; but learn how allowing the subtle ones to go unchallenged make me complicit in continuing a system marginalizes people by skin color and economic standing.

  4. Avatar
    Lydia Floren MD June 17, 2020 at 8:14 am - Reply

    Wow. Well said. And beautifully written. Thank you for opening my eyes a little wider.

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About the Author: Khaalisha Ajala, MD, MBA

Dr. Khaalisha Ajala is a hospitalist and Associate Site Director for Education at Grady Memorial Hospital in Atlanta. She cares for patients of diverse backgrounds directly and also has a deep-seeded passion for public health and patient education, always demonstrating how to bring this passion to trainee education. Using her knowledge as an MBA, Dr. Ajala has designed, developed and now maintains her own non-profit agency, Heart Beats & Hip-Hop. Through this organization, she has hosted public health fairs to conduct health screenings in less traditional local settings, where community members who may not have access to care can gain exposure to a healthcare provider. Dr. Ajala also has designed and executed successful community fundraisers, helping to build other non-profit organizations that provide essential services to the homeless in Atlanta. More broadly, she has made journeys to Thailand and Ethiopia to work with Emory trainees in educational and clinical efforts to help them engage the global community in health improvement. In Thailand, she taught students how to care for patients at risk for trafficking and sexual exploitation. While in Ethiopia, she served as an educator and clinical preceptor to Emory residents in the Global Health pathway, teaching them to care for high-risk patients at a local hospital.

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