Healthcare in Houston – Circa 1988
Dr. Xavier Brager’s mother filed for divorce when he was 10 years old. After his father started working a commercial job, he was able to secure private health insurance for Xavier and his siblings.
He remembers a snake bite as the reason for his first trip to the hospital using private insurance. For one reason or another, the cuff used to measure his blood pressure and the way it mysteriously tightened against his arm stands out as a scary moment.
Over time, the visits to the doctor’s office became a normal part of his routine—and they were fairly quick and easy.
Counting on the County
This was the opposite experience for Xavier’s mother and grandmother, who both suffered from chronic illnesses.
The two women, who lived in impoverished neighborhoods, were forced to endure egregiously long waits at the county clinic. On a typical day, the family would spend about two hours waiting to see a doctor, and another two hours waiting for the life-saving medications their mother needed.
As a fix for this inconvenience, young Xavier would often ride his bicycle down to the county clinic to brave the wait on behalf of his sick mother and grandmother, collecting their medications for them.
Potentially overwhelmed by the number of patients, the pharmacy passed out brown bags with pill bottles inside and neglected to spend time explaining their contents.
Dr. Brager: “I used to see my mother and grandmother get these brown paper bags full of medications thrown at them. I was sitting there trying to help my mother read and understand them.”
He desperately hoped the answers he’d receive when calling around the city to random pharmacists and doctors who might be willing to help answer his questions would help him care for his mother, as he did his best to help manage her chronic illnesses.
Dr. Brager: “This was at a time when we didn’t have access to information links available through Google. You had to roll with the punches and hope the bottle told you what it was for. We struggled to understand how to preserve her health together.”
Grief Before Graduation
When Xavier was just a junior in high school, his mother passed away from complications of a brain aneurysm. He couldn’t help struggling with the thought that she was failed by the healthcare system.
Dr. Brager: “I looked at the autopsy report as an adult. It was kind of disturbing to me. If she’d had better treatment and been monitored more closely, she wouldn’t have suffered the way she did.”
Mockingbird: “What about your grandmother’s health?”
Cuisine Meets Clinical Concerns
Dr. Brager: “My family is from Louisiana. Everything was served with rice. I love my grandmother, but I wasn’t shocked that she’d become diabetic. She was in and out of the hospital. She started having issues with her legs. She developed gangrene. Dementia became an issue.”
Mockingbird: “Were you a clinician by this time?”
Dr. Brager: “Yes—and I remember my aunts going from hospital system to hospital system because they didn’t feel my grandmother was being treated fairly. They would always call me to clarify what the providers were saying. The doctor would never explain things to my family in ways that they could understand. My aunts are educated women so it would’ve been easy for them to understand if the provider would have just been willing to take the time to explain things to them thoughtfully and carefully.”
Mockingbird: “Do you know if these were non Black providers?”
Dr. Brager: [Laughs] “I know for sure these were non-Black providers.”
Mockingbird: “Do you think your family would have been treated differently if the healthcare providers serving them were Black?”
Black on Black Care
Dr. Brager: “Yes. I think being African American and treating African American patients has its advantages. There can be some relatable pieces, depending on the experience, but that’s not a guarantee. If my grandmother had African American providers, they would have been more comfortable communicating with them.
Xavier’s understandably watchful aunts felt they should question everything that was happening during their mother’s care, partially because things weren’t being proactively explained to them. As an example, treatment processes, plan of action, medications and their purpose—discussions Xavier says he’s seen explained to White patients by default had been omitted completely during his grandmother’s bout with diabetes.
Mockingbird: “As a practicing pharmacist, have you noticed a difference in thoroughness of explanations of care provided when non-Black pharmacists are engaging with Black patients?”
Dr. Brager: [Laughs]. “The level of counseling is often not nearly as thorough. One of the best examples of self-advocacy among patients I’ve seen is in the Latinx community. They are often so determined to speak to someone they feel they can relate to culturally, they’ll leave the facility to find that pharmacist. They’ll travel miles away, or even a city over. In my experience, African Americans are less willing to inconvenience themselves for that benefit.”
[White] Medical Mistrust?
If medical mistrust is inspired by not trusting the person who belongs to a perceivably opposite or uninformed people group serving in a medical capacity, then could this attitude exist in more than one dynamic?
Dr. Brager’s experience as a pharmacist spans from working in low-income communities to populations with customer bases that included oil company CEOs. As an African American pharmacist, he has felt constantly challenged in affluent areas as patients questioned his ability to counsel them.
Dr. Brager: “It took about year for them to begin to trust the medical information I was providing to them. Slowly, they started warming up to me; bringing me cookies and thanking me for my help.”
This experience infers a scenario in an alternate reality where White patients are put in the position of their Black counterparts and conversely experience medical mistrust with a Black healthcare provider.
Is medical mistrust about the need to identify with people who look like us and remind us of those we are surrounded by and are closest to?
Impact of Black (in White Coats)
Mockingbird: “Do you trust the healthcare system in the United States to provide quality care for Black people in the United States?”
Dr. Brager: “No. There needs to be more people who look like me [invested] in it. When I look for a provider, I’m looking for an African American provider. When I look for a therapist, I’m looking for an African American therapist.”
Xavier noted concerns around non African American clinicians automatically assigning Black people to the statistics they learn about in their studies–limiting Black people to pathologies with no interest in understanding them as individuals.
It can be difficult to truly understand a patient without experiential context related to their everyday life. Furthermore, asking these kinds of questions can help make the patient feel that the provider cares, which has potential to being the path toward establishing trust and confidence in the care they receive.
The culture gap that exists often creates disconnects that impede effective communication, comfort and trust.
Mockingbird: “Do you see movement—traction in our healthcare system toward providing quality care for Black people in the United States?”
Dr. Brager: “Although I’ve not seen this many Black doctors anywhere else [Atlanta], I don’t notice anything different across the board. There needs to be more African American doctors in the United States.”