Certain statistics haunt Minneapolis pediatrician and internal medicine hospitalist Nathan Chomilo (M.D. ’09). “As a Black person, my risk of dying of COVID is somewhere around 1 in 1,350,” Chomilo says. “And as a Black man, my risk of dying at the hands of cops is 1 in 1,000 in my lifetime.”

According to a study published in the Proceedings of the National Academy of Sciences last year, Black men do face a 1 in 1,000 chance of dying during a police encounter over their lifetime—a rate more than 2.5 times higher than white men. Black alumni like Chomilo point to the death of George Floyd in May as a real-life example of that fear.

And with a national pandemic underway, Chomilo says being Black also makes him more likely to have an adverse outcome should he become sick. In July, the Centers for Disease Control and Prevention (CDC) reported that Black and Latinx Americans are three times as likely as white Americans to contract the novel coronavirus, and twice as likely to die from it. (In Hennepin County in Minnesota, the gulf is even larger: Black residents are over five times more likely to contract COVID-19.)

Chomilo says those statistics illustrate a widespread structural disenfranchisement for people of color when it comes to health care and health outcomes. His bleak assessment also underlines why he believes racism is truly a threat to Black Minnesotans, as well as to the health of other people of color.

As Minnesota’s new medical director for Medicaid, Chomilo is now expanding his quest to confront racism at the intersection of health care and public policy. He sees opportunity to advance a racial equity agenda in his new role, while prioritizing community-driven solutions to poor health outcomes. Among his goals? Helping institute antiracism training across the agency and using quality metrics to better measure “what’s driving some of our inequities.”

'Protest is absolutely necessary'

According to the Minnesota Department of Health (MDH), people of color, American Indians, people with disabilities, people living in poverty, and members of the LGBTQ community have “less opportunity for health and experience worse health outcomes in Minnesota.”

Studies from the MDH, the U of M, and others also show Black Americans experience dramatic disparities in chronic medical conditions, maternal and infant mortality, exposure to toxins, housing and food insecurity, unemployment, unsafe working conditions, and much more.

The MDH says that “social and economic structural factors are major contributors to overall health,” adding that, “It is not surprising that Minnesota has some of the worst health disparities in the country, because it has significant inequalities in areas such as income, education, and home ownership.”

“When you look at the long haul and what are the biggest risks for me, my children, and my grandchildren, protest [against racism] is absolutely necessary,” Chomilo says. Just days after George Floyd’s death, some 1,300 public health and infectious disease experts agreed. The signatories to an open letter to the public published online in early June said that COVID-19 was one more reason why the late May and early June antiracism protests weren’t only justified, but essential.

Chomilo, who’s a cofounder of Minnesota Doctors for Health Equity, which works to educate physicians on the root causes of health disparities, has long been a highly sought authority on structural racism in health care. He’s a frequent guest on panel discussions and in media stories, and he gives lectures and grand rounds to doctors-in-training and faculty about how “white supremacy” throughout U.S. medical history has adversely affected people of color, and to explain what physicians can do personally and professionally to dismantle structural racism.

As the son of a pharmacist from Cameroon and a nurse of Norwegian descent, Chomilo says he felt “pretty sheltered” from overt racism as a mixed-race Black boy growing up in Minnesota. “Those deeper conversations didn’t really happen in my family,” he says. “For one thing, I think my dad’s experience was very different from Black Americans who grow up here.”

Chomilo traces the beginning of his “deeper awareness” of racial dynamics to medical school. In his first year, he became involved with the U of M’s chapter of the Student National Medical Association, which supports Black, Indigenous, and other under-represented medical students. “We did a lot of work raising understanding of health disparities—but that was still a step away from understanding structural racism,” he says.

And because his parents worked in health care, “There was always this basic trust in medicine and almost lionization of it,” he says. “To me, becoming a doctor was a way to help the community.”

Chomilo helped write a statement earlier this year that the presidents of nine Minnesota physician organizations signed, asserting that systemic racism is a public health emergency in Minnesota. “As medical professionals, we see firsthand the effects of racism that have led to conditions in which people of color do not have the same opportunity as white people in Minnesota to live healthy lives,” the statement reads. “We stand in solidarity with all people protesting racial inequities. In doing so, we acknowledge that the health care system we are part of has been complicit in upholding white supremacy and reproducing oppression.... We must do more.”

And in June, Chomilo also helped lobby the Hennepin County Board of Commissioners to declare racism a public health crisis in the county. The board’s resolution, which passed 4-3, included 10 directives aimed at reducing disparities in health care, housing, education, employment, and incarceration.

Medical school awakening

Chomilo believes the conditions in which people are born, live, work, and play affect their health outcomes. These social determinants of health (or as Chomilo prefers, social drivers of health) are different for Black, Indigenous and other historically under-resourced communities than they are for white communities, he says.

As an adjunct professor of medicine at the U of M, in guest lectures and in other medical education settings Chomilo often speaks with students and faculty about the history of racism in medicine and how it permeates many aspects of health care to this day.

Chomilo points to a 2016 Association of American Medical Colleges article showing the persistence of “race-based medicine,” which treats race as a biological concept and frames health disparities as inherent. In fact, Chomilo points out, this framing is without scientific merit; race is a social construct. And it serves to reinforce health inequities.

A 2016 research article in the Proceedings of the National Academy of Sciences, titled “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites,” looked at two studies illustrating how and why Black patients are routinely undertreated for pain. “What they found was that not only did 50 percent of medical students and residents endorse at least one biological belief, but that if you endorse any biological belief about the differences between Black and white people, you are likely to rate Black people’s pain as less severe, and you are less likely to give adequate treatment,” Chomilo says. “There’s still a lot of work to do.”

To that end, Chomilo helped write and introduce a resolution to the American Academy of Pediatrics calling for a ban on race-based medicine, which results in worse patient care. “[S]haring a racial category [does] not equate to shared genetic ancestry; rather race is a marker for social risk and system oppression, and there is value in understanding how racism results in racial health disparities,” the resolution reads. At press time, the resolution was still under consideration.

In clinic, the bow-tie-clad Chomilo talks openly about race with his young patients and their caregivers. Many of the families he sees are Black, mixed-race, Hispanic, white, and Asian and African immigrants. He encourages parents “not to be afraid to engage in conversations about race, not to ‘shush’ it. That sends the message that it’s a taboo thing—we can’t be afraid to explore it.”

Susan Maas is a freelance writer in Minneapolis and the copyeditor for Minnesota Alumni.

U of M Alumna Studies Race and Health

There’s a statistic that U of M reproductive and maternal health researcher Rachel Hardeman (M.P.H. ’11, Ph.D. ’14) often cites for people:

“As a [Black] professional with the highest degree I could achieve, I am at greater risk of having an adverse birth outcome—or of experiencing maternal mortality or morbidity—than a white woman who hasn’t graduated from high school,” Hardeman says. “One of the things white people sometimes use to explain away health disparities is, ‘it’s poverty,’” she notes. But in the reproductive health equity field—in which Hardeman is a leading light— the effects of structural racism often transcend socioeconomic status.

In July, Hardeman was awarded an endowed professorship, funded by the Blue Cross Foundation, in the U of M’s School of Public Health Health Policy and Management Division to expand her research exploring how racism affects health outcomes.

“My work is pushing folks to make the connection between structural racism and the social determinants of health,” she says. “The reason your ZIP code matters for your health? [It’s] a legacy of norms and ideologies and policies that has dictated your ability to purchase a home in a certain community.”

Statistics propel Hardeman’s work, including this national one: “Black and American Indian babies are twice as likely to die in the first year of life as white babies,” she says. “Black mothers are three to four times more likely to die during or in the year following childbirth.”

While Hardeman’s expertise has been nationally respected for years, the crises of George Floyd’s murder and COVID-19—where Black and Latinx people are three times more likely to be infected, and twice as likely to die—have elevated her profile. In June, she coauthored an essay in the New England Journal of Medicine, “Stolen Breaths,” that hauntingly juxtaposes two public health disasters, the coronavirus and police violence against Black people. “Please—I can’t breathe,” the piece repeats, quoting George Floyd. The commentary concludes with several policy suggestions, including moving to universal single-payer health care, desegregating the health care workforce, and mandating and measuring equitable outcomes.

And Hardeman’s recently been quoted in the New York Times about a Philadelphia study showing “Black and Hispanic pregnant people are five times more likely to be exposed to COVID, because of their occupation and other social determinants,” she says. “We know that because of chronic and toxic stress due to racism across the lifespan, Black women are going to be more vulnerable to poor outcomes during pregnancy. Now we’re dealing with COVID on top of that.”

Hardeman recently finished a four-year project in North Minneapolis looking at police violence, stress, and reproductive health. She examined the impact of police violence on reproductive health, including preterm birth and low birth weight, and was anticipating new NIH funding for the effort as this issue of Minnesota Alumni went to press. Public health efforts continue to evolve. “So much of what I was taught as a student of public health was around behavior and lifestyle choices—‘if we could just educate these people to change’—without considering the impact of structural racism that dictates an individual’s ability to choose,” she says.