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Unspoken: One Academic Pediatric Association President's Journey

Published:December 16, 2021DOI:https://doi.org/10.1016/j.acap.2021.12.010

      Becoming President of the Academic Pediatric Association

      I remember the exact moment I got the call. It came from a friendly voice—the chair of the nominating committee, a past president of the Academic Pediatric Association (APA). I held my breath and then she said it, I had won the election for President of the APA. It had been an arduous process since in the past I had not invested time into what positions I had gotten. They had come and I had enjoyed them. The election year had been difficult. The feeling of being judged and one's merit questioned and analyzed and the undertones of who indeed was worthy were not absent from the process. But the outcome was a joyous one for me especially since it marked the year that we would celebrate the 50th anniversary of this organization. The roots and history of the organization had been shared often among its members for years: a small gathering of progressive intellectuals (yes all white and at first predominantly male) but who nonetheless championed ideas of civil liberties, children's rights and the progressive idea of paying attention to the components of “ambulatory” pediatrics, thus giving emphasis to the continuity, family-centered, and comprehensive nature of rendering child health care especially in the outpatient setting. I was the first and still am the only African American woman to have been elected president and this fact had been ever present leading up to the election.
      The year of my presidency was full of planning. I had established myself as a leader in community pediatrics—having spent 14 years at Harlem Hospital in Central Harlem and was now at Mount Sinai School of Medicine in East (Spanish) Harlem—a full Professor with multiple external grants, actively involved in patient care especially of children with complex medical-social problems and had managed to publish sufficiently to be promoted with tenure. I had received a named, endowed chair and felt supported by the Chair of the department.
      The crushing poverty, onslaught of health crises (gun violence, Human Immunodeficiency Virus/Acquired immunodeficiency syndrome, the crack/cocaine epidemic, lack of access to care) had kept me busy and squarely focused on making a difference for the Black and Brown communities that I served. So, during the year of my presidency I added to this focus organizing the annual meeting. I called on Carol Berkowitz and then a full planning committee and immersed myself in choosing the peer-reviewed talks that I would feature during the meeting, writing my speech over and over, and committing to having this 50th year of the APA celebrated with rigor in the research presented, melded with artistry. My son and the daughter of Clay Dungy (the first and to date the only African American President male of the APA) would read their poems at this meeting and we would dance. The content of my presidential speech
      • Laraque D.
      Global Child Health: reaching the tipping point for all children.
      was punctuated by the devastating earthquake in Haiti (my country of birth) 3 months prior to the meeting. This disaster killed about 250,000 people in a blink of an eye. I had gone to Haiti to be part of the recovery and my emotions were raw and underscored my presidential discourse on poverty and equity. The mood of this 50th anniversary conference was glorious, delivered to a large crowd in Vancouver, following which time the louvered doors opened to the spectacular view of the Vancouver waters.

      Things Unspoken

      It is appropriate to roll back the clock from the year 2009 to 2010 when I served as president to the beginning of my involvement in the APA. I was introduced to the APA (then the Ambulatory Pediatric Association) by Marie McCormick, my mentor when I was a Robert Wood Johnson (RWJ) Fellow in General Academic Pediatrics at the Children's Hospital of Philadelphia, University of Pennsylvania (1984–1986). As an undergraduate my major had been chemistry and as a fellow I sought to combine this knowledge base with a key question of relevance to child health. Philadelphia was known at the time, unfortunately, for high rates of lead poisoning in children, especially Black children. Our hospital along with St. Christopher's Hospital were the 2 that were most expert at the care of children with complex medical and medical-social problems necessitating advanced treatment, follow-up and prevention. My chosen research was the study of the impact of calcium status on lead poisoning. Marie was my mentor in developing a feasible and sound project, and David Cornfeld (the RWJ Fellowship Director) helped me secure intramural funding with a Medical Associates Research & Education Foundation Award and a Clinical Research Center Award.
      At that time, Marie required that all the RWJ fellows (at the time Karen Kaplan, Carol Carraccio, Irene Landaw, and I), attend meetings and eventually become members of the APA. As a junior faculty member at Columbia University based at Harlem Hospital, my academic aspirations had not abated, and I asked to be on the tenure track at Harlem Hospital whose affiliation at the time was very strong with the university. Continuing my active involvement with the APA was essential to how I viewed my academic path. At one of the early APA annual meetings, seated behind me, was an early career African American female colleague. She tapped me on the shoulder and shared with me how she was intimidated by this meeting and did not know the avenue to become a member. I said to her—well, you need 2 letters of recommendation—you now have mine and we will figure out the rest—which we did.
      I can recount countless situations where the undertones of racism and exclusion were present but remained unspoken. At the annual meeting those of us, “underrepresented minorities,” would immediately acknowledge each other's presence with a look and smile of camaraderie when passing each other in the hallways of the conference building. We did not have the language then of the terms, implicit bias/unconscious bias and microaggressions—the countless encounters that reinforced the feeling that we were not fully accepted.
      • Levy S.R.
      • Stroessner S.J.
      • Dweck C.S.
      Stereotype formation and endorsement: the role of implicit theories.
      By nature, I enjoy collaboration, I assume the best of people and am an optimist—I am at times called naive. That naivete had been protective for me since I never internalized the feelings of not being on par with others and rejected the whole concept of the glass ceiling. This stance while protective also made me vulnerable. I did not develop the image of the “angry Black woman” until later immersed in academia and experiencing the palpable feelings of “exclusion.” My approach had been to work harder. I had excelled throughout my K-12 years, never paid attention to rankings but enjoyed purely the academic pursuits. I loved chemistry and then medicine. My experience at University of California at Los Angeles and as president of the Student National Medical Association—where I first encountered a large group of Black students who excelled (in the past I had been often the only in honors classes), was exhilarating and has never left me. I had found a place of comfort. My Black peers at University of California at Los Angeles School of Medicine matched my fervor and love of medicine and we threw ourselves fully into the experience—a story for another commentary—but I share this to explain why the experience in the APA and other academic organizations was so jarring. It had not been in my frame of mind—this ever-subtle form of discrimination. This experience would later be labelled the minority tax.
      • Rodríguez J.E.
      • Campbell K.M.
      • Pololi L.H.
      Addressing disparities in academic medicine: what of the minority tax?.
      It permeated the academic spheres. My reaction was, I must admit—in part—anger—justifiable in my view, but regrettable since it was borne out of necessity and not out of hope.
      We now have analyses codified in the Critical Race Theory being hotly debated today.

      Stefancic J, Delgado R. Critical race theory: an introduction. Alabama Law Scholarly Commons. Available at: https://scholarship.law.ua.edu/fac_working_papers/47. Accessed November 30, 2021.

      Critical Race Theory details the stated hierarchy of merit and value. While I termed this experience academic racism it had remained mainly unspoken. Vivid in my mind was the clear and present danger of the color line—emphasized by my Haitian heritage and the status of “immigrant,” well aware of the history of the United States. But in one of my travels for an APA meeting, a colleague detailed to me the hierarchy of how we are viewed—stratified nicely by gender and race. I have never repeated what he said—because I rejected the notion of giving credence to that thought—just as I had rejected the idea (in my teenage years) of quickly identifying who was Irish, Jewish, Italian etc. by their name—and attaching the stereotypes of qualities based on these identities. Hearing my colleague's explanation of hierarchy out loud was jarring. And yet, I had been living it prior to and throughout my year as president of an organization that I truly loved. That hierarchy was even more complicated and nuanced by subgroup categorizations of the deserving within the broad binary analysis of the United States of White versus Black.
      The unspoken hierarchy of intellectual prowess was another nuance—the assumption of academic, white superiority, and dominance permeated every conversation. It was palpable when you participated in many meetings and even at the meetings of the Board of Directors. The APA distinguished itself from other organizations by claiming its superiority in academic rigor. The lived experience—that phenomenological construct—while increasingly acknowledged as a valid expression of the evidence of the implicit bias that permeated, I believe, was relegated to being “not evidence-based”—needing other data to valid it.
      This subtle experience of exclusion was further reflected in the scientific sessions when—despite the investigator's enthusiasm involving the science and the research question—there was the fear that you would be asked a question—the answer to which you did not know—would then be humiliated—and it did not escape your thinking that this failure on your part would be attributed to your entire cohort of Black colleagues. Contrast this to what academia should be. A free exchange of ideas and the necessity to acknowledge knowledge gaps and to actively welcome discourse to reveal what is known or not known—and how to pursue in the best scientific manner testing of the hypothesis. We all did later practice saying something along the lines of—“thank you for raising that question -and while I do not know the exact answer to your query—it does require careful review and I will endeavor to do so.” Acquiring the skill and composure to respond calmly in a public setting attended by the leading experts of many fields was indeed a challenge.
      Along the way, I engaged in many efforts in support of minority researchers in collaboration with colleagues of the Society for Pediatric Research, the American Academy of Pediatrics, and American Pediatric Society colleagues, namely, Phyllis Dennery, Fernando Mendoza and Joseph Wright. For 5 years, we led workshops on faculty development of minority researchers. Lee Pachter and Cheryl Kodjo began the New Century Scholars Program gaining support for the importance of active mentorship and sponsorship of minority researchers by both junior and senior mentors. This endeavor has continued and is now strongly supported by the American Board of Pediatrics—that support from the American Board of Pediatrics having begun under the able leadership of its past president, David Nichols. And I would be remiss in not mentioning the critical role of special interest groups in engaging in the debates regarding race. Two such Special Interest Groups (SIGs) were notable in the early days—the Race in Medicine and the Culture, Ethnicity & Healthcare SIGs which began the discussions regarding race as a social construct.
      What was missing, however, was the internal analysis by the organization, that it would be necessary to look inward and examine its own structures that perpetuated the unspoken and, reinforced the feeling of discomfort, lack of welcoming for those deemed “not qualified enough.”

      The Path Forward

      So, what is the path forward? I have the following recommendations having experienced both the highs and lows of participation and leadership of an organization that has produced important research to tackle the leading causes of morbidity and mortality for children. This organization, nonetheless, lives within the context of a racialized country with the structural inequities baked in. In my view, the following actions might bring us in greater alignment with our stated views on equity.
      • Re-examine the current Statement of Diversity and Inclusion, shown on the Mission and Vision page of the APA website. It currently reads:The APA supports diversity and inclusion in the broadest sense, including race, ethnicity, religion, socioeconomic status, sexual orientation, gender identity, ability and other characteristics. Because the larger pediatric academic medicine community does not reflect the diversity of US and global pediatric health professionals or the children they serve, the APA recognizes its responsibility to create a diverse community of academic pediatric health professionals. By intentionally integrating diversity and inclusion tenets within its core values, the APA will lead the growth and development of all APA members, including those individuals historically underrepresented in pediatric academic medicine.In that regard, the organization may want to do a 360 evaluation of the perception of its membership on faithfulness to the stated mission or what needs to be changed in the language we use relative to diversity, inclusion, equity and justice.
      • Banish elitism by explicitly stating the educational mission of inclusion of all ways of knowing.

        Beard K, Iruka IU, Laraque Arena D, et al. Dismantling Systemic Racism and Advancing Health Equity throughout Research. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202201a.

      • Continue the active support of the SIGs and creative thought in areas of complex systems such as academic organizations.
      • Continue the active support and promotion of the New Century Scholars program and other mentorship programs such as the APA Research in Academic Pediatrics Initiative on Diversity (RAPID).
      • Elect diverse candidates for the position of president and all leadership positions within the organization. The reality of the first/only is not only a burdensome position—it is exhausting. It is not effective in bringing about real, systemic change and transformation of any organization. Doing so will help shed the traces of racism and build on new visions that are inclusive.
      • Use the stated talents of APA researchers to assess, measure, monitor, and evaluate with raw numbers the success of this organization at true representation and inclusion. The current APA membership process does ask about self-identification and the analysis of the member diversity can be used to demonstrate our progress or lack thereof. This requires first an internal audit of the state of the organization and a publication of that internal review to share with the entire membership.
      • Partner actively with other organizations that have championed and implemented processes of inclusion -such as the National Medical Association. There is much to gain from respectful, bidirectional learnings.
      • Many organizations have apologized for their past history of exclusion. My sense is that the APA has felt itself above this and “not racist” in its approaches. Self-awareness of this organization's qualities and failings is important in gaining the trust of its members. I suggest that an internal review might shed light on what could be an authentic accounting of past behavior.
      • Approach the future with optimism. We have made progress and have an incredible cadre of new and evolving diverse leaders fully committed to improving the health of children, families and communities through the acquisition and use of all ways of knowing.

        Beard K, Iruka IU, Laraque Arena D, et al. Dismantling Systemic Racism and Advancing Health Equity throughout Research. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202201a.

        Our future will be bright, I believe, if we fully embrace and implement strategies that eliminate structural inequities within our own organization.

      References

        • Laraque D.
        Global Child Health: reaching the tipping point for all children.
        Acad Pediatr. 2011; 11: 226-233
        • Levy S.R.
        • Stroessner S.J.
        • Dweck C.S.
        Stereotype formation and endorsement: the role of implicit theories.
        J Pers Soc Psychol. 1998; 74: 1421-1436https://doi.org/10.1037/0022-3514.74.6.1421
        • Rodríguez J.E.
        • Campbell K.M.
        • Pololi L.H.
        Addressing disparities in academic medicine: what of the minority tax?.
        BMC Med Educ. 2015; 15: 6https://doi.org/10.1186/s12909-015-0290-9
      1. Stefancic J, Delgado R. Critical race theory: an introduction. Alabama Law Scholarly Commons. Available at: https://scholarship.law.ua.edu/fac_working_papers/47. Accessed November 30, 2021.

      2. Beard K, Iruka IU, Laraque Arena D, et al. Dismantling Systemic Racism and Advancing Health Equity throughout Research. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202201a.