By Hillel Aron
By Joseph Tsidulko
By Patrick Range McDonald
By David Futch
By Hillel Aron
By Dennis Romero
By Jill Stewart
By Dennis Romero
|Photo by Slobodan Dimitrov|
Dr. William Cunningham is revolutionizing medicine, and overseeing perhaps the most important medical-research program in Los Angeles. But first he has to get to his car — no small task, considering a rapist described only as an "African-American male" has been prowling the campus. After working late into the night at his UCLA office, Cunningham finds himself scaring every woman he passes. To solve the problem, he puts on his lab coat, and wears it until he gets to his car.
Billy Cunningham is a man who solves many social problems by donning a lab coat.
A medical professor whose specialty is health-services research for people of color, Cunningham is one of only a handful of researchers in the United States who systematically collect data with the goal of eradicating race-based disparities in medical treatment and results. His research, which is renowned among colleagues for being prolific and meticulous, has altered the U.S. government's approach to health care for minorities; he is a grass-roots revolutionary in an establishment lab coat forcing changes on a stagnant system in which inequalities in medical care have become part of the country's institutional fabric.
Policymakers used to believe that if people of color had more money, they would get better medical treatment. But thanks to researchers like Cunningham, we know that's only a small piece of the puzzle. It is not merely poverty or the inability to pay for medical care that results in the inequality. In some studies, upper-middle-class people of color in the United States have been shown to be 37 percent more likely to have poor health than upper-middle-class whites. Vietnamese women of all social strata are five times more likely to die from cervical cancer than white women. The death rate for African-American babies has been double that of white babies for hundreds of years, and the gap is currently increasing. And as new medical issues arise, they fall quickly into old patterns: People of color die much more often than whites from cardiovascular stress, obesity and HIV.
With the largest population of people of color in the United States, Los Angeles is at the center of this country's health-care crisis. One-third of adults in Los Angeles are uninsured — the worst record of any major city in the industrialized world.
In 1999, David Satcher, U.S. surgeon general under President Clinton, announced that the government would no longer accept the widening chasm in medical care between whites and minorities. It was the first time government officially acknowledged that minority health care is a problem. That same year, then-President Bill Clinton funded the 2010 REACH program to systematically collect data from populations of people of color in order to determine root causes of disparity. President Bush, however, promptly killed the funding for REACH once he took office.
At Cunningham's Santa Monica house, I sit in the living room with his Israeli wife, Sharon Vidal, his dog, Riley, and his papers. Everywhere. In piles on the floor, on the sofa, on the countertops, and if I peek around the corner, I see they have, in fact, taken over a whole room. "That was Sharon's idea," Cunningham says. He spent weeks moving his papers into the one room before Vidal moved in. Then, as Vidal tells the story, new papers just started showing up in the living room, kitchen and dining room. Vidal moves some papers from the cushion next to Cunningham and scoots over to him. She says, "Billy works harder and more passionately than anyone I know."
As with most people Cunningham meets, my first reaction to his specialty was, "Why can't we just give people of color more money?"
He says, "A layperson would say that, but that's not the whole story."
I ask for an example.
He says, "You should take my class. Health Services 100."
I imagine showing up in his class. And failing.
"Could you explain it to me now?" I ask.
"I just know," he says. "You have to approach a problem scientifically. There's a ton of data out there, and it points to disparities greater than income."
Cunningham himself has a back problem. While we talk, he stands up and sits down. Shifts. Stands. Sits. Cunningham is a man who cannot stay still.
He continues: "The scientific process makes for slow, steady progress, and eventually the weight of the evidence shines through. Remember the trouble Galileo had when he said the Earth was round?"
Cunningham is part researcher, part heretic. His work is hard to articulate. Because he and his researchers work by isolating and analyzing a single group and one disease at a time (African-Americans with sickle cell anemia; Latinos with heart disease), his work is painstakingly slow and methodical. But the process is essential to achieving parity in medical outcomes.
In his study of Latinos who are hospitalized for HIV, for example, Cunningham "controlled" for socioeconomic factors — that is, he compared Latinos to whites whose lives were similar socially and economically. And still he found that Latinos were twice as likely as whites to die of AIDS after hospitalization. Studies of cardiovascular disease find that the disease affects African-Americans more frequently than whites, even controlling for socioeconomic factors. (Cunningham himself swims regularly to counteract the statistical likelihood that he will have heart trouble.)
No one knows exactly why there exist such differences between whites and other races in medical care, only that throwing money at the problem doesn't work. Medicaid has become yet another program that has institutionalized discrepancies in health-care treatment. Blacks with the same levels of benefits as whites still experience significantly more health problems — problems that frequently go untreated.
When I ask Cunningham what he's done to help shape public policy on the matter of minority health care, he wonders whether I've read about how he helped get funding for the new National Center for Minority Health and Health Disparities — it's the fifth project on the sixth page of his rÃ©sumÃ©, he reminds me. I say no without apology: His rÃ©sumÃ© is 20 pages long. He also explains to me about the Ryan White Act, which he refers to as the "Ryan White Comprehensive AIDS Resources Emergency Act." The act provides funding to organizations that directly assist people with HIV and AIDS. Cunningham says, "My research supported the Ryan White Act in an effort to provide case management for non-medical care. This act provides money to case managers to assess problems with HIV necessary for social services."
"Okay," I say. "Thank you. I got it."
"Okay," he says. "All of that was a preamble. I haven't answered the question yet." He takes a deep breath. Then he tells me about the process of re-funding the act for another year. It was his research that helped show people that case managers needed to be employed to figure out where the problems were, and therefore funded as part of the act.
He talks more, and then he says, "Affecting policy takes time. Each individual publication contributes a little knowledge. And then there is controversy. And then similar studies come along with different conclusions. And then there is controversy about differences. It took 200 years from the time Newton discovered gravity to the time we could beat gravity by flying."
I say, "Okay, that's good for today. Thanks."
He says, "I feel like I didn't finish a thought."
Cunningham's mind for infinite detail is trapped in a world that is accustomed to boiling a health crisis down to one full-color photo spread in National Geographic.
Beginning in the 1930s, 399 African-American males signed up with the United States Public Health Service (USPHS) to receive free medical care. The service was studying the effects of syphilis on the human body, but the men were never told they had syphilis. Instead, the USPHS told the men they were being treated for "bad blood," and then the physicians in charge of the study ensured that these men went untreated so that they could study the effects of the disease. In 1947, penicillin was discovered to be a cure for syphilis, but none of the Tuskegee men received treatment. In 1972, when the study was exposed, 128 men had died of syphilis or related complications, 40 of their wives had been infected, and 19 children had contracted the disease at birth.
In the 30 years since its details were first revealed, the study has become a powerful symbol of racism in medicine. In fact, not until 1997 did the U.S. government formally apologize for the study — in a speech by President Clinton. Today, the legacy of Tuskegee is the African-American community's profound distrust of the medical establishment. In a 1997 survey, more than 20 percent of African-Americans in the Birmingham, Alabama, area said they would be unlikely to participate in any medical study.
Tuskegee is just one example of a slew of health-care injustices; after centuries of subpar medical treatment for people of color, the problem has become entrenched. Cunningham's job is not just to secure funding for studies, but to figure out how the medical establishment can once more earn the trust of people of color.
In recognition of research like Cunningham's, UCLA just received government funding for the Robert Wood Johnson Clinical Scholars program: $10 million. The crux of this program is to train physicians who research minority communities to understand why the medical system fails them. UCLA received the grant, in part, because it is in the forefront of minority health-care research, with its 12-person minority-research faculty the largest in the nation.
According to David Carlisle, California's director of statewide health planning and development, "UCLA has launched an institutional commitment to ending disparities in health care, and Dr. Cunningham is spearheading these efforts. He is plowing a new field."
The Robert Wood Johnson program will give minority medicine in Los Angeles the feel of a grass-roots political movement without losing the aura of the academy that so effectively sways politicians. Kenneth Wells, professor of psychiatry at UCLA and co-director of the scholars program, explains, "Minority communities require solutions that cannot be explored in academia. To ensure that research is relevant, we must engage with the community."
The express purpose of the grant is to "improve medical outcomes for people of color." Essentially, this is medical-speak for creating separate but equal medical treatment that specifically addresses the needs of minorities. Cunningham's research team has determined that to level out statistics like infant mortality among races, doctors must target different groups with different types of medical programs.
For example, in interviews, African-American and Latino women said they wanted "spiritually relevant" information to prevent breast cancer, which occurs twice as often in African-American women as in white women. So researchers are testing the effectiveness of distributing breast-cancer information in churches. Researchers found that in order to counter the high rates of cardiovascular disease in minorities, messages about decreasing stress must be culturally appropriate and rooted in community values.
Cunningham trains physicians who will be research leaders attached to individual communities, such as South-Central, Carson-Wilmington and the San Fernando Valley. Wells explains, "These researchers will go beyond finding the problems within communities — they will also focus on getting public policy to support this change." The program focuses on empowering community members to transform their neighborhoods into places that encourage people to adopt and sustain healthy behaviors and to avoid risky behaviors.
Once you get past the idea that passing out money on street corners solves medical problems, you have to look at the minutiae of the patient-care process to find the failures. This is what Cunningham does best.
"I did a study that showed when people are in need of food and clothing, it interferes with their ability to get medical care."
I tell him that seems obvious.
He says, "If it's so obvious, then why don't we deliver medical care at the same place we deliver food and clothes?"
I imagine the Salvation Army passing out vaccines with food baskets.
"The way we divide up these human services for bureaucracy is artificial. We treat health care and education as separate funding entities, and then we have to decide if we want to fund one or the other. Or if poor people have to get in separate lines for food and medical assistance, they have to decide, which do I need today? One way to improve the system would be just to establish a way of qualifying them once for all programs instead of checking them in for each one separately.
"My picture is that there is a system organized by need; no system where people who already have difficult lives don't have to go to 10 places to fill their needs. People shouldn't have to make a choice between starving or bleeding to death. If our government attacked this problem as thoroughly as it is attacking Iraq, we'd be much better off."
Cunningham proposes many surprising solutions to the problems he unearths in his research. He investigated how African-Americans get information about AIDS. It turns out that for this demographic, pastors and church groups are the most trusted source for medical information. "We should pass out condoms in church," says Cunningham. "Or at least pamphlets." Who else is getting dollars from the Bush administration to do research that suggests distributing condoms in church?
Back at home, Sharon Vidal describes Cunningham's family as "the black gentry." She admits that she was intimidated around them at first. "When Billy was in grade school and he got sick, his mom said, 'You can figure out which antibiotic to take. You figure it out and get it out of the drawer.'" She explains, "Being a doctor is just part of being in that family."
I ask Cunningham, "Can I talk to your mom?"
I send multiple nagging e-mails and call him twice, and I get the number.
Matilda Cunningham confirms what her daughter-in-law has already told me: The family has been churning out graduates from Howard University since the 1880s. It is probably the only African-American family in this country with four generations of physicians.
In the 1880s, Cunningham's great-grandfather was a pharmacist, but there were no doctors who would treat African-Americans in his area, so he became the de facto doctor for the community. Cunningham's great-grandparents had seven children. All of the children graduated from college — the first African-American family in Virginia that could make such a claim. Cunningham's grandfather graduated from Howard medical school in 1920. Both Cunningham's mother and his father graduated in 1951 and had practices throughout his childhood. Today Cunningham's brother is also a doctor; his sister has a Ph.D. in psychology.
I ask Cunningham's mom if it was difficult to be an African-American woman physician.
"No," she says. "It was pleasant. Everyone in our family was expected to grow up and be a physician. It was totally natural to me." She met her husband during late-night study sessions. She says, "We shared a cadaver."
I ask her about her family history before the pharmacist in 1880.
"I don't know."
I wonder out loud whether they were slaves.
"I suppose," says Matilda Cunningham. "No one ever talked about it to me. We only talked about education. Education, education, education. That was all that mattered."
Billy Cunningham did go to medical school, but he took an educational path that would not have been open to the generations before him. Cunningham knew from an early age that he wanted to be part of a group of professionals addressing the problems of racial disparities in health care. He is among the first generation to be born into a world where there are enough physicians providing basic care to the large community of African-Americans.
I ask Cunningham, "Are you an activist?"
"No," he says, "I'm a scholar. In scholarly circles we use the term 'activist' to demean someone." Then he says, "I'm an activist with evidence." But he adds, "When you try to publish a paper in The New England Journal of Medicine, you won't get published if you come off looking like you have an activist agenda. To publish in the medical community, you have to look like you don't care about the outcome."
"For Billy, it's not just about feeling bad for poor people," says Kevin Heslin, Cunningham's former student, now a researcher at Drew University. "Billy keeps an eye on the bottom line, which in the business of medical research is publishing." (To get tenure, Cunningham published 10 papers in two years — a level of productivity most academics could only dream of.) David Carlisle puts it this way: "For the first time in history, African-Americans in Billy's generation have had access to mainstream research capabilities." Cunningham is using this opportunity to show us that we need to understand minority communities to understand minority medical problems. And in fact, this approach is much more difficult than just saying minorities' problems stem from poverty.
In the medical academy, African-American professors are rare. African-American professors who are published as widely as Cunningham are even more rare. He has pushed physicians to a new level of care. He has pushed policymakers to fund minority research in ways that were unthinkable before he started writing proposals. But he still has a long way to go. He is a new kind of physician in a new field, breaking ground in places most people never walk.
"This group at UCLA is revolutionary," Cunningham tells me at the end of one of our conversations. "We are activists investigating who we are."