What “Correcting” for Race in Medicine Gets Wrong

medicine

The best comedians can help us understand complicated social issues. In 2014 Amber Ruffin made history as the first Black woman to join the writer’s room of a major late-night TV show when she began working on Late Night with Seth Meyers. Today, she hosts The Amber Ruffin Show on NBC, where her regular “How Did We Get Here” segments have analyzed complex, historically rooted topics digestible for a popular audience—with the added benefit of Ruffin’s whimsical and pointed wit.  

On March 18, 2022, Ruffin’s topic was medical racism. Specifically, what medicine and medical research call “race correction.” Most Americans haven’t heard of this common practice, but it has affected the quality of the health care provided to many millions of us for generations.  

As Ruffin correctly summarized it, “race correction” involves the adjustment of medical calculations based on the race of the patient. This might sound innocuous, but for Black Americans, it can be disastrous. 

Errors built on racism 

While professionals use race correction in calculations involving many parts of the body, Ruffin used our pandemic-fueled familiarity with respiratory conditions to explain. She and her writers did a lot of research, uncovering how, for generations, doctors have assumed that Black patients have a smaller lung capacity than white patients.  

Enter Dr. Samuel Cartwright, who in the mid-19th century dedicated himself to investigating the “diseases and peculiarities” of Black people. It was Cartwright who invented and popularized insulting and ridiculous medical conditions such as drapetomania, the “mental illness” that caused enslaved people to try to escape from servitude. This disease, wrote Cartwright in 1851, was unknown to physicians but well within the knowledge of “our planters and overseers.”  

Another “disease” conjured up by Cartwright explained the “laziness” of enslaved people. The major symptom of this condition was lesions on the back. As Ruffin told her audience through gritted teeth, “I wonder how they got there.” 

Cartwright also set out to measure the difference in lung capacity between Black and white individuals. He used the spirometer, a breathing measurement device invented in the 1840s by British surgeon John Hutchinson. Today’s spirometer is a relatively simple device: a patient breathes into a tube, and the air pressure lifts a ball up into the tube’s chamber. This device can also be used by patients recovering from conditions such as pneumonia to keep their lungs healthy.  

Cartwright decided that people of color had a lower lung capacity than white people. This incorrect idea persists to this day, causing numerous physicians to make a “race correction” in their use of the spirometer, due to the allegedly 10 percent to 15 percent less effective lung power of Black patients.  

The real causes 

Hard data to back up the assumption that race influences lung capacity is scanty. What we can be sure of is that structural racism influences where a person lives and the quality of health care they have access to, with Black Americans often living in more highly polluted and less well-resourced areas.  

Medical journal The Lancet published an entire article on this topic, asking whether “race-adjustment” of spirometer readings only serves to increase racial disparities in COVID recovery rates.  

Most likely, the article said, the fact that people of color suffer COVID infection rates at three times those of whites and a death rate as much as twice as high is due to structural inequalities. The authors predicted that long-term tests of post-COVID lung function will reveal similar disparities. Used extensively to measure lung function during COVID recovery, spirometer reading outputs come with automatic “race corrections” that often go unnoticed by the physicians using them.  

As Ruffin summed it up, there’s little evidence showing that race affects lung health but abundant data showing that “racism could.” If a doctor believes a lower-than-normal lung capacity in a Black patient doesn’t signal a problem, that doctor may not order potentially life-saving diagnostics and treatment for severe respiratory illnesses. As Ruffin put it, “all those small decisions add up.”  

Short-changing women of color 

The comedian-educator also called attention to the fact that the use of the VBAC score, which attempts to help doctors determine a woman’s chances of successful vaginal birth after a previous cesarian section, has led to unnecessary C-sections for numerous Black and Latina women.  

Until new research in 2021 prompted doctors to drop race as a component, protocols automatically had them assign a higher VBAC risk score to Black and Latina women. This often led to the automatic ordering of C-sections for these women, even though C-section births substantially increase the risk of maternal health complications and death.  

The research that brought about the change found that the higher risk scores for women of color had originally been based not on race or genetics, but on findings that single parenthood and lack of insurance were additional risk factors contraindicating vaginal birth. Somehow, “uninsured single mother” was fed into the algorithm, and the interpretation was “Black or Latina.”  

Correcting heartless calculations 

Heart failure risk score is another in this long list of “race corrections.” Physicians use this calculation to determine the level of risk of death in patients prior to hospital admission, with higher scores indicating greater risk. This protocol gives white patients what amounts to a “golden ticket” into the hospital. Being “non-black” automatically confers an additional three points. Black and Latino patients, regardless of other health concerns, frequently receive lower scores and are thus less likely to obtain needed hospital care.  

When a popular comedian can educate the public about an issue like medical racism, it’s all for the good. It’s now up to us to make some changes. 

Vulnerability and Where to Find It: A Doctor’s Tale

Medicine

Some patients we never forget.

She was a middle-aged white woman with brown hair and arms only a frequent gym-goer could possess. She walked through the clinic doors accompanied by her newfound love—newlyweds. My attending physician introduced himself and then it was my turn as the third-year medical student on the rotation.

She smiled in response, followed by a courteous, “Nice to meet you.” 

I had perched myself at the corner of the room against the sink at the base of what appeared to be an isosceles triangle. I was one of the bases, the neurology attending the other, and the patient and her husband represented the tip.

Here, I observed from my perch.

In her next few sentences she described how one morning, upon awakening, she noticed she was slurring her words of which she attributed to the notion of having suffered a mild stroke. In her mind, how could it be anything else? She was in her early 50s and unlike many of her friends she maintained a strict diet, a daily gym routine and a mentality to match. 

After multiple questions, some mild laughing with intermittent smiling even, the neurologist paused. He clasped his hands together as he let out a slow breath of air. 

“I firmly believe you have Amyotrophic Lateral Sclerosis (ALS), and the slurred speech is the beginning of this process. This is not a stroke, I’m sorry.” 

I do not know which came first—the hopeless shriek or the cascade of tears. She knew she had just been given a death sentence and despite her husband’s best efforts there was no consoling her. A tear fell from my left eye as I quickly tilted my head back looking up towards the ceiling hoping gravity would play an effect and somehow the tears would roll back into my head rather than onto my white coat. From the actions and demeanor of my attending physician it was evident he had given this news before—one too many times. Two thoughts filled my mind as sadness filled the room. 

First, I thought about the disease process itself, which I had read about the night prior characterized by “a progressive loss of motor neurons in the brain and spinal cord.” ALS is a progressive, disabling, and ultimately fatal disease of unknown cause starting with a gradual muscle weakness and wasting in the upper and lower extremities, muscle fasciculations and inevitably difficulty swallowing, phonating and breathing.1 This degenerative process continues until respiratory failure will most likely claim her life as it has so many before her.1

As my attending and I stood there watching her cry, the clock stood still. 

Why her? As time stood still, I kept asking myself. Why not her husband? Why not my attending? How would she spend her remaining months before the disease would cripple her into a wheelchair and the permanent requirement of mechanical ventilation would ensue? 

As physicians, too often, we are sculpted to believe we are invincible. We care for others at their most vulnerable time and it is always them—that is the vernacular. The patient’s tears made it clear she was not ready for such a diagnosis; she was not ready to die. I do not know if in the moment she was frightened by the certainty of death or death was far superior to the alternative life that awaited her. 

I, too, am scared of death. I am scared of being forgotten. After an obituary in a newspaper, a funeral, stories shared, beautiful words produced and dark clothing worn with covered eyes, life continues for everyone except the deceased. I wonder if any of these thoughts coursed through her mind at a rate similar to her tears.

Once her tear ducts seemingly dried up, she asked how she could obtain a second opinion. The attending told her he recommended she go to the Cleveland Clinic if she desired. She gathered her things with one tissue in hand and bloodshot eyes. As she stood up, my attending, gave her a hug she most deserved. A hug I will never forget. Once we were alone, he asked me if I was ok? “Yes, I’m ok. Thank you for asking,” I promptly replied. I thanked him for allowing me to join him in clinic then quickly left. 

I went to my car and I cried. 

I had lied. 

I was not ok. 

References:

  1. Zeller JL, Lynm C, Glass RM. Amyotrophic Lateral Sclerosis. JAMA. 2007;298(2):248. doi:10.1001/jama.298.2.248

Is the Road to Becoming A Physician Still Worth It?

adversity, medicine, Mentorship

In a simplistic answer, “Yes, it is. But it won’t be easy.” As my former track and field coach would tell me before an arduous workout, “If it were easy, everyone would do it.” Many are drawn to medicine with an affable desire to help others, but this task has a significant weight associated with it. Sadly, the mental anguish may lead some physicians to tell hopeful doctors that they should turn away and pursue a different occupation forgetting the excitement and enthusiasm they once felt. 

Naturally, over the course of a time period there are certain parts of our lives that change. One day you fall asleep at 20 years old, and the next day you wake up 21, now considered legally responsible enough to drink, gamble or even adopt a child. In contrast, the road to becoming a doctor is a long series of intentional and mindful decisions. Few of these decisions are big, some are medium and unlike the television shows most are small and boring. If you’re reading this you may wish, as I think I did at times, that we could instantaneously wake up a physician. But, the beauty in becoming a physician is in transforming into the version of yourself that will best fulfill this life of service. This becoming requires sacrifices in the form of no; no to certain parties, trips, weddings, and relationships. Instead, one will say yes to long, unappreciated and unapologetic hours with concomitant late nights in windowless rooms surrounded by books instead of people and silence instead of noise. Sometimes, I said yes to the no decisions and years later had to work much harder to make up for those responses. Furthermore, there are also decisions one will need to make during moments where we are no longer in control. 

Writer Anne Lamott, once penned, “When God is going to do something wonderful, he always starts with a hardship; when God is going to do something amazing, he starts with an impossibility.”

From a post-baccalaureate, non-traditional, student studying in a Starbucks coffee shop in Manassas, Virginia to addressing the audience as student body president at the Ohio State University College of Medicine graduation I had to navigate my failures to arrive at my successes. However, each piece of adversity I faced sculpted me into a more compassionate and understanding person and ultimately a better physician.

The first African American patient I treated, sixty-years in age, told me he had never seen a physician who looked like me—like us he meant.

If this dream will make you happy and give you the life you desire, then this field is for you. No one can answer this question for you, and no one should. The time will go by regardless. One day I walked into the auditorium for my first medical school course. The next, I was performing a nasal intubation in a patient with severe Down’s Syndrome readying the patient for the dentistry team to extract his diseased teeth. There is nothing like what I see or do on a daily basis. It is simply amazing, frightful, enlightening and humbling all in the same breath. As I said before, “Yes, it is worth it.” But, it’s up to you to decide that for yourself.

Commentary: Father’s Day and the moments stolen from too many black families

Fatherhood, medicine, Mentorship, Race

Originally published in Chicago Tribune, June 18th (online) & June 19th (in print), 2020

I once attended a funeral where the pastor asked the audience, “How do you continue to believe in God when your father has been taken from you?” I did not have an answer as I tried to pat my eyes dry with the few crumpled tissues I had.

For me, this Father’s Day will be another annual occasion where I will pick up the phone and on the other end will be the voice of a kindhearted, compassionate and articulate man. I will wish him a happy Father’s Day, and when I ask him for details of his plans for the day he will note that a day of relaxation awaits him. Next, he will inquire how things are for me with an unparalleled yearning, and once he has been informed of any new happenings an exchange of “I love you” and “See you soon” will conclude our conversation.

Yet for some, Father’s Day has become unrecognizable from the celebratory day it once was.

Ask Michael Brown’s father, Mike Brown Sr.

In America, black men are rarely seen as innocent and are sometimes even invisible.

Wearing my cloak of visibility — a doctor’s white coat — I kneeled on the ground recently with my head bent over in prayer and protest for 8 minutes and 46 seconds. The hardened and unforgiving cement left me wanting to change the position of my knee to lessen the discomfort, but I refused. Out of my periphery I saw other protesters switch their dependent leg. Some stood up, while some began to kneel on both knees to soften the unilateral pressure on just one.

But some pain cannot be lessened. The image of George Floyd with the knee of another man pressing into his neck — the man’s hands casually in his own pockets as he balanced himself on Floyd’s neck — is one. “Please, I cannot breathe,” he cried out prior to calling for his mother. Floyd’s words reverberate those of another black male, Eric Garner, who in 2014 was killed under police custody while uttering the very same last message. This is another example of a transformed Father’s Day that will never be what it once was.

Ask Ben Garner — Eric’s father.

Growing up, my family went to church almost every Sunday, but especially on Easter, Mother’s Day and Father’s Day. I’d be the last one to get up but after a shower and dressing in my Sunday’s best I would rush into my parents’ room —tie in hand. I would pass the tie to my father, and he’d stand behind me slowly crossing one end over the other. Then he would come around in front of me prior to securing the tie and sending me to admire the wonderful job he had done.

When I played soccer, if I looked to the sidelines there he was sporting his vest and transitional lens eyeglasses — the one where the lens changes to dark when one steps outside into the sun. I am sure those eyeglasses earned him the nickname “Mr. Cool McCool” by my teammates.

And, as I walked across the stage to receive my medical degree, I distinctly remember hearing, “Go Dr. J” coming from his seat. The joy of watching his son become a physician, when his own father could neither read nor write, is a moment I am sure he will never forget.

These are key moments that fill picture books, but for some families, those books will be left empty: Rayshard Brooks will not be there when his daughter scrapes her knee while learning to ride a bike. Ahmaud Arbery’s father will not see his young man become a father himself one day; he will forever be frozen at the age of 25. George Floyd will not be there to screen his daughter’s potential boyfriends as a rite of passage that encompasses being a “girl dad.” Michael Brown — 18 years old — had an entire future lying ahead of him with countless Father’s Days, but his father will only have the memory to replay of that smile that used to walk in the door — Skittles in hand.

We cannot go on like this. It has taken a once-in-a-lifetime mix of events: a pandemic, economic fears, political polarization and an untimely murder to clear the opaque lens through which society views us to see that we are and deserve more. This is the time to see the exhaustion in the hearts of black families who have to watch as another Father’s Day is altered due to racism and police brutality. And, we are tired.

Ask George Floyd’s 6-year-old daughter, Gianna.

Jason L. Campbell, M.D., M.S., recently known as The Tik Tok Doc, is a physician resident in the Department of Anesthesiology at Oregon Health & Science University in Portland, Oregon.

Dear Anxiety: But Still I Stand

medicine

I scurried across the campus to the bricks that housed the Department of Psychiatry. Sneaking in the back door, I hurried to the elevator. Fifth floor, the sign read. Sweat coursed down my back as nerves ran up my spine. A conversation with this doctor was going to determine if I would be allocated an additional four to six weeks to study for my step one board examination. This is the board examination one must pass to transition from a second year to third year medical student and begin clinical rotations in the hospital. That is what they tell you. They do not tell you this is the score that almost entirely dictates what type of physician you can become. A lower score on this exam and Ear, Nose and Throat (ENT), Orthopedic, Cardiothoracic, and Plastic surgery are subspecialties you can surely kiss goodbye because these residency programs will likely never see your application.

In the corner of the waiting room, I hid behind one of the partitions set up to enhance patient confidentiality. The psychiatrist greeted me prior to ushering me into his office. A dimly lit room, a couch and two chairs welcomed me. This felt more like an audition than an appointment. My heart was not beating, it was throbbing.

Globally, approximately 1/3 of medical students are being treated for anxiety or have been diagnosed with anxiety by a clinical practitioner. For me, I had never experienced anything like this before; sleepless nights, a lack of appetite resulting in substantial weight loss, an inability to focus, tears streaming down my cheek for no apparent reason and an unending catastrophic feeling surrounding my studies and upcoming exam. At the time I felt alone. Many years later I have come to know there are many who share this story.

At the conclusion of our visit I thanked him for his time and left down the elevator and out into the cold Midwestern evening. Staring into the distance the Ohio Stadium stood proud, a gladiator’s coliseum, while a shell of myself stood frozen in the night. He would either agree these symptoms were inhibiting my studying or he would not. The fate of my future was in his hands—this man I had only met only 60 minutes prior.

The next morning my cell phone rang.

“…We are granting you four additional weeks for your studies…”

In his report, the psychiatrist had noted the anxiety levels I was experiencing dramatically hampered my ability to adequately study.

A sigh of relief set in.

The throbbing within my chest had now decreased to a dull roar that would allow me to finally sleep for the first time in weeks. I made my way to the couch and as I began falling asleep, my mind started retracing my steps to medical school.

Abruptly, I woke up to my cell phone ringing. This time it was the pharmacy—my new prescription for anti-anxiety medications was now available for pick-up.

The journey to medicine is unique to each individual who embarks on it. One commonality is that it indirectly teaches success through repeated adverse conditions and failures—it teaches perseverance. Many of the leading educators and clinicians I have met in this sphere maintain an intrinsic motivation that far outweighs their innate level of knowledge. This intrinsic motivation increases their aspirations, knowledge and purpose; aspiring to serve as a physician, understanding that knowledge precedes healing, and a purpose dedicated to caring for others.

In essence, these men and women are the ordinary ones. They are you and me. They were once pre-medical students with a dream who became medical students embarking on a journey, then resident physicians gaining the skills and knowledge to become attending physicians. Ultimately, these attending physicians continuing to turn dreams into reality for anxious pre-medical students.

This is the journey.

The Importance of Five Minutes

anesthesiology, medicine

Originally published in July 2019 edition, ASA Monitor (citation below)

‘Unexpected death of a colleague,’ I read in the subject line.

As I combed through the remainder of the email, I came to learn that a second-year resident had died in a car accident near his hometown. It was his name that gave me pause.

Just a few weeks prior, I entered one of the campus cafeterias for a meal. There, I noticed a young man sitting alone wearing a navy-blue jacket. A University of Pennsylvania Perelman School of Medicine crest was stitched on his chest.

“Hey, man – I happened to notice your jacket. Did you attend UPenn?”

“Yeah, I did. I’m Joe! Nice to meet you.”

“It’s nice to meet you, too. A few of my closest friends also graduated from there!” I replied.

A conversation started, just pleasant banter that danced around the east coast versus west coast biases, shared colleagues and friends, Portland’s city designation with its small-town charm, and our respective medical specialties. The dialogue was short but delightful and lasted approximately five minutes in total. Before I left his table, I suggested we take a photo together to send to our mutual friends.

Our smiles are in my phone now.

In the five minutes when we spoke, a connection was formed, a foundation of trust laid. Unlikely as it seemed at the time, this simple exchange was similar to the swiftly created bond that forms when an anesthesiologist talks to their patient prior to surgery.

When I was a fourth-year medical student, I told my family and friends that I had applied to an anesthesiology residency program. Their responses varied. Most were happy but they had questions too, specifically concerns that my communication skills would be “wasted.” Knowing how much joy interacting with people brings me, they were disappointed that I would spend most of my medical practice with unconscious patients. My answer: there is a unique responsibility born in that five-minute interaction prior to surgery. In those five minutes, I may have the ability to connect to a patient, gain trust and portray a sense of safety to a complete stranger in a way someone else may not. My communication skills could be the difference between someone entering the operating room with wild fear or measured ease.

When I was a fourth-year medical student, I told my family and friends that I had applied to an anesthesiology residency program. Their responses varied. Most were happy but they had questions too, specifically concerns that my communication skills would be ‘wasted.’

I am not alone in feeling this way. “I have five minutes to convince someone I can take care of their life,” Dr. Marshall Lee – Oregon Health & Science University (OHSU) attending physician – stressed during residency orientation. This time restraint is a challenge that should be decorated for anesthesiology rather than seen as a reason to choose another specialty. A patient waiting in the preoperative area is possibly in one of the most vulnerable states of their lives. Patients may find themselves anxiety-stricken for the surgery itself, fearful regarding the aftermath, pained by the financial burden of the surgery and concerned for the risk of death. Most encounters we have with our patients are brief and delicate. A patient in this highly vulnerable state – concomitant with a short window of time – clings to every word from our lips. After a postoperative call to verify the patient is recovering appropriately, it is probable you will never see nor hear from them again. This does not detract from the memory of how you made them feel – one they may carry with them for a lifetime.1 

When recalling my conversation with Joe, I can no longer remember the nuances nor the minute details, yet I felt more connection and delight upon walking away from the table that day than after many hour-long discussions with others. As anesthesiologists, we only have a few minutes to gain the trust of the patient and family member, positively frame one’s outlook prior to their surgery, and provide the sense of comfort and reassurance they are seeking. During this brief encounter, we must gather information, set expectations and address concerns a patient may have – several factors underlying high-quality patient-physician encounters.2 One underestimated key is non-verbal communication – a grounding component of a therapeutic patient-physician relationship.1 And one example of this is evidenced in a study which demonstrates that sitting over standing is highly favored by patients as it creates a less dominant environment and more empathetic space.3 

As I embark on my anesthesiology journey, I will recall my feelings after I left Joe and the impact of a high-quality conversation – regardless of its brevity. It is a remarkable challenge that is requested of an anesthesiologist. At OHSU, attending physician Dr. Miko Enomoto is known for her saying, “the safest anxiolytic one can administer to a patient is their time, their attention and their care.” Let us never forget that in five minutes we have limitless influence on a patient and their family during one of the most vulnerable phases of their life. They may not remember the details of the conversation, but they will most certainly remember how we made them feel.

References:

  • Ha JF, Longnecker N . Doctor-patient communication: a review. Oshcner J. 2010;10(1):38-43.
  • Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 2010; 303(6814), 1385–1387.[Article]
  • Strasser F, Palmer JL, Willy J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manage. 2005; 29(5):489-497.[Article][PubMed]

Jason L. Campbell; The Importance of Five Minutes. ASA Monitor2019;83(7):44-45.

 

From Beacon to Shadow: The African-American Community is Waiting…

adversity, medicine, politics, Race, Uncategorized

“‘More blood! Stat!’” I read. The first line in “Gifted Hands.” As a 15-year-old African-American student aspiring to one-day practice medicine I could barely put down the book my mother gave me. The story of Ben Carson MD—many believed to be the guiding light if you were poor or African-American or academically challenged—was the beacon illuminating a journey from adversity to achievement. The first words in “Gifted Hands” by Ben Carson, MD sets the scene within an operating room in 1987 at the Johns Hopkins Institution in which a medical milestone occurred. Two 7-month-old conjoined twins requiring copious amounts of blood, twenty-two hours of procedure time, a seventy-member team led by him and gifted hands resulted in a successful separation of two Siamese twins—Patrick and Benjamin.

 For Dr. Carson—one of the most academically impactful members of the African-American community—the fall from grace has been anything but subtle. When questioned on May 21st, 2019 by Congresswoman Porter he was asked to define a basic housing term—an REO (Real Estate Owned)—a term used to describe a class of property owned by a lender after an unsuccessful sale at a foreclosure auction. Seemingly unknowing of the term he responded with “Oreo?” at first to which he needed clarification—a surprising response in his position as Secretary of the United States Department of Urban Housing and Development (HUD). Dr. Carson once pillared his accomplishments on the power of knowledge. Now—dismissivae of a fundamental term a person in his position should use commonly this is in stark contrast to the image the black community grew up honoring. One contemporary of the once-esteemed surgeon noted he knew firsthand what Dr. Carson went through and it was nothing short of incredible. But watching his devolution has been a pitiful sight to see.

This playbook has not changed and still illuminates the story of a poor black kid from Detroit overcoming multiple barriers—poverty, academic strife, and a system constructed against him—to become director of pediatric neurosurgery at the Johns Hopkins Hospital and perform the successful separation of 7-month-old Siamese Twins when others said it could not be done. Few African-Americans, in any field, have come from very little to achieve such success. In the last chapter—entitled “THINK BIG”—Dr. Carson writes how each letter illustrates an important piece to success. The ‘K’ stands for ‘Knowledge’ which he defines as “‘… the key to all your dreams, hopes and aspirations. If you are knowledgeable, particularly more knowledgeable than anybody else in a field, you become invaluable and write your own ticket.’” Where have these words now gone? Once so important he wrote them in a book to inspire generations to come.

A man who once changed lives with words and saved lives with actions has now perished to an online trend seemingly devoid of the basic knowledge required in his current position. The surgeon who changed history in 1987 in that operating room in Baltimore, Maryland will forever be remembered by the African-American community, but the man we see today appears to be a shadow of his former self—at best.

This is a perpetual discussion intertwining history, race, culture, politics and medicine. Some of my colleagues may not agree but I desire a return from the former Ben Carson MD.

I declare to you Dr. Carson it is never too late to give a young woman of color, who once wrote to you because her mother like yours was a maid, hope and promise that she too can make something out of very little. I declare to you Dr. Carson that there is a young black male facing academic hardship who needs you now. I declare to you Dr. Carson that the African-American community is waiting…