Building Trust with Marginalized Populations – Dr. David Carlisle, CEO of Charles R. Drew University of Medicine and Science

Dr. Desai: Hi, I'm Dr. Rishi Desai. Increasing diversity in the healthcare workforce has emerged as an important goal in light of the raised awareness of disparities in health outcomes in the U.S. based on race and ethnicity during COVID-19. Our guest today, Dr. David Carlisle, is at the forefront of boosting efforts to create a more diverse workforce as the president and CEO of the Charles R. Drew University of Medicine and Science in Los Angeles. In addition to the school of medicine, CDU has a school of nursing and is a leader in health disparities research with a focus on cancer, diabetes, cardiometabolic, and HIV/AIDS. Before leading CDU, Dr. Carlisle taught medicine at UCLA for twenty years and spent a decade leading the California Office of Statewide Health Planning and Development. Thank you so much for being with us today.

Dr. David Carlisle: My pleasure. It's indeed an honor to be here and I'm looking forward to our discussion. 

Dr. Desai: Awesome. So, let's get right into it. I'd love to kind of rewind the clock a bit and understand what first got you excited about joining the field of medicine. What are the things were you contemplating when you first got in?

Dr. Carlisle: Well, that's a really interesting question from a personal perspective in large part because my grandmother was a dedicated Christian Scientist, and my father was raised in that church as well. I remember myself going to the "mother church" in Boston when I was about low single digits of age. This career direction is kind of a dimetric opposite trajectory that my grandmother took on. 

But really the reason I wanted medicine is I was always a science nerd. In college, I was kind of propelled from hard science into medicine because medicine is basically an extension of science. I also was very interested in, of course, service. Serving people, serving the underserved, serving under resourced communities. Medicine provides a wonderful opportunity for me to fulfill that passion of mine as well.

Dr. Desai: I'll be honest. I did not expect you to include Christian Science in your family history. That's very interesting. If you're okay with it, I'd love to dive just a little bit deeper on that. I'm curious. What was it like for you to pursue this field when members of your family were obviously of a different belief system?

Dr. Carlisle: At that time, I was kind of a late teenage individual, early twenties, interested in blazing my own sort of trail, but really, to be sure, I asked my grandmother about my interest in medicine and desire to pursue a medical degree. She basically said, "More power to you. Do what you want. Follow your dreams whatever they are. Whatever you do, I will support you." So, that was basically her position. Because of her embracing my interest in medicine, I was unfettered in developing that interest.

Dr. Desai: There's a powerful message in there. Today, we have so many people that essentially will disavow or break ties with people with different belief systems from them. It's a pretty interesting thing for her to support you so unconditionally at that time. I imagined it gives a young person a huge boost of confidence. 

Dr. Carlisle: Indeed. Absolutely. It did for me. 

Dr. Desai: You have a very interesting background in clinical experience. You also earned a Master's in Public Health, and a Ph.D. in Health Sciences Research. What got you interested in those fields? What inspired that pursuit?

Dr. Carlisle: Well, I had a hint very early in college. I went to Wesleyan University in Connecticut. Between semesters in the middle of the winter, I wrote a paper on Kaiser Permanente, the healthcare system, which at that time was very early in its developmental trajectory. When I reflect back on that, I think it was the very first inkling that I had an interest in healthcare systems and healthcare delivery beyond simply seeing one patient at a time. 

So, I continued along that trajectory. It took me into being a resident at LA County Harbor-UCLA Medical Center caring for underserved and under-resourced individuals. So, I would say that throughout my career, I've always had an interest in how the healthcare system, beyond simply individual practitioners, is able to embrace and address the needs of populations in addition to individuals.

Dr. Desai: Do you mind just giving our audience a brief overview of CDU and its mission?

Dr. Carlisle: Charles R. Drew University of Medicine and Science was founded in 1966. We are very aware that we were incorporated and created as a direct response to the Watts Uprising of 1965. Our university would not exist if it wasn't for the sacrifices, pain, and suffering of individuals in South Los Angeles that ultimately culminated in the violence of the Watts Uprising of 1965, as did other institutions such as MLK County Hospital -- later, MLK Community Hospital -- and Watts Health Center. We're all about the community. Our university's mission is to train young people -- usually from underserved, under-resourced, and underrepresented populations -- and turn them into healthcare practitioners who will then return to the communities they grew up in and communities like them to practice medicine and improve the health of those communities with excellence and compassion. That's what we do. 

Dr. Desai: And so, given that background, now that COVID is clearly hitting communities of color the hardest, I'm curious to know what is CDU doing to respond? What have you seen in the greater community? What partnerships have you forged to help with that response? 

Dr. Carlisle: Yes. There's been a lot of activity around COVID. Early on in the pandemic, it seemed you had to be an international traveler or somebody from the more affluent areas of LA County to have acquired a diagnosis of COVID-19. But what we suspected strongly -- as with everything in healthcare -- when you look at populations that have no access, populations that have no resources, populations that have no ability to acquire services, that's where you're going to see the body of the COVID-19 pandemic. And yes, that's exactly what happened. Underserved and under-resourced communities became the ones that were hardest hit by COVID-19. In that sense, it's kind of a metaphor for everything in healthcare. These are the communities that have the worst outcomes across the board. Life expectancy, infant mortality, maternal mortality, and preventable mortality are all worse in underserved and under-resourced communities.

Dr. Desai: One question that I think is on everyone's mind -- and here we are thinking about Delta variant – do you imagine that it's going to be kind of a normal year? Is it going to be more remote learning? What is your sense on that right at the moment? 

Dr. Carlisle: Thank you very much for that question. This is exactly where we find ourselves. At CDU, we are mandating COVID-19 vaccinations for every member of our student body, every member of our faculty, every member of our staff who is going to be on campus, as well as our educational sites around Los Angeles and elsewhere. We are following the guidance of the LA County Health Department. We will be requiring facial protection and masking on campus outdoors, as well as indoors. The latter is, of course, in direct response to the impact of the Delta variant. 

Dr. Desai: One of the things that you said early on in our conversation about your family history spoke to the fact that people that have differences of opinion can still support one another. I'm curious how you, in your position, go about implementing on a day-to-day basis things like a vaccine mandate among employees and faculty? How do you actually communicate that in a way that captures the empathy and compassion that I know you foster while promoting good health and public health practices?

Dr. Carlisle: That's a really good question. It's a very contemporary topic for us institutionally. Throughout the pandemic we've been having weekly forums at the university where we basically discuss and explore topics related to COVID-19. We've been talking about the need to be more institutionally aggressive in combating or preventing COVID-19 on our campus. We've been saying for some time that we're likely to mandate vaccination, of course. But it goes beyond that. We're actually fortunate at CDU because we're a health professions university. Everybody at our university is either going to become a healthcare professional upon graduation or they aspire to become a healthcare professional, with few exceptions. And then, you've got our faculty and our staff who are teaching these future health professionals or supporting future health professionals. 

So, in terms of institutional culture, we're much more aligned with the public health needs to fight COVID-19 than most other institutions. Even a large university like some of those in Los Angeles may have health professions schools, but they may not necessarily be entirely a health professions institution so it's harder to go down that pathway if you're not in a health professions environment. Because we're in a health professions environment, our students are already required to undergo immunizations for a variety of things before they go see patients. COVID-19 is just another aspect of that. 

All this said, we are still having challenges with COVID-19 protocols among some persons in our community. I say that to encourage everyone who is not yet vaccinated to go get vaccinated because the likelihood of acquiring a Delta variant COVID-19 case is extremely high right now. So, yes, I think that we're ahead of so many other organizations because of who we are and what we do, but we still face challenges, particularly, with regard to vaccinations ourselves.

Dr. Desai: One of the things that I've come to appreciate during this outbreak of COVID and the Delta variant is that a lot of us wear dual hats. Certainly, we have a day job, but then you're also an ambassador of sorts, especially in your role. What you do and what you say has a lot of weight. I'm curious to get your sense on this: what do you think are some of the things that you've noticed from your vantage point that COVID has revealed about our healthcare system? May be some weaknesses that we've identified and ways that you think we can strengthen it...

Dr. Carlisle: One thing that we've learned...all last summer, we were doing testing, and then we've transitioned on to doing vaccination. We definitely ramped up our testing volume. When the surrounding community became aware that there were people on the CDU campus who are testing members of the community -- people who spoke the same languages, people who may have been through or shared with family members concerns about immigration documentation, people who shopped at the same shopping centers or may have gone to the same churches on weekends -- this is an important message because one of those barriers that was revealed or amplified by COVID-19 was trust. 

Trust is a big word in healthcare. You have to trust your doctor. You have to trust the surgeon. Trust is important. When people were able to trust us in terms of coming to get COVID-19 testing, and later, vaccinations, our numbers skyrocketed. That just underscores how important trust is. If you want to reach marginalized populations in general, but in healthcare as well, you've got to build a bridge based on trust. That's one very revealing factor.

Another is that COVID-19 just underscored something that people like me, working where I work in the healthcare system, already understood. Our healthcare safety net has frayed and people are dropping between it, through it, all the time. They're being lost to the healthcare system, or maybe they can't even get into the healthcare system. When you work in an underserved, under-resourced, and underrepresented community, you have to deal with this aspect of healthcare all the time. But if you don't, if you work in more affluent neighborhoods, communities, etc, you may not even be aware of the impact of this tattered safety net. 

I will say that the delta between the United States and other industrialized nations in terms of healthcare outcomes -- our outcomes tend to be worse than most other industrialized nations despite our astronomical spending -- is mostly mediated by our failure to bring healthcare to the communities and populations that need it most already in our own country. COVID-19 just kind of ripped the scab off this issue, so that it became much more apparent. Apologies for the medical metaphor there. It became much more apparent, but it was what people like me already knew about all the time. 

Dr. Desai: I think that's spot-on. You spent many years in state government. I'm curious what your assessment is of how government agencies have responded to COVID. Do you think that they could have done better, and specifically, at what level -- local, state, county, federal?

Dr. Carlisle: I was the OSHPD director in 2002-2003. We got exposed, from a policy perspective, to SARS. And SARS could have taken off like wildfire, but because of strong public health interventions here in Canada and China, it didn't. But that was a wake-up call. So, we were kind of prepared for COVID. Didn't ever want to go there. But I remember waking up at four o'clock in the morning December 27, 2019, and seeing a very early report about an unknown pneumonia in Wuhan, China. My reaction was, "Oh, no. I hope it's not, 'Here we go again.' " 

So, we had things pre-positioned to respond to COVID-19, but I think the pandemic got ahead of our ability to respond. The people that I know in government public health, they're all experts. They're all dedicated individuals. They did everything they could to combat COVID-19, and I admire their efforts. As in any kind of emerging emergency, you can't anticipate where the next front is going to be and so our response has tended to lag reality a little bit. 

On the other hand, we are also kind of ahead of reality. We knew early on, very early on, that we were going to have to develop vaccines to fight COVID-19 because COVID-19 is a virus, and you fight viruses for the most part, with vaccines. Fortunately, we had the basic building blocks of the COVID-19 vaccines on the shelf in the NIH lab with Dr. Fauci and Dr. Kizzmekia and others. We were ready to proceed, we just had to know what we were dealing with.

Dr. Desai: That makes a lot of sense. I think, from my perspective, it's frustrating because we have, as you said, good science at our disposal in our toolkit. Yet, it felt like at every turn, it wasn't like the governments were neutral in many cases. Sometimes, it felt like they were detrimental and that, obviously, is frustrating. 

At our core we're a teaching company. We love to fill knowledge gaps. You yourself are an educator. I'd love to get your sense on any topic that you'd like to educate us on. It could be something that you feel like there are common myths about. It could be something that you've experienced in your own personal life. Just something that you think everyone ought to know. What would that be if you could pick one thing to teach us?

Dr. Carlisle: Well, I'd have to prioritize my response by talking in the COVID-19 context and the reality today. The major policy issue today is that we are facing a clear and present danger that has already cost the lives of 600,000 Americans, more than three million people around the world, and it's going to get worse. I think what we need to be able to do is speak about some of the myths around the COVID-19 vaccines that are preventing people from getting vaccinated. 

In many countries around the world, people are begging for COVID-19 vaccination. Literally begging. They're staying indoors. They're afraid for their lives because they can't get vaccinated. In the United States, it's kind of just the opposite. Pretty much everyone who's wanted to get vaccinated has gotten vaccinated already. Now, we have roughly thirty percent of our population, or a little bit more, that just don't want to get vaccinated. We know that those are the individuals who are most likely now to develop COVID-19, or most likely to get hospitalized with COVID-19, and yes, unfortunately, most likely to die from COVID-19. What can we do to get those individuals to say yes so that they can protect themselves, their families, and their communities? This is the public health issue of the past couple of decades. The biggest issue is the failure to get COVID-19 vaccination because the benefit of it is so transformative. 

So, I'd say, if I could teach, I would speak to the myths. There are no silicon chips in the COVID-19 vaccines. There are no magnetizers. You're not going to become infertile from the vaccinations. There are no long-term side effects from the vaccines. I became mildly to moderately symptomatic for a day or so after getting my vaccination. I would gladly undergo that a thousand more times to prevent myself from getting COVID-19. I don't know of any other health care provider really -- I know there are some exceptions-- who feels otherwise. 

I think of those healthcare providers who broke down in tears as soon as they were told, "We've got the vaccine. Lineup. You're going to get it." They had been going to the hospital, to the emergency room, to the ICU, every day. All they had to protect themselves was a simple face mask, gown, and gloves. I think back to the early part of the epidemic in China. I have an image that is seared in my memory of young women nurses recruited from around China to volunteer to go into Wuhan to staff the hospitals where the existing nursing staff got sick. Some of them have died. I saw a photograph. These are all women in their twenties, maybe in their early thirties. They had cut off all their hair because at that time people thought that having long hair would give the virus a vector to infect the individual. They are gathered in a group photograph. They were smiling. They were hugging. They were waving their hands. They were going to the frontlines of the COVID-19 pandemic. This is over a year ago. I just have to ask the question. How many of those young women are still alive today? 

I don't know of a single healthcare provider -- nurse, doctor, respiratory therapist -- who said, "Forget it. I'm out of here. This is too dangerous for me." They answered the bell. We know that twenty percent of the deaths early on were of healthcare providers in this country. These are people who are making the ultimate sacrifice to protect individuals, especially today, individuals who are not vaccinated. They're making the sacrifice for you. Those who are not vaccinated, please return their favor and get vaccinated so that you don't endanger them, and they don't have to take care of you when you're dying with COVID-19.

Dr. Desai: Wow. That's an incredibly impassioned plea, and quite an image that you're drawing up of those women that were going out to the front lines. I think another group that often gets forgotten, as you just pointed out, is essential workers. Folks like bus drivers and folks that have to keep essential services going. They didn't sign up to be part of a pandemic. They signed up to get a paycheck, oftentimes, for their families. They have to be out there, and they're not privileged enough to have positions that allow them to be at lower risk to work from home. So, I really appreciate you calling that out. 

We have so many students in the audience, early career health professionals, that are probably looking at your career and thinking, "Gosh. It's so interesting how you kind of jumped around and move around and stayed true to a lot of the things that you believe in deep down in your heart." I'd be really interested to hear your advice for them as they may be starting their career in healthcare.

Dr. Carlisle: Yes. I have a lecture. The title of it is, "So you want to be a doctor?" It's kind of the inside story about being a pre-med student, and then, becoming a medical student, etc. One thing I point out is this is not like being a lawyer. It's not like getting an MBA. Being a doctor, being a healthcare professional of any type, is dangerous. There is danger here. We don't know when we go to work whether that's going to be the day that we might contract hepatitis. We might contract HIV. We might contract COVID-19. I can see one person, one moment, who is an HIV-infected homeless individual. My next patient could be a corporate CEO. 

That's one of the other beauties of healthcare. One of the inspiring beauties is that when we're doing things the right way, our doors are open to everybody. I implore people when you finally get there and you're seeing patients to think about the patients that can't see you because they don't have health insurance, not just the patients that are in your waiting room. So, those are two things. 

The third thing I would say is if there's a word that describes people who transition through college into medical school into residency into becoming doctors or dentists or pharmacists, etc., that word is tenacity. Very few of us are so brilliant and so successful that we never faced an academic or even personal challenge during our careers. Every student that I know has had to pick themselves up off the ground and start over again on their way to becoming a doctor, dentist, pharmacist, etc. I, myself, was a very good science student coming out of high school. I thought I could handle college sciences easily. My very first biology test that I took, I got a 50. I flunked it. I basically said, "Whoa. Wake up call." If you want to be pre-med, you've got to do something different here. I turned things around in a class with more than a hundred students. I got the third-highest grade on the final examination. I actually got an A in the course even though I flunked the first test that we took. 

Fast forward to medical school, I'm kind of floundering around going, "This is not like studying science in college. It's different. How do I do things differently?" I wasn't doing well in anatomy and I said, "Well, you're going to start memorizing stuff." I started memorizing. I was up until three o'clock in the morning with flashcards. I turned my performance in anatomy around. We've all faced challenges. All of us have had to overcome the challenges successfully in order to progress through our training, and it just goes on and on and on. 

Dr. Desai: Well, that's a remarkable thing for you to share with us. I think a lot of folks see someone that is as accomplished as you are, and it's hard to imagine that you had to overcome something like a low score. 

Dr. Carlisle: If I may, Rishi? Healthcare is the process of overcoming defeat. Every one of us has lost a patient. Not just lost a patient, but lost a patient that we've tried to save. Whether it's a fifteen-year-old trauma victim in the emergency room, whether it's an eighty-year-old patient that we're trying to send home who goes into sudden cardiac arrest and doesn't survive, we've all faced those challenges. Part of being a healthcare professional is knowing how to incorporate failure into being successful. I've had to go from one room where I'm doing a code blue on a patient, to the next room to see my next patient and say, "Hello. How are you doing this morning?" You have to be able to do that to become a healthcare professional.

Dr. Desai: Yes. It's a very sobering reminder of what the day-to-day requires of clinicians. Going back to your earlier point of really making sure that everyone in society has their backs by getting vaccinated, and making sure that we all do our part to get through this. So, it's a good note to end on. I want to thank you for joining the show today.

Dr. Carlisle: My pleasure. Thank you very much for the invitation. Thank you osmosis.org and Raise the Line for including me in the discourse today. I appreciate it.

Dr. Desai: Thank you. That's fantastic. I'm Rishi Desai. Thank you for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.