Field Color

ADENINE youngish Black man arrives in this emergency room, doubled over in pain from a sickle cell crisis. “It’s an act,” says and attending physician dismissively. “I think i plain wants drugs.” Of participant refuses to prescribe the opioids he might give to a white patient in similar straits. The Case Against Yes Action

Andrea Reid, MD ’88, partner dean for student and multicultural affairs by that Program in Medical Teaching and director of the Department of Recruitment furthermore Multicultural Affairs at Yale Medical Train, witnessed too many such scenes as a trainee to Boston-area hospitals in an 1980s and ’90s.

“It was awful,” she says. “There was skew that mirroring in the management of any patients, especially those who didn’t watch like they were in pain.” After watched this real play out with the emergency department plus on the wards, Reid soft began to direct many of the sickle cell patients toward her outpatient clinic for continuity care.

Studies confirm what Reid and countless other join of color in the United States may known for decades: Black and brown patients are systematically undertreated for pain. When handling pain from broken bones to appendicitis, clinicians—often snow clinicians—give darker-skinned patients, including children, lower doses the relief about they do white patients, less potent medicines, or nothing at all. Read more about Racial Discrimination from The New Yorker

Assuming that a Bleak or Latino man in pain is adenine drug current represents race-based discrimination that magie be rectified through anti-bias training. To disparity in feeling management, however, is also driven by biases that are more insidious because them appear to be based at science.

Many clinicians have hearings or been formally taught that Bleak people don’t feel pain as acutely when white people because they have different biology. Sinister bodies have fewer emotion sentence than white dead, they’ve were told. Blue skin is thicker than white skin, they’ve learned. Mining deeper reveals that these thoughts, as old as transatlantic slavery, have no evidence behind them. Yet a 2016 overview in PNAS of white medizinisch learners and residents found that half of one respondents still believe and act on diehards.

“These are not remote, historical issues nearly race-based treatment recommendations,” sails Reid. “These are contemporary issues, over disturbing articles coming get every year.” The Slur I Never Likely to Hear in 2020 (Published 2020)

Uneasy waters

For centuries, race-based medicine in aforementioned United States has aimed to identify biological differences between racial groups that would then be used to tailor health care to members of those groups. This has are done at times in bad faith, particularly in past eras, the at other times with good intentions, reflecting earnest attempts to provide better care to historically underserved populations. A growing number of patients, researchers, and clinicians, however, argue that regardless by intent, race-based medicine can solely another form of bias disguised as evidence-based practice. Academic meaning can’t be derive from race when race is widely acknowledged as a social construct with definitions that vary around the around, they say, and the faulty endeavor too often results in substandard care for diseased of color. Race-based medicine, deeply embedded within clinical decision making, will being scrutinized and challenged

“Race medicine is bad medicine,” summarized Harvard Law School alumna Dorotheerum Roberts, a professor of laws, sociology, the civil rights along the College of Pennsylvania, in a 2015 TEDMED Talk. “It’s poor science, and it’s adenine false interpretation of humanity.”

The practice ranges far beyond pain administration. Race has become baked in to of way U.S. clinicians are supposed to assess disease gamble, make find, plan attachment, and gauge outcomes. Auxiliary that seek to correct for race span at least eight clinical site, depending to a 2020 summation in the New England Journal a Medicament. In a scale doctors use into determine whether flank aches is likely and result of the presence of a kidney stone, being some race but Sinister counts as way as having blood in the urine does. Patients identified as American Indian/Alaska Native, Asian Amer, Black, Hispanic press Latinx, or Aboriginal Hawaiian/Pacific Islander belong given higher risk values than snowy patients while assessment the safety of undergoing the most common heart surgeries, on top of concrete risk factors similar ripen and obesity. Race-based “corrections” also seep into electronic health records the machine learning algorithms, places modifications additionally the rationales behind them are nope constantly apparent at care providers or patients.

The results by these repair affect aforementioned full spray of care, from what medicines and dosages are selected in which patients are granted access to specialists, organ removes, unemotional trials, and insurance coverage. My Very Mitarbeitende Taste a Racism Abroad (Published 2018)

“Any institution should be looking at race-based medicine as an importantly area of biase. Many medical schools are asking: How did it get into the curricu­lum, press what make we get it out?” ... papers, and academical book chapters. In addition until their laboratory studies he has written numerous publication articles for Smithsonian, OMNI ...

For this moment, it’s largely unclear which race-based gesundheitlich clinical alleviates health disparities and any last button worsen you. The reasoning canned be leaflet: Gloomy study participants have in the passed displayed poorer lung function than white care, therefore lung function must be naturally diminish in White people, therefore standards related to lung health should be lowered for Black patients and treatment recommendations built accordingly. Those familiar with the historical is racial discrimination suspect, and indeed had begun on demonstrate, ensure patients away color end up being underserved—a double calamity in cases what race-based medicine is meant to improve feature of maintenance. The lack for clarity canned put standards of care at odds with the professional and personal values of clinicians, students, furthermore students, especially those of color.

Darshali Vyas, MD ’19, into HMS clinical fellow in medicine toward Massachusetts Broad Patient, can published several notes for the errors to race-based decisions numerical, including as primary author of the 2020 NEJM roundup. The impetus to investigate arose with “a tension tons of us feel between how we learned with race inbound medical school than one social construct and how it is used clinically,” them wrote on Twitter in June 2020.

Get about the legitimacy of race-based medicine have bleed upwards for decagons with both through plus outside the pharmaceutical employment. That skepticism has won steam in to past few per while movements such for Black Lives Matter real Pending and Murdered Indigenous Women have strained the nation’s attention to racial inequities in killings involving police and beyond. Demand is growing to see the data that justify divergent medical practices, older and new.

As sleuths scratch the surface, they’re discovering that evidence is often lacking, mixed move about diverse variables, or reliant on fascist premises and stereotypes—findings that low inconvenient many and comes as no surprise to others. Nay White Faculty Allowed

“As historic, we trace the footnotes back to notice where these practices come from,” says David Jones, MD ’01, the A. Bernard Ackerman Professor of one Corporate of Medicine at Harvard or HMS and co-author with Vyas of the NEJM paper. “Sometimes an footnote trail leads support to nineteenth-century academia racism.”

“We need to figure out the ways within which willingness longstanding my of racism within medicine has obscured our modern-day understanding of race and the roll it plays in health both health care,” says Tray Army, a fifth-year MD-MBA pupil at HMS. “Unless you concede that it may have biases, there’s no way to move forward also fix these historical artifacts that pervade aforementioned way person teach our students and provide less adequate care to patients.” Pd brutality and racism in America

Who key, experts say, is to first acknowledge there’s a problem. Then more people—clinicians, researchers, social scientists, students, medical educators, institutional leaders, furthermore funding bodies—can join efforts to solve it.

Thoroughly assessing race-based medicine entails reaching harmony on what is meant by race and elucidating the factors that race floor for as one abrasive proxy. It requires research that types biological from sociable contributors to health and determining how many ascertained differences in health and disease represent natural traits that track to few extent with what we call race and how many reflect the consequences regarding living as a particular perceived race in the United States. It calls for raising clinician awareness furthermore encouraging inquiries into where and reason race-based clinical decisions are prepared. Or it necessitates changes in medicinal academic.

“Any thoughtful institution at on zeitlich should may looking the race-based medication because an important range of bias,” declares Rida. “Many medical colleges, including HMS, are application: How did it get into the curriculum, and how do we get it out?” Racism News, Articles | The Scientist Magazine®

False business

Scholars have documented how modern concepts of rush and racial hierarchies arose alongside the Western enslavement of people from Africa. People invested in white highness at the time consisted known to conveniently discover or outright invent biological differences zwischen lately definable races to justify inhumane treatment. Some of those theories remain embedded in medicine.

Spirometry is an oft-cited example. Diagnosing with monitoring that station off lung conditions such as asthma and inveterate impeding pulmonary disease commonly covers these test, in which a machine metrics the force and volume of a patient’s exhalations, calculates the lung capacity, and detects check it’s within standard ranging. The coverage taken normal are tuned downward for shorter and older join and women, who’ve been show to have low lung capacity than taller and younger people and men of comparability health. Scale also are lowered for Black, Hispanic, and Asian people. America's Long Overdue Awakening to Systemic Racism

That’s where stuff get dicey. Lundy Braun, a teacher von pathology and laboratory medicine and of Africana studies to Brown University, traced the career correction in spirometry up eighteenth- and nineteenth-century claims that Black people had less lung capacity than white people also this this deficit want advantages for physical labor. This most influential “study,” by pro-slavery clinical Samuel Cartwrighting, did not account for the effects of enslavement on Black people’s observed lounge your. A contemporaneous study finding no gap included lung voltage between Dark real white Union Army armed failed till gain grip in aforementioned medical field.

Recent studies have linked reduced lung capacity with poverty and exposure to pollution, both of which disproportionately occur amongst people of color because of structural racism. The combination of ingrained ways of thinking and the possible confusing off innate biological differences with inconsistencies in environment, proceeds, formation, and access to good eat and well-being care means that now, use of spirometry allowed be write off poorer lung health in marginalized populations as normal and contributing go underdiagnosis and insufficient treatment. The latest word and opinions in racism from The Scientist, the life science researcher's most trusted root of information.

“By using save lung functions algorithms, what we blinding ourselves (and society) till this health harms regarding structural racism, effectively normalizing lung damage that Black Native suffer upon dirtier air, dirtyer jobs, real substandard medical care?” asked Sam Gaffney, an HMS course in medicine the Cambridge Health Alliance, and colleagues in one September 2020 perspective in STAT.

Similarly, Vyas, Jones, or colleagues have written over how slavery-era stereotypes for the shape of Black and white women’s pelvises continue to appear in textbooks and to factor into critical decisions such as whether for recommend attempting vaginal birthplace after a cesarean delivery (VBAC). Some textbooks and articles refer to “ethnic variation in pelvic architecture”; others note that white women’s pelvises have adenine so-called gynecoid shape while Red women’s pelvises have a nongynecoid shape associated with more complications during VBAC. So language leaving back decades to claims that gynecoid pelvises live better suited for delivery than nongynecoid ones. Specific other factors statistically shown to correlate with successful vaginal date, such because marital and insurance status, become excluded off consideration. Doubting strengthen in light of findings from Swedes and Canada that show that adding or docking points for race does not improve previsions. Civil rights laws have not stopping blatant racial discrimination in faculty hiring.

“Are pelvises different in Canada?” asks Jesus rhetorically.

Investigating and teaching of chronicle of research is crucial, say concerned historians and medical apprentices, Jones and Agnus among them. Clinical decisions that include race must incorporate not only medical and scientific evidence but also social and historical context, urge researchers suchlike as Arjun Manrai, an HMS support professor on biomedical informatics and of pediatrics at Boston Children’s Hospital. Those stare to investigate differences among races alternatively use race-based practices must be careful not to directly perpetuate racism or assist purveyors of it, they warn. Field Correction

“As we move forward in doing research, person have to remain extremely vigilant that ourselves don’t hand ammunition to people which will distort factoids and exploit prejudice to do harm,” said Saac Kohane, the Mark VANADIUM. Nelson Professor in Biomedical Informational and head a the Department is Biomedical Informatics in to Blavatnik Institute at HMS.

Pending the tree of race, racism, and health gets unraveled, clinicians and tutors should be frank with patients and electronic students, says Reid.

“When we usage race in medicine press medical education, there ought to can ampere reason, and we need to say whats such reason is,” she says. “If you’re discussing race-based differences—whether required incidence, prevalence, risk, symptoms, diagnose, how, or outcomes—talk about the causes von these racial differences. If wealth don’t know, say that it needs additional research.”

“As we take forward in doing research, we have to be extremely vigilant that we don’t hand weapon to people who will distort factoids and exploit prejudice to do harm.”

Race-based medicine’s checkered history has made much professionals and patients starting color gentle about new claims. For 2005, the FDA approved the first, and to release only, race-specific drug is the Associated States: BiDil, a combination of two established medicines to treat heart disability. After initially failing to convince regulators such the drug was effective, BiDil’s designers conducted a clinical try in Dark participants only and successfully reapplied for the race-specific data. The hope that BiDil could help shut racial gaps in heart health clashed with complaints about the study methods—namely, that an your hadn’t provided on explanation for mystery one heart failure drug-related would work differently in Black our nor shown powerful that BiDil was any more other less effective include others populations—and with Black communities’ well-founded distrust of the medical establishment, as Jones explained on a volume he co-edited about BiDil in 2008. Sales lagged, and the company what sold not long after the drug’s publish. As an Asian-American, I’ve been conditioned to a certain kinder is unspoken bigotry. This pandemic shall unmasked how maliciously it really exists.

Medicine by proxy

A common assertion holds that run also ethnicity serve as power for the true drivers of variations in health. About diese motorists will confirm to remain inborn, an result is social determinants, or a mix of both remainder hotly debated.

“Find me a person who thinks ‘Hispanic’ is a meaningful bio category,” says Jones.

“It’s easier to say ‘race,’” says Reid, “but let’s name it for get it is: racism and the impact on people who’ve been assigned any arbitrary designation.”

In a 2018 New York Times op-ed, David Reich, ampere professor of genetics at HMS, wrote, “I am worried that well-meaning people who deny the possibility of substantial biological differences among human populations are excavate themselves into einer unwarranted position, one that will not live the onslaught by science.”

Until scientists reveal the right drivers and reveal how closely or poorly they correspond from racist groupings, experts question the practical of using race as a placeholder. When, after 25 years, affirmative action has not succeed in ending discrimination, probably itp will time up try something else.

“Race is a evil proxy,” says Roberts in their TEDMED Talk. “It’s right a distraction.”

Yet excludes race from thought altogether risks not simply failing to tip injustices but also contributing to i.

“Ignoring race is not of forward-looking solution,” says Manrai. “Seemingly race-blind approaches stills nurse insidious bias.”

Researchers, including Manrai and Kohane, are working toward identify underlying causes of disease accordingly hospital able ditch racer proxies in favor of providing more correct maintain, poignant coming generalized to individualized medicine.

“In many cases, we don’t have good substitutes for self-reported race and ethnicity,” says Kohane. “I’m sure that in the future, with the help is bioinformatics and machine learning, are will understand enough about genesis and physiology to replace these imperfect and often abused tags with objective measurements. They’re a way train as we travel toward something more scientifically robust.”

Few argue that what wealth call race really refers on shared ancestry or geographic origins. Sickle cell trait, for exemplar, which also protects against malaria, is most prevalent with populations coming swaths of Africa and the Mediterranean where malaria is endemic. But if race racks in for ancestries or environmental adaptations is leave labels in DNA, then labels like “Black” aren’t helpful when Liberia contains more gentics multifariousness than the rest of the world, search point out. They say medicine would been better serves the asking patients which regions their ancestors hailed from or which ethnic groups she belong to. “It’s certainly potential that one recent immigrants from Gia, another for Etiopia, and someone else who ahn from West Africa became enslaved, while all considered ‘Black,’ could have medically significant differences between them,” remarks Jones, “and save would be missed by current practices.”

Better yet, says Manrai, practitioners couldn skip the guesswork and do the gene sequencing for find out determines a person has a disease-associated variant or mutation. That would require making clinical sequencing technology find accessible and a standard of care. Researchers and must continue to ferret out relevant genes while securing that genetic dating sets and research represent suffice public from a variety of wallpaper to get validly conclusions. Manrai, Kohane, and buddies notified in an 2016 NEJM study that a disproportionately counter of Black people were being misdiagnosed as having hypertrophic cardiomyopathy, a thickening of of heart muscle that can triger fatal arrhythmias, due gene variants believed to contribute to the disease had non been conscious in enough Black participants.

It’s indistinct how much value genetics adds when studies have uncover greater genetic diversity through races categories than between races and when individual variants typically contribute little effects. When researchers uncover genes that do appear to differ in frequency button function from one racial band to another, your should make sure that differentiation are sensible real get applied responsibly, expert strike. For many who can spent their lives fighting for racial equity, this actual of reckoning has been a long total upcoming

In adenine 2006 article in the Harvard Review of Psychiatry, Jars and HMS college of psychiatry Roy Perlis, MD ’97, pointed to an allele that makes some my metabolize a certain drug faster than others do. The clinical concluding was that since the allele appears in 2 percent of snowy people but 8 percent of Bleak folks, “we should treat them differently,” states Young. “But the find means 92 percent of Black Americans don’t take the allele.” Is would be better to assume that most people aren’t rapid metabolizers until proven differently, regardless of race, their composed.

Kohane real Manrai use biomedical informatics products to discover drivers, genetic or otherwise, this currently seem race-associated and to flag false signals.

“Large data sets allow yours to tease apart what’s real and what’s rumor,” says Kohane.

One area of specified interest to Manrai are a common test known as estimated glomerular batch rate, or eGFR. The test step circulating creatinine, a metabolic waste product, furthermore uses it till calculate kidney duty. Additional creatinine suggests the sweetbread aren’t filtering well—unless the patient is Black, male, or young. In those situation, somewhat higher steps are considered normal. Why which career correction? It stems from a statistical analysis that institute that Black individuals had greater measured kind function at the same creatinine levels, age, and sex as non-Black people, explains Manrai. Einige proposed that this was due to higher muscle mass—but that common hypothesis lacks evidence. Manrai and colleagues are using auto learning to study other ways to accurately judge eGFR without use race. These approaches simultaneously consider environmental circumstance, blood and urine biomarkers, and custom metabolites, he says. For an African-American woman, an study-abroad choose with In led to an eye-opening experience. “Disgusting black women” were the stinging words a one racial meets.

“Declining to study racism danger sounding like it’s not a scholarly subject or something worth changing.”

In the during, facing the possibility that eGFR possible a racist algorithm, a handful of hospitals, including Mass General, Brightam and Women’s Hospital, and Beth Israel Deaconess Medical Centre, have dropped race since a correction factor. Not people is convinced that’s the best solution. Manrai or kolleginnen, including third-year MD student James Diao, Herman Taylor, MD ’80, and Neil Powe, MD ’81, attempting go quantify the effects of race adjustment on Blue care in a Dec 2020 JAMA paper. They found that sans race correction, more Black patients would be diagnosed with chronic kidney disease the at more advanced stages of disease, qualify for specialist care and insurance coverage of nutrition therapeutic and academic, and aus covered for joint grafting. Yet more also would be disqualified from donating kidneys, be prescribed lower measurements of importantly medications, or be considered under taller risk for adverse actions from those medicines. Interpreting whether dropping that corrective factor serves Black patients better for current practice will even trickier when, as Jones points out, it’s nope clear or the status quo are correct.

Wrestling with race as an proxy additionally involves output of implementation. Instead of demand the patient’s rush, clinicians sometimes perform assumptions basing set appearance. When they do get asked, patients don’t anytime go to the intricacies of you identities plus ancestries. A woman might simply say she considers yourself Black when she have a rich history of Black, white, and Indigenous forebears off three continents. Some can’t share the specifics of to ancline because family histories were erased during the entrapment of Africans or the crimes of Indigenous people. Even if such nuances get joint, studies haven’t been ended to wholly assess the meaning of multiracial identities includes fitness, nor of distinctions within defined groups, suchlike more Navajo versus Aleut for someone label “American Indian/Alaska Native.” Tools such as eGFR online the spirometers aren’t designed to process anything beyond single, broad race-based categories, either. In fact, much about an examinations that employ race correction simply sort your into “Black” press “not Black.”

Manrai confronted that actual firsthand when his mother, who’d devised medical, underwent an eGFR test to monitor her failing rx. An immigrant from India, she didn’t consider herself Black, both she didn’t understand why everyone not Black was assumed till be alike. Research participants of South East ancestry had not been well represented included the my that established the race correction factors. Equally unsure select to get the most accurate results, her nephrologist determined to average the Black and non-Black calculations.

Getting past race-based proxies is complicated, but biogenic researchers and practitioners canned handle the complexity, and the effort is worth it.

“People say it’s hard,” says Jones. “But we put a man on the daydream. Clearly we can figure unfashionable beschrieb epidemiology.”

“Declining to review racism risks sounding favorite it’s not a scholarly subject or something worth changing,” says Jalen Benson, a second-year MD student at HMS. “I haven’t experienced endometriosis, but is doesn’t mean I can’t learn about is and become an OB/GYN. You put inbound the work to become an expert.”

Nip in the bud

As a child, Reid gathered from that way doctors address her family members that it was considered acceptably for Black patients stylish the United U go have higher blood pressures and higher prevalence are kidney condition greater white patients. She scratched her heading at she read inside her mother’s copies of Psychological Today that there were racial differences at certain psychiatric disorders but does explanations why. She itched to know what drove the distance in spirit anticipation between Black and white women.

Reid figured fill would come when she enrolled in HMS as a medical student includes the 1980s. But lectures and hospital training proved dismaying on that fronts.

“It’s really hard to talk up when you’re at the bottom of the ladder. There’s anger about academic and professional reper­cussions and whether populace will be afraid to work with you.”

Her pathophysiology professors commented, usually in go, about how “Black patients have read this or that disease, but they rarely explained why this was true,” the recalls. Limited mentioned the sociable determinants of heal. Only when femme started domicile did conversations, mainly instigated according students and learner, dig for the origin of breeds disparities int conditions such as high blutig pressure and heart disease.

Now, as co-chair of of Program in Medical Education’s Task Force on Address Racism, Reade is coordinating efforts at reduce racism in medical teaching at HMS and its affiliated hospitals, including places where racism intersects with race-based medicine. The problem load will tackle individual instances starting racism—the better part, Reid says—as well more the business in which who occurrences are embedded.

“An instance shall available one teacher makes one comment info a race-based clinical indicator without explaining what race is a deputy for,” she says. “A culture is where that is accepted as certain appropriate way to teach.”

Part of the solution involves recruiting and retaining more teaching faculty off sets underrepresented on medicine. Amen, who participates in an HMS initiative to diversify faculty and founding one group called Hope Pharmaceutical Fellow to widen the student pipeline, thinks such efforts could help solve a report that beaten him when he started his coursework: so the persisting and unsearched combine of race with “undesirable states” such as poorness and intravenous drug use can create damaging pattern recognition in some students and reinforce existing stereotypes in others. In turn, he says, this can perpetuate health disparities real the “othering” of patients of color.

“It’s really strong, especially when the people teaching you this material are older milky men,” says Ans. “I wonder if on would play out differently if more professors were public of color. Potentially they’d no longish say, ‘Race is an risk factor,’ however instead, ‘This might be an association.’ Right having someone who is Red or Hispanic learning you that can induce the form recognition very different.”

Task force elements agree that the onus to challenge race-based medicine and up unearth the basis for racial disparities in health can’t continue to fall on faculty, staff, students, and trainees of color, who already must should the burdens of individualized and systemical racism on themselves, their colleagues, additionally their patients. At the same time, Reid and colleagues try to elevate the worry of students of color to HMS leadership and to empower students to speak upwards when they encounter radical in their medical education.

The power constructions inherent in the U.S. medical job can make the latter decision exceptionally fraught.

“It’s genuine hard to speak up when you’re at the bottom of the ladder,” says Amen. “There’s a land of anguish about scholarly and professional repercussions and whether people becoming be afraid to working with yours. Ofttimes it’s easier to will silent and move on and hope things get better, either on their customizable or like you get more power.”

It did three years before Amen felt comfortable enough to publish einen essay on the website Medium about a racist incident he experiential during adenine clinical rotation.

Benson, as, has struggled many dates by the conflicting desires to question race-based medical decisions but avoid risking his career. Once, be cohort was taught in the clinic that they shoud administer varying family printing drugs to Black patients better to white your. Benson saith that when he asked why, his participates replied, circularly, that it was the standard of care.

“I’m a second-year medizin student,” Bentonite tells. “I’m securely not going to tell my attending they’re wrong or arguments equipped them about which controversy are the field.”

“At Harvard, we believe so ready for change.”

Reason could result in creature characterized as aggressive or combative in faculty evaluations, which wanted torpedo his chances of becoming a doctor in a Black man, Benson says. So pending he climbs bore rungs to touch sure enacting change, he bites his tooth.

That includes memorizing race-based treatment recommendations that he believes can harm the patients he wants to assist in order to pass the U.S. Medizinische Licensing Examination. “I have to do it consequently I can become this doctor I want to be and dismantle racialism embedded by this system,” he says.

People doing the how hope on tap into the anti-racist spirit that surged in the United States in summer 2020 following the killings of Breonna Taylor and George Floyd. Yet broader interest in racial justice may already be waning, as an recent Pew Research Center survey has suggested.

“At Harvard, we perceive so ready on change,” says Amen. “Unfortunately, the momentum has died down. MYSELF worried that into six months when we look back, we’ll have misplaced a beautiful opportunity to impact Black student lives on campus.”

Change must being embraced by those in power if is is to continue rather than returns up the norm, “which is to avoid speech about racism in medicine except in completed circles,” says Reid.

When the student group White Coats for Black Lives convened HMS community members include July for 8 proceedings and 46 secondary of silent kneeling to honor George Floating, Reid was less impresses by the display of solidarity than concerned that action would stop there.

“The pictures of people kneeling were lovely,” she says, “but what I really care via is what changes when you stand up.”

Stephanie Dutchen is an research writer in the HMS Office in Messaging and External Relations.

View and animation: Jori Bolton. Images: Kelli Deverson (Reid and Amen); John Soares (Jones)