Some Things are Worth Losing for the Greater Things We Gain
Used as a poster child for health and justice in the academy when it was politically convenient, I am now facing intense repression for speaking up for health justice.
As I stand here at the precipice of a cliff that spells career suicide as an academic physician, I pause to wonder how I got here.
A professor of medicine at a university known for its excellence, with over two decades of service and awards for my work, some of which I accepted and others I rejected for their performativity, I never put “health equity” in my job title and never got paid to specifically work for it. I got the sense early on that any career branded with the label “health equity” would require an allegiance I would never be prepared to give. Health equity is a part of the landscape of being a physician committed to health for all, just like source control of an infection or pain management. These are expectations of our professional duty.
Used as a poster child for health and justice in the academy when it was politically convenient, I am now facing intense repression for speaking up for health justice. As institutions across the US pursue broad criminalization of dissent, the flow of weapons to Israel and the mass murder of Palestinians continue unimpeded. The point of this repression is to silence me, to make an example out of me and to cast me as out of favor, “unprofessional” and an outlier.
My work is, always has been and always will be the moral center of gravity of medicine.
But my work is, always has been and always will be the moral center of gravity of medicine. What I did not realize when I embarked on this path that would lead me here to this point of no return was that this moral center was the most dangerous thing you could assert in academic medicine. Because what logically flows from this center is the following: the right of all people to have the opportunity to be healthy and the responsibility physicians carry to create the conditions for health to be possible–for all.
Of course, many people like to speak about these things, but no one actually likes to do anything about them. To act in accordance would require a reallocation of power from those who hold too much of it to those who hold very little. And when it comes to disease, the abundance or lack of power dictates who lives, who dies and how. To disrupt dynamics of power–or to even name them–would damage one’s personal aspirations, one’s reputation and one’s career.
As I shift my weight and peer over the edge of the cliff, squinting my eyes to try in vain to make out the distance to the bottom, I can hear the thousand shards of my shattered heart move. They poke me from the inside. The welling salt water stings my eyes. The images of doctors a half a world away pleading for humanity to care as their hospitals were bombed into oblivion. The sound of their voices as they sang their commitment, refusing to leave the bedside of their bedridden patients. We will remain. Their handwriting scrawled on the mangled white board was all that was left after Israeli forces bombed, shelled and raided their way through the sacred space of healing: We did what we could. Remember us.
Standing at the edge, feeling the breeze move the curls of my graying hair over my cheeks, I look over at my colleagues who are standing at a safe distance a ways back, looking at me sideways with a mix of consternation and pity. How did she get herself into this predicament? She has always been so different from the rest of us.
And the truth of the matter is—I am different.
For as long as I can remember, I wanted to be a doctor. Not because I wanted the prestige. I never wanted to lead a department or be an expert of some esoteric medical condition. I am a generalist in every sense of the world. I love people and want to see us all thrive. I feel a kinship with the entire web of life. I am a part of the growing chorus of humans calling us back into the crucial and sacred relationships that keep us all healthy. I am passionate about teaching and sharing my vision for a world of health with the upcoming generation, a vision where physicians are whole, integrated and beloved members of the communities they serve and love. I have a knack for seeing the gaps and enjoy pushing myself and the field to extend its vast healing potential, in this particular moment of human, more than human and planetary sickness. I value the colleagues I work with who strive for excellence in our healing work together.
To learn this kind of medicine, I tuned my ear to hear the teachers who would show me how people live and how they die. Not in the hospital but in the streets.
But my vision of excellence is apparently controversial. My vision is one where systems-level interactions bring health, not just of individuals but of the whole. And to achieve this, our activity as healers must operate at both the individual and systems levels. This approach requires a different kind of training than we receive in medical school.
So I sought that training out, and that training continues to this day. To learn this kind of medicine, I tuned my ear to hear the teachers who would show me how people live and how they die. Not in the hospital but in the streets, in the alleys, in the railroad cars, in the slums, in the refugee camps and in water stops along dangerous desert border-crossings, in the interstitium of lived experience at the heart of empire. I had to learn to hear the voiceless and see the invisible–the undocumented, the unhoused, the gender queer, the Indigenous, the chronically ill and disabled, the non-English speakers, the Muslim, the Roma, the Traveller, the Black and brown, the imprisoned, the immunes–those in Roman times who were subsumed by the empire, but did not have the same rights as the conquerors. The people who fall in the cracks that were designed especially for them to fall into.
Since I came into my awareness of the world as the daughter of Punjabi immigrants growing up in California, where the original people are still healing from genocide and ongoing erasure, I have been a student of and participant in principled struggle. In medical school while I was studying the microbiology of urinary tract infections, I was simultaneously learning the histories of oppressed people, from their mouths, from their tender stories, from the aching memories of their loved ones who died before they had to. These living narratives shaped who I became as a physician more than any test score or career opportunity. I wanted to serve the communities who entrusted me with their lived knowledge, so that I would carry it to serve the benefit of all. I wanted to help understand what led to disparities in health and to heal what was hurting.
My own journey to this particular moment–where I am now staring over this edge with nothing to break my fall–was not a rapid one. For the most part, it was slow and measured. These past seven years though, the journey has accelerated.
The acceleration started when I began noticing how many Black patients were admitted to the hospital with emphysema, their lungs destroyed by some inflammatory molecule that ripped through the delicate pulmonary tissues. Typically we see this in smokers. But these people in their 30s and 40s had no smoking history or exposure. They all lived next to the Hunters Point shipyard, where the atom bombs were loaded onto ships before they were blown up over the Midway islands and eventually over Nagasaki and Hiroshima. Traces of radioactive material persist in the soil today. The dust settles onto the window sills and bookshelves of the houses nearby. The people who used to live there were predominantly Black before the latest wave of “development,” as the tech industry took over the Gold Rush city once again in the early aughts.
The acceleration increased when Oscar Grant was executed point blank by a cop on New Year's Day at the Fruitvale station, Oakland. The ripple effects were felt all over the community and the world. It became louder still when San Francisco Mission homeboy Alex Nieto was shot 59 times by cops as he was eating a burrito, taking in the sunset over his beloved cityscape from a bench on Bernal Hill, just before his work shift started. The techies were moving back into San Francisco, and they wanted our homes and our parks. Coming from the predominantly melanin-scarce suburbs from across the US, they showed up in our predominantly melanated neighborhoods and called us “foreign”, “suspicious” and “threatening.” These same people developed the technology of the dreaded quadcopter drones, which are currently executing Palestinians sheltering in tents based on AI algorithms, which some suspect try to determine who may one day grow up to be a militant. No wonder so many children are being killed.
The tempo quickened as I accompanied the Frisco 5 on hunger strike, protesting the police killings of Indigenous, Black, Latino and poor people in the neighborhoods where invading tech workers wanted our housing. Rents exploded, evictions left elders unhoused and the trauma of the killings reverberated in every family. When I saw the effects of trauma in our communities, I started voicing how racism and police violence were threats to public health. I started putting my medical work more directly into the streets and into the hands of the people who needed it to create the conditions where their health could be a possibility. Getting shot by the police is an impediment to health for the whole community. Getting swept up like trash as our unhoused and poor communities experience, can cause devastating health consequences for all of us.
The pace of my steps picked up as I headed to Standing Rock, called by a California Native youth who asked me to support the medic response. He was concerned that the police were harming Lakota elders praying for their sacred water–Mnisose or the Missouri River. They were gathered to stop the Dakota Access Pipeline from crossing their sovereign territory. The connections between extractive capitalism, the state violence required to uphold its agendas, the ongoing processes of colonialism, the impact of climate change—and ultimately our health—came into sharp focus. I watched lines of heavily armed police in military grade gear shooting rubber bullets into the faces and groins of unarmed, bare chested Native youth, praying at the water’s edge. I realized I could not call 911 for help, because these were the people firing the rounds.
It was around this time that two things happened simultaneously back at the university. Medical students from around the country were emailing me to work with me. They showed up at my university and said they came there explicitly because of my work. They wanted to be a physician who took on advancing health through challenging power. Simultaneously, the university administration started to call me in more regularly, first to try to offer “coaching” on my communication. But soon it was clear the goal was to silence me. This was six years ago.
When I spoke with my mentor, sociology professor Troy Duster, the grandson of Ida B Wells, he shared with me how many people disliked his grandmother speaking out about the lynchings in Jim Crow South–Black and white alike. We are living in similar times, except now, those of us decrying the bodies hanging in trees are cast as the racists. As we toasted Wells’ posthumous Pulitzer Prize in 2020 with lemonade outside in his front yard, Duster spoke to me about the critical importance of standing strong in our moral center to advance justice. When everyone tells you to shut up, that is exactly when you should speak up. Louder.
So I did.
In October 2023, I started communicating with Dr Ghassan Abu Sitta, a Palestinian British war surgeon who was working in Al-Ahli hospital when Israel bombed it, killing dozens of sheltering refugees. Receiving his communications daily at 3 a.m. for a span of 5 weeks, I was a witness to a genocide unfolding, told from the perspective of a colleague in an operating room across the world. He spoke of doing surgery by candlelight, running out of drinking water, not having enough anesthesia and using vinegar to clean wounds infected with the deadly Pseudomonas infection because Israel had cut off Gaza’s access to food, water, electricity and medicine. He spoke of thousands of people seeking shelter in the hospital hallways, sleeping on mats strewn across the floors of the emergency room, because their homes had been destroyed. They had assumed the hospital was safe. It wasn’t. Nowhere in Gaza is safe.
As I spoke up, my colleagues provided a list of excuses why they could not.
As I moved to share the urgency of his experiences with the medical community, with the institutions of medicine in the West, I was met with a stunning response. Everywhere around me were attempts to shut me up and to stop medical students, residents, nurses, dentists, pharmacists, lab technicians and other physicians from speaking about the avalanche of violence barreling down on Palestinians, landing squarely on the children.
As every hospital in Gaza was bombed, the acts of silencing intensified. As Israel kidnapped and tortured Palestinian healthcare workers, the repression grew. As multiple first-person accounts of doctors returning from Gaza reported sniper wounds to Palestinian toddlers’ heads, the criminal charges against protestors here racked up.
I spoke up and faced a torrent of racist repression in response. And as I spoke up, my colleagues provided a list of excuses why they could not.
It’s complicated.
I’m not knowledgeable and should not speak to things outside my area of expertise.
I don’t want to upset my supervisor–they’re my friend.
I have to get a letter from my boss for this grant next week and cannot risk it.
I have to apply for this fellowship and don’t want to ruin my chances.
I am afraid. I am not as courageous as you.
I have to protect my work in [insert whatever special program for marginalized population here] and if I speak up and I am punished, all those people will be left without the services I provide.
You have your strategy, and I don’t agree with it. I have mine.
The “You Do You” approach does not work for things that threaten our collective wellbeing. Genocide and the fascist logic that drives it—these are threats to all of humanity. For an excellent example of the stunning failure of the “You Do You” approach, look no further than the morbidity and mortality data for COVID-19. Physicians in academic medicine offered misdirected advice that led to the death and disabling of masses of Indigenous, Black, brown, chronically ill, elderly and poor people.
Individual calculated risk assessments sharpen the relief lines around power, as the powerful stay safe and the powerless die.
While community health workers were trying to shore up resources so that the people who are made most vulnerable by our society could be safe as each successive wave of virus hit, some healthcare experts offered a “calculated personal risk assessment” approach. As if a teenager spending a maskless night in a movie theater wouldn’t bring the virus home to their elder who would die. The elders who kept themselves sequestered safe at home eventually got sick and died—millions of them did.
With threats to our collective health, individual calculated risk assessments sharpen the relief lines around power, as the powerful stay safe and the powerless die. The only real move to address these threats with minimal harm is a collective approach where we insist upon the safety and health of all. Like COVID-19, the rise of fascism—where whole groups of people are oppressed, repressed or killed—is also a threat to collective health which requires this collective approach. Without it, we are overwhelmed, and many people will needlessly die. As they are right now, as Israel continues its genocide in Gaza.
When push comes to shove and the grotesque contours of power are exposed for all to see, doctors tend to side with the powerful. Not because they’re cold and unfeeling and not because they hold that much power themselves. While physicians are led to believe they are part of the elite as medicine’s hierarchies afford them some jurisdiction, they do not possess enough power to change the structures driving the disease patterns they spend their entire clinical lives trying to extinguish. Physicians have been educated in ways to maintain illiteracy around power. In academic medicine, doctors have tacitly and unknowingly pledged allegiance to power. We have been captured by a profession committed to power, not to life itself.
This list of my colleagues’ reasons to justify their silence as genocide rages in Gaza exposes something important. We cannot advance health equity if we are more concerned about our personal career or even the needs of one specific marginalized group than the collective wellbeing of all. To achieve health for all, physicians must be prepared to sacrifice the privilege we carry to confront the power that inexorably prevents that needle from moving forward. We must be prepared to commit career suicide. Without that commitment, we become performative cogs perpetuating the inequity of a system built on entrenched inequities.
No matter how one frames the silence of my colleagues—whether it is an act of self-preservation or a benevolent concern for a particular marginalized group they serve—all of it is under threat when we stay silent in the face of violent oppression. Because an injury to one group is an injury to all. As hard as some try to divide humanity, we are as connected by our threads of relations and duties to care as the mycelial web that extends its filamentous embrace around the entire globe, crossing every surface, even the seemingly barren ones.
This list of my colleagues' reasons to justify their silence as genocide rages in Gaza exposes something important.
So when Abu Sitta called me with the details unfolding in Gaza before he went to the International Court of Justice and offered the same testimony there, with my duty to collective care and my commitment to health for all, what else could I have done?
As I look over the edge of the cliff, dizzy with gravity’s coaxing of my semilunar canals, I take note of how much lighter I feel now knowing that this is the only path I knew how to take as an academic physician with a daily practice in the struggle for health and dignity. If this is its natural conclusion, so be it. Healing sometimes requires these transformative painful moments. We push through the skin to lance the abscess so the pus can escape. We call this source control. Without that action, the infection will fester, potentially grow and overwhelm the body’s ability to keep it walled off.
I take this all into account as I inch closer to the edge, with nothing to catch me now but faith. Faith that my commitment to humanity and serving health for all is more important than any career I could possibly pursue. Faith that there are times in history where it is more important to take a stand than to sit and be quiet. And understanding that in those moments, those who take a stand are often unpopular, hated and dragged. Faith that my ancestors have my back and that they knew this moment was coming. They prepared me, because they too had been dragged in their struggle against colonial oppression. Faith in knowing this: some things are worth losing for the greater things we gain.
I fix my gaze on the radical horizon where all may find the possibility of health.
I take the final step and catch my breath.
Earth gives way to air.
With water in my eyes and fire in my heart—I fall.
