Fatima Cody Stanford | Care & Disparity

Stanford:

Sometimes we will discredit things that are outside of our faith, because God sees all but God also gives us the wisdom to use tools here on earth to solve problems and to make changes in strategy. So I think sometimes there is maybe an oversimplification, maybe, of just looking at faith and not recognizing how faith is interconnected to the greater world.

Hi, I’m Dr. Fatima Cody Stanford. I am a physician and scientist at Massachusetts General Hospital and Harvard Medical School here in Boston, Massachusetts.

Stump:

Welcome to Language of God. I’m Jim Stump.

Doctor Fatima Cody Stanford has never been one to be hindered by naysayers. When people told her the things she wanted were impossible, that usually drove her to higher and higher levels of success. It pushed her through college, a masters of public health, and then medical school, just to name a few of the many credentials she has earned in her career as a scientist. And anyone who might have told she couldn’t maintain her Christian faith alongside science would have been met with the same kind of methodical denial. 

Her faith continues to fuel what she does professionally. She has seen firsthand disparities in health care treatment offered to people of color and to women. We talk to her about the causes for distrust in science with the African American community, about COVID and vaccinations rates in minority populations. And we talk about what she has focused much of her work on, the most prevalent chronic disease in the United States—obesity. In all of these topics, Dr Stanford keeps our perspective firmly with the patients, those who need the love and care of trained scientists and doctors. 

Let’s get to the conversation. 

Stump:

So Dr. Fatima Cody Stanford. Welcome to the podcast. We’re happy to be talking to you.

Stanford:

Thanks for having me. This is a delight.

Stump:

Well, let’s start with some of your background, if we could. I understand that you grew up in Atlanta, is that right?

Stanford:

That is home, always will be home. I haven’t lived there in many years, but absolutely. My family is still based in southwest Atlanta, which is where I was born and raised. I was born at Southwest Community Hospital. It’s a hospital that’s no longer there, but was a minority-serving institution, predominantly Black-owned and run, but did not have the finances to sustain themselves, especially during the 2008 financial crisis. So my family is still there. And it’s a large part of who I am as an individual. I was born and raised in John Lewis’s congressional district. So a lot of how I think and in the work that I do, really reflects, you know, kind of being raised in the bedrock of the civil rights movement here in the United States.

Stump:

As you look back, particularly on your childhood, what indications do you see that may have pointed you toward a career in medicine?

Stanford:

What was around the age of three, that I decided what I wanted to become a physician, so pretty early in life.  I was very defiant that this is what I wanted to do. I had a great mom at the time, who was a nurse manager at Mount Sinai Hospital in New York City. And she would say, “well, why don’t you want to be a nurse?” And I was like, “well, I don’t want to be the nurse, I want to be the doctor.” And so even at that young age, she tried to convince me that I wanted to be a nurse. And I think that very quickly she recognized that when I set my mind to do something that I was going to make sure that I, you know, accomplished it. And so she respected that decision. And while she’s no longer living, was there, you know, as I went through medical school and my early training, and I think was definitely proud of, you know, what I said I would do at the age of three. And now as I’m in my 40s, you know, recognizing that, you know, I was committed very early and sustained that.

Stump:

Another mark of that early commitment, I saw somewhere that you received an NIH grant at the age of 14 for young scientists. How did that come about?

Stanford:

Yeah, absolutely. That was a great introduction to science, and I think why I’m still here. I went to a high school in Atlanta public school systems. It was called Benjamin Elijah Mays High School Academy of Math and Science. And just a little bit of a history moment. Benjamin Elijah Mays was one of the primary teachers to Dr. Martin Luther King. And so that high school is named after him—or after Benjamin Mays, who was King’s, one of his primary teachers. Our academy of math and science was really geared towards improving access, particularly for those that were Black in Atlanta, in terms of pursuing careers in STEM, you know, science, technology, engineering, mathematics. And we were encouraged highly to spend a lot of our time—and I would spend my entire summers—doing clinical or basic research. So I applied for something called the high school research apprenticeship program that the NIH ran back in the 90s, and was selected to conduct basic research at Emory University. And so the research that I did with that first funding that I received from the NIH really propelled me. I went on to represent the United States as one of the finalists for the International Science and Engineering fair based upon that work that I did then and that definitely helped engage me in the field of science. And I think is why I’m still here doing you know, this work as a scientist today.

Stump:

I also see that so in college, you’re in a pre-med track of some sort, but not just in biology, you also majored in anthropology. And I wonder how that may have influenced the way you see the field of medicine?

Stanford:

Oh, absolutely. I mean, so I was an anthropology and human biology major. So anthropology was actually the overarching theme of my major. And it was really my early exposure to anthropology as a first year college student at Emory that really captured my thought process. Anthropology, obviously, is the study of cultures and populations. And so this really, you know, was my early introduction to things such as public health, It was only at that time that I really began to think about public health as a major part of my career. And so I want to, you know, thank some of my instructors, professors, etc, that were in anthropology for really helping to me to think about, not only medicine as a field, but how different populations are impacted by care delivery, which was really what a lot of that focus was in the biological anthropology world.

Stump:

And that must have had some influence on you then, in seeking a degree in public health then, even before medical school. Is that right?

Stanford:

That is 100% correct. I did have no idea that I would seek a career in public health. But it is important to note for those of you who are listening that Emory University is like literally a few steps physically away from the Centers for Disease Control and Prevention, which we know to be our nation’s bedrock of public health. So even though I was born and raised in Atlanta, knew the CDC was there, didn’t really understand how important and how prominent of a role it was playing in the nation and its public health development until I was in undergrad and began to recognize not only the physical proximity, but the significant overlay between those that were in academics at Emory in the School of Public Health, or even in the School of Medicine, that held joint appointments at the CDC. And so I said, “look, what is this public health thing? Let me let me investigate this further. I do think this will play a large role in my career in medicine.” And so you’re right, Jim, right after I finished undergrad, I did my Masters of Public Health and Health Policy and Management. It’s interesting to look at that. That was over 20 years ago. And a lot of the focus in my program at the time was looking at Hillary Clinton’s proposed health plan for universal coverage. And so it’s interesting to see how much has evolved since that time in health care, especially within the policy and management realm, but seeing her early efforts to really get us to a place of what we eventually, I think, got a taste of with, you know, the Affordable Care Act was definitely a great setup for understanding the greater system in which I would serve as a physician.

Stump:

Well, we want to hear a little bit more about the work you are actively engaged in right now. But just before that, if we might rewind the tape again, and hear some more about your upbringing as it pertains to your faith and the community of faith that you grew up in and how that may have influenced your work, too.

Stanford:

Yeah. So my earliest memory in life was at about five months of age. And people don’t believe that, but let me tell you, it was. And it was my day of my christening. I actually remember it very vividly. And I remember it from the vantage point of me now, like, I’m not looking at myself, I’m talking to you. And so I remember it from this vantage point. Yes, I’ve seen the pictures. And I just remember the day of my christening, my mom, and my maternal grandmother, you know, it was this whole big deal, right? Like, and they had to position me for the pictures. And I just thought, like, can’t they just get this together? It’s fine. You know, they just wanted to make sure I was just the right, looked just the right way. And I just remember thinking like, gosh, that just I don’t understand why this is so complicated. But I do. That’s my actually—my earliest memory in life is the day of my christening. And I really do believe that where I am today reflects highly based upon what my faith and my faith upbringing is. So I was born and raised AME, which is African Methodist Episcopal. For those that are unaware of the AME church, it was founded by slaves here in the United States as we weren’t allowed to participate in certain denominations. So AME really kind of came out of that. And so I was, I grew up as an AME person. And in the church, you know, my maternal grandmother was the first female steward in our church, in the history of our church. I grew up in Allen Temple AME in Atlanta, Georgia. So it was really a big part of who I was. I was a, you know, I sang in the choir, I was an acolyte in the church, I helped to oversee, when I was in high school, the food and clothing bank for our church. My parents, to this day, still oversee the food pantry for my church. So it was a major part of who I was. And who I am today, I think, is really governed by my faith. And so I would say a huge part of just who I am, in my upbringing,

Stump:

In the same way that you can point to your interest in anthropology, the degree in Public Health, as these giving you a bigger, sort of more expansive view of medicine, does your faith do a similar kind of thing as you approach the field of medicine with that in your background as well?

Stanford:

Yeah, absolutely. I think that it’s for some—as a person of faith, it’s hard for me to separate those out. I think the faith part of me is so much like just who I am as an individual, how I was able to navigate through certain trials and tribulations to end up exactly doing this work. I don’t think it was by chance. I think it was part of God’s will for my life to do the work that I am currently doing. And so I see my work as part of a bigger context. It’s not just about what is Fatima doing, what is it doing to kind of self serve? It’s about how do I serve as humanity. I think that was what I was here to put here to do. And me doing the exact work that I’m doing, I think was part of God’s plan. There were things that I would set my mind on, “I’m going to do this,” and God’s like, “no, that’s not what you’re doing, you’re going to do this.” And when you look back, you’re like, oh, that’s why I was being directed away from X, Y, or Z to end up, you know where I was. And I really do think that that’s governed, based upon how I see it from a faith perspective. There’s not a scientific experiment that I can go and demonstrate why I, you know, went down one path versus another or how I was being guided down different pathways, which ultimately have led me to where I am today. So yes, I think it’s the bedrock of who I am as an individual. Those are individual components, right, the public health or the public policy, or the medicine sides of me, but the entire being of me is my faith. And I think that’s really why the first memory in life is that christening, I think it was when I first came to know who I was. And I think every single day I learned more about who I am and what my purpose is here in this domain, in this room here on Earth. But I do think that my faith is an important part of governing. Anytime that I’ve stepped too far away, when I’ve become so entrenched in just the science, you know, it’s not been a wonderful time in my life. So it’s like God’s way of saying, “look, this is—I am the way the truth and the life and this is where you need to be. And through that, you’ll be able to do all of these other things that you desire to do, because that’s what my will is for you.“

Stump:

Does that direction of influence go the other way at all? So you’re talking about how your faith has influenced who you are as a person and your work. Has your practice of medicine and in medical research influenced your faith at all the way you understand or practice your faith?

Stanford:

That’s interesting. I don’t know if I can say it’s bidirectional in that way. But let’s—  I’m gonna humor you for a second. And, you know, I think about in medicine—  Let’s just, I’m gonna talk about some revelations that I’ve had. You know, we talk about these, you know, “discoveries”, and I’m putting air quotes on that on purpose, because, you know, it’s like, “oh, it was a failure”, and “oh, then it led to some discovery and it was just happenstance.” I really don’t think it’s really happenstance. I think it was, you know, God’s way of saying, “okay, yes, this isn’t what you expected, but this is what I’m going to show you.” So I think my understanding of sciences or those things that we don’t understand in science is based upon my knowledge of faith, and how that works. But we say it as like, “oh, it’s just a discovery. It was just like a nuance,” but a lot of what’s happened in medicine, right, were these things that were by mistake. Someone made a mistake and dropped something on a petri dish. Someone made a mistake and then it led to this major, you know, earth shattering, you know, discovery in medicine. And a lot of our discoveries have really come about in that way. They weren’t the well-planned out experiment, that, you know, step one we will do X and our hypothesis is, you know, Y. And, you know, it was these things that really kind of just happened. And we chalk this up to just, you know, like, oh, it was just happenstance. But is it really?I don’t believe that to be true. I do believe that it’s governed by a higher power. And in this situation, I think it’s governed by God.

Stump:

One more question in this vein. Are there particular ways in which the relationship of science and faith gets expressed in African American communities that may be unique or provide different kinds of challenges?

Stanford: 

I do think that, you know, if you’re looking at the Black community, and particularly in the American South, which is where I’ve spent most of my life, that we believe that, you know, God heals. But if you look at Jesus and his team, if we’re looking at Christianity, he also had a physician on his team, right? “Luke, heal thyself,” right? So that it’s like, okay, well, I don’t need to worry about X, Y, or Z, because God will take care of it. But also, you know, on his team of 12 disciples, Jesus had different people that had certain knowledge base to do certain things. So I think that, you know, sometimes we will discredit things that are outside of our faith, because God sees all, but God also gives us the wisdom to use tools here on earth to solve problems and to make changes in strategy. So I think sometimes there is maybe an over-simplification, maybe, of just looking at faith and not recognizing how faith is interconnected to the greater world. 

But I do think we have some potential opportunities when we’re looking at how pervasive faith is within the Black community. And actually, one of my early projects that I was involved in in the School of Public Health at Emory, did just that. It was called Healthy Body, Healthy Spirit. And it was an entire, I guess, program that was focused within the Black church community in Atlanta. Ken Resnicow who is now an investigator at Michigan, but was at Emory at the time, oversaw this effort. But he needed people like myself that were on the ground, that understood the Black faith-based community in Atlanta, to really do his work. And we were able to make significant strides by going into a place of familiarity, a place of comfort for the Black community, which for us, is the church, to deliver and render this public health intervention. And so I think that there’s a lot that can be done that we don’t see being done in science, in communities, particularly of color, particularly the Black community, where we can utilize the strong connection with faith to make strides and things such as health.

Stump:

Good. Well, that provides a nice segue into some of the other work you’re doing now that I wanted to talk to you about. You recently co-authored a short article in the New England Journal of Medicine, called Beyond Tuskegee: Vaccine Distrust and Everyday Racism. And I think the point of it is that it’s a little too easy to blame distrust of African Americans with the medical system on some of those marquee historical examples of when African Americans were taken advantage of and treated unethically. What’s the real problem then with distrust for today?

Stanford:

I think it’s everyday racism, which is you know, that’s what we tried to convey in that New England Journal article. When people are thinking about whether or not they trust the system, they’re thinking about their recent interactions with the system. So, how was I treated yesterday, or last month, or last year, when I tried to, you know, go into the healthcare setting, whether it was the hospital or in an ambulatory practice or whatever it might be. And one of the conversations I was having, actually earlier this morning with another individual really talked about how as a Black woman, regardless of the fact that I have all these degrees and residences and fellowships, I am viewed just as just a Black woman when I access health care. And what does that mean? So what are our preconceived notions and our biases towards me and what my knowledge base may be surrounding x, y, z, if you just view me as this Black woman? Do you see me as obstinate? Do you see me as willing to carry through with the treatment plan? Do you feel like you have to talk down to me, for me to understand? These are things that are experienced by even those of us that, you know, have “made it” to the quote, unquote, pinnacle of Harvard Medical School and being on faculty. And so as a Black patient, right, because I am that when I’m not serving as a doctor, I do experience what it feels like to be mistreated or devalued or for I’m saying as I’m trying to express what I feel in terms of my health, to not be, you know, taken seriously. It’s problematic, but we do know that it is very entrenched in our culture to have race bias, for us to believe certain things about groups, particularly the Black community as being inferior, as being less educated. And this plays out in the interactions within the healthcare setting. So when you’re looking at vaccine rates, for example, here in the United States, and you’re looking at what, 6.4% of blacks that have gotten vaccinated, based upon eligibility, I think this is really based upon that everyday racism that they’re experiencing, not going back to, let’s say, something like the Tuskegee Experiment, which is what I was trying to say in that piece. Because each of us, regardless of our stature, if we have black skin, we are treated, unfortunately, differently than we should be treated just because of whatever, both implicit and or explicit biases others have towards us.

Stump: 

I’m going to read just two sentences from your article that I think are just super powerful, and then wonder if you might comment on them, perhaps explaining what some of these situations are, if you have the numbers at hand of some of the disparities, because I think we need to hear this. I think we need to hear this. So you say, “every day Black Americans have their pain denied their conditions, misdiagnosed, and necessary treatment withheld by physicians. In these moments, those patients are probably not historicizing their frustration by recalling Tuskegee, but rather contemplating how an institution sworn to do no harm has failed them.”

Stanford:

Yes, it’s interesting, as I think about how well this piece was written, and I have to thank my student who worked with me on this piece, Simar Bijaj, who did a phenomenal job, and as we worked together on this piece. But I really want to, you know, use my own experience, because my own experience is one that I can speak on. I have been inpatient at a hospital in the not so distant past. When I would bring up issues that I was dealing with, you know, it was kind of brushed off. “Oh, no, that can’t be this.” And then it would exactly be what I was saying. “Oh, I’ve never seen that.” As a doctor, I’d seen it. But you know, that just led to mishap after mishap after mishap. And it made me feel that even as a doctor, I needed to get out of the hospital as soon as I could because I was not certain whether or not they would kill me. And not necessarily that they would intentionally kill me, but if you’re not listening to what the patient is saying, and the patient has valid issues and concerns, and every single time you devalue or don’t listen, exactly what the patient was telling you becomes the reality, it says to me that I don’t matter. 

I think about one of my mentees who lost both of her parents to COVID within three weeks of each other, who is a Black woman physician here in the Harvard system. And her mother died at their family home as an—keep in mind, she’s an internist—but she felt uncomfortable with her mom, as a physician, practicing actively, to be in the healthcare setting. She didn’t believe her mom would be valued. She did not believe that she would have the dignity that she deserved as she faced her last moments of life and gave those last agonal breaths. And it pains me to see that she is probably 100% correct. And was—shouldn’t even say is probably—is 100% correct, because unlike myself or herself, who are physicians practicing, understand the lingo, and even with that knowledge base, we see people like Dr. Susan Moore, who I talk about in this article, the New England Journal article, who was unable to advocate for herself, so that she could then survive this very horrible pandemic that we’re facing. She’s an intern, she was a family medicine physician trained in a great institution. She trained at Michigan. But for her, it didn’t matter. It didn’t matter when she was there needing care. And so I’ve experienced that as a Black woman physician. She experienced it. And there are countless stories. I just happened to be the person talking to you today, Jim. And so my voice is being heard. But my experience reflects the narrative of many others. If I would experience that, as someone who has my knowledge base, imagine what those that have minimal education, minimal access, what do they experience? So I think that we have to be mindful of this and recognize that it’s incumbent upon the system itself, to make changes.

[musical interlude]

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Stump:

You brought up already the disparity in vaccines for the African American community for COVID. And in your article, you had cited a survey of the percentage of African Americans that trust the vaccine. I saw an updated one just yesterday and it’s a little bit better. But still, African Americans are the lowest group in terms of responding,“yes, I’m willing to get the vaccine.” So you’re giving us context for why that might be. Is it getting any better though? Do you see that there’s progress being made, both in terms of availability of the vaccine to African American communities and their willingness to get the vaccine?

Stanford: 

So I do think we’re making small improvements in both availability and willingness to get the vaccine. But notice, I said small, small being an important adjective here. I think that, you know, unfortunately, until you start seeing, you know, people that are either very prominent individuals within the Black community, or I don’t know if you’ve seen, I published a study that came out with some great collaborators at the Kennedy School, Dr. Esther Duflo at MIT, where we actually looked at messaging, who’s delivering the messaging about things such as COVID. You know, is it white physicians or Black physicians or Hispanic physicians? Who do people like myself, i.e. Black people, want to hear that messaging from? And in that study, where we looked at over 14,000 individuals, all with a high school education or less, we found that people prefer to hear that messaging from Black doctors. Problem is that there are only 5.5% of doctors that are practicing in the United States that are Black. So now I have to—me, as a representative of the Black physician community, now have to go down and solve some of the issues that have been entrenched generation after generation for the entire community. I do appreciate that Black individuals, regardless of their education, status, want to hear from someone like me, they want to hear my voice, encouraging them to think about the vaccine. And I can tell you, when I see my patients—and I do have a much larger percentage of Black patients here at Mass General than many of my colleagues, I think, because people will seek me out because of my understanding and openness about this topic—many of my patients will say, you know, “Doctor Stanford, I’m not getting that vaccine. That’s gonna—I’m going to be the last person on earth.” And then so I’ll, you know, they usually tell me this, of course, right when their visit’s supposed to end. And I’m supposed to go to the next one. So often, I’m late for the next patient. But I think it’s an important time for me to address it. Right? So I’ll say to them why I think that, you know, they should get the vaccine, that I’ve gotten it, this is why it would help their health. And then, within a very short period of time, usually a couple of minutes, I’m able to maybe get them to shift to being in this camp of no-absolutely-not to a very-very-strong-maybe. And then often I’m getting a message from them, you know, soon thereafter, “Dr. Stanford, I got signed up for the vaccine.” Right? So it’s important to have that personal communication. And I think that my, you know, I guess we could talk to my patients, but I think my patients trust me. So I’m spending some additional time explaining to them the value of vaccination, that means something. But how many people in my community are getting that time, where they can speak to someone and voice what their concerns are, what their fears, what their hesitancy is, so that they can then make that change also? So this is something important to think about.

Stump:

So long-term remedy is to have more African Americans in the field of medicine, more people who look like the communities they’re trying to serve that can be trust-earning voices. Are there any short- or medium-term strategies you might recommend are some quicker fixes to the system, and particularly as we’re talking about COVID that’s so important here right now that we’re trying to address?

Stanford:

I think that we have to utilize tools we have, right? Social media is a powerful tool. So like now I can’t individually talk to, you know, millions of people, but maybe I could use social media to get to large swaths of individuals. And my colleagues, you know, can do the same. That’s one potential strategy. And we do know that the consumption of social media in the Black community is very high, so a place where people are going for information. We don’t have a study to show whether or not Black influencers, let’s say your Oprah Winfreys, Tyler Perrys, those types of people, if that makes a difference. But what we saw, for example, with Tyler Perry, was that he had significant vaccine hesitancy and then went ahead to get the vaccine. So maybe, it may be nice to do a study where, I haven’t done the study, but to see, did he influence people then to want to go forward with the vaccine? So that you can utilize influential people that aren’t in medicine, to actually—that have a large following, several millions of individuals—to get the voice out and begin to address this issue of distrust and vaccine hesitancy. So I think that those are some quicker fixes, right, like using what we have now, broadcasting with the limited individuals that may be able to do that work. So yeah, that’s basically, I think, a quicker fix. And there are probably some additional strategies. But that’s the first that comes to mind for me,

Stump:

Anything that the church itself might be engaged in in helping to do this?

Stanford:

Absolutely. So I think the interaction between faith and science has to happen. And I can tell you, I’m giving a lecture this week that will be sponsored by the Dana-Farber Cancer Institute here in Boston. But it also was sponsored by nine different Black churches here in the Boston community. I’ll be talking about COVID and the Black community. So they’ll be hearing me talk about this. But I’m talking to a group where we’ve brought together science and faith, particularly within the Black community. And I think that’s a magical combination. We’re using two trusted sources and combining them to get the message out. So I think efforts like this particular effort that, for this lecture that I’ll be giving this week, is something that we should be doing more of. Going into the communities, bridging that with the persons that are experts that have that overlay between science, right, and religion and faith, and, you know, making that happen. So I think we can do that. And I’m happy to be a part of some of that work. And quite a bit of time that I spend, you know, outside of this very ultra-academic setting is in working with particularly Black church communities.

Stump:

Well, in your article we were referring to, one of the things you say is that Black scientists sharing their stories is paramount. And we’re doing our best to help get some of those stories out there. And for you, the story of your professional career isn’t so much about COVID, as it has been about obesity. So tell us a bit about the problem of obesity in our country and what your work with that has been?

Stanford:

Absolutely. So what we do know is that obesity is by far the most prevalent chronic disease here in the United States. And when I’m giving prevalence, it’s important for us to recognize, you know, based upon the current data, this is really based on 2018 data coming out of the CDC. 42.4% of US adults based upon 2018 data, keep in mind, we’re in 2021, have this disease we call obesity. That’s US adults. That’s almost half, not quite, but 42.4% in 2018. And we could probably argue, and I think we would all agree that possibly is higher, right? 

Stump:

The pandemic hasn’t helped that, I’m afraid. 

Stanford:

Yeah, it has not helped that. When we’re looking at the pediatric population, we’re talking on the order of about 19%, based upon 2017/2018 data with obesity. So we’re talking about large amounts of individuals. It is bigger than any chronic disease we’ve ever seen in our lifetime. The problem is, we don’t treat it for the disease that it is. And it was only in 2013 that the American Medical Association voted to acknowledge obesity as a complex multifactorial disease process that it is. So I came to Boston to do my fellowship training in obesity medicine, because unfortunately, and I published a study in the International Journal of Obesity in 2020 that—2019/2020, pre-pandemic somewhere in that portion of time—looking at education we’ve got regarding obesity in medical schools, residencies and fellowship programs throughout the entire world—I didn’t focus on the United States because I wanted to see what was the global view—and unfortunately, the global view is dismal. No one is really being trained on how to diagnose, treat, prevent obesity, despite the fact that it’s the most prevalent chronic disease in the entire world. And so that’s problematic to me. It’s part of what drew me to the work. But a lot of also what drew me to the work was the disparities that we see in rates of obesity. So if we’re looking at Black women, a group that I belong to, Black women have the highest rates of obesity here in the United States. Close to 60% of Black women have this disease of obesity.

Stump:

To what do you attribute that disparity?

Stanford:

It’s multifactorial. I think there’s racism. We’ve seen the Black Women’s Health Study with Yvette Cozier out of Boston University, showing that both everyday racism and lifetime racism contributes to obesity. We know that that to be the case, right? Because obesity is an inflammatory state. Racism is in a state of inflammation. It’s characterized by increased adipose, or fat tissue deposition, particularly in areas that are problematic, like the midsection. So the greater the lifetime exposure of racism, the higher the fat deposition, the higher the chronic inflammation, the higher the disease. That’s one possible explanation. And there are some—

Stump:

Can you explain just that bit a little bit further. I want to make sure I just—so the prevalence of racism itself has a physical effect in how fat is stored in the body? That’s what you’re saying?

Stanford:

Definitively. That’s exactly what I’m—yes. So we have great data. So I think, I think Yvette Cozier’s data out of the Black Women’s Health Study, which is the largest prospective control trial looking at Black women, really shows this. I mean, she started publishing this work in large form back in 2014, out of the Black Woman’s Health Study. Now people are finally paying attention to it. But we’ve known this link between actual systemic and everyday racism, to actual poor health outcomes and higher likelihood of obesity and Black women particularly, which is the group, right, that has the highest rates of obesity. So that’s one possible explanation. 

I think that also when we look at BMI criteria—BMI criteria did not—or I don’t know if you know, the BMI tables were drawn based upon the Metropolitan Life Insurance tables back in the 1930s. Black people were not included in these actuarial tables, which determine cut-offs for insurance based upon who was dying based upon weight class. So when we’re looking at this BMI criteria, the BMI criteria doesn’t broadly, you know, expand to include Black individuals, Hispanic individuals, for example. And actually, I redrew the BMI chart in 2019 in the Mayo Clinic proceedings with current NHANES, which is the National Health and Nutrition Examination Survey data. And interestingly enough, for Black women, the BMI curve shifts, actually upwards instead of being 30 as the cutoff for different disease processes, which I looked at, which were hypertension, dyslipidemia, and diabetes, it shifts up to somewhere between 31 and 33 for Black women, based upon current data, not that historical data from the 1930s. So we have some issues with measurement. Right? 

I think that there are some genetic issues. For example, there was a large GWAS—which is a genome wide association study—that was performed out of the NIH, in 2018, where they found a specific variant called the Sema4D, that was only present in individuals of African descent, both here in the United States, and in Ghana, Kenya and Nigeria. They also looked at over, I think, 30,000 individuals in that particular study. They looked at White individuals, they looked at Asian individuals, and none of those individuals, did they see the Sema4D variant that counted for a five BMI point difference in those that had it versus those that did not. So I mean, we, you know, there’s so many different factors that, I think, account for the differences that we see in the prevalence of obesity within the Black community. But that’s part of what led me to this work is to continue to uncover and to expose, you know, what we see—whether it’s racism, whether it’s genetics, whether it’s measurement issues—that we see that might differ from the Black community versus the white community, for example.

Stump:

So how are treatment options changing with what you’re discovering and how this ought to be best addressed?

Stanford:

So I think that you know, the problem is that we just don’t use the treatments that we have available. So if we’re looking at treatment, we have three primary categories of treatment, which include behavioral therapy, pharmacotherapy and surgical intervention. And this is for both pediatric and adult patients. In general if we look at the utilization of medications or pharmacotherapy for the treatment of obesity, currently only 2% of patients that qualify for pharmacotherapy for the treatment of obesity in the United States get access to it. So that’s pretty dismal, right, 2%? Or at least 98% are not. And then with regards to surgical intervention, and by surgical intervention I mean metabolic and bariatric surgery, usually in the form of something called a sleeve gastrectomy or a roux-en-Y gastric bypass, only 1% of individuals get access to that. And that is by far the best treatment for severe obesity in both the pediatric and adult population. So it’s great to have tools. But if we don’t utilize the tools for the patients that need them, it really doesn’t matter. It’s just a shiny object that is on a shelf that we don’t access. And so I think that we need to be thoughtful about making sure that patients that need access to multimodal therapy, get access to that care.

Stump:

And can you say maybe a word just about—so you’ve talked about how prevalent obesity is, what are some of the bigger impacts on communities and societies because of this, or the ways that it influences way of life? The kinds of food options that should be there? Or why is this such a big problem?

Stanford:

Yeah, I think this is, you know, when I present this in a lecture, I present a slide that shows 100 potential reasons why this is a big problem, but I’ll try to pull out a few of these to capture the essence of the severity of this problem. We know that the problem of obesity itself, or the disease of obesity itself, is costing this country in excess of $500 billion a year. We think it’s closer to probably a trillion. So if we’re looking at healthcare expenditures, if patients have obesity, that’s how high we’re seeing it. With regards to issues such as presenteeism, meaning good showing up to work, and absenteeism, patients with obesity are more likely to have absenteeism, more likely to have significant illness that precludes their ability to be active, involved, engaged in the work that they do, regardless of what their work might be. In terms of contributors, we know that things that we do, doctors do, can cause this problem of obesity. Indeed, that we think about 20% of the obesity struggles that patients have in this country are due to medications that we prescribe to you. Medications like lithium, Depakote, Tegretol, Celexa, Cymbalta, Effexor, Zoloft, Paxil, Prozac, Ambien, Trazodone, Lunesta, Gabapentin, Glyburide, Glipizide, Glimepiride, Metoprolol, Atenolol, Propranolol, long term insulin, long term Prednisone just to name the ones I can think of right then. All of these medications have a potential for causing weight gain. But often, we as doctors, are unaware that we are a contributor to the problem that our patients are indeed facing. And sometimes we have to utilize those medications because there aren’t alternatives to those medications for those patients. So that’s one, you know, kind of big swath of things. 

I would be remiss if I didn’t talk about our sleep quality and duration, which has just deteriorated over time as we become a more global society, right? Like I am encouraged to be given talking to my colleagues over in Melbourne, Australia, which obviously are very different timezone than me here on the East Coast of the United States. But if I’m up talking to them at three in the morning, and I get some project accomplished, I’m lauded in my career. “Oh my gosh, Dr. Stanford did this work with her collaborators there.” And we do have this ability to interact, but not always in a healthy fashion. Our brains—so the organ that controls our weight, is our brain, particularly the hypothalamus. It tells our body, not only how much to eat, but how much to store. When we do anything to disrupt how the brain operates, like change our circadian rhythm, for example, our brain wants to be awake when it’s bright outside, like you’re seeing behind me, and it wants to be asleep when it’s dark outside. But often, especially if us in the professional world, or whatever our professions, we are encouraged to keep pushing, to keep doing work. And we may shift ourselves such that we’re going to sleep at two or three in the morning, waking back up at five or six in the morning. And that just doesn’t work really well with the brain. The brain decides, hey, that’s a serious stressor. I’m going to store more, because something’s going on. The problem is the brain saw stress as a time that a famine was coming. That’s what happened. When we would experience stress as humans, that meant a famine was on the way. Problem is now there’s no—not that famines can’t happen—there is no famine, right? The stress is chronic stressors from our work environment. We talked about racism, we talked about, you know, family environment, these chronic stressors lead to more storage of fat, okay? Storage of fat, especially in the midsection, not a good thing. And so this is what we’ve seen over time. So these are I mean, I could keep going on and on. But these are some of the things that we think about when we think about obesity and its impact on society. 

Stump:

Interesting. Well, our time’s running down here. We’ve talked about the work you’re doing now and something about your past. How about the future? What do you expect the trajectory of your career and your interests, the things you’re working on to look like over the next generation here? 

Stanford:

You know, so since this is a faith based podcast, I get to say, you know, it’s not my will, but Thine be done. I really have to follow what God’s plan is for my life. I’ve learned that anytime that I’ve tried to do the planning, God has quickly course corrected me to whatever was supposed to be my plan. So I mean, I can tell you now I will finish my MBA in just a few months, so I’m thinking about the business side, right? So I have my BS, MD, MPH, MPa, MBA. So a few degrees to kind of, you know, intertwine some of my thoughts on. You know, obviously, obesity as a disease, health disparities and health equity issues, and wanting to obviously affect the larger population as a whole, but thinking about monetizing it. Because in academia, we don’t often do a good job with that. So I’m really, I don’t know exactly the next steps beyond what I do as a physician, scientist and educator, media person. But I’m open and receptive to, you know, the many possibilities that I could explore, you know, outside of just even what I’m doing on a day to day basis, which is, you know, seeing my patients, conducting my research and a lot of my education and media engagement. So, I’m open. You know, Jim, I think I’m going to be a bit more receptive to the universe and God guiding me than I may have been in the past. And, you know, I’m excited about what there is to come. I think that it’s only the beginning, believe it or not.

Stump:

Any parting words, in terms of advice for perhaps young people who are considering a career in medicine or public health?

Stanford:

I would say the key thing is just don’t give up. I think that especially as a Black woman physician scientist, at various points in my career, and even probably currently, people are like, “you can’t do that. There’s no way you’re going to pull that off.” Every single time someone tells me that, I don’t know if you guys are listening, that is like fuel to my fire. You know, it’s like the one thing you don’t say to me. Like, you tell me I could do it and I’m kind of like, eh, maybe not that exciting. But when you tell me I can’t, it gives me so much energy to not only do whatever I said it was, but to like, pulverize that goal and then reach another height. So I guess going back to what to do, don’t let anyone tell you that you’re incapable of doing something. I think that it’s important for us to recognize that if we draw upon our faith, and my favorite scripture, which I’m going to quote now really reflects this, and this is from the first epistle of John chapter 15, verses 14 and 15. And it states “and this is the confidence that we have in him. That if we ask anything according to His will, he hears us. And if we know he hears us whatsoever we ask, we know we have the petitions that we desire of him.” So that reflects who I am as an individual, I think listening to me, I think that you might think that that’s indeed how I see the space. My first book that I wrote, that’s the inscription in the front cover, because it’s really been my guiding principle. And as I continue to grow in Christ, as I continue to grow in science, I think that just the world is my oyster, and I will follow God’s will to make sure I’m doing the best for God’s people, for people that haven’t yet recognized how God is influential in their lives. And I’ll continue to do this until my time here is done.

Stump:

Great. Well, thanks so much for talking to us. 

Stanford:

Thank You. 

Stump:

I hope we might do it again sometime. And maybe I should say, you’re never going to be able to talk to us again as a way of manipulating you into making sure that you really will do that.

Stanford:

[laughs] That’s a good strategy. Now you’ve learned the secret. “You can’t do that. “I’m like, really? I can’t do that? Oh, let me show you.” So yes. Thanks so much, Jim. 

Stump:

Oh, thank you.

BioLogos:

Language of God is produced by BioLogos. It has been funded in part by the John Templeton Foundation and more than 300 individuals who donated to our crowdfunding campaign. Language of God is produced and mixed by Colin Hoogerwerf. That’s me. Our theme song is by Breakmaster Cylinder. We are produced out of the remote workspaces and homes of BioLogos staff in Grand Rapids, Michigan.

If you have questions or want to join in a conversation about this episode find a link in the show notes for the BioLogos forum. Find more episodes of Language of God on your favorite podcast app or at our website, biologos.org, where you will also find tons of great articles and resources on faith and science. Thanks for listening.