Dr. Cecelia Calhoun: Taking on Systemic Inequities

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Cece Calhoun, but first we like to check in on health news. Harlan, what’s on your mind?

Harlan Krumholz: Well, gee, Howie, maybe we should go back and start talking about the pandemic again, because it’s sort of... it’s a gift that keeps on giving. I mean, we’re in at this moment in time where society really wants to pretend as if there’s no pandemic occurring and yet, as least where we live, the rates are increasing, concerns are rising, and there’s a lot of apprehension in the air. Let’s just go through some of the things that are going on. We’ve seen these new variants sort of come through, we’re now at BA.4, BA.5, that’s kind of starting to crest I think, in the second quarter. And I think many regions in the U.S. now are seeing a smaller number of cases, but not the Northeast. Northeast is starting to see growth. And I think the expectation is that that will start going around the country. And emblematic of it is what went on in D.C. after the Correspondents’ Dinner, after the Gridiron Dinner. You’re seeing people going to events and lots of people coming down, still testing positive.

The global deaths, though, continue to steadily fall with infection fatality risk of Omicron, at least in a report from the UK, now being in the range of flu. So what we’re seeing is the spread of the virus, people getting sick; especially for the vaccinated population, we may be getting to a point where, yeah, this isn’t completely benign, but we’ve driven down the risk, at least on this set of variants, to the point where it’s sort of rivaling flu. That’s what the data from from the UK has to say.

Howard Forman: And just to be clear, when you say the infection fatality rate is down, we’re talking about the overall population. So a lot of that is impacted by prior vaccine, by prior infection-acquired immunity and the presence of Paxlovid and other therapeutics, right?

Harlan Krumholz: So I think this is, yeah, there are three things involved when people sort of hear about this. One is what’s going on with the variant itself. What we’re seeing is increased infectivity, that as this virus evolves, it gets a little smarter about how to spread among we humans. And so it seems to be doing so with sort of greater ease over time. The pathogenicity, the danger of the variant, if anything, seems to be decreasing, but how it manifests in our population has to do with what treatments we have available, the host, us, how we are, and the virus itself. And I say that because when we were in February 2020, March 2020, even end of January 2020, the U.S., no one had ever seen this before; their bodies weren’t prepared. Not only were there no vaccines, there had been no prior infections. It was a naive, we call naive population. So we were very susceptible. Susceptible to the harm and susceptible to the infection.

The population has changed now. Lots of people have been infected. So they have antibodies hanging around, and vaccinated, as you say, there are now some treatments that are effective, and the virus itself doesn’t seem to be taking a turn towards more dangerous. If anything, it seems to be a little bit less dangerous. Now, the pace of emergence of new variants with even higher transmission potential continues to be concerning. And we’re seeing even out of South Africa the emergence of several new variants, but a question that experts that I talk to have is whether or not... I mean, these variants are coming off the sort of same tree—they’re very close to the prior ones—but we’ve had some major emergence of variants that are very different. Omicron was very different than, for example, Delta that preceded. And so the question is about whether that’s going to happen.

So that’s all kind of percolating in the background. I’ll just say one more thing that might be on people’s mind, which is, what about this second booster, the fourth dose of the vaccine. In this country, it’s authorized for people I believe over 50, and yet not many people are getting that. In fact, not a lot of people have even gotten the third dose in this country. And as you know, there’s still people who haven’t been vaccinated at all. But the evidence out of Israel, and that’s the best evidence there is, suggests that that fourth dose, if you get to that far out, does provide a pretty durable protection against severe disease. There’s some question about whether the short-term protection against infection, whether that protection wanes, it’s only short-term, maybe eight weeks, something like that, but the protection against severe disease seems to be more durable.

And then one more thing of interest. Some people are saying, well, I’m going to hold out for the next generation of vaccines. And I can only say that the data so far from Moderna is that this one that is including the original plus beta booster, that is bi-valent—it’s got more coverage—hasn’t so far shown that it’s better than the original. So why is that? I know a lot of people are discussing issues around what the mechanism of that might be. But so far, we don’t have evidence that the vaccines around the corner are dominantly better than the ones we have now. But there is a thought: maybe by the fall, we might have one that might be better. But if you’re going to get the fourth dose now, that’ll be six months later. Likely it’ll be time for a new one. So we’re still sorting all this out. I don’t know whether you got the fourth dose, but my parents did. And I actually, this week I decided I was going to get the fourth dose, and I went ahead and did it.

Howard Forman: Yeah. My parents obviously got the fourth dose a few weeks ago. I’m still not, but I’m exactly six months out this week from my third dose. I’m trying to wait out a little bit longer, but that’s what I tell people, if you’re at high risk for a adverse outcome, that you should be being fully vaccinated. And I tell people, please test early and treat early. The testing is still really important for people at high risk in particular, because it allows you to get treatment earlier. And the treatments we have now do make a difference.

Harlan Krumholz: The only other key news I think is that there’s a lot of talk about what the right, for Paxlovid, whether or not people who stop it according to the current recommendations end up rebounding there. We still have stuff to work out around treatments, vaccines, this epidemiology. It’s interesting, two years in, lots of progress, still lots of questions. Still lots of questions.

Howard Forman: Couldn’t agree more. I’ve said to people, like, just because we did a trial using Paxlovid for five days doesn’t mean that’s the right dosing. Maybe it should have been seven. Maybe it should have been three with a few days off and three more. We don’t know, but hopefully we’ll get those answers.

Harlan Krumholz: Yep. Yep. Okay. Let’s get to our guest, Howie.

Howard Forman: I’m really excited to introduce Dr. Cece Calhoun. Dr. Calhoun is an assistant professor of medicine and an assistant professor of pediatrics in hematology at Yale Cancer Center. She’s a hematologist oncologist who specializes in adolescents and young adults with sickle cell disease. She wants to help bridge the health literacy gap between providers and young sickle cell patients and has dedicated her research work to systematically improving transitions of care from adolescents to adult sickle cell care. In 2019, she received the Pozen-Commonwealth Fund Fellowship in Minority Health Leadership at Yale. That’s how I met her. And she is one of the health equity champions at Yale’s Equity Research and Innovation Center led by Dr. Marcella Nunez-Smith. She received her medical degree from Wayne State University in her native state of Michigan, her master of science in public health and clinical fellowship at Washington University School of Medicine. And now obviously her MBA from Yale University School of Management.

So first of all, could not be happier to have you joining us today on the podcast. And I want to start off by asking you to tell us what your journey has been like, because I’ve heard you tell this before. I want to hear about how you go from Michigan to St. Louis to Yale, and what is your thought process about how you’re going to impact the world?

Cece Calhoun: Yeah. So first of all, thank you both for having me. It’s such a fantastic... it’s always great to be in conversation with you, but I also appreciate the opportunity to talk about my own work but highlight sickle cell patients. So before I start talking about me, thanks for giving me the space for them. So that’s such an interesting question, because I think when you look back in hindsight, things kind of coalesce in ways you never imagined, but I think I knew that I wanted to make an impact. I didn’t know how that was going to be. And each piece at every step kind of has become more and more clear. And I hope that it continues that way. So like you said, I was born and raised in Detroit, Michigan, best city in the world. Don’t argue me about it. And I grew up on the east side of Detroit, which is notorious for kind of being the less refined side of town.

I kind of don’t think I realized I had any disadvantages or that I was poor until I went to a very nice private high school in the suburbs. Cranbrook Kingswood is the name of it. For reference, Mitt Romney went there when his dad was governor, and we had like a Penske and Hertz family. It was designed by Eliel Saarinen, whose son designed Ingalls Rink here and the arch in St. Louis, so that was kind of a full circle moment. But one of the biggest things it did for me was exposure. Right? It showed me the huge contrast in every level of kind of privilege. And in many ways I was able to access that and have space to be curious.

And I remember thinking when I was in high school, I was like, oh, I really like working with athletes, I really like... maybe I want to be a physical therapist, but a girl I played basketball with, her dad was chief of general surgery at this local hospital. And he was my... I consider him to be my first mentor. And he said, “Cece, I don’t know, you sure you don’t want to be a doctor?” So for the month of May in our senior year, we got to do a senior May project. He’s like, “You should come shadow me.” So I got to shadow him in the hospital as a high school student because he had authority. And that was my exposure to medicine. And I was like, yeah, I do think I want to do this.

And when I went to undergrad, that’s when, at University of Michigan, that’s when I kind of developed this, really, social justice lens. And while my family growing up—and particularly my father—had always encouraged my sister and I, had ingrained in us a deep sense of pride about being Black and our culture. It coalesced with medicine for me when I got to undergrad. I was like, yeah, I still want to be a doctor, but I want to do something that’s going to impact my community. Right? And so that was the first time I participated in research. I got to work with this anesthesiologist, Carmen Green, who looked at prescription medication availability by zip code. That was my first exposure to kind of like health disparities and what does that look like.

And there are inequities. It’s not just from when I went to high school and I’ll look at all these fine things here in the suburbs; it happens in our medical care. And I was like, okay, cool. So I’m not going to be... I don’t think I’ll be an orthopedic surgeon anymore, but I do want to do health and I want to do it in a way that affects my community. And so I applied to med school and came back home for med school, which was, I think, one of the biggest gifts for me, because it’s such a challenging time. And to be surrounded by my family, they kept me grounded. My pediatric rotation was the hem-onc [hematology-oncology] floor at a children’s hospital in Michigan. And that’s where I saw my first sickle cell patient who had a stroke. She was eight years old, and she had a overt stroke and she couldn’t move; I think it was the right side of her body.

Now, in hindsight, I know that shouldn’t, shouldn’t happen. We should be screening for vascular changes in persons with sickle cell age zero to 16. And so we should have been able to detect that and have her own chronic transfusions. And maybe she was identified, and maybe there were barriers that we don’t know about. For me, that left an impact. And so I was like, okay, this is it for me. It’s medicine. It’s my community. I love the science. I’m going to work with patients with sickle cell.

Howard Forman: So I just want to make sure, for our listeners, can you just tell us again, what is sickle cell disease?

Cece Calhoun: So sickle cell disease is an inherited disease of the red blood cells. It’s something that patients are born with. And I often explain it that instead of looking like a jelly donut, which is kind of what our normal red blood cells look like, the cells because of a small change in our genetics result in a shape that looks like a banana or a crescent or a sickle. In addition to being misshapen, they’re also very brittle and very sticky. And if we think about our blood vessels as pipes, those cells can get kind of clogged up in the pipe, stick to one another and damage the blood vessels. In any place in our body where there’s small blood vessels, you get consequences from sickle cell. Most people think of it as pain, and that’s the most common presenting place, but just like that eight-year-old that I saw, any place where we have tiny vessels, like our brain, can be subject to complications from sickle cell.

And oftentimes this overlies a background of socioeconomic disparity, of injustice in health, making the care of patients with sickle cell much more complicated. And so when I saw this young lady, when I was in med school, who was eight, for me it represented the nexus of all the things that had been important to me. And it’s become more salient to me because I grew up on the east side of Detroit. Every vaccine I got was in a federally qualified healthcare center [FQHC]. I now recognize, likely that physicians taking care of me were in my neighborhood working because they wanted to help get their student loans. We had the area where there was incentive for student loan repayment where I lived. And I’m thankful for the care that I got. And so now I think that it is my job as a healthcare provider not just to change policy and practice through research but to also take all the knowledge I have and give it to people who were me, who were the girl in FQHC, to care for themselves. And I think that happens on every level, and that’s kind of what has motivated my journey.

So I think I stopped at med school. So I kind of knew then. I was like, I’m going to be a sickle cell doctor. I want to do transplant. Right? Which is the only cure. I was like, this is the only cure for sickle cell. Naturally, if you’re going to affect the people, you got to do transplant. Right? But as I went through my fellowship, and again, this is the importance of mentors to me, I met a woman, Allison King, she’s an MD PhD. She has her MPH at Wash U [Washington University in St. Louis], she’s a pediatric hematologist as well and she does health outcomes research, who helped me understand the impact I could have through outcomes and clinical research and how I could reach more people than just the ones that I see in clinic, but ones that I may never see, through doing rigorous research and taking this passion and putting it into a career. And so that’s when I was like, okay, I’m going to do research.

I like interacting with people. I love taking challenges that I see in clinic and getting the privilege to say, okay, let me answer them in a rigorous and structured way. And it’s a true gift. And so, I have mentioned, it’s kind of funny because my family is like, “Well, you’re a doctor. You see patients.” There are no doctors in my family at any level, no cousins, nothing. And so they’re like, “But wait, okay, wait, how many...? Okay. But if you’re not in clinic... Well, what do you mean, girl? What are you doing?” And so I’m trying to explain to them, like, “Yeah, I see challenges in clinic, and then I try to use these methods, and then I ask these questions, but I spend a lot of time writing.” And they’re like, “Okay.” But it is really, really a privilege that I hope will have lasting impact.

And that work has led me here. And to you, Howie, to the School of Management. Because one of the beautiful things about research is that when you ask questions, you end up having more questions. And learning about the barriers that sickle cell patients face, I realize it’s kind of a systemic issue, and I don’t really know how this system works. And so the opportunity for the Pozen-Commonwealth Fund Fellowship opened up for me to get that knowledge. And now I’m just trying to apply it and do my best.

Harlan Krumholz: No, that’s terrific. Here’s a question I have for you just listening about your journey. Early on in high school, you end up in an environment that’s very different from where you’re growing up. We hear a lot and talk a lot about how we can create the means by which we can create more diverse and inclusive schools and workplaces, and medicine’s got so much work to do in this area. And one of the central challenges is that, okay, you bring somebody in, how do they feel welcome? How do they feel safe? How can we help them feel confident? Maybe you could just reflect a little bit, what was that like at the beginning and what were the skills, and what can we learn from your journey that can make it better for people who follow, besides just making sure that our environments and our ecosystems are more diverse so that people don’t feel that it’s such a foreign place? But can you reflect on that a little bit?

Cece Calhoun: Yeah. So I think one thing, too, I lived on campus, so I was a boarding student at high school. So I was like 13, living away from my parents.

Harlan Krumholz: How far was it from your home?

Cece Calhoun: Probably like 45 minutes, which seemed like a lifetime.

Harlan Krumholz: Yeah.

Cece Calhoun: But it was really kind of preparation for the future.

Harlan Krumholz: I mean, you must have been nervous just to start there.

Cece Calhoun: Oh, the first day, I cried and I cried and I told my dad, “I want to go home.” Okay?

Harlan Krumholz: Yeah, I bet.

Cece Calhoun: In fact, when I was applying for the scholarship that paid for my high school, I had gotten really absent. I was like, I don’t want to go, I’m not taking the test. And my mom called my grandmother, and she was like, “Just try, baby.” And I was like, “Okay.” And then I ended up getting the full ride, and she was like, “You’re going.” And the first day I was like, “I want to go home.” And I mean, the campus is gorgeous. Okay? Beautiful. Yale looks great. Okay? But my high school campus... Okay?

Harlan Krumholz: Yeah, yeah.

Cece Calhoun: ...is beautiful. Okay. And I just cried, and I wanted to go home. And I just remember my grandma saying, “Okay, just try. Just try.” And I mean, high school is such a developmentally important place. You are a young person. You’re trying to figure out your way in the world. That was one of the spaces I got to do. And so for me, I think part of it was a foundation that my parents had already set in terms of the pride I had and being like who I was, but I think it was my high school experience that kind of taught me that it’s important to know yourself, especially in the spaces where you are the only one. And it’s something that has carried me through every experience. I am often the only one.

Harlan Krumholz: Yeah, still, right? Still.

Cece Calhoun: Even still. Yeah. Even still. And it’s 2022, which is very strange. Right? But I think that was where I started to lay the foundation of really getting to know what is important to me in my own why, but I would’ve never been challenged to do that at that age if I was still in a familiar environment. I think the second piece was never, ever underestimating the importance of our educators, and having adults and mentors and sponsors—Howie—who believe in you when you don’t believe in yourself. Right? When they see you... When you see yourself as a small, somebody who’s small and unimportant, but there are people who you admire, who really pull out of you, things within yourself. It’s so important. Because it’s hard. It’s a very... it can be very, very challenging.

But I really believe that the work that I do, that we do, the community that I have, that we do is so important. And there have been moments where there’s so much room for self-doubt, always. But then I think about the undergrads that I mentor who are trying to go to med school, and that’s like the final... it seems like the biggest thing in the world for them, is to get into med school. And you’re like, no, actually there’s steps after that and you can do this. You’re capable.

Or I think about my own research lab and team I’m building, one of which has Howie’s students in it, and she’s just, the young lady is just incredible and brilliant. She’s applying for her first award, and we took some time as a group to kind of like talk through it. And I’m like, “If they don’t pick you, they’re fools, because you are the best person for this job.” And her saying to me, “Cece, that means a lot, being in this space means a lot.” Because when I was in high school and everybody looked different from me, and when my peers who are also learning to mature also are like, “What are you doing here?” I think having a community around you that sees you, that believes in you, and that allows you to be your full self is so important.

And so I think one of my biggest privileges is being able to be authentic in every space that I’m in. Like even now, I feel that all the work that I do is for my sickle cell patients is to...but one of my biggest successes is being able to see others and make them feel seen by being my authentic self. And I think I learned that lesson in high school.

Howard Forman: What—

Harlan Krumholz: Howie, I want her. I want to sign up. I want her to be my mentor. I’m actually going to get in line because—

Howard Forman: She is, she is inspirational. And I don’t want to let her go without talking about the unique work that she does, bridging pediatrics and adult sickle cell treatment and management. And also for you to even reflect on the fact that when you were at Wash U you were in the Department of Pediatrics, and now you’re in the Department of Medicine doing the same basic job. So I’m just curious if you want to just give us a couple of minutes on that.

Cece Calhoun: Yeah, absolutely. So what I really try to do is leverage the methods of implementation science, which is all about increasing the uptake of evidence-based practice into usual care, leverage that to really overcome, efficiently overcome the barriers that adolescents and young adults with sickle cell face as they transition from pediatrics to adult care. There is very clear and objective data about the rise in mortality around that time, about the increase in utilization around that time. So we know that transition period is a problem. And the first phases of my work really said why, you know, and corroborated by my colleagues across the nation about how complex it is, about how it’s just not about sickle cell but about the many factors external to our healthcare, well, within and external to our healthcare system, that impact their ability to access care. The way they perceive themselves, the way they engage with providers, the way they navigate their own communities, all are challenging. Right?

And so implementation science is saying, well, if we have something evidence-based that we can use, let’s get it going. And so I know that there are guidelines, the American Academy of Pediatrics has produced guidelines about transition. And there are other organizations who are doing great work. And so my question is like, all right, so we got providers who want to do the best job, we got patients that want to be well. What are we missing here? And these are the questions that I try to answer with my own work. We had our lab meetings today and I have some very curious data, so I’m kind of excited about that, but that’s what I try, what I try to bridge. And I think I learned a lot about implementation science at Wash U, where there’s some great folks who have written and really are leading our field in the application of implementation science to healthcare, and who have served as mentors, who have given me great advice throughout that.

And so with young adults with sickle cell, okay, so I always like to tell people, look, like you were saying, look, I’m a doctor now, right? I’m successful, right? But when I was 16, 17, 18, 19, 20, you do really silly things. Okay? You fall and crack your head. And I don’t have a chronic disease. And so you add onto that a chronic disease that shows up in a variety of ways, you add onto that poverty, you add onto that stigma, and then you can see how hard it could be to get through those spaces. And then when we think more practically about that is, there’s a possibility of an adult hematologist who, ah, care for sickle cell patients. Okay?

When I think about myself individually, like how did I end up on medicine, it’s because in researching transition patients, I care for them. In clinic, those are my kids. Those are my people. So that spans both pediatric and adult populations. And so even when I was at Wash U, my title was in pediatrics, but I was, had clinic in our adult hospital, where Howie did residency. So here, I was able to really do that. I am able to do both here and have an appointment in medicine.

Harlan Krumholz: Let me just ask you one quick question about this, because I really enjoyed the papers that you’ve written. I like how you are sort of bringing together the mixed methods, I really love when there’s some qualitative research in there that elicits, really gets to amplifying the voice of the people you’re trying to help and learn from them. And anyway, there’s so much here that’s so interesting, but... there’s no “but.” The one thing that came out for me that I wanted to ask you about is these kids, as they make this transition, there’s so much that they’re still dealing with developmentally, especially in the adolescent period, what have you learned about how best to connect with them?

Because you were talking about educational interventions; you’re talking about breaking down barriers, making it easier for them, and a lot of times, this isn’t the most important thing on their mind. Right? So I just wonder, as I was reading your work, it just was striking to me how important it is around, I call implementation science, it’s like, how do we actually do this?

Cece Calhoun: Yeah.

Harlan Krumholz: How do we get people engaged and so forth? But what wisdom have you generated, do you think, around how to actually reach a lot of these people?

Cece Calhoun: So that is a great question. Right? So I think one of my value propositions is showing up as an African American and to care for patients who are majority African American. I mean, sickle cell is an evolutionary trait, and anyplace where malaria is endemic, that’s where sickle cell trait is prevalent. And because of the transatlantic slave trade, here we are. Sorry to be crass, but... I think part of it is—

Harlan Krumholz: No, it’s not crass. It’s truth.

Cece Calhoun: It is truth. But part of it is that engagement in clinic. But that value proposition is the fact that I don’t have to overcome a lot of like cultural nuances to communicate with my patients about why I’m asking you to take hydroxyurea, or understanding what is important to them, which to your point is kind of the beautiful part of how qualitative research, right, it’s not prescriptive. It’s saying, well, what do you need? Okay, let’s understand that and let’s pair with what we know, or what things are working. And I think that is an approach that we need to have, whether it is in clinic or whether it is in our research. We have to shift our culture a bit to say, well, what is it that is actually important to the people we are trying to serve? Okay? And, I think, understanding that. So it may not be transitioning to adult care.

For the young adults I see in clinic, my priority might be like, I really want to work, or all my friends are doing X, Y, Z. And so then how do I frame my care around that? Listen, I want you to do that too. In order for us to get there, here are the things that keep you out of the hospital, away from me, with your friends. So it’s saying, like, what do you want and how do we move our system, move our practices to help them get there? I think that is one of the things that’s most important.

And then I think the other piece is what are the things that can hold them accountable? Right? Because everybody doesn’t have a mom and dad. Is it an auntie, is it a CBO [community-based organization] that they go to? Is it their teacher? Who are the people in their lives that are helping to hold them accountable, and how do we as a healthcare system support those folks, too? So we focus a lot on our patients, obviously, but a lot of the transition in my work is with the parents, too, saying like, hey, back up a little bit, less so and so, or finding supports in place like, okay, well, we believe in you, we got you, and if you struggle, go to mom, go to your auntie here. That’s one of my aunties.

Harlan Krumholz: Well, I’ll just say... well, and I know we’re getting to the end, but I’ll just say that I think it’s a model for the entire healthcare system. Because what you’re saying is, we look at the whole patient.

Cece Calhoun: Absolutely.

Harlan Krumholz: And we look at the context of their lives and the issues that they’re dealing with, and then the medical stuff is part of that, but it’s not defining of them. We have to understand the whole thing. I really, I love all the stuff you’re doing. So appreciate that you took the time to be with us today.

Cece Calhoun: Anytime.

Harlan Krumholz: And I just say, I think it’s important work, not just for sickle cell, but it sets a really great example for how we ought to be thinking about holistic care and culturally sensitive care for whatever population we’re dealing with around us. And then you sharing your personal story, by the way, you know I’m not going to forget that. That’s really—

Cece Calhoun: Oh, thanks, guys.

Harlan Krumholz: ... amazing.

Howard Forman: Thank you.

Harlan Krumholz: So thank you so much for that.

Howard Forman: Thank you so much for coming, Cece.

Harlan Krumholz: That was really great.

Cece Calhoun: Yeah. Anytime. It went by so fast.

Harlan Krumholz: Hey Howie, that was really great. So what’s on your mind now besides what we’ve been talking about?

Howard Forman: Yeah. So it’s not often that I can come up with something that’s inspiring, but this week I can. I don’t know that I’ve made a movie or a TV recommendation here before, but I want to make a pitch for a show called Heartstopper. It is an LGBT series targeted at adolescents, but a former student who happens to be a surgeon now recommended it to me. And I was inspired by it. It is about a circle of high school friends finding their level of comfort with being gay, lesbian, and transgender in a society that is overwhelmingly not. And until you watch it, you don’t even realize the massive void it fills.

Owen Jones, a popular writer in the UK, in The Guardian wrote, “Young LGBTQ+ people now have a show with relatable and frankly adorable characters who face hardship, but who also have the possibility of happiness. Because of that, this show will be a lifeline for many.” And he means this literally since LGBT youth are four times as likely as they’re straight peers to attempt suicide. Positive representations can only help, but they remain sparse. And it gets back to some degree to our guests today talking about representation.

You can find any number of family-oriented shows featuring straight characters with a “coming of age” storyline, but there is an absolute paucity for LGBT folks, and such a marginalized group might need this the most, even if all teenagers face angst and challenges. Suicides and behavioral health challenges among children and young adults have recently risen to historic levels. For most of media history, members of the LGBT community have been relegated to second fiddle, playing either the foil, the fool, or the villain. Tolerance might be found, but never really full acceptance. And we are now at a time when even tolerance seems to be fading in many areas, with bills passed in Florida and other states that put such youth in the crossfire of culture wars. This show doesn’t portray utopia, but to use Mr. Jones’s words again, “Queer people living and loving, finding acceptance and yes, confronting challenges like anybody else and seeking to overcome them.” It is available on Netflix. I recommend it to anyone, whether you’re straight or LGBT, whether you’re young or old, single or attached, let me know what you think.

Harlan Krumholz: Well, that sounds great. By the way, Netflix needs some good news this week, so it’s good that you’re promoting their programming, but—

Howard Forman: I am. I’m giving them help.

Harlan Krumholz: This contrasted with the story in The New York Times this week on Ed Koch. It just reminds me how recent it is that even someone in a position of power and influence felt cowed by public opinion and what would be the consequences of just admitting his sexuality and enable him to be his authentic self, that he had to hide who he was all those years out of fear. And it just wasn’t that long ago. I mean, by the way, people of course still face a lot of challenges today. We know that. I’m not minimizing that, but I mean, it’s just recent history that, the Ed Koch thing, I don’t know, that story really touched me also, just to think, the pain that he was in.

Howard Forman: Yeah. And let me just say this, I was 12 years old when he was elected. I knew I was gay at that age, and he was pretty much known to be gay or at least it was a very strong innuendo at that time. And the one lesson I learned was that you had to be ashamed of yourself if you were gay, that it was not something that you could be comfortable about. And that’s why this show means so much to me because children need to see that they’re not freaks, that they’re not outsiders, that they shouldn’t be ashamed of who they are. And I will say that story about Ed Koch impacted me the same way you are talking about it. It reminded me of the shame I felt.

Harlan Krumholz: Yeah. And you’re reminding me that it not only harmed him but so many others, and including the article talks about the impact on AIDS and HIV and so forth because he was inhibited to really take on the issue because of those. But anyway, thank you for sharing that, Howie. That’s amazing. And I’m definitely going to take a look at that. That sounds great.

Howard Forman: Thanks.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale, that’s H-M-K Yale.

Howard Forman: And I’m @thehowie, that’s @ T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.