"Bent Nail" Research and "Make It Plain Advocacy"

A clinician's patients taught him how to make a difference.

Posted Nov 05, 2019

Not long after arriving at the University of Illinois at Chicago in 1995, I got to know Carl Bell, whose writings on violence and trauma in the African American community were already well known to me. He famously taught all to “get rid of the rat,” a metaphor for the public health approach – addressing the community-level factors which drive individual health – poor services, violence, drugs and alcohol, education opportunities, incarceration, racism – what in global health we now call the social determinants of health.

At that time I was working with a different traumatized population: refugees from Bosnia-Herzegovina. I was looking for innovative solutions that fit their context and culture which could advance the science in refugee health. I latched on to another core Carl Bell teaching point –  everyone, even under the most adverse and traumatized conditions, has protective resources – which in the case of Bosnians seemed to lie within their strong multi-generational families – and in global health, discourse is what we now call resilience.    

I found a very helpful model in Carl Bell’s CHAMP program (Chicago HIV Prevention and Adolescent Mental Health Project, along with Dr. Roberta Paikoff and Dr. Mary McKay) which was an NIH funded UIC initiative that developed and evaluated a prevention curriculum for youth and families in schools. From this model, I learned about prevention in mental health, and how to do NIH funded services research, and it became the basis for our CAFES program (Coffee and Education Family and Support) which we developed for refugee families from Bosnia and Kosovo in Chicago. 

Carl Bell took the CHAMP model to South Africa, also with NIH R01 funding, where it was successfully adapted. Under the leadership of Carl Bell’s collaborator, Dr. Mary McKay, now Dean of the Brown School at Washington University, the CHAMP approach has since been expanded and extended to meet the mental health and health prevention needs of youth and families impacted by poverty in many U.S. and global contexts. 

Again guided and inspired by Carl Bell and Mary McKay, we developed family interventions for refugees and migrants, which we have since brought (with NIH funding) to Tajikistan, Kosovo, and Turkey, and returned back to the U.S. for further work with refugee and migrant communities. All of this illustrates a key global health principle of connecting innovations and investments in low-income countries abroad and low-resource communities in high-income countries.

These are just a few of the many invaluable academic and life lessons taught by Carl Bell. I tell you now because, in August 2019, Carl Bell died suddenly and unexpectedly. He left us far too soon but left us with extraordinary gifts. 

Carl was a saint of service to African American patients, a saint of “bent nail” research and “make it plain” advocacy.  

I want to say a few more things about Carl Bell, by focusing on his latest work, Fetal Alcohol Exposure in the African American Community. 

They say don’t judge a book by its cover, but you can tell by looking at the cover, this is no ordinary book. We see a city liquor store below and Carl floating above, looking us in the eye with a pained expression that says, “I have a serious message to impart.” 

This book unravels the mystery of a modern-day public mental health catastrophe that particularly strikes African Americans. It outlines Carl’s journey of discovery in our nation’s “food swamps” – urban communities drowning in alcohol. 

Remarkably, it is also Carl’s testimony of his life as an African American physician, a practitioner of psychiatry, a researcher, and a thought leader.

It reaches way back to his grandfather, William Yancy Bell, who received a Ph.D. from Yale in 1924, to Carl’s days at Meharry Medical College, and to his lifelong love of his African American patients. 

It tells the story of how drawing on his “reference points”, he knit together the intelligence, the character, and the drive to become the man we all knew as Dr. Carl Bell. 

It shows how a physician took risks and learned to use science and advocacy to fight against a public health crisis and for the people.

You see, having known firsthand those of “high caliber black intelligence,” Carl rejected false understandings embedded in psychiatric knowledge that are based on racist assumptions. 

He said: “The idea of an inferior black culture does not make sense.”

Carl sought the truths that could make a difference in people’s lives and brought his science to the clinic. “To get proof, I relied on my predominately African-American clinical population to teach me the truth.”

As a Meharian, Carl learned to “do good work where it’s most needed” and to “do more with less” and to, “learn despite obstacles.”

Carl achieved scientific discovery in high volume clinical work. At Jackson Park Hospital, he observed African Americans with bipolar disorder being misdiagnosed as schizophrenic so he did another study.

He took Brian Flay’s super complex theory and distilled it down to 7 field principles:  rebuilding the village, creating access to technology, connectedness, social skills, self-esteem, reestablishing the adult protective shield; minimizing the effects of trauma.

This became Carl’s sacred text which he preached in the hallowed halls of the NIH and the National Academy of Science, in innumerable community meetings and countless media stories.

Carl called himself out for being blind to the pervasive destructive impact of alcohol: “Much of the prevention work I was doing in the African American community was missing the boat.  None of it directly focused on the issue of Fetal Alcohol Exposure that I later realized was one of the root causes of all the problems I had been studying in my career.”

To investigate fetal alcohol syndrome, he first reflected on clinical encounters and case studies, suspected a pattern, then did a chart audit at the Community Mental Health Council, then a study of recently admitted inpatients at Jackson Park, next a random sample of outpatients, and then a formal chart review in a family medicine clinic.

Through the book, he humbly says: “I never realized”  “I did not understand”  “We missed the boat”.  And so he observed his community.  He listened to his patients.  He checked the charts.  Until he understood.

This took incredible curiosity, tenacity, commitment, compassion, and scientific rigor. 

Thankfully, Carl had enough time to complete this last chapter of research, to put it on the page, to make sure that we “get it.” He told it in a scientific language in the journals, and in plain language in the media and in this 138-page book so that everyday folks and policymakers get it too.

Carl’s quest is by no means over – not for fetal alcohol, mental health care, or violence prevention.  It is our quest too and he is counting on us to carry it forward.