17 January 2020
Dear Interested Readers,
The Power and Importance To Healthcare Of Dr. King’s “Letter From A Birmingham Jail”
Why are black people sicker, and why do they die earlier, than other racial groups? Many factors likely contribute to the increased morbidity and mortality among black people. It is undeniable, though, that one of those factors is the care that they receive from their providers. Black people simply are not receiving the same quality of health care that their white counterparts receive, and this second-rate health care is shortening their lives.
In 2005, the Institute of Medicine—a not-for-profit, non-governmental organization that now calls itself the National Academy of Medicine (NAM)—released a report documenting that the poverty in which black people disproportionately live cannot account for the fact that black people are sicker and have shorter life spans than their white complements. NAM found that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.” By “lower-quality health care,” NAM meant the concrete, inferior care that physicians give their black patients. NAM reported that minority persons are less likely than white persons to be given appropriate cardiac care, to receive kidney dialysis or transplants, and to receive the best treatments for stroke, cancer, or AIDS. It concluded by describing an “uncomfortable reality”: “some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care.”
That quote does not come from an article in the medical literature. “Implicit Bias and Racial Disparities in Health Care” was written by Khiara Bridges, an anthropologist and attorney at the University of California Berkeley School of Law and was published by the American Bar Association. Before you become upset and concerned that she implying that white physicians are racist and that their individual biases are the explanation for the findings she goes on to say:
Thus, physicians’ explicit racial biases likely cannot account for racial disparities in health. That is, if physicians’ choices around which treatments to prescribe and which care to offer are harming their patients of color, it is unlikely that physicians are intentionally doing so; nor is it likely that physicians are aware that they have beliefs about people of color that negatively impact the way they practice medicine.
So what is the explanation?
…physicians, like the rest of the American public, have implicit biases. They have views about racial minorities of which they are not consciously aware—views that lead them to make unintentional, and ultimately harmful, judgments about people of color. Indeed, when physicians were given the Implicit Association Test (IAT)—a test that purports to measure test takers’ implicit biases by asking them to link images of black and white faces with pleasant and unpleasant words under intense time constraints—they tend to associate white faces and pleasant words (and vice versa) more easily than black faces and pleasant words (and vice versa).
She concludes by implying that our implicit biases arise from many factors including our culture, from the persistent segregation within our cities, and from the structure of our delivery system. We may deny personal biases of any kind, but the data is about how the results that the entire system delivers to people of color is hard to ignore.
The list of structural factors that make people of color sicker than their white counterparts is long. If providers’ implicit racial biases contribute to excess morbidity and mortality among people of color, we must recognize that individuals with implicit biases practice medicine within and alongside structures that compromise the health of people of color.
Malcolm Gladwell, whose mother is a Jamaican of African descent, reported his own inability to pass a test that shows he has no implicit racial bias in his book, Blink: The Power of Thinking Without Thinking. He suggests that implicit biases manifest themselves in our reflexive acts. His explanation would fit with Daniel Kahneman’s concepts of thinking fast and thinking slow. This line of thought suggests that our biases are the equivalent of knee jerk responses that occur without much contemplation. Since Gladwell reported that the test revealed him to have some implicit racial bias there has been some evidence to question the validity of the test’s ability to uncover subconscious racism, but that does not mean that most of us are free of some element of implicit racism. The test may be a better judge of implicit racism in a population than in an individual, and it becomes more valid for an individual if the test is taken many times, which Gladwell did do. Even those who criticize the test that Gladwell took, confess that there is no controversy over the fact that as a society, and for many many of us as individuals, we are not yet free of the biases and derivative damage to individuals, and to us collectively as a society, that are associated with our unresolved implicit racial bias. This is disturbing fact that is hard to admit, and is a painful reality for many thoughtful people. Our persistent difficulties with race have implications for us all. Our unsettled feelings about race even makes the expansion of healthcare coverage more difficult as expressed in the article, “Why Doesn’t The United States Have Universal Healthcare?: The Answer Has Everything To Do With Race” written by Jeneen Interlandi and published last August in the New York Times Magazine.
Dr. Martin Luther King, Jr. gave his life leading the Civil Rights movement of the fifties and sixties. We remember him for his combination of wisdom, courage, committent, and effective strategies that made us face our explicitly racist laws. In his “Letter From A Birmingham Jail” he describes the origin of his passion, and why he was so committed to the “direct action” of non violence. I am sure that he was wise enough to know that even after the explicit racism that was so obvious in our laws that is described so well in “The Letter” was corrected, we would still have implicit racism. I believe his famous “I Have A Dream Speech” is his description of a world without either explicit or implicit racism.
Wednesday was the 92nd birthday of Martin Luther King, Jr. It is impossible for me to think of him without being overwhelmed by memories of what I observed and the attitudes that surrounded me as a child in the Jim Crow South. People whom I loved dearly were socially acceptable racists who did not understand that their view of race was unfairly injurious to people that they professed to honor and respect as equal creations of a God they both worshiped. In retrospect, it reminds me of the story about the power of culture that was told by the late David Foster Wallace, who surely was one of the the most important writers of the late twentieth century, in his speech and little book, “This Is Water: Some Thoughts, Delivered on a Significant Occasion, about Living a Compassionate Life.”
Wallace tells the story of an old fish who was out for a leisurely swim when he encounters two younger fish. The old fish asks “How’s the water, boys?” The younger fish look dumbfounded and wonder, “What is water?” What follows is a discussion of how many aspects of our lives go unnoticed and need more attention, especially our concerns for others. My takeaway is that we are influenced by cultural forces which we often don’t notice or fully understand. Implicit racism was the water I swam in as I grew up, and unfortunately there is evidence in our health statistics, in our courts, in our schools, in our places of employment, in the military, and yes, even in our churches, that so far our efforts to change “the water” have not removed the odor of implicit racism from our individual lives, our system of care delivery, or our communities.
It has become my habit when writing each year at the time of Dr. King’s holiday to mention Dr King’s famous quote about healthcare. Last year I discovered in an article from PNHP (Physicians For A National Health Program) by a historian from Wellesley College that suggests that the full quote about health care is inclusive of inequality and an explanation for his non violent resistance to the status quo:
“We are concerned about the constant use of federal funds to support this most notorious expression of segregation. Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.
“I see no alternative to direct action and creative nonviolence to raise the conscience of the nation.”
That form of the quote brings in our collective failure as a nation by connecting it to the loss of human life and is an explanation of his justification for the “direct action and creative nonviolent movement” to which Dr. King committed his life. It is a much more powerful statement than the quote that we usually see:
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane…”
It has become a belief of mine that the best way to honor Dr. King each year, and to make a small effort to continue the impact of his sacrifice, is to read his words with a devotion and focus that approaches the attention that we give scripture. As I wrote last March in a piece entitled “Thoughts From the Birmingham Civil Right Institute,” it is important to read his magnificent justification for direct action nonviolence that he wrote from jail to a group of eight clergymen, Catholic, Protestant, and Jewish, who had written a public letter, A Call To Unity, protesting the involvement of outside agitators (like Dr. King) and advising black protestors to leave the streets and patiently await justice from the courts.
I am particularly drawn to the letter because Dr. King’s vigorous response to the “concerned clergy” crosses my mind every time I hear a politician talk about the necessity to go slow with healthcare reform. Politicians who make these comments then expresses their concern for the negative impact that vigorous efforts to provide healthcare equity for those who are underinsured or uninsured might have on those of us who like the care we have now, and on all those employed in the systems of the status quo. Some of those same voices are seeking ways to further contract the porous social safety net that we have as a shabby defense against the multitude of barriers that we call the social determinants of (poor) health.
Those arguments negate the urgency of the painful realities of death and a greater disease burden of pain and suffering that is carried by the uninsured and underinsured in our country. Beyond those obvious realities is the immoral fact that implicit racial biases that we don’t seem to be able to eradicate produce measurable inequities in outcomes for Black Americans, even when they do have insurance coverage.
If you were born before 1950 you may well have a sense of the setting that goes with “A Letter From A Birmingham Jail.” If you were only watching shows like “American Bandstand” and “Wagon Train” in 1963, or if you were not yet on this earth in 1963, I would suggest that you click here for a very good five minute video that sets the stage. Come to think of it, everyone please watch the video, and then read the letter. If, after you watch the little video, you would prefer to listen to the letter, click here.
In jail, Dr. King had time on his hands, a cause to defend, charges to make against a callous white status quo, and a need to express his significant disappointment with the lack of “Christian” love coming from the white churches that should have been rallying to his cause, if they had any understanding of who Christ was, and what his message meant. The letter is didactic and it drips a high level of irony and intense intellectual sarcasm that emanates from his frustration with the slow pace of change, and his personal experience with racism that relegated him, his children, and twenty million other Black Americans to second class citizenship. I think it would be impossible for me to try to “condense it.” I will offer you some of the famous phrases that move me as bullet points after giving you his “introduction” which establishes his right “to be there.”
WHILE confined here in the Birmingham city jail, I came across your recent statement calling our present activities “unwise and untimely.” Seldom, if ever, do I pause to answer criticism of my work and ideas. If I sought to answer all of the criticisms that cross my desk, my secretaries would be engaged in little else in the course of the day, and I would have no time for constructive work. But since I feel that you are men of genuine good will and your criticisms are sincerely set forth, I would like to answer your statement in what I hope will be patient and reasonable terms.
I think I should give the reason for my being in Birmingham, since you have been influenced by the argument of “outsiders coming in.” I have the honor of serving as president of the Southern Christian Leadership Conference, an organization operating in every Southern state, with headquarters in Atlanta, Georgia. We have some eighty-five affiliate organizations all across the South, one being the Alabama Christian Movement for Human Rights. Whenever necessary and possible, we share staff, educational and financial resources with our affiliates. Several months ago our local affiliate here in Birmingham invited us to be on call to engage in a nonviolent direct-action program if such were deemed necessary. We readily consented, and when the hour came we lived up to our promises. So I am here, along with several members of my staff, because we were invited here. I am here because I have basic organizational ties here.
Beyond this, I am in Birmingham because injustice is here….Moreover, I am cognizant of the interrelatedness of all communities and states. I cannot sit idly by in Atlanta and not be concerned about what happens in Birmingham. Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly. Never again can we afford to live with the narrow, provincial “outside agitator” idea. Anyone who lives inside the United States can never be considered an outsider.
My favorite quotes from the speech follow:
- …we had no alternative except that of preparing for direct action, whereby we would present our very bodies as a means of laying our case before the conscience of the local and national community.
- Nonviolent direct action seeks to create such a crisis and establish such creative tension that a community that has consistently refused to negotiate is forced to confront the issue...So, the purpose of direct action is to create a situation so crisis-packed that it will inevitably open the door to negotiation.
- I must say to you that we have not made a single gain in civil rights without determined legal and nonviolent pressure. History is the long and tragic story of the fact that privileged groups seldom give up their privileges voluntarily.
- ..as Reinhold Niebuhr has reminded us, groups are more immoral than individuals.
- We know through painful experience that freedom is never voluntarily given by the oppressor; it must be demanded by the oppressed.
- For years now I have heard the word “wait.” It rings in the ear of every Negro with a piercing familiarity. This “wait” has almost always meant “never.”
- …when you see the vast majority of your twenty million Negro brothers smothering in an airtight cage of poverty in the midst of an affluent society; when you suddenly find your tongue twisted and your speech stammering as you seek to explain to your six-year-old daughter why she cannot go to the public amusement park that has just been advertised on television, and see tears welling up in her little eyes when she is told that Funtown is closed to colored children, and see the depressing clouds of inferiority begin to form in her little mental sky, and see her begin to distort her little personality by unconsciously developing a bitterness toward white people; when you have to concoct an answer for a five-year-old son asking in agonizing pathos, “Daddy, why do white people treat colored people so mean?”; when you take a cross-country drive and find it necessary to sleep night after night in the uncomfortable corners of your automobile because no motel will accept you; when you are humiliated day in and day out by nagging signs reading “white” and “colored”; when your first name becomes “nigger” and your middle name becomes “boy” (however old you are) and your last name becomes “John,” and when your wife and mother are never given the respected title “Mrs.”; when you are harried by day and haunted by night by the fact that you are a Negro, living constantly at tiptoe stance, never knowing what to expect next, and plagued with inner fears and outer resentments; when you are forever fighting a degenerating sense of “nobodyness” — then you will understand why we find it difficult to wait.
- …there are two types of laws: there are just laws, and there are unjust laws. I would agree with St. Augustine that “An unjust law is no law at all.”
- All segregation statutes are unjust because segregation distorts the soul and damages the personality. It gives the segregator a false sense of superiority and the segregated a false sense of inferiority. To use the words of Martin Buber, the great Jewish philosopher, segregation substitutes an “I – it” relationship for the “I – thou” relationship and ends up relegating persons to the status of things.
- An unjust law is a code that a majority inflicts on a minority that is not binding on itself.
- I have almost reached the regrettable conclusion that the Negro’s great stumbling block in the stride toward freedom is not the White Citizens Councillor or the Ku Klux Klanner but the white moderate who is more devoted to order than to justice…
- We will have to repent in this generation not merely for the vitriolic words and actions of the bad people but for the appalling silence of the good people.
- I’m grateful to God that, through the Negro church, the dimension of nonviolence entered our struggle. If this philosophy had not emerged, I am convinced that by now many streets of the South would be flowing with floods of blood.
- Oppressed people cannot remain oppressed forever.
- I gradually gained a bit of satisfaction from being considered an extremist. Was not Jesus an extremist in love? — “Love your enemies, bless them that curse you, pray for them that despitefully use you.” Was not Amos an extremist for justice? — “Let justice roll down like waters and righteousness like a mighty stream.” Was not Paul an extremist for the gospel of Jesus Christ? — “I bear in my body the marks of the Lord Jesus.” Was not Martin Luther an extremist? — “Here I stand; I can do no other so help me God.” Was not John Bunyan an extremist? — “I will stay in jail to the end of my days before I make a mockery of my conscience.” Was not Abraham Lincoln an extremist? — “This nation cannot survive half slave and half free.” Was not Thomas Jefferson an extremist? — “We hold these truths to be self-evident, that all men are created equal.” So the question is not whether we will be extremist, but what kind of extremists we will be. Will we be extremists for hate, or will we be extremists for love?
- LET me rush on to mention my other disappointment. I have been disappointed with the white church and its leadership. Of course, there are some notable exceptions…But despite these notable exceptions, I must honestly reiterate that I have been disappointed with the church. I do not say that as one of those negative critics who can always find something wrong with the church. I say it as a minister of the gospel who loves the church, who was nurtured in its bosom, who has been sustained by its Spiritual blessings, and who will remain true to it as long as the cord of life shall lengthen.
- I have heard numerous religious leaders of the South call upon their worshipers to comply with a desegregation decision because it is the law, but I have longed to hear white ministers say, follow this decree because integration is morally right and the Negro is your brother. In the midst of blatant injustices inflicted upon the Negro, I have watched white churches stand on the sidelines and merely mouth pious irrelevancies and sanctimonious trivialities. In the midst of a mighty struggle to rid our nation of racial and economic injustice, I have heard so many ministers say, “Those are social issues which the gospel has nothing to do with,” and I have watched so many churches commit themselves to a completely otherworldly religion which made a strange distinction between bodies and souls, the sacred and the secular...It [the white church] is so often the arch supporter of the status quo.
- Abused and scorned though we may be, our destiny is tied up with the destiny of America.
- Over the last few years I have consistently preached that nonviolence demands that the means we use must be as pure as the ends we seek.
It’s been 57 years since Dr. King wrote his letter. We have seen some changes, but three white supremacists have been arrested this week who were allegedly preparing to do something at an upcoming “pro gun” rally in Richmond, Virginia. We still have a long way to go before Dr. King’s “I have a Dream Speech” becomes a reality in our society, and the equity in healthcare access and outcomes that every American has a right to expect is an accomplished expectation. Many Americans are continuing to wait and hope for compassion and equity in healthcare, and in all aspects of their lives. How much longer can they wait? They have been waiting for a very, very long time, and I am afraid the answer to “how long?’ is still “blowin’ in the wind.”
Yes, and how many years can some people exist
Before they’re allowed to be free?
Yes, and how many times can a man turn his head
And pretend that he just doesn’t see?
The answer, my friend, is blowin’ in the wind
The answer is blowin’ in the wind
It’s Cold Again and That’s Good! Plus Some Other Stuff
It’s been a strange winter. Last Sunday it was near sixty. Yesterday we got five inches of fluffy fresh snow. Today, the high in New London will be 12. I feel like we have been on a weather yo-yo. Quite frankly, I like winter to be winter. I feel abused when we are whip-sawed between the cold weather of winter and a tease of spring. My wife does not agree. For her a perfect winter would be no snow.
With my wife’s preference you might ask, “Why don’t the two of you winter somewhere warm?” I think the answer is that we enjoy community. Being a part of community is negated by spending four, five, or six months somewhere else. Our resolution is to go away for a week or so to some place that is a little warmer a few times each winter. For us that’s pretty easy with family in North Carolina, South Carolina, Georgia, Florida, Alabama, New Mexico, and California.
During this strange winter, I am detoxing from sports. I was almost totally disinterested in the recent college football championship. I may be done with college football, and football in general. I am likely to watch the Super Bowl, if Jimmy Garoppolo and the 49ers are playing. If he is not playing, I will check out the offerings on PBS. Baseball is my passion, but this week we have learned that the art of “stealing signs” has been enhanced by technology, and has crossed some sort of line. There is something very strange about a world where there are pitchers who make over $7,000 for every pitch, whether it is a ball or strike, and where there are hitters who make $125,000 for every hit, whether it is a bunt or a homer. If don’t believe me do the math by dividing some recent salaries for hitters of note by the number 200, the number of hits they might be expected to produce. Their salary per hit goes up if they have a bad year! Next consider that the maximum workload of a great starting pitcher would be 100 pitches or less for about 30 to 35 games. At most, that is 3500 pitches in games per year divided by salaries that often exceed $25,000,000. Most of the “stars” don’t throw that many pitches in a year, so the gain per pitch goes up if they fail or are hurt. When the performance or non performance stakes can be that high, is it any wonder that there are those who seek an advantage from performance enhancing drugs or a “stolen sign.”
As I think about sports, I realize that there are some aspects of sports and entertainment where Black Americans have been treated with some equity, but even that was a struggle as the heroic story of Jackie Robinson demonstrates. When I say that there is more fairness in sports and entertainment than in other parts of our society, I also realize that there is still inequity in management in sports and entertainment, and as the recent Oscar nominations again reveal, there is inequity in the recognition of excellent performances. Sports, entertainment and the weather are not the only things I have been thinking about as we stand on the brink of who knows what in the continuing drama of impeachment.
One thing that I have come to enjoy no matter what the weather, no matter what sports event is pending, and no matter what historic event may or may not be evolving in Washington, is to go around my town looking for good scenes to capture with my smartphone camera. The header on this post is one of those pictures. Mount Kearsarge and Mount Sunapee are like bookends on either side of my town. Each mountain has a lake that lies in front of it. The combination of fields, woods, snow, lake, and mountain is a banquet for any person who likes to take pictures of what they see. My only comment about the picture is that I took it in mid December before Pleasant Lake was completely frozen. Look closely and you will see some open water.
As always, I hope things are well with you, and that this weekend you will be out and about with care because there is a big storm moving across the country and headed for us tomorrow! I will be greeting it with the joyous expectation of more snow! Winter is back.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
