August 27, 2021
Dear Interested Readers,
Structural Racism In Medicine
On Monday I found the August 26 edition of The New England Journal in my mail. As usual, I read the table of contents while standing in the post office in front of my mailbox. Usually, the articles that interest me these days are in the “Perspective” section at the front of the journal but this week the gold I found was near the end of the listing. I had scoped out “Remembering Past Lessons about Structural Racism–Recentering Black Theorist of Health and Society in the Medicine and Society section before leaving the post office and knew that I needed to share its message with you in today’s letter. The article comes from Johns Hopkins University and its authors Alexandre White, Ph.D., Rachel L.J.Thornton, M.D., Ph.D., and Jeremy A. Greene, M.D., Ph.D. represent a spectrum of expertise from the schools of arts and sciences, the medical school, and the school of public health. After reading the article which is well supported by forty-five references, my conclusion was that the authors have made the case that since the 1890s we have had irrefutable evidence of structural racism in medicine and have not made much progress in rectifying the damage to human life that results from the convenient racist idea that in some way Black human beings are physiologically, intellectually, and perhaps even morally different and inferior to the White race and those supposed differences in some way justify racist policies and structure even if those policies and structures shorten lives and are a correctable source of human misery.
The attitude of White superiority and the neglect of the contradicting scientific evidence that creates structural racism may be expected from those who have much to gain or maintain from our current “caste” system, but those ideas and positions are antithetical to the foundations of medical practice, medical education, and the structure of a healthcare system that has as one of its primary objectives improving the health of the nation. In the introduction to the story of the groundbreaking work of W.E.B. Du Bois and colleagues, The Philadelphia Negro, published in 1899, the authors write:
Imagine your city is being ravaged by an infectious disease epidemic whose morbidity and mortality are disproportionately borne by Black Americans. A prominent scholar of health disparities reports that this “strikingly excessive rate,” often misattributed to putative biologic or genetic differences between Black and White bodies, must be understood as a spotlight illuminating the fundamental racial inequities in American society. This structural impact of race and racism as social determinants of health, rather than any biology of racial difference, confers on Black Americans a higher risk of getting sick and lower chances of having access to or adequate service from the health care system.
They conclude that the scenario would describe our moment in time as COVID disproportionately ravages minority populations but the reference is to the 1890s. Writing about our times a little further along the authors continue [The bolding is my addition for emphasis]:
Since the first data on racial disparities in Covid-19 mortality were published in April 2020, and in the wake of widespread mobilization and attention to bodily effects of structural racism after the police killing of George Floyd last May, more health care experts have acknowledged the centrality of structural racism as a driver of racial and ethnic disparities in clinical medicine and public health. …Their work contradicts a prevailing myth that physicians are always impartial and that medical and public health institutions are somehow unaffected by the inequities and biases that saturate all aspects of American life.
We have reached an inflection point where understanding structural racism may become a central focus and core requirement of medical education, with social theory incorporated into health policy and medical practice. Though the mounting resolve to address structural racism as a fundamental problem in American medicine and public health is welcome and overdue, the existence and effects of that racism are not revelatory.
The theory and empirical grounding for this work were laid out more than a century ago by Du Bois and his colleagues in the Atlanta school of sociology…But their message was forgotten, actively suppressed by the very forces of structural racism they described. What would the health professions look like if every medical, nursing, or public health student studied Du Bois in their first year?
Wow! What a terrific question! As we shake our heads while reading about the controversies over mentioning “critical race theory” or associated subjects like “intersectionality” in public schools and universities we are not talking much about what we are doing in healthcare where one of the most effective vectors of change is the curriculum of medical education.
Over fifty years ago, when I was in medical school, the faculty was focused on how to promote the basic sciences. We barely had a mention of the fundamental aspects of health like nutrition and exercise, much less the social factors that often contributed more to the development of disease and early deaths than any infectious agent or genetic defect. It was not until 2007 when Stephen Schroder underlined the lethality of social issues in his Shattuck Lecture that the contribution of social issues to premature death was briefly brought to the attention of many academics. The curriculum was in flux back in the 60s, but the movement was toward even more basic science and not toward any attention to the social factors that were the origin of a major share of premature deaths. The hot topic of the time at my school was a proposal for a joint program between Harvard Medical School and MIT. More basic science was all the rage and in 1970 The Harvard–MIT Program in Health Sciences and Technology was launched. It doesn’t take long for some meaningful changes to become realities as long as no one is offended.
Beginning in the early 70s. Harvard Medical School under the leadership of Dean Robert Ebert did try to diversify its admissions, but I fear that Ibram X. Kendi would not accept that as an antiracist activity if it did not change outcomes. I can’t speak from first-hand experience as a student but in my forty years as an attending and practitioner within the Harvard system of care, I don’t remember any activity other than trying to diversify staff that directly promoted health equity or effectively reduced disparities in outcomes. I should add that although I became more sensitive to the issues of race and tried to go out of my way to be aware of my own implicit racial bias, I can’t point to any direct improvements in outcomes that I could say that I accomplished. Reversing 400 years of bias rooted in the misinformed position that there are biological differences in resistance to disease, stamina, and character will not go away by simple decree or by some individuals speaking out against a system literally built or structured on a foundation of racism.
The authors meticulously describe the work of Du Bois and his team as they gathered and analyzed the data which supports the thesis of structural racism and the resultant inequality and healthcare disparities between the White and Black populations living in Philadelphia as described in The Philadelphia Negro. They write:
Du Bois did not use the terms “structural racism” and “health disparities,” but his approach was closely related to these current concepts. He sought to describe how striking differences in health outcomes could be produced in different populations in the same city because of the racial demarcation of real estate, employment, and education and of intentional efforts to deprive Black Philadelphians, less than a generation removed from slavery, of full citizenship.
… The Philadelphia Negro… drew on extensive qualitative interviews with all families in the seventh ward (the neighborhood that was the focus of the study), combined with detailed surveys, archival materials, ethnographic and participant observation, and cross-checking of all qualitative and quantitative data to ensure accuracy across methods. It thus built a foundation of empirical social science methods that contrasted starkly with the often racist, casual, and anecdotal methods that were dominant at the time.
Du Bois’ methods were comparative and historical…It was not a single snapshot of circumstances as an indicator of absolute differences between groups, so common at the time. Rather, it described the differences in health and economic status in Black and White populations as historically and socially constituted by the dynamics of slavery and migration before and after emancipation…This approach illuminated both the general effects of living conditions on individual health and the specific and pervasive role of racism as a structural and organizing force of American society.
In Stamped From the Beginning: The Definitive History of Racist Ideas in America, which won the National Book Award for nonfiction in 2016, Ibram Kendi uses Du Bois as one of his five “guides” to understanding race in America since the sixteenth century. In the preface he describes why he chose Du Bois as the exemplar of his era:
The nation’s first great professionally trained Black scholar, W.E.B. Du Bois (1868-1963), our fourth tour guide, initially adopted Garrison’s racist idea [that Blacks should elevate themselves and assimilate into society]. But he also stood at the forefront of antiracist ideas, challenging Jim Crow’s rise in the late nineteenth century. Over the course of his long and storied career into the twentieth century, Du Bois’s double-consciousness of racist and antiracist ideas amazingly transfigured into a single consciousness of antiracism. In the process, however, his influence waned. In the 1950s and 1960s, racist arguments once again became the most influential ideas drawing Americans to the cause of civil rights. Later, civil rights and Black power advances–and the sensationalized “crises” of Black single-parent households, welfare “queens,” affirmative action, and violent rebels and criminals–all fed a ravishing racist backlash to the racial progress of the sixties…
It would seem that one of the greatest barriers to achieving progress toward equity and an antiracist America is the progress we make toward the goal. History would suggest that progress toward an antiracist society begets a backlash that reverses recent gains. There is no better example of this cyclic problem than the election of Donald Trump after so many scholars claimed that the election of Barack Obama signaled that we had become “post-racial.”
The authors continue with their explanation of the times of Du Bois and their similarity to our time:
Whereas Park [Earlier, the authors described Robert Park. He was a contemporary professor of social sciences at the University of Chicago who was a social Darwinist who preached that “racial differences were a given and allowed for only a very slow gradualist incorporation of Black communities into urban life.”] and his colleagues assumed that racial differences were fixed and health disparities therefore inevitable, early Black social scientists envisioned a science of health disparities that would support meaningful action to advance equitable health and social outcomes. They insisted that Black people were not a “problem” to be explained or solved by social-science and medical authorities, but human beings deserving of full personhood. In his 1903 book, The Souls of Black Folk, Du Bois asked, “How does it feel to be a problem? He worked to shift the goals of social analysis away from blaming social ills on individuals or groups toward a richer understanding of the ways in which power relations shape life and health outcomes…In the 1970s and 1980s, Black feminist theorists Audre Lorde and Kimberlé Crenshaw demonstrated how socially inscribed forms of difference such as race, class, gender, and sexual orientation did not inhabit separate coordinate planes. These forces intersect in powerful and synergistic ways, and understanding that intersectionality is crucial to elucidating how power relations produce social disparities. These perspectives…are now part of a basic toolkit for understanding health disparities. Mainstream medicine did not even acknowledge their contributions for decades.
I resonated with the concept expressed by the authors that despite growing concern about healthcare disparities in the Black community and in some political circles mainstream healthcare has been resistant to change and to viewing Black people as anything other than a collection of problems that engender healthcare disparities rather than the unfortunate recipients of the blunt end of policies that perpetuate an adverse mix of the social determinants of health. They accuse us of ignoring Du Bois and following in the footsteps of Park.
Instead, for most of the 20th century, mainstream physicians who thought about the social world emulated Park’s clinical detachment and deterministic sensibility rather than Du Bois’ community engagement and dynamic analysis. Perhaps that choice is unsurprising for a profession that routinely excluded Black physicians from membership in local, state, and national medical societies from Reconstruction until the late 1960s. Between 1944 and 1968, the American Medical Association voted 11 times to condemn racial discrimination in the abstract, while upholding the right of state and national medical associations to continue excluding Black physicians…Even when 20th-century physicians began writing about social determinants of health, they tended to focus on patients’ problematic behaviors, largely ignoring the actions, biases, or predilections of physicians — let alone the design of health care systems.
The authors realize that just rediscovering the work of Du Bois will not lead to change. They face that reality and ask us some critical questions.
Of course, mere rediscovery of Du Bois’ trailblazing studies of structural racism is not progress, nor is recognition of racism as a pervasive, persistent force within health care a sufficient strategy for remediation. How do we move beyond rediscovery to transformation that breaks this cycle and produces meaningful progress toward health equity? The most pressing question for the future of American medicine is whether we will act on the extensive evidence base that Black scholars and physicians have continued to build…To create a health system that recognizes the full personhood of Black patients and practitioners, we need to acknowledge the active process by which Black scholars have been marginalized and discounted.
The authors end their history lesson by expressing the hope that a rediscovery of the work of Du Bois, now 120 plus years in the past, might be a step toward more effectively managing healthcare disparities.
Recentering the work of Du Bois,.. and other Black theorists of health and society could help medical professionals, medical and public health scientists, and medical sociologists reckon with our skewed assessment of culpability for racial health disparities. It could prod medical educators, doctors, medical schools, and health care systems to question their assumptions and priorities in the interest of recognizing and rectifying medicine’s complicity in propagating inequities. Revisiting their work today helps us engage with race as a phenomenon continuously written and rewritten in the lived health disparities of millions of Americans. Only with awareness and knowledge can we change behavior, motivate action, redesign systems, and monitor progress toward equity and justice.
Could it be as they wish? Is this some new version of the path toward Dr. King’s dream or will healthcare and its leaders continue to focus elsewhere while paying lip service to the need to rectify the impact of 400 years of American racism in healthcare. I have listened to many interviews of black thought leaders. I am thinking specifically about interviews with Ta-Nehisi Coates, Nikole Hannah Jones, Isabel Wilkerson, Heather McGahee, and Ibram Kendi. When asked about what to expect they all demonstrate some reticence to express hope for change in the near term. I think that their apprehensions arise from their understanding of history and the disappointments they have experienced when the truth is treated as conjecture rather than an explanation that leads to actions that create real change.
Recently, when Ezra Klein interviewed Ibram Kendi, at the end of the conversation he asked the same basic question that I have heard many times before:
Ezra Klein
Let me ask you, as we come to the end here, if you could build a couple of institutions or implement a couple of changes that you think would really advance antiracism, what would they be? What are the things that you think are realistic but on the outside of realistic that you hope to see in the next five years?
Ibram X. Kendi
So let me just say one at a principle level and one at a policy level. I think the principle — and this becomes a principle within the courts, which, of course, is outlandish, but you asked. That instead of the current principle that was affirmed recently by the Supreme Court decision in Arizona voting law, that pretty much in order to prove that a policy is, let’s say, racist we have to show intent, instead, if a policy had disparate impact, then it could be defined as a policy that potentially needs to be eradicated and presumably is even unconstitutional or even is racist towards a particular group. To complicate it further, as we talked about earlier, certain policies can have disparate impact for different groups. But if it’s a policy that is, let’s say, primarily making it harder for Black, brown, and indigenous people to vote, and it’s not as hard for white Americans, then we would know that that’s a policy that the court should be striking down. I think at a policy level, to me, the two data points that demonstrate the cumulative effect of racist policies and practices and even ideas and violence and abuse are racial health disparities, but more specifically the life expectancy gap and the racial wealth gap. And I don’t know of a single policy in which we can eliminate the life expectancy gap, but I do know of a single policy that has the potential to eliminate, if targeted and implemented correctly, has the capacity to eliminate the racial wealth gap, and that’s reparations.
To use a common reference for absurdity or the unlikeliness of something happening, most folks, and I think that Kendi and other Black thought leaders believe to be true, “pigs will fly” before we have reparations. The closest thing to reparations that might eventually be produced by Congress would be social policies and legislation that help all Americans who are living in poverty. That is why President Biden’s extension of the definition of infrastructure and his American Families act is so important. With the situation in Afghanistan capturing most of the attention of the nation, the slim possibility that these pieces of legislation will pass in any form or size becomes more doubtful. Kendi’s answer and his recurrent theme throughout the interview was that outcomes matter. He seems to be suggesting that he believes that addressing medical disparities so effectively that we see an improvement in the life expectancies of Black and other minorities would be the sort of outcome that proves we have introduced a needed element of antiracism into the structure of healthcare. Despite all that we think we have done, we have barely begun. We have a lot of work yet to do.
I’m A Proud Granddad Who Is Pleased With The Changes To Be Seen
Today’s header is what you see when you look out of the window of my granddaughter’s dorm room. It was snapped on Tuesday, a very hot and muggy day, but otherwise, the sun was shining and “Henri” was just a miserable recent memory and not an active concern. Considering all the meteorological possibilities, it was a great day for the class of 2025 to show up at Bowdoin College.
As I tottered around the campus on my cane trying to be useful carrying light suitcases or holding doors, several things besides the spectacular campus scenery and facilities impressed me. The most notable of my observations was the diversity of the class of 2025. Here is the overview:
The 520 members of the Class of 2025 are:
- 51% men, 49% women
- 71% from outside of New England
- 40% students of color
- 12% international background
- 8% Maine residents
- 17% first generation to earn a four-year degree
- 13 states with ten or more students (CA, CO, CT, FL, IL, MA, MD, ME, NJ, NY, PA, TX, WA)
The demographics seem to be quite representative of the country and that fact alone makes me happy that my granddaughter is part of the class of 2025. I was delighted to learn that Henry Wadsworth Longfellow and Nathanial Hawthorne were members of the class of 1825 and that Hawthorne, like my granddaughter, lived in Maine Hall. He might have had the same view when he looked out of the window in his room.
I am not a novice observer of first days in college. I have had the experience many times, and at some very good schools where my four sons graduated: The University of Pennsylvania, Gettysburg College, Reed College, and Skidmore College. I think that if you were to plot diversity against “class of” you would discover that with each successive trip for a first day of college the diversity to be observed has increased. That is a very good thing, but the rate of change has been glacial.
The initial point to the plot on this graph of the Lindsey family’s experience with diversity in college might have been my father’s first day of college at Mars Hill Junior College in the mountains northwest of Asheville, North Carolina in the fall of 1937. I doubt there was any ethnic or racial diversity to measure then. At least his class was coed. I visited the campus with him about a month before his death in 2018 and can report that he noticed that there have been changes, though much of the campus remains as it was in his day. If you click on the link above you can see that old Mars Hill now calls itself a university and has a very diverse student body. Dad finished his last two years of college at Furman University which is also much more diverse than it was when he graduated in 1941.
My own first day of college is now almost sixty years in the rearview mirror. More than I realized at the time it was a historic day. On that hot September day in 1963, the University of South Carolina enrolled its first three black students since 1877 during reconstruction, and diversity began to climb the “y-axis” of my imaginary plot. The only thing that I remember about the day, which may be a distortion of my memory in time, was that the female student, Henrie Monteith Treadwell was initially the only person in an entire dormitory, and was protected by members of the South Carolina National Guard. I can’t confirm that fact, but it is what I remember. I hope that I am wrong or that her isolation was brief. Please click on the link attached to her name to read about Dr. Treadwell’s remarkable life and all her accomplishments in science and leadership after her graduation from The University of South Carolina.
The public schools in South Carolina were integrated very slowly after The Supreme Court ruled that “separate but equal” was unconstitutional in 1954 in the famous Brown v. Board of Education of Topeka. It took until September 1963, nine years after “Brown,” for the first African American student, Milicent Brown, a 15-year high school student, to be allowed to enroll in a public school in Charleston, South Carolina. All of South Carolina’s public schools were not integrated until the early 70s.
Perhaps it was because I grew up in the last violent moments of Jim Crow and witnessed the damage that injustice wrought on everyone in the community, or perhaps it was because I was a witness to the indignities of the protracted process of integration, or observed the frustrations of Black Americans created by the persistent resistance to the equity that has lasted throughout my lifetime that the diverse scene at Bowdoin seemed so important to me. My last “first day of college experience with one of my sons was in 2003. There has been measurable progress since then and it’s my hope that these fresh faces of the class 0f 2025 will accelerate the changes which are long overdue. Maybe someday “structural racism” in all aspects of life will be past history, and not an active concern. Structural racism is not history yet. It is still a current event, but I am already looking forward to measuring more change in this needlessly long and protracted process of social change when my next “first day” of college occurs in 2032 which should be when my oldest grandson enters college. The time does fly. So we must get busy to make 2032 measurably better than 2021.
Be well; be antiracist,
Gene
