Post #1: Introduction
The recent murders of George Floyd in Minneapolis and Breonna Taylor just up the road in Louisville have raised awareness of systemic racial injustice in our country. I believe it is important to comment on this topic and will use several upcoming posts to do so. I hope this generates some discussion and opportunities for continued learning and growth (starting with myself). First, some qualifiers:
- This is not a political statement. I want to focus on medicine and our programmatic response. However, any reasoned comment on this topic cannot ignore the role of policies in creating and maintaining structural racism.
- This represents my views and perspective. As program director, it also reflects our residency program, but I do not speak on behalf of my residents, faculty, departmental staff, or the broader university.
- Relatedly and most importantly, this represents the views and perspective of a cis gendered white man of high socioeconomic status. I am the beneficiary of race. I have no experiential knowledge of this topic, and while I have vetted these posts with several colleagues and peers, I am certain that parts of this will be insensitive and perhaps inaccurate. I apologize in advance, especially if this somehow adds to the pain of any Black or Brown readers. Please critique these posts harshly and contact me with comments.
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Where do we go from here? That’s the biggest question I have for myself and our society, and while I clearly have no answer, there are others with ideas. Research from Movement Netlab, a social movement think tank, frames social movements in cycles: from rising anger, to a trigger moment, heroic phase, disillusionment, learning and reflection, and re-growth (and then repeat).
https://movementnetlab.org/movement-cycle
According to this model, it would appear we are or near the peak, suggesting a contraction is coming. If we want to realize some of the changes the current movement is demanding, it will require sustained efforts to fight through the upcoming waves; on their own, words, institutional statements, and blog posts accomplish very little. With that in mind, I want to orient the remainder of this conversation around three areas within our profession that are necessary for long-term change: learning, reflection, and action.
Post #2: Learning – Race isn’t Scientific
See the prior post introducing this topic. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“White man, hear me! History, as nearly no one seems to know, is not merely something to be read. And it does not refer merely, or even principally, to the past. On the contrary, the great force of history comes from the fact that we carry it within us, are unconsciously controlled by it in many ways, and history is literally present in all that we do. It could scarcely be otherwise, since it is to history that we owe our frames of reference, our identities and our aspirations. And it is with great pains and terror that one begins to realize this.” James Baldwin, “White Man’s Guilt” in The Price of the Ticket
Race is not inherent. It is neither scientific nor biologic. It was created. Consider those statements for a moment. They are radical – they fly in the face of what is taught and understood from grade through medical school. For an excellent review on the history of race, read The History of White People by Nell Irvin Painter or Stamped from the Beginning: The Definitive History of Racist Ideas in America by Ibram X Kendi. If you’d rather listen, the second season of the podcast Scene on Radio entitled Seeing White covers this well.
There are aspects of racial science that seem appalling by today’s standards. A great book that covers the bullets below and much more is Superior: The Return of Race Science by Angela Saini:
- Carl Linnaeus, the father of taxonomy, in his tenth edition of Systema Naturae in 1758 created a human hierarchy within the animal kingdom in the following order: H. sapiens europacus, H. sapiens americanus, H. sapiens asiaticus, and H. sapiens afer. Their corresponding colors of white, red, yellow, and black remain with us today.
- Dr. Samuel Morton, the founder of anthropology in the United States, published Crania Americana in 1839 evaluating his collection of human skulls – the largest in the world – and determined from a detailed analysis of nearly 100 skulls that the Caucasian race has the largest mean internal capacity and therefore the highest intellectual endowment of all races.
- The biologist Francis Galton, cousin of Charles Darwin, coined the term “eugenics” in 1883 from the Greek prefix eu for “well” or good”. His intent was to use social control to improve the health and intelligence of future generations.
- In 1907, the first involuntary sterilization law was passed in the state of Indiana (and not repealed until 1974), with eugenicists endorsing the heredity of criminality, mental health issues, and poverty. An excellent podcast episode on this dark period of US history was produced by “Radiolab”.
- Eugenics reached its logical culmination with the holocaust. Karl Pearson, who is known for his contribution to statistics (he’s the “p” in p-value), was also the successor to in the eugenics movement. He brought the below box to London, representing 30 locks of artificial hair, with the most “desirable” colors and textures in the middle. This device was initially trialed by the Nazis during the first genocide of World War II in Namibia, where ¾ of those deemed to be “non-white” were systematically killed.
- A similar Nazi scientific device utilized eye color to measure race, especially amongst the Jewish people and for similar purposes
Comparable atrocities are well known to medicine specifically, with these serving as two examples:
- Dr. J Marion Sims, president of the American Medical Association and founder of the American Society of Gynecology in the late 1800s, performed up to 30 procedures each on 11 enslaved, healthy women over 4 years to develop his procedure to treat vesicovaginal fistulas. These women were provided no anesthesia even though it was available, yet used it when performing the procedure on white women a few years later. He claimed – as was widely believed – that Blacks did not feel pain the same way as whites.
- In 1932, the US Public Health Service began its “Study of Syphilis in the Untreated Negro Male” in six hundred syphilis-infected sharecroppers in Tuskegee, Alabama. The investigators secretly withheld treatment and awaited death of the participants to confirm the hypothesis that syphilis more likely influenced the cardiovascular rather than neurologic system of Blacks compared to whites, in part due to the findings of Morton above that buttressed the belief that Blacks had relatively primitive and underdeveloped brains. The study was initially projected to last 6 months, but was not halted until 1972 – forty years later – when it was exposed by the media.
The Public Health Service took photographs during the Tuskegee syphilis study, but no captions remain. This is one of them.
These episodes stand out as historical reminders. We can collectively shudder, yet feel comforted that we have moved on and are more enlightened.
Turns out we’re not. The protests in the streets of our nation today suggest otherwise. Recent scientific literature also suggests otherwise. Both are just harder to see. Harriet A. Washington argues in her book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present these are not isolated events and relying solely on the stories fails “to discern the stubborn and illuminating patterns characterizing the medical abuse of African Americans.”
While the human genome project finished 20 years ago in June 2000 and demonstrated that “human beings, regardless of race, are more than 99.9 percent the same” and there “are greater genetic differences between individuals of the same racial group than between individuals of different groups”, our literature is filled with studies analyzing genetic differences based on race, ancestry, descent, or other analogous terms. These are being published today. And this is despite the fact that the US Census Bureau and National Institutes of Health (NIH) amongst many other governing bodies claim that race is “a social category recognized by the United States and does not attempt to define race biologically, anthropologically, or genetically.”
Race is not scientific. While we may take that statement for granted, the converse remains entrenched in our profession at an institutional and individual level. For example, in 2016 (to repeat, 2016) a study of 121 white resident physicians at the University of Virginia found that over half believed: Blacks’ nerve endings are less sensitive than whites’ (see Marion Sims above), whites’ have larger brains than Blacks’ (see Morton above), and Blacks’ skin is thicker than whites’.
Hoffman KM, Trawalter S, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS 2016;113(16):4296-4301.
Race is not scientific. But, race absolutely is real. It carries social, economic, and medical significance, and to be “color blind” is perilous as a healthcare provider. The next post covers this in greater detail. What I want to emphasize in conclusion, though, is how important it is to not just learn about these matters, but better understand the implicit biases we carry into the exam room as a result not just of our socialization, but the historical roots of racial science that remain pervasive in ourselves and profession today.
Wearing red stained garments to symbolize the blood shed by his research subjects, protestors called for the removal of the Dr. James Marion Sims statue at Manhattan’s Central Park. Called the father of modern gynecology, his critics cite Sims’ experiments on black female slaves, without their consent.
(Howard Simmons/New York Daily News)
Post #3: Learning – Race is Real
See the prior posts introducing this topic and exploring the scientific myth of race. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“Although the concept of race invokes seemingly biological based human characteristics (so-called phenotypes), selection of these particular human features for purposes of racial signification is always and necessarily a social and historical process. Indeed, the categories employed to differentiate among human beings along racial lines reveal themselves, upon serious examination, to be at best imprecise, and at worst completely arbitrary. They may be arbitrary, but they are not meaningless. Race is strategic; race does ideological and political work.” Michael Omi and Howard Winant, Racial Formation in the United States
We need to go no further than the current crisis to see this in action. As is now widely acknowledged, current SARS COVID-19 mortality data in the US suggests a disparity based on race and ethnicity, with Black, and to a slightly lesser extent, Latinx patients suffering at much higher rates than whites.
As I limitedly argued in the last post, race is not scientific, so the reason for these disparate outcomes are not – at least not primarily – biologic. Prominent leaders in our country still hold this belief, however, including a physician senator when questioned on the data in his own state. But the truth of the matter is far more complex and damning. As explained recently in JAMA, there are two likely explanations for these data: racial and ethnic minorities have a disproportionate number of underlying comorbidities and risk factors, and minorities, especially in urban areas, live in more crowded neighborhoods and households and more likely to be employed in public-facing jobs; social distancing, safe at home, and other public safety efforts are privileges not extended or available to many in these communities. “As more data emerge, there will likely be evidence of racial/ethnic health disparities due to differential loss of health insurance, poorer quality of care, inequitable distribution of scarce testing and hospital resources, the digital divide, food insecurity, housing insecurity, and work-related exposures.”
These factors are called the social determinants of health, which broadly include all conditions in life that shape health. These are more specifically summarized in six categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (including transportation, housing, security, community self-efficiency), and fairness (in general, sufficient redistribution of wealth and income to ensure social and economic security and equity).
These social conditions help explain why, for example Black individuals at birth have a life expectancy of 3.5 years less than white individuals, 70-80% of which can be explained by socioeconomic factors, and a Black infant born in the US is more than twice as likely to die before their first birthday than a white infant.
Many of these determinants are “far upstream of health care and are deeply rooted in the distribution of money and power, at local and national levels”. These roots are foundational to our country, and a very limited and topical review of some of the branches include:
- Over the past 30 years, the U.S penal population exploded from around 300,000 to more than 2 million, with drug convictions accounting for the majority of the increase. The United States imprisons a larger percentage of its Black population than South Africa did at the height of apartheid.
- These stark racial disparities cannot be explained by rates of drug crime. Studies show that people of all colors use and sell illegal drugs at remarkably similar rates, yet in some states, Black men have been admitted to prison on drug charges at rates twenty to fifty times greater than those of white men.
- More African American adults are under correctional control today – in prison or jail, on probation or parole – than were enslaved in 1850, a decade before the Civil War began. The mass incarceration of people of color is a big part of the reason that a Black child born today is less likely to be raised by both parents than a Black child born during slavery.
- The total population of Black males in Chicago with a felony record (including both current an ex-felons) is equivalent to 55 percent of the Black adult male population and an astonishing 80 percent of the adult Black male workforce in the Chicago area. More than 70 percent of all criminal cases in the Chicago area involves a class D felony drug possession charge, the lowest-level felony charge.
- Black individuals are 3.23 times more likely than white individuals to be killed by a police officer in the United States.
- Black people fatally shot by police are twice as likely as white people to be unarmed.
- Bias in administrative records results in many studies underestimating or discriminately masking racial bias in policing.
- In 1910, Black Americans owned over 14 million acres of land, but today our population of 40 million Black Americans own only 8 million acres.
- Black Americans own less than 1% of rural land in the country. The five largest white landowners own more rural land than all of Black America combined.
- “The Color of Law: A Forgotten History of how our Government Segregated America” provides a detailed history of racial housing policy. Here is a map of redlining in Lexington, KY in 1940.
Mapping Inequality: Redlining in New Deal America
- The Black poverty rate in 2018 was 22%. It was 9% in whites.
- The Black unemployment rate has been at least twice as high as whites for the past fifty years.
- The median net worth of white households is roughly ten times that of Black households.
- More recently, by April of 2020, among the estimated 36 million jobs lost due to COVID-19, roughly 40% were by persons with an annual household income of less than $40,000. Unemployment rates at that time were 14.2%, 16.7%, and 18.9% among white, Black, and Latinx individuals, respectively.
This is (one reason) why acknowledging race is important, and it is absolutely imperative we do so in medicine. Circling back to COVID-19, the racial disparities were not widely or immediately recognized in the early months of the pandemic because municipalities were not reporting data broken down by race and ethnicity. This color-blind approach clearly can be harmful: “To insist on color blindness is to deny the experience of people of color in a highly racialized society and to absolve oneself of any role in the process.” A recent report of leading ophthalmology journals found that in 2019, 88% of studies reported background information including patient age and sex, but only 43% reported race and/or ethnicity.
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To summarize up to this point, race is a sociopolitical construct that serves to create systematic inequity. It harms individuals and communities and directly impacts health. For those reasons and others, it is essential that we report race in the literature and continually raise awareness of these inequities. Simultaneously, it is important that we recognize these are not inherent or biologic traits, but the result of social injustices. The next post will try and make this more personal, including a discussion on the role of implicit bias in healthcare. The final post will focus on ways we can respond, including plans within our program.
Post #4: Implicit Bias and Personal Reflection
See the prior posts introducing this topic, exploring the scientific myth of race, and elaborating why race is still very real. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“One wishes that Americans – white Americans – would read, for their own sakes, this record and stop defending themselves against it. Only then will they be enabled to change their lives. The fact that they have not yet been able to do this – to face their history to change their lives – hideously menaces this country. Indeed, it menaces the entire world.” James Baldwin, “White Man’s Guilt” in The Price of the Ticket
Collection of Dr. Samuel Morton. See Post #2. https://www.penn.museum/sites/expedition/the-samuel-george-morton-cranial-collection/
The last two posts provided examples of egregious racist acts and policies within science and broader society, and how they are intertwined and still very much with us today. A study of medical residents in 2016 demonstrated the racial biases we carry into the hospital, which demonstrates a form of implicit bias: “People – all people – hold some implicit biases. A bias is a negative attitude about one group of people relative to another group of people. However, the distinguishing feature of an implicit bias is the negative association operates unintentionally or unconsciously.”
The quote above is from the book Just Medicine: A Cure for Racial Inequality in American Health Care by Dayna Bowen Matthew. She details the history of racial healthcare laws and policies that formed the framework for much of our inequality today, but also argues the importance of individual implicit bias at the level of the physician-patient encounter and how that influences the overall healthcare system.
https://www.aft.org/ae/winter2015-2016/staats
If you haven’t, take the Implicit Association Test (IAT): https://implicit.harvard.edu/implicit/. This widely used and validated test has revealed the harm of our implicit biases in many different arenas including prosecuting attorneys in the criminal justice system, the jury selection process, employment hiring and promotion decisions, and school disciplinary actions. Police officers with higher IAT scores (white favored implicit biases) more readily shoot unarmed Blacks than unarmed whites during video game simulations.
Healthcare workers are not exceptional and test no differently than the rest of the population. In her book, Dr. Matthew presents “The Biased Care Model” [figure below] and details six mechanisms by which health care providers’ racial and ethnic biases contribute to disparate health outcomes. Her argument is compelling and well worth the read. If you remain unconvinced on the role of implicit bias in racial inequity, specifically in healthcare and explicitly at the level of the individual provider, then please consider reviewing these or other resources.
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“When racist ideas resound, denials that those ideas are racist typically follow. When racist policies resound, denials that those policies are racist also follow. Denial is in the heart of racism, beating across ideologies, races, and nations. It is beating within us.” Ibram X Kendi, “How to be an Antiracist“
Even if it is not explicit, most (if not all) of us carry implicit racist biases. That can be hard to accept, since we believe ourselves to be good and honest people. But what I’ve tried to argue to this point is we are a product of a long history of racist ideas, policies, science, and socialization that is deeply entrenched within ourselves. Denying this truth is harmful, but so is ignoring it. If we believe racial equity is important in our greater profession and in our own office, then it requires constant vigilance against our own biases. As stated by Michelle Alexander in The New Jim Crow: Mass Incarceration in the Age of Colorblindness, “This system of control depends far more on racial indifference (defined as a lack of compassion and caring about race and racial groups) than racial hostility – a feature it actually shares with its predecessors.”
The final post on this topic will explore some actionable items related to all of this, with the intent of creating accountability for our programmatic response.
Post #5: Action – This is our lane
See the prior posts introducing this topic, exploring the scientific myth of race, elaborating why race is still very real, and the role of implicit bias. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Reverend Martin Luther King, Jr., 1965
https://www.amazon.com/Martin-Luther-King-Selma-March/dp/B0722Q32VG
These words were spoken in Montgomery, Alabama at the end of the march from Selma. Dr. King walked alongside black and white physicians he invited from the Medical Committee for Human Rights. They were there for two primary purposes: to give care to injured marchers and to observe to the abuse suffered.
We, too, must bear witness. For many of us (myself included), this woefully starts with watching, reading, listening, and finally beginning to learn. For instance – ashamedly – I just recently learned after the death of Congressman John Lewis, that Dr. King’s march was in response to one by John Lewis and others where nonviolent protestors were attacked by state troopers with clubs and tear gas; our future Congressman was severely beaten and sustained head injuries. Mr. Lewis’s march was in response to the police shooting of Jimmie Lee Jackson, a 26 year-old church deacon who was attempting to protect his mother from the nightstick of a police officer during a demonstration.
As physicians, though, it does not end with observation. Our education is purposeful – to heal. Unequivocally, both conscious and unconscious racism worsens disease. It leads to inequity in life and death. We cannot heal without combating racism.
In her book “Just Medicine” that I mentioned in the last post, Dayna Bowen Matthew borrows from Thomas Frieden’s Health Impact Pyramid [figure below] to discuss the varying ways public health efforts can impact outcomes. Conceptually, the higher the level of the pyramid, the less public impact. Dr. Matthew uses this figure to implore the need for lower level interventions to truly combat racial inequality in healthcare, and while I encourage reading her book to learn about it, I do not believe I give anything away by stating her plan requires changes in the medicolegal system. Similarly, Ibram X Kendi argues that dismantling racism necessitates policy much more than personal change. Therefore, if we want to truly promote racial healing, as individuals and institutions we need to support broad and encompassing change. We must hold our leaders accountable and elect officials that will enact antiracist policies.
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“Racist” and “antiracist” are like peelable name tags that are placed, and replaced based on what someone is doing or not doing, supporting or expressing in each moment. These are not permanent tattoos. No one becomes a racist or antiracist. We can only strive to be one or the other. We can unknowingly strive to be a racist. We can knowingly strive to be an antiracist. Like fighting an addiction, being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination.
Ibram X Kendi
I started this series with the intent of discussing a few steps I want to take within our program. Admittedly, they are near the apex of the health impact pyramid above. They also are introductory and insufficient. But, they are tangible and accountable: judge our program by these actions and our outcomes.
Education: Social science literature encouragingly indicates that implicit biases are malleable. Even though they are accumulated over a lifetime, we can counteract (although not likely fully eliminate) them with “personal, social, and situational pressures.” With that in mind (see the pun there), I am committed to promoting regular implicit bias education in our didactic curriculum. As a learner rather than an educator on this topic, I will lean heavily on others, and welcome any and all ideas and resources.
The limited data on implicit bias in medical training suggests that early in training physicians are less likely to allow perceptions of race and social class to influence clinical decisions than later on. As Dayna Bowen Matthew explains: “Most medical schools include cultural competency training in their curricula. However, the negative perceptions modeled by seasoned physicians, and possibly other health professionals as well, do not disappear simply because of medical school training in cultural competence … cultural competency training has little impact on the transfer of implicit biases from senior practitioners to their medical students.” Consequently, the behavior modeled by our faculty is passed to our residents, residents to our medical students, and so on. For educational efforts to have an impact, it must encompass our entire department, and we need to be aware the outsized role modeling behavior plays.
Recruitment: According to the most recent census estimate, 14.5% of individuals in Lexington, KY and 13.4% of the entire US population are Black. Our department and residency program do not reflect our population. While we intentionally recruit with racial and gender inclusion in mind, it clearly is insufficient. Last year I wrote on the initial intent compared to the current use of USMLE scores and potential concerns with the void left if (and now when) the scoring system changes. Given this and the disruption to the entire recruitment season as a result of COVID-19, a more holistic review process is needed. I will advocate for systematic advances within our specialty, but also commit to intentional and rigorous changes to our program level application review process. All members of our application review and interview committees will also be required to go through implicit bias training prior to participating.
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I hope those that took the time to read these posts found use in them. I hope even more that if you are someone like me, your eyes are similarly starting to open. This is just the beginning for our program, and I will provide updates as they come. The changes we make, and lessons learned will influence many other aspects of our training and clinical environment. Please reach out with any comments, concerns, or suggestions.
The good news is that racist and antiracist are not fixed identities. We can be a racist one minute and an antiracist the next. What we say about race, what we do about race, in each moment, determines what – not who – we are.”