Today’s post is a summary of and reflection on '“Race, medicine, and health care in the United States: a historical survey.” I strongly encourage reading the article; full text is linked to above. At the same time, I’m assuming most people haven’t and pulling quotes and summaries liberally. My comments are in italics.

Abstract

Racism in medicine, a problem with roots over 2,500 years old, is a historical continuum that continuously affects African-American health and the way they receive healthcare. Racism is, at least in part, responsible for the fact African-Americans, since arriving as slaves, have had the worst health care, the worst health status, and the worst health outcome of any racial or ethnic group in the U.S. Many famous doctors, philosophers, and scientists of each historical era were involved in creating and perpetuating racial inferiority mythology and stereotypes. Such theories were routinely taught in U.S. medical schools in the 18th, 19th, and first half of the 20th centuries. The conceptualization of race moved from the biological to the sociological sphere with the march of science. The atmosphere created by racial inferiority theories and stereotypes, 246 years of black chattel slavery, along with biased educational processes, almost inevitably led to medical and scientific abuse, unethical experimentation, and over utilization of African-Americans as subjects for teaching and training purposes. Byrd WM, Clayton LA. Race, medicine, and health care in the United States: a historical survey. J Natl Med Assoc. 2001 Mar;93(3 Suppl):11S-34S.

Opening thoughts:

This article was published in the wake of a 1999 article documenting racial and gender bias distorting clinical decision-making in cardiac care (Schulman et al, 1999). The Schulman article in the New England Journal of Medicine led to an uproar, a furor, of well-meaning white, male physicians who did not want to believe that their profession had a ‘race problem.’ Oh, and also those who did not see such differences as any kind of a problem. The Letters to the Editor of the NEJM were overflowing. The data was sound and to many convincing - and convicting. It prompted a new wave of introspection and, eventually, some efforts toward change. Byrd and Clayton had an ambitious but single-minded goal: to provide the historical context and evidence for racism within the U.S. health care system and for the unique character of American scientific racism. They weren’t documenting current inequity. They didn’t suggest next steps. They didn’t provide solutions. They asked their readers to expend effort “to understand, explain how and why…the deleterious effects race and racism have on American medicine and the health system (p11S).” They trusted this evidence will be enough to prompt correction.

It is an avalanche of evidence. As the authors drily stated, “some of this text may seem over-documented compared to conventional studies (p12S).” There are 10 pages of citations for 14 pages of prose.

Themes:

• Racism in health care stems to antiquity; at the same time, racism against Black people in the US has unique characteristics and unique impacts on US health care. Byrd and Clayton carefully documented how the virulent, competitive racism within the U.S. infects the more generic scientific racism of eugenics and pseudoscience.

• Essentially every ‘Father of Some Subject’ within the history of biology and medicine ascribed to and perpetuated pseudoscientific racist theories. Byrd and Clayton named names and showed images of primary sources. More recently, “much of the material on scientific racism emanated from schools and universities and was included in core curricula of the nations’s leading educational institution. Thus…at least five generations of well-educated Americans, including physicians were brainwashed with this pseudoscientific, racist material…Whether they had previously been racist or not, [this exposure] undoubtedly influenced their policies in racialist directions (p 23S).”

• Cases of unethical, racist behavior within the medical field (The Tuskegee experiment, Henrietta Lack) were not simply Horrible Events by Horrible People; rather, they were horribly common standard operating procedure. Unethical experiments, closing down vital black medical schools, exploitation in research laboratories, “hysterectomies performed on black women (laughingly referred to by white physicians as Mississippi appendectomies) (p24S).”

• The US health care ‘system’ was built upon racism and classism; these values are perpetuated within its ongoing structure. This embedded racism facilitates poor health status and outcomes for Black Americans; it also contributes to the resistance to change the system. Thinking about the impact of racism on the healthcare policy debate is a paradigm shift for me.

• The medical profession discriminates against patients and fellow physicians. “Racial discrimination against black doctors…has included, but is not limited to: the peer review process, obtaining and maintaining hospital staff privileges, obtaining appointments for key hospital committees, virtual exclusion from many vitally important postgraduate specialty and sub-specialty training programs, and obtaining faculty appointments at teaching hospitals.'“

Final thoughts from me: While reading, I experienced dissonance between the emotional realities of what the authors were reporting and the detached tone required in scientific writing. When urgency or righteous anger slips through, it is with a dry wit. This article is a penultimate example of professional code shifting.

Last word, from Byrd and Clayton, in 2001:

Will the health system fall prey to what opinion researchers’ call white racial resentment and/or belief in principle/policy implantation disconnect - possibly the latest manifestation of America’s anti-black racism? These attitudes and beliefs may be driving U.S. society’s cynical, harsh, intolerant, some consider unrealistic and socially irresponsible demands that African-Americans - still being victimized by discrimination, institutional racism, and some forms of apartheid - overcome the effects of 246 years of chattel slavery (64.4% of the African-American social experience) and 100 years of legal segregation, discrimination, and brutal segregation (26.18% of the African American experience) in less than 35 years (9.42% of the African-American social experience).

Next Monday, 10/19/20, I’ll be reflecting on implicit bias. Explore the resources at https://implicit.harvard.edu/implicit/.