Black and Blue
The Origins and Consequences of Medical Racism
By John Hoberman
UNIVERSITY OF CALIFORNIA PRESS Copyright © 2012 The Regents of the University of California
All rights reserved.
The Nature of Medical Racism
The Origins and Consequences of Medical Racism
The idea that discredited (and even disgraceful) ideas about racial differences might play a role in medical diagnosis and treatment is a possibility that some doctors find profoundly disturbing. The racially biased treatment of patients would appear to be a grievous violation of medical ethics and a direct threat to the dignity of the profession. Yet, in the course of the last two decades, the medical literature has published hundreds of peer-reviewed studies that point to racially motivated decisions by physicians either to deny appropriate care to black patients or to inflict on them extreme procedures (such as amputations) that many white patients would be spared. "How are we to explain, let alone justify, such broad evidence of racial disparity in a health care system committed in principle to providing care to all patients?" the socially active physician H. Jack Geiger asked in 1996. His reply to his own question offered two possible explanations. The first option was to attribute the observed disparity to "unspecified cultural differences" or decisions made by black patients who did not understand that they needed medical care. The second and more discomfiting explanation was, as Dr. Geiger phrased it, "racism—that is, racially discriminatory rationing by physicians and health care institutions." Confronting the data that he had felt compelled to present to the medical community, Dr. Geiger could not bring himself to categorize the documented behavior of his medical colleagues as racist. Indeed, he added, "if racism is involved it is unlikely to be overt or even conscious." For this conscientious physician, medical racism that implied individual culpability was still somehow unreal, a specter to be exorcized rather than a threat to be acknowledged and confronted.
Black and Blue is the first systematic description of how doctors think about racial differences and how this kind of thinking affects the treatment of their patients. While some fine studies of medical racism have appeared, they have not examined the thought processes and behaviors of physicians in any sort of detailed way. In effect, these studies have not seen fit to enter into the physician's private sphere where specific racial fantasies and misinformation distort diagnoses and treatments. Nor have they shown much interest in identifying the specific origins of racially motivated diagnoses and treatments of black patients that have ranged across the entire spectrum of medical sub-disciplines, from cardiology to obstetrics to psychiatry. It is true that American physicians have been "major perpetrators of racialist dogma," as a monumental history of American medical racism states. Black and Blue moves beyond such general claims about racially motivated medical behaviors and describes how mainstream medicine devised racial interpretations that have been applied to every organ system of the human body.
The studies to date have occasionally noted but failed to describe the oral traditions that convey medico-racial folklore and persist over generations of medical students and doctors. As we shall see, the physician-authors who have taken the trouble to write about the racial dimension of medicine confirm that the medical profession has never embarked upon this kind of self-scrutiny in a serious manner. Interestingly, the medical profession's lack of interest in confronting the racial complexes of doctors has created little activism among even the most concerned medical observers beyond ritualized expressions of concern. While these white "medical liberals" profess to be "troubled" by this topic, their efforts at raising consciousness have been episodic and have never acquired the political traction that might catalyze a more effective reckoning with the racially motivated and medically harmful behaviors that have been proven beyond a doubt to exist. It is, therefore, no accident that this book-length examination of the racially motivated mental habits and professional mores of doctors is the work of an outsider to the medical profession.
At the same time, I would point out that this history and analysis of medical racism is the work of a grateful outsider. The criticism of the medical profession presented in this book is not motivated by personal dissatisfaction with doctors. On the contrary, physicians have served me well throughout a long life that has included an open-heart surgery that saved me from a debilitating future of congestive heart failure. My father was a physician-scientist, and his commitment to his patients was inspiring. I learned about medical racism in the library while doing research for another book. I was stunned by the overt racism that appeared in medical journals such as the Journal of the American Medical Association or the American Heart Journal during the first half of the twentieth century. So was my father, who received his M.D. in 1946, a man of anti-racist principles, who knew the famous African American physician Charles Drew in Boston before the latter's premature death in 1950. As a Jew who had experienced anti-Semitic insults, my father was aware of the reality of bigotry in American society. But the medical racism of American physicians during his lifetime had somehow passed him by.
"AVOIDANCE AND EVASION"
"The general awkwardness surrounding racial issues in our society bleeds into medicine," the prominent African American cardiologist Clyde Yancy observed in 2009. This awkwardness about practicing and discussing race relations has long been a fact of medical life the profession has been slow to recognize or deal with in a deliberate or systematic way. The political conservatism of the medical establishment was evident even during the civil rights movement, as the national leadership of the American Medical Association (AMA) deferred to the racist exclusionary policies of state medical societies and refused to intervene on behalf of black physicians who sought membership in the AMA and the professional status they had long been denied.
Today the great majority of doctors are likely to regard information about medical racism as of little relevance to their professional lives. This is hardly surprising, given that large majorities of white Americans take little or no interest in the special problems their African American fellow citizens experience. There has long been, and there remains, a widespread conviction among whites today that the disadvantages blacks face are of their own making, since formal racial equality was established by the civil rights and voting rights laws and affirmative action initiatives, all of which date from the 1960s. And there is no reason to assume that the racial views of doctors differ in any significant ways from those of the general population.
My own firsthand exposure to how physicians receive news about medical racism occurred on a chilly evening in New York City in November 1999. A friendly bioethicist had arranged for me to attend a discussion of the medical profession's treatment of African Americans at the New York Academy of Medicine at Fifth Avenue and 103rd Street in Manhattan. The host, as I recall, was the vice president of the academy. He stood before a seated group of his medical colleagues and told them what the medical literature had by now demonstrated beyond a doubt: American medicine was failing to serve the African American population in a racially equitable manner. The question before them, he said, was whether or not they as a profession were going to choose to "own" this issue, to take responsibility for the uncomfortable reality of racially unequal medical treatment.
Fifty professionally and financially comfortable physicians listened to this pitch in their chairs. I saw no one on the edge of his or her seat. While it was clear that the speaker took this matter seriously, the tone of his comments did not convey a sense of urgency or an expectation of medical activism from those who sat before him. On the contrary, it was clear that making the effort to repair this injustice and take more responsibility for the health of black people was being presented, not as an ethical obligation, but as an option. The ethical obligation was real to the speaker, but one sensed that he did not really expect his colleagues to rally to this cause.
American medicine's disengagement from the black population is only one dimension of the much larger racial disengagement that characterizes American society as a whole. Ignoring African Americans or relegating them to marginal status has been a deeply rooted American habit. In his classic An American Dilemma (1944), Gunnar Myrdal commented that, in the literature on American democracy he had read, "the subject of the Negro is a void or is taken care of by some awkward, mostly un-informed and helpless, excuses." Ralph Bunche, whose extraordinary career as a black academic foreign policy expert and international diplomat culminated in the 1950 Nobel Peace Prize, told Myrdal in 1940 that "consciously or unconsciously, America has contrived an artful technique of avoidance and evasion" to separate itself from its Negro citizens.
A generation later the famous black psychologist Kenneth B. Clark explained white racial detachment as a form of emotional self-defense on the part of whites. "The tendency to discuss disturbing social issues such as racial discrimination, segregation, and economic exploitation in detached, legal, political, socio-economic, or psychological terms as if these persistent problems did not involve the suffering of actual human beings," Clark wrote in Dark Ghetto (1965), "is so contrary to empirical evidence that it must be interpreted as a protective device." The "purist approach rooted in the belief that detachment or enforced distance from the human consequences of persistent injustice is objectively desirable," and he added, is "a subconscious protection against personal pain and direct involvement in moral controversies." For many people, the most threatening controversy that might personally implicate them is racism. Maurice Berger has pointed out that, in an age of political correctness, "most people will do almost anything to preserve the comfortable illusion of themselves as free of prejudice."
The sheer magnitude of the African American health disaster can produce both emotional detachment and a dehumanizing sociological reduction of black life to its bleakest essentials. The recitation of endless statistics documenting medical racial disparities depersonalizes the human dimension of what is happening to black people. Our attention is displaced from the specific behaviors and predicaments of doctors and patients into an abstract dimension of enormous and hopelessly complicated social processes that can only be imagined. What is more, as one Indian-British physician has noted, "documenting inequalities may have little impact on reducing them."
The statistical depersonalization of black people and its association with disease were recognized as far back as 1951 by James Baldwin, long before sociology became the conceptual language of race relations during the heady days of the Great Society in the mid-1960s. The Negro, he wrote, "is a social and not a personal or human problem; to think of him is to think of statistics, slums, rapes, injustices, remote violence; it is to be confronted with an endless cataloguing of losses, gains, skirmishes; it is to feel virtuous, outraged, helpless, as though his continuing status among us were somehow analogous to disease—cancer, perhaps, or tuberculosis—which must be checked, even though it cannot be cured." The black person exists in the form of various social disasters, human life conceived as numerical formulas, and threatening but incurable disease processes. The black individual remains invisible and unknown, and this too has its consequences. For as Baldwin points out, "The privacy or obscurity of Negro life makes that life capable, in our imaginations, of producing anything at all," including all of the dysfunctional behaviors that physicians and many others customarily associate with black people.
The traditional detachment of the medical profession from identifying and solving its racial problems has been evident in the medical literature and in the work of medical authors who are at liberty to range farther and deeper into social and personal issues than is possible in medical journals. David Satcher, a young black physician who became surgeon general of the United States in 1998, pointed out in 1973 that: "Much has been written about the doctor-patient relationship and its many challenges and ramifications. However, almost nothing is written about the effects of race on this relationship." (In his pioneering commentary on doctor-patient race relations, David Levy made the same point about the pediatric literature in 1985.) Then, as now, the great majority of doctors were white men whose ignorance and naïveté regarding their black patients had long been evident to black physicians. The estrangement from blacks that resulted from this mind-set has expressed itself in many ways. In 1940, Time reported that "few white doctors dare to operate on their 'massively' infected Negro patients" afflicted with tuberculosis. At this time black doctors noted with chagrined amusement that, "The average young white physician enters practice with the idea that all Negroes have syphilis or tuberculosis." A generation later the medical anthropologist George Devereux described his observations of "White-Negro doctor-patient pairs" and the diagnostic errors that resulted from the doctor's" 'tactful' reluctance to examine closely the most distinctive portions of a racially alien patient's body." White dermatologists may be alternately alarmed about or unaware of the characteristics of black skin and the emotional consequences of skin problems for patients. White doctors sometimes underestimate the intelligence and self-control of black patients and treat them accordingly. The cumulative effects of such naïveté are often evident to blacks but are less evident to the white medical community that does not monitor and report on such incidents.
The writings produced by white physician-authors reflect the social distance from African Americans they share with a large majority of their fellow citizens. As the black sociologist Orlando Patterson noted in November 2009, "in the privacy of homes and neighborhoods we are more segregated than in the Jim Crow era." Various degrees of segregation occur within "the disciplined cultural spaces of marriages, homes, neighborhoods, schools and churches." Hospitals and clinics are disciplined cultural spaces that are subject to the same racial tensions and estrangements that occur within the other "disciplined" social venues. It is, therefore, not surprising that physicians who write about race relations within these medical spaces tend to avoid direct confrontations with uncomfortable racial issues. For example, a collection of 80 reflective columns by doctors taken from the pages of the Journal of the American Medical Association during the 1980s contains many profound and moving stories that together constitute the most sympathetic portrait of the medical profession I can imagine. Of the hundreds of people who appear in these stories, there is exactly one African American patient, a humble sharecropper in sweltering Alabama who is grateful to find a white medical student who is willing to talk to him. An elderly black hospital orderly is sympathetically presented as incarnating one of the classic folkloric images of black humanity: the musical Negro. From these dozens of medical authors, there are a handful of references to "slum children," inner-city "juvenile delinquents," and a six-year-old West African child who dies despite the best efforts of the American physician who tries to save him. There are no black doctors or nurses. All but a few picturesque and stereotypical examples of black humanity were apparently absent from the recollections of most of a hundred physicians.
Paul Austin's Something for the Pain (2008), a candid, caustic, sensitive, and sophisticated memoir of his many years as an emergency room (ER) doctor in North Carolina, refers to race rarely, carefully, and allusively. The tone of a young black mother's voice has "a brittle edge" until the doctor's gentle manner wins her over. The author refuses to give a racial edge to the hostility of a despairing young black man whose mother lies dying in the ER. Thoughtful writing of this kind reminds us of medicine's color-blind ideal; and it is likely that some physician-authors avoid the topic of race out of fidelity to the dream of medical care that transcends color.
The problem with color-blind writing about medicine is that it ignores the long history and persisting reality of racially motivated medical behaviors that can alienate, injure, and sometimes kill black patients. Another genre of medical writing focuses on the brutal conditions experienced by doctors who practice medicine in the ghetto. Doctors Talk About Themselves (1988) describes the emotional impact on doctors of dealing with the dregs of humanity who show up in inner-city ERs: "You see such awful things that are totally beyond any experience you have ever had. You ask, 'How can people live like this?'" In this "snake pit" the cynicism that has been widely observed in older medical students becomes complete, as beleaguered and resentful physicians absorb "every conceivable kind of abuse" from their black clientele. (Continues...)
Excerpted from Black and Blue by John Hoberman. Copyright © 2012 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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