Race and Medicine

Chronic diseases pose a significant problem in the United States resulting in substantial morbidity, mortality, disability, and cost. The CMS Office of Minority Health has designed an interactive map, the Mapping Medicare Disparities Tool, to identify areas of disparities between subgroups of Medicare beneficiaries (e.g., racial and ethnic groups) in health outcomes, utilization, and spending. It is an excellent starting point to understand and investigate geographic and racial and ethnic differences in health outcomes. This information may be used to inform policy decisions and to target populations and geographies for potential interventions.

In their first year in medical school, all students learn to take a social history. As they transform their eyes, ears, and hands into sensors for detecting hidden causes of disease, they also learn to ask probing questions to illuminate patients’ social contexts. What pathogenic exposures might a patient face en route to immigrate to the United States from Guatemala, in being subjected to police violence and arrest in a heavily patrolled nonwhite neighborhood, in working in pesticide-laden fields, or as a result of exclusion from health care coverage? Answers to such questions can dramatically change a diagnostic picture or therapeutic plan. Yet by the clinical years of medical school, students learn that the social history is often collapsed into a record of three biobehavioral exposures — to alcohol, tobacco, and illicit drugs. Much of what they read in clinical journals appears to corroborate the assumption that in clinical medicine, the biologic and behavioral world of a patient’s body is more important than the social world outside it.

"As someone who went through the training, hiring, and socialization of a career in law enforcement, I wanted to give a first-hand account of why I believe police officers are the way they are. Not to excuse their behavior, but to explain it and to indict the structures that perpetuate it.
"I believe that if everyone understood how we’re trained and brought up in the profession, it would inform the demands our communities should be making of a new way of community safety. If I tell you how we were made, I hope it will empower you to unmake us."

For physicians, the words “I can’t breathe” are a primal cry for help. As many physicians have left their comfort zones to care for patients with Covid-19–associated respiratory failure, the role of the medical profession in addressing this life-defining need has rarely been clearer. But as George Floyd’s repeated cry of “I can’t breathe” while he was being murdered by a Minneapolis police officer has resounded through the country, the physician’s role has seemed less clear. Police brutality against black people, and the systemic racism of which it is but one lethal manifestation, is a festering public health crisis. Can the medical profession use the tools in its armamentarium to address this deep-rooted disease?

Health care reform has been associated with presidents and national leaders, but communities, workers, activists, and health care professionals have made their voices heard in the debate about whether and how to make quality health care available to all. For All the People: A Century of Citizen Action in Health Care Reform tells the lesser-known story of how movements of ordinary citizens helped shape the changing American health care system.

In Racism without Racists, Eduardo Bonilla-Silva articulates why “color blindness,” an ethos based on the belief that race is no longer relevant, is contradictory and harmful. Color-blind policies, such as race-neutral mortgage practices and Medicare and Medicaid rules, have resulted in discrimination against black people and greater burdens on communities of color. 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. Many clinicians and policymakers are therefore alarmed by recent state-based crisis standards of care (CSCs) that provide a color-blind process for determining whether a patient with Covid-19 respiratory failure lives or dies.

When Leonidas H. Berry (1902–1995) graduated from Rush Medical College in 1929, racial segregation was a harsh and codified reality in America. Along with racially segregated schools, restaurants, and buses, medicine was subject to an enforced racial order and characterized by a vast inequality. Medical practices and clinics were segregated by race, few medical schools admitted black students, and many hospitals would not hire black doctors or admit black patients...

Studies have shown that both longitudinal alternative medical curricular tracks and short-term global health electives have long-term benefits upon the professional development of participants, suggesting that the GHFF is likely to do the same. The author also argues that the GHFF is an advantageous model of global health education compared to standard offerings and provides a unique curricular model by which to foster the development of social values—such as professionalism, advocacy, and social justice—that are widely considered lacking in today’s medical education.

After World War II, the medical civil rights movement increasingly focused on ending segregation in the mainstream health care system. The National Medical Association, the organization of black physicians, protested the pro-segregation provisions of the 1948 Hill-Burton Hospital Survey and Construction Act, and demanded an end to racial discrimination by the American Medical Association, which permitted all-white local chapters. The interracial Medical Committee for Civil Rights (MCCR) was founded by physicians John Holloman Jr. and Walter Lear in 1963. The MCCR made national headlines by picketing the AMA’s convention in Atlantic City that year with signs asking the AMA to “end all segregation and discrimination in medical care.”

A 55-year-old man, Mr. N. presented to the UCLA emergency department (ED) reporting auditory hallucinations and thoughts of suicide. This was his sixth visit to the UCLA ED over a period of a few months; each visit was precipitated by his losing his medication and experiencing worsening psychotic symptoms and suicidal thoughts. During all but one of these visits, the examining physicians concluded that Mr. N. did not meet the criteria for psychiatric inpatient care. A typical note read, “He is only in the ER for food and shelter. …He has been homeless for many years. Given that he came to the ER to seek shelter, he has proven himself capable of making plans.”

In a 2019 op-ed in the Wall Street Journal entitled “Take Two Aspi-rin and Call Me by My Pronouns,” former University of Pennsylvania Dean of Medical Education Stan-ley Goldfarb echoed a dismissal that some physicians have been voicing for decades. Why should medical training focus on social factors, Goldfarb asked, when medicine’s purpose is to cure in-dividual patients? His essay as-sumed that one can effectively cure patients while ignoring the world in which they live. Unfor-tunately, that is an empirically untenable position.

"The results showed significant indirect effects of incarceration history on depressive symptoms via negative police encounters and police avoidance. Unemployment moderated the indirect effect via police avoidance. Participants with a history of incarceration who were unemployed reported significantly higher police avoidance and, in turn, higher depressive symptoms. Moderation of unemployment on the indirect effect via negative police encounters was not significant."

"We investigated links between police brutality and poor health outcomes among Blacks and identified five intersecting pathways: (1) fatal injuries that increase population-specific mortality rates; (2) adverse physiological responses that increase morbidity; (3) racist public reactions that cause stress; (4) arrests, incarcerations, and legal, medical, and funeral bills that cause financial strain; and (5) integrated oppressive structures that cause systematic disempowerment."

"Over the life course, about 1 in every 1,000 black men can expect to be killed by police. Risk of being killed by police peaks between the ages of 20 y and 35 y for men and women and for all racial and ethnic groups. Black women and men and American Indian and Alaska Native women and men are significantly more likely than white women and men to be killed by police. Latino men are also more likely to be killed by police than are white men."

In Minnesota, where black Americans account for 6% of the population but 14% of Covid-19 cases and 33% of Covid-19 deaths, George Floyd died at the hands of police.

Americans don’t see me, or Ahmaud Arbery, running down the road—they see their fear.
-Ibram X. Kendi

African American/Black persons (BPs) believe subtle, rather than overt, interpersonal racism is increasing. Sue and colleagues describe interpersonal racism as racial microaggressions: “routine” marginalizing indignities by White persons (WPs) toward BPs that contribute to health stress. In this narrative, exploratory study, Black adults (n = 10) were asked about specific racial microaggressions; they all experienced multiple types. Categorical and narrative analysis captured interpretations, strategies, and health stress attributions. Six iconic narratives contextualized health stress responses. Diverse mental and physical symptoms were attributed to racial microaggressions. Few strategies in response had positive outcomes. Future research includes development of coping strategies for BPs in these interactions, exploration of WPs awareness of their behaviors, and preventing racial microaggressions in health encounters that exacerbate health disparities.