The national racial reckoning over reparations and critical race theory is taking over the world of medicine and health care. Prestigious medical journals, top medical schools and elite medical centers are adopting the language of social justice activism and vowing to confront “systemic racism,” dismantle “structural violence” and disrupt “white supremacy” in their institutional cultures.
Some activist physicians describe the present-day health care system with such ominous terms as a “medical caste system” or “medical apartheid,” the latter locution taken from the title of a 2007 book about America’s history of medical experimentation on enslaved blacks and freedmen.
“Modern American medicine has historical roots in scientific racism and eugenics movements,” according to a February article in the New England Journal of Medicine titled “How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities.” “Black communities became medical training grounds and a source of profit, reinforcing the American medical caste system that we have today.”
Rare is the doctor who is willing to publicly question claims of white privilege and implicit bias in the healthcare system, and already several doctors who have publicly pushed back have been demoted and have filed legal actions alleging retaliation. This year the medical profession received an unequivocal message when two editors of the prestigious Journal of the American Medical Association resigned under pressure over a podcast that aired opinions expressing skepticism that the United States is plagued by systemic racism.
Part 2 Thursday: Retaliation, and the Moral Dilemmas of the New Order
While racialized politics has infused every corner of American life, the moral stakes in the health care arena go far beyond, say, the perceived slights called microaggressions. The medical literature, lately drawing on critical race theory, depicts the health care industry itself as a historical source of illness in — and even killing of — black and brown bodies. That would make medicine analogous to policing and criminal justice, the other social institutions directly blamed for maiming and murdering black people.
During the last year, more than 200 governmental bodies and private institutions have declared racism a public health care crisis, a step that potentially clears the way for taking more aggressive action to protect public health by hiring more black doctors, academics, administrators and editors as caretakers and gatekeepers.
“If for no other reason than atonement … addressing racial equity is a just cause for academic medicine,” Clyde Yancy, chief of cardiology and vice dean for diversity and inclusion at Northwestern University’s Feinberg School of Medicine, wrote last year in the Journal of the American Medical Association, or JAMA, in a piece titled “Academic Medicine and Black Lives Matter.”
“What exists today as the infrastructure for scientific discovery and medicine reflects structural racism that has evolved from a biased, stained, and oppressive history against Black individuals,” Yancy wrote. “All physicians, and particularly those in academic medicine, can and should address racial equality and engage with Black Lives Matter because atonement matters.”
The movement is just beginning reshape the practice of medicine, but a primary assumption is that white doctors and institutions are pervaded with unconscious bias, and that black doctors, who are significantly underrepresented in the profession, would provide better care to black patients. But because black students typically get lower scores and lower grades, increasing the ranks of African American and other minority practitioners would likely require moving away from a reliance on conventional measures of academic qualification, such as undergraduate grades and standardized test scores.
According to this line of reasoning, grades and scores may not be a reliable measure of future potential for underrepresented minority groups because such students must first overcome an array of obstacles and challenges – from biased teachers to unprepared parents — to catch up to their more privileged white classmates, according to a piece written by a trio of black physicians in the New England Journal of Medicine last year.
“Ultimately, physicians’ skill and quality are defined by the care they provide to patients over the span of a career — a value that no three-digit test score can anticipate,” the New England Journal piece states.
Efforts to improve health outcomes for black patients are advancing on many fronts. They include a Boston hospital pilot project to offer preferential admissions to non-white patients for heart care; prioritizing non-whites for COVID-19 vaccinations; and the changing of a United States Medical Licensing Examination test from a graded score to pass/fail to help minority students succeed.
The Accreditation Council for Graduate Medical Education is adding a diversity requirement for accrediting U.S. residency and fellowship programs for newly minted doctors; and Northwestern University and its Feinberg School of Medicine are seeking to improve diversity by eliminating a six-decade-old Honors Program in Medical Education.
Medical schools are adding units on critical race theory, intersectionality, implicit bias, identity, oppression, allyship, power and privilege to their curricula. Medical students are learning about medical exploitation and medical experimentation on enslaved blacks, black prisoners and other unwitting subjects. And staple reading assignments in med schools feature such non-medical polemics as Robin DiAngelo’s “White Fragility” and Ibram X. Kendi’s “How to Be an Antiracist.”
This year alone, six state medical boards have added a requirement for training in “antiracism,” implicit bias or cultural competency for doctors in some practice areas to be eligible for a medical license, raising the total to 13 jurisdictions that require such training; eight other board are reviewing such proposals, according to the Federation of State Medical Boards.
All of this comes at a time when medical schools are experiencing dramatic changes on the gender front as well, where it is becoming customary for medical professionals to announce their gender pronouns as a matter of standard etiquette, and some medical schools are replacing the phrase “pregnant women” with “birthing people” in the interest of inclusiveness. Indeed, the issues of race and gender are intersectionally linked in the world of social justice advocacy, and some anti-racist and equity manifestos include a sex and gender platform, such as adding more chest binders and gender-affirming practices, reducing heteronormative bias, and advocating for “LGBTQIA2S+” causes. These efforts, which have been building for years, seem to be moving the needle. Medical school applications from black and Hispanic students surged between 2013 and 2020, according to data from the Association of American Medical Colleges. As a result, black students accounted for 9.5% of all first-year med students in 2020, up from 7% in 2013, while first-year students identifying as Hispanic jumped to 12% from 9.1% over the same period.
Meanwhile, the percentage of white medical students is diminishing. The 2019-21 academic year marked the first time that self-identified whites accounted for less than half of the nation’s medical students.
The public health profession has long been in the vanguard of seeing medicine as a social science and politics as medicine on a grand scale. Last year, at a time when public gatherings were discouraged or banned to prevent the spread of the coronavirus, more than 1,200 public health officials signed a letter last year encouraging public participation in mass protests in support of Black Lives Matter.
“This should not be confused with a permissive stance on all gatherings, particularly protests against stay-home orders,” the petition states. “Those actions not only oppose public health interventions, but are also rooted in white nationalism and run contrary to respect for Black lives.”
Such developments trouble skeptics worried about the repercussions for patient care and for the training of physicians. They say the moral fervor reduces complex policy to simplistic slogans and indiscriminately blames all racial disparities on a nebulous menace – white supremacy or systemic racism – while discounting the influence of cultural differences and individual initiative. It then attacks the perceived problem through blunt weapons as such racial preferences, ideological conformity and emotional blackmail.
“The fundamental problem with social justice in public health is that there are no limiting principles to it,” American Enterprise Institute senior fellow and author Sally Satel wrote in the journal Liberties this year.
“Differences of any kind — in income, education, school performance, and, of course, health — are manifestations of racism and racism alone,” Satel wrote. “The practice of ‘equity,’ the enactment of critical race theory, permits, if not endorses, unequal treatment of the dominant group in order to arrive at equal group outcomes, even if it is to the detriment of ailing individuals.”
Satel is among those who doubt equity is attainable, given the complex underlying factors that shape human health. But some medical ethics experts are pushing in the other direction and going so far as to argue that equalizing group outcomes between blacks and whites may necessitate tolerating a greater loss of life.
Whose Hippocratic Oath Is It?
The medical ethics quandary tests the foundational principle of medicine itself, the Hippocratic Oath, by which doctors take a vow to “do no harm.” In the current cultural moment in which critical race theory is upending long-held assumptions about colorblindness, bioethics experts are reassessing the traditional understanding of harm and healing in ways that would have been unthinkable in the past.
For these reasons, the skeptics see the profession swept up in a moral panic and headed for a massive over-correction, while advocates see the stakes for minority patients in life-and-death terms.
“It’s a very ideological approach to things: ‘People are going to die, so you have to agree with everything I say. And if you disagree with it, you want people to die apparently,’ ” said William Jacobson, clinical professor of law at Cornell Law School and president of the Legal Insurrection Foundation, which runs the conservative websites legalinsurrection.com and criticalrace.org.
“And it also is extremely lucrative for consultants and administrators who have a vested interested in perpetuating the problem and these efforts,” said Jacobson, who is involved in litigation against SUNY Upstate Medical University for internal communications related to the school’s planned equity strategy.
Lurking just under the surface of this debate is the sensitive question no one wants to discuss on the record: the quality of med students and doctors who have lower test scores and worse grades, and presumably would not have been admitted if not for affirmative action. That’s an issue broached by Norman Wang, a University of Pittsburgh cardiologist whose peer-reviewed article questioning the legality of racial preferences was, four months after publication, retracted, leading to Wang’s demotion and public denunciation by his employer and by the journal that initially saw fit to run his article.
“Long-term academic solutions and excellence should not be sacrificed for short-term demographic optics,” Wang wrote in the article. “Ultimately, all who aspire to a profession in medicine and cardiology must be assessed as individuals on the basis of their personal merits, not their racial and ethnic identities.”
In last year’s JAMA piece, Yancy acknowledged the racial reckoning will require a period of trial and error.
“What works is simply not clear,” Yancy wrote. “In the haste to achieve racial equity in medicine, many are rushing to embrace the same strategies: implicit bias testing; bias mitigation seminars; cluster hiring of diverse faculty members; eliminating any evidence of race-based medicine from curricula; hiring of chief diversity officers; no longer reporting race in research reports.”
A more detailed sampling of several recent “anti-racist” initiatives shows the radical character of the transformation within the medical profession that is now underway.
The American Medical Association, the nation’s premier professional group with more than 270,000 member doctors, in May announced a racial justice strategy that would encourage all physicians to develop a “critical consciousness” and align with “anti-oppressive and anti-racist praxis” to dismantle what it described as white patriarchy and other systems of oppression. The AMA seeks to promote the “invisible-ized” collective narratives of black, “Latinx,” LGBTQ+ and other historically marginalized physicians and patients.
The AMA’s 86-page strategic plan endorses critical race theory, intersectionality and equity as core elements of a medical school education. Consistent with those doctrines, the AMA’s equity strategy repudiates equal treatment and meritocracy, denouncing them as “malignant,” white supremacist ideologies that serve to obscure “true power and site of responsibility.” The AMA condemns the “detrimental effects of colonization, racial capitalism, and enduring forms of supremacism” that contribute to a “persistent cycle of structural violence.”
The State University of New York’s Upstate Medical University, in Syracuse, founded in 1834 and employing more nearly 11,000 people, last year assembled a diversity task force to advance “the herculean task” of eradicating racial health disparities. The task force’s first recommendation: the creation of implementation and “Oversight Tiger Teams” – echoing a term deployed by NASA in 1970 for the Apollo 13 space mission — to oversee and prioritize 65 proposed action items.
Among the 164-page task force report’s charges: “Health care professionals must explicitly acknowledge that race and racism are at the root of these health disparities.” All students and staff are to receive training in “bystander intervention” for bias, all new faculty hires would be required to sign a written pledge affirming a commitment to diversity, equity and inclusion, and staff with advanced training in anti-racism would be identified by wearable buttons. Medical school applications would add questions about the applicant’s commitment to social justice, and include “a statement that if the student does not have this desire they may not want to consider [SUNY] Upstate.”
WhiteCoats4BlackLives, a medical student organization that has grown to some 75 chapters out of the National White Coat Die-In demonstrations in 2014, represents up-and-coming leaders in the medical profession. The organization supports the Palestinian liberation movement, advocates the “abolition of police forces,” and urges medical schools to research the backgrounds of their founders and leaders for racist and oppressive pasts. WC4BL’s 289-page report from 2019 says the med school curriculum must explicitly teach that “it is the dominant groups’ pursuit of power that contributes to illness.” Among the group’s policy proposals: Medical schools must eliminate racial grading disparities, compensate “community advocates and people of color” for anti-racist activism, and equip physicians-in-training with tools to dismantle systemic racism, including “training in activism and organizing.”
Origins of a Movement
What has led up to this point? One place to start is the voluminous research on racial health disparities and the grim picture this body of work depicts. The 1985 Heckler Report, a nine-volume study issued by the Department of Health and Human Services, officially called the “Report of the Secretary’s Task Force on Black and Minority Health,” reported a five-year difference in life expectancy between blacks and whites, and double the infant mortality rate for blacks compared to whites — disparities that are similar to this day. The federal government’s first study of the black-white health gap noted 59,000 black deaths a year caused by the disparities.
A 2003 report commissioned by the U.S. Congress and produced by the Institute of Medicine (since renamed to the National Academy of Medicine) referred to some 600 studies on racial disparities over the previous three decades. The 700-plus-page report, called “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” said black patients are less likely to receive appropriate cardiac medication, coronary artery bypass surgery, hemodialysis, kidney transplantation, pediatric care and many surgical procedures — even when accounting for variations in insurance status, income, age and other factors.
“Unequal Treatment” reported that black Medicare patients were more likely to receive overly aggressive treatment in several procedures: bilateral orchiectomy (i.e., castration) and amputation. Yancy said those two disparities hold true today.
The report found that racial and ethnic minority patients were more likely to refuse treatment, but the refusal rates among African Americans “are generally small and that minority patient refusal does not fully explain healthcare disparities.”
The 2003 report sounds presciently contemporary in its bleak assessment of the status quo.
“These studies illustrate that much of American social and economic life remains ordered by race and ethnicity, with minorities disadvantaged relative to whites,” the report said. The report also provided one of the axioms of systemic racism: “There is considerable empirical evidence that even well-meaning whites who are not overtly biased and who do not believe that they are prejudiced typically demonstrate unconscious implicit negative racial attitudes and stereotypes.”
A 2016 study on disparate pain treatment said that half of white medical students and residents have “false and fantastical” beliefs that black people have a higher pain tolerance. The study was seeking an explanation for why black patients are less likely to receive opioids for pain treatment or to receive lower doses, a pattern that holds even for children.
A 2019 study, referencing more than 300 papers on racial health disparities, noted that the racial outcomes are impervious to social class: “At every level of education and income, African Americans have a lower life expectancy at age 25 than do whites and Hispanics (or Latinos), and blacks with a college degree or more education have a lower life expectancy than do whites and Hispanics who graduated from high school.”
For the past quarter-century, public health experts had accepted a general explanation for these disparities – attributing them to “social determinants of health” – a term that covers living conditions and socioeconomic factors that ultimately determine one’s life expectancy. But these social determinants existed somewhere out in the world, beyond the scope of doctors, and the medical solutions seemed speculative, unknown or ultimately unknowable.
Over time, public health researchers began attributing the racial disparities with growing insistence to an anterior cause – an invisible force operating within American society, ranging from unconscious bias to policing patterns and even to the practice of medicine itself. In other words: systemic racism. Framing the disparities as the result of social determinants of health left the medical profession powerless – for how can a health care provider treat a patient suffering from social conditions? The social determinants existed somewhere out in the world, beyond the scope of doctors, and the medical solutions seemed speculative, unknown or ultimately unknowable. But zeroing in on systemic racism has thrown open the doors to a whole new set of interventions, which translate into the anti-racism movement now sweeping through the medical profession.
“It’s the thing that causes the adverse impact of social determinants of health on specific communities,” said Matthew Wynia, a University of Colorado professor of medicine and director of the Center for Bioethics and Humanities. “To just say it’s because ‘they live in bad neighborhoods,’ that is not a full explanation. This is all about 400 years of history.”
Wynia said there are only a handful of possible explanations for why black people have consistently worse health outcomes: bad genetics, irresponsible behavior, individual racism on the part of whites, or social structures. Wynia said the first two explanations – bad genes and bad choices – are the very definitions of racism, and individual white racists do exist but within the context of a larger problem: “Societal factors have got to be the favorite there.”
Satel agreed that increasing the ranks of the nation’s African American doctors and other practitioners would be a welcome development, especially if these doctors, physicians’ assistants, and nurse practitioners dedicated themselves to serving poor communities that have a shortage of doctors and clinics. She said a higher level of doctor-patient trust would very likely increase compliance with taking medications and following doctor’s orders.
But a common question that comes up is: What can a doctor or a hospital do to alleviate health conditions caused by substandard housing or a failing school system? How does diagnosing medical conditions with political theories guide a doctor in treating a patient?There is no single answer, but one advocate suggests a redefinition of a physician’s scope of practice: Doctors have a moral obligation to become politically active so they can work to dismantle the social structures that harm their patients’ health.
“We’re often taught as doctors to be apolitical, be quiet, don’t say anything, but that silence is just reinforcing the problems that got us here to begin with,” said Stella Safo, assistant clinical professor at the Icahn School of Medicine at Mount Sinai, in New York City. Safo was one of the doctors who started the petition for JAMA to become more racially aware and restructure its leadership after it approved a podcast in which a JAMA editor questioned the existence of systemic racism (see sidebar).
Another doctor involved in the JAMA petition was Brittani James, a Chicago-based physician and assistant professor in the College of Medicine at the University of Illinois, who has developed a longitudinal anti-racism course that med students will take over four years; the course was piloted in the 2020-21 academic year.
“What we’re trying to get them to understand is that it’s not going to stop until we get to the root of the problem, which is all of us are agents in the system,” said James, who also treats low-income patients in an urban clinic, and describes herself as an activist, radical black feminist, and anti-racism scholar.
“We do not name and acknowledge that we are built on a system designed to keep able-bodied white males alive,” James said. “If you’re anybody but a straight able-bodied white male, our system is not optimized for you. That’s reality.”
An underlying problem in health care, from the standpoint of critical race theory, is the profit motive that disincentivizes health care providers from caring for the uninsured and the poor.
“This really rattles people because people really do not want to critique capitalism, but we have to look at it,” James said. “The resounding argument is essentially that capitalism requires a pool of dehumanized labor so they can be exploited for profit. I personally think that capitalism is an unsustainable system.”
But the critics say that applying critical race theory to medicine too often devolves into an exercise in conformational bias that seeks only the evidence that confirms the theory of systemic racism, ignores or disallows contradictory evidence, and imposes forced interpretations on complex data.
“They start with the conclusion. And there can be no deviation from the conclusion,” said Jacobson, the conservative law professor at Cornell. “You cannot question the conclusion because the conclusion of systemic racism is the starting point. It stifles dissenting views. It stifles open inquiry.”
Other scholars express similar frustrations. Satel’s article in the Liberties journal, titled “Do No Harm: Critical Race Theory and Medicine,” cites an anonymous colleague who related participating in a group discussion about stress and suicide among black youth. “The tacit rule was that only fear of police aggression and subjection to discrimination were allowable explanations,” the anonymous doctor recalled, “not the psychological torture of bullying by classmates or the quotidian terror of neighborhood gun violence.”
It will likely take years to know whether efforts to achieve equity – that is: equal outcomes by race — and make amends for past wrongs will make a dent in medical treatment and lifespans for people of color.
“There is no evidence that any one step necessarily minimizes that gap,” said Yancy, past president of the American Heart Association in an interview with RealClearInvestigations. “As well, the disparities evolved over decades and so it’s difficult to think that a single intervention or set of interventions over just a few short years would begin to narrow those disparities.”
“It is a process that that we’re engaged with, a hypothesis that we hope to prove,” Yancy said. “So we’re beginning what is a very tough pivot. It will take generations to execute this pivot.”
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