Actions Speak Louder: Is Medicine Complicit in the Ill Health of Black America?
On December 10th, 2014, 2000 students at over 70 medical schools protested police violence and the deaths of Mike Brown and Eric Garner by holding die-ins across the country. As a part of this action, a national coalition of medical students committed to racial justice formed under the banner of White Coats for Black Lives. In response to and in solidarity with recent student activism at Mizzou and other undergraduate campuses, White Coats for Black Lives students across the nation are mobilizing to hold demonstrations demanding an end to the systemic racism that permeates our medical schools and hospitals. The lack of diversity among medical students and faculty, implicit and explicit racism within the curriculum, and the poor health outcomes of low-income Black communities, so often in proximity to our campuses, has galvanized a growing collective of medical students to change their institutions from the inside.
We have an intimate view into our patients’ lives as medical students, and we see racism impacting health at every step of our training. In trauma centers, we are reminded of victims like Tamir Rice and Laquan McDonald as we take care of people shot and killed by the police. In clinics, we see the higher rates of diabetes, heart disease, stroke, and premature birth among Black communities. In our schools, we see the fewer resources that support the disproportionately low numbers of Black, Latino, and Native American students and faculty. These trends reflect the structural racism that characterizes many aspects of American life beyond healthcare: in housing, employment, education, incarceration rates, the stratification of wealth, and more.
For years, the medical community has allowed Black Americans to receive less effective health care than white Americans.
As an institution, medicine cannot ignore the health statistics and social contexts of our communities of color. According to the Centers for Disease Control and Prevention, Black Americans continue to die more frequently and at younger ages in every measurable health cause aside from drug-induced deaths and suicide. If the life expectancy of Black Americans were ranked separately among nations, it would rank 100 places lower than white Americans (75.3 years compared to 78.8) according to the CIA. Infant mortality alone for Black Americans as a single group would rank 88th globally. These statistics only hint at the extent of health disparities in the US that face multiple minority populations. Research shows that physicians, often unconsciously, hold racial biases towards patients, and these biases manifest in the differential treatment of Black patients. Medical treatment for Black patients often differs from the “gold standard” of evidence-based medicine. Black patients are less likely to receive pain medication for the the same conditions as white patients, and they are less likely to receive life-saving interventions when presenting with symptoms of a heart attack, among other examples. For years, the medical community has allowed Black Americans to receive less effective health care than white Americans. This holds true even when comparisons are drawn between patients with the same socioeconomic and insurance status.
Though we are taught in medical school that these health disparities exist, we are not taught the historical and institutional reasons for their formation or ways they can be reduced. Nor are we effectively prepared to recognize or counteract the biases in our training that impact daily interactions with patients. Instead, race is conflated with culture and genetics, rather than defined and understood as a social construct. We are expected to memorize, unquestioned, that people of color are inherently predisposed to everything from premature death to diabetes and hypertension. Even though poor evidence exists for a genetic definition of race, the notion that race as an innate biological variable produces health disparities is allowed to rest unchallenged on projector screens in lecture halls across the country. Although many medical students may appropriately resist the conclusion that race is biological, the no less noxious emphasis on race as culture teaches physicians in training that differences in health behavior arise from patient behaviors. Without a critique of the sociopolitical and historical contexts that create the conditions for poor health, such as housing discrimination and disproportionate rates of incarceration, our training disproportionately places blame on patients, especially Black patients. Health disparities are therefore traced, deliberately, back to genetics and race-based culture, barring an understanding of the structural roots of racism that underpins these disparities from both medical education and practice.
The highest number of matriculating Black male medical students in the last 40 years was 542 in 1978. In 2014, there were only 515.
There are many ways to take active, meaningful, and intentional steps to reduce racism within the American healthcare system. One crucial starting point is within medical schools, where future physicians are nurtured and trained. Cultivating a diverse workforce is pivotal to ameliorating health disparities, as minority physicians are more likely than non-minority physicians to work in areas with higher proportions of Black and Latino populations, see Medicaid and uninsured patients, and conduct research about health disparities. However, racism operates at the level of medical school admissions similarly to other institutions of higher education, as indicated by the makeup of our medical school classes. The highest number of matriculating Black male medical students in the last 40 years was 542 in 1978. In 2014, there were only 515. That same year, medical schools admitted 35% of white, 35% of Asian, and 40% of Latino applicants, but only 28% of Black applicants. U.S. medical school classes in 2011 consisted of of 6.1% Black, 8.5% Latino, and 0.2% Native American students, far from the 13%, 17%, and 1% of the country that these groups comprise. Diversity benefits every student: Black, Hispanic, Asian American and Pacific Islander, Arab American, Native American, multiracial, and white. Interrogating who is accepted into the field of medicine reveals the need for policies that ensure a greater presence of minorities underrepresented in medicine.
We need to break the silence and formally acknowledge racism within our medical schools and our healthcare system. Future physicians must understand the historical and present day roots of the suffering of their patients of color. Structural competency, which “aims to develop a language and set of interventions to reduce health inequalities at the level of neighborhoods, institutions and policies,” is a powerful way for medical students to learn how oppression operates along axes of race, gender, and class. History, economics, sociology, and anthropology are powerful tools for understanding racial inequity in health from the level of individual relationships to the level of entire populations. Further, a curriculum that integrates these fields is a natural extension of the focus within the medical community on systems of health. Teaching structural competency counteracts racist narratives and dismantles their sources, producing critically thinking physicians who leave medical school believing patients of color can and should be free of poor health.
This month, medical students nationwide stand in solidarity as members of White Coats for Black Lives to demand two things of our medical schools. First, we demand that admissions offices actively recruit, admit, and retain Black, Brown, and Native students so that our medical schools reflect the diversity of the patients we train to serve. These efforts should be augmented by establishing effective pipeline programs, setting aside scholarship funds, and providing structured mentorship throughout medical school. Second, low-income patients of color who live in the communities around our medical campuses are often excluded from the very hospitals that claim to serve them, particularly if these patients are uninsured or publicly insured. We demand that members of our local communities, particularly people of color, have full access to care at academic medical centers without financial or other hardship. Our hospitals and schools loudly claim to be committed to diversity and to caring for the health of our communities, but their #actionsspeaklouder.
Charlotte Austin, Icahn School of Medicine at Mount Sinai, New York, NY
Lovelee Brown, Geisel School of Medicine at Dartmouth University, Hanover, NH
Joniqua Ceasar, Baylor College of Medicine, Houston, Texas
Ann Crawford-Roberts, Icahn School of Medicine at Mount Sinai, New York, NY
Jonathan Jiménez, MD, MPH, Department of Community & Family Medicine, Duke University School of Medicine, Durham, NC
Mansi Shah, Case Western Reserve University School of Medicine, Cleveland, OH
Jennifer Tsai, Warren Alpert Medical School at Brown University, Providence, RI
