Here Are Some Possible Solutions To Medicine’s Systemic Racism Problem
Within medicine, racism can corrupt the patient-doctor relationship; it also affects the treatment of trainees.
August 05, 2020 at 6:31 pm
Co-written by Tahj Blow and Lala Tanmoy Das
We are in an unprecedented time.
In response to anti-Black police brutality, variations on these words have reverberated in media reports, protests and across kitchen tables over the past weeks. Police brutality is not the only symptom of systemic racism, however. Focusing on law enforcement is a reductive solution to a complex set of problems. The cessation of American Apartheid requires that all social institutions eliminate their contributions to institutional racism.
Medicine and science are not exempt from this responsibility, despite swift condemnations of racist policing by medical institutions. Medicine has played an essential role in perpetuating systemic racism through the codification of race itself. From scientific polygenism to eugenics, the justifications for slavery and discrimination relied heavily on pseudoscientific claims about the inferiority of Black people and other non-whites. Racism cannot thrive without race.
Today, overt hierarchization of the races has evolved into a new medical racism, its logic rendered more subtle and insidious by the seeming support of statistics. The ripple effect of medical racism’s assertions pervades not only medicine and science, but is also used to justify white supremacy in social and criminal justice policy.
Within medicine, racism can corrupt the patient-doctor relationship; it also affects the treatment of trainees. After a weekend galvanized by New York protests, L., a Black medical student, was joined at her workstation by her attending physician and medical team. L. took her turn sharing weekend updates.
“I bet you went to the protests,” the attending pointed at her and said.
“I hope you didn’t bring a gun to the hospital to take out your anger.”
Everyone laughed and L. joined nervously.
L. is far from alone. Medical trainees of underrepresented backgrounds tolerate both microaggressions and explicit discrimination, and bear witness to this mistreatment of patients who look like them. Although medical centers have established channels for anonymous reporting of mistreatment, fear of career repercussions is often a deterrent. Despite efforts like 24-hour hotlines and direct reporting to academic deans, the protections afforded to offenders by titles, finances and institutional prestige often thwart positive change.
To correct these failures, many medical institutions have implemented anti-bias training initiatives, touting them as a panacea to institutional racism. However, research has often shown that implicit bias training not only fails to alter behavior or change workplace culture, but may actually normalize stereotyping. Instead of promoting anti-racist behavior, our current methods disincentivize the application of comprehensive, structural, radical interventions necessary to address workplace bias.
So, where do we go from here?
First, we must recalibrate medical education to teach racism, not race.
In 2018, Serena Williams sparked a national conversation on racial disparities in maternal mortality. In a lunch conversation one of us had at that time, a non-Black medical student expressed her surprise, presuming that larger hip width makes childbirth easier for Black women. When informed of Black women’s unequal treatment, she waved off the fact, citing the genetics of Blackness as the probable cause of disparate outcomes.
Medical education, and the licensing exams that shape it, must acknowledge the sociopolitical, structural factors that contribute to racial and ethnic health disparities, rather than perpetuate narratives emphasizing physiological differences among races.
From diabetes to heart disease, students are routinely taught that Blackness itself leads to disease. Teaching race as an epidemiological risk factor, without discussion of the structural insults leading to these statistics, confers biological truth to the social construct. It upholds racial essentialism, suggesting innate differences in the Black body and allowing racial bias to persist.
Alternatively, medical curricula must emphasize the effect of redlining on increasing pollution in Black neighborhoods, escalating the prevalence of asthma in Black children. Students must be taught about the physical toll of the unrelenting stress of racial discrimination contributing to hypertension. The field must address the misuse of race corrections in debunked medical algorithms. It must address practitioners’ failure to prescribe adequate pain medication to Black cancer and postsurgical patients, as compared to their white counterparts. This is critical to ending dangerous stereotypes otherwise persisting in the minds of medical trainees.
Second, we must invest in genomic research and studies of the epigenetics of risk genes in order to provide truly personalized medicine to patients of non-European ancestry. Currently, genetic analysis lacks the granularity necessary to accurately determine risk or prognosis, and guide treatment, for patients with African ancestry. Diagnostic shortcuts often use phenotypic Blackness as a proxy for genetic ancestry, even though the presence of high-risk alleles may vary by country origin and within ethnic groups. Efforts to determine genetic risk scores in Black patients are further stymied by science’s inequitable focus on European genetics.
In genetic studies, individuals with genes associated with European origin are overrepresented at a rate nearly five times their percentage of the global population. Comparatively, individuals with genes of African ancestry are understudied at a rate only one-sixth of their global representation. As a result, patients of European genetic ancestry benefit from more nuanced clinical care, based on their individual genetics — whereas Black patients are often treated as a monolith. Treatment recommendations, like first-line treatment for hypertension, are determined by their skin color. In this paradigm, disparities in treatment and health outcomes are inevitable.
Third, we must effectively teach allyship — the concerted practice of social justice and inclusion by a majority group to advance the interests of a marginalized group. Following racist encounters, Black, Indigenous and People of color (BIPOC) often must seek safe spaces with their peers to have their experiences validated and discussed, an experience that contributes to a sense of isolation in the professional arena. Teaching allyship requires that non-BIPOC participants be involved in a way that encourages them to learn from leaders among their peers, propose their own solutions to biased encounters and be held accountable by marginalized groups. This was demonstrated with the successful “Advocates to Allies” program, pioneered by North Dakota State University in 2008 to combat inequity for women. Such a framework could be replicated in medical institutions, where BIPOC patients, students, staff and faculty experience a biased environment. These changes are particularly important, as our society becomes more diverse and efforts to promote BIPOC recruitment and retention can outpace strategies to improve racism in medical culture.
Finally, national accreditation and ranking organizations must impose anti-racism grading metrics to hold medical institutions accountable. Medical schools and academic health centers currently lack standardized measures for the implementation of anti-racist medical education and healthcare practices. Although White Coats for Black Lives’ Racial Justice Report Card provides a viable tool for appraising institutions, participation in the assessment is voluntary. As a result, institutions only change as much as they see fit, enabling variable treatment of patients, trainees and professionals of color.
Standardized evaluation of anti-racism policies and practices must be nationally mandated by professional medical organizations (i.e. the Association of American Medical Colleges, The Joint Commission, etc.). The Healthcare Equality Index, a national measure for equity in LGBTQ patient care, establishes a model for creating systemic, objective measures of diversity and inclusion. Subsequent rating of anti-racism policies should be reported by both the U.S. News Rankings and the Medical Student Admissions Requirement (MSAR) database.
While abolishing systemic racism will take time, these are some immediate measures medicine can undertake in the near term. Eliminating racial essentialism, and instead making critical race theory an integral part of medical education and training, can help foster an anti-racist medical system.
Reine-Marcelle Ibala is an MD student at Weill Cornell Medical College in New York City.
Tahj Blow is an MD student at Weill Cornell Medical College in New York City.
Lala Tanmoy Das is an MD-PhD student in the Weill Cornell/Rockefeller University/Memorial Sloan Kettering Tri-Institutional Program in New York City.