Black and Blue. John Hoberman
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Even this tepid call to action was too much for Dr. Sally Satel, whose response to this document appeared in The Wall Street Journal under the title “Racist Doctors? Don't Believe the Media Hype.”51 The authors' refusal to call doctors racists was irrelevant to this conservative ideologue; the real offense of the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care was to have even considered the possibility that American doctors might be capable of racially motivated misconduct on a scale exceeding the misdeeds of a few bad apples.
One antidote to tentative medical liberalism and obstinate conservative denial is historical knowledge of the relationship between American medicine and the black population over the past century. The publication of a massive history of modern medical racism in 2002, while noted in the press, should have had a greater catalytic effect than it did.52 That it did not shows that historical documentation of medical racism is not enough, because these narratives can easily promote the mistaken view that medical racism was a phase that modern medicine has left behind. Understanding how this illusion has prevailed becomes possible once we realize what modern doctors do not know about the racial attitudes and behaviors of their twentieth-century predecessors. Without this knowledge doctors will be literally unable to imagine their own capacity for racially motivated behavior. They will remain unaware of how the “hidden curriculum” of medical training perpetuates racial folklore that can do harm. They will continue to interpret traits and conditions of environmental origin as evidence of a “black” racial essence. In short, a medical profession that remains unaware of the racist legacy of American medicine cannot even begin to pursue meaningful reform.
The author of this book agrees with the Harvard ethicists that this situation requires “a critical perspective that has largely been ignored by most research to date.” And anyone who doubts that doctors are capable of ignoring entire dimensions of their own medical experiences need only read Jerome Groopman's How Doctors Think. For even as he ignores the race factor in medicine, the author of How Doctors Think has a lot to say about the limitations of current medical thinking. Do doctors' feelings about patients or their social backgrounds affect their thinking? “Nearly all of the practicing physicians I queried were intrigued by the questions but confessed that they had never really thought about how they think.” What Groopman and his colleagues “rarely recognized, and what physicians still rarely discussed as medical students, interns, residents, and indeed throughout lives, is how…emotions influence a doctor's perceptions and judgments, his actions and reactions.” “I cannot recall a single instance,” he says, “when an attending physician taught us to think about social context.”53
No medical culture that is so devoid of introspective activity regarding human emotions and social realities can understand the consequences of its entanglement with America's racial traumas. It is my hope that Black and Blue will enable physicians, and those who study the world of medicine, to understand how our racial complexes have infiltrated medical thinking and practice, and how a disengagement from these complexes might begin.
2. Black Patients and White Doctors
THE AFRICAN AMERICAN HEALTH CALAMITY: THE SILENCE
The ongoing medical calamity experienced by the African American population since the Emancipation of 1865 has never provoked the public outrage or the political mobilizations associated with other forms of racial injustice and suffering. Jim Crow segregation, the repression of black voting rights, the demoralizing poverty of the inner cities, and police brutality against blacks have all galvanized movements or urban uprisings. A professed concern about the state of the black family produced the Million Man March of 1995 and the enormous publicity that surrounded it. Yet comparable expressions of protest against the traumatic medical history black Americans endure have not happened. The outrage that followed revelations in 1972 about the Tuskegee Syphilis Experiment, an unethical study carried out on poor black sharecroppers over a period of forty years, did not produce anything like an organized movement. This brief firestorm of publicity also demonstrated the limited usefulness and double-edged character of such information in a racially polarized society. For what the black population learned about the one truly infamous example of American medical racism simply deepened a long-standing mistrust of the white medical establishment that had already established itself as a black oral tradition. For that reason the aftereffects of the exposé may have killed more African Americans than the experiment did. The Tuskegee scandal left behind a damaging emotional legacy rather than an organized response to the tremendous toll of premature death and preventable disease that has afflicted African Americans over many generations. The unhappy fact is that the most intense black feelings about the state of black health that achieve public expression are the widely believed conspiracy theories about government plots to exterminate black people by spreading the AIDS virus. The credence that is invested in such stories derives from a larger set of fears about black vulnerability to assorted dangers that can appear paranoid to most whites. Yet the fact is that what blacks believe about African American health and illness is often associated with ostensibly bizarre urban rumors that draw upon deeply entrenched memories of medical abuse and other traumas.
The sheer magnitude of the African American health crisis has been documented repeatedly, exhaustively, and—in important ways— fruitlessly. The number of annual “excess deaths” occurring in the African American population as of 2002 was estimated to have been 83,570.1 Measured over decades, this points to a toll numbering in the millions. African Americans die of heart disease, strokes, cancers, liver disease, diabetes, childbirth, tuberculosis, and premature birth at much greater rates than non-Hispanic whites.2 “The average length of a Negro's life in the South at present is 35 years,” Booker T. Washington wrote in 1915. By 1947 black life expectancy had risen to 57 years as opposed to 66 years for whites.3 As of 1998 whites were still living six years longer than blacks (70 versus 76 years). During the 1990s the “years of healthy life” gap stood at about eight years.4 These are the statistics underlying the discussion about whether African Americans live long enough to collect the Social Security payments they make over their working lifetimes.
How can we account for the lack of urgency attending a major public health emergency that is covered regularly in the media but that fails to ignite in the way some other crises do? Why, for example, have American physicians chosen not to regard black health issues as a public health emergency?
One reason for the low public profile of the black health crisis is its apparent intractability. As one observer put it back in 1990: “The poor ranking of America's black population in the indices of poor health is a scandal of such long standing that it has lost the power to shock.”5 Or as a Health Affairs editorial commented in 2005: “The very persistence and intractability of these symptoms may constitute an insidious disincentive to act.”6 The flood of research papers documenting the medical suffering of the black population has become a kind of dirge, an endless tale of woe and victimization that can create an impression of overwhelming hopelessness and thus paralyze the will to enact policies that might begin to reverse the dire conditions that are described. The recitation of endless statistics documenting the racial health gap can also have the effect of depersonalizing and obscuring the human reality of what is happening to people. Our attention is displaced from the behaviors of doctors and patients into an abstract dimension of enormous and hopelessly complicated social phenomena that can only be imagined or, at best, theorized.
The bureaucratic language in which the data on racial health disparities are presented promotes this sense of anonymous forces acting on people who remain invisible. The soporific and euphemizing effects of public health jargon conceal what can go wrong in relationships between medical professionals (regardless of their race) and their black clients. Indeed, a major argument of this book is that these relationships are often profoundly affected by traditional ideas about racial differences that have survived to a much greater degree than the medical establishment is willing to concede. This false assumption about physicians' immunity to racially motivated thinking helps to account for the limitations of the instructional programs in “cultural competence” that some medical schools now offer in their attempts to sensitize medical students to the needs and circumstances of minority patients.