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Getting Our Knees Off Black People’s Necks: An Anti-Racist Approach to Medical Care

Doi: 10.1377/forefront.20201029.167296

The coronavirus pandemic has exposed the racist structures, policies, and ideologies that are killing Black lives with impunity. Then on May 25th, 2020, a police officer charged with protecting the community instead exerted the weight of his knee and the force of his power to end George Floyd’s life, a painful visual depiction of racism that most were unable to deny. Health care workers have joined worldwide protests against the pandemic of American racism; but we, too, must ask how we can get our knees off Black people’s necks.

Racism and anti-Blackness in our country’s structures and medical systems can be seen as clearly as the footage of Mr. Floyd’s life being taken. They warrant immediate reform. Drawing upon Ibram Kendi’s scholarship, we propose an anti-racist approach to medical care that emphasizes recognizing racism’s historical roots, identifying racism within ourselves and our medical systems, and then dismantling it with the ultimate goal of challenging enduring racial health disparities.

An Anti-Racist Approach to Clinical Care: Five Core Components

Learn the legacy of racism in American medicine to avoid perpetuating it.

American medicine, like most American institutions, has served as a vehicle for white supremacy and anti-Blackness. Key historical arcs include a false narrative of Black biological inferiority used to justify unequal treatment and human rights abuses, Black professional exclusion, and silence and inaction regarding racial injustice. The following examples are illustrative though by no means comprehensive.

American medicine legitimized slavery by using scientific authority and false sciences to claim that Black people were biologically inferior and physically strong enough to endure exploitation and abuse. Doctors helped determine whether or not enslaved people were sick or feigning illness and pathologized runaway slaves, prescribing whipping as a treatment. Father of American gynecology J. Marion Sims perfected surgical techniques on enslaved young women without anesthesia, ignoring their screams and arguing they felt no pain. Racist beliefs endured into the 1960s when psychiatrists diagnosed “angry” politically active Black men involved in the civil rights movement with a reactive protest psychosis, rather than condemning the violent injustice they were protesting.

Racism has also been prevalent in medical research. Early studies of the genetic basis of race promoted scientific racism’s tenet of white supremacy and Black inferiority, fueling 20th-century eugenics campaigns and mass sterilization efforts targeting Black women. A 1990s study prescribing the now-banned drug fenfluramine to 34 children of color attempted to link violence to biology and parenting practices, rather than the social forces of race-based poverty, unemployment, and over-policing. The institutions involved were investigated but not formally sanctioned, and pre-eminent medical publications did not identify the inherent racism involved in publishing the study’s findings. Even after the Human Genome Project refuted the genetic basis of race, a 2006 study concluded that its data were “suggestive of genetic differences between Africans and non-Africans that influence blood pressure.” A later reanalysis found that education accounted for these differences in blood pressure.

To echo a recent New England Journal of Medicine editorial, “Slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to the present, and that legacy infects medicine as it does all social institutions.” Tracing the thick line of oppression from past to present positions health care providers to protect the Black community against a medical establishment that has exploited them for centuries. Historical understanding also deepens racial consciousness, which can challenge the implicit bias governing discriminatory behavior. For example, a novel, historically informed “Foundations in Racism” curriculum emphasizes white supremacy’s pervasive reach in all major American institutions as crucial knowledge to master before considering anti-racist practices.

Admit to being racist to become anti-racist.

The historical legacy of racism facilitates recognizing racism in our everyday professional lives, beginning with our own admission to being racist. Acknowledging racism within ourselves and our systems of care affords us the opportunity to challenge it with anti-racist interventions. Racism is everywhere rather than nowhere, and every clinical action is either racist or anti-racist, perpetuating racism in clinical care or championing against it. Racism and the white supremacy upon which it is constructed still operate when no people of color are in the room because white health care workers and patients disproportionately benefit from our pro-white medical system. Illuminating this less recognized form of racism facilitates efforts to traverse it, for example identifying when white patients receive preferential attention and care, while minority patients are neglected, blamed for their illness, or denied the best available treatment options. Given the robust evidence base regarding racism’s impact on health, health care providers bear the burden of responsibility for equalizing care, beginning with owning the racism within themselves and the health care systems in which they work.

Slow down: Pause to heighten racial consciousness and prepare for challenging racism.

Discriminatory behavior stemming from implicit bias is a neurobiological reality indicative of deep racial socialization and a human tendency to categorize. Our fast, automatic brain, which governs most of our behaviors, works from unconscious associations and beliefs and drives discriminatory behavior. Our slow, more deliberate and thoughtful brain, which can challenge it, is activated far less frequently. Fortunately, pausing long enough to heighten racial consciousness can help check the implicit biases that drive discriminatory behavior. For example, when the Oakland Police Department  added a single question to determine the validity of traffic stops (“Is this stop intelligence-led?”), the number of stops involving Black drivers  declined 43% over the course of two years. The Racial Healing Handbook and Me and White Supremacy offer structured guidance for health care providers committed to heightening racial consciousness by probing the racism living and breathing within them.

Clinical checks driven by heightened racial consciousness could save Black lives. In 2017, three weeks after giving birth, Dr. Shalon Irving, a Black epidemiologist at the Centers for Disease Control and Prevention, died, despite pursuing multiple post-partum medical visits for a poorly healing caesarean-section wound and alarmingly high blood pressure. She was never hospitalized. Checking racism would involve emphasizing that Black mothers like her are two to three times more likely to die from pregnancy-related causes than are white mothers. It would empathize with the stress Irving experienced as a single Black mother in the era of Trayvon Martin and Tamir Rice, and scrutinize the risk of pro-white implicit bias and denigration of Black suffering silencing her and her own mother’s pleas for help. Slowing down long enough to check this racism could have helped her providers save her life by offering treatment, rather than discharge.

Identify and oppose racism at the individual, institutional, and policy level.

Consciously rejecting the collective denial of racism and reframing all clinical actions as

racist or anti-racist through slowed, reflective thinking paves the way for identifying and opposing racism on multiple levels.

At the individual level, racism in the clinical encounter is particularly prone to microaggressions, the brief verbal, behavioral, or environmental indignities that ignore, ridicule, or dismiss patient’s concerns. Kendi has posited that “microaggression” is, in fact, a misnomer for racist abuse, which can be deadly in a health care setting. As a prime example, health care providers initially ignored Serena Williams’s complaints of shortness of breath after giving birth, only to diagnose her with a life-threatening pulmonary embolus after she demanded a CT scan. An anti-racist approach would have communicated respect for Ms. Williams’s self-report, considered her elevated risk of mortality, and immediately evaluated her complaint.

In 2019, one of the authors observed a clinician ignore a young, suicidal Black woman’s pleas for help in quitting survival sex work, saying “she knew what she was getting into” and assuming she was “not a good fit” for inpatient treatment. An anti-racist reframe would not only advocate for hospitalization as the standard of care for the woman’s elevated suicide risk. It also would acknowledge the racist ideology of Black female hypersexuality, used to attack Black women’s sexual health and overall wellbeing, which possibly influenced the clinician’s decision to deny care.

Anti-racist perspectives redefine other interactions, too. Black family members showing up in health care settings to advocate for patients are frequently accused of being demanding, rather than supported as they rightfully challenge a system that has historically mistreated them and denied them care. They should be welcomed. Minority patients deemed “non-compliant” with treatment are more likely overwhelmed by the racist structures governing their lives—including health care. They should be supported through outreach that extends to the family members who support their care.

At the institutional and policy level, racist policies and ideologies can influence diagnosis. Anti-racist assessments, for example of purported disruptive behaviors in minority children, go beyond a cursory examination of symptoms and additionally evaluate the racist context in which behaviors emerge. Within the educational system, children of color, when compared to their white peers, are subjected to harsher disciplinary measures that disproportionately funnel them into juvenile detention and prison settings. Diagnosing the racist structures and policies causing detriment avoids pathologizing the child. Discerning racism’s presence and explaining its health consequences to families renders it more visible, prevents misdiagnosis, and allows health care providers to advocate for more supportive, non-discriminatory teaching at the child’s school.

Coercive clinical practices, such as seclusion, restraint, and intramuscular medication administration, are typically used when risk for violence is considered high, based on clinical factors such as the mental exam. An anti-racist approach weighs the high risk of abusing power and actualizing pervasive racist ideologies regarding Black violence and criminality. When used injudiciously, these coercive practices traumatize and reify the disproportionate use of punishment and violence against people of color. Accordingly, a young Black man, likely to have been racially victimized by police and school officials, arriving in restraints to an emergency department should be spared additional force at all costs. Efforts to de-escalate the encounter, reach out to family, and assess the toll racism has taken on his life facilitate a therapeutic intervention, rather than a violent one. Similar considerations can be taken when performing invasive procedures, surgical and otherwise, to ensure they are beneficial, rather than sources of additional trauma and harm.

Policies can promote or sustain racial inequality. Minority individuals often have less access to quality health care, due to being disproportionately uninsured or publicly insured. High-quality specialty programs may determine that minority patients with complex presentations (associated with their racially unjust socioeconomic circumstances) are “not a good fit,” for example due to a missed appointment. Structurally informed interventions help patients traverse barriers to care while policy measures promote equality more broadly. The Affordable Care Act targeted racial inequality but has not fulfilled its full potential because states with large Black populations did not expand Medicaid. Anti-racist health care providers advocate for universal health care, with distributive justice as a goal. They simultaneously recognize clinicians’ and health care systems’ well established “racially discriminatory rationing” of treatment options, a practice that denies Black patients the same services and interventions offered to white patients, regardless of socioeconomics or insurance.

Any act of racism, no matter how small, is toxic and perpetuates health disparities. Racist clinical care, whether it involves negligent care of minorities or greater attention to the health and wellbeing of white people, constitutes grave medical error; and similar to child and elder abuse, it should be reportable. Health care providers benefiting from white supremacy and overrepresented in positions of leadership avail themselves of an important opportunity to defray their minority colleagues’ “minority tax” and pay their “majority tax” by initiating conversations and taking the lead in checking racism in its various forms. Documentation in medical records and discussion during case presentations and rounds are immediate and practical vehicles for integrating anti-racist clinical practices. Racial identifiers should only be used if they promote a probing examination of the racism negatively attacking the patient’s wellbeing. Quality measures of health care systems should assess inclusiveness of underserved populations and health care disparities, with equitable care recognized as higher quality care.

Our hospitals and health care institutions must become involved in human capital and economic development in local communities.

As we identify and abolish racism within our health care systems, we must work to reduce the injustices of the enduring racist legacy of segregation upon which this country was built. Health systems often serve as anchors in communities and should, therefore, take an active part in building health equity. Developments over the last decade have indeed encouraged this activity, often requiring that nonprofit hospitals become “community hubs.” In return for state, federal, and local tax relief, many hospitals provide “community benefit,” which often involves direct community engagement. Nonprofit hospitals are mandated to conduct community health needs assessments, frequently with health equity as a focus. By monitoring these assessments and encouraging partnership with public health officials, nonprofit hospitals can achieve greater community linkages using existing mechanisms tied to protecting nonprofit status and its associated tax breaks. Nonprofit hospitals and all systems of care should partner with minority communities to build trust and provide desperately needed resources to overcome the vast differences in wealth enduring in our country today.

Conclusion

An anti-racist approach to medical care cannot overcome the structural racism embedded within our country nor rectify centuries of oppression and injustice. Nor does it address the racism and racist abuse experienced by Black medical students, residents, and attending physicians. Despite its shortcomings, however, an anti-racist approach empowers health care providers to immediately challenge the racism and anti-Blackness that ended George Floyd’s life. By admitting to being racist in order to become anti-racist, we can redirect the weight of our authority to get off Black people’s necks and to protect them instead. We encourage similar approaches focused on other racial, sexual, and gender minority communities, too.

Sponsored Content: Actum

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July 2024 Medicare, COVID-19 & More