White Coats for Black Lives: Addressing Racism in Medicine
Over the past few days, healthcare workers across the country have gathered in peaceful protest to show support for and solidarity with the Black community. As we do this, it's important to understand how racism has run rampant in the medical system throughout history, including today.
Sexual and reproductive healthcare has a dark past, with many of the most infamous racist controversies in medicine occurring in our field. In the 1840s, J. Marion Sims - known by some as the "father of modern gynecology" - performed experimental surgeries for vesicovaginal fistulae on unanesthetized enslaved Black women, operating on one woman 30 times. Although anesthesia such as use of ether was becoming more common during his time, there was a general belief that Black people did not experience pain to the degree that white people do. He openly supported the South during the Civil War and expressed racist sentiments. An instrument still used by gynecologists every single day, the Sims retractor, is named for him.
Starting in 1907, many states developed compulsory sterilization legislation, allowing forced sterilization of people thought to have "undesirable" characteristics, which ultimately disproportionately affected Black women. Physicians in locations without specific legislation were not innocent to these practices. Sometimes sterilization was performed under the guise of an alternative operation such as an appendectomy, sometimes consent was obtained via devious tactics such as when an illiterate parent was advised to sign for their children, sometimes patients were coerced with threat of withholding other healthcare or welfare services, and sometimes the procedures were simply performed without any care regarding consent or patient participation. Many of those sterilized were teenagers. The United States did not create federal guidelines AGAINST these practices until 1978, although that did not necessarily stop them.
In the 1950s, Henrietta Lacks, a poor Black woman, received care for cervical cancer at Johns Hopkins Hospital. This was the only area hospital that would treat Black patients, albeit in segregated wards. As was common practice at the hospital at the time, marginalized patients were exploited for research without their informed consent. Cells were removed from Henrietta's cervix that went on to be used in research worldwide, contributing to a number of medical advancements including the polio vaccine. Without the knowledge or consent of surviving family members - who only discovered the history of Henrietta's cells through the media - and without any consideration for medical privacy, her name was eventually made public, along with personal information including DNA sequencing that could be linked to and directly impact her family members.
Also in the 1950s, Margaret Sanger and George Pincus experimented on poor Puerto Rican women in development of the first birth control pill. The women were unaware that they were part of an experiment and were not told about potential side effects of the medication. When they did report side effects, they were often ignored.
From 1932 to 1972, the Public Health Service and Tuskegee University conducted a study of syphilis on 600 Black men, about 2/3 of whom were infected. They told the participants only that they would receive free healthcare. They did not reveal the diagnosis to those infected, despite known significant sequelae of the disease. The study continued well beyond the time when penicillin became the accepted standard treatment for the disease and as those infected suffered.
These are the types of blatant acts of racism that we certainly hope aren't continuing in medicine today. However, studies continue to show that race impacts how medical professionals treat patients. For example, non-white patients wait longer in emergency rooms, are undertreated for pain, and are less likely to have important testing performed for accurate diagnosis and treatment. Black patients are 3-4 times more likely to die than their white counterparts during pregnancy and the postpartum period, and countless stories have become public about these patients having their concerns overlooked or ignored.
Distrust of the medical system and fear of these significant negative outcomes can lead to BIPOC avoiding medical care, even when greatly needed. In addition, systemic racism's impact on education, income, health insurance, child care, transportation, and housing presents other obstacles to care. This all can lead to delayed and missed diagnoses and ultimately unnecessary distress and death.
This is extremely problematic, because BIPOC are at an increased risk for many diseases and conditions. During medical school, we learn race is the risk factor. Most times this is stated without explanation, but often it is attributed to genetic factors. While certainly this is true for some conditions - such as sickle cell anemia - the stress and trauma of living in a racist society contributes to others. If you're a white person, think of how you physically feel in the setting of severe anxiety. Now imagine feeling like that all the time. The biochemical response that occurs in the body with a persistent high-stress state can contribute to countless chronic medical issues.
Some studies suggest that Black patients have better outcomes when they are cared for by a Black healthcare provider. This can be difficult to achieve. Racism can impact the initial goals of someone wanting to enter a healthcare profession as well as their success in achieving them. The first United States medical school was established in 1765, but the man credited as being the first Black American to hold a medical degree in the United States was James McCune Smith in 1837 - and he had to go to medical school out of the country due to racist admission practices. In 2008, the immediate past president of the American Medical Association (AMA) publicly apologized for "100 years" of racist practices that impacted Black physicians. It was not until 1968 that Black physicians could become members, and finally in 1994 - after 147 years as an organization - the AMA had its first Black president. By 2018 data compiled from various sources, 5% of United States physicians were identified as Black or African American while 2019 Census Bureau data identified 13.7% of the total US population as such. There's a disconnect in the absolute numbers of Black physicians in our country and certainly in those holding leadership positions.
I can't possibly provide an all-encompassing review of racism in medicine in a short blog post. Many books have been published on the subject (you can find some here), and there's certainly more that has yet to be covered. Those of us in medicine need to recognize how racism has shaped our field so that we can create change. While we stand in solidarity for Black lives, we must also commit to research, education, advocacy, hiring practices, and policies that achieve healthcare equity for those Black lives.