In August 1619, a Portuguese ship carrying more than 20 enslaved Africans docked at the British colony of Virginia. In that moment, slavery was established as an American institution. Four hundred years after that pivotal event, with the legacy of human bondage still permeating every aspect of American society, the New York Times Magazine published a special issue titled “The 1619 Project.” This ambitious endeavor aims to place “the consequences of slavery and the contributions of Black Americans at the very center of the story we tell ourselves about who we are,” the Times editors write. (Listen to Times reporter Nikole Hannah-Jones, who led the project, discuss her inspiration for the “massive undertaking” with Reveal podcast host Al Letson.) Naturally, health care has been profoundly influenced by the story of race in America, and the magazine gave that topic its due.
Linda Villarosa, project director of journalism at the City College of New York, examines the country’s dark history of medical experimentation on Black people. In the early 19th century, the physician Thomas Hamilton — a wealthy plantation owner — was “obsessed with proving that physiological differences between Black and white people existed,” Villarosa writes. He subjected John Brown, an enslaved man in Georgia, to painful medical experiments in an effort to determine whether the skin of Black people was physically thicker than that of whites.
Hamilton was far from alone in his racial obsessions and misconceptions, including the belief that Black people have higher tolerance for pain. These myths, “presented as fact and legitimized in medical journals, bolstered society’s view that enslaved people were fit for little outside forced labor and provided support for racist ideology and discriminatory public policies,” Villarosa writes.
Modern-day medical education and practice still reflect the fallacies underlying all forms of racial discrimination. Villarosa refers to a literature review published in the American Medical Association Journal of Ethics in 2013 that found “overwhelming evidence that the management of pain in the United States is inequitable.” African Americans and Hispanics were less likely than white patients to receive adequate pain medication, even though they were less likely to misuse drugs, the journal reported. What’s more, a 2015 survey of 222 medical students and residents found that 58% endorsed the myth that Black people have physically thicker skin than white people, and 12% endorsed the myth that Black people have nerve endings that are less sensitive to pain than white people’s nerve endings.
The Freedmen’s Bureau — Underfunded and Understaffed
In another piece for the 1619 Project, Jeneen Interlandi, a Times editorial board member and magazine contributor, takes a deep dive into the nation’s first federal health care program — the Freedman’s Bureau. During Reconstruction following the Civil War, Congress established the bureau to provide health care, education, and other types of aid to people who had been emancipated. But the bureau’s medical division was understaffed and underfunded — and no match for epidemics like smallpox that devastated makeshift camps for the formerly enslaved.
“As the death toll rose, [white lawmakers] developed a new theory: Blacks were so ill-suited to freedom that the entire race was going extinct,” Interlandi writes. This convenient theory of Black extinction gave political cover to legislators for providing inadequate federal assistance and allowed them to shape laws to preserve racial segregation, Interlandi reports.
The legacy of those discriminatory laws is evident in contemporary racial disparities in health and health status. Interlandi writes that such laws are “as foundational as democracy itself.” The history of exclusionary health policies in the US has repeated itself over the centuries — Interlandi gives the recent example of several states, most of them former slavery states that fought with the Confederacy in the Civil War, refusing to participate in the Affordable Care Act’s Medicaid expansion. Those states are Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.
As previously described in a CHCF issue brief, the Medicaid expansion has been associated with improvements in coverage rates in California. A recently published issue brief by the Commonwealth Fund documents the reduced gap in uninsured rates among Black adults, Hispanic adults, and white adults since the ACA. However, the gap has shrunk more in states that expanded Medicaid than in those that did not. The Commonwealth Fund researchers conclude, “Our results suggest that expansions of Medicaid in additional states would likely reduce disparities further.”
Emancipation from Structural Racism
The movement within health care to acknowledge and address the role of racism in the poorer health outcomes of people of color is growing. Recently the American Academy of Pediatrics (AAP) released its first policy statement on the impact of racism on child and adolescent health. “Recognizing that racism has significant adverse effects on the individual who receives, commits, and observes racism, substantial investments in dismantling structural racism are required to facilitate the society shifts necessary for optimal development of children in the United States,” the AAP states.
Maria Trent, MD, MPH, professor of pediatrics at Johns Hopkins School of Medicine and coauthor of the statement, tells the Times’ Perri Klass, MD, that racism is a socially transmitted disease affecting those who are targeted as well as those who witness it. “It’s taught, it’s passed down, but the impacts on children and families are significant from a health perspective,” Trent says.
The AAP policy statement called on pediatricians and other child health professionals to examine their own biases, foster diverse and welcoming pediatric practices, and advocate for initiatives that help redress biases and inequities in the health care delivery system.
In a commentary for Scientific American, Erin Daksha-Talati Paquette, MD, JD, M.Bioethics, an assistant professor of pediatrics at Northwestern University, writes, “The education of future medical providers is surely an important step in creating a future health care workforce that is sensitive to the impact of racism on health.”
Training Across the Board
But Paquette goes further, arguing that training is needed not only in medical schools and hospitals but across the educational continuum because “biases are present in young children as early as preschool.” By teaching both children and health professional trainees to appreciate diversity, social change can occur over time, she said.
Training has produced successes by making people aware of their biases and privileges, but education about implicit bias has limitations. “By focusing on individuals as the primary site for solutions, implicit bias depoliticizes gender inequity, shifting focus away from the historical, social, structural, and political contexts in which those inequities are produced and maintained,” writes Cheryl Pritlove and colleagues from Canada’s Li Ka Shing Knowledge Institute in The Lancet.
Although they were writing about gender inequity, the same limitations of implicit bias training hold true for racial inequity. “The implicit bias narrative . . . lets us off the hook,” Olivia Goldhill observed in Quartz. “And if implicit bias is a weak scapegoat, we must confront the troubling reality that society is still, disturbingly, all too consciously racist and sexist.”
Some research suggests that cultural humility training — “a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves” — may be a more appropriate and sustainable form of education for health care providers.
As the health care industry reconciles its historical wrongs with a pressing need to provide equitable care to an increasingly diverse nation, it should heed the spirit of this warning from the Associated Press Stylebook, the copyediting bible for news organizations: “Do not use ‘racially charged’ or similar terms as euphemisms for ‘racist’ or ‘racism’ when the latter terms are truly applicable.”
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