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1. The Nature of Medical Racism

The Origins and Consequences of Medical Racism

INTRODUCTION

The idea that discredited (and even disgraceful) ideas about racial differences might play a role in medical diagnosis and treatment is a possibility that some doctors find profoundly disturbing. The racially biased treatment of patients would appear to be a grievous violation of medical ethics and a direct threat to the dignity of the profession. Yet, in the course of the last two decades, the medical literature has published hundreds of peer-reviewed studies that point to racially motivated decisions by physicians either to deny appropriate care to black patients or to inflict on them extreme procedures (such as amputations) that many white patients would be spared.¹ “How are we to explain, let alone justify, such broad evidence of racial disparity in a health care system committed in principle to providing care to all patients?” the socially active physician H. Jack Geiger asked in 1996. His reply to his own question offered two possible explanations. The first option was to attribute the observed disparity to “unspecified cultural differences” or decisions made by black patients who did not understand that they needed medical care. The second and more discomfiting explanation was, as Dr. Geiger phrased it, “racism—that is, racially discriminatory rationing by physicians and health care institutions.” Confronting the data that he had felt compelled to present to the medical community, Dr. Geiger could not bring himself to categorize the documented behavior of his medical colleagues as racist. Indeed, he added, “if racism is involved it is unlikely to be overt or even conscious.”² For this conscientious physician, medical racism that implied individual culpability was still somehow unreal, a specter to be exorcized rather than a threat to be acknowledged and confronted.

Black and Blue is the first systematic description of how doctors think about racial differences and how this kind of thinking affects the treatment of their patients. While some fine studies of medical racism have appeared, they have not examined the thought processes and behaviors of physicians in any sort of detailed way. In effect, these studies have not seen fit to enter into the physician's private sphere where specific racial fantasies and misinformation distort diagnoses and treatments. Nor have they shown much interest in identifying the specific origins of racially motivated diagnoses and treatments of black patients that have ranged across the entire spectrum of medical sub-disciplines, from cardiology to obstetrics to psychiatry. It is true that American physicians have been “major perpetrators of racialist dogma,” as a monumental history of American medical racism states.³ Black and Blue moves beyond such general claims about racially motivated medical behaviors and describes how mainstream medicine devised racial interpretations that have been applied to every organ system of the human body.

The studies to date have occasionally noted but failed to describe the oral traditions that convey medico-racial folklore and persist over generations of medical students and doctors. As we shall see, the physicianauthors who have taken the trouble to write about the racial dimension of medicine confirm that the medical profession has never embarked upon this kind of self-scrutiny in a serious manner. Interestingly, the medical profession's lack of interest in confronting the racial complexes of doctors has created little activism among even the most concerned medical observers beyond ritualized expressions of concern. While these white “medical liberals” profess to be “troubled” by this topic, their efforts at raising consciousness have been episodic and have never acquired the political traction that might catalyze a more effective reckoning with the racially motivated and medically harmful behaviors that have been proven beyond a doubt to exist. It is, therefore, no accident that this book-length examination of the racially motivated mental habits and professional mores of doctors is the work of an outsider to the medical profession.

At the same time, I would point out that this history and analysis of medical racism is the work of a grateful outsider. The criticism of the medical profession presented in this book is not motivated by personal dissatisfaction with doctors. On the contrary, physicians have served me well throughout a long life that has included an open-heart surgery that saved me from a debilitating future of congestive heart failure. My father was a physician-scientist, and his commitment to his patients was inspiring. I learned about medical racism in the library while doing research for another book. I was stunned by the overt racism that appeared in medical journals such as the Journal of the American Medical Association or the American Heart Journal during the first half of the twentieth century. So was my father, who received his M.D. in 1946, a man of anti-racist principles, who knew the famous African American physician Charles Drew in Boston before the latter's premature death in 1950. As a Jew who had experienced anti-Semitic insults, my father was aware of the reality of bigotry in American society. But the medical racism of American physicians during his lifetime had somehow passed him by.

“AVOIDANCE AND EVASION”

“The general awkwardness surrounding racial issues in our society bleeds into medicine,” the prominent African American cardiologist Clyde Yancy observed in 2009.⁴ This awkwardness about practicing and discussing race relations has long been a fact of medical life the profession has been slow to recognize or deal with in a deliberate or systematic way. The political conservatism of the medical establishment was evident even during the civil rights movement, as the national leadership of the American Medical Association (AMA) deferred to the racist exclusionary policies of state medical societies and refused to intervene on behalf of black physicians who sought membership in the AMA and the professional status they had long been denied.⁵

Today the great majority of doctors are likely to regard information about medical racism as of little relevance to their professional lives. This is hardly surprising, given that large majorities of white Americans take little or no interest in the special problems their African American fellow citizens experience. There has long been, and there remains, a widespread conviction among whites today that the disadvantages blacks face are of their own making, since formal racial equality was established by the civil rights and voting rights laws and affirmative action initiatives, all of which date from the 1960s. And there is no reason to assume that the racial views of doctors differ in any significant ways from those of the general population.

My own firsthand exposure to how physicians receive news about medical racism occurred on a chilly evening in New York City in November 1999. A friendly bioethicist had arranged for me to attend a discussion of the medical profession's treatment of African Americans at the New York Academy of Medicine at Fifth Avenue and 103rd Street in Manhattan. The host, as I recall, was the vice president of the academy. He stood before a seated group of his medical colleagues and told them what the medical literature had by now demonstrated beyond a doubt: American medicine was failing to serve the African American population in a racially equitable manner. The question before them, he said, was whether or not they as a profession were going to choose to “own” this issue, to take responsibility for the uncomfortable reality of racially unequal medical treatment.

Fifty professionally and financially comfortable physicians listened to this pitch in their chairs. I saw no one on the edge of his or her seat. While it was clear that the speaker took this matter seriously, the tone of his comments did not convey a sense of urgency or an expectation of medical activism from those who sat before him. On the contrary, it was clear that making the effort to repair this injustice and take more responsibility for the health of black people was being presented, not as an ethical obligation, but as an option. The ethical obligation was real to the speaker, but one sensed that he did not really expect his colleagues to rally to this cause.

American medicine's disengagement from the black population is only one dimension of the much larger racial disengagement that characterizes American society as a whole. Ignoring African Americans or relegating them to marginal status has been a deeply rooted American habit. In his classic An American Dilemma (1944), Gunnar Myrdal commented that, in the literature on American democracy he had read, “the subject of the Negro is a void or is taken care of by some awkward, mostly un-informed and helpless, excuses.” Ralph Bunche, whose extraordinary career as a black academic foreign policy expert and international diplomat culminated in the 1950 Nobel Peace Prize, told Myrdal in 1940 that “consciously or unconsciously, America has contrived an artful technique of avoidance and evasion” to separate itself from its Negro citizens.⁶

A generation later the famous black psychologist Kenneth B. Clark explained white racial detachment as a form of emotional self-defense on the part of whites. “The tendency to discuss disturbing social issues such as racial discrimination, segregation, and economic exploitation in detached, legal, political, socio-economic, or psychological terms as if these persistent problems did not involve the suffering of actual human beings,” Clark wrote in Dark Ghetto (1965), “is so contrary to empirical evidence that it must be interpreted as a protective device.” The “purist approach rooted in the belief that detachment or enforced distance from the human consequences of persistent injustice is objectively desirable,” and he added, is “a subconscious protection against personal pain and direct involvement in moral controversies.”⁷ For many people, the most threatening controversy that might personally implicate them is racism. Maurice Berger has pointed out that, in an age of political correctness, “most people will do almost anything to preserve the comfortable illusion of themselves as free of prejudice.”⁸

The sheer magnitude of the African American health disaster can produce both emotional detachment and a dehumanizing sociological reduction of black life to its bleakest essentials. The recitation of endless statistics documenting medical racial disparities depersonalizes the human dimension of what is happening to black people. Our attention is displaced from the specific behaviors and predicaments of doctors and patients into an abstract dimension of enormous and hopelessly complicated social processes that can only be imagined. What is more, as one Indian-British physician has noted, “documenting inequalities may have little impact on reducing them.”⁹

The statistical depersonalization of black people and its association with disease were recognized as far back as 1951 by James Baldwin, long before sociology became the conceptual language of race relations during the heady days of the Great Society in the mid-1960s. The Negro, he wrote, “is a social and not a personal or human problem; to think of him is to think of statistics, slums, rapes, injustices, remote violence; it is to be confronted with an endless cataloguing of losses, gains, skirmishes; it is to feel virtuous, outraged, helpless, as though his continuing status among us were somehow analogous to disease—cancer, perhaps, or tuberculosis—which must be checked, even though it cannot be cured.”¹⁰ The black person exists in the form of various social disasters, human life conceived as numerical formulas, and threatening but incurable disease processes. The black individual remains invisible and unknown, and this too has its consequences. For as Baldwin points out, “The privacy or obscurity of Negro life makes that life capable, in our imaginations, of producing anything at all,”¹¹ including all of the dysfunctional behaviors that physicians and many others customarily associate with black people.

The traditional detachment of the medical profession from identifying and solving its racial problems has been evident in the medical literature and in the work of medical authors who are at liberty to range farther and deeper into social and personal issues than is possible in medical journals. David Satcher, a young black physician who became surgeon general of the United States in 1998, pointed out in 1973 that: “Much has been written about the doctor-patient relationship and its many challenges and ramifications. However, almost nothing is written about the effects of race on this relationship.”¹² (In his pioneering commentary on doctor-patient race relations, David Levy made the same point about the pediatric literature in 1985.¹³) Then, as now, the great majority of doctors were white men whose ignorance and naïveté regarding their black patients had long been evident to black physicians. The estrangement from blacks that resulted from this mind-set has expressed itself in many ways. In 1940, Time reported that “few white doctors dare to operate on their 'massively' infected Negro patients” afflicted with tuberculosis.¹⁴ At this time black doctors noted with chagrined amusement that, “The average young white physician enters practice with the idea that all Negroes have syphilis or tuberculosis.”¹⁵ A generation later the medical anthropologist George Devereux described his observations of “White-Negro doctor-patient pairs” and the diagnostic errors that resulted from the doctor's “'tactful' reluctance to examine closely the most distinctive portions of a racially alien patient's body.”¹⁶ White dermatologists may be alternately alarmed about or unaware of the characteristics of black skin and the emotional consequences of skin problems for patients.¹⁷ White doctors sometimes underestimate the intelligence and self-control of black patients and treat them accordingly.¹⁸ The cumulative effects of such naïveté are often evident to blacks but are less evident to the white medical community that does not monitor and report on such incidents.

The writings produced by white physician-authors reflect the social distance from African Americans they share with a large majority of their fellow citizens. As the black sociologist Orlando Patterson noted in November 2009, “in the privacy of homes and neighborhoods we are more segregated than in the Jim Crow era.” Various degrees of segregation occur within “the disciplined cultural spaces of marriages, homes, neighborhoods, schools and churches.”¹⁹ Hospitals and clinics are disciplined cultural spaces that are subject to the same racial tensions and estrangements that occur within the other “disciplined” social venues. It is, therefore, not surprising that physicians who write about race relations within these medical spaces tend to avoid direct confrontations with uncomfortable racial issues. For example, a collection of 80 reflective columns by doctors taken from the pages of the Journal of the American Medical Association during the 1980s contains many profound and moving stories that together constitute the most sympathetic portrait of the medical profession I can imagine. Of the hundreds of people who appear in these stories, there is exactly one African American patient, a humble sharecropper in sweltering Alabama who is grateful to find a white medical student who is willing to talk to him. An elderly black hospital orderly is sympathetically presented as incarnating one of the classic folkloric images of black humanity: the musical Negro. From these dozens of medical authors, there are a handful of references to “slum children,” inner-city “juvenile delinquents,” and a six-year-old West African child who dies despite the best efforts of the American physician who tries to save him. There are no black doctors or nurses. All but a few picturesque and stereotypical examples of black humanity were apparently absent from the recollections of most of a hundred physicians.²⁰

Paul Austin's Something for the Pain (2008), a candid, caustic, sensitive, and sophisticated memoir of his many years as an emergency room (ER) doctor in North Carolina, refers to race rarely, carefully, and allusively. The tone of a young black mother's voice has “a brittle edge” until the doctor's gentle manner wins her over. The author refuses to give a racial edge to the hostility of a despairing young black man whose mother lies dying in the ER.²¹ Thoughtful writing of this kind reminds us of medicine's color-blind ideal; and it is likely that some physician-authors avoid the topic of race out of fidelity to the dream of medical care that transcends color.

The problem with color-blind writing about medicine is that it ignores the long history and persisting reality of racially motivated medical behaviors that can alienate, injure, and sometimes kill black patients. Another genre of medical writing focuses on the brutal conditions experienced by doctors who practice medicine in the ghetto. Doctors Talk About Themselves (1988) describes the emotional impact on doctors of dealing with the dregs of humanity who show up in inner-city ERs: “You see such awful things that are totally beyond any experience you have ever had. You ask, 'How can people live like this?'” In this “snake pit” the cynicism that has been widely observed in older medical students becomes complete, as beleaguered and resentful physicians absorb “every conceivable kind of abuse” from their black clientele.²²

Finally, there is medical writing that ignores the race issue entirely. Jerome Groopman's 2007 bestseller How Doctors Think does not contain a single sentence that addresses the question of how doctors think about race. Groopman confirms that there is a great deal of potentially useful thinking that doctors do not do. He knows that social context and the doctor's emotions matter. But he is unwilling or unable to connect these commonsensical principles to real-life scenarios that involve interactions between patients and physicians across the racial divide.

JUDGING HOW PHYSICIANS BEHAVE

Making judgments about what goes wrong between white doctors and black patients requires a sense of realism and humility on the part of those who observe and analyze these relationships. White professionals in other occupations—professors, for example—should be subject to the same kind of scrutiny of their professional conduct. An important difference is that academics do not as a rule have access to the intimate details pertaining to the minds and bodies of their students. Nor are professors traumatized in the line of duty in the ways that ER doctors or oncologists and other physicians can be. Relations with students are seldom fraught with fateful consequences that might result from a professor's incompetence. In addition, most university students are courteous and cooperative people who can be expected to conduct themselves in a reasonable manner and in their own best interest. The patient population that doctors serve is not so easily managed. My father retired from practicing outpatient medicine in his late seventies when he became exasperated with the noncompliant behavior of the patients he encountered at a hospital in the Bronx, many of whom must have been black or Hispanic. Noncompliance, such as a refusal to take prescribed medications or to stop smoking or drinking, is a massive problem for doctors. Noncompliant students, on the other hand, will either change their behaviors or fail their courses and vanish from their professors' classrooms.

JUDGING PHYSICIAN CONDUCT: PRIVACY AND THE “HALO EFFECT”

The detection of racially motivated diagnoses and treatments by physicians remains an ineffectual statistical exercise that has been repeated in hundreds of papers in medical journals over the past two decades. The systematic use of diagnostic and treatment protocols by doctors who track outcomes and adjust care is modern medicine's best hope for improving the services it offers patients. But peer-reviewed evidence of racially biased medicine has produced no reforms remotely comparable to what is now being done at many hospitals to improve survival rates among diabetics and preterm infants. Frequent calls for “further research” into the causes of racial health disparities simply defer the possibility of intervention into racially motivated behaviors into the indefinite future.

So the fundamental questions here are: Why has the medical profession never systematically studied how physicians produce racially motivated diagnoses and treatments that can cause medical harm? And how has traditional, and often defamatory, racial folklore been absorbed into medical practice in specific forms that have infiltrated medical specialties from cardiology to obstetrics to psychiatry?

Traditional norms discourage the analysis and assessment of physician conduct or even misconduct. The medical community, like some other professional groups, has been reluctant to discipline its members for unprofessional and even harmful conduct. As one physician-author noted in 1988, “doctors are unwilling to blow the whistle on other doctors. It's somehow bad manners or breaking the faith of the medical profession to report a bad doctor.”²³ In this sense, the practice of medicine, like police work, is more of a fraternal order than a scientific community that recognizes and acts upon its responsibility to monitor and correct the deviant and dangerous misconduct of its practitioners.

Another powerful factor that shields doctors from scrutiny is the “halo effect” that wraps physicians in an aura of benevolent power. “Doctors,” a New York Times writer noted in 2009, “have a degree of professional autonomy that is probably unmatched outside of academia. And that is how we like it. We think of our doctors as wise men and women who can combine knowledge and instinct to land on just the right treatment.”²⁴ The combination of benevolent intent and the power to heal has traditionally conferred upon doctors “a degree of professional autonomy” that can make them appear as sages who have earned a status that puts them beyond the judgments of observers who do not belong to the guild.

The physician's authority and autonomy can promote a socially conservative identity that resists both personal self-examination and social reforms. Social conservatives may not see the causal relationship between self-scrutiny and a willingness to promote social change, including the profound social changes that antiracist policies require. Even today, social conservatives (and others) retain the option of preserving the traditional racial hierarchy and its racist folklore inside their heads, while conforming to antiracist public norms that enforce public civility and a degree of racial integration within “disciplined” workplaces such as hospitals and clinics. There can be no doubt that many doctors choose this option, thereby disciplining their social conduct but not their racial imaginations.

Given the degree of autonomy traditionally accorded to doctors, requiring them to examine their own feelings about race, and perhaps change their behaviors, will be regarded by many of them as an invasion of privacy. Whether doctors are entitled to this privacy depends on what privacy may conceal. If it is true that “few people are free of unconscious fantasies about imagined racial characteristics,” as one prescient physician wrote in 1985, then the existence of unconscious fantasies with potential medical consequences challenges the right to privacy of the doctor who harbors them.²⁵ According to the prominent physician and author Sherwin Nuland, “conscious and unconscious prejudice pervades rounds, teaching conferences, and even decision-making.”²⁶ In a word, it can be medically dysfunctional for physicians to preserve and act upon their “private” racist fantasies and beliefs.

Another traditional aspect of physician privacy is the right of doctors to be apolitical and uninvolved in public policy. As two proponents of medical curriculum reform wrote in 1994: “Although organized medicine may occasionally take a stand on matters of public policy and bioethics, such positions are often weakened by medicine's long-standing position that individual physicians cannot be expected to act contrary to their own moral beliefs.”²⁷ While this position appears to defend acts of conscience, some physicians will find it difficult to distinguish between their moral beliefs and their intuitions about racial differences. Those who believe that the traditional Western racial hierarchy is an expression of natural law may well reject the positive (man-made) laws that mandate racial equality. In such cases, how will apolitical and social policy-averse physicians establish relationships with black patients? These patients are, after all, people who require sympathetic racial attitudes on the part of those who treat them.

The racially “conservative” physician thus finds himself in a difficult position, caught between the demands of modern racial etiquette and his own private beliefs about racial traits and differences. It is, therefore, not surprising that the medical school instruction in “cultural competence” that is designed to resolve such conflicts has encountered much resistance for this and other reasons. It is easy, for example, to argue that an already crowded medical curriculum simply has no room for “touchy-feely” instruction in human relations that displaces courses in the “hard” medical sciences. Many doctors who are asked to expand their emotional repertories to include new attitudes toward blacks and other racial groups will reject this as an unreasonable and unrealistic demand on their emotional resources that amounts to a violation of personal privacy.

For this reason the very idea of asking doctors to examine their own feelings for the purpose of better serving their patients already represents radical reform. Integrating the race issue into this process is a further complication that many doctors will interpret as mandated political correctness and unrelated to improving medical treatment. Another factor involved in requiring medical professionals to engage in self-examination is the emotional stress that is often a part of medical practice. The ER doctor Paul Austin has thought deeply about the emotional costs of his medical practice and reached some conclusions that depart from the stereotype of the “caring” and “compassionate” physician. Compassion “isn't an emotion. It's an action. A discipline.” Similarly, “emotional distance may not always indicate a failure of empathy.” Austin recognizes both the practical value and the costs of emotional distance, which can promote emotional survival but also repress feelings in ways that can eventually harm both the physician and his patients.²⁸

Doctors may also find the task of introspection time-consuming and impractical. “Frequently physicians think that dealing with emotions is opening a Pandora's box, that they'll be asked about things they can't do anything about, and that it will take a lot more time—especially if the feelings are about sadness or anger.”²⁹ Inside this Pandora's box lurk the devastating consequences of poverty and family trauma that impact the lives of black patients in a disproportionate way. And it is true that the doctor can do little or nothing in a direct way about social conditions or dysfunctional relationships. What the doctor can do is to study his or her own responses to traumatized people. This process should make it possible to distinguish between the unique identity of the patient and the racial folkloric traits conveyed by the oral tradition described later in this book.

The idea of providing or requiring psychotherapy for racially prejudiced physicians has been heard in the past and has gone nowhere as a way to prevent medical racism. “For psychiatrists who lack the empathy needed for work with all groups of people,” David Levy wrote in 1985, “psychoanalysis has been recommended to erase distorted perspectives concerning race or at least to enable them to become more aware of when their irrational attitudes might impede the treatment process.”³⁰ Two decades later the same proposal appeared in Academic Medicine: “When they are not brought to the level of consciousness, physicians' personal attitudes, biases, fears, emotional reflexes, psychological defenses, and moods can interfere with their abilities to arrive at an accurate diagnosis, prescribe appropriate treatment, and promote healing.”³¹ From the perspective of many white physicians, therapeutic intervention will be construed as an intolerable intrusion. From the perspective of many black patients and physicians, the therapeutic option may be regarded as the least the profession can do to protect them from racially motivated mistreatment. Once again the professional's right to privacy confronts the patient's right to unbiased treatment.

THE ORAL TRADITION

Physicians' “private beliefs” about racial differences can have effects that extend beyond their own medical practices. The physician's private sphere also takes the form of an oral tradition that conveys racial folkloric beliefs from one generation to the next. In 1983, for example, a paper in the American Heart Journal raised the question of “whether a 'traditional' diagnostic belief exists that blacks simply do not develop myocardial infarction.” That “traditional” belief did, in fact, exist, and has persisted, as this book will demonstrate. Interestingly, this author is unsure as to whether this belief was real, and he suggested that “a broad survey of physicians' beliefs and attitudes on these issues” would be in order.³² Three decades later, this and other surveys of physicians' beliefs about racial traits still have not been done. While the racial history of American cardiology does appear later in this book, the survey proposed in 1983 would have done far more to improve the care of black heart patients.

Medical students, too, can participate in this process. As a former student wrote to me in 2005: “One of my MCAT class teachers is finishing his 3rd year at [University of Texas] Southwestern Medical School now. He tells us interesting things about the patients he sees. For example, he has observed that African Americans are genetically more athletic than other races (overall), but they also have a much greater risk of having high blood pressure and certain types of cancer.”³³ We may assume that the genetic reductionism that prompted this medical student's imaginative claim about athletic genes continues to thrive alongside other bits of uninformed gossip in “the oral culture of medical training.” For this reason all medical personnel should keep in mind that medical gossip thrives, “not so much at the bedside (medicine's preeminent metaphor) but via its more insidious and evil twin, 'the corridor.'”³⁴ African Americans know and fear this oral tradition as “the silent curriculum” that many white doctors carry around in their heads. But the positive image of the medical profession, along with the racial imbalance of power that conceals much black suffering, has effectively shielded the oral tradition from public scrutiny.

PHYSICIANS SHARE THE RACIAL ATTITUDES OF THEIR FELLOW CITIZENS

The pervasiveness of the oral tradition raises an important question about doctors' racial beliefs: Do the racial attitudes of physicians differ from those of the general population? Recent sociological findings indicate that while “whites have largely abandoned principled racism…they have not necessarily given up negative racial stereotypes” or “negative sentiments and beliefs about African Americans.”³⁵ The prominent black sociologist William Julius Wilson reported in 2009: “The idea that the federal government 'has a special obligation to help improve the living standards of blacks' because they ‘have been discriminated against for so long’ was supported by only one in five whites in 2001, and has never exceeded support by more than one in four since 1975. Significantly, the lack of white support for this idea is not related to background factors such as level of education and age.”³⁶In short, a large majority of the white population is either unwilling or unable to see African American problems in their historical context and has only limited knowledge of what the black experience has been like.

The research I have done for this book confirms that physicians share the racial attitudes of their fellow citizens. Indeed, their intimate involvement with medically afflicted black bodies and minds may even create and intensify feelings about the racial differences they perceive. There is, then, no evident reason to assume that doctors feel greater sympathy toward or possess a greater understanding of African Americans that most whites do. On the contrary, it is probable that many doctors, like police officers, are exposed to more than their fair share of extreme and unattractive behaviors of the troubled and the indigent, a disproportionate number of whom may be black. These experiences do not produce racial goodwill. Consequently, as one African American physician commented in 1990: “The problem is not that medical providers are ethically deficient compared with the public, it is that we are no longer any better. Our ranks include racists and virtually every other variety of impaired citizenry.”³⁷

Medical authors have occasionally wondered about how they as a group compare to the general public regarding racial prejudice. “As health professionals,” two physicians wrote in 2002, “we need to become aware of any deep-seated attitudinal biases that parallel those of the general public and the media and confuse our best clinical intentions.”³⁸ A year later, H. Jack Geiger, who has been disinclined to acknowledge the existence of systemic medical racism, noted “the persistence and prevalence of racist beliefs and discriminatory behaviors in contemporary American society,” and reluctantly conceded that doctors are not “fully insulated from attitudes toward race, ethnicity, and social class that are prevalent (though often unacknowledged) in the larger society.” At the same time, Geiger's assertion that “most physicians” possess a “conscious commitment to anti-discriminatory principles” appears to claim that the racial enlightenment of doctors exceeds that of the general public.³⁹ It is worth noting that Geiger's emphasis on doctors' relative immunity from prejudice aligns him with racism-denying conservatives who have directed caustic attacks on medical liberals such as himself. From the conservative perspective, even taking seriously the possibility of systemic medical racism expresses an unwarranted and offensive lack of confidence in the (white) medical profession as a whole.

It is important to recognize the role that political conservatives have played in promoting the “halo effect” that protects this powerful, and predominantly white, professional community. It has been an axiom of political conservatism, and its traditional emphasis on white male authority, that physicians are beyond criticism regarding the racial attitudes that a majority of white Americans share. The conservative social policy analyst Byron M. Roth, for example, found “questionable the charge that blacks suffer disproportionate health problems because racism taints American medicine. Doctors and nurses are among the least likely candidates upon whom to pin the label of bigotry.”⁴⁰ The psychiatrist and conservative ideologue Sally Satel has made a public career of promoting the mistaken argument that “political correctness is corrupting medicine.”⁴¹ In fact, and as this book demonstrates, the medical profession is a predominantly conservative professional community that has tended to resist “politically correct” norms and policies.

THE MEDICAL LIBERALS

As is so often the case in American policy debates, the conservative attack on “politically correct” medicine has not been matched by a comparably vigorous response from the “liberal” side. The grand document of medical liberalism is Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003), a publication of the prestigious Institute of Medicine, the health arm of the National Academy of Sciences.⁴² In his contribution to this volume, H. Jack Geiger portrays doctors as the helpless victims of a stereotyping process that is “automatically triggered and operates below the level of conscious awareness.” Once again medical racism remains for this author a hypothesis rather than a documented reality: “[F]urther research is necessary,” he says, “to clarify whether sociocultural and educational incongruity between providers and patients translates into misunderstandings about patients' preferences and expectations, and to evaluate the extent to which stereotyping, discrimination and bias exist in the hospital setting.”⁴³ The fact that these hypothetical misunderstandings and stereotypes had already been thoroughly documented inside and outside of the medical literature appears to be unknown to this author. Only ignorance of the history of medical racism in the United States can account for naïveté on this scale. A similar essay by a team of medical ethicists repeats Geiger's claims about “well-meaning” medical personnel and the unfortunate consequences for minority patients of “clinician errors” that cannot be blamed on doctors who are the victims of their own “unconscious” biases.⁴⁴

And what about the effects of the medical school experience on students' attitudes toward patients who are resented for one reason or another? “One of the few areas of universal agreement concerning students' development,” Academic Medicine reported in 1996, “is that medical training can make students and residents more cynical and insensitive.”⁴⁵But not when it comes to race at Harvard Medical School, these ethicists report. Among the medical students they observed, “political correctness appears to be the normative order in public discussion. Medical students with whom we spoke note they never hear overtly negative racist comments in the hospital or among classmates. This sensitivity is new to the late twentieth-century generation of medical students and faculty in our study area.”⁴⁶ Yet in the same year the Institute of Medicine volume appeared, another author in Academic Medicine who studied other medical students cites “a derogatory term widely used by students and faculty members to refer to patients from the skid row area of the city.”⁴⁷ A decade earlier, Academic Medicine had observed that medical students sometimes saw patients as “sources of frustration and antagonism—evocatively recast as 'hits,' 'gomers,' 'geeks,' and 'dirtballs.' They become 'the enemy,' with students feeling justified in their use of negative labels and corresponding behaviors.”⁴⁸ Are Harvard medical students really immune to the racist banter more realistic observers have noted? The credulity of the Harvard ethicists, who take at face value medical students' assurances about their generation's racial enlightenment, perfectly complements Geiger's dogged resistance to the idea that physicians should be held responsible for racially motivated decisions that derive from unconscious impulses.⁴⁹

Medical liberals who adopt the exculpatory approach to physician responsibility are in no position to contest the claims of conservatives who argue that medical racism is a minor issue or does not exist at all. The Unequal Treatment report first issued in 2002, the product of a committee chaired by a former president of the American Medical Association, Alan Nelson, is a thoroughly moderate document. The strongest language in Dr. Nelson's speech to the Institute of Medicine on March 22, 2002, reads as follows: “Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care. While indirect evidence from several lines of research support this statement, a greater understanding of the prevalence and influence of the processes is needed and should be sought through research.”⁵⁰ Here, as elsewhere, medical liberalism was still treating the effects of “stereotyping, prejudice, and clinical uncertainty” as hypothetical, and there is the usual call for additional research, an implicit claim that the medical status of African Americans—and the behavior of their doctors—was still too complicated to understand.

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.