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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.

Playing down or denying the urgency of the medical problems of black people is also accepted because it can serve the emotional interests of both whites and blacks. Even racist whites have found opportunities for feeling magnanimous about their concern for black health. The white Christian masters of antebellum slave plantations, for example, saw themselves as medically conscientious guardians of their black wards, even if their primary motive was to maximize the efficiency of the labor force. The mistaken idea that these slaves had enjoyed excellent health under the supervision of their white overseers became a staple of post-emancipation racial mythology.

The severe health problems that afflicted the liberated and impoverished black population following emancipation were now interpreted as one more pernicious effect of the freedom that had created social conditions in which the allegedly filthy hygienic habits and disease-spreading sexual licentiousness of black people could flourish. Black health problems became a major source of racist resentment. As the Journal of the American Medical Association commented in 1909: “In former times they lived a healthy out-door life, and, if for no other reason, in the commercial interests of their owners they were well fed, clothed and lodged. In the last half-century, however, they have left their open-air life and gravitated into the cities, without any one to overlook their physical well-being. Their happy-go-lucky disposition has led them to ignore all principles of sanitation—even if they had an opportunity of becoming acquainted with them….”⁷ The medical misery of black people was rationalized as a natural consequence of the “disposition” that had brought about a state of degradation for which whites bore no responsibility. The only responsibility incumbent upon white health authorities was to do everything possible to make sure that unhealthy blacks did not infect the white population.

A half century after this JAMA commentary, Dr. Robert A. Hingson of the Case Western Reserve University School of Medicine in Cleveland told the readers of the nation's only black-edited medical journal that the very survival of African Americans had been made possible by “the humanitarian and scientific ministrations of a compassionate nation,” in which the (white) medical profession had played a principal role. This anesthesiologist's report on black and white mortality during obstetrics and surgery suggests that he was more compassionate than most of his peers toward the plight of the black patients who were dying under anesthesia in much greater numbers than their white counterparts. He even quotes Franklin D. Roosevelt on the unmet needs of the nation's poor. At the same time, he appears to have been oblivious to the entrenched medical racism of his own profession, which he believed bore no responsibility for the medical problems of his black patients. “We shall leave it to the sociologist to determine the damage the scars of history have left upon the black man,” he writes. Separating the medical profession from the damage done to black people in this way expresses a tenacious and self-protective institutional instinct that still prevails over the self-critical approaches to the racial health disparities that have emerged since Hingson pointed to the “racial melancholia” that “all physicians, and especially all psychiatrists” recognized as a syndrome affecting the black population in the 1950s.⁸ The persistence of this self-defensive posture among white physicians is evident both in the medical literature and from other sources that describe dysfunctional relationships between white doctors and black patients.

The desperate conditions created by urban poverty have ensured a constant flow of disordered or self-destructive black patients to emergency rooms staffed by white and foreign-born physicians who draw their own conclusions about racial character: “I did a year of training in general medicine at a university-affiliated, inner-city hospital,” says one doctor, “and it was the worst year of my life. The place was a snake pit.” Constant exposure to the self-destructive behaviors indulged in by what appear to be disproportionate numbers of an ethnic group can have a devastating effect on how doctors feel about such people: “The patients were there either because they abused drugs, or had an illness like diabetes that they wouldn't take care of, or were alcoholic, or had gotten beaten on the head while they were robbing a store. Almost all of them had self-inflicted illness. It's very hard to get real sympathetic with people who make themselves sick.”⁹ These scenarios, in which disorderly, recalcitrant, and criminal individuals demoralize the physicians who attempt to help them, can reinforce in doctors' minds some deeply rooted ideas about intractable social pathologies from which some blacks seem unable to escape.

Negative images of black patients among white physicians have not been limited to the most deranged or irresponsible black patients who show up in the nation's emergency rooms. American medicine's traditional strategies for minimizing white responsibility for black health problems have always included a more general denigration of the intelligence and emotional stability of blacks who seek medical care. During the first half of the twentieth century, white doctors' impatience with “the Negro patient” became a familiar theme in the medical literature. “He is an unwieldy, unwilling, unsatisfactory patient,” JAMA reported in 1899.¹⁰ The principal “obstacles to negro practice,” according to a 1908 JAMA extract from the Mississippi Medical Monthly, were “a delight in fooling the doctor if possible; an utter inability to understand and follow directions; the interposition of outsiders, who dissuade from obedience to instructions; the undying fondness for filling his belly; his morbid dread of water; his poverty and filth, and fondness for night prowling and sexual excesses.”¹¹ Over the next half century a medical folklore made up of many such assessments of “the Negro patient” appeared in the medical literature. These accounts presented blacks as particularly exasperating examples of what came be known as “noncompliant” patients who lack the intelligence or the self-discipline to follow doctors' orders.

The other and ostensibly different type of “Negro patient” who provoked medical commentary during the era of Jim Crow was the docile simpleton who displayed a striking medical naïveté or a slavish version of compliance that evoked the submissive Sambo stereotype. White doctors commented on his “optimism” or stoicism or “the absence of worry” in such people. “Complications are accepted as being foreordained and unavoidable. The majority of them bear pain, impairment of function, and the destruction of tissue with little complaint or apprehension,” two urologists write in 1935.¹² “His idea of the medical world,” a syphilis expert wrote in 1910, “is that there is a remedy for every disease and that all that the doctor does is to select the right medicine.”¹³ Dr. R. A. Vonderlehr, a participant in the Tuskegee scandal, commented in 1936: “The average negro is a most congenial person and he has a tendency to agree with almost everything that one wishes him to agree with.”¹⁴

A sometimes fatal consequence of this disconnect between doctor and patient has been a tendency among blacks to neglect symptoms and delay visits to the doctor. “The average negro,” an Arkansas doctor wrote in 1926, “does not call for medical aid until he thinks himself seriously ill. He first tries all kinds of charms, herbs and teas, thereby cheating himself of his best opportunity of recovery.” This doctor also notes “much confusion in medical terms. They have no such words as stools, urine, etc., in their vocabulary.”¹⁵ A cardiologist comments in 1927 on how differently blacks and whites describe chest pain: “That which the white man speaks of in a striking, graphic manner, the negro refers to as 'misery in the stomach' or 'misery in the chest.'”¹⁶ Speaking a medical language of their own, such black patients appear to have received little sympathy from the white physicians who could not understand them. Today such problems persist but are wrapped in a depersonalizing jargon that speaks of “the complex interaction between physician and patient” or “problems in communicating with their physicians.” This terminology can make physicians and patients equally disoriented participants in a process that may seem beyond remedy or the responsibility of either party.

Comments about the black patient's tendency to ignore symptoms and delay treatment have appeared in the medical literature for the last century. But the tone in which such behaviors are described in today's medical journals has changed from one of impatience and contempt to a more politically correct humane understanding of circumstances and motives. Sarcasm and exasperation have been replaced by the somber (and often stultifying) idiom of public health professionals and their recognition of sociological factors bearing on black health problems that offer an alternative to simply blaming the victims.

In summary, the American medical establishment has never mobilized on behalf of a medically traumatized African American population. The early twentieth-century white public health officials and doctors who feared the black population in the South as an infectious “reservoir of disease,” due to the ravages of tuberculosis and syphilis, were primarily concerned about protecting the health of their own racial community. As the chief health officer of Savannah, Georgia, warned in 1904, it was necessary to reduce disease among blacks, because “in doing this we protect ourselves.”¹⁷ “They knead our bread and rock our babies to sleep in their arms, dress them, fondle them, and kiss them,” a physician from Florida reminded the American Public Health Association in 1912; “can anyone doubt that we may not escape this close exposure?”¹⁸ The Southern white population did, in fact, escape the feared consequences of their close exposure to their black servants; widespread fears of infection proved unfounded. But the hysterical element inherent in this sort of white thinking about black disease has manifested itself in various forms up to the present day.

For decades afterward, the stereotype of the irresponsible “Negro patient,” whether sullen and recalcitrant or ignorant and docile, served to rationalize the black man's subordinate status and relieve both the white physician and society at large of the responsibility for taking on “Negro” medical problems as a serious social project. Doctors' judgments about perceived black immorality prompted them to turn their backs on the Negro patient: “Some physicians of the day were overtly judgmental and spoke of blacks as having earned their illnesses as just recompense for wicked life-styles.”¹⁹ Over the past century the razor-slashed, shot-gunned, and overdosed black men and women who have come staggering into hospital emergency rooms after their bouts of Saturday night mayhem have left behind a racial stigma in the minds of the many doctors who have treated them. The tardiness and medical noncompliance of the far greater number of black people who simply do not trust white medical institutions have persuaded many medical personnel that efforts to promote black health face insuperable obstacles. In his classic study of the Tuskegee experiment, James H. Jones points out: “Private physicians had long agreed that the [syphilis] problem was serious, but most despaired of being able to do anything about it, preferring instead to exchange stories on the difficulties of treating black patients.”²⁰ Over the past two decades the medical establishment has adapted to the challenge of widening “racial health disparities” by embracing epidemiological research and clinical studies while omitting the most candid accounts of difficult patients. These publications dress up medical suffering and hardship, as well as failed doctor-patient relationships, in a psychological and sociological jargon that excludes or strictly limits any deeper (and necessarily historical) discussion of racially biased ideas and behaviors among medical personnel.

MEDICAL VULNERABILITY AND RACIAL DEFAMATION

African Americans, including physicians, have long had their own reasons not to draw special attention to their health problems. The medical defamation of black people by whites in positions of authority has taken many forms over the past two centuries and has done incalculable damage to race relations in general and to black confidence in a medical system that has always been controlled by whites. In addition, medical folklore about blacks has played a major role in the history of American racism and its campaign to stigmatize black people as both immoral and inherently inferior.

During the era of slavery, the campaign of defamation aimed primarily at justifying plantation slavery on physiological and psychological grounds. Slave owners and the plantation physicians who served them found it convenient to talk about black slaves' “efficiency as laborers in [a] hot, damp, close, suffocating atmosphere—where, instead of suffering and dying, as the white man would, they are healthier, happier and more prolific than in their native Africa.” This physiological rationale for putting slaves into the heat of the cotton fields was accompanied by a psychological rationale—regarding the slaves' deficient willpower—that justified keeping them under the control of whites.²¹ An elaborate system of racist ideas about black anatomy and physiology gave chattel slavery an ostensibly scientific foundation and remained influential well into the twentieth century.

The most destructive defamatory campaign lasted for decades after emancipation and portrayed blacks as a disease-ridden and biologically degenerate race. A 1915 article in the Southern Medical Journal, to choose from one of many examples, called the Negro “a hive of dangerous germs, perhaps the great disease-spreader among the other subspecies of Homo sapiens.”²² Predictions that syphilis and tuberculosis would eventually bring about their extinction were common before and after the turn of the century. In his influential Race Traits and Tendencies of the American Negro (1896), Frederick L. Hoffman had welcomed the news that contemporary rates of “constitutional and respiratory diseases” would henceforth limit the growth of the black population. “It is sufficient to know,” he writes, “that in the struggle for race supremacy the black race is not holding its own….”²³ Many African Americans were thus made aware that millions of whites, including some doctors, were looking forward to their extinction as a race.

The Social Darwinism of this era constantly evoked the idea of a racial competition that African Americans were fated to lose. In the context of this deadly serious contest, black medical problems became nothing less than harbingers of racial extinction. Constant reports of high rates of syphilis among blacks reinforced folkloric ideas about their sexual immorality that attained the status of dogma for many white physicians and further intensified black hostility toward the medical profession. “It is the prevailing opinion,” one doctor writes in 1915, “that practically every negro who has reached middle life is syphilitic, an opinion which finds support in the exceedingly lax moral standards of the race.”²⁴ Here is the heritage of medical defamation that makes today's African Americans reluctant to protest against the legacy of medical racism by declaring, “Look how sick we are!”

Public discussions of black medical inferiority forced black leaders, and black doctors in particular, into the position of having to defend the biological integrity of the “race” and even the capacity of Negroes to benefit from medical therapies—a campaign that persists up to the present day in the case of certain medications. The Urban League's official publication declared in 1924, for example, that “the Negro possesses 'biologic fitness'” and, contrary to the belief of some white doctors, is also capable of responding to the treatment for pulmonary tuberculosis.²⁵ In 1932, a white member of the American Social Hygiene Association welcomed “the willingness of Negro leaders to face statistics relative to actual health conditions. A few years ago the Negro was inclined to interpret statements and figures regarding syphilis and gonorrhea as a racial indictment.”²⁶ Black people understood that defamatory claims about black sexual behavior were poisoning race relations and alienating black people from white doctors.

Describing the medical problems of black people without causing offense has been a long-standing problem. A black physician writing in the Urban League magazine in 1941 strives for balance by acknowledging the seriousness of the “Negro health problem” while refusing to accept the familiar claims about the sickliness of his people. “The health of the Negro is a problem,” he writes, “but, before submitting proof, let us define the premise. The health of the Negro, as used by the intelligent and honest observer and narrator is not by assertion or implication a derogatory statement. Certainly, it is not intended to place undue emphasis upon his susceptibility to disease or his maladjustment in the complex pattern of American life.” The challenge for Dr. Roscoe C. Brown of the U.S. Public Health Service was to confront two ideological adversaries. On one side were the white doctors who made a policy of exploiting black health problems to promote the idea of racial inferiority and the ideal of segregation. On the other side were those of his fellow blacks who resented public discussions of the state of their health and favored “a more euphemistic and optimistic declaration of racial parity in health status and life expectancy.”²⁷ In 1945 the first African American physician to earn a masters degree in public health, Dr. Paul B. Cornely, struck a blow for the medical integration of all Americans by declaring that “there is [no] such an entity as a 'Negro Health Problem,' for the health achievements and problems of this racial group are merely expressions of the total health situation of the country.”²⁸ A decade later Cornely was able to report some incremental progress in the desegregation of an American medical system that was still refusing to embrace racial integration.²⁹ But the era of real militancy directed against the de facto racism of the American Medical Association and its segregated medical system was yet to come.

Open resentment of pessimistic and unflattering descriptions of black health problems emerged along with other expressions of black self-assertion during the 1960s. On occasion these reactions reversed white claims about black infirmity and exhibited a rhetorical inflation that distorted reality. On March 24, 1961, for example, Malcolm X, invoking the spectacle of biblical wrath, told a white audience at Harvard Law School the following: “Your people are being afflicted with increasing epidemics of illness, disease, and plagues, with which God is striking you because of your criminal acts against the twenty million ex-slaves.”³⁰ The same need for compensatory illusion appeared a year later when a black doctor told the annual meeting of the National Medical Association that slavery had been “the greatest biological experiment of all times” and a eugenic boon to black Americans.³¹ In a different vein, the Reverend Martin Luther King, Jr accused the American Medical Association in 1966 of promulgating a racist “conspiracy of inaction” against black people. Amidst all of the apolitical and now routine celebrations of Dr. King, this prescient analysis and protest against institutional medical racism has been forgot-ten.³² By 1968 Paul Cornely had taken note of the radical moment and warned that racial health disparities were adding “fuel to the smoldering Negro revolution which explodes intermittently.”³³ During the 1966 riots in Chicago, blacks had burned down a health clinic on the city's West Side. In 1969 Newsweek informed its readers that “slum dwellers themselves wryly refer to municipal hospital clinics as 'the butchershop' or 'the plantation.'”³⁴ It is no accident that these gritty details appeared, not in a medical journal, but in a newsmagazine that was uncensored by the editorial policies of medical editors.

The point here is not that the highly credentialed Paul Cornely had become a radical. On the contrary, his conduct as a black physician and public health official remained self-disciplined and professional throughout this period of growing black dissatisfaction with the medical care white authorities chose to make available to Negro patients. What matters here is Cornely's professional deportment, his adherence to the standards of what I wish to call “the black physician as gentleman,” the black medical man of this era who constantly had to control his anger as he devoted himself to caring for black patients in circumstances that racist practices made difficult or impossible. This self-control included not alienating the white medical establishment on which black doctors were deeply dependent. While some of these men must have imagined a social protest movement that would relieve the medical misery of the black masses, the public expression of such anger and demands for relief do not begin to appear until the militant rhetoric of the 1960s offered political cover to black doctors who were moved to protest.

Black physicians have been a beleaguered and often disdained minority within the medical profession, and this marginal status has limited their ability to challenge the white medical establishment. During the early decades of the twentieth century, blacks and whites alike questioned both their competence and their motives. Black doctors were also blamed for the state of black health: “The Federal Government inadvertently contributed to the embarrassment of the Negro physician when it perennially issued statistics that showed the Negro death rate to be from 5 to 7 times higher than that of the general population. These figures could be interpreted in one of two ways. First, that the Negro was biologically different or inferior, a conclusion reached by Dr. Stoddard of Harvard and later by Dr. Putnam of Princeton. Second, that the treatment the Negro received was pathetically inadequate. The latter conclusion would reflect on the competence of Negro physicians who took care of these people….”³⁵

Even in their own medical schools, the black historian and journalist Carter G. Woodson wrote in 1933, black medical students were made to feel inferior “in being reminded of their role as germ carriers.” Nor could black doctors be effective if their own people did not believe they were competent, since they “had difficulty in making their own people believe that they could cure a complaint, fill a tooth, or compound a prescription.”³⁶

The self-assertive attitude among blacks that advanced during the civil rights decade also changed attitudes toward black physicians. In 1970 Time reported that African Americans were feeling an “increasing sense of security visiting a black rather than a white doctor. This is a complete reversal of the older pattern: blacks used to take their minor ills to a black doctor, but seek a supposedly superior white practitioner for major medical matters because there were few black specialists.”³⁷ This attraction of black middle-class patients to the “great white father image” was still being discussed in the African American medical press in 1985.³⁸ The black population was still emerging from a period that included the marginalizing and humiliation of its medical personnel, who still lacked the prestige to mount an effective campaign against the consequences of medical racism. In fact, the professional status of the black physician can still be called into question. As one of my African American students wrote in 2001: “Patients discriminate against physicians. Blacks prefer a white doctor on the white or so-called ‘good’ side of town.”

The ability of African Americans to campaign against the causes of their medical misfortunes has also been limited by the sheer volume of disease and disability, along with the accompanying demoralization, with which they and their doctors have had to contend up to the present day. Listening to physicians who care for the black poor at Meharry Medical College, it is easy to conclude that impoverished African Americans in particular have come to accept impairment by severe medical problems as a way of life. Under the doctors' attitude of realism one senses an undercurrent of resignation. “I think we are losing the war in terms of prevention,” says one doctor. “It's a socioeconomic thing. Most poor people don't have adequate access. They don't have good insurance, good education. They don't come unless it impairs their ability to work. By that time the damage has already been done.” A second black doctor addresses the issue of group demoralization head on: “The biggest issue,” he says, “is self-esteem. I don't think our hopes go as far as white people's. Our teachers don't expect us to do more. We have a tendency to let things get worse. We get caught up in crime, drugs, prison.”³⁹ Given the emotional burden of group suffering on this scale, any sense of collective grievance that might be mobilized in the form of public protest becomes overwhelmed by doctors' and patients' immediate needs to cope and survive, whether physically or emotionally. This emotional burden is compounded by the shortage of black medical personnel in many parts of the country. “We have one black surgeon in Savannah, no black nephrologists, one black gastroenterologist, two black pediatricians, both women, no black dermatologists,” a black physician commented in 1999.⁴⁰ A young black professional once told me how difficult it was for him and his wife to find a black pediatrician in as large a metropolitan area as Austin, Texas. The stresses and discomfiting situations black clients seeking black physicians experience are seldom noted in the accounts of black health issues produced by public health officials. Here, too, African Americans are expected to adapt to circumstances and endure a variety of difficult situations that are otherwise reserved for poor whites and other people who exist on the margins of society.

Contemplating this long history of medical ordeals suggests that some African Americans have, to one degree or another, become resigned to medical infirmity, because the fatal combination of poverty and institutional medical racism has made medical hardship a fact of life. Today, the memory of these hardships persists in the form of an estrangement from the medical profession that will be described throughout much of this book. But it is also important to recognize the value to black people of an adaptive response to medical hardship that amounts to more than a habituation to silent suffering. Medical hardship has played a significant role in the creation of an African American doctrine of survival—a cultural ideology that portrays black people as resilient and dignified survivors rather than as downtrodden victims.

Self-assertive expressions about black resilience can also cross the line into a kind of compensatory make-believe. In his remarkable anthology of African American testimonies Drylongso (1980), the black cultural anthropologist John Langston Gwaltney records the following declaration from a poor African American woman who had survived many hardships: “Most black people think that they are mentally and physically better than white people, and I think that they are physically superior to white people. I think it goes back to slavery-time. I think that only the strongest of us were able to survive, so that gave us better stock to start with.”⁴¹

Eugenic fantasies of this kind have long served as emotionally satisfying responses to defamatory claims about the biological and mental health of blacks. The imaginary racial advantage can also take the form of a presumed superior resistance to disease. In 1970, for example, Time reported that almost half of the African American population believed that “whites are more apt to catch diseases” than blacks, a folkloric belief that has always been contradicted by the public health data.⁴² Jet magazine reported in 1984 that having a “touch of diabetes” had helped blacks survive the ordeals of slavery, yet another variation on the eugenic interpretation of black enslavement.⁴³ A medically disadvantageous use of black “hardiness” is what the journalist Ellis Cose has called “an ethic of toughness” that “makes it very hard to admit that you are in pain or need help either physical or psychological.” Dr. Jean Bonhomme, president of the National Black Men's Health Network, calls this trait “pathological stoicism,” and he regards it as a health threat.⁴⁴

Stoicism of this kind can affect African American attitudes toward coping with depression. One study found that almost two-thirds of African Americans regard depression as a “personal weakness,” and that the same proportion “reported they believed prayer and faith alone would successfully treat depression ‘almost all of the time’ or 'some of the time.'” A quarter said they would “handle” clinical depression alone, and only a third said they would take antidepressant medication if it were prescribed by a doctor, as compared to 69 percent of the general population.⁴⁵

The stoic approach to depression incorporates several mutually related themes that have shaped African American responses to disease and medical hardship. Medical stoicism on the part of blacks is in part an abstention from participating in a medical culture that whites have created and controlled. The African American cardiologist Richard Allen Williams pointed out the following thirty years ago: “A person with chest pains may be so angry at the medical system that he may refuse to go to the hospital and may die at home. If such behavior occurs on a large scale, the effect that it will have on morbidity and mortality statistics is obvious.”⁴⁶ The medical and public health literatures, which seldom look at patient behavior as a product of historical experience, treat this sort of recalcitrance as a kind of passive negligence, while others will see such recalcitrance as self-assertive and even self-protective behavior.

Medical stoicism has been embraced because it expresses a toughness or “hardiness” that can serve as a source of racial pride. Such feelings, as we have seen, can inspire eugenic fantasies of black racial superiority. “The fact,” the black writer George Schuyler said in 1927, “is that in America conditions have made the average Negro more alert, more resourceful, more intelligent, and hence more interesting than the average Nordic. Certainly if the best measure of intelligence is ability to survive in a changing or hostile environment, and if one considers that the Negro is not only surviving but improving all the time in health, wealth, and culture, one must agree that he possesses a high degree of intelligence.” At a time when the ideas of Sigmund Freud were taking the eastern seaboard of the United States by storm, Schuyler ridiculed the psychiatric fashions and emotional insecurities of “sophisticated whites” by alluding to the psychological hardiness of his fellow blacks: “It is difficult to imagine,” he wrote, “a group of intelligent Negroes sprawling around a drawing-room, consuming cigarettes and synthetic gin while discussing their complexes and inhibitions.”⁴⁷

The idea that black emotional hardiness makes psychiatry unnecessary for black people exemplifies the stoic attitude that prompts some African Americans to make fewer rather than more demands on the medical system. Medical stoicism, an ethos of self-reliance, self-defensive eugenic thinking, and a doctrine of black hardiness, is a belief-system that encourages African American estrangement from the medical system. “The experience of inferior racial status has not transformed the Negro into a super human being,” the black psychologist Kenneth B. Clark wrote in 1965.⁴⁸ But some African Americans have believed otherwise, persuaded that the extraordinary hardships of the African American experience must have produced a race of strong and tenacious survivors. This tension between the eugenic and tragic interpretations of the African American experience has persisted into our own era.

Calling racial health disparities a civil rights issue has become one argument health care reformers use. The Reverend Al Sharpton's declaration in 1998 that the black health crisis is “the new civil rights battle of the 21st century” did not galvanize African Americans because—unlike the O. J. Simpson verdict—it cannot be reduced to a single dramatic event that symbolizes the experience of shared oppression.⁴⁹ Even the Tuskegee revelations, and the sordid details they revealed, failed to produce that kind of community outrage. The preceding pages have offered an explanation of why open revolt against medical racism has not taken place. The relevant factors include the sheer magnitude of the black health crisis and the demoralization it has caused among black laypeople and physicians alike; the mind-numbing jargon that smothers human suffering in sociological abstractions in the medical and public health literatures; the racial imbalance of power that has limited the power and influence of black physicians; the enduring reputation of “the Negro patient” among physicians, not excluding some black and foreign-born physicians; the long history of estrangement of African Americans from the medical system in general; African Americans' reluctance to draw attention to health problems that have been exploited for the purpose of defaming them as a race; and the belief in black hardiness and the medical stoicism it can encourage.

HOW DO (WHITE) PHYSICIANS THINK ABOUT RACE? EVIDENCE OF MEDICAL RACISM

Over the past twenty-five years the most prestigious American medical journals have produced massive evidence confirming that racially biased diagnosis and treatments are a fact of life in American medicine.⁵⁰ These analyses document racially biased behaviors and have prompted one official investigation and no disciplinary proceedings. Other professionals serving the public, such as policemen or professors, are not granted such immunity from scrutiny of their professional conduct. The racially motivated habits whose effects are presented in the medical literature as statistical data are so ingrained that some doctors do not deviate from them even when they know their interactions with black patients are being recorded for observation.⁵¹ Their personal eccentricities and the specific harms they cause to their patients remain anonymous, buried in the statistics that make it into print. Concealed behind the sterile terminology about racial “disparities” and “cultural differences” are an unknown number of biased behaviors that in other social venues might be regarded as negligence or violations of the law.

What evidence do we have that doctors employ racially motivated thinking when dealing with patients of color? The abundant data that indicate differential diagnosis and treatment for a wide range of diseases and disorders are one type of evidence. Their crucial disadvantage is that they portray collective behavior rather than the more detailed scenarios of private professional conduct that do not appear in the medical literature. The motives for some physician behaviors can be deduced on the basis of what is known about the history of racialist thinking by physicians. Deductions of this kind are indispensable to understanding racially motivated medical thinking and behavior, given the dearth of current survey data about physicians' racial thoughts and fantasies. But they are open to the objection that what we know about doctors' racial complexes from the overt medical racism of the past may not apply to modern practitioners who have supposedly absorbed socially sanctioned disapproval of racist speech and behaviors and conduct themselves accordingly. This book's methodology is based on the premise that, to the contrary, significant aspects of the medical racial folklore of the pre-civil rights period have persisted and adapted to modern circumstances to a greater extent than many have assumed possible in an age of officially mandated racial equality and racially civil public discourse.

There is, in fact, no reason to assume that medical students and doctors are less likely to absorb and act upon the racial fantasies that still suffuse modern societies. In 2001, for example, three white medical students at the University of Alabama at Birmingham were exposed by the news media after they wore blackface to a Halloween party. One was dressed as Stevie Wonder, the second as a character from the Fat Albert cartoon show, and the third as a black woman.⁵² The medical school officials who handled this case, with whom I communicated, resolved this matter by accepting public apologies and devoting a day to racial sensitivity training. The idea that this behavior demonstrated character defects that might make these individuals unfit to practice medicine apparently did not figure in the process that finally certified them as fit to treat black patients. This incident also raises the question of where cultural stereotyping ends and biological race fantasies begin. Blackface signifies a fantasy of racial transformation, just as cross-dressing signifies a fantasy of gender transformation. These medical students found gratification in taking on the identities of a blind singer, a comical cartoon image, and the generic black female who has traditionally ranked at the bottom of our racial hierarchy. These future physicians regarded playing with distorted versions of the black body as a kind of entertainment. One can only wonder what the experience of public humiliation and a day of racial sensitivity training may have done to temper or redirect their fantasies about black bodies in ways that might serve the interests of the African American patients who will some day consult them for medical treatment.

The most thoroughly documented racial disparities concern the diagnosis and treatment of heart disease, the leading cause of death in the United States among blacks as well as whites. This book argues that the medical folklore about blacks and cardiovascular diseases that was so evident throughout the twentieth century has distorted some doctors' responses to heart disease in black patients. The absence of this historical perspective in the current medical literature demonstrates the naïveté of medical authors who regard racially differential diagnosis and treatment of heart disease as a mysterious phenomenon whose causes have somehow eluded our understanding. Reading our way back through the relevant medical publications on coronary disease will help to clarify the mystery. At this point let us survey the findings about racially disparate treatment of patients requiring therapy for heart disease that have appeared since the late 1980s.

As of 1989 white patients were undergoing one-third more coronary catheterizations and more than twice as many coronary angioplasties as black patients.⁵³ In 1993 researchers confirmed that “white patients consistently underwent invasive cardiac procedures more often than black patients.”⁵⁴ In a 1996 editorial in the New England Journal of Medicine, H. Jack Geiger expressed deep concern about the unequal treatment of heart disease: “Perhaps most consistent—and most disturbing—are the repeated findings that blacks with ischemic heart disease, even those enrolled in Medicare or free-care systems, are much less likely to undergo angiography, angioplasty, or coronary-artery bypass grafting (CABG).”⁵⁵ A 1997 report came to similar conclusions regarding bypass surgery; the author called this finding “disturbing, because we also found that they were not due to differences in the severity of disease or to coexisting illnesses.”⁵⁶ A 2000 report confirmed that “medical therapies are currently underused in the treatment of black, female, and poor patients” who have suffered acute myocardial infarction. “This variation was not explained by severity of illness, physician specialty, hospital, and geographic characteristics”⁵⁷— possible confounding factors this study ruled out, leaving physician bias as the most probable explanation for why black patients were offered fewer therapeutic procedures. A 2005 survey of racial differences in the management of acute myocardial infarction covering between 1994 and 2002 found that racial differences in care had persisted rather than diminished during this period.⁵⁸

Racially differential practices have also been found to affect the treatment of early-stage lung cancer. One research team wrote the following in 1999: “Our analyses suggest that the lower survival rate among black patients with early-stage, non-small-lung cancer, as compared with white patients, is largely explained by the lower rate of surgical treatment among blacks.”⁵⁹ The same conclusion was reiterated in 2006: “Black patients obtain surgery for lung cancer less often than whites, even after access to care has been demonstrated. They are likely not to have surgery recommended, and more likely to refuse surgery.”⁶⁰ It is historically conditioned fear that causes some black patients to refuse surgery even when it would be in their best interest to consent. The medical literature refers to these decisions as examples of “patient preferences,” as though these decisions to reject surgery were free and autonomous acts on the part of empowered medical consumers. In fact, blacks' fears of surgery persist because the medical profession has never addressed the consequences of its racist history in a way that might reassure African Americans who feel estranged from the medical system.

Heart and cancer surgeries are generally regarded as desirable procedures that benefit patients, and that is why racially differential access to them is unjust. There are other kinds of surgery that are undesirable when better alternatives exist, and here too black patients have borne an extra burden of suffering. The effects of a hysterectomy, for example, are likely to be more of an ordeal for a black woman than for her white counterpart, since “black women are more likely to get the more invasive kind of hysterectomy, which doesn't require a large incision. The vaginal operation is more expensive and harder, and studies have shown it is used more on women higher on the socioeconomic scale.”⁶¹ It was reported in 1996 and 1998 that black patients with diabetes and circulatory problems were less likely than whites to have leg-sparing surgery and were more likely to undergo the amputation of these limbs. Yet precisely the reverse was true of a more beneficial type of operation, since blacks were less than half as likely as whites to get hip replacements.⁶² Here, too, “patient preferences” dissuade some black patients from undergoing hip or knee surgeries because they “report less confidence in the efficacy” of such operations.⁶³ Accepting such “patient preferences” as autonomous decisions is mistaken, since the black patient's lack of confidence in the procedures is an expression of mistrust rooted in a group history of traumatic experiences involving the medical profession.⁶⁴

Evidence of racially differential thinking by physicians has also appeared in studies of emergency room analgesia.⁶⁵ Making judgments about doctors' unequal provision of pain relief to members of different racial or ethnic groups is complicated by three related factors—the subjective nature of pain perception, those cultural factors that may influence an individual's response to the experience of pain, and folkloric ideas about racially differential responses to pain.⁶⁶ Doctors' judgments have been affected by a traditional medical folklore about racial differences in pain sensitivity, in particular the idea that black people do not feel pain as acutely as whites do. “I can find no evidence to support the belief that the Negro does not feel pain as well as the white person,” one cardiologist wrote in 1942, and this assertion made him a dissenter among his peers.⁶⁷ But historical knowledge of this kind is rare among today's medical researchers. The author of a 1993 JAMA article that found Hispanic patients got less pain relief than whites comments: “The mechanism by which ethnicity influences pain management decisions is unclear.” He and his colleagues, he reports, were now involved in “an attempt to discover whether physicians assess pain differently in patients of different ethnic groups.”⁶⁸ The abundance of published evidence confirming that physicians for many years have based pain assessments on racial distinctions appears to have been unknown to him. It did not occur to this author to look for evidence of what he was looking for in the medical literature that preceded him. And, even if he had sought and found it, he might have assumed that today's physicians, unlike their predecessors, are too enlightened to think of pain thresholds as a racial trait.

Confirming the likelihood of racially discriminatory behaviors by physicians in a statistically convincing way is complicated and requires controlling for so-called confounding factors. The fact that the diagnoses and treatments offered to black and white patients may not be identical does not in and of itself demonstrate biased judgments or behaviors on the part of physicians. Other factors, such as biological or cultural differences, may account for these discrepancies. Economic and educational status can have enormous effects on health quite apart from how physicians behave. Poverty and illiteracy are powerful predictors of medical problems regardless of a patient's race or ethnicity or of how doctors respond to that person's medical problems. Racially motivated behaviors on the part of doctors may be absent or difficult to identify precisely because they coexist with other plausible contributing factors, such as unemployment or dietary habits, for which doctors do not bear a direct responsibility.

Conscientious physicians and medical scientists acknowledge confounding factors even as they may propose a diagnostic or therapeutic scenario that documents medically discriminatory behavior. For example, the author of one of the studies of heart disease previously cited cautions that “racial variation in rates of coronary revascularization may have resulted in part from differences in the prevalence of disease, the severity of disease, and other clinical factors.”⁶⁹ If heart disease occurs more often in one group than another, then that in itself might account for different numbers of procedures in the respective patient populations. Similarly, if the severity of a disease differs in blacks and whites for biological reasons—glaucoma, for example, is a more serious disorder in blacks than in whites—then different treatments may be appropriate. Determining whether the appearance of more (or more severe) disease in one racial group is due at least in part to biological factors remains difficult and controversial for reasons we will examine next.

RESISTANCE TO THE CRITIQUE OF RACIAL BIAS IN MEDICINE

American medicine has reacted ambivalently to the hundreds of studies that have documented racial disparities in health care. On the one hand, medical journals publish the reports that confirm the disparities, and these reports are sometimes accompanied by editorial commentaries that describe the disparities as intolerable and call for action to reverse them. At the same time, these medical authors have developed a rhetorical strategy that allows them to deplore racial health and treatment disparities without taking responsibility for them. Even the liberal white doctors who actually care about racial injustice in medicine have found ways to formulate their analyses of physician behaviors in such a way as to avoid threatening their own self-images and exposing the profession to critical scrutiny by outsiders.

Ambivalence about confirming the existence of medical racism has also been evident in the federal agencies responsible for monitoring and improving public health. In 1985 the Department of Health and Human Services (HHS) released its Report of the Secretary's Task Force on Black and Minority Health, documenting many health disparities. In 1999, Congress instructed the Agency for Healthcare Research and Quality (AHRQ) to publish an annual report, beginning in 2003, to document “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations.” The first National Healthcare Disparities Report (NHDR) was released in 2003, the second in 2004, and a third (and more complete) report in 2005.⁷⁰ The National Academies' Institute of Medicine issued a similar report in 2002.⁷¹ The chairman of the committee that wrote the report, a former president of the American Medical Association (AMA), commented: “The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing strategies to reduce and eliminate them.” At the same time, the National Academies' news release, summarizing the implications of the report, made notable use of the exculpating rhetoric and euphemizing vocabulary alluded to previously: “The report says that although it is reasonable to assume that the vast majority of health care providers find prejudice morally abhorrent, several studies show that even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes. In addition, the time pressures that characterize many clinical encounters, as well as the complex thinking and decision-making they require, may increase the likelihood that stereotyping will occur.”⁷²

This is the standard medical liberal's interpretation of the individual doctor's racially motivated behavior. According to this account, the “vast majority” of medical personnel are committed antiracists; “well-meaning” people succumb to “unconscious negative racial attitudes and stereotypes” that are hidden from them and for which, therefore, they cannot be held responsible until they are made aware of them. The stereotyping of patients originates in external circumstances such as “time pressures” that exacerbate the already formidable challenges of “complex thinking and decision-making.” There is, of course, some truth to this interpretation, including the essential point that a person can be unaware of his or her racial attitudes and their consequences for other people. But this is also a children's book version of medical reality that has been sanitized to preserve the self-image of the medical profession. The racial goodwill of the “vast majority” of white practitioners is taken for granted. Their racially motivated behaviors originate in unconscious attitudes and hectic schedules that do not allow them to be their true and racially wholesome selves. The black patients who may have been subjected to racially motivated negligence are absent from a drama that is focused on the needs of its white dramatis personae.

A similarly evasive strategy is evident in the influential and expanding field of biomedical ethics, which has effectively taken a pass on the issue of medical racism. The fifth edition of the standard text, Beauchamp and Childress' Principles of Biomedical Ethics (2001), devotes exactly one and one-half pages to the “unfair distribution of health care based on race.” Its approach is entirely sociological; we are presented with the familiar data about lower black rates of cardiac surgery and organ transplantation and nothing on the psychology or possible misbehaviors of the individual physician.⁷³ Here, too, medical professionals are exempted from scrutiny that might challenge their image as uniformly humane and impartial caregivers. Similarly, The Oxford Handbook of Bioethics (2009) includes nothing about race and medical ethics.

Despite its self-exculpating agenda, the liberal perspective on health disparities and medical racism is self-critical when compared with right-wing responses to criticism of the medical profession's treatment of minority patients. Resistance to even acknowledging the reality of racial health disparities can appear in state or federal agencies when the ideological winds in government are blowing in from the conservative end of the political spectrum. The deputy administrator for the Wisconsin Division of Public Health, Kenneth Baldwin, stated the following in 2001: “I'm not willing to say or place [sic] racism as a reason for [the] health disparity. I think it would be naïve to say that, when there is no one answer to the problem.” This official preferred to identify poverty as the explanation for differential health outcomes and suggest that race was irrelevant to higher rates of black morbidity and mortality.⁷⁴

The same preference for nonracial explanations for racial health disparities came to public attention in 2004 when political appointees in the Department of Health and Human Services (DHHS) of President George W. Bush were found to have altered a federal report on health disparities based on the 2002 Institute of Medicine report. The original version of this report issued in July 2003 concluded that racial disparities are “pervasive in our healthcare system.”⁷⁵ This finding was too much for DHHS conservatives, so the version released in December 2003 was edited to present a more upbeat interpretation of the data. For example, “A report by the special investigative division of the Congressional Committee on Government Reform found that the word ‘disparity,’ mentioned 30 times in the ‘key findings’ of the [initial] draft, was used only twice in the key findings of the final version.”⁷⁶ M. Gregg Bloche, a physician and bioethicist who had served on the Institute of Medicine Committee, commented in 2004: “In playing down our conclusion, the rewrite broke with the great weight of scientific opinion…. By insisting that the AHRQ researchers treat the existence of racial disparities as an unproven hypothesis rather than an established premise for their report, those who ordered the rewrite imposed their politics on federal science.” The conservatives went so far as to demand that the AHRQ researchers do the virtually impossible—control for enormously complex confounding factors such as the effects of social class and education—or eliminate all claims about disparities from the report. When leaks from DHHS forced the DHHS Secretary, Tommy Thompson, to release the original and uncensored version, he called the initial release of the altered report a “mistake.”⁷⁷

Why did DHHS conservatives want to suppress data about racial health disparities? M. Gregg Bloche pointed to their disdain for governmentsponsored social engineering and the related emphasis on personal responsibility: “A coherent vision motivated the proponents of the rewrite. This vision stresses the centrality of personal responsibility, both for our health and for our circumstances more generally. To call the rewrite's supporters racially insensitive oversimplifies matters.”⁷⁸ The conservatives' other urgent priority was to suppress any claim that doctors were guilty of racially motivated misconduct. That is why the rewritten version, while acknowledging that “some socioeconomic, racial, ethnic and geographic differences exist,” also states the following: “There is no implication that these differences result in adverse health outcomes or imply moral error or prejudice in any way [emphasis added].”⁷⁹ Like the medical liberals, these medical policy conservatives were deeply invested in protecting the image of white physicians. This required them in turn to make the absurd claim that physicians are somehow immune to the effects of racial prejudice. In reality, a doctor who was incapable of falling into “moral error” would have to be a godlike creature. It is this element of hard-bitten denial that separates the obdurate conservative from the medical liberal whose ideas about the physician's intrinsically benign temperament are less extreme and are more open to correction on the basis of evidence.

One critic of Secretary Thompson's decision to release the original health disparities report was Dr. Sally L. Satel, a psychiatrist who specializes in the treatment of drug addiction and is affiliated with the conservative American Enterprise Institute. “Secretary Thompson succumbed to political pressure that was applied by members of Congress who are identified with ethnic causes,” she charged.⁸⁰ The idea that racial health disparities do not originate in prejudice or injustice has been a fundamental premise of the ideologically driven views on race and medicine that Satel has published over many years. While conceding that some “lingering bias” may persist in the medical system, Satel's position is that “many race-related differences in health care are not what they seem.” Physicians and public health professionals who see racism in medicine are “indoctrinologists” who demonstrate a “stubborn reluctance to acknowledge that each person has some responsibility for preserving his or her own health— an attitude that threatens to reverse the gains made by public health in the past century.” She opposes any federal spending on research that is based on the idea that racism might affect African American health. Finally, she argues that racially differential treatment of whites and blacks results in part from anatomical differences between the races that disadvantage black patients.⁸¹ In summary, Satel's argument against what she regards as politically correct medicine amounts to a comprehensive defense of American physicians against the idea that racially motivated behaviors play any significant role in their relationships with black or other minority patients.

MEDICAL LIBERALISM AND THE MEDICAL LITERATURE

The conservative exculpation of physicians differs from the medical liberal's version in that the liberal analysis of physician behavior is more open-minded, far more concerned with ensuring social justice, and somewhat more willing to expose doctors' behavior to critical scrutiny. Still, the liberal consensus that has emerged over the last two decades almost always gives physicians the benefit of the doubt. These authors assume that American physicians are simply too conscientious to be capable of racially discriminatory diagnosis and treatment. They find it implausible that doctors would be as capable of absorbing and acting upon racial folklore as other people are.

The medical literature's response to overwhelming evidence of racially biased (and potentially deadly) behaviors has thus combined two strategies. On the one hand, there are the hundreds of peer-reviewed reports of racially differential diagnosis and treatment. At the same time, the presentation of these data employs a rhetoric of alibis, euphemism, and denial.⁸² The purpose of these rhetorical strategies is to demonstrate that, regardless of what the statistical evidence says about their behavior, American physicians are not “racists” who require reformation or public exposure. Many self-exculpating formulations of this kind have appeared in the medical and public health literatures, including a recent proposal that “racially based clinical stereotypes” are merely “cognitive 'shortcut[s]' busy clinicians may use to help order their world.”⁸³ Here again we see “time pressure” invoked as a mitigating factor in the event the doctor employs racial stereotyping. This is not to deny the real pressures that HMO-mandated assembly-line medicine inflicts on busy physicians. The problem is that the hectic schedule is invoked to deemphasize the racial stereotypes that may be affecting clinicians' judgment when they encounter black patients. The significance of this terminology lies in the discomfiting details it leaves out and in the alibis it presents to the reader: Physicians who practice racially biased medicine are not themselves racists, but are simply too busy to behave more carefully. They are distracted rather than negligent or hostile. Racial bias is presented as an impersonal phenomenon for which doctors do not bear individual responsibility.

A major failing of the medical authors who have addressed the issue of medical racism in the medical literature is their lack of interest in the history of medical racism itself. Scientists' habit of relying on the most recently published work has come at the price of ignoring the history of medical thinking that has preceded and often influenced later thinking about race. Some physicians have thus acquired a naïve view of the history of race relations within the profession. Here, for example, we encounter the (white) physician who suggests in 1997 that African Americans' “lack of trust in the medical establishment may have originated with the disclosures about the Tuskegee syphilis study”—as if the racial misconduct of white physicians had somehow begun in 1972.⁸⁴ The overt racism displayed by American medical authors in JAMA and other medical journals up until the Second World War appears to be unknown to the great majority of medical authors. This historical ignorance has in turn had a profound effect on the capacity of physicians to even imagine that doctors might behave in racially biased ways for which they might be held accountable.

Another obstacle to acknowledging the role of race in medical practice is a disproportionate emphasis on the complexity of the origins of racial disparities and how much about them remains unknown. The truisms that result from this sort of agnosticism distract readers from what is or should be known about racial factors but was apparently unknown to the authors who profess ignorance. The coauthors of a study of racially unequal treatment for heart disease, for example, wrote in 1989 that “we need to understand more about the complex interaction between physician and patient” that leads to inequality of medical treatments.⁸⁵ In this case the tautological assertion that we need to understand more about what we don't understand obscures the more salient point, which is that critical analyses of “the complex interaction between physician and patient” had already appeared in the medical literature. In 1973 JAMA published David Satcher's observations on the racially insensitive conduct of many physicians and medical students he had watched interacting with black patients.⁸⁶ In 1979 the Annals of Internal Medicine published John Eisenberg's seminal article on “Sociologic Influences on Decision-Making by Clinicians.”⁸⁷ In 1985 Pediatrics published David Levy's examination of “White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship.”⁸⁸ To be sure, these prescient essays and a few others were buried among thousands of other communications in the medical literature with which they competed for attention. (The African American-edited Journal of the National Medical Association was then, and remains today, essentially ignored by the medical community and the news media.) The larger point is that these publications demonstrated a keen awareness of what the medical literature would eventually come to euphemize as “communication problems” between doctors and their patients. So it was, in fact, possible to recognize and think systematically about these problems before the flood of publications on racial health disparities began in the late 1980s.

What is most striking in retrospect is how impervious the medical literature has remained to the essential observations and recommendations that appear in these “early” publications, all of which postdate the civil rights era. The irony is that physicians' lack of interest in understanding their own professional behavior in its social context, which is one of Eisenberg's basic points about how doctors see themselves, has played a key role in keeping detailed and accurate accounts of black-white medical relationships and the effects of biomedical racial folklore out of the medical and public health literatures. “Physicians often object,” Eisenberg notes, “to being asked questions relating to professional and social factors, especially religious affiliation and social class origin. This denial of social influences is not limited to medical clinicians,” since even clinical psychologists tend to believe in their own invulnerability to social and cultural factors.⁸⁹ Removing doctors from their social context offers the additional benefit of preserving the privacy of professional conduct. The absolute right to professional autonomy (and the authoritative judgments this implies) thrives in isolation from challenges to physicians' conduct toward patients who may or may not be satisfied with the doctors' manner or medical recommendations. Many years ago, David Satcher—who would later became surgeon general of the United States—observed the following: “Many white physicians with whom I trained preferred black patients because they believed the black patient was less likely to be critical and to express dissatisfaction or to question procedures. Most white physicians interpreted the master-servant relationship as a good doctor-patient relationship. Their patients were ‘happy.’”⁹⁰ Keeping the doctors “happy” depended on their being unaware of how their ostensibly submissive black patients might actually feel about them.

Socially progressive medical liberals also participate in the strategy of denial through an inability or unwillingness to see medical race relations in their historical context. Seeing the Tuskegee scandal as a unique and temporary blemish on the honor of American medicine, they are likely to have little or no idea of how their predecessors judged and treated “the Negro patients” they encountered. Contemplating the possibility that the racial health disparities they found so “disturbing” might be due to “racially discriminatory rationing by physicians and health care institutions,” H. Jack Geiger commented: “We do not yet know enough to make that charge definitively.”⁹¹ In fact, Geiger's New England Journal editorial, titled “Race and Health Care—An American Dilemma?” (1996), is the prototype of the medical liberal response to racial health disparities. On the one hand, Geiger confronts the documented disparities and offers none of the conservative alibis that purport to explain them. But he simply cannot bring himself to believe “definitively” that his medical colleagues and the institutions to which they belong are capable of “racially discriminatory” professional behavior. Here, too, we see an important consequence of historical ignorance or naïveté. For either Geiger is unaware of the various forms of medical racism that were rampant in American medicine during the first half of the twentieth century, or he believes that racially motivated conduct on the part of American physicians was somehow abolished by civil rights legislation and the unofficial rules of political correctness that have been widely adopted since that time.

This sort of medical agnosticism has the advantage of incorporating a kind of intellectual modesty into its refusal to judge complex behavior. “We do not presume to know whether bias is truly at work in this setting,” two medical authors state in their 1999 article on “Racial Disparity in Rates of Surgery for Lung Cancer.” “Evidence that bias on the part of physicians (either overt prejudice or subconscious perceptions) influences access to optimal cancer care is disheartening,” they comment, but it is too soon to tell whether even “subconscious perceptions” might be affecting the therapeutic relationship.⁹² These authors, like Geiger, await “definitive” proof that would “truly” convince them. “Researchers,” the Chronicle of Higher Education reported a year later, “want to investigate further whether minority patients are intimidated by white doctors, or whether doctors use medical terminology that some undereducated people, whatever their race, may have particular difficulty understanding.”⁹³

Even a passing familiarity with American social history would have assisted the researchers who were trying to figure out whether black patients might be intimidated by white doctors. Intimidation in every social venue was the social logic of Jim Crow racism, and the social universe of American medicine was no exception to this rule. The real question here is how medical researchers could be so unaware of the basic facts of life regarding race relations in the United States during the course of the twentieth century. This historical ignorance leads in turn to medical complacency toward the feelings of black patients whose personal histories lead back to the long era of Jim Crow medicine. Today's physicians seem to be unaware that the prejudices and practices of their predecessors traumatized generations of African Americans, for whom a distrust of white doctors became a cultural legacy that persists to this day on a scale few whites can imagine. Once again, the real mystery posed by these researchers is how they could have embraced the naïve assumption that black-white relations in medicine can be studied outside of the historical context that shaped them.

The agnostic approach to health disparities continues to predominate in the medical literature. The authors of a 2005 report on the management of heart disease in blacks and whites, which documents the persistence rather than the narrowing of racial health disparities, conclude the following: “Despite considerable debate, reasons for these differences are largely unknown. Potential explanations are sex and racial differences in eligibility for treatment, clinical contraindications, and confounding by other clinical factors.” These authors propose that “persistent differences in treatments and procedures according to sex and race reflect some unmeasured characteristic of patients or a health care factor that has not changed over time.”⁹⁴ The racist phase of American cardiology and its diagnostic legacy that are examined in Chapter 3 go unmentioned and, I suspect, unimagined by these authors. What is more, every explanatory term they use is obfuscating, misleading, or essentially meaningless. “Eligibility for treatment” usually refers to poverty; “clinical contraindications” can result from judgments by physicians that may express racial bias; “unmeasured characteristics” can include various aspects of an African American identity that may complicate diagnosis and treatment; a “health care factor that has not changed over time” could be virtually anything, including medical forms of racial bias. As we will see in greater detail, those medical authors who address racial issues in the professional literature employ a terminology and a rhetorical strategy that effectively eliminate the relevant historical factors as well as accurate descriptions of how race relations work in the world of American medicine today.

One issue that most medical authors evade is whether physicians have a responsibility to monitor their own unconscious motivations for the purpose of earning and retaining the trust of their patients. David Levy's 1985 paper on doctor-patient relationships introduces the basic distinction about conscious and unconscious behaviors. “The white physician,” he points out, “need seldom contend with conscious prejudice in himself. However, he must be alert to the possibility of unconscious prejudice or negative counter-transference which impedes the doctor-patient relationship.” For example, “unconscious prejudice may cause the white physician to over-identify with the black patient, i.e., lean over backwards and become overindulgent, paternalistic, and condescending.”⁹⁵ But Levy's emphasis on the doctor's responsibility to monitor and adjust for his own state of mind—a well-known professional obligation of the psychiatrist—has not been taken up by the medical commentators who followed him.

Knowledge of the racial dimension of our medical history would also curb the temptation to excuse racially biased behaviors by distinguishing between “overt” and “subtle” misbehaviors. The physician's obligation to practice a degree of self-observation is noted by a few of the physicians who have touched on the interpersonal dynamics of race relations in medicine. “Many physicians would deny,” John Z. Ayanian wrote in 1993, “that overt racism affects medical decisions, but few could overlook the subtle racial biases that can permeate reasoning and communication with patients and other physicians.”⁹⁶ Here the distinction between overt and subtle is not invoked to excuse “subtle” physician behavior that might also be of “unconscious” origin. But the standard presentation of scenarios involving potential bias addresses the issues of motivation and self-awareness by establishing the racial innocence of the medical personnel whose behavior might be questioned. An early (1980) paper on measuring racial bias offers the following response to the discovery of possible bias: “Based on these measured treatment differences we conclude that there is some indication of racial bias. Our experience with the staff indicates that this bias is not due to hostility or contempt for black patients but from subtle stereotyping and greater familiarity with and preference for white patients. Feedback of the results of our data to the staff was met by an openness to consider racial bias as a possible explanation” [emphasis added].⁹⁷ The medical staff is given a clean bill of emotional health vis-à-vis race on the basis of the authors' “experience” with them. The preferred explanation of possible bias is, as is so often the case in these publications, “subtle stereotyping” for which no one is directly responsible. The “preference for white patients” that might be a sign of racist feelings about blacks is left unexplored.

Emphasizing the distinction between open racial hostility (“overt racism” or “overt prejudice”) and ostensibly unconscious prejudice (“subtle racial biases” or “subconscious perceptions”) is an essential feature of the rhetoric of exculpation that shapes most of these commentaries. “We're not talking about people who are overtly racist,” a health disparities researcher said in 1998. “Physicians have very busy worlds. The encounters [with patients] are quick. These are things that increase stereotyping.”⁹⁸ One problem with the frequently invoked distinction between the overt and the subtle, quite apart from the standard disconnect from historical experience, is the idea that objectionable racially motivated behaviors announce themselves in the form of overt prejudice. The rhetorical effect of this claim is to exonerate the silent majority whose feelings about race remain inconspicuous. To be sure, these people may be influenced by “subtle stereotyping,” but this mental state is itself regarded as exonerating because the stereotyping is too subtle to be noticed by those who have fallen under its sway. The challenge of holding doctors accountable for their behavior remains deferred until that time when the entire situation will be better understood. A rationale for deferring the assigning of responsibility for racially unequal cardiac care appears in a 1993 New England Journal article:

The extent to which subtle or overt racism underlies racial differences in the use of cardiac procedures is unclear. We believe that inadequate health education, differences in patients' preferences for invasive management, delivery systems that are unfriendly to members of certain cultures, and overt racism all may play a part. Allocating responsibility more precisely will require studies that control for angiographic data and directly examine interactions between patients and medical professionals.⁹⁹

Deferred along with the allocating of responsibility is the question of why the medical profession has done so little to promote the studies of “interactions between patients and medical professionals” that might get physicians to recognize the ways in which medical relationships involving blacks and whites can and do go wrong.

This portrait of the physicians' vulnerability to “prejudice” effectively exonerates them of responsibility, since denigrating or hostile motives are presumed to be absent. Even though they are filled with “moral abhorrence” at racial prejudice, physicians “may not recognize manifestations of prejudice in their own behavior.” Given this predicament, one might think that the authors would call for some sort of training to liberate doctors from their racial stereotypes. But they decline to do so, calling instead for more research, since the evidence linking stereotyping and prejudice to disparities in health care is merely “indirect.”

The sheer obfuscation and confusion the agnostic approach to disparities can cause are particularly evident at the end of a New England Journal article that attracted wide publicity following its publication in 1999. The notoriety of “The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization” resulted from its misleading presentation of statistical evidence that exaggerated its findings of physician bias.¹⁰⁰ An unnoted irony of this media event was that a paper that infuriated some physicians by exaggerating findings of bias concluded with a version of the standard exoneration of physicians whose tangled jargon is in a class by itself:

Our finding that the race and sex of the patient influence the recommendations of physicians independently of other factors may suggest bias on the part of the physicians. However, our study could not assess the form of bias. Bias may represent overt prejudice on the part of physicians or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient's membership in a target group automatically activates a cultural stereotype in the physician's memory regardless of the level of prejudice the physician has.¹⁰¹

Following the familiar distinction between “overt prejudice” and “subconscious bias,” the final sentence of this passage makes a point of dissociating physicians from their own racial bias. According to this psychology of prejudice, there is no relationship between the cultural stereotype that is “automatically activated” in physicians' memory and the “level of prejudice” they may harbor. Once again the minds of doctors are presented as playthings that are at the mercy of forces operating “automatically” outside them. Physicians “have” a “level of prejudice” in the same sense that they “have” other more innocuous traits for which they bear no responsibility. “Subconscious bias” serves as physicians' alibi not to be held responsible for their racially motivated behaviors.

Racially motivated feelings and behaviors on the part of physicians can also play a role in their decisions about whether medical treatments will be offered to patients, and whether those patients will feel inclined to accept treatments from medical personnel they may not trust. Black patients are frequently reported to be less willing to undergo “technologically intensive interventions” such as surgery. “Blacks with cerebro-vascular disease are more averse to the risks of surgery than whites and are more likely than whites to refuse coronary artery bypass surgery when it is offered. Similarly, blacks with end-stage renal disease are somewhat less likely than whites to want renal transplantation…. Black men with osteoarthritis perceived the risk of joint replacement to be higher, the rehabilitation longer and more painful, and the ultimate functional outcome less favorable than white men's perceptions…. Black patients appeared to fear perioperative risks of coronary artery bypass graft surgery more than whites did.”¹⁰² This reluctance to be operated on applies to a variety of procedures. “Blacks also report less confidence in the efficacy of knee or hip replacement, suggesting that lack of information about risks and benefits, compounded by a general distrust of the health care system, is a partial determinant of the observed lower operation rates.”¹⁰³ Jeffrey N. Katz pointed out in 2001 that one source of these fears may be the fact that “the risks of mortality and complications following coronary artery bypass graft surgery are higher in blacks than in whites, even after adjustment for case severity. Referring physicians may communicate these local risk patterns to their patients.” For example, black physicians tend to be somewhat more pessimistic about the benefits of joint replacement operations than their white colleagues.¹⁰⁴ White physicians may also doubt that kidney transplantation promotes the survival of blacks to the same degree as it does that of whites.¹⁰⁵

The treatments black patients either prefer or avoid can have a great deal to do with beliefs or feelings of which white medical personnel may be unaware. Conspiracy theories and urban rumors about medical dangers have circulated in the black community for many years. Some African American patients have reported a widespread belief in the black community that being exposed to air during lung cancer surgery can make the tumor spread, causing some patients to refuse the surgery and to disbelieve physicians' assurances that this fear is unwarranted.¹⁰⁶ African American patients can also be influenced by racial stereotypes in ways that prevent them from acting on their preferences. One study, for example, found that “black women were uncomfortable talking to physicians about menopause, fearing that they would sound unintelligent or mentally impaired, and were dissatisfied with the discussions when they did raise the subject with their doctors.”¹⁰⁷

Many years passed before medical authors began to abandon the practice of invoking “patient preferences” as a convenient alibi for inferior medical care and to begin to talk candidly about the role that fear and distrust can play in these decisions. “Patient ‘preference’ for less intensive treatment,” Katz noted, “may in fact represent resignation to the perceived status quo—that interventions are unavailable, unaffordable, ineffective, or unduly risky—even if those perceptions are not accurate.”¹⁰⁸ But the greatest degree of candor about how preferences work appears, not in the medical literature, but in newspaper coverage of racial health disparities. It was Newsday, not the New England Journal, that in 1998 published the following commentary by Ed Hannan, a professor and chairman of the Department of Health Policy, Management and Behavior at the School of Public Health at the State University at Albany: “One of the things alleged by those who say that there are truly not racial differences [in treatment] is that blacks tend to turn down procedures that have been offered to them. But what we found, essentially, is that the physician did not recommend the surgery.”¹⁰⁹ Dr. Robert Gaston, a transplant surgeon at the University of Alabama in Birmingham, the largest transplant center in the United States, told Newsday that doctors dealing with poor African Americans in particular “will come up to a person and say something like, ‘You really don't want a transplant, do you?’”¹¹⁰ A 1999 study concluded that: “Among the patients in our study who desired transplantation…black patients were less likely than white patients to have been evaluated and placed on a waiting list or given a transplant.”¹¹¹ These black patients had expressed a preference for undergoing surgery. Their doctors, for whatever reasons, did not always prefer to accommodate their wishes.

These reports make clear the rhetorical significance of the term “patient preferences,” which effectively removes physicians from the decision-making process, thereby exempting them from responsibility for whichever treatment choice is made. The other misleading function of this term is to endow black patients with an independence and a sense of security that not all of them are likely to feel in a modern hospital setting. A white physician who treats a black patient in 2012 may not realize that the patient's medical clock may be set at 1952 or 1922, depending on the legacy that medical racism has left in that person's family over many years. The patient's decision not to undergo surgery in the present may have been shaped by a traumatic past whose effects neither the doctor nor the patient understands. But the fact that the doctor does not grasp what is happening will not prevent the consequences of a misunderstanding.

The preceding analysis of medical rhetoric and vocabulary asserts that American medical authors have failed to produce an honest and accurate assessment of their own behaviors in the domain of race relations. The constant use of various euphemisms to gentrify race relations and envelope doctors' behaviors in a sanitizing jargon points to a deeply rooted resistance to self-scrutiny and real reform. The exceptions to this rule are few. M. Gregg Bloche calls the “overwhelming” evidence that “members of disadvantaged minority groups receive poorer health care than whites” a “bitter truth.”¹¹² But this sharp acknowledgment of failure sounds a discordant note in a medical literature that has long been in denial about race matters. As three African American physicians pointed out in JAMA as far back as 1989, “the most likely reason for these inequalities is that physicians value black lives less than white lives.” Commenting on a JAMA article on racial inequalities in treatments for heart disease, they go on to call this study an exercise in evasion, since “racism is considered only briefly, lastly, and politely as 'socio-cultural factors influencing physician and patient decision making.'” They cannot understand why the authors “stopped shy of implicating racism. Their own article carefully documents the evidence in the medical literature.”¹¹³ More than two decades later, the medical literature continues to practice this sort of denial. The verbal evidence of this stalemate is the persistence of stultifying jargon. The alienation of white doctors from black patients is a problem of “patient physician race concordance.” Black patients may experience “less patient-centered” visits than white patients and hear a “less positive affective tone” when doctors address them.¹¹⁴

The medical literature thus remains in one sense an elaborate arrangement whereby white physicians are insulated from certain kinds of discomfiting information about the medical suffering of black people and from knowledge of how black patients or colleagues assess their professional behavior. The voices of black patients and physicians appear, infrequently, in newspapers.¹¹⁵ Black people's analyses of how white physicians behave in interracial encounters play no significant role in American medicine's halfhearted attempts to deal with its half-acknowledged race problem.

The effect of these publications about doctor-patient relationships has not been to promote the reform of medical training or to negotiate a new relationship with the black population. The actual result has been more publications of the same kind. There are no studies of how doctors actually think about their black patients, no inventories of stereotypes, few inquiries into racially motivated diagnostic errors, and no analyses of the transmission of racial folklore from one medical generation to the next. Apart from an occasional reference to the Tuskegee Syphilis Experiment, references to the history of medical racism in the United States are almost entirely absent. Editorial gatekeepers ensure that potentially discomfiting penetrations of the physician's private sphere do not appear in the professional literature. American medicine thus persists in the mistaken belief that it has left the world of racially inspired medical folklore far behind.

Deciphering the racial complexes of physicians in the medical literature of the post-civil rights era is difficult due to the obscurantist jargon medical authors use to take the sting, the pungency, and the menace out of race relations as they are acted out in medical settings. Sanitizing race in this way also serves to protect the privacy of doctors whose racial beliefs are officially regarded as humane until there is dramatic evidence to suggest otherwise. The sanctity of the private sphere within which physicians' thoughts and feelings shape their decisions derives from their traditional sense of autonomy. Physicians who acknowledge that racially motivated judgments can affect medical practice may challenge doctors' assumed right to privacy by advocating some kind of therapeutic intervention. “If we recognize our own negative racial attitudes,” David Levy wrote, “we should ask ourselves why we need them and then do something to effect personal growth and change. For psychiatrists who lack the empathy needed for work with all groups of people, 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.”¹¹⁶

THE PHYSICIAN'S PRIVATE SPHERE

A generation after Levy wrote these words, prescribing psychotherapy for racially troubled physicians remains an improbable and even exotic proposal for reform. An alternative to the status quo would be the systematic detection and exposure of racially motivated conduct by doctors—an option the medical profession has never embraced. The legal scholar Dorothy Roberts, who has written on the medical racism that has been inflicted on black women, has challenged the pretense of medical autonomy and argued that “doctors' ‘private’ moral dilemmas involving their patients are actually interpreted and resolved according to relationships of power in the larger society.” Highly trained and affluent physicians (or lawyers or professors) can, in fact, exercise illegitimate and unethical forms of power over their undereducated patients (or clients or students), white or black. Roberts's objective, therefore, is “to shatter the myth that the interaction between physician and patient is a private matter.”¹¹⁷

Resistance to the shattering of this “myth” of privacy is embedded in the medical profession, and is directly related to physicians' sense that professional conduct is independent of the larger social forces (such as race relations) that operate in the wider world outside the office. Most doctors, according to the physician and health policy scholar Troyen Brennan, “think a patient is best treated if the physician follows her personal and ethical code in dealing with sensitive issues…. Nor do most of my colleagues think that medical ethics should define a public role for physicians, or that health law and policy should represent moral challenges for physi-cians.”¹¹⁸ The problem is that many (and probably a majority of) physicians have not developed “personal and ethical codes” that would enable them to deal successfully with “sensitive issues” like race in a comfortable and competent way. Where, indeed, would the physician's “personal and ethical code” for racial encounters come from? Our social institutions do little to prepare any of us for race matters, and medical education does little to remedy this deficit (see Chapter 5).

The result of laissez-faire race relations in the medical world is an unregulated environment in which patients in general, and black patients in particular, hold the weaker cards. The executive vice president for medical affairs at a Long Island, New York, hospital defended this limited view of a doctor's accountability (and his own) in 1998 in the following terms: “The issue for us is to accept patients without regard to race, creed, color, national origin or ability to pay. After that, how the cookie crumbles is something over which we have little or no control and, I think, little or no responsibility.” This administrator had no plans to monitor the racial conduct of the physicians who practice medicine at his hospital, and he apparently saw no reason to do so. The consequences of this policy, according to Kathleen Gaffney, the Nassau County health commissioner, are predictable: “You get treated by what you look like. If you're black…the physician is less likely to take your symptoms as seriously, so you may not get the same response. There continue to be health care stereotypes in terms of minority patients being less compliant, they 'don't take their drugs,' and there is also a perception they are less motivated and less educated. It becomes a self-fulfilling prophecy because they're treated differently by health professionals.”¹¹⁹

Physicians' sense of entitlement to privacy in their professional conduct is not limited to American practitioners. Most British physicians, too, expect to be left alone to manage race relations on their own terms. The following anecdote is instructive in this regard. After hearing a South Asian medical student speak on the needs of minority ethnic children in the National Health Service (NHS), the speaker's white peers “reacted negatively: 'He's off again!' some said. Others felt insulted that I could even consider that they would ever discriminate against anybody. Some groaned that they wanted a 'serious medical topic,' which to them this wasn't. Most saw it as a political statement, bearing no relationship to their future in medicine.” And some white doctors extend the same racial privilege to white patients. A South Asian doctor in Birmingham “provoked outrage when he planned to screen his prospective patients for racist views.”¹²⁰ Encounters with racist patients have long been part of being an African American physician.

The task of understanding how doctors think and feel about race is also made more difficult by the fact that the accumulated survey data about racial attitudes focuses on attitudes toward economic status, social policies, and other sociological topics. Opinion surveys of racial attitudes typically measure respondents' attitudes toward affirmative action, economic status, the state of race relations, voting rights, educational achievement, enforcement of civil rights laws, sources of inequality, the effects of interracial contact, or “the racial healing process.” These data, too, present collective information about attitudes and pose few questions that are directly relevant to the medical setting. Questions focusing on racial stereotypes of laziness and intellectual inferiority would be relevant to studying the attitudes of doctors who may doubt the willingness of black patients to understand and follow their instructions. But doctors also deal with the intricacies, and the intimate aspects, of human bodies that do not figure in published survey data. The sociologists and political scientists who produce most of these studies do not include the questions about anatomical or physiological traits that could illuminate how medical students or doctors might think about their black patients.

In fact, it is unlikely that social scientists would see any reason to pose such questions, given the widespread and mistaken assumption that biological fantasies about racial difference are largely extinct. Second, many social scientists conducting research on race would feel uncomfortable about posing such questions. The days when whites refused to share the same swimming pool water with black bathers are gone, and modern people feel an understandable reluctance to revisit the primal fears that insisted on this sort of biological quarantine from racial aliens. Yet the biological level is precisely where we must go to explore the racial fantasies of medical personnel. There are even some survey data that can help us reassess the assumption that biological racism is a thing of the past. For example, a political scientist's 2004 study of support for the Mississippi state flag found that a biologically themed “old-fashioned” racism was far more prevalent among college students than he and others had expected it to be. “Old-fashioned” racism in early twenty-first-century Mississippi included the belief that “differences that exist between Blacks and Whites are attributed to God's divine plan”—implying a belief in the polygenist doctrine of separate creations—and that blacks and whites should not intermarry, thereby mingling their racially distinct genomes.¹²¹ In fact, many years of social conditioning have made race biological thinking a fundamental aspect of how we continue to think about racial differences, even if understandable (and generally commendable) social pressures keep most of these ideas from circulating widely in our public media.

Social scientists' lack of interest in investigating biological fantasies about racial differences has been matched by a similar disinterest on the part of journalists, with a few exceptions. A Washington Post-ABC News poll reported in 1981, for example, that close to one-quarter of white adults still regarded blacks as inferior human beings, a judgment that suggests a belief in genetic inferiority.¹²² A National Opinion Research Center study released in 1990 reported that 56 percent of whites believed blacks were “violence-prone,” although the idea of a biological basis for this trait was not explored.¹²³ (A suspected biological trait was explored at the New York State Psychiatric Institute during the period between 1993 and 1996, when 100 black and Hispanic younger brothers of juvenile delinquents were given the subsequently banned diet drug fenfluramine “to test a theory that violent or criminal behavior may be predicted by levels of certain brain chemicals.”¹²⁴) In October 1963, only months after Dr. Martin Luther King's March on Washington, Newsweek reported that 71 percent of whites thought that black people “smell different”¹²⁵—a biological fantasy about black bodies that can be traced back to the racist plantation physician Samuel Cartwright.¹²⁶ Our problem is to relate such findings to how doctors think and behave. For example, if about a quarter of white Americans believe black people are somehow inferior, is there any reason to assume that about a quarter of America's physicians are somehow immune to this sort of racial thinking?

PLAYING ANTHROPOLOGIST

An embarrassing and revealing episode involving racial misbehavior by a physician was the 2000 scandal that engulfed Dr. William (Reyn) Archer III, an obstetrician-gynecologist and the son of a powerful Republican congressman, who was appointed Texas health commissioner by Governor George W. Bush in 1997. Over the next three years, Dr. Archer made a number of eccentric and controversial statements, public and private, on such topics as the emasculating effects of birth control and Hispanic attitudes toward marriage. The end came when he told an African American doctor of internal medicine that she was “too smart in a way,” and that using one's intellect to get ahead was “what white people do.” Then, playing anthropologist, he observed that her light-colored skin placed her in an African American “elite.”¹²⁷ It turned out that Dr. Archer had once said “that he likes to look at health and other problems with an anthropologist's eye, examining the customs, behavioral issues and cultural values that might be contributing factors.”¹²⁸ The racially eccentric conversations of the highest-ranking physician in Texas were made public only because they were secretly tape-recorded by the black female physician to whom he directed his remarks. The medical profession did nothing to dissociate itself from this authoritarian personality or his primitive racial fantasies. Dr. Archer's urgent need to play racial anthropologist finally led to his resignation from public office in late 2000, but the Texas chapter of the American Medical Association played no role in removing him from public office.¹²⁹

The ironic aspect of this awkward and protracted drama is that physicians should, in fact, take an “anthropological” interest in the backgrounds, habits, and life circumstances of their patients for the purpose of giving them well-informed care. But there is a crucial difference between the amateur cultural anthropology that acquaints the physician with the lives of his patients and the amateur racial anthropology that searches for racial essences and becomes fixated on apparent racial differences that can inspire both voyeuristic fascination and misleading fantasies in white observers.

What we may call “playing anthropologist” also occurs outside the doctor's office. Young African American women, for example, have told me of being approached in public places by white male strangers who proceeded to comment on the anatomy of their heads or bodies. The comments made by these men were not overtly lewd or hostile, but rather expressed an “anthropological” curiosity about black women. They also demonstrated a willingness to treat black women as if they were specimens on display, another ritual that was common in the nineteenth century. In this sense, “playing anthropologist” involves both a curiosity about the anatomy of the racial alien and a sense of entitlement that confers a right to examine her body for evidence of racial difference.

These inquiring approaches to black women are attempts to answer what the African American journalist Susan Richardson calls “black questions” from complete strangers. She found it frustrating that “after so many centuries in this country, my people were still a mystery to many whites. I have friends who belligerently refuse to answer questions about our curly hair, the variation in our skin color from chocolate to 'high yella' and our culture, especially when they are asked if we are related to the exotic peoples in National Geographic.”¹³⁰ Troubling encounters with racially curious whites are among the emotional “micro-aggressions” many African Americans experience on a regular basis.¹³¹ At the same time, these emotional stressors and their effects remain unknown to the great majority of whites, who assume that Americans of all skin colors share an essentially homogenous and egalitarian social environment in which everyone has an opportunity to thrive. Physicians who share this overly sanguine view of the black experience and who treat African American patients will eventually overlook signs or symptoms that are relevant to the proper diagnosis and treatment of people who are under more stress than the doctors perceive.

The behaviors of these amateur anthropologists are culturally aberrant only in their frank self-assertion. Most racial curiosity remains just that—an unexpressed interest in racial differences that might take the form of speculations about racial athletic aptitude or IQ scores or sexual prowess. Speculations of this kind originate in the traditional racial folklore that persists inside the heads of the vast majority of modern people, including the great majority of doctors, regardless of whether they are black or white.

The presence of discomfiting racial folklore inside the heads of modern people is continually on display in the awkward statements that prominent people have made in recent decades. In 2005, William J. Bennett, a former Republican secretary of education in the Reagan administration, ignited a national controversy when he fantasized on his radio program that “if you wanted to reduce crime, you could, if that were your sole purpose, you could abort every black baby in this country, and your crime rate would go down.” He then added: “That would be an impossible, ridiculous, and morally reprehensible thing to do, but your crime rate would go down.”¹³² While Bennett defended his remarks as a “thought experiment about public policy,” a black journalist at The New York Times called them “twisted fantasies.”¹³³ Another African American commentator who was “shocked and angered” by these remarks noted that Bennett had “instantly connected crime and race.”¹³⁴ Bennett countered that he could not grasp why a genocidal fantasy about a vulnerable racial minority descended from slaves might offend anyone. The Pulitzer Prize-winning syndicated columnist Charles Krauthammer, a graduate of Harvard Medical School, described “crack babies” in 1988 as a “biologic underclass whose biological inferiority is stamped at birth”¹³⁵— a judgment that turned out to be as mistaken as it was heartless.

Another fantasy about racial biology appeared in a comment Senator Daniel Patrick Moynihan made in 1994 about the consequences of the outof-wedlock births that occur at a higher rate among African Americans. “I mean, if you were a biologist, you could find yourself talking about speciation here,” that is, the creation of a new species. “It has something to do [with] a changed condition in biological circumstances.”¹³⁶ A year later the president of Rutgers University, a liberal affirmative-action proponent named Francis Lawrence, told a faculty meeting the following: “The average SAT (score) for African Americans is 750. Do we set standards in the future so we don't admit anybody? Or do we deal with a disadvantaged population that doesn't have that genetic, hereditary background to have a higher average?”¹³⁷ While none of the more than 30 faculty members who were present took exception to this assessment of African American intelligence, the release of a tape recording of the remark provoked a storm of publicity that almost cost Lawrence his job.¹³⁸

None of these men belong to the racist fringe as it is traditionally de-fined; on the contrary, all of them have occupied leadership positions in mainstream American institutions: state or presidential cabinets, a flagship state university, syndicated journalism, the United States Senate. None of them were dismissed or demoted for endorsing or playing with race biological themes in controversial or offensive ways. Only the hapless and obsessive Reyn Archer, isolated in his Jim Crow world of uppity blacks and the specter of lynching, lacked the facile talent to talk his way out of trouble. The desperate Francis Lawrence, by way of contrast, claimed that, while he and his wife had refused on principle to read The Bell Curve, his preoccupation with its outrageous claims about racial intelligence had somehow reversed the ideological force field in his brain and prompted him to say the exact opposite of what he had meant.

These incidents offer useful evidence because they expose the private racial imaginations of modern people to public scrutiny. What they show is that race-biological ideas can still inform white thinking about blacks to a degree that goes unacknowledged in our episodic and fitful “dialogue on race” that promises so much and accomplishes so little. It should be obvious that physicians, given their intimate contact with patients' minds and bodies, participate in this process as much as or more than most other people. It is possible that physicians are exposed to more racial folklore than other professionals, precisely because they absorb the ideas that circulate in society at large as well as those that are generated within the medical culture and circulate by word of mouth.

One of the central claims of this book is that folkloric beliefs about racial differences have persisted over many generations and have kept an evolving racial anthropology alive both inside and outside the medical profession. American medical authors seem to be unaware of or uninterested in folkloric material of this kind. Reports of racially awkward incidents involving white doctors and black patients (or, for that matter, black doctors and white patients) almost never appear in print. An anesthesiologist who told a nonphysician I know that the spinal fluid of black patients is thicker than that of whites will never appear as a case study in a medical journal because editors do not regard reports of this kind as suitable for publication. Medical journals are more disposed to describing on occasion the folkloric beliefs of patients. A senior physician at a Veterans Administration hospital in New York told me: “In my experience, when the notion of folklore enters medical discourse it invariably concerns the patient's folklore about himself—a folk remedy, a ‘primitive’/uneducated/unscientific/old country notion they have about their body. That doctors have a ‘folklore’ about their patients, let alone that they operate on the basis of folklore, is hardly ever recognized, talked about or acknowledged. The flip side of course is that the patients have their own folkloric concepts of their doctors (e.g., ‘you just want to experiment’)”.¹³⁹ It is not surprising that doctors can think of themselves as immune to folkloric thinking while ascribing such beliefs to their unsophisticated patients. This is, however, an illusion that is encouraged and maintained by the absence of appropriate instruction about racial folklore in medical school curricula and continuing education.

Medically significant racial folklore is known among African Americans and some doctors as the “silent curriculum” or, as the VA hospital physician reported to me, as the “hidden curriculum.”¹⁴⁰ “Are you aware of the term 'hidden curriculum' as it applies to medical student education?” the VA doctor asked me:

The term is very much in vogue in med-ed [medical education] circles. It refers to precisely what you're referencing…the under-the-radar shaping of attitudes and behaviors that can lead to a lifetime of bad habits, a parallel education picked up despite the best efforts of formal lectures and rounds. So much of medical education is informal, anecdotal, on the fly, and unsupervised. Residents are largely educated by other residents. It's all very intense, imitative, personal, hierarchical and riddled with “dependency issues.” An off-hand remark in a midnight I.C.U. to a sleep deprived intern can make an impression disproportionate to its accuracy.¹⁴¹

This insider's account of how medical habits are acquired focuses on the role of oral tradition—the private transmission of concepts and information, whether accurate, inaccurate, or innocuous—beyond the purview of formal instruction or supervision. Dr. Judith Gwaltmey, a professor of medicine and physiology at Boston University, puts it as follows: “There are lots of little stories that physicians believe that are neither scientifically based nor proven. That's the problem.”¹⁴² As the VA doctor points out, the oral transmission of these “little stories” can have a profound influence on how medical personnel interpret a patient and his or her symptoms:

Are you aware that the in-hospital case presentations frequently begin something like: Mr. Jones is a 70-year-old African-American/ white/Hispanic (choose one) male with a chief complaint of x-y-z? The racial identifier has a privileged status, up front, implying that everything that follows is potentially colored (no pun intended) by that fact as importantly as the facts of sex or age. The alternative in the case presentation format is to put that piece of information into what is called the social history or physical exam, assuming it even merits inclusion as a pivotal fact. Case presentations are delicate organisms, and the activation of bias early in the hearing can be deadly.¹⁴³

This account of how the racial presentation of a patient occurs in clinical medicine corresponds perfectly to a description that appeared in the Annals of Internal Medicine in 1996. The problem with giving patients racial identities in this manner is that “a physician's assumptions about a patient's race that result in the elimination of possible diseases or the narrowing of focus to one disease in the differential diagnosis may have serious negative consequences.” This author points to the case of a European boy (coded “white”) who presented with abdominal pain and anemia and whose surgery was abruptly canceled when his previously undiagnosed sickle-cell anemia came to light. A second case, concerning a young man coded “black,” ended in his death after he was treated for a sickle-cell crisis his doctors inferred on the basis of his presumed “race” and the patient's remark that he had once been told he had “sickle cell.”¹⁴⁴ “What surgeon has not been embarrassed,” a white physician asked in 1960, “by operating for acute appendicitis, only to find a normal appendix because he failed to remember sickle cell disease in the differential diagnosis.”¹⁴⁵ The fact that this physician, Dr. John Scudder, registers embarrassment rather than alarm reflects the casual approach to diagnosing black patients we have already seen in a number of cases from previous decades. A year earlier, a paper on blood transfusions by Dr. Scudder had produced a front-page story in The New York Times titled “Blood Expert Says Transfusion Between Races May Be Perilous.” “This may sound wrong sociologically,” he commented, “but it is scientifically correct.”¹⁴⁶ In May 1960 the African American-edited Journal of the National Medical Association noted that, following the news coverage of Dr. Scudder's paper, “several states have enacted laws or implemented old measures stipulating that Negro blood be separated.”¹⁴⁷ What had alarmed Scudder was the immune response of “a white war veteran” to a blood transfusion from a “Negro donor” whose blood did not contain an atypical antibody matching that of the white patient. Scudder proceeded to recommend, on the basis of the differing racial distributions of blood groups and antibodies, the racial segregation of blood to avoid dangerous incompatibilities.

Case studies of medical folklore and how these ideas are transmitted from one generation to the next are never analyzed in the mainstream medical literature. An interesting example of this sort of analysis appeared several decades ago in the black-edited Journal of the National Medical Association, at a time when the civil rights movement was encouraging black self-assertion in every social venue, including medicine. In his article on “Racial Contrasts in Obstetrics and Gynecology,” the white obstetrician William F. Mengert announced that his purpose was “to examine objectively each racial contrast in obstetrics and gynecology and place it in one of two categories: folklore or real difference. When this is done it becomes obvious that many racial contrasts depend upon social factors such as custom, social and financial station, rather than race.” Over the previous century, as we will see later on in this book, many medical authors had made little or no effort to distinguish between the folkloric beliefs that circulated among doctors and real scientific information.

The white physician who confesses in print to having mistakenly believed in “Negro” traits or disorders has been an absolutely exceptional contributor to the medical literature. White physicians commented occasionally during the Jim Crow era on their colleagues' inaccurate ideas about racial differences, even as pseudoscientific racial interpretations of the human organism and its diseases continued to predominate over this sort of caution. Some physicians understood, for example, that the stereotype of the venereal disease-ridden Negro was likely to produce some medical misjudgments. “In approaching the subject of syphilis in the negro,” a Charleston, South Carolina, doctor writes in 1915, “there is especial need to guard ourselves against preconceived notions. It is the prevailing opinion that practically every negro who has reached middle life is syphilitic, an opinion which finds support in the exceedingly lax moral standards of the race. This opinion may be true, but I have not been able to find any definite and exact data upon which it is based.”¹⁴⁸ “I am…prepared to admit, in the light of recent investigations,” another Charleston doctor wrote two years later, “that in all probability some [eye] affections which were attributed to syphilis may have been tuberculosis…. It behooves us to jack up, as it were, our diagnostic machinery to meet the times.”¹⁴⁹

The medical men of this period were willing to concede that physicians were vulnerable to some other mistaken ideas about black patients in addition to the constant harping on the perils of the syphilitic Negro. It is not true, a professor at the Atlanta Medical College asserts in 1915, that the Negro race “is not afflicted with adenoids in the nasopharynx,” even if local variations in the disorder have created this impression.¹⁵⁰ In 1925, a JAMA editorial on “Rectal Pathology in the Negro” warned against making “sweeping generalizations” about Negro tissues on the premise that the black man is an evolutionary (“atavistic”) throwback.¹⁵¹ It is now clear, a New Orleans doctor wrote in 1932, “that in spite of a rather widely held opinion to the contrary, the negro race is quite as susceptible to this terrible disease [cancer] as is any other race and people.”¹⁵² (Newsweek told its readers in 1963 that “Negroes are far less prone to cancer than whites.”¹⁵³) A Columbia University psychologist who in 1939 compared blacks to apes cautiously noted that the medical literature “has carried with it many superstitions in regard to predisposition of the colored race for certain types of mental disturbances or a relative infrequency for others.”¹⁵⁴ If doctors think infectious mononucleosis is relatively rare among “the colored,” two physicians from Richmond, Virginia wrote in 1944, it is probably because they have not bothered to examine the blood smears of their black patients.¹⁵⁵ A counterpart to the Southern physician, the British colonial physician, could make his own mistakes. A doctor who had assumed that “reticulocytes were larger in Africans than in Europeans” confessed his “misapprehension” in 1952.¹⁵⁶

These confessions of error in the medical literature show that the pseudoscientific consequences of racially motivated medical thinking— “preconceived notions,” “sweeping generalizations,” and “superstitions” among them—were making themselves apparent to the more open-minded sort of medical man even during the era of Jim Crow segregation. The other major theme that runs through these observations about diagnosing blacks is the careless and mistaken assumption that these people enjoyed various degrees of immunity to a variety of disorders: adenoids, cancer, mononucleosis, and many more. In addition, these doctors sometimes concede that such careless and mistaken diagnoses were the direct result of medical negligence on the part of white practitioners who did not take the trouble to examine their black patients with sufficient care. As one physician noted in 1920, in the case of suspected exophthalmic goiter, blacks “are often less minutely examined than white patients.”¹⁵⁷ If the Negro infant death rate for congenital malformations is half that of white infants, another doctor surmises in 1932, “This difference is probably due, in part, to less careful observation of Negroes.”¹⁵⁸ A 1946 JAMA commentary on “Maternal Care and the Negro” concluded that “errors in judgment and technic as well as neglect on the part of the physician were 50 per cent more frequent in the care of colored mothers.”¹⁵⁹ The impact such observations might have had on the doctors who made them would surely have been buffered by the profound racial paternalism that characterized the medical profession at this time. In the words of the commentator on obstetrical neglect: “The educational and intellectual deficiencies of the Negro favor poor obstetric results.” It is for this reason that these comments should be read as confessions of error rather than as a recognition of ethical deficiencies.

Apart from this climate of prejudice, there is another way to understand why physicians might avoid careful examination of black patients in some cases. In some Southern towns, black patients could wait from four to six hours just to be seen, and some were not asked to remove their clothes for physical examinations.¹⁶⁰ There is no one way to explain physician behavior of this kind; some practitioners must have made a conscious decision to give black people short shrift, while others may have been reacting to phobias rooted in apprehensions about racial differences, whether these were cultural or biological. The psychoanalyst and anthropologist George Devereux has offered some explanations of such behaviors based on what he observed while instructing fourth-year students at the Temple University School of Medicine in the 1960s. His assignment was to show the medical students the “psychiatric clues” that emerge during physical examinations. “The assumption that the racially alien patient must look ‘different,’” he says, “leads to diagnostic oversights quite as often [as] does an unawareness of genuine racial differences.” Uncertainty about the thin calves of a South African tribesman or the scanty pubic hair of Indian patients could lead to false diagnoses. He points to a syndrome he calls the “'tactful' reluctance to examine closely the most distinctive portions of a racially alien patient's body.” The small healed scars on an elderly black patient elicited no inquiries from “an exceptionally able” white doctor. Similarly, Devereux noticed that the medical students generally avoided “the characteristically prognathous lower half” of black people's faces. This may have been due to a phobic response to a frequently (and viciously) caricatured aspect of “black” physiognomy racists have traditionally associated with the great apes. One doctor did not examine an abdominal scar resulting from an appendectomy because he assumed, in accordance with the stereotype of the knife-wielding black criminal, that it was a razor slash. “I never saw a doctor routinely examine a Negro male's inguinal rings,” Devereux reports, “perhaps because of the myth that a large penis is a racial characteristic of the Negro.”¹⁶¹

More recent evidence described in the following suggests that the hidden (and occasionally overt) complexes and phobias that white doctors brought to the interpretation of the black body in the 1960s continue to affect the behavior of a significant number of doctors today. The tightening of politically correct rules governing racial discourse that has taken place since that era should not be mistaken for a purging of racial folklore from the minds of modern people. Few doctors, David Levy noted in Pediatrics many years ago, “are free of unconscious fantasies about imagined racial characteristics.” His analysis of how the white doctor-black patient relationship can go wrong is still a rarity in the medical literature. Unlike the numerous commentators on racial health disparities who employ terms like “unconscious prejudice” and take the analysis no further, Levy describes specific scenarios that can result from this syndrome. He thereby enters that private domain medical editors have long treated as inviolable. There is, for example, the doctor who overcompensates for his racial feelings by becoming “overindulgent, paternalistic, and condescending.” Then there is the doctor who enters into “a conspiracy of silence” about the race issue with his black patient, in that both “share the view that [ostensible racial] differences are signs of minority group inferiority and to discuss them would be tantamount to discussing a missing limb with an amputee.” Physicians can also be naïve about what counts as maladaptive behavior in the context of the African American experience; for example, suspiciousness that might strike whites as pathological may be justified given the emotional stressors many black people have to deal with.¹⁶² The conventions that have determined what can be published in mainstream medical journals have effectively prevented the mapping of this terrain.

African American physicians' observations of how their white counterparts treat black patients have occasionally appeared in medical publications. “It may not be in bad taste,” a black gynecologist wrote in the JNMA in 1920,

to call attention to the young doctor of the dominant race who must get his first practical experience at the risk of our women. All of us who reside in the larger cities are aware of his activities. It is only necessary to say in regards to his efforts that more organs of female reproduction are laid upon his altar, a sacrifice to his ignorance and for the benefit of his training than perhaps ever was sacrificed, as to function, by the ignorant mid-wife or the criminal abortionist.¹⁶³

Half a century later the future Surgeon General David Satcher described a less destructive, but similarly exploitative, arrangement that put black women's reproductive organs at the disposal of white doctors-in-training. Black patients, he wrote in JAMA, “are frequently exploited for teaching sessions. One black woman related to me that she had had nine pelvic examinations by physicians and students and had never been told whether her pelvis was normal or abnormal.”¹⁶⁴

The official publication of the Urban League, which was founded in 1910 as the Committee on Urban Conditions among Negroes, noted in 1924 that in many American localities there was “a prevalent idea among white medical men that all Negroes, especially if they cannot make another diagnosis, have syphilis. This idea is so well grounded that they will often treat as syphilis a case that shows repeated negative blood tests, absolutely lack all clinical symptoms and with an entirely negative history.” Here are the careless diagnostic habits noted earlier by white physicians who mention (but do not quite deplore) this sort of racially motivated neglect. This black author also emphasizes the importance of “the Negro physician and nurse,” since “those of the white race in quite a number of cases look upon Negroes as mere subjects for observation.”¹⁶⁵ Here is an early reference to the African American anxieties about being mistreated as experimental material that haunt the black community to this day. The power of the syphilis theme to shape medical thinking was evident the same year in Mississippi; there, medical men were speculating about why they had been unable to find any blind newborns among the black population. “Some doctors say that the Negroes, through generations of contact with venereal diseases, have developed a kind of immunity which protects the new-born baby's eye from the ever-present sources of infection.”¹⁶⁶ As was often the case, the imagined racial trait was a protective effect—“a kind of immunity”—that implied black people required less medical attention than less hardy types. As Gunnar Myrdal pointed out most of a century ago in An American Dilemma, “Diseases which are not frequently a cause of death are reported so badly or reported for such inadequate samples that it is almost inevitable that Negroes would appear to be immune to them even if they were not really so.”¹⁶⁷

Careless diagnostic habits can still occur when black patients seek treatment. Racial misinformation about blacks and heart disease causes some physicians to regard high blood pressure as “normal” in African American patients. (There are doctors in Europe who regard hypertrophic cardiomyopathy [an enlarged heart] as “absolutely normal” in Africans.¹⁶⁸) Disputed assumptions about racial physiology and drugs causes some doctors to believe that certain blood pressure medications do not benefit black patients—a claim that black cardiologists have contested. There are physicians who assume that most black patients are diabetic. Others assume that the painful symptoms of sickle-cell disease are signs of drug withdrawal and refuse these patients the narcotic-grade drugs that can relieve their pain. Antiquated ideas about blacks' immunity to pain manifest themselves in the failure to provide adequate doses of analgesic drugs in hospitals and emergency rooms; the refusal to provide pain relief may also originate in ideas about blacks as drug-seeking or especially prone to addiction. Many gynecologists have automatically diagnosed a black woman with symptoms of endometriosis as having pelvic inflammatory disease (PID), based on the assumption that black women are sexually promiscuous. This diagnosis can lead in turn to the sterilization of the affected woman. “Physicians have been known to diagnose, manage, and make recommendations based on perceptions they acquire from the literature. They have, for example, failed to order appropriate tests to detect macrosomia or intrauterine growth retardation because 'black women are less apt to know they are pregnant early in pregnancy than white women'.”¹⁶⁹ Today, it is indefensible to offer medical advice based on folkloric assumptions about what African Americans know or don't know about their health. This practice continues on account of the sheer momentum of traditional racial folklore. We will now examine how the assigning of racial essences to human traits originates and is perpetuated both outside and inside the world of medicine.

FROM RACIAL FOLKLORE TO RACIAL MEDICINE

When modern physicians offer racially motivated diagnoses and treatments, they are participating in a living tradition of which they are unaware, and medical school curricula do little to enlighten them. The fundamental tenet of Western racism is that blacks and whites are opposite racial types, and the most important correlate of this principle is that black human beings are less complex organisms than white human beings. These two ideas, operating together, have created a racially differentiated human biology that has suffused the tissues, fluids, bones, nerves, and organ systems of the human body with racial meanings that over the last century have influenced medical thinking in significant ways. Most of the major human organs and organ systems have their own racial histories, depending on how they have been interpreted in their social and historical contexts. In a similar fashion, many diseases and disorders have been effectively coded “white” or “black,” depending on whether they are associated with modernity (“white”) or socially backward (“black”) ways of life. The various forms of black medical “hardiness”—dermatological, neurological, surgical, venereal, cardiac, reproductive, and more—all presume a more primitive (and less complex) human type that is biologically different from the civilized white man. This racial doctrine of biological (and medical) difference is the ideological dimension of the “colonial medicine” described at length in a later section of this book.

The racial anthropology of the nineteenth century and the colonial medicine to which it gave birth are the prototypes of the modern-day racial medicine described previously in capsule form. The racial anthropology of this era was also an evolutionary doctrine that posited a developmental hierarchy predicated on a polarity between racially inferior blacks and racially superior whites. A representative text of this genre is “On the Negro's Place in Nature,” published in 1864 by James Hunt, PhD, president of the Anthropological Society of London. “The Negro race, in some of its characters, is the lowest of existing races,” he writes, “while in others it approaches the highest type of European; and this is the case with other savage races. We find the same thing in the Anthropoid Apes, where some species resemble man in one character, and some in another.”¹⁷⁰ This Victorian Age theme of differential human evolution and its related analogy between the “lower” races and the great apes or other animals persisted for many years in the thinking of Euro-American anthropologists and medical men.

This evolutionary theory of human racial differences also appears in later medical publications on race. In 1925, The Journal of the Michigan State Medical Society published an article endorsing the view that “the female negro pelvis is similar in many respects to the pelvis of the female gorilla,” arguing that “it seems but logical to conclude that the negro pelvis shows a reversion toward the type found in the lower animals.”¹⁷¹ The 1929 volume of the Transactions of the American Gynecological Society includes a casual endorsement of the idea that “the negro lies nearer to the common stem than does the European and so is nearer to the childhood of the race.”¹⁷² In 1939, the flagship journal of American psychiatry allowed a Columbia University psychologist to propose in its pages “that in the negro there are characteristics approaching the apes with a greater variability of form and structure.”¹⁷³

Simpleminded pseudo-Darwinian reasoning also equated black human beings with darker kinds of animals. Researchers at the University of Oklahoma in 1925 conducted a pharmacological experiment on the premise “that black feathers in chickens were the genetic equivalent of African heritage in humans.”¹⁷⁴ Readers of the 1928 volume of the American Journal of Physical Anthropology were told that, “It is natural to associate the low death rate of negroes from skin diseases and skin cancer with the presence of large amounts of pigment. Among animals there are many cases in which darker varieties are relatively immune to various diseases.”¹⁷⁵ Two contributors to the 1930 volume of JAMA compared black and white babies with black and white rats on the premise that skin color corresponds to a deeper biological analogy.¹⁷⁶ Other publications suggested that “evolutionary changes in teeth” had left black dental development at a primitive stage.¹⁷⁷

That such primitive pseudoscientific fantasies about racial differences passed editorial review at flagship journals like JAMA and Psychiatry during this period is a commentary on how influential some of the categories of Victorian racial anthropology remained well into the twentieth century. Nor should we assume that this influence was extinguished on account of the racial watershed marked by the Second World War. The racial integration of professional sports and the military services were landmark social and political events that were catalyzed by the drafting of African American men into the racially segregated armed services. But these and other social reforms such as school integration (1954) and voting rights (1964) did not remove the racial folklore inside people's heads.

The ignorance that results from this information vacuum helps to account for the shock and surprise that attend the scandals caused by prominent people who finally succumb to the power of racial fantasies that would have been better left unspoken. It is significant that these awkward events entangle liberals as well as right-wing ideologues like William Bennett and Patrick Buchanan, who once wrote that black crime “is, like sickle cell anemia, a ghetto sickness”—as vicious an example of racist medical defamation as our society has heard since the days of Jim Crow.¹⁷⁸ When presidential candidate Jimmy Carter suddenly endorsed the “ethnic purity” of American neighborhoods in April 1976, he showed—as the case of Francis Lawrence did twenty years later—the fine emotional line that can separate professed racial enlightenment from the unreformed thought habits that lurk within.¹⁷⁹ It is a measure of our racial civility that the threshold of socially acceptable discourse is seldom breached in public life. But not all violations of this standard result from heretical impulses that break through the ideological self-discipline of those who profess racial equality. We must distinguish between those whose principled self-restraint has been breached by the sudden urge to express a socially forbidden racial thought, and others who ignore or disdain the social rules that govern public talk about racial differences. These are the commentators who can slip into a nineteenth-century racial idiom and wonder what all the fuss is about.

The influential official or policy maker of this kind who appears oblivious to the unofficial rules of racial discourse is useful for our purposes, because he allows us to see how racial folklore can still shape the thinking that goes into medical policy making. A notorious case of this kind erupted in February 1992 when Dr. Frederick K. Goodwin, then administrator of the Alcohol, Drug Abuse, and Mental Health Administration, commented on the so-called Violence Initiative that was being sponsored by the Department of Health and Human Services. The goal of this program was to develop pharmacological or other therapeutic interventions against male violence that was implicitly identified as violent behavior by young blacks. Dr. Goodwin's remarks made it seem as though he had traveled back in time and embraced the mentality of a racial “ethnologist” like James Hunt. According to Goodwin's evolutionary model, the male violence of the black American ghetto was a reversion to the chaos of the primeval African jungle and its primitive inhabitants. Male monkeys, he said, are violent and hypersexual, suggesting “some interesting evolutionary implications.” The progeny produced by their frequent copulations will “offset the fact that half of them are dying.” He then proposed an analogy with “inner city areas” and “the loss of some of the civilizing evolutionary things that we have built up…. Maybe it isn't just the careless use of the word when people call certain areas of certain cities, jungles.”¹⁸⁰ The medical and social implications of the Violence Initiative were clear. As the African American political scientist Ronald Walters put it: “If there is a reason for this kind of research, the aim is to find a drug. And if you begin using drugs to pacify young black males, as is often done with Ritalin for hyperactivity, you're creating a regime of social control.”¹⁸¹ Goodwin's grossly stereotyping and speculative sociobiology provoked both support for the project and a bitter backlash.¹⁸² This controversy made it clear that the evolutionary racism of the late nineteenth century could still play a role in late twentieth-century thinking about race among influential psychiatrists.