Medicine and Society

Jan 2023
Peer-Reviewed

How Does Racial Segregation Taint Medical Pedagogy?

Harriet A. Washington, MA
AMA J Ethics. 2023;25(1):E72-78. doi: 10.1001/amajethics.2023.72.

Abstract

Persistence of racial segregation makes equitable health care impossible for African Americans, as does the supra-geographic segregation perpetuated by enduring racial medical mythologies that remain unchallenged in health professions education. This article canvasses how these mythologies exacerbate myopia in health professions practice and education, maintain barriers, and perpetuate racial health inequity.

Codifying Racial Segregation

In 1870, the American Medical Association (AMA) twice excluded1 the racially integrated delegation from Washington, DC, to the AMA’s national meetings while admitting a White one.2 Between 1846 and 1910, the AMA developed a state-based organizational structure that excluded most African American physicians even as the association shaped medical education.2 Schools commonly rejected Black medical aspirants like James McCune Smith, who moved to Glasgow, Scotland, where he earned his medical degree in 1837,3 and Daniel Laing, Isaac Snowden, and Martin Delaney, who were admitted to Harvard Medical School in 1850 but were expelled when White students protested.4

African American physicians responded by founding their own societies2,4,5 and medical schools because the relatively few Black patients admitted to White hospitals were typically pressed into service as “teaching material” and research subjects.6 When the AMA decided to elevate medical education by creating the Council on Medical Education in 1904, it did not essay to treat the 9 million underserved African Americans in the South.2 Instead, the AMA Council commissioned the Carnegie Foundation for the Advancement of Teaching to evaluate American medical education and produce the 1910 Flexner Report, which recommended closing all but 2 of 7 African American medical schools—Howard and Meharry.7 Moreover, the report castigated African American physicians—already denigrated as purveyors of drugs, alcohol, and abortion8,9—as “limited,” declaring: “A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an M.D. degree is dangerous.”7 Five of the 7 schools closed, and the number of African American physicians plummeted, ensuring that Black patients’ needs remained unmet. A lingering consequence today is that only 5% of US physicians are Black.10 And though African American men, who have the nation’s lowest life expectancy, fare best when cared for by Black men physicians,11 Black men constituted just 2.9% of medical students in 2019.12

As the civil rights era dawned, African American physicians advocated for Medicare and Medicaid legislation that the AMA disparaged as “socialized medicine.”13 The AMA’s long-standing resistance to these programs included distributing pamphlets to members declaring that “Help should be given to those who need it but not to those who are able to take care of their own needs” and warning that such governmental insurance programs “would result in the overcrowding and overutilization of hospitals by those who could be better cared for at home.” Other AMA promotional materials asked: “Would socialized medicine lead to socialization of other phases of life?”14 As I have noted elsewhere, it was Medicare that “enforced hospital desegregation via the 1964 Title VI of the Civil Rights Act, but de facto segregation and bias lingered, even in the North.”15 De jure segregation ended without support of the AMA.2

Contemporary Segregation

As Nancy Krieger and colleagues have shown, segregation still dictates many African Americans’ health status.16,17 Black women born in segregated states are more likely than those born in nonsegregated states to have estrogen receptor-positive breast cancer,16 yet clinical education is largely silent on this and other significant health effects of discrimination.17,18 Moreover, utilization of racial genetics in medicine ignores its role as an extension of biological dimorphism promulgated by 19th-century scientists6,19 to support African American racial inferiority. In 2005, for example, isosorbide dinitrate/hydralazine was approved by the US Food and Drug Administration to treat congestive heart failure in African Americans only, based on a theory of racial genetic vulnerability.20 The drug’s adoption continues centuries of medicine’s espousing biological dimorphism to support the claim that Black and White Americans suffer different diseases and require different treatments.6,21

Despite habitually being treated as a biological category, race is a social construct, one that medical texts address in a profoundly illogical manner. Research papers, textbooks, and lectures treat racial groups as a significant patient descriptor even as they fail to define terms like African American, Black, White, and Hispanic/Latinx. Medical discourse may fail to address ethnicity in a nuanced way, as when Black and White categories are set in opposition to broad Hispanic labels that ignore the fact that Hispanics are members of an ethnic group whose composition varies widely and whose members can identify as multiracial.22 Moreover, texts and lectures can stress race as a social construct even as prominent and consistent use of race-based medicine sends a very different message to students, as it serves to reify race.23

Tailoring interventions to race remains a powerful part of medical education that keeps some African Americans getting appropriate care. 

Medical education is relatively silent about clinical guidelines that deploy race to assess everything from treating urinary tract infections in infants24 to the advisability of vaginal birth after caesarian section.25 For example, the American Heart Association’s Get With the Guidelines–Heart Failure Risk Score predicts the risk of death in hospitalized patients but adds 3 unexplained additional points to any “nonblack” patient, thereby categorizing all Black patients as lower risk26 (and therefore less likely to receive aggressive care27). Similarly, equations used in estimating glomerular filtration rate (eGFR) add a point or more to the eGFR of Black patients, suggesting that Black patients have better kidney function.26 Use of these tools results in denying procedures to African American patients.26 Thus, tailoring treatment to race remains a powerful part of medical education that in some instances prevents African Americans from receiving treatment, just as barring the doors of hospitals to Black patients once restricted their care.

Pedagogical Silence as Iatrogenic Harm

“The maxim is ‘Qui tacet consentit.… Silence gives consent,’” wrote Robert Bolt in A Man for All Seasons.28 Medical pedagogy’s silence—its failure to address persistent mythologies that threaten the health care of African Americans—gives stigmatizing beliefs credence and inflates health care disparities by barring access to treatment. A legion of beliefs—such as that African Americans’ bodies differed so dramatically from White people’s that they did not feel pain29 and were immune to killers like heatstroke and yellow fever—supported enslavement 30,31,32,33,34,35,36 and the yawning chasm between White and African American health profiles.6,37

Today, the same mythologies persist to hobble the health care and health status of African Americans. For example, a 2016 study documented that more than half of all medical student respondents and most resident physicians still believe that African Americans do not feel pain as White patients do and that they have “thicker skin” and “stronger bones.”38 These myths are not inscribed in medical textbooks, so it is likely that students are taught them on clinical floors as they frequently observe African Americans in pain being dismissed as drug seeking and sent away without analgesia. Such neglect is exacerbated by stigmatizing language in medical charts, which is 2.5 times as likely to be found in the records of Black patients as White ones.39

Resurgence of both biologic dimorphism and blame-the-victim theories during the COVID-19 pandemic took the form of putative genetic differences.40 The surgeon general’s invoking alleged behaviors—such as drug and alcohol use, obesity, and failure to practice social distancing41—to explain African Americans’ high rates of infection and death42,43 eclipsed discussions of documented risks to African Americans posed by environmental racism,44 low rates of health insurance coverage, and a relative paucity of personal physicians.43 At the same time, medical journals and news media decried African Americans’ shunning of COVID vaccine trials while invoking the imaginary primary or even solitary role of the 1932-1972 US Public Health Service Study at Tuskegee (in which the US Public Health Service withheld standard-of-care antibiotic treatment from hundreds of Black men in Alabama who had been diagnosed with syphilis) in buttressing a purportedly widespread African American aversion to research and vaccination.45,46,47,48 Actually, 4 centuries of medical abuse, not overreaction to a single study, has fomented some African Americans’ resistance to a variety of research and treatment initiatives.49,50 However, the frequent claim that African Americans shunned the COVID trials en masse is fictitious.51 The real culprits that prevented nonelderly people of color from receiving vaccines were health policy decisions, such as prioritizing the elderly and health care and high-status workers52 but not the essential workers earning low wages who often shared their risks.

Conclusion

Racial segregation, both de jure and de facto, has powerfully separated African Americans from equitable health care. But so does the extra-geographic segregation perpetuated by persistent racial medical mythologies. To achieve more equitable care without racial bias, medical curricula should actively correct errors not only in texts but also in clinical teaching and modeling. Correcting the history of medicine canon to identify disparate treatment, abuse, and erroneous beliefs is an important step that has already begun in texts such as Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century,53 Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present,6 and Medicine and Slavery: The Diseases and Health Care of Blacks in Antebellum Virginia34 and within inclusive curricula.54 Expanding this education will equip students to interrogate racial bias in patient care and policies.

The COVID-19 pandemic has thrown the overreliance on biological dimorphism and the prevalence of blame-the-victim theories into sharp relief. Clinicians must eschew these and allied clinical stances, such as the belief in disparate pain sensitivity and the reliance on racial algorithms. But correcting these stances and beliefs should extend to frank indictments of them for the benefit of students and healers in training.

References

  1. Reyburn RR, Stephenson JG, Augusta AT, et al. A plea for racial equality. The New Era (Washington). January 27, 1870. In: Morais H, ed. The History of the Negro in Medicine. Association for the Study of Negro Life and History and Publishers; 1967:215-216.

  2. Baker RB, Washington HA, Olakanmi O, et al; Writing Group on the History of African Americans and the Medical Profession. Creating a segregated medical profession: African American physicians and organized medicine, 1846-1910. J Natl Med Assoc. 2009;101(6):501-512.

  3. Washington HA. James McCune Smith, MD. In: Kendi IX, Blain K, eds. Four Hundred Souls: A Community History of African America, 1619-2019. One World; 2021:205-208.

  4. Nercessian NN. Against All Odds: The Legacy of Students of African Descent at Harvard Medical School Before Affirmative Action, 1850-1968. Harvard University Press; 2004.

  5. Hyde DR, Wolff P, Gross A, Hoffman EL. The American Medical Association: power, purpose, and politics in organized medicine. Yale Law J. 1954;63(7):937-102.
  6. Washington H. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Doubleday; 2007.

  7. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Carnegie Foundation for the Advancement of Teaching; 1910. Accessed March 7, 2022. http://archive.carnegiefoundation.org/publications/pdfs/elibrary/Carnegie_Flexner_Report.pdf

  8. Washington HA. Foreword. In: Tallman JQ. The Notorious Dr Flippin: Abortion and Consequence in the Early Twentieth Century. Texas Tech University Press; 2011:i-xxii.

  9. Link EP. The civil rights activities of three great Negro physicians (1840-1940). J Negro Hist. 1967;52(3):169-184.
  10. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. Association of American Medical Colleges. Accessed August 31, 2022. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018

  11. Torres N. Research: having a black doctor led black men to receive more-effective care. Harvard Business Review. August 10, 2018. Accessed March 8, 2022. https://hbr.org/2018/08/research-having-a-black-doctor-led-black-men-to-receive-more-effective-care

  12. Morris DB, Gruppuso PA, McGee HA, Murillo AL, Grover A, Adashi EY. Diversity of the national medical student body—four decades of inequities. N Engl J Med. 2021;384(17):1661-1668.
  13. Braunold J. Why don’t Medicare and Medicaid cover dental health services? AMA J Ethics. 2022;24(1):E89-E98.

  14. Palmer KS. A brief history: universal health care efforts in the US. Paper presented at: Meeting of Physicians for a National Health Program; Spring 1999; San Francisco, CA. Accessed August 31, 2022. https://pnhp.org/a-brief-history-universal-health-care-efforts-in-the-us/

  15. Washington HA. When a Black man’s heart was transplanted without consent. New York Times. August 18, 2020. Accessed February 3, 2022. https://www.nytimes.com/2020/08/18/books/review/the-organ-thieves-chip-jones.html?searchResultPosition=2

  16. Krieger N, Jahn JL, Waterman PD, Chen JT. Breast cancer estrogen receptor status according to biological generation: US Black and White women born 1915-1979. Am J Epidemiol. 2018;187(5):960-970.
  17. Krieger N, Chen JT, Coull BA, Beckfield J, Kiang MV, Waterman PD. Jim Crow and premature mortality among the US Black and White population, 1960-2009: an age-period-cohort analysis. Epidemiology. 2014;25(4):494-504.
  18. Braun L. Theorizing race and racism: preliminary reflections on the medical curriculum. Am J Law Med. 2017;43(2-3):239-256.
  19. Braun L. Breathing Race Into the Machine: The Surprising Career of the Spirometer from Planation to Genetics. University of Minnesota Press; 2014.

  20. Kahn J. Race in a Bottle: The Story of BiDil and Racialized Medicine in a Post-genomic Age. Columbia University Press; 2014.

  21. Cartwright SA. Report on the diseases and physical peculiarities of the Negro race. New Orleans Med Surg J. 1851;7:691-715. Accessed March 7, 2022.

  22. Parker K, Horowitz JM, Morin R, Lopez MH. Chapter 7: the many dimensions of Hispanic racial identity. Pew Research Center. June 11, 2015. Accessed August 31, 2022. https://www.pewresearch.org/social-trends/2015/06/11/chapter-7-the-many-dimensions-of-hispanic-racial-identity/#fn-20730-

  23. Dutchen S. Field correction: race-based medicine, deeply embedded in clinical decision making, is being scrutinized and challenged. Harvard Medicine. Winter 2021. Accessed August 31, 2022. https://hms.harvard.edu/magazine/racism-medicine/field-correction

  24. Kowalsky RH, Rondini AC, Platt SL. The case for removing race from the American Academy of Pediatrics clinical practice guideline for urinary tract infection in infants and young children with fever. JAMA Pediatr. 2020;174(3):229-230.
  25. Vyas DA, Jones DS, Meadows AR, Diouf K, Nour NM, Schantz-Dunn J. Challenging the use of race in the vaginal birth after cesarean section calculator. Womens Health Issues. 2019;29(3):201-204.
  26. Vyas DA, Eisenstein HG, Jones DS. Hidden in plain sight—reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874-882.
  27. Eberly LA, Richterman A, Beckett AG, et al. Identification of racial inequities in access to specialized inpatient heart failure care at an academic medical center. Circ Heart Fail. 2019;12(11):e006214.

  28. Bolt R. A Man for all Seasons: A Play in Two Acts. Bloomsbury; 2013.

  29. Bourke J. Pain sensitivity: an unnatural history from 1800 to 1965. J Med Humanit. 2014;35(3):301-319.
  30. Fisher W. Physicians and slavery in the antebellum Southern Medical Journal. J Hist Med Allied Sci. 1968;23(1):36-49.
  31. Savitt T. The use of Blacks for medical experimentation and demonstration in the Old South. J South Hist. 1982;48(3):331-348.
  32. Brown J. Slave Life in Georgia: A Narrative of the Life, Sufferings, and Escape of John Brown, A Fugitive Slave, Now in England. WM Watts; 1855.

  33. Gordon MB. Aesculapius Comes to the Colonies: The Story of the Early Days of Medicine in the Thirteen Original Colonies. Ventnor Publisher; 1949.

  34. Savitt TL. Medicine and Slavery: The Diseases and Health Care of Blacks in Antebellum Virginia. University of Illinois Press; 2002.

  35. Blakeley RL, Harrington JM. Bones in the Basement: Postmortem Racism in Nineteenth-Century Medical Training. Smithsonian Institution Press; 1997.

  36. Breeden JO. States-rights medicine in the old South. Bull N Y Acad Med. 1976;52(3):348-372.
  37. Hogarth RA. Medicalizing Blackness: Making Racial Difference in the Atlantic World, 1780-1840. University of North Carolina Press; 2017.

  38. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301.
  39. Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: documenting racial bias in the electronic health record. Health Aff (Millwood). 2022;41(2):203-211.
  40. Washington HA. Medizinische apartheid in zeiten von corona: rassismus im gesundheitssystem der Vereinigten Staaten. Bundeszentrale fur Politische Bildung. November 6, 2021. Accessed September 23, 2022. https://www.bpb.de/shop/zeitschriften/apuz/medizin-und-ethik-in-der-pandemie-2021/334623/medizinische-apartheid-in-zeiten-von-corona/

  41. Surgeon General: Coronavirus warning to minority communities “not meant to be offensive.” MSNBC. April 10, 2020. Accessed May 5, 2021. https://www.msnbc.com/msnbc/watch/surgeon-general-apologizes-for-language-in-coronavirus-warning-to-minority-communities-81902149671

  42. Gawthrop E. The color of coronavirus: Covid-19 deaths by race and ethnicity in the US. APM Research Lab. September 14, 2022. Accessed September 23, 2022. https://www.apmresearchlab.org/covid/deaths-by-race

  43. Peck P. The virus is showing Black people what they knew all along. Atlantic. December 22, 2020. Accessed September 23, 2022. https://www.theatlantic.com/health/archive/2020/12/pandemic-black-death-toll-racism/617460/

  44. Washington HA. How environmental racism is fuelling the coronavirus pandemic. Nature. May 19, 2020. Accessed June 6, 2022. https://www.nature.com/articles/d41586-020-01453-y

  45. Frederick WAI, Montgomery Rice V, Carlisle DM, Hildreth JEK. We need to recruit more Black Americans in vaccine trials. New York Times. September 11, 2020. Accessed June 6, 2022. https://www.nytimes.com/2020/09/11/opinion/vaccine-testing-black-americans.html

  46. Weintraub K. “Sign me up”: why people of color are vital to getting a successful COVID-19 vaccine. USA Today. Updated August 22, 2020. Accessed September 23, 2022. https://www.usatoday.com/story/news/health/2020/08/20/covid-19-vaccine-trials-need-diverse-volunteers/3297954001/

  47. Bolster K. AstraZeneca/Oxford COVID-19 vaccine study seeking minority participants. NBC. January 11, 2021. Accessed June 6, 2022. https://www.nbc12.com/2021/01/11/astrazenecaoxford-covid-vaccine-study-seeking-minority-participants/

  48. Singletary M. Black participation in Covid-19 vaccine trials is key to Black economic recovery. Washington Post. October 27, 2020. Accessed June 6, 2022. https://www.washingtonpost.com/business/2020/10/27/covid-vaccine-trials-need-blacks/

  49. Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc. 2005;97(7):951-956.

  50. Scharff DP, Mathews KJ, Jackson P, Hoffsuemmer J, Martin E, Edwards D. More than Tuskegee: understanding mistrust about research participation. J Health Care Poor Underserved. 2010;21(3):879-897.
  51. Artiga S, Kates J, Michaud J, Hill L. Racial diversity within COVID-19 clinical trials: key questions and answers. Kaiser Family Foundation. January 26, 2021. Accessed September 1, 2022. https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-diversity-within-covid-19-vaccine-clinical-trials-key-questions-and-answers/

  52. Gayle H, Foege W, Brown L, Kahn B, eds; National Academies of Sciences, Engineering, and Medicine. Framework for Equitable Allocation of COVID-19 Vaccine. National Academies Press; 2020.

  53. Roberts DE. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century. 2nd ed. New Press; 2012.

  54. Health equity advocacy and anti-racism. Pritzker School of Medicine, University of Chicago. Accessed August 31, 2022. https://pritzker.uchicago.edu/node/2246

Editor's Note

Background image by Julia O’Brien.

Citation

AMA J Ethics. 2023;25(1):E72-78.

DOI

10.1001/amajethics.2023.72.

Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.