Driving home from the hospital one evening this summer, I came upon a cavalcade of cop cars and people chanting in the South End. Rolling down the window, I learned marchers were peacefully demonstrating for an end to police brutality against African-Americans — part of the struggle that continues in cities across the country.
I thought back on the protesters recently when an older black patient at my hospital asked for her main physician to be switched from a white doctor to a black one. Both doctors were well qualified to provide meaningful care, so the change seemed unnecessary. But she had grown up during the 1950s and 1960s, an era during which a deep distrust of the American medical profession was sown by the actions of doctors at the expense of black patients.
As in policing, African-American health has historically been at the mercy of white power and privilege. Perhaps the most infamous abuse remains the 40-year-long Tuskegee “study,” during which the United States Public Health Service dishonestly withheld medical treatment from black sharecroppers ravaged by syphilis, simply to observe how the disease progressed. When the truth was finally revealed in the 1970s and the program ended, the deception of researchers only confirmed the suspicion many blacks held toward medical institutions. After all, throughout the first half of the 20th century, many Southern hospitals were segregated and blacks often directed to shoddier facilities with lethally long wait times. African-American moms were forced to return home to deliver their babies in unsanitary conditions. African-Americans were turned away from renowned hospitals in Boston, too. National desegregation at medical facilities didn’t come until the mid-’60s, with passage of the Civil Rights Act, followed by Medicare and federal incentives.
Five decades have passed since then. But five decades isn’t very long — not when the memory of segregated health care remains alive in the stories recounted in black households. “I think that this distrust is built into the social DNA of black culture,” says Thomas Laveist, at George Washington University, who studies health care inequity. “And why shouldn’t it be, when you consider the history of untrustworthy medical care over the centuries?”
Today, blacks are still less likely to seek preventive medical care than whites. They are almost twice as likely to have diabetes, are 30 percent more likely to die from heart disease, and are the most obese ethnic group in the United States. Black babies are more than two times more likely to die before their first birthday. The death rate from all cancers is 25 percent higher for African Americans. Tuskegee’s legacy continues in today’s research: Even though blacks are more likely than whites to be afflicted by cancer, they are vastly underenrolled in clinical cancer trials.
Meanwhile, bias, Laveist reminds me, runs both ways. Project Implicit — a nonprofit international collaboration that examines how subconscious attitudes might affect our behavior — studies the effect of race in doctors’ clinical decisions. One study showed American doctors are less likely to administer clot-busting drugs to blacks having a heart attack; another revealed they are less likely to refer them for cardiac catheterization. None of the doctors in the research were outwardly racist, but their misjudgments were shaped by their unconscious bias.
I’ve always believed medical work could break down walls and surmount social obstacles . I still think that, at its best, medicine rests on such ideals. But for us to believe that doctors are immune to bias — racial or otherwise — is a fallacy that can cause harm.
How do we fix problems as intransigent as mistrust in a community or a doctor’s unconscious bias? I mulled that over recently as I drove through lower Roxbury to visit the Whittier Street Health Center. After six years in Boston, I was ashamed that I had never really been in the neighborhood before — nor had I been to a clinic like Whittier. Inside, I saw signs written in Spanish, Arabic, and Yoruba . Ninety percent of patients are ethnic minorities, the largest proportion being black. More than half are below the federal poverty limit and more than a third have no insurance.
This was a partitioned population that carried a disproportionate burden of illness, yet the clinic had adopted ways to reach out to them. A medical team frequently traveled to Roxbury housing developments. A gym downstairs was kept open late at night so that patients could exercise whenever they had some time. And every Thursday patients would come to the clinic’s garden to learn how to grow and cook their own vegetables.
One of the best ways for us to improve relationships between doctors and disenfranchised patients is simply to recognize that racial preconceptions continue to affect clinical practice, even if it’s not intentional. Repairing these relationships means increasing exposure between the groups. But such opportunities, even in medical schools, are still not common.
If we don’t build these kinds of bridges, we’ll continue to see enormous gulfs between the health outcomes of blacks and whites in our city and others. The average life expectancy in Roxbury, a Whittier clinician told me, is around 59 years. A few blocks away in Back Bay, near where I practice, it’s 84.
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