You can’t ask your co-worker for narcotics the same way you can ask for extra Advil stashed in their purse or backpack. There are good reasons for this. Drugs like Advil or Tylenol carry little association with danger and can be easily bought at any local drugstore. While they are perfectly good for minimal pain relief from headaches or muscle soreness, they are underequipped for addressing major sources of pain. In comparison, opioid narcotics are serious painkillers. They carry risk of addiction and overdose, and can only be accessed with a physician prescription.
Now imagine you break your arm or leg, and the doctor in the emergency room prescribes you Tylenol.
To be clear, long bone fractures are often used in scientific studies specifically because they are always excruciating, and there is little range in the variation of patient pain. Breaking your leg or your arm hurts a lot, no matter how it happened.
Now if that broken bone is beneath black skin, the attending physician doing your initial work up and admittance exam is twice as likely to prescribe Tylenol for your fractured leg, and is twice as likely to prescribe opioid painkillers for the broken leg of the white patient next to you. In fact, in comparison to a white patient, a black one is half as likely to receive any sort of pain medication during an emergency room assessment of a broken bone.
These statistics are not rare. African-American children are more likely than white children to be suspended from school or diagnosed with vague, psycho-behavioral ailments such as “oppositional defiance disorder.” Antipsychotic drugs, as opposed to counseling or therapy that look into child behavior as a fixable issue rather than a pathology, are prescribed four times more often to children covered by Medicaid as to children covered by private insurance. This issue of class intersects with race and disproportionately impacts children of color. Black and Hispanic patients are less likely to be prescribed opioid pain medications that carry higher risk of abuse, trafficking and addiction.
Pain and mental illness especially cannot be measured by pricking your finger or stepping on a scale. In the absence of quantitative measures, it is ultimately physician judgment that will determine how to treat a patient. Physicians, however, do not render their perceptions within a vacuum. The cultural makeup of America inevitably shapes physician perception of patient moral and social character, which is not unrelated to the doctor’s formulation and judgment of that patient’s medical issues.
These same perceptions of moral and social character explain why black men are more likely to be jailed for drug charges that white men more frequently commit, why in 2014 more than 80 percent of New York City stop-and-frisk suspects were people of color despite their constituting less than 30 percent of the local population, and why a young unarmed man can be shot in the middle of the street and left there for hours.
The August 9 shooting of 18-year-old Michael Brown in Ferguson, Missouri is a recent and tangible illustration of how systemic racism operates and impacts the perception and treatment of black bodies. Although Michael Brown’s death is generally understood as a political issue, it also illuminates current conditions of health care inequality. While issues of medicine and politics are often cast as different and discrete social and scientific realms, analysis of health care demonstrates that medicine is, at its heart, also a political issue. Indeed, the events that have unfolded in Ferguson have everything to do with why people of color in this country lose their health and lives at staggeringly higher rates in comparison to their white counterparts. Health care inequality cannot be understood outside the context of systemic racism. The understanding of Michael Brown’s death as a function of institutional oppression helps to explain why individuals proclaiming an interest in medicine or health care disparities should have their attention focused on Ferguson. While the landscape regarding Ferguson is heavily dotted with scholars, civil rights leaders, politicians and journalists, attention from health care providers has remained largely absent. Just as the shooting of Michael Brown has helped the larger public recognize how the US criminal justice system is racially biased, analyzing the event’s foundations in institutional racism invites parallel scrutiny of our health care system. These same racial factors explain why both the American criminal justice system and the American health care system continue to produce extremely racialized outcomes despite both being supposedly and superficially race neutral. Our institutions are susceptible to the same vulnerabilities.
Ferguson helps us understand the racial climate that allows injustices to exist under seemingly race-blind policies. It is impossible to imagine a situation in which an unarmed white woman raising her hands in surrender would be shot by a police officer multiple times. This simple acknowledgment begs a number of questions about the structural forces that equate black individuals with criminals. Michael Brown, as an unarmed individual standing several feet away from pursuing officer Darren Wilson, could not have been seen as a threat in any instance except one where his identity as a black male had been previously framed as an inherent menace. Why are criminals so often imagined to be black men, and how does this conception create conditions in which unarmed black men can be shot on the street? Systemic racism is at the foundation of the forces that package and stereotype young black men, that turn “blackness” into a pathology, and overall so greatly impact our systems’ abilities to care for, adjudicate, and see populations of color.
Michael Brown’s body was attacked in the abstract before he was shot, it was attacked physically on the afternoon of August 9, and it continued to be attacked in the days and weeks following. In the days after the shooting, Bill Maher dubbed Brown a “thug” and a “criminal,” while The New York Times suggested he was “no angel.” Multiple media news outlets mobilized classic black tropes and labeled Brown as a “gang member,” a “hulking thug” and a “ghetto rapper” with no consideration of why such descriptions, true or false, were relevant to the events surrounding his death. The controversy surrounding Michael Brown’s character is further evidence of a system that unjustly scrutinizes certain identities. The injustice in question was an unlawful shooting situated in a culture of police brutality, and yet public conversation often involves Brown’s history as if it could justify Darren Wilson’s actions, as if a supposedly moral evaluation can validate a legal one. These perceptions of Michael Brown demonstrate the kind of value judgments and stereotypes structural racism continues to foster. There are thousands of 18-year-olds of every race who smoke, rap and drink, and yet it is so much more often young men of color that are presupposed as “thugs” and threats to society.
The cultural biases that led Officer Wilson to shoot Brown permeate our culture, and this culture does not cease to exist within medical schools and inside hospital wards. Inevitably, these biases influence the conditions in which doctors shape their decisions regarding diagnostic recommendation, treatment prescription, and patient understanding. Essentialism, the oversimplified assumption or perception that certain populations have congruent values, behaviors, or tendencies, is a major operation, contribution, and byproduct of racism. Essentializing young black men, and indeed any and all populations, creates barriers to equal care and access by influencing the way doctors understand, listen, see, and treat their patients.
This manifestation of institutional oppression folds directly into racial profiling. Black patients are still associated with sickle cell anemia despite evidence that shows rates of sickle cell increase in all geographic areas with high prevalence of malaria, including Greece, Turkey, and India. Gay men are still prohibited from donating blood because of a historical association with HIV and AIDS. Asian women are still targeted in abortion clinics because of presumptions regarding cultural infanticide. Assumptions of patient character or capability impact medical practice by casting patients in roles that doctors expect them to fill. Systemic racism explains why doctors may assume black patients are more likely to exhibit drug-seeking behavior and exaggerate their pain. It explains why physicians may unconsciously presuppose black patients to be too irresponsible to self-administer addictive opioid drug treatments, have higher predisposition towards substance abuse, or require antipsychotic medication. It explains why we cannot create solutions to health care disparities without recognizing the ways in which systemic racism prevents equal quality and access to health. The prejudices on display in Ferguson can just as readily be found in the waiting room.
At the center of this issue is a startling fact: if the life expectancy of African Americans in the United States equaled that of their white counterparts, there would be 83,750 fewer black deaths a year. In certain cities, one out of three black deaths would not have occurred if black and white mortality rates were the same. Black infant mortality is two-and-a-half times higher than it is for whites. Black patients are less likely to be put on transplant lists, receive aggressive cardiovascular intervention, and receive hip fracture repair; yet they are more likely to receive lower limb amputation as result of delayed care. The statistics are as jarring as they are extensive. Again and again, studies show that even when controlling for income, occupation and education, African-American citizens receive lower quality care.
To me, this circles back to issues of medical education. While medical knowledge is heavily rooted in the biomedical model, the provision of health care needs to explicitly address the social context of medicine. It is not productive to be “race-blind” in a racist society, and we need to directly address issues of race within health care if we want to make progress. For those interested in health care disparities, the events in Ferguson should not be seen as a peripheral current events issue, but rather an increasingly important platform by which we can better understand how and why racial inequalities continue to exist. The shooting of Michael Brown remains a primary access point in assessing how racism dictates not only racialized health outcomes and access to care, but also one’s ability to receive equal treatment and quality of care in the context of personal, and thus physician, bias. Questions about health care access, policy, insurance and care quality are very much discussions of human rights, dignity and citizenship.
Health care professionals need to be more critical of the ways in which individual perceptions shaped by systemic racism often leak into practice. The unconscious formation of these stereotypes is dangerous because they often remain unacknowledged and are thus extra insidious by virtue of their subtlety. The doctors prescribing Advil to black patients in lieu of the opioid painkillers they are more apt to give their white patients are likely not trying to discriminate — their decisions may be imperceptibly influenced by inclinations they cannot name or identify succinctly. Similarly, Darren Wilson perhaps did not make the conscious decision to attack Brown in a way he would not have pursued a white individual, but he learned and lived in a society in which being black divorces one from “angelic” qualities and can apparently warrant suspicion and six bullet holes. These issues do not revolve around the isolated mistakes of individual doctors or policemen, but rather systems that are structurally unsound. It is not a question about bad apples, but tainted soil. Implicit biases exist even in people, and doctors, who are vigorously anti-racist. Understanding the legacy of systemic racism helps us to recognize the ways we ourselves may be complicit in structural racism by virtue of acting within a system that is structurally designed to give lower quality health care to the people who are most disempowered and marginalized. At the end of the day, while recognizing institutional forces can help explain widespread inequality, institutions are run by people, and until we allocate greater responsibility and accountability to the people who perpetuate this issue, this problem will never be solved.
Michael Brown’s death is one symptom of the sickness systemic racism produces. Like symptoms, it decries a larger problem and prompts us to search for its root cause, and the breadth of its infection. The public often extrapolates that medicine, as an extension of science, is an objective, factual practice. Even as medical students, we learn in our textbooks the histological characteristics of cells, the mechanisms of glomerular filtration, pulmonary measurements, biochemical pathways and diagnostic tests used to identify symptoms and syndromes. It is easy to presume that medicine is colorblind, and the care we give a rational process. But cells are not people, and science is not health care. Doctoring is an inherently social discipline that revolves around patient-doctor interaction, and the few minutes doctors have with their patients last only long enough to develop snapshot judgments that go on to dictate the diagnosis and care patients will receive. Pretending medicine is a rational exercise denies its role as a social force and allows its continued participation in structural racism to go undiagnosed.
On a case-to-case basis, in which structural racism manifests as higher rates of amputation, fewer follow-ups, less effective pain medication, or preconceived assumptions of ability, it may be easy to assume that the racism that creates health care disparities is not quite as insidious as the police brutality we see splashed across our newspapers and TV screens. The diminished scrutiny the medical system receives by virtue of its reputation as an objective practice, however, makes it harder to see that health care itself is also a primary source and outlet of institutional racism. Michael Brown is one of many victims systemic racism has claimed, and until doctors acknowledge the position of medicine within institutional racism, our health care system will continue to reproduce tragedies like Ferguson, even in the absence of a smoking gun.
For further reading or inquiry, the resources listed below informed the writing of this article.
Betancourt, Joseph R., et al. “Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care.“Public Health Reports 118.4 (2003): 293.
Johnson, Rachel L., et al. “Patient race/ethnicity and quality of patient-physician communication during medical visits.” American Journal of Public Health 94.12 (2004): 2084-2090.
Kawachi, Ichiro, Norman Daniels, and Dean E. Robinson. “Health disparities by race and class: why both matter.” Health Affairs 24.2 (2005): 343-352.
Roberts, Dorothy. Fatal invention: How science, politics, and big business re-create race in the twenty-first century. The New Press, 2011.
Smedley, Brian D., Adrienne Y. Stith, and Alan R. Nelson, eds. Unequal treatment: confronting racial and ethnic disparities in health care (with CD). National Academies Press, 2009.
UPDATE [12/6/2014 at 9:30am EST]: The above references were added to reflect additional research that was used by the author to inform this article. They are included for further study by our readers.
UPDATE [12/8/2014 at 8:00am EST]: A sentence in the first paragraph was changed from “Drugs like Advil or Tylenol carry no association with danger…” to “Drugs like Advil or Tylenol carry little association with danger…” to more accurately reflect clinical knowledge.
Writer-in-Training and in-Training Staff Member
Warren Alpert Medical School of Brown University
The white coat is a scary, scary thing, and I'm still trying to figure out if I should have one. If you like screaming about ethnic rage, dance, or the woes of medical education, we should probably do some of those fun activities that friends do.
I have few answers, many questions. Dialogue is huge. Feel free to email with questions and comments!
