of “clinician errors” that cannot be blamed on doctors who are the victims of their own “unconscious” biases.44
And what about the effects of the medical school experience on students' attitudes toward patients who are resented for one reason or another? “One of the few areas of universal agreement concerning students' development,” Academic Medicine reported in 1996, “is that medical training can make students and residents more cynical and insensitive.”45But not when it comes to race at Harvard Medical School, these ethicists report. Among the medical students they observed, “political correctness appears to be the normative order in public discussion. Medical students with whom we spoke note they never hear overtly negative racist comments in the hospital or among classmates. This sensitivity is new to the late twentieth-century generation of medical students and faculty in our study area.”46 Yet in the same year the Institute of Medicine volume appeared, another author in Academic Medicine who studied other medical students cites “a derogatory term widely used by students and faculty members to refer to patients from the skid row area of the city.”47 A decade earlier, Academic Medicine had observed that medical students sometimes saw patients as “sources of frustration and antagonism—evocatively recast as 'hits,' 'gomers,' 'geeks,' and 'dirtballs.' They become 'the enemy,' with students feeling justified in their use of negative labels and corresponding behaviors.”48 Are Harvard medical students really immune to the racist banter more realistic observers have noted? The credulity of the Harvard ethicists, who take at face value medical students' assurances about their generation's racial enlightenment, perfectly complements Geiger's dogged resistance to the idea that physicians should be held responsible for racially motivated decisions that derive from unconscious impulses.49
Medical liberals who adopt the exculpatory approach to physician responsibility are in no position to contest the claims of conservatives who argue that medical racism is a minor issue or does not exist at all. The Unequal Treatment report first issued in 2002, the product of a committee chaired by a former president of the American Medical Association, Alan Nelson, is a thoroughly moderate document. The strongest language in Dr. Nelson's speech to the Institute of Medicine on March 22, 2002, reads as follows: “Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care. While indirect evidence from several lines of research support this statement, a greater understanding of the prevalence and influence of the processes is needed and should be sought through research.”50 Here, as elsewhere, medical liberalism was still treating the effects of “stereotyping, prejudice, and clinical uncertainty” as hypothetical, and there is the usual call for additional research, an implicit claim that the medical status of African Americans—and the behavior of their doctors—was still too complicated to understand.
Even this tepid call to action was too much for Dr. Sally Satel, whose response to this document appeared in The Wall Street Journal under the title “Racist Doctors? Don't Believe the Media Hype.”51 The authors' refusal to call doctors racists was irrelevant to this conservative ideologue; the real offense of the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care was to have even considered the possibility that American doctors might be capable of racially motivated misconduct on a scale exceeding the misdeeds of a few bad apples.
One antidote to tentative medical liberalism and obstinate conservative denial is historical knowledge of the relationship between American medicine and the black population over the past century. The publication of a massive history of modern medical racism in 2002, while noted in the press, should have had a greater catalytic effect than it did.52 That it did not shows that historical documentation of medical racism is not enough, because these narratives can easily promote the mistaken view that medical racism was a phase that modern medicine has left behind. Understanding how this illusion has prevailed becomes possible once we realize what modern doctors do not know about the racial attitudes and behaviors of their twentieth-century predecessors. Without this knowledge doctors will be literally unable to imagine their own capacity for racially motivated behavior. They will remain unaware of how the “hidden curriculum” of medical training perpetuates racial folklore that can do harm. They will continue to interpret traits and conditions of environmental origin as evidence of a “black” racial essence. In short, a medical profession that remains unaware of the racist legacy of American medicine cannot even begin to pursue meaningful reform.
The author of this book agrees with the Harvard ethicists that this situation requires “a critical perspective that has largely been ignored by most research to date.” And anyone who doubts that doctors are capable of ignoring entire dimensions of their own medical experiences need only read Jerome Groopman's How Doctors Think. For even as he ignores the race factor in medicine, the author of How Doctors Think has a lot to say about the limitations of current medical thinking. Do doctors' feelings about patients or their social backgrounds affect their thinking? “Nearly all of the practicing physicians I queried were intrigued by the questions but confessed that they had never really thought about how they think.” What Groopman and his colleagues “rarely recognized, and what physicians still rarely discussed as medical students, interns, residents, and indeed throughout lives, is how…emotions influence a doctor's perceptions and judgments, his actions and reactions.” “I cannot recall a single instance,” he says, “when an attending physician taught us to think about social context.”53
No medical culture that is so devoid of introspective activity regarding human emotions and social realities can understand the consequences of its entanglement with America's racial traumas. It is my hope that Black and Blue will enable physicians, and those who study the world of medicine, to understand how our racial complexes have infiltrated medical thinking and practice, and how a disengagement from these complexes might begin.
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
