The Perkins Perspective | Reviews | Winter 2014
Review: Racial Disparities in U.S. Health Care
By Christina Childs
Black and Blue: The Origins and Consequences of Medical Racism
John M. Hoberman
Berkeley: University of California Press (2012), 306 pages
For more than a century of U.S. health care, the ubiquitous nature of racial prejudices in American society has informed the diagnosis and treatment of black patients, according to Black and Blue author John Hoberman, a University of Texas professor.
The book’s title alludes to a scene in Ralph Ellison’s Invisible Man when the protagonist enters the street to hear Louis Armstrong singing lyrics: “What did i do ... to be so black and blue?” The prior lines set it up. Armstrong sings, “How would it end ... i ain't got a friend. My only sin ... is in my skin.”
Hoberman, with a doctorate in Scandinavian languages and literature, may seem an unlikely candidate to author texts on the black experience and medical racism in the United States. Yet his earlier books, including Darwin's Athletes: How Sport Has Damaged Black America and Preserved the Myth of Race (1997), attest to his expertise in European cultural and intellectual history with special interests in Sportwissenschaft (the science of sport) and the history of ideas about race.
A Challenge to the Medical Community
But why medical racism? Hoberman, the son of a physician based in the Bronx, was exposed to the negative side of diversity in a health care setting, seeing that some races, more than others, tend to be noncompliant in health care. In Black and Blue, he provides evidence that these gaps in medical care and treatment have a historical context that many physicians and others interested in disparities in health care might neglect.
Beginning with a question posed by the long-time medical activist H. Jack Geiger in 1996, Hoberman asks, “How are we to explain, let alone justify, such broad evidence of racial disparity in a health care system committed in principle to providing care to all patients?” (p. 1). Thus, he interrogates how racial thinking informs how American doctors interpret racial differences and treat black patients.
Yet Black and Blue goes beyond the standard investigations. In Chapter 2, Hoberman urges the medical community to think about the history of the African-American when considering the inconsistencies between black and white health. He writes, “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” (p. 45).
He also identifies two types of medical ideological perspectives informing the practice of medicine: The Medical Liberals and the Medical Conservatives. Medical conservatism is the idea that “medical racism is a minor issue or does not exist at all” (p. 15).
Medical Conservatives tend to ignore the data and consider evaluating doctors on the premise of racial bias as an invasion of their privacy, he argues. Medical Liberals, on the other hand, acknowledge racial disparities in health care, but deflect blame off the medical profession. They tend to believe “bias, stereotyping, prejudice and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.” (p. 15). They tend to render data on disparities as theories, and not fact, and that “further research may be necessary” when considering the information, no matter how abundant. Neither the liberal nor the conservative way of thinking about health care is correct, writes Hoberman, and that cannot be resolved without introspection from the medical community, as well as examining history to identify the reasons for these beliefs.
While Hoberman described how physicians look at the medical world, he also described how they look at patients and the human body.
Stereotypes and Preconceived Notions
One of the most intriguing dimensions of Hoberman’s Black and Blue is the section about stereotypes and preconceived notions about African-descended or African-American bodies in comparison to European-descended or white bodies. These theories draw on theories about either “hardiness” or medical stoicism in formulating theses about why African-Americans fail to participate in medicine, especially psychiatry.
Hoberman posits how this kind of thinking impacts every stage of development from birth to death: “While black children have been hyper visible as presumed victims and sociopaths, the black elderly have tended to be socially invisible …” (p. 81). As one can imagine both hyper-visibility and invisibility have consequences for black health. African-Americans' mortality is briefer on both ends of life in comparison to their white counterparts. The literature points to the social determinants of health, including class, education, and racial prejudice, as well as environmental racism, as contributing factors.
More importantly, medical and scientific racism has consequences for medical abuse and neglect. This question about the role of defamatory racial folklore infiltrating medical practices and medical specialties informs Hoberman’s inquiry. The idea 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 project” (p. 24).
On the other hand, some doctors believed that organs and tissue of the human body (including eyes, heart, skin, teeth and muscles) result in immunities, and weaknesses of the human body. In competitive sports, such as football, blacks were regarded as “Indestructible and thus immune to injury” as recently as the mid-20th century. The belief that blacks had more effective muscle mass and a high pain tolerance than whites led to this inaccurate conclusion. One can imagine how these ideas emerged in American slavery and persisted through myths in competitive sports and other areas.
All these different forms of racial thinking had one overarching consequence, according to Hoberman: The American medical establishment never mobilized on behalf of a medically traumatized African-American community.
An important and poignant dimension of Black and Blue is Hoberman’s thoughts and advice on improving race relations between doctors and patients. “First, medical students entering the profession should understand the value system and social dynamics of the medical world they have entered” (p. 218).
This includes, he adds, informing medical students about the history of medical mistrust in the black community, addressing and identifying medical racism within the physician community, and learning from African-American physicians about learning to work with African-Americans in a health care setting to avoid tension between black and white doctors.
As an African-American premed student ― who has participated in the American health care system ― I found Black and Blue accurately identifies and explains the cause and the state of medical mistrust in the indigenous black community, writ large. From the vantage of my and my family’s personal experiences, many of Hoberman’s conclusions seem to be correct. This book has helped me further understand why there is a large disparity between black and white in health care. And this book should be read by anybody interested in medicine or race relations in the United States. Black and Blue serves as an excellent source for why the two topics are so closely related.
Christina Childs was born and raised in Minnetonka, Minnesota. A freshman, she is studying biology at Seattle Pacific University, and intends to become a medical examiner. She likes to listen to music and explore Seattle on the weekends.
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