Black and Blue. John Hoberman
this matter by accepting public apologies and devoting a day to racial sensitivity training. The idea that this behavior demonstrated character defects that might make these individuals unfit to practice medicine apparently did not figure in the process that finally certified them as fit to treat black patients. This incident also raises the question of where cultural stereotyping ends and biological race fantasies begin. Blackface signifies a fantasy of racial transformation, just as cross-dressing signifies a fantasy of gender transformation. These medical students found gratification in taking on the identities of a blind singer, a comical cartoon image, and the generic black female who has traditionally ranked at the bottom of our racial hierarchy. These future physicians regarded playing with distorted versions of the black body as a kind of entertainment. One can only wonder what the experience of public humiliation and a day of racial sensitivity training may have done to temper or redirect their fantasies about black bodies in ways that might serve the interests of the African American patients who will some day consult them for medical treatment.
The most thoroughly documented racial disparities concern the diagnosis and treatment of heart disease, the leading cause of death in the United States among blacks as well as whites. This book argues that the medical folklore about blacks and cardiovascular diseases that was so evident throughout the twentieth century has distorted some doctors' responses to heart disease in black patients. The absence of this historical perspective in the current medical literature demonstrates the naïveté of medical authors who regard racially differential diagnosis and treatment of heart disease as a mysterious phenomenon whose causes have somehow eluded our understanding. Reading our way back through the relevant medical publications on coronary disease will help to clarify the mystery. At this point let us survey the findings about racially disparate treatment of patients requiring therapy for heart disease that have appeared since the late 1980s.
As of 1989 white patients were undergoing one-third more coronary catheterizations and more than twice as many coronary angioplasties as black patients.53 In 1993 researchers confirmed that “white patients consistently underwent invasive cardiac procedures more often than black patients.”54 In a 1996 editorial in the New England Journal of Medicine, H. Jack Geiger expressed deep concern about the unequal treatment of heart disease: “Perhaps most consistent—and most disturbing—are the repeated findings that blacks with ischemic heart disease, even those enrolled in Medicare or free-care systems, are much less likely to undergo angiography, angioplasty, or coronary-artery bypass grafting (CABG).”55 A 1997 report came to similar conclusions regarding bypass surgery; the author called this finding “disturbing, because we also found that they were not due to differences in the severity of disease or to coexisting illnesses.”56 A 2000 report confirmed that “medical therapies are currently underused in the treatment of black, female, and poor patients” who have suffered acute myocardial infarction. “This variation was not explained by severity of illness, physician specialty, hospital, and geographic characteristics”57— possible confounding factors this study ruled out, leaving physician bias as the most probable explanation for why black patients were offered fewer therapeutic procedures. A 2005 survey of racial differences in the management of acute myocardial infarction covering between 1994 and 2002 found that racial differences in care had persisted rather than diminished during this period.58
Racially differential practices have also been found to affect the treatment of early-stage lung cancer. One research team wrote the following in 1999: “Our analyses suggest that the lower survival rate among black patients with early-stage, non-small-lung cancer, as compared with white patients, is largely explained by the lower rate of surgical treatment among blacks.”59 The same conclusion was reiterated in 2006: “Black patients obtain surgery for lung cancer less often than whites, even after access to care has been demonstrated. They are likely not to have surgery recommended, and more likely to refuse surgery.”60 It is historically conditioned fear that causes some black patients to refuse surgery even when it would be in their best interest to consent. The medical literature refers to these decisions as examples of “patient preferences,” as though these decisions to reject surgery were free and autonomous acts on the part of empowered medical consumers. In fact, blacks' fears of surgery persist because the medical profession has never addressed the consequences of its racist history in a way that might reassure African Americans who feel estranged from the medical system.
Heart and cancer surgeries are generally regarded as desirable procedures that benefit patients, and that is why racially differential access to them is unjust. There are other kinds of surgery that are undesirable when better alternatives exist, and here too black patients have borne an extra burden of suffering. The effects of a hysterectomy, for example, are likely to be more of an ordeal for a black woman than for her white counterpart, since “black women are more likely to get the more invasive kind of hysterectomy, which doesn't require a large incision. The vaginal operation is more expensive and harder, and studies have shown it is used more on women higher on the socioeconomic scale.”61 It was reported in 1996 and 1998 that black patients with diabetes and circulatory problems were less likely than whites to have leg-sparing surgery and were more likely to undergo the amputation of these limbs. Yet precisely the reverse was true of a more beneficial type of operation, since blacks were less than half as likely as whites to get hip replacements.62 Here, too, “patient preferences” dissuade some black patients from undergoing hip or knee surgeries because they “report less confidence in the efficacy” of such operations.63 Accepting such “patient preferences” as autonomous decisions is mistaken, since the black patient's lack of confidence in the procedures is an expression of mistrust rooted in a group history of traumatic experiences involving the medical profession.64
Evidence of racially differential thinking by physicians has also appeared in studies of emergency room analgesia.65 Making judgments about doctors' unequal provision of pain relief to members of different racial or ethnic groups is complicated by three related factors—the subjective nature of pain perception, those cultural factors that may influence an individual's response to the experience of pain, and folkloric ideas about racially differential responses to pain.66 Doctors' judgments have been affected by a traditional medical folklore about racial differences in pain sensitivity, in particular the idea that black people do not feel pain as acutely as whites do. “I can find no evidence to support the belief that the Negro does not feel pain as well as the white person,” one cardiologist wrote in 1942, and this assertion made him a dissenter among his peers.67 But historical knowledge of this kind is rare among today's medical researchers. The author of a 1993 JAMA article that found Hispanic patients got less pain relief than whites comments: “The mechanism by which ethnicity influences pain management decisions is unclear.” He and his colleagues, he reports, were now involved in “an attempt to discover whether physicians assess pain differently in patients of different ethnic groups.”68 The abundance of published evidence confirming that physicians for many years have based pain assessments on racial distinctions appears to have been unknown to him. It did not occur to this author to look for evidence of what he was looking for in the medical literature that preceded him. And, even if he had sought and found it, he might have assumed that today's physicians, unlike their predecessors, are too enlightened to think of pain thresholds as a racial trait.
Confirming the likelihood of racially discriminatory behaviors by physicians in a statistically convincing way is complicated and requires controlling for so-called confounding factors. The fact that the diagnoses and treatments offered to black and white patients may not be identical does not in and of itself demonstrate biased judgments or behaviors on the part of physicians. Other factors, such as biological or cultural differences, may account for these discrepancies. Economic and educational status can have enormous effects on health quite apart from how physicians behave. Poverty and illiteracy are powerful predictors of medical problems regardless of a patient's race or ethnicity or of how doctors respond to that person's medical problems. Racially motivated behaviors on the part of doctors may be absent or difficult to identify precisely because they coexist with other plausible contributing factors, such as unemployment or dietary habits, for which doctors do not bear a direct responsibility.
Conscientious physicians and medical scientists acknowledge confounding factors even as they