Black and Blue. John Hoberman
and Gynecology during the Twentieth Century
4. MEDICAL APARTHEID, INTERNAL COLONIALISM, AND THE TASK OF AMERICAN PSYCHIATRY
Introduction
“Africanizing” the Black Image
American Psychiatry as Racial Medicine
The Racial Primitive in American Psychiatry
The Task of Black Psychiatry
Colonial Medical Status
5. A MEDICAL SCHOOL SYLLABUS ON RACE
Introduction
The Doctor-Patient Relationship
The Problem Patient
Medical Authors' Aversion to Race
Race and Medical Education: The Search for “Cultural Competence” 207
Two Official Versions of “Cultural Competence”
Physicians' Beliefs about Racial Differences: A (Belated) Study
A Medical Curriculum on Race
Practical Advice for Physicians
Social Class, Misdiagnoses, and Therapeutic Fatalism
“Cultural Competence” as Knowledge of Stereotype Systems
Raceless Humanism: “Medical Humanities” and the Evasion of Difference
Medical Curriculum Change Is Possible: The Case of Abortion Training
Acknowledgments
Like any work of research produced over a long period of time, this book has been made possible by the efforts of many people and institutions. Much of the research was done at the Francis A. Countway Library of Medicine at Harvard Medical School, the John Crerar Library at the University of Chicago, and the Life Sciences Library at the University of Texas at Austin. I am grateful to those who have built and maintained these wonderful collections. This work has benefited greatly from years of classroom discussions with the University of Texas students who have taken “Race and Medicine in African-American Life” since 2001; some of their stories are in the book. Many colleagues, friends, and correspondents have generously contributed to this project by providing information, ideas, invitations, introductions, good conversation, and comments about the manuscript. I would like to offer my special thanks to Rachel Brown Ater, MSW, Carl C. Bell, MD, Deborah Bolnick, PhD, Khiara Bridges, PhD, David Broad, PhD, Robert Eisenberg, MD, Adriane Fugh-Berman, MD, John Hartigan, PhD, Edward Havranek, MD, Crystal Hlaing, MD, David Hoberman, PhD, Eric P. Hoffman, PhD, Michelle Holmes, MD, Joel Howell, MD, PhD, Sherman A. James, PhD, Shannon Jones, III, MPA, Jay Kaufman, PhD, David J. Malebranche, MD, Jonathan Marks, PhD, David Morris, PhD, Thomas Murray, PhD, Robert S. Schell, MD, and John Valentine, PhD.
This book was made possible by Stan Holwitz, former Associate Director of the University of California Press. Stan's belief in the importance of investigating race relations in American medicine never wavered, and I will be forever grateful for his loyalty and support. Following Stan's retirement, Naomi Schneider, Executive Editor for the Social Sciences at UC Press, took on the project and saw it through to completion. I am very grateful for her commitment and tenacity. Thanks also to Stacy Eisenstark, Acquisitions Coordinator; Hannah Love, Associate Editor for Health; and Kate Warne, Managing Editor. Heather McElwain did a fine job as copy editor of the manuscript. I am also grateful to Michael Bohrer- Clancy, Project Manager at Macmillan Publication Services North America, for supervising the final production of the book.
Finally, I thank my wife Louisa for her companionship and her understanding of the research-oriented life. It is a life she has known first hand. During the long years of work on Black and Blue, she inspired me once again by remaking her professional life with a courage and determination I have always admired. It is a pleasure to acknowledge how much she has done on behalf of this book and everything else we are fortunate to have.
1. The Nature of Medical Racism
The Origins and Consequences of Medical Racism
INTRODUCTION
The idea that discredited (and even disgraceful) ideas about racial differences might play a role in medical diagnosis and treatment is a possibility that some doctors find profoundly disturbing. The racially biased treatment of patients would appear to be a grievous violation of medical ethics and a direct threat to the dignity of the profession. Yet, in the course of the last two decades, the medical literature has published hundreds of peer-reviewed studies that point to racially motivated decisions by physicians either to deny appropriate care to black patients or to inflict on them extreme procedures (such as amputations) that many white patients would be spared.1 “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?” the socially active physician H. Jack Geiger asked in 1996. His reply to his own question offered two possible explanations. The first option was to attribute the observed disparity to “unspecified cultural differences” or decisions made by black patients who did not understand that they needed medical care. The second and more discomfiting explanation was, as Dr. Geiger phrased it, “racism—that is, racially discriminatory rationing by physicians and health care institutions.” Confronting the data that he had felt compelled to present to the medical community, Dr. Geiger could not bring himself to categorize the documented behavior of his medical colleagues as racist. Indeed, he added, “if racism is involved it is unlikely to be overt or even conscious.”2 For this conscientious physician, medical racism that implied individual culpability was still somehow unreal, a specter to be exorcized rather than a threat to be acknowledged and confronted.
Black and Blue is the first systematic description of how doctors think about racial differences and how this kind of thinking affects the treatment of their patients. While some fine studies of medical racism have appeared, they have not examined the thought processes and behaviors of physicians in any sort of detailed way. In effect, these studies have not seen fit to enter into the physician's private sphere where specific racial fantasies and misinformation distort diagnoses and treatments. Nor have they shown much interest in identifying the specific origins of racially motivated diagnoses and treatments of black patients that have ranged across the entire spectrum of medical sub-disciplines, from cardiology to obstetrics to psychiatry. It is true that American physicians have been “major perpetrators of racialist dogma,” as a monumental history of American medical racism states.3 Black and Blue moves beyond such general claims about racially motivated medical behaviors and describes how mainstream medicine devised racial interpretations that have been applied to every organ system of the human body.
The studies to date have occasionally noted but failed to describe the oral traditions that convey medico-racial folklore and persist over generations of medical students and doctors. As we shall see, the physicianauthors who have taken the trouble to write about the racial dimension of medicine confirm that the medical profession has never embarked upon this kind of self-scrutiny in a serious manner. Interestingly, the medical profession's lack of interest in confronting the racial complexes of doctors has created little activism among even the most concerned medical observers beyond ritualized expressions of concern. While these white “medical liberals” profess to be “troubled” by this topic, their efforts at raising consciousness have been episodic and have never acquired the political traction that