Black and Blue. John Hoberman
students the “psychiatric clues” that emerge during physical examinations. “The assumption that the racially alien patient must look ‘different,’” he says, “leads to diagnostic oversights quite as often [as] does an unawareness of genuine racial differences.” Uncertainty about the thin calves of a South African tribesman or the scanty pubic hair of Indian patients could lead to false diagnoses. He points to a syndrome he calls the “'tactful' reluctance to examine closely the most distinctive portions of a racially alien patient's body.” The small healed scars on an elderly black patient elicited no inquiries from “an exceptionally able” white doctor. Similarly, Devereux noticed that the medical students generally avoided “the characteristically prognathous lower half” of black people's faces. This may have been due to a phobic response to a frequently (and viciously) caricatured aspect of “black” physiognomy racists have traditionally associated with the great apes. One doctor did not examine an abdominal scar resulting from an appendectomy because he assumed, in accordance with the stereotype of the knife-wielding black criminal, that it was a razor slash. “I never saw a doctor routinely examine a Negro male's inguinal rings,” Devereux reports, “perhaps because of the myth that a large penis is a racial characteristic of the Negro.”161
More recent evidence described in the following suggests that the hidden (and occasionally overt) complexes and phobias that white doctors brought to the interpretation of the black body in the 1960s continue to affect the behavior of a significant number of doctors today. The tightening of politically correct rules governing racial discourse that has taken place since that era should not be mistaken for a purging of racial folklore from the minds of modern people. Few doctors, David Levy noted in Pediatrics many years ago, “are free of unconscious fantasies about imagined racial characteristics.” His analysis of how the white doctor-black patient relationship can go wrong is still a rarity in the medical literature. Unlike the numerous commentators on racial health disparities who employ terms like “unconscious prejudice” and take the analysis no further, Levy describes specific scenarios that can result from this syndrome. He thereby enters that private domain medical editors have long treated as inviolable. There is, for example, the doctor who overcompensates for his racial feelings by becoming “overindulgent, paternalistic, and condescending.” Then there is the doctor who enters into “a conspiracy of silence” about the race issue with his black patient, in that both “share the view that [ostensible racial] differences are signs of minority group inferiority and to discuss them would be tantamount to discussing a missing limb with an amputee.” Physicians can also be naïve about what counts as maladaptive behavior in the context of the African American experience; for example, suspiciousness that might strike whites as pathological may be justified given the emotional stressors many black people have to deal with.162 The conventions that have determined what can be published in mainstream medical journals have effectively prevented the mapping of this terrain.
African American physicians' observations of how their white counterparts treat black patients have occasionally appeared in medical publications. “It may not be in bad taste,” a black gynecologist wrote in the JNMA in 1920,
to call attention to the young doctor of the dominant race who must get his first practical experience at the risk of our women. All of us who reside in the larger cities are aware of his activities. It is only necessary to say in regards to his efforts that more organs of female reproduction are laid upon his altar, a sacrifice to his ignorance and for the benefit of his training than perhaps ever was sacrificed, as to function, by the ignorant mid-wife or the criminal abortionist.163
Half a century later the future Surgeon General David Satcher described a less destructive, but similarly exploitative, arrangement that put black women's reproductive organs at the disposal of white doctors-in-training. Black patients, he wrote in JAMA, “are frequently exploited for teaching sessions. One black woman related to me that she had had nine pelvic examinations by physicians and students and had never been told whether her pelvis was normal or abnormal.”164
The official publication of the Urban League, which was founded in 1910 as the Committee on Urban Conditions among Negroes, noted in 1924 that in many American localities there was “a prevalent idea among white medical men that all Negroes, especially if they cannot make another diagnosis, have syphilis. This idea is so well grounded that they will often treat as syphilis a case that shows repeated negative blood tests, absolutely lack all clinical symptoms and with an entirely negative history.” Here are the careless diagnostic habits noted earlier by white physicians who mention (but do not quite deplore) this sort of racially motivated neglect. This black author also emphasizes the importance of “the Negro physician and nurse,” since “those of the white race in quite a number of cases look upon Negroes as mere subjects for observation.”165 Here is an early reference to the African American anxieties about being mistreated as experimental material that haunt the black community to this day. The power of the syphilis theme to shape medical thinking was evident the same year in Mississippi; there, medical men were speculating about why they had been unable to find any blind newborns among the black population. “Some doctors say that the Negroes, through generations of contact with venereal diseases, have developed a kind of immunity which protects the new-born baby's eye from the ever-present sources of infection.”166 As was often the case, the imagined racial trait was a protective effect—“a kind of immunity”—that implied black people required less medical attention than less hardy types. As Gunnar Myrdal pointed out most of a century ago in An American Dilemma, “Diseases which are not frequently a cause of death are reported so badly or reported for such inadequate samples that it is almost inevitable that Negroes would appear to be immune to them even if they were not really so.”167
Careless diagnostic habits can still occur when black patients seek treatment. Racial misinformation about blacks and heart disease causes some physicians to regard high blood pressure as “normal” in African American patients. (There are doctors in Europe who regard hypertrophic cardiomyopathy [an enlarged heart] as “absolutely normal” in Africans.168) Disputed assumptions about racial physiology and drugs causes some doctors to believe that certain blood pressure medications do not benefit black patients—a claim that black cardiologists have contested. There are physicians who assume that most black patients are diabetic. Others assume that the painful symptoms of sickle-cell disease are signs of drug withdrawal and refuse these patients the narcotic-grade drugs that can relieve their pain. Antiquated ideas about blacks' immunity to pain manifest themselves in the failure to provide adequate doses of analgesic drugs in hospitals and emergency rooms; the refusal to provide pain relief may also originate in ideas about blacks as drug-seeking or especially prone to addiction. Many gynecologists have automatically diagnosed a black woman with symptoms of endometriosis as having pelvic inflammatory disease (PID), based on the assumption that black women are sexually promiscuous. This diagnosis can lead in turn to the sterilization of the affected woman. “Physicians have been known to diagnose, manage, and make recommendations based on perceptions they acquire from the literature. They have, for example, failed to order appropriate tests to detect macrosomia or intrauterine growth retardation because 'black women are less apt to know they are pregnant early in pregnancy than white women'.”169 Today, it is indefensible to offer medical advice based on folkloric assumptions about what African Americans know or don't know about their health. This practice continues on account of the sheer momentum of traditional racial folklore. We will now examine how the assigning of racial essences to human traits originates and is perpetuated both outside and inside the world of medicine.
FROM RACIAL FOLKLORE TO RACIAL MEDICINE
When modern physicians offer racially motivated diagnoses and treatments, they are participating in a living tradition of which they are unaware, and medical school curricula do little to enlighten them. The fundamental tenet of Western racism is that blacks and whites are opposite racial types, and the most important correlate of this principle is that black human beings are less complex organisms than white human beings. These two ideas, operating together, have created a racially differentiated human biology that has suffused the tissues, fluids, bones, nerves, and organ systems of the human body with racial meanings that over the last century have influenced medical thinking in significant ways. Most of the major human organs