Race Correction and Inequalities in Medicine

The history of medicine is fraught with unnecessary racialization. In “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body,” Comaroff writes about how the black body became “associated with degradation, disease, and contagion” and how colonial medicine “link[ed] racial intercourse with the origin of sickness.” These overtly racist ideas have decreased in influence over time. However, even today, the remainders of these ideas still manifest themselves in racial inequalities in treatment and access to medical resources, and in the general racialization of medicine, both in the U.S. and around the world.

Smedley and Smedley write about the consistent racial and ethnic disparities in health care in their paper, “Race as Biology is Fiction, Racism as a Social Problem is Real.” They report a series of shocking statistics, which include that Africans Americans and Hispanics in the U.S. tend to receive lower quality health care across many different disease areas, African Americans are more likely than whites to “receive less desirable services, such as amputation,” and that these disparities are “found across a wide range of clinical settings including public and private hospitals, teaching and nonteaching hospitals.…” Similarly, Livingston details a scenario where a patient O (a black man) is expected to endure an incredible amount of pain during a bone-marrow biopsy without making any sounds of pain. When Mr. J (a white man) undergoes a similar bone marrow aspiration, Dr. A holds his hand and the Motswana nurse comforts him. Livingston writes that “his whiteness apparently creates different expectations around his stoicism.” Smedley and Smedley write that racialized science (and any science that looks for differences between racial groups) can only maintain and reinforce existing inequalities. Although many racial disparities in health are also the product of socioeconomic differences, Smedley and Smedley argue that when we accept this concept, there is the implicit idea that these socioeconomic differences are acceptable.

In her recent book, Breathing Race into the Machine, Lundy Braun writes about racial comparisons in lung capacity and about the race correction of spirometers. Since the 19th century, it has been a well-established concept in scientific literature and in the medical community that African Americans (and most other racial groups other than people classified as whites) have a lower lung capacity than whites. Therefore, when doctors measure patients’ lung capacity even today, their spirometer values are “race corrected.” This means that the spirometer values considered “normal” for black patients are reduced, and black patients are not offered treatment or any sort of medical interventions for lower lung capacities than white patients with the same numbers. There are a few issues with this practice.

First, using race to correct for lower lung capacity ignores socioeconomic or environmental reasons for this decreased lung capacity. Often race issues are tied to socioeconomic differences and socioeconomic factors in lung capacity can also be connected to environmental explanations. Neighborhoods with lower socioeconomic status and high rates of minorities have also been shown to have higher rates of environmental pollution. Secondly, there is the issue of whether race should even be considered when taking this kind of medical measurement. When Braun interviewed physicians, they did not have a standardized way of determining race. Some physicians determined their patients’ race by looking at them and others asked patients to self-identify. Modern genomics show that there is more genetic variation within a race than there is between races, so using race as a biological concept seems even more flawed.

In the scene from Improvising Medicine, the doctors expect different things from the black man than from the white man and accordingly treat the two patients in different manners. However, juxtaposing Braun’s work on spirometers and race correction with Smedley and Smedley’s statistics on racial inequalities seems to create a sort of tension. Medical professionals are acknowledging how a certain minority group has worse health than others, but at the same time, they continue to be given worse care in the hospital. Race is one of the major factors in health care inequalities, and it would seem like acknowledging it would help fix this problem. Often, the first step to resolving an issue is addressing the issue and determining the roots of the problem. Nonetheless, the race correction of spirometers seems racist and unproductive in its current use.

It would be incredibly problematic if this type of race correction occurred globally and included other measures of health. Race correction could become a way of explaining structural violence and inequality produced by racial and socioeconomic factors, as well as becoming a method through which further inequalities were perpetuated through the decreased distribution of therapy or other medical interventions to these groups.

 

Discussion Questions:

  1. How do we move forward from simply acknowledging and naming racial inequalities in health to working to eliminate these inequalities (especially if simply making physicians aware of these inequalities doesn’t change anything)?
  2. If race is more of a social concept than a biological one, how productive is it to acknowledge race in terms of medical inequalities?
  3. How can race correction (and other similar viewpoints in the general public or in the medical community) be eliminated?
  4. Thinking about how “normal” is thought of differently (in relation to PTSD symptoms in Liberia, or classifying “normal” around the world), can race correction be justified if it shifts measurements towards the average value of the under-privileged community?

 

Sources:

Comaroff, Jean. 1997. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power and Practice, S. Lindenbaum, and M. Lock. University of California press, 305-29.

J. Livingston. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham, N.C.: Duke University Press.

Shaban, H. 2014. “How Racism Creeps Into Medicine.” The Atlantic. [http://www.theatlantic.com/health/archive/2014/08/how-racism-creeps-into-medicine/378618/, accessed Sept 29, 2015].

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.

40 thoughts on “Race Correction and Inequalities in Medicine”

  1. I would like to say how great this post was. I really enjoyed how you brought up thoughts on racial corrections and mistreatment of minority patients as well as recognizing the colonial history of medicine.

    To sort of contribute to the discussion, I think it would be interesting think about how global health workers internalize these racial metrics into practice when working with communities that are different in environmental, socio-economical, and cultural conditions compared to the US?

    Also, I think it would be great to work through how WHO and other organizations alike standardize these metrics to determine if certain population’s health status especially when thinking about chronic illnesses? Or is their primary focus now to try to alleviate acute infection?

    1. Hi Jack,

      That’s an interesting point. I agree that healthcare workers who are providing care in other countries or to different groups of people will have implicit biases that can affect their work in ways they may not even realize. I wonder how much the cultural competency being taught in medical school can change these hidden biases.

      I definitely believe the WHO should be working to decrease both chronic illnesses and infectious diseases. I think we need to look more at the dichotomy between defining diseases and symptoms differently based on the region/group of people (which makes sense to me with the PTSD example) and setting “normal” values based on race (that could eventually hinder treatment). Where do we draw the line here?

  2. Hey Methma,

    You make a great point that internalizing and accepting racial inequalities in health can lead to the mistreatment and perhaps even misdiagnosis of minorities. When doctors have assumptions based on race and ethnicity of minorities, their diagnosis can be biased and lead to misdiagnosis and lower-quality treatment for those patients.

    Going off of Jack’s question, I think it’s really hard for global health workers to completely eliminate the bias resulting from the racialized medical measurements and assumptions, especially if medical instruments are built to be “race correcting.” When volunteer organizations visit low-income countries to try to help improve the health care there, there is a readily apparent power dynamic between the volunteers offering medical treatment and the patients seeking treatment. The patients of the low-income countries are vulnerable to misdiagnosis and mistreatment, especially since most of them do not have access to education to help them become health literate to know about the latest medical advancements. With this underlying dynamic between the health workers and patients, the volunteers may unintentionally be providing less-quality treatment than they would if they were treating White patients, for instance, even with the best of intentions.

    In the ideal situation, global health would consist of each individual being treated for his/her discrete symptoms, rather than getting “personalized” medical care that is actually based on race, whether it be self-reported or determined by the patient’s appearance. I personally don’t believe race correction is justified in any situation, since medicine should be individualized based on each person’s symptoms and, in more technologically-advanced situations, genomics, not based on the racial or ethnic group a person identifies with.

    1. Hi Yuki,

      Thanks for your comment. I agree with your first point – especially with the recent popularity of “voluntourism,” it is hard to avoid these (sometimes problematic) power dynamics.

      About your last point: I am curious to see how you propose using genomics for diagnoses? Do you mean looking for genetic markers of disease?

      1. Hey Methma,

        Yes, I was referring to the personalized medicine based in genomics and customizing treatments and predicting disease risks based on a genomic screening process. I’m sorry that wasn’t clear.

  3. Hi Methma,
    I found your blog to be very interesting and it tied many of the readings together in a useful fashion. I think what you wrote about is something that needs to be more widely acknowledged and dealt with. While doing these readings, I was appalled to learn of the stark differences between blacks and whites, especially in a society when everyone should be well informed of these discrepancies.
    To answer your first question, I think it is important to acknowledge and address these issues. However, it has proven that that is not enough. Actions need to be taken. First off, I think that these issues should be recognized by politicians, as they influence the health care system greatly. If an issue like this is brought to the attention of the government, there should be absolutely no reason for them to not take action. I think it is crucial for all physicians to be aware of this serious inequality. The more aware that physicians are of this inequality, the more likely it is to be changed. I don’t think this will be a quick process, but I think it needs to start somewhere.
    To answer your second question, I think that it is very important to recognize race in terms of medical inequalities. Nobody should be burdened with lack of medical resources based on the color of their skin. Medical inequalities should be nonexistent. While that is the ideal situation, the current world makes that seem somewhat unrealistic. However, it is crucial to acknowledge this, because the more people that know about it, the more people can help fix it.

    1. Hi Julianne,

      Thanks for your comment. I think politicians advocating for health equality is a great idea. Perhaps this is another grassroots movement (like those Paul Farmer discusses) that should be more active in our time.

      I agree with you that spreading knowledge about racial healthcare inequalities if important. I’m curious as to what you think of the fact that it was this knowledge that led to these race correction practices. Do you think more of that will occur if more politicians and physicians were aware of the inequalities?

      1. Hi Methma,

        If the government could intervene and become a prominent role in reducing the oppression that several racial groups experience, there would be better health equality globally. However, as you mentioned, it is possible for more race correction practices to occur with greater awareness of this issue.

        Race correction practices can have many setbacks, as they classify racial groups to be medically homogenous. However, with the right approaches, intellectual studies and advice, politicians and physicians can understand potential unintended consequences, and rather create solutions to all of the problems surrounding these issues.

        1. Hi Julianne,

          How do you suggest dealing with politicians who don’t seem to see or understand the current race issues in America? Is it the duty of physicians to advocate for health equality? And how would we make sure that this intellectual advice doesn’t lead to further unfavorable practices like race correction?

          1. Hi Methma,

            To start, the politicians who don’t recognize or understand the current race issues in America should not attain high roles in government. (They should not be voted in if they are unaware of this serious issue, in my opinion.) I do believe that physicians should advocate for health equality. As should everyone else. If more and more people advocate for health equality, then more awareness and potential solutions will be created. What do you think about this?

          2. Hi Julianne,

            I think that would be the ideal situation. However, I believe Trump – especially in relation to what he said just tonight about barring Muslims from the US – is proof of how people who do not accept racial tensions (or religious differences) can garner widespread support in political elections (based on the current polls). I agree with you that increasing advocacy and education of health inequities (and the need for advocacy) are important goals to strive towards.

  4. Hello Methma,

    You’ve certainly presented a very balanced insight into the influence of patient race in a physician’s quality of and approach to providing care. I wholeheartedly agree with you that acknowledging race is a double-edged sword. Recognizing that certain racial minority groups have poorer health outcomes is important, and more resources should be allocated to basic research that delves deeper into why this is. At the same time, this system of using racially relativistic lens of practicing medicine (like through the race correction of diagnostic instruments and techniques) clearly creates an system in care that sets lower standards for what is “healthy” for certain minority groups. Intrinsically, such a system delivers inadequate care to its patients and creates stark racial inequities in health.

    Another salient example of the unequal treatment of patients based on racial differences can be observed in the prescription of pain medications. We’ve discussed in class how certain groups may wrongly be labeled as having higher pain tolerances than other groups. As one group found, African Americans are less likely to receive pain medications than White Americans even in instances when they demonstrate low pain tolerance (http://journalofethics.ama-assn.org/2013/05/pfor1-1305.html), further elucidating how the issue of racializing care is deeply rooted throughout health care field.

    I think eliminating these inequalities has to go beyond making physicians and other health care professionals aware of the existence of these disparities. In theory, since physicians undergo various forms of training in order to be fully licensed to practice, an aspect of this training should involve prospective physicians undergoing evaluations that make them self-aware of their own inherent racial biases. While it is important to acknowledge disparities in health outcomes across different racial groups, this cannot and should not be used as a justification for different standards in care.

    1. Hi Sachit,

      Thanks for your comment and the article link. I am constantly astonished at how these old, stereotyped ideas of “African resilience/stoicism” and other misinformation still manifest themselves in inequalities like it was described in the Pain and Ethnicity article.

      I think your idea of physicians undergoing a cultural competency evaluation is really interesting. At the end, it mentions “increasing education and training of health care professionals on these topics” and I believe there is a movement towards teaching more cultural competency in medical schools than ever before. I’ve seen quite a few cultural competency self-assessments but I’m not sure how prevalent these are in medical schools around the country. From the viewpoint of one whoe isn’t in the medical school/healthcare provider sphere, a lot of cultural competency training seems at least a little self-motivated. While this is a step forward, I think medical schools need to work on increasing their cultural competency education until these inequalities and possible sources of discrimination start to significantly decrease.

      1. Hi Methma,

        I share your sentiments. In fact, I actually had a similar discussion with Jacob on his blog post. Personally, I think that cultural competency and sensitivity training should begin even before one has reached medical school, perhaps as early as during one’s undergraduate education (thereby targeting pre-med and public health students). To me, the earlier start to cultural sensitivity training increases the likelihood of future doctors and community health workers internalizing the need of approaching their work with a more culturally relativistic lens.

        1. Hi Sachit,

          I think that sounds like a great idea and I agree – it is never too early to start cultivating an accepting mindset/worldview that will lead to (hopefully) fewer inequalities in the future.

  5. Hi Methma,
    Thank you for your insightful blog post. You have brought up a subject that needs acknowledgment and solutions.

    I think it is extremely productive and essential to acknowledge race in terms of medical inequalities. Race may not be a biological concept, but the fact that it is a social problem means that it creates very evident social and biological effects. To acknowledge race is not racist, but not to acknowledge race is. Recognizing that people are of different races is essential to providing them proper care; exploring racial backgrounds provides an opportunities to perceive need and to improve care. It does become an issue, however, when race interferes with the standards of care given to a certain population, as you mention with race correction.

    Working to eliminate these inequalities is obviously a daunting task because of the fact that the medical institution is embedded in various, complex, and interconnected social structures. While having healthcare professionals and the public recognize inequities is key, I think that taking the step to listen to those being oppressed is even more important. When people are not part of certain communities facing equalities, they, as outsiders, cannot truly understand what is best for these communities (regardless of how much education they have received). What is important is working WITH these communities rather than just FOR these communities. Perhaps what these communities want is specialized care for the needs that they face as a community; this comes from introducing health care professionals who understand their experiences and cultural values. In addition, medical information needs to be made more accessible so that people can better understand their health needs and know how to talk about them with a doctor. Doctors have a lot of authority, and in order to avoid a power dynamic, it is important for people to have the agency to voice their concerns and advocate for their health needs.

    1. Hi Nini,

      Thanks for your comment. You’ve teased apart the issue with acknowledging race in general vs. race in treatment really well and I agree with you that we should work with these communities instead of for them. Another point I would add to your plan of of making medical information more available is that I think we should work on making higher education more possible for the lower socioeconomic classes (which often overlap with minorities), so that there are more doctors who have the cultural experiences of the people they are treating.

      1. Methma,
        You’ve brought up an incredibly important point with which I completely agree. Obviously all health professionals should make it a point to understand the individual backgrounds of their patients (although, I know this would be considered “inefficient” in many healthcare companies/HMOs/hospitals, etc.). But, as you indicated, the people who can best understand and empathize with oppressed communities are those who come from oppressed communities. It is therefore crucial that we work to make higher education possible for those communities. Thanks for making that point clear!

  6. Hi Methma,

    Like a few people mentioned in the above comments, I was also quite shocked by the drastically different standards of care given to people within the same community solely based on physical appearance or self-identified race. We mentioned in class about how socioeconomic status and perceptions of race are interconnected–that one leads to another in an endless cycle that began with colonization. If we think about who had the power in history to have a voice, we can realize that the racism that ensued has led to the unequal quality of health care today.

    Through your multiple examples, it is clear that using race corrections or making assumptions based on race ignores a plethora of factors that can contribute to the individual being treated. I think Yuki makes a very valuable point about treating patients based on their individual experiences and symptoms, because that is a way of avoiding assumptions or “corrections” based on appearance. Misdiagnoses and fatal mistakes can be made through grouping people together, even when it is simply because people with the aim to help are misinformed. Those who are studying to become doctors or training to be volunteers should be explicitly taught about the idea of race and how treating people on this notion should not be acceptable. This would require reforming medical education itself, but bringing this into awareness could make a huge impact on how the entire world views race.

    I know that many people–when talking about race–are confused, because it is evident that people are different. There is no doubt that different people will react to treatments in a variety of ways, but I believe that only genetics and genetic screening should be used if we want to examine factors such as susceptibility to malaria. These biological factors are valid, and are also specific to individuals, because it allows us to analyze environment, geography and history of illness on a strictly biological level. It is much more accurate and can erase the risk of fatal assumptions.

    The idea of normality is one that is difficult to grasp, because normal can be interpreted differently, not only on a national level, but also on a community or even individual level. Thus, shifting “normal” measurements based on an average in the community is still a poor means of establishing treatment.

    1. Hi Thu,

      Thanks for your comment, I agree with a lot of your points. Do you have any ideas on the most effective ways to bring awareness of these ideas into the medical practice? You talked about how those who are studying to become doctors or training to be volunteers should be taught about race and how treating people on this notion should not be acceptable. I wonder whether there is a good way to do this, without furthering ideas of currently existing racial inequalities as natural or self-evident or unchangeable, which could lead to race correction, for example.

  7. Hi Methma,

    The questions both you and Jack raise about race correction and biases learned by doctors in medical school and in their own countries really underpin the issues of medical inequalities and how they can be solved. Colonialism and the residual effects of slavery have left lasting effects on people all over the world. Unfortunately we are still dealing with these effects both in the US and in other countries as evidenced by this very topic we’re discussing.

    I found another article discussing issues with race correction in spirometry in research conducted at Brown (https://news.brown.edu/articles/2013/06/spirometers). I think this article illustrates that we need to actively critique and challenge current medical practices and teachings to make progress in alleviating the health disparities among races rather just acknowledging that these issues are present as you address in your first question.

    1. Hi Zelda,

      Thanks for your comment and the link to the article – it looks like that came out just before Braun’s book (and the article I used) was published . It is hard to believe that (as the article states), when it was found that most groups non-white groups had a lower lung capacity than whites, “a majority of papers explained difference as either innate or due to anthropometric factors with about 23 percent citing environmental factors.” The study also found that hardly any of the papers (6%) looked at socioeconomic factors, something that we know is tied very closely to general health and health inequality.
      Do you have any ideas of how to challenge current medical practices and teachings in order to actually make a difference in alleviating health inequalities?

  8. Hi Methma-

    You brought up several great points and highlighted some of the most interesting, surprising, horrific things I learned from these readings.

    I’ve always wondered about the first question you raised. As a concentrator in public health, I am used to seeing shocking statistics about mortality and morbidity differences between races. The expected pain tolerance differences in the Livingston book was a completely new point that I had never heard of before. Does knowing that a problem exists in terms of racial inequality in health really do anything? I’m not so sure. I think I agree with Yuki that in order to combat these racial inequalities, we need to be treating patients on an individual basis according to their individual needs and not according to racial standards that have been set as the ‘norm’ (I hope that makes sense). I think it’s important to know that these inequalities are there, but I don’t think that we can stop with simply education. Instead we need to take that information, and know that since there is no biological base to race, that the way we treat patients’ biologies should not have anything to do with race but instead should be solely based on their biological symptoms, sicknesses, reactions, etc. As I mentioned before, this practice of race correction is really new to me, so I am not sure I best know how to eliminate it or justify it. To me, it doesn’t seem justifiable at all, but it is a really interesting point that if it shifts measurements towards the average value of the underprivileged it might not be a bad thing. This is something that we discussed a bit in section in terms of grant writing–if something is exaggerated or altered from the true reality of what it is, but these exaggerations/inaccuracies end up creating medical interventions that benefit the underprivileged, is that morally/ethically wrong or is it right?

    I don’t really have an answer. Part of me thinks that of course race corrections are horrible because they’re not biologically justifiable and are simply not the biological reality. However, as someone really interested in improving health for those who are the most negatively impacted by it, using these standards to actually improve health of those that are the least healthy, isn’t such a bad thing either…

    These are great, and also very difficult questions. I’m not sure what the right answers are. I have heard arguments for saying that health outcomes can’t be based on race because race isn’t biological. While I agree with that statement, I think that there are impacts that race has on social factors that then impact health, so it is impossible to say that there isn’t an association or that race doesn’t impact health. I think that it is wrong to deny these associations because to start any sort of change we need to acknowledge this problem.

    1. Hi Rebecca,

      Thanks for your comment! I think you verbalized a lot of the struggles with race correction well and I agree that we need to do more than simply being aware of the problem (although I believe this type of education is always a good start). Could you elaborate a little more on what you were referencing with the grant writing scenario? I think publishing inaccuracies as fact is not ever morally acceptable, but I also believe that the current health inequalities do manifest themselves in some very shocking statistics. It seems to me that if more people knew about these inequalities and more people felt the need to fix them, the current standings would be more than enough to spur them to act. For me, the question then becomes, how do we get people to act once they acknowledge that a problem exists?

  9. Hi Methma,

    I really enjoyed you blog post and how it touches upon racial inequalities in health care, which is a sensitive and common subject. I found it so shocking to see how many racial and ethnic minorities receive lower quality of health care because of their background.

    Concerning your first and second question, I think that although we have made a lot of progress in the medical field, the health inequalities among minorities is still a very prevalent problem many people have to face every day. Although many people are aware of it and acknowledge that it is happening, it might be difficult for some people to completely eliminate that bias during the treatment of their patient. One way to move forward might be for the health community to acknowledge the situation and try to change by talking to the health workers and emphasizing the treatment of people individually based on their symptoms without looking at their racial and ethnic background. Although this could reduce the amount of bias minorities experience, I do not think that it will eliminate it entirely. Because race is has now become more a social than biological concept, I think that it plays a very important role in medical inequalities. I find it unfair that this concept of racial difference causes people to get different treatments and diagnostics based on the color of their skin.
    I think that all your other questions are very important and interesting but also very complex. Although I really hope that imposing measures in health systems will decrease racial correction, eliminating racial inequalities entirely might be a very long and complex task.

    1. Hi Claire,

      Thanks for your comment. I agree that it is very unfair how race can change how one is treated in a healthcare setting, when the patient is at their most fragile state. How do you think the healthcare community should talk to its providers, like you brought up? Do you think the WHO should mandate a cultural competency kind of training or should that be up to individual countries or individual medical schools and practices? And what other kinds of measures on health systems would you put in place (that you mentioned at the end of your comment)?

      1. Hi Methma,

        As we have seen throughout our classes and readings, I think that it is very important for the healthcare community to emphasize the importance that doctors need to take the individual background of each patient into consideration when treating him or her.
        I do think that having each individual country mandate a cultural competency kind of training would be the best option. As we saw in class, each country has a different culture and views interventions differently. Therefore, I think that having the WHO set up these regulations would be too difficult and would ignore the cultural and local diversity each country experiences.
        I also think that increasing awareness and education in these communities are another way to possibly reduce race inequalities.

        1. Hi Claire,

          I definitely agree that it would be ideal for each country to set up their own cultural competency training. The only reason I suggested the WHO is because of a possible lack of funding or motivation (in the face of other pressing needs) to do so. How do you think we could get every country that needs these kind of regulations to set up this kind of training/manual?

  10. Methma, I thought you presented a well-rounded argument on a topic not often talked about. This dichotomy between recognizing medical inequalities people of minority races face and trying to eliminate “race correlation” is a hard point to tackle. On one hand, it’s important to acknowledge that African Americans often receive lower quality care and have worse health outcomes for many diseases, but also that because of this, the standard of comparison (as for things like lung capacity) should not be different from that of a white person.

    Race is not a biological concept, but a social one. Yet, most people still think of it as a biological concept; people of different races are vastly different from each other biologically, socially, and therefore medically. Since race is a social concept, however, it may not be productive to acknowledge racial medical inequalities. But how do inequalities then get shown? How are rights for minority groups advocated if there aren’t statistics for people to see? (as statistics is what creates change in this world) So, how productive is it to acknowledge race in terms of medical inequalities? I don’t think I have a definitive answer for that.

    I do think that it is difficult to point out internal racial biases. Sachit brought up a wonderful idea about creating an evaluation of self-awareness of inherent racial biases. It’s hard to point out to people racial biases if they’re not of that race. There’s a social experiment, where people in the room with Brown eyes are treated better than people in the room with Blue eyes. Over the course of the time, the brown eyed people buy into the experiment and start to say why they’re better than blue-eyed people. I wonder if something like this could be adapted in a broader context to teach about racial biases and why they’re still around. http://www.janeelliott.com/ (Here’s a website where you could find more info if you’re interested.)

    1. Hi Katherine,

      Thanks for your comment and bringing in the Blue Eyes/Brown Eyes social experiment. I’d read about that experiment before but never thought of it in the context of teaching about implicit biases, race, and health inequality. That sounds like a great idea. I also agree with you that statistics are very important for spurring change. I think people need to see things as they currently are and see the extent of an issue, to find the drive and desire to change inequalities.
      Secondly, this type of cultural competency/racial biases education is incredibly important, but if it is accomplished in the wrong way, it could be ineffective (or less effective than its potential). Showing healthcare providers examples of inherent racial biases and how easy it is to create them – through examples of social experiments in the past like the one you mentioned – sounds like a very effective way to start a discussion about racial biases without being too confrontational or hostile.

  11. Thank you, Methma, for an extremely thought-provoking post. I truly enjoyed the discussions thus far, addressing race, racial inequalities, and differences in health outcomes in a manner that aims to eliminate medical inequalities. From what I understand, there seems to be a blurry line between acknowledging race (and other differences) and ‘othering’. While acknowledging race does not necessarily evoke racism, othering does because it makes a clear, negative distinction between an “us” and a “them.” “Their” distinct difference causes “us” to treat “them” differently and, thus, hold them to altered expectations. As mentioned previously, “African resilience” served as the rationale for the unequal distribution of pain medications among African Americans and white Americans. African Americans were thought to be able to withstand greater amounts of pain. This more covert racism highlights the need for explicit culturally competent trainings for physicians, nurses, and other health care workers interacting with patients.

    Although an awareness of racial inequalities may not lead to immediate action, it may contribute to eliminating racial health inequalities in the long run. We just have to consider the following questions: Who will conduct these trainings? How will these trainings be enforced for all personnel? How will workers’ performance be assessed? How will they continue to practice these skills in everyday life? I believe that these are some of the key questions that we need answers for to determine that all patients will receive the same quality of care.

    Following Yuki and Katherine’s points about the detrimental effects of internalizing racial biases, I would actually like to invite you all to take Harvard’s Implicit Association Test to understand what unconscious associations you may hold, and see how these associations may affect your everyday interactions and possible career paths. Although some may think that ignoring difference, specifically race and skin tone, is key to “leveling the playing field,” we should consider how “color-blindness” actually inhibits our ability to think about and discuss difference in a productive manner. It affords whites the privilege to never have to consider how minorities actually experience race and invalidates fundamental parts of one’s identity. Color-blindness makes it difficult to address internalized unconscious biases, perpetuating racism. As Nini stated, “To acknowledge race is not racist, but not to acknowledge race is.”

    1. Hi Natalie,

      Thanks for your comment! I think the point you bring up about “othering” is really important, as is thinking about racism and unconscious associations. In terms of the questions you posed, I agree that it is important to talk about the structure for cultural competency education from the beginning all the way through a physician’s practice. In that same vein, it would be really useful to have further training modules and assessments every few years. I think this new cultural competency education movement is relatively new so there will definitely need to be a lot of work done in figuring out the details of the training at medical schools and hospitals across the country.

  12. Chapter 7 in the Farmer textbook talks about how adapting to local context is an important tenet of effective global health delivery and I wonder how this can be applied to health at home, in the U.S. Having different lung capacity data of averages across different communities (and therefore different socioeconomic statuses and different races) could be useful, but I think that these should only be used to determine the underlying issues of these differences, instead of using averages to set a normal (leading to race correction in the measurement of health).

  13. Hi Methma,
    Thanks for your insightful post on the unnecessary racialization of healthcare treatment in the US. I often feel that mainstream discourse around health disparities focuses only on access to care as the underlying problem, and does not talk about varying treatment quality by medical providers as an issue that needs to be addressed. I appreciated your discussion of how problematic race correction is, and reading your comments about how in Braun’s book, physicians did not have a consistent way of determining race or even have a standard way of “race correcting” for lung capacities, which rendered the practice not only harmful but also inconsistent and fairly useless.

    To delve into your fourth question, like most people who have commented on your post I think there is no ethical situation to race correct in the US when looking at people who all use the same healthcare system. Jack and Yuki brought up the potential biases of people performing global health work, and how we can strive to correct against implicit unequal health treatment. While correcting against bias is absolutely essential, going even further I began to think about how the notion of “correcting” health factors by population is still applicable for all global health workers in a way that seems similar to what Braun describes. The way doctors evaluate what treatment options are available for a person with a given disease inherently depends on the nation one is in, and is often highly correlated to race. For example, it takes a much lower threshold to declare a disease an emergency in Western developed nations than it does in developing nations, because of the expectations of health outcomes for different populations. In Improvising Medicine, Julie Livingston talks about how severe a tumor is deemed in Botswana is vastly different than in developed nations, and notions of what suffering means are vastly different than those in western nations. While we strive to work against the notion of different standards of health for different races in the US, we should also strive to work against the idea that different populations are predestined to have different tolerances for health ailments as well.

    1. Hi Alana,

      Thanks for your comment! I think you brought up a very important point about our attitudes in relation to health and a level of ideal health in different regions of the world, based on available resources, previous levels of health, race, and socioeconomic status. This reminds me of the stoic primitive, and the idea that people in other countries have to handle treatment without much palliative care – but just because they can, it does not mean they should. I believe it is important to advocate for the highest level of care possible, although this often goes against cost-effectiveness measures. We always seem to end up at the question of how we can acquire funding for this basic human right of being healthy. Nonetheless, I agree with you that the first step is changing the attitudes towards health and life expectancies in “others” around the world.

  14. Hi Methma!

    In another class, a guest speaker showed us an article I think you will find fascinating. It concerns the drug Bidil, and its race specific use for cardiovascular issues. When confronted with this article and its accompanying research study, I felt incredulous. If we know that race is a social construction then how could we support treatment that validates the dangerous association between race and biology? The idea that some drugs are more suitable to blacks and some more suitable to whites in a way supports the racist arguments you have adeptly described in your post above. However, this study begs us to look further. Could it be, as you suggest in your lung capacity example, that it is not race but factors often associated with race such as socioeconomic status or environmental exposures that are contributing to this racial discrepancy in the response to certain cardiovascular drugs? Or, if indeed this study is sound, then wouldn’t it be wrong not to provide the best, most effective treatment to individuals? And wouldn’t this lead to further studying of racial responses to other treatments? And would this be a good thing or a bad thing?
    p.s. I think the way you articulate the end of your post by suggesting race correction as a way to perpetuate inequality and explain structural violence is right on point, and was a great way to sum up your thoughts.

    Here is the link to the article about Bidil:
    http://www.nbcnews.com/id/8336206/ns/health-heart_health/t/fda-approves-first-race-specific-medication/#.VmXvheODGko

    1. Hi Elena,

      Thanks so much for your comments! I just read the article on BiDil and am very curious to know the mechanism of the drug, such that it had different levels of effectiveness on different people. I am curious as to whether this drug worked because the initial levels of heart failure between the two patient populations were already different, or were caused by different sources – or the drug worked due to different environmental factors, like you suggested. If the drug works, I am hesitant to admonish the use or prescribing of the drug; but I do not believe that racialized science should be the way forward (like our Smedley and Smedley reading said). What do you think? Is medicine specific for “racial groups” another step (or the right step) towards personalized medicine, like the article suggests?

  15. Hi Methma, thanks for your post! You present some very interesting ideas here about race and medicine, and how that relates to inequalities in patient care. While perhaps not the worst in terms of DALYs or disability more generally, the pain example in particular affected me pretty viscerally. It seems clearly terrible and absurd to deny the suffering of certain populations and then use that to justify providing a lower quality of care. Tying this to the idea of the “stoic primitive” that we talked about in class, I agree that we still today implicitly see echoes of the racialized medicine practiced in the colonies, in the assumptions that black bodies deal with pain in a different way, are inherently “different” and “other.” I think this ties too into the idea of appropriate technology and cost-effectiveness analysis, in that palliative care and other aspects of medicine that help “civilize” but also rehumanize and decrease suffering for the patient are sometimes considered unnecessary and even excessive or an inappropriate use of funds in the context of global health. We should, these theories posit, use the limited money available to treat people and reduce disease – often different though from suffering. To bring in another theoretical point, it often seems these measures focus on the population at the expense of the individual, ignoring the suffering of the person to protect and intervene for the group.

    Another part of your post that stood out to me was the observation that doctors don’t really have a good idea of what “race” is anyway, and that the identifiers they use, like skin color, can be both misleading and problematic. This relates intimately, too, to the idea of “race correction” that you bring up – a disturbing feature of health measurements today. I’d be interested to know as well if something similar does happen in global health – for example, if what a “healthy weight” for a child is, based on GOBI, corresponds to the U.S. or is lower.

    1. Hi Allison,

      Thanks for your analysis of the issue and connections to other aspects of health and health measurements. I think the relationship the “stoic primitive” and how that is now tied to appropriate technology is particularly important. I would also be curious to know about a healthy child’s weight around the world, like you suggested. Although it may be the same number in different places, I still think the threshold for medication or urgent medical action would be very different based on the resources, culture, and identity/background of caregivers in the specific setting.

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