A Better Approach to Race in Medicine
Real inequalities need solving. Social justice posturing only makes things worse.
Earlier this year, UCLA Medical School was exposed by Washington Free Beacon reporter Aaron Sibarium as the paradigmatic exemplar of DEI run amok. It’s hard to imagine how Saturday Night Live could skewer this discourse more savagely than by simply quoting verbatim from a guest lecture given to students by “poverty scholar” Lisa “Tiny” Gray-Garcia: a prayer (with students urged to drop to their hands and knees) to “Mama Earth”; the rejection of the “crapatalist lie…[of] private property”; the dismissal of medicine as “white science.” Is there anything more to be said about the appropriateness of content like this in a mandatory course for first-year medical students other than just… no?
And that’s the real harm of such programming—not that it’s performative, or divisive, or completely irrelevant to the education of tomorrow’s doctors, although it is all those things. It’s that this rhetoric obscures urgent issues at the intersection of race and medicine, while alienating many potential allies who could, and should, help address them.
Historically, black people have borne a disproportionate share of the burden of American medical instruction and research, their bodies subjected to involuntary exhibition, dissection, and experimentation. The most well-known example of such exploitation is the Tuskegee Syphilis Study. Conducted by the United States Public Health Service from 1932-1972, this project charted the course of untreated syphilis in almost 400 black men from Macon County, Alabama. The subjects were never told they had syphilis (they believed they had “bad blood”) and treatment was actively withheld, even after penicillin was widely adopted as a cure post-World War II. Ultimately, more than 120 men died of syphilis or complications from it, 40 of their wives developed the disease, and almost 20 babies were born with it.
Tuskegee rightly remains a touchstone in our collective memory, a common explanation for the current distrust more than half of black Americans feel for the medical profession. But that reasoning might let today’s healthcare system off the hook too easily. Dr. Karen Lincoln, a professor of social work at the University of Southern California, believes that Tuskegee is a useful scapegoat that diverts attention from contemporary problems reported by black patients, including patronizing attitudes, the minimization or dismissal of symptoms and needs, and medical and pharmaceutical “deserts” that make accessing care extraordinarily challenging.
Unsurprisingly, these findings translate into significant health disparities. Black adults are 60% more likely to be diagnosed with diabetes than non-Hispanic white adults, and more than three times as likely to be diagnosed with end-stage renal disease. Hypertension is also much more common in black populations; one New York City study reported prevalence rates of almost 30% for non-Hispanic white adults compared to close to 45% for black adults. And while white people are more likely to be diagnosed with most cancers, black people are more likely to die from them, a finding largely attributed to the later stage of diagnosis in black patients.
Many health differences can be at least partially attributed to the significant black-white income gap (the median black household wealth is about a tenth of that of the median white household). But not all can. Maternal and infant morbidity and mortality is much higher for black mothers and babies, even controlling for income. A 2023 study using California data found that the richest black mothers experienced more infant mortality than the poorest white mothers. (Maternal mortality was similar between these two groups, despite the significant difference in resources.)
It’s hard to imagine a serious argument that tomorrow’s physicians shouldn’t be invested in ameliorating these disparities. But it’s even harder to imagine a serious argument that leading them in chants of “Free, free Palestine”—as happened at UCLA—will improve the health of a single person.
The answer is not to take politics out of medicine, as some critics have proposed. It’s an impossible goal anyway. Politics and health are inexorably intertwined, from the control of reproductive care, to the regulation (or lack thereof) of toxic substances like lead or DDT, to access to essential medications (remember “Pharma Bro” Martin Shkreli, who hiked the cost of an antiparasitic drug by 4000% in 2015?). Stripping medical school curricula of anything remotely resembling social policy in favor of an exclusive focus on “fundamental knowledge of disease processes,” as Dr. Stanley Goldfarb called for in a 2019 Wall Street Journal op-ed, would itself be a political statement, excluding from some of our most important debates exactly those experts best equipped to speak to the health impacts of such policies. It would also result in an impoverished medical education, since as much as 80% of our health is shaped by social determinants.
Although the backlash against UCLA has been dismissed as a “right-wing and Republican project” motivated by “racism,” such accusations skirt the key question exposed by all the media coverage—which isn’t, fundamentally, whether racial disparities in health should be taught in medical schools. A 2020 survey by the American Medical Association’s Accelerating Change in Medical Education Consortium found that 64% of their member institutions were already prioritizing social determinants of health in their curricula, and called for “dedicated action” to expand this to all medical schools. The fundamental question is how? How should medical educators, and the physicians they train, approach these complex and persistent problems?
The same way, I hope, that they approach everything else. We depend on our physicians to use evidence-based processes in the research and treatment of illness: to generate actionable and falsifiable hypotheses based on current knowledge, to use those findings to shape interventions, and to be willing to change these strategies based on whether or not they work. Reducing or, hopefully, one day eliminating healthcare disparities requires the same empirical approach.
And that work is being done. One promising development is the emergence of new participatory research models that invite community engagement with the design and implementation of research that directly affects them. Perhaps medical schools should solicit such community input in their curricula development. My hypothesis? That black patients from underserved neighborhoods don’t actually want their future physicians spending their limited classroom hours being lectured about settler colonialism or how to spell “womxn” with an x—that social justice, for them, would mean treating their urgent and specific healthcare needs with the rigor they deserve.
Amy S.F. Lutz is a historian of medicine at the University of Pennsylvania in Philadelphia and Vice President of the National Council on Severe Autism.
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Nice piece. But “taking politics out of medicine” can mean more than one thing. Calls to take politics out of the curriculum are not generally aimed at teaching about health disparities and social policy. These topics clearly have a rightful place in any curricular attempt to situate the medical profession in society—as most if not all medical schools seek to do. One may favor such topics in the medical curriculum but also favor taking politics in the form of political indoctrination or advocacy out of the curriculum. Medical education should aim to teach future doctors about health and society but should seek to do so without foreclosing political debate.
At the risk of sounding disparaging, there is real value in allowing the students exposure to Tiny and her production. It’s an interesting study in psychosocial behavior and perspectives of medicine by skeptics. There are a large population of patients who are not only skeptical or fearful of healthcare providers and evidence based medicine, and many who believe they are being deceived, extorted, subjected to non-consensual testing and treatments, despite the best communication and respectful implementation of care.
Being in an urban center on the North American West Coast has provided myself ample anecdotal evidence of the high concentration of “Tinys” in these populations. So at best this was a half day immersion with a living model whose best instincts are working against their own interests, and trying to empathize with their situation to best create a reasonable plan of care and at least address some of their problems. At worst this is school faculty tacitly endorsing ideology and claims that run contrary to best practices and shows little regard for real problem solving and data driven policies.