As 2019 winds to a close, the IAPHS Blog will feature a series of posts responding to the 400 Years of Inequality Campaign and call to action. In commemoration of the 400th Anniversary of the arrival of the first African Americans to be sold into bondage, these posts reflect on and acknowledge the ongoing history of racism in this country and its continued role in shaping population health inequalities. This is our third blog post in the series.
The ideas of white racial superiority that were fundamental to the social structure of slavery continue to undergrid several aspects of healthcare infrastructures in ways that maintain population-level racial health disparties. The racial logic that enslavers held alike about Black people’s inferiority in 1619 and throughout the existence of chattel slavery in the colonial project of the United States is cornerstone to the discriminatory healthcare culture and deployment of a calculus that devalues Black lives through automated medical technology. As 2019 marks 400 years since the arrival of the first enslaved Africans onto Powhatan land, it is once again necessary to consider how slavery and systematic racism continue to inform medical practices to the detriment of population health, particularly for Black and Brown individuals.
The connection between racial logics, slavery, and medicine must be made clear in order to better understand the persistence of racial disparties in population health. Racial logics are how race as an ideological construct and social phenomenon exists within a racial structure to produce differential statuses between racialized social groups. Ideas of biological racial differences emerged to buttress the institution of slavery and allow for the domination of Black and Brown people. Author Saidiya Hartman writes in 2016 that slavery established a “racial calculus” that devalues Black lives and remains in the “afterlife of slavery” which includes “skewed life chances, limited access to health and education, premature death, incarceration, and impoverishment.” The afterlife of slavery also includes negative experiences in healthcare for Black patients and medical technology based on racist logic as a major source of racial health disparities.
This alarming social problem can be traced to the dehumanizing nature of slavery and minstrel shows which gained tremendous popularity even before the abolition of slavery in the U.S. These shows, which began in the 1830s, bolstered pro-slavery racial logic by placing exaggerated and mythical stereotypes about Black people on the center stage for white audiences.
The ranking of Black lives as subhuman, less deserving, and less valuable parallels how Black patient populations often receive suboptimal medical care. This alarming social problem can be traced to the dehumanizing nature of slavery and minstrel shows which gained tremendous popularity even before the abolition of slavery in the U.S. These shows, which began in the 1830s, bolstered pro-slavery racial logic by placing exaggerated and mythical stereotypes about Black people on the center stage for white audiences. By understanding the popularity of minstrel shows and how particular exaggerations of Black people were seen as comical, one can see how when Black patients seek healthcare, providers too frequently see Black patients as superhuman or perceive their pain symptoms as exaggerated.
One study of African Americans in Central and Southeast Seattle found that nearly one-third reported having experienced discrimination at some point in their lifetimes when seeking healthcare and 16% reported such experiences in the past year. Black patients, particularly Black women, are often stereotyped as unintelligent, irrational, noncompliant, and their symptoms are frequently undertreated and ignored. Perhaps nowhere is this more evident than the dismal Black maternal mortality rate in the U.S. and the hundreds of stories in which Black women in labor are mistreated and seen as incompetent. A recent video of a nurse mocking patients in pain sparked the Twitter hashtag #PatientsAreNotFaking attached to hundreds of stories of people, particularly people of color, falling on the other side of power and becoming the target of condescension while seeking healthcare. It is no coincidence that patients of same-race providers often have better healthcare experiences, more preventative care usage, and lower mortality rates. The mockery and the undertreatment of Black people are jointly part of the afterlife of slavery that contributes to large racial disparties in population health and mortality.
The mockery and the undertreatment of Black people are jointly part of the afterlife of slavery that contributes to large racial disparties in population health and mortality.
Common healthcare algorithms are another example of racist logic in medicine which deploys a “racial calculus” that devalues Black lives. A recent study found that an algorithm widely used by hospitals and insurers to manage the healthcare for nearly 200 million people in the United States every year to allocate health care services to patients systematically discriminates against Black people. The researchers found that the algorithm was less likely to refer Black people to services that improve care for patients with complex medical needs than White people who were equally sick. Algorithms do not create themselves — they are created by humans who live in a social structure where biases, discrimination, and differential treatment based on race are fundamental aspects of society. This algorithm, like the formulas used to calculate lung function, kidney function, and health risk scores, is built using historical data that includes legacies of segregated hospitals, racist scientists and medical curricula, and exploitation of racially marginalized groups. Without intentional considerations of systemic racism in the afterlife of slavery, these calculations in medicine that ambiguously take race into account can deepen already existing inequities.
Racism is innovative, and since the arrival of the first 20 enslaved Africans and the simultaneous displacement of indigenous people, the creation of complex systems, algorithms, and medical technology has functioned to maintain the vast racial health disparities observed in the present day.
The racial logics that devalued Black lives in 1619 have been reconfigured for the contemporary political, cultural, and economic contexts in the afterlife of slavery.
Wherever there are racial disparities, there is racism. The racial logics that devalued Black lives in 1619 have been reconfigured for the contemporary political, cultural, and economic contexts in the afterlife of slavery. Culture, medical practices, and algorithms are not permanent, and neither should be the negative health outcomes for racially marginalized groups. Serious attention must continue to be given to how healthcare infrastructures, clinical practices and culture, and medical technology continue to maintain and deepen racial disparities in the United States.