Reckoning with the Past as an Antiracist Physician Leader

The medical field has both hurt and healed. Physician leaders can build an antiracist medical practice, beginning with an examination of the past. Here are five steps for success.

Step 1: Reckon with Past Internal Racism.

Review the internal institutional workings of your practice as far back in time as you are able. If you identify incidents of internal racism, first acknowledge, then apologize, then act.

For example, if your hospital, until recent decades, hired people of color only as janitorial or non-medical staff, recognize that by denying non-whites access to higher-paying jobs, the hospital contributed to the wealth gap. Also acknowledge that hiring non-whites in professional roles in parity with their presence in the population doesn’t change the fact that their communities still lag financially behind those who’ve had disproportionate access to such opportunities all along.

In such a case, acting could mean helping people of color grow their capital by investing in minority-owned businesses or partnering with an organization like Prosperity Now that engages in projects, research, and advocacy to help people of color and low-income people of all races produce wealth.

Ultimately, both remorse and remedy are key. The latter helps make things right; the former helps make them real. Too often, people think of systemic racism as abstract or theoretical, but when organizations and communities offer a full and public accounting of their perpetration and explain the consequences, the public recognizes systemic racism as a real force carried out by real entities with real effects on real people.

Step 2: Reckon with Atonement and Work Off the Past.

Audit your facility’s history to uncover and elucidate instances of harming people of color or directly benefitting from harming them. Your audit should be comprehensive and not targeted to a specific form of injustice.

Resources are available to help such investigations. For example, “The Legacies of British Slave-ownership” database and the Dictionary of British Slave Traders (forthcoming) trace the slave-wealth of organizations/communities, the individuals who funded them, and the assets purchased by such funds. The “Morrill Act of 1862 Indigenous Land Parcels Database” identifies parcels of land seized violently from indigenous nations. Historians and other professionals can be helpful also.(1)

But be mindful that not all racial injustices link to high-profile atrocities. For example, your clinic may have been able to snap up cheap land in a gentrifying community of color because the property values had been wracked by redlining — the practice of denying credit to and disinvesting in minority neighborhoods.

If your organization perpetrated or directly profited from harm to people of color, then, as in Step One, apology and atonement are imperative. For example, suppose the medical school where you teach was enriched by slavery. You might urge your institution to follow the example of the Virginia Theological Seminary. VTS is spending income from a special endowment (that represents 1.1% of its total endowment)(2) making what it refers to as “reparations” to the descendants of slaves who worked on its campus and to African Americans employed there during segregation. (The seminary has hired historians and genealogists to locate those descendants). It also supports the work of African-American alumni, invests in the development of African-American clergy, supports efforts toward “justice and inclusion,” and mobilizes for governmental reparations.

The school acknowledges that such initiatives are but a “start.”(3) Your medical school could also make reparations, address racism as a public health crisis, and invest in the education of African-American physicians. The latter is possible by supporting and duplicating programs such as the SSTRIDE and Master’s Bridge programs at Florida State University or the Student National Medical Association’s Pipeline Mentoring Institute program. There is also the AMA’s Doctors Back to School Program, which sends doctors to visit elementary schools in underrepresented communities to educate children about futures in medicine; and the AMA’s Minority Scholars Award, which offers tuition assistance to medical students.

Step 3: Reckon with the History of Systemic Racism on Fields and by Fields.

Read works such as Harriet A. Washington’s Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. (Harlem Moon/Random House, 2006) Better yet, start an antiracist doctor book club to encourage your colleagues to read these works as well.

Acquaint yourself with disparities such as how Black patients are three times more likely to undergo diabetic amputations than non-Black patients, even though their amputations are often preventable, and how the average number of amputations for peripheral artery disease per 10,000 per year in a geographic area has a positive correlation with the percentage of the population enslaved there in 1860. Then learn the best practices for preserving Black patients’ limbs.(4)

Research and duplicate or adapt programs such as the Yale School of Public Health’s U.S. Health Justice Concentration.

Step 4: Reckon with the Legacy of Racism and Imperialism in Medicine.

Make rectifying the legacy of imperialism and racism through truth and reconciliation, atonement, and reparation a priority.

Here’s how that can look in practice:

Biopiracy is the intellectual property theft of traditional ecological knowledge such as plant strains cultivated by indigenous botanists or ethnopharmacological knowledge. More than two decades ago, researchers calculated that if intellectual property royalties were paid for biopiracy, the United States would owe “Third World” countries $5.1 billion a year for pharmaceuticals(5) — and since then, the thieving has continued.

Establish a code of ethics in your research laboratory to prevent the plundering of medical expertise; if your organization has engaged in biopiracy in the past, make restitution.

Step 5: Do Things Differently in the Present So That the Future Looks Different Than the Past.

Hire in an antiracist fashion. Consider how your facility, practice, or institution reviews employee applications. Are applicants required to submit a photograph? Do application reviewers discover photographs of candidates while researching them online? Consider that, in 2020, the U.S. Army decided to stop using candidates’ photographs in promotion board hearings because it found that when there were no photographs to reference, minorities and women were more likely to be promoted.(6) Thus, though it’s counterintuitive, colorblindness in this context can help organizations hire a more diverse staff.

Choose your staff the way lawyers choose jurors, and though it’s prudent to research candidates online, try to limit the negative impact of knowing an applicant’s race. An antiracist system for initial review of applications could look like this:

1. Neither require nor allow photographs with applications.

2. Initially sort applications into “yes” and “no” stacks.

3. Have a second person research the online presence of those in the “yes” stack and perform a second round of eliminations.

When attorneys who are choosing juries for trials dismiss a potential juror from the jury pool, they generally must give a reason for doing so, and the juror’s race cannot be why. However, in some countries, including the United States, attorneys are allowed a certain number of peremptory strikes — the chance to strike jurors without saying why.

You see the problem here, right?(7) The second person in your hiring process must offer a specific reason for placing any application in the “no” pile — no peremptory strikes allowed.

While there may be so many unsuitable candidates in the first round of reviewing applications that it would be inefficient and burdensome to give a reason for every rejection (yet ideal, if possible), from the second review through the extension of offers, disallow peremptory challenges. As the hiring process continues, prevent anyone seeing what the candidates look like for as long as possible.

When the first reviewer gets the applications back, they should look at those in the new “no” pile to see if any merit challenges.

If a lawyer thinks his or her adversary might have stricken a potential juror based on race, he or she can make what’s called a Batson challenge, named for Batson v. Kentucky, the case in which the U.S. Supreme Court ruled it illegal for prosecutors to reject potential jurors based solely on race (which was permissible until 1986). When a lawyer makes a Batson challenge, opposing counsel must defend their strike by proffering a non-racial reason.

Thus, if the second reviewer places an application in the “no” pile and notes that he or she went online and found that the applicant was disciplined for medical malpractice, the first reviewer might trust that the rejection is fair. However, if the second reviewer’s note says that the candidate “isn’t conservatively groomed” or uses other particularly subjective language, the first reviewer should make a Batson challenge.

First reviewer: What do you mean by “isn’t conservatively groomed?”

Second reviewer: You know…not clean cut…wild-looking hair.

First reviewer: Describe “wild-looking hair” for me.

Second reviewer: You know — it was halfway down his back and in those rope things.

First reviewer: “Locs?”

Second reviewer: I guess.

First reviewer: Okay, well, if that was your only concern, put him back in the “yes” pile. Don’t fall into stereotypes of what a doctor, nurse, medical school professor, or researcher should look like!

By reckoning with the past, an antiracist physician leader can make the future brighter — and healthier!

References

1. Rosenberg E. German Billionaire Family that Owns Einstein Bros. Bagels Admits Nazi Past. Washington Post, March 25, 2019. www.washingtonpost.com/history/2019/03/25/german-billionaire-family-that-owns-einstein-bros-bagels-admits-nazi-past .

2. Millard E. Diocese of New York Establishes Reparations Fund, Adopts Anti-Slavery Resolutions from 1860. Episcopal News Service, November 12, 2019, https://www.episcopalnewsservice.org/2019/11/12/diocese-of-new-york-establishes-reparations-fund-adopts-anti-slavery-resolutions-from-1860/

3. Virginia Theological Seminary. Virginia Theological Seminary Affirms Reparations Program. Virginia Theological Seminary. June 9, 2020. https://vts.edu/press-release/virginia-theological-seminary-affirms-reparations-program ; Forson TS. Enslaved Labor Built These Universities. Now They Are Starting To Repay the Debt. USA Today, October 14, 2020. www.usatoday.com/story/news/education/2020/02/12/colleges-slavery-offering-atonement-reparations/2612821001 .

4. Presser L. The Black American Amputation Epidemic. ProPublica. May 19, 2020. https://features.propublica.org/diabetes-amputations/black-american-amputation-epidemic .

5. Aoki K. Neocolonialism, Anticommons Property, and Biopiracy in the (Not-so-Brave) New World Order of International Intellectual Property Protection. Indiana Journal of Global Legal Studies. 1998;6(1):49–50. www.repository.law.indiana.edu/ijgls/vol6/iss1/2 .

6. Cooper H. Addressing Diversity, Army Will Remove Photos of Officer Candidates in Promotion Reviews. New York Times. June 25, 2020. www.nytimes.com/2020/06/25/us/politics/army-pentagon-race-promotions.html .

7. Edelman G. Why Is It So Easy for Prosecutors to Strike Black Jurors? The New Yorker. June 5, 2015. www.newyorker.com/news/news-desk/why-is-it-so-easy-for-prosecutors-to-strike-black-jurors .