Black and Blue: The Origins and Consequences of Medical Racism
by John Hoberman
University of California Press
We’ve heard the statistics on black and white mortality rates in the United States. Black infants are up to three times as likely to die as babies of other races. Black patients have lower survival rates from cancer and are hospitalized twice as often as whites for preventable conditions such as high blood pressure and type 2 diabetes.
How does this happen in the twenty-first century, when a black man is the president of the United States and three of the last four surgeons general have been black? Why do whites receive more potentially lifesaving cardiac procedures than blacks? Why are black patients less likely to have cancer surgery recommended to them? Why are black patients with diabetes and circulatory problems more likely to have limbs amputated?
Racism, says John Hoberman. In his scathing book Black and Blue: The Origins and Consequences of Medical Racism, he documents how the racial prejudices of the larger American society have influenced the diagnosis and treatment of black patients over the past century, and how those practices continue today. The book is a relentless and thoroughly researched account of racial discrimination by the largely white medical establishment, composed of medical school faculty, editorial boards of scientific journals, and professional associations such as the American Medical Association that develop medical school curricula and influence decisions about research. While Hoberman offers an unsatisfying solution to these problems, the book is thorough enough to make anyone—physician, layperson, black, white—question his or her own racial prejudices and assumptions.
Hoberman points out that the troubling reality of racial inequality in health care doesn’t match the medical establishment’s opinion of itself. In a 2010 study, 75 percent of white doctors said that patients are never treated unfairly based on race. Only 20 percent of black doctors agreed. These numbers aren’t surprising given the racial makeup of physicians in the United States. Between 1978 and 2008, just over 6 percent of American physicians were black (African Americans made up approximately 12–13 percent of the total US population during this same period). These percentages aren’t likely to change anytime soon, because medical school enrollment isn’t keeping pace with the changing demographics of the country. In 2011, minorities made up more than 36 percent of the US population but only 8 percent of the US medical-school student body.
Hoberman says that the medical establishment has failed to acknowledge its role in the history of racial discrimination. He spends the bulk of the book surveying medical and scientific scholarship from the past century. What he finds is that physicians long accepted racial folklore about supposed biological differences between the races. For example, doctors used to believe that blacks were less sensitive to pain because they had thicker nerve fibers. This myth often led doctors to deny proper pain relief to black patients. Many doctors also assumed that black skin provided natural protection against the sun—an assumption that led to underdiagnosis of skin cancer. As recently as 1939, the Southern Medical Journal reported, “Due to anatomical differences, the full-blooded negro is seldom affected by skin diseases common to the white man.”
Hoberman calls this “racialization,” or using pseudoscientific rationales to define racial differences in physiology. The idea that blacks are more primitive human beings than whites stemmed from the same historical racist ideas that European colonizers used to justify black African slavery. This later developed into subtler stereotyping. Conditions associated with the stresses of modern “civilized” life were labeled “white.” Whites supposedly suffered more from myopia and other vision problems caused by the strain of reading too much. White businessmen were prone to digestive problems and ulcers because they shouldered “the burdens and responsibilities of administration and management in business and politics.” Blacks, on the other hand, supposedly possessed an innate physical “hardiness” that made them less susceptible to these “white” diseases. Instead, they were allegedly prone to sexually transmitted infections, drug abuse, and alcoholism because of their “careless” and “primitive” lifestyles. Hoberman points out a classic example of endometriosis. As late as 1950, some doctors believed that it occurred only in white women, because they assumed sexually transmitted diseases were the source of any gynecological problems in black women.
Black and Blue can be rather dry and academic in parts of this historical tour. For instance, chapter 3, in which Hoberman catalogs how racial characteristics have been assigned to various organs, diseases, age groups, and personalities, contains 328 citations. It reads like a book-length review paper, a subgenre of medical scholarship in which an author surveys a number of studies to summarize the current state of research on a particular treatment or disease. Yet this relentlessness and depth of detail are what gives the book its weight.
The book becomes more compelling as Hoberman turns his attention to the medical establishment’s attempts to repair the damage that centuries of medical racism have inflicted upon African Americans. He is highly skeptical. “Today’s physicians seem to be unaware that the prejudices and practices of their predecessors traumatized generations of African Americans, for whom a distrust of white doctors become a cultural legacy that persists to this day on a scale few whites can imagine,” he writes.
Hoberman says that the powers that be pay only lip service to the problem. In his view, national medical leaders want to believe that outright racism is a thing of the Jim Crow past, and refuse to acknowledge their role in perpetuating discrimination:
The medical literature thus remains in one sense an elaborate arrangement whereby white physicians are insulated from certain kinds of discomfiting information about the medical suffering of black people and from knowledge of how black patients or colleagues assess their professional behavior. The voices of black patients and physicians appear, infrequently, in newspapers. Black people’s analyses of how white physicians behave in interracial encounters play no significant role in American medicine’s half-hearted attempts to deal with its half-acknowledged race problem.
And later he heaps further scorn on physicians and medical scholars: “American medical authors’ general lack of interest in race relations, and the tacit censorship enforced by the norms of professional courtesy, have ruled out serious scrutiny of physicians’ thinking about racial health disparities in the pages of these journals; in a word, assessing the racial sophistication of physicians has never been a priority for American medical authors.”
Hoberman, a professor of Germanic studies at the University of Texas, claims that only an outsider could examine the racial prejudices of medical professionals, because they are unwilling to do so themselves. He has taken this approach to writing about race before, in Darwin’s Athletes, a critical examination of the influence of sports on African American culture. He received sharp criticism for that book from black intellectuals who felt that he took a one-sided negative view of this part of the black experience and ignored the positive role that athletics have also played in black life.
In my view, Hoberman’s stance sets him up for charges of cynicism in Black and Blue as well. He offers few solutions and expresses no confidence in the medical establishment’s intentions to correct these wrongs. He dismisses most attempts to address racial health disparities, such as courses to teach medical students about the specific needs of minority patients with inadequate access to health care, as ham-handed and paternalistic. He says his own book is an alternative to the standard cultural competency curriculum in medical schools, which suffers from “its lack of historical perspective and its reliance on sanitizing and euphemizing language to describe racial attitudes and race relations in medicine.”
In his conclusion, Hoberman suggests that the ultimate solution would involve the formation of a coalition of wealthy African American philanthropists, the Congressional Black Caucus, white liberal allies, and “the reincarnation in medical form of a great African American leader.” This group would “make black doctors and black interests visible to whites as they never have been before” and reform medical education by including more black voices in the design of curriculum and research.
The medical field does face significant hurdles in addressing cultural competence in its ranks, but its failures have more to do with the disproportionately small number of minority doctors than with medical school curricula. Hoberman’s claim that only a confluence of wealth, power, and the emergence of a mythical leader can solve these problems ignores the work already being done to address long-standing racial disparities in health and medical education. Programs such as the Urban Health Program at the University of Illinois at Chicago and the Urban Health Primary Care Residency Program at Johns Hopkins recruit minority medical students and train physicians to give minority patients from underserved communities better access to routine preventative health care.
I work in the communications department at an academic medical center that has similar programs to address racial health care disparities. I’ve interviewed physicians and researchers about their work on the South Side of Chicago, and they care deeply about providing this traditionally neglected area with the same quality of medical care that is afforded to more affluent white communities in other parts of the city. They routinely work side by side with patients and community leaders in projects such as after-school programs at elementary schools to fight childhood obesity and primary care clinics that focus on preventative care for chronic conditions like diabetes.
To dismiss such efforts around the country as insufficient or ineffective suggests that Hoberman is more interested in casting blame from his position as an “outsider” than in giving a true assessment of the work being done to address the problems he so painstakingly documents. Still, Black and Blue is a valuable chronicle of the disturbing history of racism in US medicine. It should serve as a stark reminder of the depth of racial discrimination working against medical professionals trying to address health care disparities in this country.