Monday, June 22, 2020

What are the practical steps that we in medicine can take against racism?

This is a guest post by Seiji Yamada, MD, MPH & Gregory Maskarinec PhD, colleagues from Hawai'i

In this essay, we discuss what we in medicine in Hawaiʻi can do about racism.

This NY Times opinion piece "It’s Not Obesity. It’s Slavery" by Sabrina Strings, an associate professor of sociology at the University of California at Irvine, decries the victim-blaming attribution of the disproportionate coronavirus risk among blacks to their co-morbidities. The essay starts off as follows: 

About five years ago, I was invited to sit in on a meeting about health in the African-American community. Several important figures in the fields of public health and economics were present. A freshly minted Ph.D., I felt strangely like an interloper. I was also the only black person in the room.

One of the facilitators introduced me to the other participants and said something to the effect of “Sabrina, what do you think? Why are black people sick?”

It was a question asked in earnest. Some of the experts had devoted their entire careers to addressing questions surrounding racial health inequities. Years of research, and in some instances failed interventions, had left them baffled. Why are black people so sick?

My answer was swift and unequivocal.


What Sabrina Strings is pointing out here is the importance of history and its legacy of ongoing structural violence. Interviewed by Fareed Zakaria on "Why COVID-19 hit black Americans so hard," Harvard School of Public Health Prof. David Williams notes that for every dollar of income made by white households, black households make 59 cents. For every dollar of assets owned by white households, black households own 10 cents, and Latino households own 12 cents.

The Academic Medicine article "Changing How Race Is Portrayed in Medical Education: Recommendations From Medical Students," outlines how American medicine was historically steeped in racism. We also have the historical legacy of the Tuskegee, a United States Public Health Service study in which 399 black men were observed for decades with their syphilis infections untreated. Who was the first to object? Dr. Irwin "Irv" Schatz, former chair of the University of Hawai`i Dept. of Medicine, in 1965.

Closer to us in the Pacific, we have the legacy of the Marshall Islanders, deliberately exposed to fallout radiation Project 4.1 of the March 1, 1954 Castle Bravo thermonuclear test, then subsequently subjected to human radiation experiments for which they gave no consent. 

That the Marshallese had their human rights denied in this way reflects how they were viewed as less than human. With regard to Utrik Atoll, in a post-Bravo 1956 research planning meeting of the Atomic Energy Commission (AEC) Advisory Committee on Biology and Medicine, Merril Eisenbud, the director of the AEC Health and Safety Laboratory, noted (as quoted by Barbara Rose Johnston 2007, 25):

They had been living on that Island; now that Island is safe to live on but is by far the most contaminated place in the world and it will be very interesting to go back and get good environmental data, how many per square mile; what isotopes are involved and a sample of food changes in many humans through their urines, so as to get a measure of the human uptake when people live in a contaminated environment.

Now, data of this type has never been available. While it is true that these people do not live, I would say, the way Westerners do, civilized people, it is nevertheless also true that these people are more like us than mice. So that is something which will be done this winter.

[Photo: Holly Barker, Bravo for the Marshallese]

 That migrants from Micronesia continue to be denied participation in Medicaid (Med-QUEST) also reflects how they continue to be viewed as the "other" - not deserving of the access to health care as the rest of us. Micronesians also experience racism within Hawai`i's health care system. (See "Discrimination in Hawai‘i and the Health of Micronesians and Marshallese" and "Chuukese community experiences of racial discrimination and other barriers to healthcare.")

The public policy is complemented by more overt racism. One of my Chuukese patients (a man with two jobs, while his wife worked another, but living out of their car) reported to me that he was stopped by the police, told to exit his car, and was slammed against the hood of his car by the policeman.

What are the practical steps that we in medicine can take against racism?

We need to address the systemic racism against Native Hawaiians and Pacific Islanders.

We need to address the distrust that Native Hawaiians and Pacific Islanders have toward the health system and its practitioners to improve access.

We need a health insurance system that includes Micronesians.

We must address the economic marginalization of people who work full-time but cannot afford a home.

We must address the catastrophic on-going military occupation of these islands.

This is a broad outline of the steps that must be taken. We call upon all involved in medicine in Hawaiʻi to make it a reality.


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