Some recent events have prompted us to change focus slightly. In early February 2019, it was revealed that the Democratic Governor of Virginia Ralph Northam, a board-certified physician, had posted inflammatory racist content on his yearbook page from Eastern Virginia School of Medicine. It pictured a white person in “Blackface” standing next to a person in a Klu Klux Klan robe and hood.
Northam originally took responsibility for the photo but never revealed which person, the one in Blackface or the Klansman, was himself. The following day, he back-tracked, claiming not to know how that photo got on his yearbook page.
Since then, the scandals among Virginia’s highest state leadership escalated to a mind-boggling level: you literally cannot make this stuff up! But let’s not dive into the drama. Let’s stick with Governor Northam and the racist photos. There was no shortage of discussion, outrage, anxiety, and every other emotion. African-Americans, who supported him in large numbers, were outraged.
I think what bothered me most was something that was not being discussed. These photos were not from an Undergraduate yearbook, but a Medical School yearbook. We have also learned the Eastern Virginia Medical School routinely posted racist photos in their yearbook. The graduate Ralph Northam M.D. was becoming a practicing physician. What I was seeing before my very own eyes were the roots of a phenomenon we recognize as medical racism.
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The way I like to define medical racism is the differential provision of care and treatment of diseases based on race. Quite simply, patients of one race get care that is consistent with the standards, while patients of a different race, usually minorities, get different care that may be sub-standard and potentially dangerous. Let me provide an extreme example.
About 10 years ago, while I was at Johns Hopkins University School of Medicine, Congressman Elijah Cummings of Maryland was the keynote speaker for a program commemorating Dr. Martin Luther King. Congressman Cummings described an incident many decades earlier where his grandfather was critically ill.
Two white physicians, an older doctor and a younger doctor, arrived at their home. After examining his very sick grandfather, the younger doctor proclaimed, “If we do not admit this man to the hospital immediately, he will die”. The older doctor responded “So what? He’s just a nigger.”
His grandfather was not admitted by the doctors and he passed the next morning. This is an extreme case of a man getting sub-standard care because of his race. Simply because he was African-American, he was denied care consistent with the standard for a person in his medical condition. As a result, he died.
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I doubt Governor Northam, M.D. has ever performed an autopsy on the victim of a lynching perpetrated by the Klu Klux Klan or any other terrorist group. If he had, he would be stunned by the horrific physical trauma and sheer brutality of such a death, not to mention the gruesome mutilations that often accompanied lynchings, a common tool employed by the Ku Klux Klan most often on innocent victims.
As a physician, he would comprehend the tremendous cruelty of such an act at a level that many of us wouldn’t. Physicians save lives; Ku Klux Klansmen destroy lives. You can’t do both.
If you think it’s a joke to pose as a Klansman and to mock black people by dressing in Black-face, can you really provide good quality care for African-Americans? Do you have the sensitivity to be a true advocate for your patients, in light of our historical reality and the tremendous socioeconomic disparities that lead to worse health outcomes in minority communities? By engaging in this behavior, are you primed to practice medical racism?
Much of medical racism is far more subtle than what Congressman Cumming’s grandfather experienced. One of the best demonstrations of medical racism came from studies with the Veteran’s Administration Hospitals.
These studies are so valuable because all veterans get free medical care, so differential access to care based on race is eliminated. A patient’s ability to pay for care is not a factor determining their access to care. These studies are also instructive because you have a group of physicians providing care to all patients at a particular facility, regardless of the patients’ race.
But amid the seemingly equal playing field, some disturbing trends were found. In a large 2010 study, racial disparities were found in the prescribing of cardioprotective drugs and life-saving procedures across VA hospitals. Specifically, black patients were three times less likely than whites to receive coronary artery bypass grafting, a life-saving intervention for patients with coronary artery disease.
The authors conclude that the lower rates of prescribing cardioprotective drugs and coronary bypass surgery at least partially accounted for the higher rates of cardiac morbidity in black patients. Countless studies have found similar disparities in health outcomes due to disparities in the delivery of care based on race.
For HIV disease, it was notable that long after we had potent combinations of drugs that could completely suppress the virus, African-Americans continued to be prescribed single drugs, too weak to suppress the virus alone and often with lots of side-effects. Oftentimes, the same physicians prescribing the effective combinations for white patients would prescribe inferior therapy for African-American patients.
Not only that, but some studies showed that drugs used to prevent deadly infections in patients with advanced HIV disease (prophylaxis for opportunistic infections) were prescribed less frequently in black patients than white patients. No surprise, these disparities in prescribing contributed to worse outcomes and increased mortality among African-Americans with HIV disease.
Let me make one thing perfectly clear. Having a white physician if you are black does not mean you will get inferior health care any more than having a black physician guarantees you will get quality care. I have many outstanding white colleagues who work very hard to ensure that all their patients get top-notch care, irrespective of race, and they would be appalled to find a physician or other provider who would engage in the unethical or immoral practice.
Nevertheless, medical racism is a real and persistent manifestation of systemic racism in American society. The horrific legacy of the Tuskegee Syphilis Experiment, the secret sterilization of black girls, and other medical crimes continue to drive distrust of the medical establishment by blacks and other minorities. Many blacks still believe that HIV disease was created and specifically targeted to the African-American community. It can be hard to convince patients otherwise when our communities have actually been the victims of such conspiracies.
It may take some effort to get the quality team that you need. Find medical providers (physicians, nurses, pharmacists, nutritionists, mental health professionals) who you trust. Use your instincts to help guide you but also consider referrals and recommendations from others.
Most importantly, is your medical condition being well-managed and are any problems being properly addressed? You must be proactive in your care and have some ability to understand and monitor your own health (e.g. Is my blood pressure controlled? Are my hemoglobin A1c and fasting glucose improving? Is my plasma HIV viral load undetectable?).
Can I access my providers when I have questions or problems? Does my provider explain to me what’s going on at a level I can understand? Does my provider answer my questions and how do they feel about me raising issues I come across in my own research? Do they listen to me and involve me in decision making? Does my medical team communicate with each other and coordinate my care?
Whether they are black, white, Asian, Latino or another race or ethnicity, evaluate these areas.
Patients who don’t feel comfortable with or respected by their provider are likely not to adhere to taking their medication. It may affect their overall health-seeking behavior. Patients who believe the HIV epidemic is a conspiracy often believe the medicines don’t work and frequently will not take them. The experiences that patients have with the health care system, which can be shaped by race, will determine how engaged they are in their care.
In the next article, we will explore how racism contributes to driving the epidemic and also the impact of stigma in contracting the disease and accessing care.
Dr. Crawford has over 25 years of experience in the treatment of HIV. While at Howard University School of Medicine, he worked in two HIV-specialty clinics at Howard University Hospital. He then did clinical research as a visiting scientist with the AIDS Clinical Trials Group (ACTG) at Johns Hopkins University School of Medicine. He served as the Assistant Chief of Public Health Research with the Military HIV Research Program where he managed research studies under the President’s Emergency Plan for AID Relief (PEPFAR) in four African countries.
He is currently working in the Division of AIDS in the National Institutes of Health. He has published research in the leading infectious diseases journals and serves on the Editorial Board of the journal AIDS. Any views and perspectives in his articles on blackdoctor.org are not representative of any agency or organization but a reflection of his personal views.
