DEI/CRT
Is a Black Physician Shortage Killing African-Americans?
Cover art for the book Legacy: A Black Physician Reckons With Racism in Medicine by Uché Blackstock.
A Review of Legacy: a Black Physician Reckons With Racism in Medicine by Dr. Uché Blackstock
Ethnic and racial disparities in public health is an acknowledged part of the policy and social landscape of our times. It is well known that minority groups, especially African-Americans, tend to be screened, diagnosed and treated for major illnesses like cancer and heart disease far less frequently than White Americans – and as a result, Black mortality rates for these diseases tend to be considerably higher. While the US public health establishment has taken some important steps to eliminate these disparities, they remain, in most cases, quite stark. But less well-known is the fact that the number of ethnic and racial minorities, especially men, attending US medical schools and becoming doctors hasn’t really budged much in decades. Indeed, the numbers have actually declined somewhat percentage-wise from the 1940s, when systemic racism in hiring and law was more pronounced. Racial barriers in hiring and promotion at the highest levels of institutional medicine – especially when it comes to African-Americans – turn out to be deeply entrenched, with few signs of progress ahead.
Dr. Uché Blackstock, author of this impressive 2024 New York Times bestseller, is well aware of this historical “legacy.” She grew up under the informal tutelage of her mother, an African-American doctor who tended to underserved communities in the predominantly Black neighborhoods in Crown Heights, New York. Blackstock remembers fondly her earliest years in the hood when she and her sister used to do their homework in the hospitals and clinics where their mother worked. Her mother, she said, enjoyed a special bond with her predominantly African American patients, who saw her not just as a medical professional but as a sympathetic voice and advocate. Watching her mother make her daily rounds, she learned just how important it is for Black patients – especially elderly ones – to feel recognized and respected by their physicians. A White doctor or nurse might be proficiently trained and even sympathetic, but that distinctive element of co-ethnic bonding born of a shared experience of surviving racial discrimination and inequality is invariably lacking, she argues. That shared experience – and the mutual empathy that naturally flows from it – is what gives African-American patients the motivation to take their medicine and to follow treatment regimens as suggested, overcoming their often deeply ingrained skepticism toward and even disdain for well-meaning White doctors and nurses, due to past and recurring experiences of neglect and mistreatment. This co-ethnic bonding can greatly affect the quality of clinical outcomes, Blackstock insists. It can even mean the difference between life and death.
Part of the beauty of this book is the way Blackstock moves back and forth between the poignant details of her family history – and the “legacy” left to her by her mother – and the legacy of Black exclusion from the ranks of medical officialdom. How African-Americans managed to be incorporated into professional medicine at all started almost by accident, Blackstock notes. “It was only after the Civil War, with thousands of injured veterans in desperate need of medical care, that a small handful of Black trainees began to be admitted to White medical schools in the North,” she writes. “And it wasn’t until Reconstruction that a number of Black medical schools sprung up in the South, enabling us to finally have access to medical training in large numbers.”
But, predictably, the movement didn’t last. A federal investigation conducted in the early 1900s by Abraham Flexner, an avowed racist, called for the shutting down of fledgling Black medical schools, arguing that African-Americans should be limited to the role of lower-level “sanitarians” catering to the needs of Whites and not be granted full-fledged MD status. Most – but not all – of the Black medical schools then in existence were shuttered; there was a stigma of 
second-class status attached to African-Africans in the field of professional medicine that endured for decades, Blackstock notes. She estimates that some 40,000 or more doctors might have entered the medical workforce had those Black medical schools survived, alleviating the current doctor shortage. Instead, only 5.7% of all US doctors today are African-American, well less half of the US population percentage that is Black – a woeful shortfall.
The experience of Blackstock’s mother – who attended and graduated from Harvard Medical School – was in some ways exceptional; she managed to break through the glass ceiling to become a trained and respected doctor. Even so, she soon found herself denied entry to the de facto White-only ranks of higher-level medical administration. Her father, a proud Jamaican immigrant who had been a small peasant land holder in his native land, likewise faced repeated denials of advancement in the public education field. Blackstock says she and her family shared their experiences of racism around the evening kitchen table but her parents were determined not to let their children internalize racial stigma or defer their dreams of advancement. She and her sister were constantly encouraged to excel in school – which they both did, with flying colors.
Blackstock’s critique of the effects of racism on African-American health and well-being is a searing one. It’s not just lack of health insurance or access to Black doctors that makes for substandard outcomes. It’s the entire pattern of segregated Black lives in housing and employment and the trauma of living with overt and covert racism that leaves so many African-Americans with reduced health status, she argues. Many African-Americans don’t have access to good jobs, schools or homes – thanks, in part, to blatant redlining – and they often lack the reliable transportation and income to shop for better food and attend better health facilities, all the while suffering higher levels of toxic exposure. Their circumscribed lives in inner-city enclaves keep them isolated and depressed and their men and children prone to asocial and self-destructive behavior, leading to high levels of depression and mental and emotional illnesses and reducing their life expectancy. Only a privileged few manage to escape this self-defeating cycle.
Blackstock rightly insists that the US public health establishment take into account the larger circumstances of African-American impoverishment as well as the stark limits still being placed on professional advancement in medicine. She, like her mother, was able to break through the barriers and graduate from Harvard Medical School, the creme de la creme. But she also catalogues many of the historic medical injustices imposed upon Black Americans – and rarely mentioned, if at all, in medical school – that she learned about only later – for example, the notorious Tuskegee Experiment, which saw hundreds of Black men treated as guinea pigs to test the ravages of untreated syphilis on the human body. Many other racist assumptions about African-Americans – some of them dating to slave times –are built into professional medical education, she notes, including the idea that Blacks have “naturally” stronger kidneys due to their presumably larger muscle mass – an assumption that has kept Blacks at a disadvantage when waiting for a kidney transplant list. “Throughout my medical education, differences between Black and white patients were passed off as information, as data, as the objective truth. No one made the point that using race as an aid in diagnosis might lead to bias and stereotyping, which in turn could lead to misdiagnosis, harming Black patients,” the author writes.
Blackstock’s mother never lived to see her daughter practice medicine. She died at the age of 47 from acute myeloid leukemia, a blood cancer disease (for which Blacks have a 38% 5-year survival rate compared to 55% for Whites). Blackstok watched her slowly wither away and pledged to carry on her legacy which she did by becoming an ER doctor at the same hospitals where her mother had worked, and then by joining the permanent faculty at the NYU School of Medicine. By working at a multicultural city hospital like Bellevue but also at an elite hospital like Tisch, she experienced the vast disparities in care and also the discomfort that her White patients felt being cared for by a Black doctor – and by a Black woman to boot. Many of her Tisch patients not only questioned her authority verbally to her face but deliberately tried to undermine it. “This was 21st century New York City. No one held signs over the doors of Tisch and Bellevue saying COLORED and WHITES, but even so these White patients seemed to sense that I must have walked through the wrong door” she writes.
The last part of Legacy brings Blackstock’s life story up to the present. It was the George Floyd riots and the emergence of Black Lives Matter – and then the COVID-19 pandemic – that was the final catalyst that prompted the writing of her book, she says. Despite some impressive gains – in society and medicine – systemic racism is alive and well. Health conditions for Black Americans have actually worsened over the past decade – the Black female mortality rate, for example, is now at the level it was 25 years ago, she notes. And while life expectancy declined slightly – by a year – for White Americans due to the pandemic, the figure for Black Americans – who struggled to gain equal access to the vaccine amid their own concerns and fears about its efficacy – was a full 3 years. Blacks were less likely to get tested for COVID and their mortality rates from the disease were also higher.
And consider this: in 2023, 5,665 Black people applied to US medical schools, about 10% of all applicants, according to the Association of American Medical Colleges (AAMC). That’s less than the share of Blacks in the US population. But it’s also a 4.3% decrease in applications from the previous year. And with the Trump administration’s crackdowns on DEI policies across the board, these numbers will likely get even worse in the years ahead.
Fittingly, Legacy ends where it began – with Blackstock’s mother. The Epilogue is one of the book’s most moving sections – and could well leave you in tears. Blackstock managed to uncover an essay her mother wrote – and got published – back in 1996 about African-Americans in medicine – which she quotes at length. Her mother’s words and concise expressive style will likely remind you of her daughter’s. In that essay her mother asked herself many of the same questions Blackstock asked – about whether and how to serve the world as a doctor, whether it’s worth the bigotry and abuse and the psychic toll it takes. Blackstock’s sister, Oni, also became a doctor, and like Uché, found the primary inspiration in the work and legacy of their Mom. Blackstock’s not so sure she wants her own two children to follow in her own footsteps knowing the challenges they will face. They’ve had lives of relative privilege; she wants to protect them from abuse, but she knows what a gift she received from her own mother, and what a powerful influence trained doctors can exert – on their patients and their profession.
“Our mother exposed us to the possibility that we could be physicians, too, and that was incredibly powerful seeing someone you love and admire doing this work. She cleared a path for us, so that all we had to do was follow in her wake,” she writes.
This is a fine plain-spoken book – part family memoir, part personal reflection and part incisive social criticism – that combines erudition and empathy on every page. It should be required reading in the public health field. One can only hope that in reading her story – and tens of thousands already have, in fact – more young African-Americans, especially women, might be inspired to pursue a full-time career in medicine and demand the same access to the influential citadels of medical training that Blackstock enjoyed, which would allow them to serve proudly whatever community might need them. Americans of all backgrounds face a panoply of outstanding public health problems – including chronic and preventable diseases that only seem to get worse with each passing year. The unmet needs of our communities – Black and White, Brown and Yellow, young and old – are as vast as ever. Not having enough trained and compassionate Black physicians isn’t just killing African-Americans – it’s killing all of us.
No comments:
Post a Comment