By Michele K. Evans, M.D., Lisa Rosenbaum, M.D., Debra Malina, Ph.D., Stephen Morrissey, Ph.D., and Eric J. Rubin, M.D., Ph.D.
The New England Journal of Medicine, June 10, 2020
The role of the physician in times of social injustice and societal distress is difficult to navigate. Since the importation of enslaved Africans as chattel to provide the labor that built this country began, Americans have functioned within the intricate injustices that are the vestiges of that institution. Slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to the present, and that legacy infects medicine as it does all social institutions.
In an effort to engender trust in what they would like to see as a “postracial” society, some U.S. clinicians proclaim that they ”don’t see color.” But color must be seen. By looking through a racially impervious lens, clinicians neglect the life experiences and historical inequities that shape patients and disease processes. They may inadvertently feed the robust structural racism that influences access to care, quality of care, and resultant health disparities.
In the review of systems, we query patients about exposure to toxicants, but we never ask about one of the most dangerous toxicants: racism. The work of David Williams details the morbidity and risk of death related to perceived discrimination. Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on black Americans and other minority populations.
Even as the social contract between the government and the American people has frayed in the complex struggle over the pandemic, racial injustice, and police brutality, physicians must reflect on the condition of medicine’s own contract with society. Our society expects physicians to live up to standards of professionalism, deliver state-of-the-art, timely care with competence and integrity, and promote the public good. To carry out these duties, physician-citizens must recognize the harm inflicted by discrimination and racism and consider this environmental agent of disease as a vital sign — alongside blood pressure, pulse, weight, and temperature — that provides important information about a patient’s condition. Medical skill has allowed us to respond rapidly to a novel virus to save lives; we must also use our expertise to address racism and injustice and to protect vulnerable people from harm.
Now, amid an acute public health crisis that is transforming medicine, perhaps we have an opportunity to reset our priorities to face this deeper, more chronic crisis as well. It is time to reimagine the medical interaction and the doctor–patient relationship, recommitting ourselves to the quiet work of doctoring and building trust with individual patients. We can become more conscious of our biases when we care for minority patients and push ourselves to go the extra mile.
As the vulnerability and inadequacy of our health care system are once again exposed, it is also time to reconceive that system, including the development of its workforce.
Direct action to eliminate persistent health disparities obliges us to redouble our demands for a system that recognizes health care as a human right, providing an avenue to health equity for all.
Although effecting such fundamental transformation may feel impossible, the energy, idealism, and visions of young people have long fueled movements for change. Martin Luther King, Jr., was 26 when he led the Montgomery bus boycott and 34 when he delivered his powerful “I have a dream” oration. If we blend our voices with those of the newest members of our profession to advocate for the most vulnerable and to reinvigorate every aspect of their care, perhaps we can use our current public health crisis as a catalyst to, as Reverend Al Sharpton put it, “turn this moment into a movement.”
The full article can be accessed for free at this link:
https://www.nejm.org…
Comment:
By Don McCanne, M.D.
We’ve heard these phrases before:
- “society expects physicians to promote the public good”
- “As the vulnerability and inadequacy of our health care system are once again exposed, it is time to reconceive that system”
- “a system that recognizes health care as a human right”
- “health equity for all”
- “turn this moment into a movement”
Nowhere in this article did the authors mention a universal, accessible, equitable, and efficiently-administered national health program – a single payer model of an improved Medicare for All – but that would provide a tremendous start and major contribution to a strong foundation for treating systemic racism. It’s doable and affordable.
Let’s turn this moment into a movement.
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