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Self-Perpetuating Mythology - the Degenerate Black Patient

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 Rene Bowser

Excerpted from Rene Bowser, Racial Bias in Medical Treatment, 105 Dickinson Law Review 365-383, 371-381 (Spring 2001) (71 footnotes)

 

To understand the dynamics that contribute to racial bias in medical treatment, this essay looks at clinical decision making from an institutional perspective. The striking replication of racial disparities across numerous medical diagnostic categories and in nearly every type of health care setting strongly suggests that more powerful forces are at work than the unconscious racism of some White physicians.

An institutional analysis is helpful for two principle reasons. First, it identifies and clarifies the symbiotic relationship between actors who discriminate, on the one hand, and specific organiza-tional practices, norms and processes that perpetuate discrim-ination, on the other. Moreover, an institutional analysis addresses the issue of effect and practice, rather than intent. Institutional actors may harbor no racial prejudice but, nevertheless may help perpetuate organizational patterns and processes that become self- sustaining and discriminatory.

Medical institutions, I suggest, carve up the world into mutually exclusive domains of Black and White, each possessing distinct meanings for physicians. These institutions express and recreate generally negative understandings about Black patients. Institutional bias in medicine is an unseen, self-sustaining force. This essay turns to New Institutionalism to explain how these institutions work.

New Institutionalism gives the term "institution" a distinct technical meaning; it refers to self-perpetuating patterns and practices made in reliance on taken-for-granted background knowledge, rather than organizations. These patterns and practices rely on and are antecedent to unspoken rules and unexamined background knowledge--the "natural facts of life" that any member of the organization knows.

Institutions in this technical sense are largely invisible and typically rely on an analogy to nature so as not to be seen as a contrived social arrangement formed to privilege one set of competing interests over another. Moreover, institutionalized, patterns and behaviors are reproduced because individuals can not conceive of alternatives, or view alternatives as unrealistic. Finally, institutions suffer from amnesia; the present is like no other period and, therefore, present patterns and practices share no link to the same activities performed in the past.

Not all institutions are racist. New Institutionalism defines institutional racism as those self-perpetuating patterns and practices made in reliance on taken-for-granted background knowledge about race that serve to lower a particular racial group's status.

What, then, are the institutions in medicine that produce and reinforce racial disparities in medical treatment? The first institu-tion, I argue, is the practice of conducting comparative medical studies of Blacks and Whites to understand the poorer health outcomes of Blacks. I refer to this institution as racialized research.

A. Racialized Research Makes African-Americans Sick

Researchers conduct comparative medical and epidemiological studies to explain observed differences in health outcomes between Blacks and Whites. This work uses race as a variable to explain differences in the incidence of disease among the "races", variations in health outcomes, differences in survival rates from all types of diseases, disparities in responses to treatments, and differences in the etiology or pathways of disease.

Collectively, racialized research constructs Black patients as degenerate in relation to the White norm. Blacks are viewed as biologically different, and this work frequently infers that there exists a genetic basis for disease in Blacks not found in Whites. Based on these differences, racialized research reports that Blacks respond more poorly to treatment, are more likely to die from expensive invasive medical procedures, and possess more virulent diseases and tumors. Further, racialized research suggests that Blacks are genetically disposed to a host of chronic diseases, including hypertension, obesity, prostate cancer, low-birth weight infants, left ventricular dysfunction, nicotine addiction, asthma, and Alzheimer's disease.

Numerous papers published in the modern medical literature also reference race as an independent risk factor related to survival from prostate cancer, breast cancer, lung cancer, brain cancer, colon cancer and esophageal cancer. Moreover, Blacks are viewed as having less favorable prognoses than White patients for other medical conditions such as Hodgkin's disease.

From a cultural perspective, Blacks are similarly viewed as degenerate in relation to the White norm. Racialized research suggests that Blacks are less likely to comply with medical treatment, less likely to be knowledgeable about their disease, less likely to view the disease as diminishing their quality of life, and less likely to be involved in promoting their own health.

Thus, as a general matter, racialized research collectively fosters the background understanding that "these sorts of people don't do well." Black difference and inferiority take on a rule-like status and constitute the unquestioned backgroundknowledge used by researchers studying Black health. As I argue below, this unconsidered background knowledge influences whether and how physicians treat Black patients.

The current search for biological difference is undeniably linked to the past. Historically, comparative medical studies were intentionally undertaken to identify biological differences in Blacks in order to stamp these individuals as inferior. The search for difference was synonymous with the search for inferiority. Medicine provided much of the theory and data that correlated differences in skin color, hair texture, physical appearance, and behavior between Blacks and Whites to confirm the superiority of Whites. Indeed, medicine played a crucial role in providing "scientific" justifications for slavery and Jim Crow laws.

While current methodologies are arguably more sophisticated, the institution of searching for difference is the same. Fullilove puts it this way:

All to often, when race is found to explain a significant portion of the variation in some health outcome, little is done to explain the meaning of the association. The result is that medical researchers act as if there were inherent--if undefined--differences between racial groups that, once signaled, require no further explanation. In an odd way, there is little difference at times between our modern science and the discredited practice of using science and medicine to justify slavery in the antebellum South: each assumes that racial differences are of unquestioned importance.

This is not to say that medical research is monolithic and that current practices have gone unquestioned. Thoughtful researchers have asked for a justification as to why "race" is so frequently used as a key variable in medical and epidemiological research, when only a small percentage of the variations between humans in total genetic material can be attributed to differences in "race", and why so many diseases are linked without proof to this small amount of diversity.

Race is a social construct, not a scientific reality. Geneticists have further shown that the differences between classically described racial groups account for only 10 percent of genetic variation (much of which is due to genes associated with skin color). This figure is only slightly greater than the 6 percent variation that exists between nations, such as the populations of France and Spain, or between different tribes in Africa. Furthermore, greater genetic variation exists within the populations categorized as Black and White than between these populations.

Consistent difference in one gene between populations is extremely rare and accounts for only a tiny proportion of total potential variation. The usually cited case, sickle cell anemia, is the unusual case. Such a single gene abnormality can be handled on its own merit without reference to dubious racial categories. Genetic variation in a single gene, such as that for sickle cell anemia in Blacks or Tay Sachs disease in Ashenazi Jews, does not imply that populations that possess that gene will vary in important ways for other health conditions. Such a false analogy would suggest that White Australians who possess a particular gene for skin cancer are predisposed to other diseases.

The recent sequencing of the human genome provides additional evidence that race has little biological meaning. As one scientist has pointed out:

In view of the sad part that race and ethnicity still play in most societies, concerns that genetic analyses of different human populations could be abused are appropriate. Fortunately, from the few studies of nuclear DNA sequences, it is clear that what is called 'race', although culturally important, reflects just a few continuous traits determined by a tiny fraction of our genes. This tiny fraction gives no indication of variations at other parts of our genome. Thus, from the perspective of nuclear genes, it is often the case that two persons from the same part of the world who look superficially alike are less related to each other than they are to persons from other parts of the world who look different.

Racialized research is also complicated by the problem of perception. In nearly all racialized research published in the United States, the comparison group has been the majority (White population). Far from being a neutral category, this approach consolidates Whites as the group with which all "others" should be compared; it also disregards research that demonstrates the value of studying variations in health among, say, African-Americans, as opposed to always comparing them with White Americans.

The use of the white body as the point of comparison is neither neutral nor objective. Whiteness is relational, and its use as a scientific variable is inherently laden with meanings about differ-ence, deviance and superiority. Whiteness as a variable obscures the heterogeneity among White populations and maintains White race consciousness. It also allows researchers to ignore the social, economic and political advantages of being White in the United States, and the implications of such White privilege for health.

As Osbourne and Feit have put it: "The social consequences of racial comparisons in medical publications may depend more on the perceptions that adverse comparisons reinforce in society than on the accuracy of the data, the intent of the authors, or the correctness of their interpretations."

After years of studying differences between Blacks and Whites, there is little evidence that such research has paid positive dividends to Blacks. As one prominent radiation and medical oncologist has noted: "Thus far the designation of race as a major health care variable has not resulted in the improvement of care for anyone. Those who have benefited most from such practices have been health care researchers."

In the face of such criticism, there must be reasons why the findings and conclusions of racialized research fill the pages of the most prominent medical journals. The explanation is complex, but at its simplest level, comparative research is self-sustaining because the scientific truth obtained from prior research, that Blacks are different, is accepted. The a priori sense of rightness of this background knowledge is unquestioned because it is founded on an analogy to nature. In the minds of some, it seems "natural" that people who have different genes for phenotypic traits like skin color should also possess different genes for physiological function.

Thus, to understand the inferior health status of Blacks in this country, researchers are institutionally channeled to look for the genetic difference that causes a susceptibility to disease and a lower survival rate once the disease has manifested itself. There are differences among the races. But, institutional amnesia causes them to ignore or forget the fact that, historically, racial construction did not occur in a vacuum, but in the context of a dominant ideology, perceived economic interests and psychological necessity.

Racialized research is maintained and perpetuated because many researchers can not imagine plausible alternative non-biological explanations of the inferior health status of African Americans. In the 19th century, progressive voices that argued that the poor health status of Blacks was due to racism, rather than innate racial differences, were silenced. Today, the institution of racialized medical research continues this intellectual apartheid; "White physicians who focus on racism as opposed to cultural peculiarities or the genetic basis of disease are likely to be considered both as not 'real scientists' and as dangerous."

Starting with a belief in Black biological differences and some statistical knowledge, a Black-White difference can almost always be found. Research grants and evidence of "hard" clinical research ability and productivity are vital in terms of prestige, recognition and promotion. Racialized research is a major industry, and showing difference enhances the researcher's status. As Kaufman and Cooper have pointed out: "Questionable techniques may be retained if they provide what is believed to be the 'right' answer, and in a society with deeply ingrained beliefs about racial differences, a scientific confirmation of these differences is the expected, and therefore the 'right', answer."

B. Bedside Bias and Racialized Research

Now the other half of the argument. This essay suggests that physicians rely on the findings and conclusions of racialized research in treating African-American patients. The result is a pattern or practice of less treatment. I refer to this institution as bedside bias.

In deciding whether or how to treat a Black patient, a physician's decision is guided by the institutional understandings about Black health. Clinical practice is increasingly evidence-based. The "best evidence" is generally studies from the biomedical literature that study treatment outcomes, survival rates, prognoses and the like. The dubious findings and conclusions of racialized research provide some of the "best evidence."

In a recent discussion on race and medicine, I asked a group of about forty fourth-year medical students whether they would recommend heart bypass surgery for a Black patient, given the fact that the "best evidence" points to a substantially lower survival rate for Blacks from this procedure. Although certainly not a scientific survey, several students stated that they would use such evidence in making a treatment decision based on a belief in the validity of the survival data; others stated that because their education is heavily evidence-based, they are expected to rely on such information. Black students, however, stated that they would not rely on this "best evidence" and, instead, would evaluate the patient on an individualized basis.

Reliance on the taken-for-granted medical knowledge about Black health also saves time and lowers transactions costs. Patient race is one of the leadoff indicators in clinical rounds and medical presentations. Physicians use race because they believe that it contains useful information, rather than being an unscientific, socially constructed concept. In this regard, Steven Caldwell argues that race "serves as little more than a 'jog' to the memory of busy clinicians."

White physicians spend less time with Black patients and frequently, do not include Black patients in clinical decision making. By relying on taken-for-granted background information, physicians may miss clinically relevant information, or assume the presence or absence of genetic or cultural factors that, in fact, may or may not be present. A physician might rule out autoimmune hepatitis in a Black patient presenting with symptoms of fever, malaise, weakness, nausea and abdominal distress because racial-ized research indicates that this form of hepatitis is associated with specific histocompatibility antigens, which are less prevalent in Blacks. Instead, the patient may be diagnosed with another form of hepatitis and given the incorrect treatment.

Of course, the cultural context of the physician/patient relationship is another important consideration. Patient race is associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient and beliefs about patients' likelihood of substance abuse and non- compliance. Moreover, physician education contributes to the formation of medical stereotypes. Group interaction and socialization into the medical profession sustain and reinforce these views.

The cultural context of the physician/patient encounter is indirectly linked to the institution of racialized research. The use of race as a scientific variable medicalizes difference; that is, it legitimates and naturalizes racial categories. The reliance on cultural stereotypes in the physician/patient encounter can be reconceptualized as institutional racism because it treats race as an unquestioned, natural part of the social order, and creates false and unconsidered good/bad dichotomies that lower the health status of Blacks.

Physicians, therefore, are not understood simply as unbiased agents of science who display affective neutrality and objectivity toward all patients. Indeed, assumptions about a disease can vary based on the patient's "race." As Harris argues, "[b]ackground assumptions that shape how the body is formally or informally categorized constitute its meaning for physicians."

Many of these background assumptions are formed from physician socialization and a reliance on the findings of racialized research. The utility of a given procedure is often decided a priori, without an individualized assessment of the patient's condition. It is known that these sorts of people don't do very well. Writing almost a century ago, W.E.B. Dubois made a similar observation: "We must not forget that most Americans answer all queries regarding the Negro a priori, and that the least the human courtesy can do is listen to the evidence.

 
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 03/10/2010

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