Black and Blue: The Origins and Consequences of Medical Racism

It is unusual for two African American psychiatrists to review a book, with a provocative title containing the “R” word, for the American Journal of Psychiatry (AJP). The request for an analysis of John Hoberman’s new text, Black and Blue: The Origins and Consequences of Medical Racism, came with a question about whether it warranted review at all in AJP. We agree that not only should a review of a book on this subject be published in AJP, but those in AJP’s audience who have an interest in the intersection of race and health should be introduced to Hoberman’s comprehensive work on this thorny and important subject. In fact, one of Hoberman’s assertions is that editorial gatekeepers have prevented the history of medical racism from being explored in medical literature. So from our vantage point, AJP readers and the medical profession have everything to gain from an honest, intellectual excursion into this subject. This is not to say that the going will be easy, as it requires some effort to follow the author’s wide-ranging argumentation, to sift through his substantial accumulation of data, to evaluate the reasoning he employs, and to weigh the political implications of his conclusions.

The first part of the book’s title, Black and Blue, suggests that we African Americans have been beaten up along the way or perhaps have just suffered a great deal over the years in seeking equal medical care in this country. But that’s the psychiatrist in us looking for metaphors. Hoberman is concrete from the start: the title draws sharp attention to the unfortunate state of the African American community’s health status in contemporary America. Disparities in health and mental health status are prevalent in the United States. Black people die sooner and live sicker than their white counterparts. In recent literature, these disparities have been associated with disproportionate exposure to the social determinants of health that include poverty, racial discrimination, unsafe and unhealthful living environments, limited educational opportunities, and misguided social policies.

Disparities have also been documented in the quality of care African Americans and other ethnically diverse population groups receive. The Institute of Medicine report, Unequal Treatment, presented a compelling review of the literature confirming that African Americans are more likely to receive substandard health care than whites and that this finding held even when socioeconomic status and other factors were controlled. Two of the explanations for substandard treatment of African Americans were negative stereotypes and unconscious bias.

In Black and Blue, Hoberman sets out to prove that racial disparities in health care are the result of racism. He energetically pulls together data to buttress his claim: the historic racism of the American Medical Association (AMA); color-blind writing in medicine; the little that is written about the effect of race on the physician-patient relationship; resistance of doctors to penetration of their private and independent practice of medicine; doctors’ ignorance of the history of medical racism; and their denial, even when they know the history. While these data may contribute to racial disparities, they cannot account for the total picture of unequal outcomes in medical care and cannot explain the notion that the disparities are the result of intentional actions based on race. And indeed, Hoberman acknowledges this by noting that other elements may contribute to the disparities, such as black patients’ social conditions; their unusual trauma histories; doctors’ own fears, biases, and psychological defenses; and oral traditions about black patients’ traits and medical characteristics. Hoberman quickly dismisses his own acknowledgment and continues on his trek to prove his major claim. But every reader will understand that in logically proving a point, one cannot dispense with bothersome facts. The result is that Hoberman does not prove his claim, and we are left to contend with the result that vexes all of us: health disparities are a fact of life in this country. The problem is complex, and many factors likely contribute to the existence of these disparities, including racism.

However, raising serious doubts about Hoberman’s principal theorem doesn’t deter him from continuing on the voyage that he has set for himself. That is at least partly why readers must be strong-willed and determined to stay the course. He goes on to criticize a number of groups and organizations. He blames them all for having some responsibility for these racial health care disparities and asserts that all the collectives should have done more to alleviate the suffering of those who come out on the dirty end of the inequalities. He attacks a long list of people, organizations, and areas of study, including the psychiatrist and public commentator Sally Satel, white physicians, medical researchers, Institute of Medicine reports, biomedical ethicists, the American Medical Association (AMA), the Department of Health and Human Services, and medical authors. He even holds medical journal editors responsible for not publishing manuscripts that focus on race-related issues, as though the editorial process relies solely on editors.

Nevertheless, our analysis and critique of Hoberman’s false equation does not detract from the value of the book to the extent that we should conclude there is nothing to recommend it. Black and Blue examines interesting territory. In fact, one of the book’s strengths is its extensive historical review of how African Americans have been viewed as medical subjects. The author documents numerous examples of what he refers to as “defamatory racial folklore,” wherein blacks were regarded as an infectious reservoir of disease, lacking in self-discipline and intelligence, biologically degenerate, submissive, primitive, savage, lazy, child-like, and sexually promiscuous. While it is impossible to know with certainty when and how these stereotypes were manifested in the medical care black patients received from white doctors, these disturbing descriptions of black people by white physicians are documented in the peer-reviewed medical literature from previous decades, including AJP. These characterizations were clearly made before the emergence of the concept of political correctness.

Another area of the text worth our attention is the consideration given to psychiatry. Our specialty receives a great deal of attention in Black and Blue. Stereotypes of the mental health status of blacks with terms like drapetomania, describing the inherent psychopathology of the runaway slave, at one end of the spectrum and at the opposite end denying that blacks were ever capable of being complex enough to present with depression or anxiety are just a few of the historical examples presented that exemplify yesteryear’s psychiatrists’ prejudiced views of African Americans. Hoberman goes on to point out how blacks’ own claims of their emotional hardiness and stoicism may have partly accounted for their unwillingness to seek psychological care. But white psychiatrists also relied on these claims to justify their own inattention to black patients.

Hoberman is at his best when he brings to the fore the history of medical racism in this country. This historical aspect of the narrative can stand on its own, without its having to be forced into the functional theorem of the book, in proving certain groups’ responsibility for health care disparities. So it is important to read his account of the AMA’s systematic bias against African American physicians and how the AMA kept them out of the organization for many years. And while the AMA in recent years issued an official apology to black physicians and has joined with the National Medical Association to form the Commission to End Healthcare Disparities, it is necessary that black and white physicians understand the history of this significant organization called the AMA. Of course, the unspoken point here is that many young psychiatrists have little knowledge of the history of APA’s participation in this narrative of medical racism.

There is one last important reason for reading this book. It concerns the indictment that Hoberman issues against all physicians and all medical associations. He challenges us to contemplate how much we have done to address the inequalities in medical care that black patients face and how much we have done to challenge the status quo and catalyze needed changes. If we have done nothing or little, we are therefore guilty of being complicit in the silence that surrounds this tragedy in American health care. Hoberman takes no prisoners here. He offers no sympathy and does no serious exploration of the reasons we might advance to account for how we have managed ourselves. We all have to look into our private mirrors, make our assessments, and talk with our inner selves about what we’ve done with our talents. But any book that can produce such contextualized introspection is worth reading.