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Dismantling racism in your personal and professional spheres
On May 25, 2020, George Floyd was murdered by a White police officer who held his knee on Floyd’s neck for nine and a half minutes. Nine and a half minutes. George Floyd was not the first Black person killed by law enforcement. He has not been the last. Much has been written about why Floyd’s murder sparked unprecedented worldwide outrage despite being far from unprecedented itself. We cannot be so naive as to think what happened was new, and we should not ignore the tireless work that so many have been doing to fight racism up to this point. But for many who have been stirred to do something for the first time, especially White people, the question has been,
“What do I do?” The answer is, do the work.
This article is centered on anti-Black racism with a focus on medicine. We recognize that there is racism against other minoritized groups. Each group deserves attention and to have their stories told. We recognize intersectionality and that an individual has multiple identities and that these may compound the marginalization they experience. This too deserves attention.
However, we cannot satisfactorily explore any of these concepts within the confines of a single article. Our intention is to use this forum to promote further conversation, specifically about anti-Black racism in medicine. We hope it compels you to begin learning to recognize and dismantle racism in yourself and your surroundings, both at home and at work.
Being a health care provider requires lifelong learning. If we practiced only what we learned in training, our patients could suffer. So we continually seek out updated research and guidelines to best treat our patients. Understanding how racism impacts your patients, colleagues, family, and friends is your responsibility as much as understanding guidelines for standards of care. We must resist the urge to feel this is someone else’s duty. It is the job of each and every one of us. We must do the work.
Race is real but it’s not biologic
It is imperative to understand that race is not a biologic category. Phenotypic differences between humans do not reliably map to racial categories. Racial categories themselves have morphed over the centuries, and interpretation of race has been litigated in this country since its founding.1 People who identify as a given race do not have inherent biology that is different from those who identify as another race. It may then be tempting to try to erase race from our thinking, and, indeed, the idea of being “color blind” was long worn as a badge of honor signifying a commitment to equality. So this is the tension: if race exists, it must be a biologic trait and with it must go other inherent traits. But if race is not a biologic entity, perhaps it is not real and, therefore, should be ignored. In fact, neither is true. Race is not based on genetic or biologic inheritance, but it is a social and political categorization that is real and has very real ramifications. As we will discuss further, race does have a biologic impact on individuals. The mechanism by which that happens is racism.
Continue to: What is racism, and who is racist?...
What is racism, and who is racist?
Various definitions of racism have been offered:
- prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is minoritized or marginalized2
- a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race3
- the systemic oppression of a racial group to the social, economic, and political advantage of another; a political or social system founded on racism and designed to execute its principles.3
The common themes in these definitions are power, hierarchy, and oppression. Racism is a fabricated system to justify and reinforce power for some and disenfranchisement for others based on race. The system is pervasive and beneficial to the group that it serves.
Ibram X. Kendi posits that all racism is structural racism: “‘Institutional racism’ and ‘structural racism’ and ‘systemic racism’ are redundant. Racism itself is institutional, structural, and systemic.”4 This is not saying that individuals don’t enact racism, but it emphasizes that racism is not the action of a “few bad apples.” Furthermore, it underscores that race was created to bolster power structures ensuring White dominance. The racism that has followed, in all of its forms, is both because these ideas were created in the first place and to perpetuate that ongoing power structure.4
Dorothy Roberts, JD, writes in her book Fatal Invention that, while grouping people and creating hierarchy has always happened amongst humans, there is a specific history in our country of using race to create and perpetuate the dominance of White people and the subjugation of Black people.
Kendi also asserts that there is no neutrality with regard to racism—there is racist and antiracist: “A racist: one who is supporting a racist policy through their actions or inaction or expressing a racist idea. An antiracist: one who is supporting an antiracist policy through their actions or expressing an antiracist idea.”4 He describes all people as moving in and out of being racist and antiracist, and states “being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination.”4 In thinking about race and racism in this way, we all must grapple with our own racism, but in so doing are taking a step toward antiracism.
History is important
Among the most important things one can do in a journey to dismantle racism is learn the history of racism.
The infrastructure and institutions of our nation were created on a foundation of slavery, including the origins of American medicine and gynecology. Physicians in the antebellum South performed inspections of enslaved people’s bodies to certify them for sale.5 The ability to assign market value to a Black person’s body was published as an essential physician competency.5
Gynecology has a particularly painful history with regard to slavery. By 1808, transatlantic slave trade was banned in the United States and, as Dr. Cooper Owens describes in her book Medical Bondage: Race, Gender, and the Origins of American Gynecology, this made reproduction of enslaved people within the United States a priority for slave owners and those invested in an economy that depended on slavery.6 Gynecologists were permitted unrestricted access to enslaved women for experiments to optimize reproduction. Many of these physicians became prominent voices adding to the canon of racialized medicine. Medical journals themselves gained reverence because of heightened interest in keeping enslaved people alive and just well enough to work and reproduce.6 Today, we hold sacred the relationship between a patient and their physician. We must understand that there was no such relationship between a doctor and an enslaved person. The relationship was between the doctor and slave owner.6,7 Slavery does not allow for the autonomy of the enslaved. This is the context in which we must understand the discoveries of gynecologists during that time.
Despite the abolition of slavery with the passage of the 13th amendment, racist policies remained ubiquitous in the United States. Segregation of Black people was codified not only in the Jim Crow South but also in the North. Interracial marriage was outlawed by all but 9 states.
While there are numerous federal policies that led to cumulative and egregious disadvantage for Black Americans, one powerful example is redlining. In 1934 the Federal Housing Administration was created, and by insuring private mortgages, the FHA made it easier for eligible home buyers to obtain financing. The FHA used a system of maps that graded neighborhoods. Racial composition of neighborhoods was overtly used as a component of grading, and the presence of Black people led a neighborhood to be downgraded or redlined.8,9 This meant Black people were largely ineligible for FHA-backed loans. In The Color of Law, Richard Rothstein writes, “Today’s residential segregation in the North, South, Midwest, and West is not the unintended consequence of individual choices and of otherwise well-meaning law or regulation but of unhidden public policy that explicitly segregated every metropolitan area in the United States.The policy was so systematic and forceful that its effects endure to the present time.”9
Though these specific policies are no longer in place, many correlations have been found between historically redlined neighborhoods and higher rates of diseases today, including diabetes, hypertension, asthma, and preterm deliveries.10 These policies also have played a role in creating the wealth gap—directly by limiting the opportunity for home ownership, which translates to intergenerational wealth, and indirectly by the disinvestment in neighborhoods where Black people live, leading to reduced access to quality education, decreased employment opportunities, and increased environmental hazards.8,11
Continue to: Health disparities...
Health disparities
The numerous health disparities, more accurately termed health inequities, suffered by racial minority groups is well documented.12
COVID-19 death and vaccination-rate inequities. Early in the COVID-19 pandemic, data emerged that racial minorities were being disparately affected.13 In December 2020, the Centers for Disease Control and Prevention (CDC) reported that Hispanic or Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native people had all died at higher rates than White Americans.14 These racial groups had higher hospitalization rates across age groups and, after adjusting for age, rates of hospitalization were 2.8 to 3.4 times higher.15 We are continuing to learn what factors contribute to these inequities, but it has highlighted how racist policies have led to disparate access to health care, or even clean air, clean water, and nutritious food, and left communities of color more vulnerable to severe illness and death from COVID-19. With the advent of vaccines for COVID-19, we continue to see racial disparities as Black Americans have the lowest rates of vaccination.16 All of these inequities have to be understood in the context of the racist structures that exist in our society. As medical providers, we must understand and help to dismantle these structures.
Pregnancy-related mortality (PRM) inequities. A powerful example of a persistent health inequity in our field is the well-known disparity in pregnancy-related mortality when examining this outcome by race. Per CDC analysis of data on PRM from 2007–2016, Black women died at a rate 3.2 times higher than White women. This disparity was even greater in patients older than 30 years of age. When they compared rates while controlling for the highest level of education, the disparity is even more pronounced: PRM rate for those with a college degree or higher was 5.2 times greater for Black people compared with White people.16The CDC also reported that, in 2018, the infant mortality for non-Hispanic Black infants was 10.8 per 1,000 live births, compared with 4.6 per 1,000 live births for White infants. This is a rate 2.4-times higher for Black infants.17 Dr. Cooper Owens and Dr. Fett note in their article, “Black maternal and infant health: Historical legacies of slavery,” that in 1850 this rate was 1.6-times higher for Black infants, which means the inequity was worse in 2018 America than in the antebellum South.5
The role of patient experience
As discussed, governmental policies have created persistent inequities in wealth, access to health care, and exposure to environmental toxins, among many other disparities. However, the data finding that highly educated Black pregnant patients suffer markedly increased risk of maternal death, indicate that inequities cannot be attributed only to education or lack of access to health care. This is where some will once again lean on the idea that there is something inherently different about Black people. But if we know that race was created and is not an empiric category, we must consider the social variables impacting Black patients’ experience.
As Linda Blount, President and CEO of the Black Women’s Health Imperative, put it, “Race is not a risk factor. It is the lived experience of being a Black woman in this society that is the risk factor.”18 So how much of these inequities can be accounted for by differential treatment of Black patients? There is, for example, data on the disproportionately lower rates of Black renal transplant recipients and inordinately higher rates of amputations among Black patients.19,20 None of us wants to think we are treating our Black patients differently, but the data demand that we ask ourselves if we are. Some of this is built into the system. For example, in their article “Hidden in plain sight—Reconsidering the use of race correction in clinical algorithms,” Vyas and colleagues outline a list of calculators and algorithms that include race.21 This means we may be using these calculators and changing outcomes for our patients based on their race. This is only one example of racism hidden within guidelines and standards of care.
The existence of racism on an interpersonal level also cannot be denied. This could lead to differential care specifically, but also can manifest by way of the toll it takes on a patient generally. This is the concept of allostatic load or weathering: the chronic stress of experiencing racism creates detrimental physiologic change. There is ongoing research into epigenetic modifications from stress that could be impacting health outcomes in Black populations.
Continue to: What is the work we need to do?...
What is the work we need to do?
Become educated. We have discussed taking the initiative to learn about the history of racism, including the legacies of slavery and the ongoing impact of racism on health. This knowledge is foundational and sometimes transformative. It allows us to see opportunities for antiracism and gives us the knowledge to begin meaningful conversations.
Take action. We must take inventory within our lives. What are our spheres of influence? What are our resources? Where can we make an impact? Right now, you can take out a pen and paper and write down all the roles you play. Look for opportunities in personal interactions and daily routines. Unfortunately, there will be many opportunities to speak up against racism—although this is rarely easy. Find articles, podcasts, and workshops on upstander training. One framework to respond to microaggressions has been proposed by faculty at Boston University Medical Center using the acronym LIFT (Lights on, Impact vs Intent, Full stop, Teach).22 It advises highlighting, clarifying, and directly addressing problematic comments with such statements as “I heard you say…” or “What did you mean by that comment?”, or a more direct “Statements like that are not OK with me,” or a teaching statement of “I read an article that made me think differently about comments like the one you made...”22 How and when to employ these strategies takes deliberate practice and will be uncomfortable. But we must do the work.
Practice empathetic listening. In a podcast discussion with Brené Brown on creating transformative cultures, Aiko Bethea, a leader in diversity and equity innovation, implores listeners to believe people of color.23,24 Draw on the history you’ve learned and understand the context in which Black people live in our society. Don’t brush off your Black friend who is upset about being stopped by security. That wasn’t the first time she was in that situation. Take seriously your patient’s concern that they are not being treated appropriately because of being Black. At the same time, do not think of Black people as a monolith or a stereotype. Respect people’s individuality.
Teach our kids all of this. We must also find ways to make change on a larger scale—within our practices, hospitals, medical schools, places of worship, town councils, school boards, state legislatures, and so on. If you are in a faculty position, you can reach out to leadership to scrutinize the curriculum while also ensuring that what and how you are teaching aligns with your antiracist principles. Question the theories, calculators, and algorithms being used and taught. Inquire about policies around recruitment of trainees and faculty as well as promotion, and implement strategies to make this inclusive and equitable. If you run a practice, you can ensure hiring and compensation policies are equitable. Examine patient access and barriers that your minoritized patients are facing, and address those barriers. Share resources and tools that you find helpful and develop a community of colleagues to develop with and hold one another accountable.
In her June 2020 article, An Open Letter to Corporate America, Philanthropy, Academia, etc: What now?, Bethea lays out an extensive framework for approaching antiracism at a high level.25 Among the principles she emphasizes is that the work of diversity, equity, and inclusion should not be siloed and cannot continue to be undervalued. It must be viewed as leadership and engaged in by leadership. The work of diversity, equity, and inclusion for any given institution must be explicit, intentional, measured, and transparent. Within that work, antiracism deserves individual attention. This work must center the people of color for whom you are pursuing equity. White people must resist the urge to make this about them.25
Drs. Esther Choo and J. Nwando Olayiwola present their proposals for combating racism in two 2020 Lancet articles.26,27 They discuss anticipating failure and backlash and learning from them but not being derailed by them. They emphasize the need for ongoing, serious financial investment and transformation in leadership. They also point out the need for data, discouraging more research on well-established inequities while recommending investigating interventions.26,27 If you are in leadership positions, read these articles and many more. Enact these principles. Make the investment. If you are not in such a position, find ways to hold your organization’s leadership accountable. Find ways to get a seat at the table and steer the conversation. In medicine, we have to make change at every level of our organizations. That will include the very difficult work of changing climate and culture. In addition, we have to look not only within our organizations but also to the communities we serve. Those voices must be valued in this conversation.
Will this take time? Yes. Will this be hard? Yes. Can you do everything? No. Can you do your part? Yes! Do the work.
- Roberts D. Fatal Invention: How Science, Politics and Big Business Re-create Race in the Twenty-First Century. The New Press: New York, New York; 2012.
- Definition of racism in English. Lexico web site. https://www.lexico. com/en/definition/racism. Accessed July 30, 2021.
- Definition of racism. Merriam-Webster web site. https://www .merriam-webster.com/dictionary/racism. Accessed July 30, 2021.
- Kendi IX. How To Be an Antiracist. One World: New York, NY; 2019.
- Cooper Owens D, Fett SM. Black maternal and infant health: historical legacies of slavery. Am J Public Health. 2019;109:1342-1345. doi: 10.2105/AJPH.2019.305243.
- Cooper Owens D. Medical Bondage: Race, Gender, and the Origins of American Gynecology. University of Georgia Press: Athens, GA; 2017.
- Washington H. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Anchor Books: New York, NY; 2006.
- Coates T. The case for reparations. The Atlantic. 2014;313.5:54-71.
- Rothstein R. The Color of the Law: A Forgotten History of How our Government Segregated America. Liveright Publishing Corporation: New York, NY; 2017.
- Nelson RK, Ayers EL; The Digital Scholarship Lab and the National Community Reinvestment Coalition. American Panorama, ed. Not Even Past: Social Vulnerability and the Legacy of Redlining. https://dsl.richmond.edu/socialvulnerability. Accessed July 30, 2021.
- Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105-125. doi: 10.1146 /annurev-publhealth-040218-043750.
- Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press: Washington, DC; 2003.
- Artiga S, Corallo B, Pham O. Racial disparities in COVID-19: key findings from available data and analysis. KFF web site. August 17, 2020. https://www.kff.org/racial-equity-and-health-policy/issue-brief /racial-disparities-covid-19-key-findings-available-data-analysis/. Accessed July 30, 2021.
- Disparities in deaths from COVID-19. Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019-ncov /community/health-equity/racial-ethnic-disparities/disparities -deaths.html. Updated December 10, 2020. Accessed July 30, 2021.
- Disparities in COVID-19 hospitalizations. Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019 -ncov/community/health-equity/racial-ethnic-disparities/disparities -hospitalization.html. Updated July 28, 2021. Accessed July 30, 2021.
- COVID data tracker. Centers for Disease Control and Prevention web site. https://covid.cdc.gov/covid-data-tracker/#vaccination -demographics-trends. Accessed July 30, 2021.
- Infant mortality. Centers for Disease Control and Prevention web site. https://www.cdc.gov/reproductivehealth/maternalinfanthealth /infantmortality.htm. Last reviewed September 2020. Accessed July 30, 2021.
- Roeder A. America is failing its Black mothers. Harvard Public Health. Winter 2019. https://www.hsph.harvard.edu/magazine/magazine _article/america-is-failing-its-black-mothers/. Accessed July 30, 2021.
- Ku E, Lee BK, McCulloch CE, et al. Racial and ethnic disparities in kidney transplant access within a theoretical context of medical eligibility. Transplantation. 2020;104:1437-1444. doi: 10.1097/TP .0000000000002962.
- Arya S, Binney Z, Khakharia A, et al. Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease. J Am Heart Assoc. 2018;7:e007425. doi: 10.1161 /JAHA.117.007425.
- Vyas DA, Eisenstein LG, Jones DS, et al. Hidden in plain sight— reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383:874-882. doi: 10.1056/NEJMms2004740.
- A Curriculum to Increase Faculty Engagement in the CLER Program. Boston University Medical Center web site. https://www.bumc .bu.edu/facdev-medicine/files/2020/05/Bystander-Training-for -Microaggressions-Executive-Summary.pdf. Accessed July 30, 2021.
- Brenè with Aiko Bethea on inclusivity at work: the heart of hard conversations. Spotify web site. https://open.spotify.com/episod e/3IODQ37EurkFf0zMNhazqI?si=wJIZgzpWTDCF1QVhwAdhiw. Accessed July 30, 2021.
- Brenè with Aiko Bethea on creating transformative cultures. Spotify web site. https://open.spotify.com/episode/7K47gQF5Ruc7MAXxEN q6jI?si=X0pzd2NnRAGwMD-bkyg-VQ. Accessed July 30, 2021.
- Bethea A. An open letter to corporate America, philanthropy, academia, etc.: What now? June 1, 2020. https://aikobethea.medium. com/an-open-letter-to-corporate-america-philanthropy-academiaetc-what-now-8b2d3a310f22. Accessed July 30, 2021.
- Choo E. Seven things organisations should be doing to combat racism. Lancet. 2020;396:157. doi:10.1016/S0140-6736(20)31565-8.
- Olayiwola JN, Choo E. Seven more things organisations should be doing to combat racism. Lancet. 2020;396:593. doi: 10.1016/S0140 -6736(20)31718-9.
On May 25, 2020, George Floyd was murdered by a White police officer who held his knee on Floyd’s neck for nine and a half minutes. Nine and a half minutes. George Floyd was not the first Black person killed by law enforcement. He has not been the last. Much has been written about why Floyd’s murder sparked unprecedented worldwide outrage despite being far from unprecedented itself. We cannot be so naive as to think what happened was new, and we should not ignore the tireless work that so many have been doing to fight racism up to this point. But for many who have been stirred to do something for the first time, especially White people, the question has been,
“What do I do?” The answer is, do the work.
This article is centered on anti-Black racism with a focus on medicine. We recognize that there is racism against other minoritized groups. Each group deserves attention and to have their stories told. We recognize intersectionality and that an individual has multiple identities and that these may compound the marginalization they experience. This too deserves attention.
However, we cannot satisfactorily explore any of these concepts within the confines of a single article. Our intention is to use this forum to promote further conversation, specifically about anti-Black racism in medicine. We hope it compels you to begin learning to recognize and dismantle racism in yourself and your surroundings, both at home and at work.
Being a health care provider requires lifelong learning. If we practiced only what we learned in training, our patients could suffer. So we continually seek out updated research and guidelines to best treat our patients. Understanding how racism impacts your patients, colleagues, family, and friends is your responsibility as much as understanding guidelines for standards of care. We must resist the urge to feel this is someone else’s duty. It is the job of each and every one of us. We must do the work.
Race is real but it’s not biologic
It is imperative to understand that race is not a biologic category. Phenotypic differences between humans do not reliably map to racial categories. Racial categories themselves have morphed over the centuries, and interpretation of race has been litigated in this country since its founding.1 People who identify as a given race do not have inherent biology that is different from those who identify as another race. It may then be tempting to try to erase race from our thinking, and, indeed, the idea of being “color blind” was long worn as a badge of honor signifying a commitment to equality. So this is the tension: if race exists, it must be a biologic trait and with it must go other inherent traits. But if race is not a biologic entity, perhaps it is not real and, therefore, should be ignored. In fact, neither is true. Race is not based on genetic or biologic inheritance, but it is a social and political categorization that is real and has very real ramifications. As we will discuss further, race does have a biologic impact on individuals. The mechanism by which that happens is racism.
Continue to: What is racism, and who is racist?...
What is racism, and who is racist?
Various definitions of racism have been offered:
- prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is minoritized or marginalized2
- a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race3
- the systemic oppression of a racial group to the social, economic, and political advantage of another; a political or social system founded on racism and designed to execute its principles.3
The common themes in these definitions are power, hierarchy, and oppression. Racism is a fabricated system to justify and reinforce power for some and disenfranchisement for others based on race. The system is pervasive and beneficial to the group that it serves.
Ibram X. Kendi posits that all racism is structural racism: “‘Institutional racism’ and ‘structural racism’ and ‘systemic racism’ are redundant. Racism itself is institutional, structural, and systemic.”4 This is not saying that individuals don’t enact racism, but it emphasizes that racism is not the action of a “few bad apples.” Furthermore, it underscores that race was created to bolster power structures ensuring White dominance. The racism that has followed, in all of its forms, is both because these ideas were created in the first place and to perpetuate that ongoing power structure.4
Dorothy Roberts, JD, writes in her book Fatal Invention that, while grouping people and creating hierarchy has always happened amongst humans, there is a specific history in our country of using race to create and perpetuate the dominance of White people and the subjugation of Black people.
Kendi also asserts that there is no neutrality with regard to racism—there is racist and antiracist: “A racist: one who is supporting a racist policy through their actions or inaction or expressing a racist idea. An antiracist: one who is supporting an antiracist policy through their actions or expressing an antiracist idea.”4 He describes all people as moving in and out of being racist and antiracist, and states “being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination.”4 In thinking about race and racism in this way, we all must grapple with our own racism, but in so doing are taking a step toward antiracism.
History is important
Among the most important things one can do in a journey to dismantle racism is learn the history of racism.
The infrastructure and institutions of our nation were created on a foundation of slavery, including the origins of American medicine and gynecology. Physicians in the antebellum South performed inspections of enslaved people’s bodies to certify them for sale.5 The ability to assign market value to a Black person’s body was published as an essential physician competency.5
Gynecology has a particularly painful history with regard to slavery. By 1808, transatlantic slave trade was banned in the United States and, as Dr. Cooper Owens describes in her book Medical Bondage: Race, Gender, and the Origins of American Gynecology, this made reproduction of enslaved people within the United States a priority for slave owners and those invested in an economy that depended on slavery.6 Gynecologists were permitted unrestricted access to enslaved women for experiments to optimize reproduction. Many of these physicians became prominent voices adding to the canon of racialized medicine. Medical journals themselves gained reverence because of heightened interest in keeping enslaved people alive and just well enough to work and reproduce.6 Today, we hold sacred the relationship between a patient and their physician. We must understand that there was no such relationship between a doctor and an enslaved person. The relationship was between the doctor and slave owner.6,7 Slavery does not allow for the autonomy of the enslaved. This is the context in which we must understand the discoveries of gynecologists during that time.
Despite the abolition of slavery with the passage of the 13th amendment, racist policies remained ubiquitous in the United States. Segregation of Black people was codified not only in the Jim Crow South but also in the North. Interracial marriage was outlawed by all but 9 states.
While there are numerous federal policies that led to cumulative and egregious disadvantage for Black Americans, one powerful example is redlining. In 1934 the Federal Housing Administration was created, and by insuring private mortgages, the FHA made it easier for eligible home buyers to obtain financing. The FHA used a system of maps that graded neighborhoods. Racial composition of neighborhoods was overtly used as a component of grading, and the presence of Black people led a neighborhood to be downgraded or redlined.8,9 This meant Black people were largely ineligible for FHA-backed loans. In The Color of Law, Richard Rothstein writes, “Today’s residential segregation in the North, South, Midwest, and West is not the unintended consequence of individual choices and of otherwise well-meaning law or regulation but of unhidden public policy that explicitly segregated every metropolitan area in the United States.The policy was so systematic and forceful that its effects endure to the present time.”9
Though these specific policies are no longer in place, many correlations have been found between historically redlined neighborhoods and higher rates of diseases today, including diabetes, hypertension, asthma, and preterm deliveries.10 These policies also have played a role in creating the wealth gap—directly by limiting the opportunity for home ownership, which translates to intergenerational wealth, and indirectly by the disinvestment in neighborhoods where Black people live, leading to reduced access to quality education, decreased employment opportunities, and increased environmental hazards.8,11
Continue to: Health disparities...
Health disparities
The numerous health disparities, more accurately termed health inequities, suffered by racial minority groups is well documented.12
COVID-19 death and vaccination-rate inequities. Early in the COVID-19 pandemic, data emerged that racial minorities were being disparately affected.13 In December 2020, the Centers for Disease Control and Prevention (CDC) reported that Hispanic or Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native people had all died at higher rates than White Americans.14 These racial groups had higher hospitalization rates across age groups and, after adjusting for age, rates of hospitalization were 2.8 to 3.4 times higher.15 We are continuing to learn what factors contribute to these inequities, but it has highlighted how racist policies have led to disparate access to health care, or even clean air, clean water, and nutritious food, and left communities of color more vulnerable to severe illness and death from COVID-19. With the advent of vaccines for COVID-19, we continue to see racial disparities as Black Americans have the lowest rates of vaccination.16 All of these inequities have to be understood in the context of the racist structures that exist in our society. As medical providers, we must understand and help to dismantle these structures.
Pregnancy-related mortality (PRM) inequities. A powerful example of a persistent health inequity in our field is the well-known disparity in pregnancy-related mortality when examining this outcome by race. Per CDC analysis of data on PRM from 2007–2016, Black women died at a rate 3.2 times higher than White women. This disparity was even greater in patients older than 30 years of age. When they compared rates while controlling for the highest level of education, the disparity is even more pronounced: PRM rate for those with a college degree or higher was 5.2 times greater for Black people compared with White people.16The CDC also reported that, in 2018, the infant mortality for non-Hispanic Black infants was 10.8 per 1,000 live births, compared with 4.6 per 1,000 live births for White infants. This is a rate 2.4-times higher for Black infants.17 Dr. Cooper Owens and Dr. Fett note in their article, “Black maternal and infant health: Historical legacies of slavery,” that in 1850 this rate was 1.6-times higher for Black infants, which means the inequity was worse in 2018 America than in the antebellum South.5
The role of patient experience
As discussed, governmental policies have created persistent inequities in wealth, access to health care, and exposure to environmental toxins, among many other disparities. However, the data finding that highly educated Black pregnant patients suffer markedly increased risk of maternal death, indicate that inequities cannot be attributed only to education or lack of access to health care. This is where some will once again lean on the idea that there is something inherently different about Black people. But if we know that race was created and is not an empiric category, we must consider the social variables impacting Black patients’ experience.
As Linda Blount, President and CEO of the Black Women’s Health Imperative, put it, “Race is not a risk factor. It is the lived experience of being a Black woman in this society that is the risk factor.”18 So how much of these inequities can be accounted for by differential treatment of Black patients? There is, for example, data on the disproportionately lower rates of Black renal transplant recipients and inordinately higher rates of amputations among Black patients.19,20 None of us wants to think we are treating our Black patients differently, but the data demand that we ask ourselves if we are. Some of this is built into the system. For example, in their article “Hidden in plain sight—Reconsidering the use of race correction in clinical algorithms,” Vyas and colleagues outline a list of calculators and algorithms that include race.21 This means we may be using these calculators and changing outcomes for our patients based on their race. This is only one example of racism hidden within guidelines and standards of care.
The existence of racism on an interpersonal level also cannot be denied. This could lead to differential care specifically, but also can manifest by way of the toll it takes on a patient generally. This is the concept of allostatic load or weathering: the chronic stress of experiencing racism creates detrimental physiologic change. There is ongoing research into epigenetic modifications from stress that could be impacting health outcomes in Black populations.
Continue to: What is the work we need to do?...
What is the work we need to do?
Become educated. We have discussed taking the initiative to learn about the history of racism, including the legacies of slavery and the ongoing impact of racism on health. This knowledge is foundational and sometimes transformative. It allows us to see opportunities for antiracism and gives us the knowledge to begin meaningful conversations.
Take action. We must take inventory within our lives. What are our spheres of influence? What are our resources? Where can we make an impact? Right now, you can take out a pen and paper and write down all the roles you play. Look for opportunities in personal interactions and daily routines. Unfortunately, there will be many opportunities to speak up against racism—although this is rarely easy. Find articles, podcasts, and workshops on upstander training. One framework to respond to microaggressions has been proposed by faculty at Boston University Medical Center using the acronym LIFT (Lights on, Impact vs Intent, Full stop, Teach).22 It advises highlighting, clarifying, and directly addressing problematic comments with such statements as “I heard you say…” or “What did you mean by that comment?”, or a more direct “Statements like that are not OK with me,” or a teaching statement of “I read an article that made me think differently about comments like the one you made...”22 How and when to employ these strategies takes deliberate practice and will be uncomfortable. But we must do the work.
Practice empathetic listening. In a podcast discussion with Brené Brown on creating transformative cultures, Aiko Bethea, a leader in diversity and equity innovation, implores listeners to believe people of color.23,24 Draw on the history you’ve learned and understand the context in which Black people live in our society. Don’t brush off your Black friend who is upset about being stopped by security. That wasn’t the first time she was in that situation. Take seriously your patient’s concern that they are not being treated appropriately because of being Black. At the same time, do not think of Black people as a monolith or a stereotype. Respect people’s individuality.
Teach our kids all of this. We must also find ways to make change on a larger scale—within our practices, hospitals, medical schools, places of worship, town councils, school boards, state legislatures, and so on. If you are in a faculty position, you can reach out to leadership to scrutinize the curriculum while also ensuring that what and how you are teaching aligns with your antiracist principles. Question the theories, calculators, and algorithms being used and taught. Inquire about policies around recruitment of trainees and faculty as well as promotion, and implement strategies to make this inclusive and equitable. If you run a practice, you can ensure hiring and compensation policies are equitable. Examine patient access and barriers that your minoritized patients are facing, and address those barriers. Share resources and tools that you find helpful and develop a community of colleagues to develop with and hold one another accountable.
In her June 2020 article, An Open Letter to Corporate America, Philanthropy, Academia, etc: What now?, Bethea lays out an extensive framework for approaching antiracism at a high level.25 Among the principles she emphasizes is that the work of diversity, equity, and inclusion should not be siloed and cannot continue to be undervalued. It must be viewed as leadership and engaged in by leadership. The work of diversity, equity, and inclusion for any given institution must be explicit, intentional, measured, and transparent. Within that work, antiracism deserves individual attention. This work must center the people of color for whom you are pursuing equity. White people must resist the urge to make this about them.25
Drs. Esther Choo and J. Nwando Olayiwola present their proposals for combating racism in two 2020 Lancet articles.26,27 They discuss anticipating failure and backlash and learning from them but not being derailed by them. They emphasize the need for ongoing, serious financial investment and transformation in leadership. They also point out the need for data, discouraging more research on well-established inequities while recommending investigating interventions.26,27 If you are in leadership positions, read these articles and many more. Enact these principles. Make the investment. If you are not in such a position, find ways to hold your organization’s leadership accountable. Find ways to get a seat at the table and steer the conversation. In medicine, we have to make change at every level of our organizations. That will include the very difficult work of changing climate and culture. In addition, we have to look not only within our organizations but also to the communities we serve. Those voices must be valued in this conversation.
Will this take time? Yes. Will this be hard? Yes. Can you do everything? No. Can you do your part? Yes! Do the work.
On May 25, 2020, George Floyd was murdered by a White police officer who held his knee on Floyd’s neck for nine and a half minutes. Nine and a half minutes. George Floyd was not the first Black person killed by law enforcement. He has not been the last. Much has been written about why Floyd’s murder sparked unprecedented worldwide outrage despite being far from unprecedented itself. We cannot be so naive as to think what happened was new, and we should not ignore the tireless work that so many have been doing to fight racism up to this point. But for many who have been stirred to do something for the first time, especially White people, the question has been,
“What do I do?” The answer is, do the work.
This article is centered on anti-Black racism with a focus on medicine. We recognize that there is racism against other minoritized groups. Each group deserves attention and to have their stories told. We recognize intersectionality and that an individual has multiple identities and that these may compound the marginalization they experience. This too deserves attention.
However, we cannot satisfactorily explore any of these concepts within the confines of a single article. Our intention is to use this forum to promote further conversation, specifically about anti-Black racism in medicine. We hope it compels you to begin learning to recognize and dismantle racism in yourself and your surroundings, both at home and at work.
Being a health care provider requires lifelong learning. If we practiced only what we learned in training, our patients could suffer. So we continually seek out updated research and guidelines to best treat our patients. Understanding how racism impacts your patients, colleagues, family, and friends is your responsibility as much as understanding guidelines for standards of care. We must resist the urge to feel this is someone else’s duty. It is the job of each and every one of us. We must do the work.
Race is real but it’s not biologic
It is imperative to understand that race is not a biologic category. Phenotypic differences between humans do not reliably map to racial categories. Racial categories themselves have morphed over the centuries, and interpretation of race has been litigated in this country since its founding.1 People who identify as a given race do not have inherent biology that is different from those who identify as another race. It may then be tempting to try to erase race from our thinking, and, indeed, the idea of being “color blind” was long worn as a badge of honor signifying a commitment to equality. So this is the tension: if race exists, it must be a biologic trait and with it must go other inherent traits. But if race is not a biologic entity, perhaps it is not real and, therefore, should be ignored. In fact, neither is true. Race is not based on genetic or biologic inheritance, but it is a social and political categorization that is real and has very real ramifications. As we will discuss further, race does have a biologic impact on individuals. The mechanism by which that happens is racism.
Continue to: What is racism, and who is racist?...
What is racism, and who is racist?
Various definitions of racism have been offered:
- prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is minoritized or marginalized2
- a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race3
- the systemic oppression of a racial group to the social, economic, and political advantage of another; a political or social system founded on racism and designed to execute its principles.3
The common themes in these definitions are power, hierarchy, and oppression. Racism is a fabricated system to justify and reinforce power for some and disenfranchisement for others based on race. The system is pervasive and beneficial to the group that it serves.
Ibram X. Kendi posits that all racism is structural racism: “‘Institutional racism’ and ‘structural racism’ and ‘systemic racism’ are redundant. Racism itself is institutional, structural, and systemic.”4 This is not saying that individuals don’t enact racism, but it emphasizes that racism is not the action of a “few bad apples.” Furthermore, it underscores that race was created to bolster power structures ensuring White dominance. The racism that has followed, in all of its forms, is both because these ideas were created in the first place and to perpetuate that ongoing power structure.4
Dorothy Roberts, JD, writes in her book Fatal Invention that, while grouping people and creating hierarchy has always happened amongst humans, there is a specific history in our country of using race to create and perpetuate the dominance of White people and the subjugation of Black people.
Kendi also asserts that there is no neutrality with regard to racism—there is racist and antiracist: “A racist: one who is supporting a racist policy through their actions or inaction or expressing a racist idea. An antiracist: one who is supporting an antiracist policy through their actions or expressing an antiracist idea.”4 He describes all people as moving in and out of being racist and antiracist, and states “being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination.”4 In thinking about race and racism in this way, we all must grapple with our own racism, but in so doing are taking a step toward antiracism.
History is important
Among the most important things one can do in a journey to dismantle racism is learn the history of racism.
The infrastructure and institutions of our nation were created on a foundation of slavery, including the origins of American medicine and gynecology. Physicians in the antebellum South performed inspections of enslaved people’s bodies to certify them for sale.5 The ability to assign market value to a Black person’s body was published as an essential physician competency.5
Gynecology has a particularly painful history with regard to slavery. By 1808, transatlantic slave trade was banned in the United States and, as Dr. Cooper Owens describes in her book Medical Bondage: Race, Gender, and the Origins of American Gynecology, this made reproduction of enslaved people within the United States a priority for slave owners and those invested in an economy that depended on slavery.6 Gynecologists were permitted unrestricted access to enslaved women for experiments to optimize reproduction. Many of these physicians became prominent voices adding to the canon of racialized medicine. Medical journals themselves gained reverence because of heightened interest in keeping enslaved people alive and just well enough to work and reproduce.6 Today, we hold sacred the relationship between a patient and their physician. We must understand that there was no such relationship between a doctor and an enslaved person. The relationship was between the doctor and slave owner.6,7 Slavery does not allow for the autonomy of the enslaved. This is the context in which we must understand the discoveries of gynecologists during that time.
Despite the abolition of slavery with the passage of the 13th amendment, racist policies remained ubiquitous in the United States. Segregation of Black people was codified not only in the Jim Crow South but also in the North. Interracial marriage was outlawed by all but 9 states.
While there are numerous federal policies that led to cumulative and egregious disadvantage for Black Americans, one powerful example is redlining. In 1934 the Federal Housing Administration was created, and by insuring private mortgages, the FHA made it easier for eligible home buyers to obtain financing. The FHA used a system of maps that graded neighborhoods. Racial composition of neighborhoods was overtly used as a component of grading, and the presence of Black people led a neighborhood to be downgraded or redlined.8,9 This meant Black people were largely ineligible for FHA-backed loans. In The Color of Law, Richard Rothstein writes, “Today’s residential segregation in the North, South, Midwest, and West is not the unintended consequence of individual choices and of otherwise well-meaning law or regulation but of unhidden public policy that explicitly segregated every metropolitan area in the United States.The policy was so systematic and forceful that its effects endure to the present time.”9
Though these specific policies are no longer in place, many correlations have been found between historically redlined neighborhoods and higher rates of diseases today, including diabetes, hypertension, asthma, and preterm deliveries.10 These policies also have played a role in creating the wealth gap—directly by limiting the opportunity for home ownership, which translates to intergenerational wealth, and indirectly by the disinvestment in neighborhoods where Black people live, leading to reduced access to quality education, decreased employment opportunities, and increased environmental hazards.8,11
Continue to: Health disparities...
Health disparities
The numerous health disparities, more accurately termed health inequities, suffered by racial minority groups is well documented.12
COVID-19 death and vaccination-rate inequities. Early in the COVID-19 pandemic, data emerged that racial minorities were being disparately affected.13 In December 2020, the Centers for Disease Control and Prevention (CDC) reported that Hispanic or Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native people had all died at higher rates than White Americans.14 These racial groups had higher hospitalization rates across age groups and, after adjusting for age, rates of hospitalization were 2.8 to 3.4 times higher.15 We are continuing to learn what factors contribute to these inequities, but it has highlighted how racist policies have led to disparate access to health care, or even clean air, clean water, and nutritious food, and left communities of color more vulnerable to severe illness and death from COVID-19. With the advent of vaccines for COVID-19, we continue to see racial disparities as Black Americans have the lowest rates of vaccination.16 All of these inequities have to be understood in the context of the racist structures that exist in our society. As medical providers, we must understand and help to dismantle these structures.
Pregnancy-related mortality (PRM) inequities. A powerful example of a persistent health inequity in our field is the well-known disparity in pregnancy-related mortality when examining this outcome by race. Per CDC analysis of data on PRM from 2007–2016, Black women died at a rate 3.2 times higher than White women. This disparity was even greater in patients older than 30 years of age. When they compared rates while controlling for the highest level of education, the disparity is even more pronounced: PRM rate for those with a college degree or higher was 5.2 times greater for Black people compared with White people.16The CDC also reported that, in 2018, the infant mortality for non-Hispanic Black infants was 10.8 per 1,000 live births, compared with 4.6 per 1,000 live births for White infants. This is a rate 2.4-times higher for Black infants.17 Dr. Cooper Owens and Dr. Fett note in their article, “Black maternal and infant health: Historical legacies of slavery,” that in 1850 this rate was 1.6-times higher for Black infants, which means the inequity was worse in 2018 America than in the antebellum South.5
The role of patient experience
As discussed, governmental policies have created persistent inequities in wealth, access to health care, and exposure to environmental toxins, among many other disparities. However, the data finding that highly educated Black pregnant patients suffer markedly increased risk of maternal death, indicate that inequities cannot be attributed only to education or lack of access to health care. This is where some will once again lean on the idea that there is something inherently different about Black people. But if we know that race was created and is not an empiric category, we must consider the social variables impacting Black patients’ experience.
As Linda Blount, President and CEO of the Black Women’s Health Imperative, put it, “Race is not a risk factor. It is the lived experience of being a Black woman in this society that is the risk factor.”18 So how much of these inequities can be accounted for by differential treatment of Black patients? There is, for example, data on the disproportionately lower rates of Black renal transplant recipients and inordinately higher rates of amputations among Black patients.19,20 None of us wants to think we are treating our Black patients differently, but the data demand that we ask ourselves if we are. Some of this is built into the system. For example, in their article “Hidden in plain sight—Reconsidering the use of race correction in clinical algorithms,” Vyas and colleagues outline a list of calculators and algorithms that include race.21 This means we may be using these calculators and changing outcomes for our patients based on their race. This is only one example of racism hidden within guidelines and standards of care.
The existence of racism on an interpersonal level also cannot be denied. This could lead to differential care specifically, but also can manifest by way of the toll it takes on a patient generally. This is the concept of allostatic load or weathering: the chronic stress of experiencing racism creates detrimental physiologic change. There is ongoing research into epigenetic modifications from stress that could be impacting health outcomes in Black populations.
Continue to: What is the work we need to do?...
What is the work we need to do?
Become educated. We have discussed taking the initiative to learn about the history of racism, including the legacies of slavery and the ongoing impact of racism on health. This knowledge is foundational and sometimes transformative. It allows us to see opportunities for antiracism and gives us the knowledge to begin meaningful conversations.
Take action. We must take inventory within our lives. What are our spheres of influence? What are our resources? Where can we make an impact? Right now, you can take out a pen and paper and write down all the roles you play. Look for opportunities in personal interactions and daily routines. Unfortunately, there will be many opportunities to speak up against racism—although this is rarely easy. Find articles, podcasts, and workshops on upstander training. One framework to respond to microaggressions has been proposed by faculty at Boston University Medical Center using the acronym LIFT (Lights on, Impact vs Intent, Full stop, Teach).22 It advises highlighting, clarifying, and directly addressing problematic comments with such statements as “I heard you say…” or “What did you mean by that comment?”, or a more direct “Statements like that are not OK with me,” or a teaching statement of “I read an article that made me think differently about comments like the one you made...”22 How and when to employ these strategies takes deliberate practice and will be uncomfortable. But we must do the work.
Practice empathetic listening. In a podcast discussion with Brené Brown on creating transformative cultures, Aiko Bethea, a leader in diversity and equity innovation, implores listeners to believe people of color.23,24 Draw on the history you’ve learned and understand the context in which Black people live in our society. Don’t brush off your Black friend who is upset about being stopped by security. That wasn’t the first time she was in that situation. Take seriously your patient’s concern that they are not being treated appropriately because of being Black. At the same time, do not think of Black people as a monolith or a stereotype. Respect people’s individuality.
Teach our kids all of this. We must also find ways to make change on a larger scale—within our practices, hospitals, medical schools, places of worship, town councils, school boards, state legislatures, and so on. If you are in a faculty position, you can reach out to leadership to scrutinize the curriculum while also ensuring that what and how you are teaching aligns with your antiracist principles. Question the theories, calculators, and algorithms being used and taught. Inquire about policies around recruitment of trainees and faculty as well as promotion, and implement strategies to make this inclusive and equitable. If you run a practice, you can ensure hiring and compensation policies are equitable. Examine patient access and barriers that your minoritized patients are facing, and address those barriers. Share resources and tools that you find helpful and develop a community of colleagues to develop with and hold one another accountable.
In her June 2020 article, An Open Letter to Corporate America, Philanthropy, Academia, etc: What now?, Bethea lays out an extensive framework for approaching antiracism at a high level.25 Among the principles she emphasizes is that the work of diversity, equity, and inclusion should not be siloed and cannot continue to be undervalued. It must be viewed as leadership and engaged in by leadership. The work of diversity, equity, and inclusion for any given institution must be explicit, intentional, measured, and transparent. Within that work, antiracism deserves individual attention. This work must center the people of color for whom you are pursuing equity. White people must resist the urge to make this about them.25
Drs. Esther Choo and J. Nwando Olayiwola present their proposals for combating racism in two 2020 Lancet articles.26,27 They discuss anticipating failure and backlash and learning from them but not being derailed by them. They emphasize the need for ongoing, serious financial investment and transformation in leadership. They also point out the need for data, discouraging more research on well-established inequities while recommending investigating interventions.26,27 If you are in leadership positions, read these articles and many more. Enact these principles. Make the investment. If you are not in such a position, find ways to hold your organization’s leadership accountable. Find ways to get a seat at the table and steer the conversation. In medicine, we have to make change at every level of our organizations. That will include the very difficult work of changing climate and culture. In addition, we have to look not only within our organizations but also to the communities we serve. Those voices must be valued in this conversation.
Will this take time? Yes. Will this be hard? Yes. Can you do everything? No. Can you do your part? Yes! Do the work.
- Roberts D. Fatal Invention: How Science, Politics and Big Business Re-create Race in the Twenty-First Century. The New Press: New York, New York; 2012.
- Definition of racism in English. Lexico web site. https://www.lexico. com/en/definition/racism. Accessed July 30, 2021.
- Definition of racism. Merriam-Webster web site. https://www .merriam-webster.com/dictionary/racism. Accessed July 30, 2021.
- Kendi IX. How To Be an Antiracist. One World: New York, NY; 2019.
- Cooper Owens D, Fett SM. Black maternal and infant health: historical legacies of slavery. Am J Public Health. 2019;109:1342-1345. doi: 10.2105/AJPH.2019.305243.
- Cooper Owens D. Medical Bondage: Race, Gender, and the Origins of American Gynecology. University of Georgia Press: Athens, GA; 2017.
- Washington H. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Anchor Books: New York, NY; 2006.
- Coates T. The case for reparations. The Atlantic. 2014;313.5:54-71.
- Rothstein R. The Color of the Law: A Forgotten History of How our Government Segregated America. Liveright Publishing Corporation: New York, NY; 2017.
- Nelson RK, Ayers EL; The Digital Scholarship Lab and the National Community Reinvestment Coalition. American Panorama, ed. Not Even Past: Social Vulnerability and the Legacy of Redlining. https://dsl.richmond.edu/socialvulnerability. Accessed July 30, 2021.
- Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105-125. doi: 10.1146 /annurev-publhealth-040218-043750.
- Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press: Washington, DC; 2003.
- Artiga S, Corallo B, Pham O. Racial disparities in COVID-19: key findings from available data and analysis. KFF web site. August 17, 2020. https://www.kff.org/racial-equity-and-health-policy/issue-brief /racial-disparities-covid-19-key-findings-available-data-analysis/. Accessed July 30, 2021.
- Disparities in deaths from COVID-19. Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019-ncov /community/health-equity/racial-ethnic-disparities/disparities -deaths.html. Updated December 10, 2020. Accessed July 30, 2021.
- Disparities in COVID-19 hospitalizations. Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019 -ncov/community/health-equity/racial-ethnic-disparities/disparities -hospitalization.html. Updated July 28, 2021. Accessed July 30, 2021.
- COVID data tracker. Centers for Disease Control and Prevention web site. https://covid.cdc.gov/covid-data-tracker/#vaccination -demographics-trends. Accessed July 30, 2021.
- Infant mortality. Centers for Disease Control and Prevention web site. https://www.cdc.gov/reproductivehealth/maternalinfanthealth /infantmortality.htm. Last reviewed September 2020. Accessed July 30, 2021.
- Roeder A. America is failing its Black mothers. Harvard Public Health. Winter 2019. https://www.hsph.harvard.edu/magazine/magazine _article/america-is-failing-its-black-mothers/. Accessed July 30, 2021.
- Ku E, Lee BK, McCulloch CE, et al. Racial and ethnic disparities in kidney transplant access within a theoretical context of medical eligibility. Transplantation. 2020;104:1437-1444. doi: 10.1097/TP .0000000000002962.
- Arya S, Binney Z, Khakharia A, et al. Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease. J Am Heart Assoc. 2018;7:e007425. doi: 10.1161 /JAHA.117.007425.
- Vyas DA, Eisenstein LG, Jones DS, et al. Hidden in plain sight— reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383:874-882. doi: 10.1056/NEJMms2004740.
- A Curriculum to Increase Faculty Engagement in the CLER Program. Boston University Medical Center web site. https://www.bumc .bu.edu/facdev-medicine/files/2020/05/Bystander-Training-for -Microaggressions-Executive-Summary.pdf. Accessed July 30, 2021.
- Brenè with Aiko Bethea on inclusivity at work: the heart of hard conversations. Spotify web site. https://open.spotify.com/episod e/3IODQ37EurkFf0zMNhazqI?si=wJIZgzpWTDCF1QVhwAdhiw. Accessed July 30, 2021.
- Brenè with Aiko Bethea on creating transformative cultures. Spotify web site. https://open.spotify.com/episode/7K47gQF5Ruc7MAXxEN q6jI?si=X0pzd2NnRAGwMD-bkyg-VQ. Accessed July 30, 2021.
- Bethea A. An open letter to corporate America, philanthropy, academia, etc.: What now? June 1, 2020. https://aikobethea.medium. com/an-open-letter-to-corporate-america-philanthropy-academiaetc-what-now-8b2d3a310f22. Accessed July 30, 2021.
- Choo E. Seven things organisations should be doing to combat racism. Lancet. 2020;396:157. doi:10.1016/S0140-6736(20)31565-8.
- Olayiwola JN, Choo E. Seven more things organisations should be doing to combat racism. Lancet. 2020;396:593. doi: 10.1016/S0140 -6736(20)31718-9.
- Roberts D. Fatal Invention: How Science, Politics and Big Business Re-create Race in the Twenty-First Century. The New Press: New York, New York; 2012.
- Definition of racism in English. Lexico web site. https://www.lexico. com/en/definition/racism. Accessed July 30, 2021.
- Definition of racism. Merriam-Webster web site. https://www .merriam-webster.com/dictionary/racism. Accessed July 30, 2021.
- Kendi IX. How To Be an Antiracist. One World: New York, NY; 2019.
- Cooper Owens D, Fett SM. Black maternal and infant health: historical legacies of slavery. Am J Public Health. 2019;109:1342-1345. doi: 10.2105/AJPH.2019.305243.
- Cooper Owens D. Medical Bondage: Race, Gender, and the Origins of American Gynecology. University of Georgia Press: Athens, GA; 2017.
- Washington H. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Anchor Books: New York, NY; 2006.
- Coates T. The case for reparations. The Atlantic. 2014;313.5:54-71.
- Rothstein R. The Color of the Law: A Forgotten History of How our Government Segregated America. Liveright Publishing Corporation: New York, NY; 2017.
- Nelson RK, Ayers EL; The Digital Scholarship Lab and the National Community Reinvestment Coalition. American Panorama, ed. Not Even Past: Social Vulnerability and the Legacy of Redlining. https://dsl.richmond.edu/socialvulnerability. Accessed July 30, 2021.
- Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105-125. doi: 10.1146 /annurev-publhealth-040218-043750.
- Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press: Washington, DC; 2003.
- Artiga S, Corallo B, Pham O. Racial disparities in COVID-19: key findings from available data and analysis. KFF web site. August 17, 2020. https://www.kff.org/racial-equity-and-health-policy/issue-brief /racial-disparities-covid-19-key-findings-available-data-analysis/. Accessed July 30, 2021.
- Disparities in deaths from COVID-19. Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019-ncov /community/health-equity/racial-ethnic-disparities/disparities -deaths.html. Updated December 10, 2020. Accessed July 30, 2021.
- Disparities in COVID-19 hospitalizations. Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019 -ncov/community/health-equity/racial-ethnic-disparities/disparities -hospitalization.html. Updated July 28, 2021. Accessed July 30, 2021.
- COVID data tracker. Centers for Disease Control and Prevention web site. https://covid.cdc.gov/covid-data-tracker/#vaccination -demographics-trends. Accessed July 30, 2021.
- Infant mortality. Centers for Disease Control and Prevention web site. https://www.cdc.gov/reproductivehealth/maternalinfanthealth /infantmortality.htm. Last reviewed September 2020. Accessed July 30, 2021.
- Roeder A. America is failing its Black mothers. Harvard Public Health. Winter 2019. https://www.hsph.harvard.edu/magazine/magazine _article/america-is-failing-its-black-mothers/. Accessed July 30, 2021.
- Ku E, Lee BK, McCulloch CE, et al. Racial and ethnic disparities in kidney transplant access within a theoretical context of medical eligibility. Transplantation. 2020;104:1437-1444. doi: 10.1097/TP .0000000000002962.
- Arya S, Binney Z, Khakharia A, et al. Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease. J Am Heart Assoc. 2018;7:e007425. doi: 10.1161 /JAHA.117.007425.
- Vyas DA, Eisenstein LG, Jones DS, et al. Hidden in plain sight— reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383:874-882. doi: 10.1056/NEJMms2004740.
- A Curriculum to Increase Faculty Engagement in the CLER Program. Boston University Medical Center web site. https://www.bumc .bu.edu/facdev-medicine/files/2020/05/Bystander-Training-for -Microaggressions-Executive-Summary.pdf. Accessed July 30, 2021.
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