Tag: racism and racial discrimination

Black or ‘Other’? Doctors may be relying on race to make decisions about your health | CNN

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Editor’s Note: CNN’s “History Refocused” series features surprising and personal stories from America’s past to bring depth to conflicts still raging today.



CNN
 — 

When she first learned about race correction, Naomi Nkinsi was one of five Black medical students in her class at the University of Washington.

Nkinsi remembers the professor talking about an equation doctors use to measure kidney function. The professor said eGFR equations adjust for several variables, including the patient’s age, sex and race. When it comes to race, doctors have only two options: Black or “Other.”

Nkinsi was dumbfounded.

“It was really shocking to me,” says Nkinsi, now a third-year medical and masters of public health student, “to come into school and see that not only is there interpersonal racism between patients and physicians … there’s actually racism built into the very algorithms that we use.”

At the heart of a controversy brewing in America’s hospitals is a simple belief, medical students say: Math shouldn’t be racist.

The argument over race correction has raised questions about the scientific data doctors rely on to treat people of color. It’s attracted the attention of Congress and led to a big lawsuit against the NFL.

What happens next could affect how millions of Americans are treated.

Carolyn Roberts, a historian of medicine and science at Yale University, says slavery and the American medical system were in a codependent relationship for much of the 19th century and well into the 20th.

“They relied on one another to thrive,” Roberts says.

It was common to test experimental treatments first on Black people so they could be given to White people once proven safe. But when the goal was justifying slavery, doctors published articles alleging substantive physical differences between White and Black bodies — like Dr. Samuel Cartwright’s claim in 1851 that Black people have weaker lungs, which is why grueling work in the fields was essential (his words) to their progress.

The effects of Cartwright’s falsehood, and others like it, linger today.

In 2016, researchers asked White medical students and residents about 15 alleged differences between Black and White bodies. Forty percent of first-year medical students and 25% of residents said they believed Black people have thicker skin, and 7% of all students and residents surveyed said Black people have less sensitive nerve endings. The doctors-in-training who believed these myths — and they are myths — were less likely to prescribe adequate pain medication to Black patients.

To fight this kind of bias, hospitals urge doctors to rely on objective measures of health. Scientific equations tell physicians everything from how well your kidneys are working to whether or not you should have a natural birth after a C-section. They predict your risk of dying during heart surgery, evaluate brain damage and measure your lung capacity.

But what if these equations are also racially biased?

Race correction is the use of a patient’s race in a scientific equation that can influence how they are treated. In other words, some diagnostic algorithms and risk predictor tools adjust or “correct” their results based on a person’s race.

The New England Journal of Medicine article “Hidden in Plain Sight” includes a partial list of 13 medical equations that use race correction. Take the Vaginal Birth After Cesarean calculator, for example. Doctors use this calculator to predict the likelihood of a successful vaginal delivery after a prior C-section. If you are Black or Hispanic, your score is adjusted to show a lower chance of success. That means your doctor is more likely to encourage another C-section, which could put you at risk for blood loss, infection and a longer recovery period.

Cartwright, the racist doctor from the 1800s, also developed his own version of a tool called the spirometer to measure lung capacity. Doctors still use spirometers today, and most include a race correction for Black patients to account for their supposedly shallower breaths.

Turns out, second-year medical student Carina Seah wryly told CNN, math is as racist as the people who make it.

The biggest problem with using race in medicine? Race isn’t a biological category. It’s a social one.

“It’s based on this idea that human beings are naturally divided into these big groups called races,” says Dorothy Roberts, a professor of law and sociology at the University of Pennsylvania, who has made challenging race correction in medicine her life’s work. “But that’s not what race is. Race is a completely invented social category. The very idea that human beings are divided into races is a made-up idea.”

Ancestry is biological. Where we come from — or more accurately, who we come from — impacts our DNA. But a patient’s skin color isn’t always an accurate reflection of their ancestry.

Look at Tiger Woods, Roberts says. Woods coined the term “Cablinasian” to describe his mix of Caucasian, Black, American Indian and Asian ancestries. But to many Americans, he’s Black.

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“You can be half Black and half White in this country and you are Black,” says Seah, who is getting her medical degree and a PhD in genetics and genomics at the Icahn School of Medicine at Mount Sinai in New York. “You can be a quarter Black in this country — if you have dark skin, you are Black.”

So it can be misleading, Seah says, even dangerous, for doctors to judge a patient’s ancestry by glancing at their skin. A patient with a White mother and Black father could have a genetic mutation that typically presents in patients of European ancestry, Seah says, but a doctor may not think to test for it if they only see Black skin.

“You have to ask, how Black is Black enough?” Nkinsi asks. And there’s another problem, she says, with using a social construct like race in medicine. “It also puts the blame on the patient, and it puts the blame on the race itself. Like being Black is inherently the cause of these diseases.”

Naomi Nkinsi is a third-year medical and masters of public health student at the University of Washington in Seattle. She has been advocating for the removal of race correction in medicine.

After she learned about the eGFR equation in 2018, Nkinsi began asking questions about race correction. She wasn’t alone — on social media she found other students struggling with the use of race in medicine. In the spring of 2020, following a first-year physiology lecture, Seah joined the conversation. But the medical profession is nothing if not hierarchical; Nkinsi and Seah say students are encouraged to defer to doctors who have been practicing for decades.

Then on May 25, 2020, George Floyd was killed by police in Minneapolis.

His death and the growing momentum around Black Lives Matter helped ignite what Dr. Darshali A. Vyas calls an “overdue reckoning” in the medical community around race and race correction. A few institutions had already taken steps to remove race from the eGFR equation. Students across the country demanded more, and hospitals began to listen.

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Four days after Floyd’s death, the University of Washington announced it was removing race correction from the eGFR equation. In June, the Boston-based hospital system Mass General Brigham where Vyas is a second-year Internal Medicine resident followed suit. Seah and a fellow student at Mount Sinai, Paloma Orozco Scott, started an online petition and collected over 1600 signatures asking their hospital to do the same.

Studies show removing race from the eGFR equation will change how patients at those hospitals are treated. Researchers from Brigham and Women’s Hospital and Penn Medicine estimated up to one in every three Black patients with kidney disease would have been reclassified if the race multiplier wasn’t applied in earlier calculations, with a quarter going from stage 3 to stage 4 CKD (Chronic Kidney Disease).

That reclassification is good and bad, says Dr. Neil Powe, chief of medicine at Zuckerberg San Francisco General Hospital. Black patients newly diagnosed with kidney disease will be able to see specialists who can devise better treatment plans. And more patients will be placed on kidney transplant lists.

On the flip side, Powe says, more African Americans diagnosed with kidney disease means fewer who are eligible to donate kidneys, when there’s already a shortage. And a kidney disease diagnosis can change everything from a patient’s diabetes medication to their life insurance costs.

Dr. Neil Powe says by simply removing race from the eGFR equations,

Powe worries simply eliminating race from these equations is a knee-jerk response — one that may exacerbate health disparities instead of solve them. For too long, Powe says, doctors had to fight for diversity in medical studies.

The most recent eGFR equation, known as the CKD-EPI equation, was developed using data pooled from 26 studies, which included almost 3,000 patients who self-identified as Black. Researchers found the equation they were developing was more accurate for Black patients when it was adjusted by a factor of about 1.2. They didn’t determine exactly what was causing the difference in Black patients, but their conclusion is supported by other research that links Black race and African ancestry with higher levels of creatinine, a waste product filtered by the kidneys.

Put simply: In the eGFR equation, researchers used race as a substitute for an unknown factor because they think that factor is more common in people of African descent.

Last August, Vyas co-authored the “Hidden in Plain Sight” article about race correction. Vyas says most of the equations she wrote about were developed in a similar way to the eGFR formula: Researchers found Black people were more or less likely to have certain outcomes and decided race was worth including in the final equation, often without knowing the real cause of the link.

“When you go back to the original studies that validated (these equations), a lot of them did not provide any sort of rationale for why they include race, which I think is appalling.” That’s what’s most concerning, Vyas says – “how willing we are to believe that race is relevant in these ways.”

Vyas is clear she isn’t calling for race-blind medicine. Physicians cannot ignore structural racism, she says, and the impact it has on patients’ health.

Powe has been studying the racial disparities in kidney disease for more than 30 years. He can spout the statistics easily: Black people are three times more likely to suffer from kidney failure, and make up more than 35% of patients on dialysis in the US. The eGFR equation, he says, did not cause these disparities — they existed long before the formula.

“We want to cure disparities, let’s go after the things that really matter, some of which may be racist,” he says. “But to put all our stock and think that the equation is causing this is just wrong because it didn’t create those.”

In discussions about removing race correction, Powe likes to pose a question: Instead of normalizing to the “Other” group in the eGFR equation, as many of these hospitals are doing, why don’t we give everyone the value assigned to Black people? By ignoring the differences researchers saw, he says, “You’re taking the data on African Americans, and you’re throwing it in the trash.”

Powe is co-chair of a joint task force set up by the National Kidney Foundation and the American Society of Nephrology to look at the use of race in eGFR equations. The leaders of both organizations have publicly stated race should not be included in equations used to estimate kidney function. On April 9, the task force released an interim report that outlined the challenges in identifying and implementing a new equation that’s representative of all groups. The group is expected to issue its final recommendations for hospitals this summer.

Race correction is used to assess the kidneys and the lungs. What about the brain?

In 2013, the NFL settled a class-action lawsuit brought by thousands of former players and their families that accused the league of concealing what it knew about the dangers of concussions. The NFL agreed to pay $765 million, without admitting fault, to fund medical exams and compensate players for concussion-related health issues, among other things. Then in 2020, two retired players sued the NFL for allegedly discriminating against Black players who submitted claims in that settlement.

01 race correction Kevin Henry Najeh Davenport SPLIT

The players, Najeh Davenport and Kevin Henry, said the NFL race-corrected their neurological exams, which prevented them from being compensated.

According to court documents, former NFL players being evaluated for neurocognitive impairment were assumed to have started with worse cognitive function if they were Black. So if a Black player and a White player received the exact same scores on a battery of thinking and memory tests, the Black player would appear to have suffered less impairment. And therefore, the lawsuit stated, would be less likely to qualify for a payout.

Race correction is common in neuropsychology using something called Heaton norms, says Katherine Possin, an associate professor at the University of California San Francisco. Heaton norms are essentially benchmark average scores on cognitive tests.

Here’s how it works: To measure the impact of a concussion (or multiple concussions over time), doctors compare how well the patient’s brain works now to how well it worked before.

“The best way to get that baseline was to test you 10 years ago, but that’s not something we obviously have for many people,” Possin says. So doctors estimate your “before” abilities using an average score from a group of healthy individuals, and adjust that score for demographic factors known to affect brain function, like your age.

Heaton norms adjust for race, Possin says, because race has been linked in studies to lower cognitive scores. To be clear, that’s not because of any biological differences in Black and White brains, she says; it’s because of social factors like education and poverty that can impact cognitive development. And this is where the big problem lies.

In early March, a judge in Pennsylvania dismissed the players’ lawsuit and ordered a mediator to address concerns about how race correction was being used. In a statement to CNN, the NFL said there is no merit to the players’ claim of discrimination, but it is committed to helping find alternative testing techniques that do not employ race-based norms.

The NFL case, Possin wrote in JAMA, has “exposed a major weakness in the field of neuropsychology: the use of race-adjusted norms as a crude proxy for lifelong social experience.”

This happens in nearly every field of medicine. Race is not only used as a poor substitute for genetics and ancestry, it’s used as a substitute for access to health care, or lifestyle factors like diet and exercise, socioeconomic status and education. It’s no secret that racial disparities exist in all of these. But there’s a danger in using race to talk about them, Yale historian Carolyn Roberts says.

We know, for example, that Black Americans have been disproportionally affected by Covid-19. But it’s not because Black bodies respond differently to the virus. It’s because, as Dr. Anthony Fauci has noted, a disproportionate number of Black people have jobs that put them at higher risk and have less access to quality health care. “What are we making scientific and biological when it actually isn’t?” Roberts asks.

Vyas says using race as a proxy for these disparities in clinical algorithms can also create a vicious cycle.

“There’s a risk there, we argue, of simply building these into the system and almost accepting them as fact instead of focusing on really addressing the root causes,” Vyas says. “If we systematize these existing disparities … we risk ensuring that these trends will simply continue.”

Nearly everyone on both sides of the race correction controversy agrees that race isn’t an accurate, biological measure. Yet doctors and researchers continue to use it as a substitute. Math shouldn’t be racist, Nkinsi says, and it shouldn’t be lazy.

“We’re saying that we know that this race-based medicine is wrong, but we’re going to keep doing it because we simply don’t have the will or the imagination or the creativity to think of something better,” Nkinsi says. “That is a slap in the face.”

Shortly after Vyas’ article published in The New England Journal of Medicine, the House Ways and Means Committee sent letters to several professional medical societies requesting information on the misuse of race in clinical algorithms. In response to the lawmakers’ request, the Agency for Healthcare Research and Quality is also gathering information on the use of race-based algorithms in medicine. Recently, a note appeared on the Maternal Fetal Medicine Units Network’s website for the Vaginal Birth After Cesarean equation — a new calculator that doesn’t include race and ethnicity is being developed.

Dorothy Roberts is excited to see change on the horizon. But she’s also a bit frustrated. The harm caused by race correction is something she’s been trying to tell doctors about for years.

“I’ve taught so many audiences about the meaning of race and the history of racism in America and the audiences I get the most resistance from are doctors,” Roberts says. “They’re offended that there would be any suggestion that what they do is racist.”

Nkinsi and Seah both encountered opposition from colleagues in their fight to change the eGFR equation. Several doctors interviewed for this story argued the change in a race-corrected scores is so small, it wouldn’t change clinical decisions.

If that’s the case, Vyas wonders, why include race at all?

“It all comes from the desire for one to dominate another group and justify it,” says Roberts. “In the past, it was slavery, but the same kinds of justifications work today to explain away all the continued racial inequality that we see in America… It is mass incarceration. It’s huge gaps in health. It’s huge differences in income and wealth.”

It’s easier, she says, to believe these are innate biological differences than to address the structural racism that caused them.



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A quarter of Americans live with polluted air, with people of color and those in Western states disproportionately affected, report says | CNN

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CNN
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About 1 in 4 people in the United States – more than 119 million residents – live with air pollution that can hurt their health and shorten their lives, according to a new report from the American Lung Association. People of color are disproportionately affected, as are residents of Western cities.

Since President Richard Nixon signed the Clean Air Act in 1970, emissions of outdoor air pollutants have fallen 78%, according to the US Environmental Protection Agency. But Wednesday’s 2023 State of the Air report, which focuses on ozone and particle pollution, shows that millions put their health on the line every time they step outside.

To capture pollution levels at the county level, researchers analyzed data collected by the EPA’s Air Quality System, a repository of ambient air quality data from more than 10,000 monitors. They characterized the hourly average ozone concentration and the 24-hour average particle pollution concentration for 2019-21 at each monitoring site and factored in year-round pollution information from the EPA.

There were significant improvements in some areas. Generally, 17.6 million fewer people were breathing unhealthy air than in last year’s report, due largely to falling levels of ozone in some regions.

Ozone pollution is the main ingredient in smog. It comes from cars, power plants and refineries. Exposure to ozone can immediately exacerbate asthma symptoms, and people with long-term exposure to higher levels face a significantly higher risk of death from respiratory diseases than those who live with cleaner air.

Around 25% more counties got an A grade in the report for lower levels of ozone pollution. Some of that improvement can be attributed to the Clean Air Act, according to Katherine Pruitt, author of the report and the American Lung Association’s national senior director for policy.

Emission controls have helped, she said, as has the country’s continuing move away from its reliance on coal for its energy needs. Even something simple as the increase in the number of people who work from home has played a role.

“The Biden administration has set themselves a good, strong to do list of things that will help with environmental justice and climate protection,” Pruitt said. “They’re moving kind of slow, though. So we’d like them to pick up the pace.”

Despite the progress, not everyone was lucky enough to live in a county with good ozone levels. More than 100 million people live in counties that get an F for ozone smog, the report says.

Western and Southwestern cities are the most ozone-polluted, with 10 of the 25 most-polluted cities in California. New York, Chicago and Hartford, Connecticut, were the only three on that list east of the Mississippi River.

The five metropolitan areas with the worst ozone pollution are Los Angeles-Long Beach, California; Visalia, California; Bakersfield, California; Fresno-Madera-Hanford, California; and Phoenix-Mesa, Arizona.

Particle pollution, the other form of pollution tracked in the report, still seems to be a significant issue for the US.

Often hard to see, particle pollution is a mix of solid and liquid droplets that may come in the form of dirt, dust, soot or smoke. Coal- and natural gas-fired power plants create it, as do cars, agriculture, unpaved roads, construction sites and wildfires.

Particle pollution is so tiny – 1/20th of a width of a human hair – that it can travel past your body’s usual defenses.

Instead of being carried out when you exhale, it can get stuck in your lungs or go into your bloodstream. The particles cause irritation and inflammation and may lead to respiratory problems. Exposure can cause cancer, stroke or heart attack; it could also aggravate asthma, and it has even been associated with a higher risk of depression and anxiety, studies show.

The new report says the number of people living in counties with failing grades for daily spikes of particle pollution was the highest it has been in a decade. Nearly 64 million live with these kind of unhealthy spikes in counties that get failing grades.

One driver of the high amounts of particle pollution are the wildfires that have consumed hundreds of thousands of acres. In 2021 alone, there were 14,407 fires, many in the West, according to the National Interagency Fire Center. There used to be a wildfire season, experts say, but now they happen year-round.

Those fires are why the regions with the highest concentrations of air pollution are largely in the West.

When the American Lung Association started producing its report in 2004, 106 counties in 30 states got failing grades for daily spikes in particle pollution. Fewer than half were in eight states west of the Rocky Mountains. Today, 111 counties in 19 states got Fs for spikes in particle pollution, and all but eight counties are in the West, the report says.

Urban centers in the Rust Belt and the industrialized East had gotten the most failing grades in the early 2000s, but many have cleaned up and now get passing grades.

Bakersfield, California, displaced Fresno as the metropolitan area with the worst short-term particle pollution, but Fresno did not suddenly develop cleaner air. That city still had the most-polluted label for year-round particle pollution, tied with Visalia, in the agricultural San Joaquin Valley.

Los Angeles is still the city with the worst ozone pollution, according to the report, as it has been for all but one of the years included in the report.

California has some of the more progressive environmental legislation in the country, but the climate crisis has not been kind to the state, said Tarik Benmarhnia, an air pollution and wildfire researcher at the University of California, San Diego, who did not work on the new report.

“All these cities like Bakersfield and Visalia are in a valley near the forests that are seeing big fires. There’s also intense agricultural and industrial work there, so they unfortunately have all the worst conditions for air pollution,” Benmarhnia said.

There are some newcomers to the list of the 25 areas with the most particle pollution, including Denver and Fargo, North Dakota. Reno, Nevada; Yakima and Spokane, Washington; and Boise, Idaho; all made the worst list this year.

San Luis Obispo, California; Portland, Oregon; and Seattle and Bellingham, Washington; all moved off the list of worst 25 cities.

Residents in the cities ranked worst for particle pollution are living with more of it, the report says. In the top 25 cities with the worst air, the average number of days residents were exposed to high levels of fine particle pollution increased to a weighted average of 18.3, up from 16.5 in last year’s report.

East of the Mississippi, Pittsburgh and Lancaster, Pennsylvania, were the two worst metropolitan areas in the country, posting more days high in fine particle pollution in this year’s report.

Not everyone experiences pollution the same way in the US. Regardless of the region, communities of color bear the brunt of the problem.

Specifically, although people of color make up 41% of the overall US population, they are 54% of the nearly 120 million people living in counties with at least one failing grade for unhealthy air. And in the counties with the worst air quality, 72% of the 18 million residents are people of color, the report said.

Other research has also shown this trend. On maps that lay out areas with high levels of air pollution and where communities were redlined – areas where Black people were forced to live – they line up perfectly, Pruitt said.

“Then, the other aspect is, when you have a community of color that is a voluntary community, people aren’t forced to live there, those are communities that tend to have less of a voice, so decision makers place polluting sources in those communities because there’s not as much howling by people with power when they do. So those communities get the highways; they get the landfills; they get the fence lines,” she said.

There’s a myth that only poor communities live with disproportionate pollution levels, says Chris Tessum, a professor in the Civil and Environmental Engineering Department of the University of Illinois. Tessum, who was not involved in the new report, says race really is the determining factor.

“The thinking is that people with more money will buy better property, which has lower air pollution and that’s just the way of the world or whatever, but that’s just kind of emphatically not, not true,” he said.

Communities need to play a key role in making decisions to help clean air, Tessum said.

“People that have the power will use that power to benefit themselves and not the people that have been historically overburdened,” he said.

The new report says government and residents can make a difference. One suggestion is to leverage Inflation Reduction Act funding to help reduce emissions at ports and to invest in zero-emission heavy-duty vehicles and in infrastructure that would improve air quality monitoring.

States can also use the Clean Air Act authority to adopt the California zero-emissions standards for cars and trucks, the report says.

At the federal level, agencies must finalize stronger limits on air pollution to truly protect public health and advance environmental justice, the report says, including standards to move the country toward zero-emissions vehicles. The EPA also has to set stronger national standards for particle pollution and ozone, the researchers say.

Pruitt said she knows firsthand how better policies can work. She said growing up before the Clean Air Act, pollution was so high that she could see it every time she stepped outside. Today, the pollution is not nearly as visible.

“I’m in my mid-60s, and of course, air pollution was very tangible when I was young, but these days, thank goodness it isn’t. Most people don’t see it,” she said. Unless a person has a lung condition, they may not even feel it.

But just because you can’t see it or feel it doesn’t mean it’s not there. Pruitt encourages people to remember that no level of pollution is safe. The World Health Organization estimates that the combined effects of ambient air pollution and household air pollution are associated with 6.7 million premature deaths annually.

“People don’t really recognize that what they’re breathing is impacting their health,” Pruitt said.

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Only 5.7% of US doctors are Black, and experts warn the shortage harms public health | CNN

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CNN
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When being truly honest with herself, Seun Adebagbo says, she can describe what drove her to go to medical school in a single word: self-preservation.

Adebagbo, who was born in Nigeria and grew up in Boston, said that as a child, she often saw tensions between certain aspects of Western medicine and beliefs within Nigerian culture. She yearned to have the expertise to bridge those worlds and help translate medical information while combating misinformation – for her loved ones and for herself.

“I wanted to go into medicine because I felt like, ‘Who better to mediate that tension than someone like me, who knows what it’s like to exist in both?’ ” said Adebagbo, 26, who graduated from Stanford University and is now a third-year medical school student in Massachusetts.

“The deeper I got into my medical education, the more I realized, if I’m in the system, I know how it works. I not only know the science, but I also know how the system works,” she said of how in many Black and brown communities, there can be limited access to care and resources within the medical system.

This has enabled Adebagbo to connect with patients of color in her rotations. She recognizes that their encounters with her are brief, she said, and so she tries to empower them to advocate for themselves in the health system.

“I know what to ask for on the patient side if I’m worried about something for myself. But then also, for my parents and my family,” Adebagbo said. “Because the way you have to move in the system as a Black person is very different, especially if you’re coming from a background where you don’t have family members that are doctors, you don’t know anyone in your periphery that went into medicine.”

Seun Adebagbo presenting her poster presentation as a first author at an international symposium and annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

Only about 5.7% of physicians in the United States identify as Black or African American, according to the the latest data from the Association of American Medical Colleges. This statistic does not reflect the communities they serve, as an estimated 12% of the US population is Black or African American.

And while the proportion of Black physicians in the US has risen over the past 120 years, some research shows, it’s still extremely low.

One reason why the percentage of US doctors who are Black remains far below that of the US population that is Black can be traced to how Black people have been “historically excluded from medicine” and the “institutional and systemic racism in our society,” said Michael Dill, the Association of American Medical Colleges’ director of workforce studies.

“And it occurs over the course of what I think of as the trajectory to becoming a physician,” Dill said. At young ages, exposure to the sciences, science education resources, mentors and role models all make it more likely that a child could become a doctor – but such exposures and resources sometimes are disproportionately not as accessible in the Black community.

“We can improve our admissions to medical school, make them more holistic, try to remove bias from that, but that’s still not going to solve the problem,” Dill said.

“We need to look at which schools produce the most medical students and figure out how we improve the representation of Black students in those schools,” he said. “That requires going back to pre-college – high school, middle school, elementary school, kindergarten, pre-K – we need to do better in all of those places in order to elevate the overall trajectory to becoming a physician and make it more likely that we will get more Black doctors in the long run.”

Many US medical schools have a history of not admitting non-Whites. The first Black American to hold a medical degree, Dr. James McCune Smith, had to enroll at the University of Glasgow Medical School in Scotland.

Smith received his MD in 1837, returned to New York City and went on to become the first Black person to own and operate a pharmacy in the United States, and to be published in US medical journals.

A few decades later, in 1900, 1.3% of physicians were Black, compared with 11.6% of the US population, according to a study published in the Journal of General Internal Medicine in 2021.

Around that time, seven medical schools were established specifically for Black students between 1868 and 1904, according to Duke University’s Medical Center Library & Archives. But by 1923, only two of those schools remained: Howard University Medical School in Washington and Meharry Medical School in Nashville.

In 1940, only 2.8% of physicians were Black, but 9.7% of the US population was Black; by 2018, 5.4% of physicians were Black, but 12.8% of the population was Black.

“The more surprising thing to me was for Black men,” said Dr. Dan Ly, an author of the study in the Journal of General Internal Medicine and assistant professor of medicine at the University of California, Los Angeles.

Data on only Black men who were physicians over the years showed that they represented 1.3% of the physician workforce in 1900, “because all physicians were pretty much men in the past,” Ly said. Black men represented 2.7% of the physician workforce in 1940 and 2.6% in 2018.

“That’s 80 years of no improvement,” Ly said. “So the increase in the percent of physicians who were Black over the past 80 years has been the entrance of Black women in the physician workforce.”

Over more than four decades between 1978 and 2019, the proportion of medical school enrollees who identify as Black, Hispanic or members of other underrepresented groups has stayed “well below” the proportions that each group represented in the general US population, according to a 2021 report in The New England Journal of Medicine.

Diversity in some medical schools also was affected in states with bans on affirmative action programs, according to a study published last year in the Annals of Internal Medicine. That study included data on 21 public medical schools across eight states with affirmative action bans from 1985 to 2019: Arizona, California, Florida, Michigan, Nebraska, Oklahoma, Texas and Washington.

The study found that the percentage of enrolled students from underrepresented racial and ethnic groups was on average about 15% in the year before the bans were implemented but fell more than a third by five years after the bans.

Now, the United States is reckoning with medicine’s history of racism.

In 2008, the American Medical Association, the nation’s largest organization of physicians, issued an apology for its history of discriminatory policies toward Black doctors, including those that effectively restricted the association’s membership to Whites. In 2021, the US Centers for Disease Control and Prevention declared racism a “serious public health threat.”

One encouraging datapoint says that the number of Black or African American first-year medical school students increased 21% between the academic years of 2020 and 2021, according to the Association of American Medical Colleges, which Dill said shows promise for the future.

“Does the fact that it’s higher in medical school mean that eventually we will have a higher percentage of physicians who are Black? The answer is yes,” he said.

“We will see the change occur slowly over time,” he said. “So, that means the percentage of the youngest physicians that are Black will grow appreciably, but the percentage of all physicians who are Black will rise much more slowly, since new physicians are only a small percentage of the entire workforce.”

But some medical school students could leave their career track along the way. A paper published last year in JAMA Internal Medicine found that among a cohort of more than 33,000 students, those who identified as an underrepresented race or ethnicity in medicine – such as Black or Hispanic – were more likely to withdraw from or be forced out of school.

Among White students, 2.3% left medical school in the academic years of 2014-15 and 2015-16, compared with 5.2% of Hispanic students, 5.7% of Black students and 11% of American Indian, Alaska Native, Native Hawaiian and Pacific Islander students, the study found.

The researchers wrote in the study that “the findings highlight a need to retain students from marginalized groups in medical school.”

During her surgical rotation in medical school, Adebagbo said, she saw no Black surgeons at the hospital. While having more physicians and faculty of color in mentorship roles can help retain young Black medical school students like herself, she calls on non-Black doctors and faculty to create a positive, clinical learning environment, giving the same support and feedback to Black students as they may provide to non-Black students – which she argues will make a difference.

“Despite the discomfort that may arise on the giver of feedback’s side, it’s necessary for the growth and development of students. You’re hurting that student from becoming a better student on that rotation, not giving them that situational awareness that they need,” she said. “That’s what ends up happening with students of color. No one tells them, and it seems as if it’s a pattern, then by the end of the rotation, it becomes, ‘Well, you’ve made so many mistakes, so we should just dismiss you [for resident trainees] or we can’t give you honors or high pass [for medical students].’ “

Seun Adebagbo, right, with the site director (second from left) and two peers on her last day of her surgery rotation.

Adebagbo says she had one site director, a White male physician, during her surgery rotation who genuinely cared, listened and wanted to see her grow as a person and physician.

“He has been the first site director who has legit listened to me, my experiences navigating third year as a Black woman and tried to understand and put it in perspective – a privilege I’m not afforded often,” Adebagbo said. “He made making mistakes, growing and learning from them a safe and non-traumatizing experience. Not everyone may understand the depths of what I’m saying, but those who do will understand why I was so grateful for that experience.”

But not all attending physicians are like her “mentor,” as she calls him.

For Dr. David Howard, one question haunted his thoughts in medical school.

During those strenuous days at Johns Hopkins University, when all-night study sessions and grueling examinations were the norm, his mind whispered: Where do I fit?

Howard, now a 43-year-old ob/gyn in New Jersey, reflects with pride – and candor – on the day in 2009 when he completed his doctoral degrees, becoming both an MD and a PhD.

At the time, “I felt like I didn’t fit,” Howard said. “I’m sure I’m not the only person who has thought those thoughts.”

Howard was one of very few men in the obstetrics and gynecology specialty, where most providers were women – and he is Black. He saw very few peers who looked like him and extremely few faculty in leadership positions who looked like him.

“When you’re going through a really difficult training program, it makes a big difference if there are people like you in the leadership positions,” he said, adding that this contributes to the disproportionate number of Black medical school students and residents who decide to leave the profession or are “not treated equally” when they may make a mistake.

Early on in his career, Howard shifted his thinking from “Where do I fit?” to “How do I fit?”

He even authored a paper in 2017, published in the American Journal of Obstetrics and Gynecology, about this self-reflection.

“Only slightly different semantically, the second question shifts focus away from the ‘where’ that implies an existing location. Instead, ‘how’ requires me to illustrate my relationship with existing labels and systems, rather than within them, allowing a multitude of answers to my question of ‘how do I fit?’ ” Howard wrote.

“Despite the challenges and realities of the medical field today, I fit wherever and however I can, actively shaping my space and resisting the assumptions that first prompted me to ask where I fit,” he said. “To finally answer my question: I don’t fit, but I am here anyway.”

The United States has made “some progress” with diversity in both clinical medicine and research – but diversity in medicine is still not at the point where it needs to be, said Dr. Dan Barouch, a professor at Harvard Medical School and director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center in Boston, who has been an advocate for diversity and inclusion.

That point, essentially, would be where diversity in the physician workforce reflects the diversity in their patient population.

“It’s particularly important to have a diverse physician workforce to aptly serve the patients,” Barouch said. “We want to increase diversity in academia as well, but it’s particularly important for doctors, because having a diverse workforce is critical for the best patient encounters, and to build trust.”

Service to patients and patient trust are both among the cornerstones critical to the status of public health, according to researchers.

One example of broken trust between physicians and Black patients happened in the 1930s, when the US Public Health Service and the Tuskegee Institute launched an unethical study in which researchers let syphilis progress in Black men without treating them for the disease. The study ended in 1972.

Among Black men, “there were declines in health utilization, increases in medical mistrust and subsequent increases in mortality for about the 10- to 15-year period following the disclosure event,” when the true nature of the study was exposed in 1972, said Dr. Marcella Alsan, an infectious disease physician and professor of public policy at Harvard Kennedy School.

Yet research suggests that when Black physicians are treating Black patients, that trust can be rebuilt.

For instance, the impact is so significant that having Black physicians care for Black patients could shrink the difference in cardiovascular deaths among White versus Black patients by 19%, according to a paper written by Alsan while she was attending Stanford University, along with colleagues Dr. Owen Garrick and Grant Graziani. It was published in 2019 in the American Economic Review.

That research was conducted in the fall and winter of 2017 and 2018 in Oakland, California, where 637 Black men were randomly assigned to visit either a Black or a non-Black male doctor. The visits included discussions and evaluations of blood pressure, body mass index, cholesterol levels and diabetes, as well as flu vaccinations.

The researchers found that, when the patients and doctors had the opportunity to meet in person, the patients assigned to a Black doctor were more likely to demand preventive health care services, especially services that were invasive, such as flu shots or diabetes screenings that involve drawing blood.

“We saw a dramatic increase in their likelihood of getting preventive care when they engage with Black physicians,” said Garrick, who now serves as chief medical officer of CVS Health’s clinical trial services, working to raise awareness of how more diverse groups of patients are needed to participate in clinical research.

Initially, “it didn’t look like there was a strong preference for Black doctors versus non-Black doctors. It was only when people actually had a chance to communicate with their physicians, talk about ‘Why should I be getting these preventative care services?’ ” Alsan said.

The researchers analyzed their findings to estimate that if Black men were more likely to undergo preventive health measures when they see a Black doctor, having more Black doctors could significantly improve the health and life expectancy of Black Americans.

The nation’s shortage of Black physicians is concerning, experts warn, as it contributes to some of the disproportionate effects that infectious diseases, chronic diseases and other medical ailments have on communities of color. This in itself poses public health risks.

For example, in the United States, Black newborns die at three times the rate of White newborns, but a study published in 2020 in the Proceedings of the National Academy of Sciences found that Black infants are more likely to survive if they are being treated by a Black physician.

Black men and Black women are also about six to 14.5 times as likely to die of HIV than White men and White women, partly due to having less access to effective antiretroviral therapies. But Black people with HIV got such therapies significantly later when they saw White providers, compared with Black patients who saw Black providers and White patients who saw White providers in a study published in 2004 in the Journal of General Internal Medicine.

And when Black patients receive care from Black doctors, those visits tend to be longer and have higher ratings of patients feeling satisfied, according to a separate study of more than 200 adults seeing 31 physicians, published in 2003 in the journal Annals of Internal Medicine.

“There’s plenty of evidence, and other research has shown that the more the workforce in a health care setting really reflects the community it serves, the more open the patient population is to recommendations and instructions from their doctor,” said Dr. Mahshid Abir, an emergency physician and a senior physician policy researcher at the RAND Corp., a nonpartisan research institution.

But it can be rare to find health systems in which the diversity of the workforce reflects the diversity of the patients.

During her 15-year career as an emergency physician, Abir said, she has worked in many emergency departments across the United States – in the Northeast, South and Midwest – and in each place, the diversity of the health care workforce did not mirror the patient populations.

This lack of diversity in medicine is “not talked about enough,” Abir said.

“The research that’s been conducted has shown that it makes a difference in how well patients do, how healthy they are, how long they live,” she said. “Especially at this juncture in history in the United States, where social justice is in the forefront, this is one of the most actionable places where we can make a difference.”

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Lovie Smith said the NFL had ‘a problem’ about Black coaches. A year later he was fired and the league is being criticized yet again about its lack of diversity | CNN

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CNN
 — 

When Lovie Smith was hired by the Houston Texans in February 2022 as the team’s new head coach, he said the NFL had “a problem” with hiring Black coaches and diversity.

“I realize the amount of Black head coaches there are in the National Football League,” Smith told reporters just under a year ago.

“There’s Mike Tomlin and I think there’s me, I don’t know of many more. So there’s a problem, and it’s obvious for us. And after there’s a problem, what are you going to do about it?”

Smith was fired Monday at the end of his one and only season at the helm of the Texans, finishing with a record of 3-13-1.

Smith is the second Black coach in two years to be relieved of his duties by the Texans, which fired David Culley at the end of the 2021 season.

Smith’s time in charge wasn’t full of wins and high points – though his parting gift to the organization was a last-minute Hail Mary victory over the Indianapolis Colts, which saw them relinquish the No. 1 pick in the 2023 NFL draft to the Chicago Bears. But his Texans team showed togetherness and competence, traits often desired by outfits undergoing a rebuild.

Houston general manager Nick Caserio said Smith’s firing was the best decision for the team right now.

“On behalf of the entire organization, I would like to thank Lovie Smith for everything he has contributed to our team over the last two seasons as a coach and a leader,” Caserio said in a statement.

“I’m constantly evaluating our football operation and believe this is the best decision for us at this time. It is my responsibility to build a comprehensive and competitive program that can sustain success over a long period of time. We aren’t there right now, however, with the support of the McNair family and the resources available to us, I’m confident in the direction of our football program moving forward.”

But the firing of the 64-year-old coach, the Texans organization as a whole, and the measures implemented by the league to promote diversity have been heavily criticized by former players and TV pundits.

“The Houston Texans have fired Lovie Smith after 1 year. Using 2 Black Head Coaches to tank and then firing them after 1 year shouldn’t sit right with anyone,” former NFL quarterback Robert Griffin III tweeted Sunday, when news of Smith’s firing broke.

On ESPN, Stephen A. Smith and NFL Hall of Famer Michael Irvin also condemned the decision. Smith called the Texans organization an “atrocity.”

“They are an embarrassment. And as far as I’m concerned, if you’re an African American, and you aspire to be a head coach in the National Football League, there are 31 teams you should hope for. You should hope beyond God that the Houston Texans never call you,” Smith said.

Irvin said Black coaches are being used as “scapegoats” by the Texans.

“It’s a mess in Houston and they bring these guys in and they use them as scapegoats. And this is what African American coaches have been yelling about for a while and it’s blatant, right in our face,” he said.

When CNN contacted the Texans for comment, the team highlighted the moment at Monday’s news conference when Caserio was asked why any Black coach would consider working for the team, and his response was that individual candidates would have to make their own choices.

Smith on the sidelines during a game against the Indianapolis Colts.

“In the end it’s not about race. It’s about finding quality coaches,” the general manager said. “There’s a lot of quality coaches. David (Culley) is a quality coach. Lovie (Smith) is a quality coach.

“In the end, each coach has their own beliefs. Each coach has their own philosophy. Each coach has their comfort level about what we’re doing. That’s all I can do is just be honest and forthright, which I’ve done from the day that I took this job, and I’m going to continue to do that and try to find a coach that we feel makes the most sense for this organization. That’s the simplest way I can answer it, and that’s my commitment.

“That’s what I’m hired to do, and that’s what I’m in the position to do. At some point, if somebody feels that that’s not the right decision for this organization, then I have to respect that, and I have to accept it.”

CNN has reached out to Lovie Smith for comment.

At the beginning of the 2022 season, NFL.com reported Smith was one one of just six minority head coaches in the NFL, a low number in a league where nearly 70% of the players are Black.

Since Art Shell was hired by the Los Angeles Raiders in 1989 as the first Black head coach in modern history, there have been 191 people hired as head coaches, but just 24 have been Black.

However, the NFL has taken steps to increase diversity in the coaching ranks.

Notably, in 2003, the NFL introduced the Rooney Rule to improve hiring practices in a bid to “increase the number of minorities hired in head coach, general manager, and executive positions.”

But the Rooney Rule hasn’t been an unqualified success.

In 2003, the Detroit Lions were fined $200,000 for not interviewing any minority coaches before hiring Steve Mariucci as their new head coach.

In response to criticism, the NFL announced it was setting up a diversity advisory committee of outside experts to review its hiring practices last March. Teams would also be required to hire minority coaches as offensive assistants.

Despite changes to the rule being implemented in recent years to strengthen it, a 2022 lawsuit alleges that some teams have implemented “sham” interviews to fulfill the league’s diversity requirements.

Last February, former Miami Dolphins head coach Brian Flores filed a federal civil lawsuit against the NFL, the New York Giants, the Denver Broncos and the Miami Dolphins organizations alleging racial discrimination.

Flores looks on during his time as the head coach of the Miami Dolphins during a game against the New York Jets.

Flores, who is Black, said in his lawsuit that the Giants interviewed him for their vacant head coaching job under disingenuous circumstances.

Two months after submitting the initial lawsuit, Flores added the Texans to it, alleging the organization declined to hire him this offseason as head coach “due to his decision to file this action and speak publicly about systemic discrimination in the NFL.”

In response to the lawsuit, the Texans said their “search for our head coach was very thorough and inclusive.”

The NFL called Flores’ allegations meritless.

“The NFL and our clubs are deeply committed to ensuring equitable employment practices and continue to make progress in providing equitable opportunities throughout our organizations,” the league said in response to the lawsuit.

“Diversity is core to everything we do, and there are few issues on which our clubs and our internal leadership team spend more time. We will defend against these claims, which are without merit.”

But 12 months after firing their last Black head coach, the Texans have fired another one.

“How do you hire two African Americans, leave them one year and then get rid them?” questioned NFL Hall of Famer Irvin.

“You know the mess that Houston is,” Irvin added. “We get the worst jobs and we don’t get the opportunity to fix the worst jobs, just like this.

“I don’t know any great White coach that would take the (Texans) job unless you give them some guarantees. ‘You’re going to have to guarantee me four years to turn this place around.’ But the African American coaches can’t come in with that power because Lovie wouldn’t have got another job.

“This was his last chance to get back into the NFL and you have to take what’s on the table to try to change that.”

Irvin speaks on media row ahead of Super Bowl LVI on February 10, 2022 in Los Angeles.

The Texans are now searching for a new head coach under general manager Caserio. The new appointment will be Caserio’s third coach in the role: It is almost unprecedented for a general manager to get the opportunity to hire a third head coach with the same team.

Texans chairman and CEO Cal McNair said he would take on a more active role in the hiring process. The next head coach will be the organization’s fourth in three years.

According to the NFL, the Texans have requested to speak to five candidates already about filling Smith’s position, a list that includes two Black coaches.

After Smith was hired in March 2021, McNair said: “I’ve never seen a more thorough, inclusive, and in-depth process than what Nick (Caserio) just went through with our coaching search.”

At that introductory news conference, Smith spoke candidly about how to bring greater diversity to the NFL coaching ranks.

“People in positions of authority throughout – head coaches, general managers – you’ve got to be deliberate about trying to get more Black athletes in some of the quality control positions just throughout your program. If you get that, they can move up, that’s one way to get more.”

Smith continued: “It’s not just an interview, if you’re interviewing a Black guy. It’s about having a whole lot of guys to choose from that look like me. And it’s just not about talk. You look at my staff, that’s what I believe in. And letting those guys show you who they are. That’s how we can increase it, then it’s left up to people to choose. We all have an opportunity to choose, and that’s how I think we’ll get it done.”



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Indigenous and Black children increasingly experiencing racism, new study shows | CNN

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CNN
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A growing percentage of Indigenous and Black parents in the United States reported that their children have faced racist experiences, according to a study published in the Journal of Osteopathic Medicine.

The study looked at parental reporting of racist experiences their children faced between 2016 and 2020. Data came from the National Survey of Children’s Health, a nationally representative survey directed by groups within the US Department of Health and Human Services.

The researchers, led by Dr. Micah Hartwell at Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation, and Amy Hendrix-Dicken of the University of Oklahoma (Tulsa) School of Community Medicine, concluded there was an increase in reported racial incidents experienced by minority children from roughly 6.7% in 2016 to 9.3% by 2020.

By comparison, 1% of parents of White children reported their kids had faced discrimination in 2016, and that increased to 1.7% in 2020.

Structural racism is taking a toll on children’s mental health

Indigenous children experienced discrimination at rates ranging from 10.8% in 2016 to 15.7% in 2020, and Black children ranging from 9.69% in 2018 to 15.04% in 2020, according to the report.

Hendrix-Dicken says the findings are significant because exposure to discrimination in early childhood can have long-term consequences on health.

“Our study underlines the need for clinicians to expand their anti-racism resources and also highlights the role culturally competent health care can play in lessening the effects of adverse childhood experiences with racism,” said Hendrix-Dicken in a news release.

“As an Indigenous person myself, perhaps the most personally significant and surprising finding is the rate at which Indigenous children are experiencing discrimination,” added Hendrix-Dicken.

In a phone interview with CNN, Hartwell outlined strategies to mitigate the root cause of the findings.

“There is a ton of stuff minority communities have done if that was better represented within our education and childcare and just overall knowledge of coverage, that would provide a more equal context,” Hartwell said.

“Understanding cultural context, historical trauma and providing mental health services from a culturally informed perspective is the best thing the medical community can do,” added Hartwell who is also a Clinical Assistant Professor of Psychiatry and Behavioral Sciences at Oklahoma State University.

Covenant Elenwo, a medical student who worked on the study with Hartwell told CNN, “When looking at some of the historical trauma that has come with being Black and Indigenous, we must understand some of the trauma has not been dealt with even now in 2022.”



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