Health inequity is real, and it can be seen in statistics that show there are more than 74,000 excess deaths among Black people compared with white people each year in the 30 largest American cities.
This includes the home of the AMA’s headquarters, Chicago, where racial inequities in mortality rates result in an average of 3,804 excess deaths among Black people a year compared to white people, according to a study published in JAMA Network Open. Examining the city’s statistics even further finds that a 14-year life-expectancy gap exists between affluent and historically under-resourced communities only a short distance apart.
“Health inequities didn’t just happen,” said anesthesiologist William A. McDade, MD, PhD. “We have a system designed to create the results that are obtained.”
Dr. McDade, the chief diversity, equity and inclusion officer for the Accreditation Council for Graduate Medical Education (ACGME), provided introductory remarks during “History of Racism in U.S. Health Care, Root Causes of Today’s Hierarchy and Systems of Power,” the inaugural online event of a quarterly virtual National Health Equity Grand Rounds series intended to deepen understanding and shape discourse around health inequities. Registration is open for the second event, scheduled for May 9.
The series is led by the AMA in collaboration with ACGME, the National Center for Interprofessional Practice and Education and RespectAbility. The first event explored root causes of present-day health inequities and the historical and contemporary social, economic, political, geographic and environmental forces that created them.
“Evidence shows that racism—as a system of power and oppression embedded into policies and culture—is at the root of these inequities, said AMA Senior Vice President and Chief Health Equity Officer Aletha Maybank, MD, MPH, who moderated the event.
“It also structures opportunity and basically saps society of its full potential and energy,” Dr. Maybank added. “It's the result of decisions made by people within institutions over generations and at this current time.”
One such decision highlighted by Dr. Maybank was the recommendation in the 1910 Flexner Report that led to the closure of five of the seven Black medical schools and all the women’s medical schools operating at the time.
“What are the impacts of the decision?” she said. “We can see that the lack of diversity within the physician community as it relates to race and ethnicity as one of those impacts.”
AMA moves forward on reconciliation
Dr. Maybank, who became the founding director of the AMA Center for Health Equity in 2019, highlighted how the AMA has moved from an organization that permitted state and local medical societies to explicitly exclude women and Black physicians from representation in the House of Delegates, to one adopting anti-racist policies that seek optimal health for all.
It's doubtful that “any institution can move forward and make real commitments to equity, justice and anti-racism without looking at their past,” she said.
After the Institute of Medicine, now the National Academy of Medicine, released its 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the AMA began examining the organization’s role (PDF) in creating the inequities detailed in the report.
Dr. Maybank noted that AMA Past President Alan Nelson, MD, was co-editor of the report.
This examination included convening a writing group to review and analyze the historical roots of the racial divide in the AMA and other U.S. medical organizations and produced a report “African American Physicians and Organized Medicine, 1846-1968,” that was published in JAMA.
Work in this area culminated with an apology (PDF) delivered by Ronald Davis, MD, then the AMA’s immediate past president, at the 2008 annual meeting of the National Medical Association—the oldest and largest organization of Black physicians founded in response to the AMA’s repeated exclusion of Black physicians who sought membership at the organization.
More recently, the AMA House of Delegates adopted three anti-racism policies in 2020, including one that recognized racism as a public health threat. Dr. Maybank credited the AMA’s medical student members and the AMA Minority Affairs Section for getting those policies adopted.
“The policies really helped create this space and door that we really needed at the AMA to ensure that we were able to approach this work and have a strategy around fostering pathways for truth, reconciliation and healing for the AMA’s past,” Dr. Maybank said, adding that she was particularly thankful for the support AMA CEO and Executive Vice President James L. Madara, MD, has shown for this work.
Harriet A. Washington, MA, an award-winning medical writer, ethicist and editor, was one of the members of the writing group that produced the JAMA report, and served as the keynote speaker for this first National Health Equity Grand Rounds event.
Washington, author of the book Medical Apartheid, discussed how the U.S. remains haunted by past segregation practices that created inequities in health care access that are “driving the death and disproportionate illness of huge numbers of people in this country.”
There are also lingering myths about Black people, including that they don’t feel pain like white people do.
“They claimed that you could amputate a Black person’s leg and he would hand it to you—completely absurd,” she said.
While perhaps no longer included in textbooks, Washington noted that medical students and resident physicians are taught this in more subtle ways as “they see, routinely, Black people presenting in pain and being sent away without effective medication and labeled as drug seeking.”
Tuskegee is not the whole story
Washington also spoke out against the belief that abuse of Black people in medical experiments begins and ends with the U.S. Public Health Service Syphilis Study at Tuskegee.
“Yesterday's horrors were indeed real and were indeed documented quite heavily,” she said.
She noted the case of J. Marion Sims, MD, credited as the “father of modern gynecology,” who was memorialized with statues in his honor in New York and Alabama. These have been taken down as many of the procedures he pioneered were developed through unethical experimentation on enslaved women in the 1840s, as he operated on them without anesthesia and without consent.
“Honoring people who have abused others is a very good way of perpetuating that abuse,” Washington said. “It sends a message to people who are being trained that this behavior will not be punished, and that this behavior is acceptable.”
She also noted how University of California San Francisco (UCSF) is now reckoning with experiments its dermatology faculty conducted in the 1960s and 1970s that included exposing prison inmates to pesticides and herbicides.
AMA President Jack Resneck Jr., MD, became chair of the UCSF dermatology department in September and joined others for the panel discussion that followed Washington’s talk. He discussed being part of both the AMA’s and UCSF’s efforts to reconcile their pasts.
“There's no blueprint to follow, but humility and listening are so important,” said Dr. Resneck.
He noted that his department is attempting to “take a 30,000-foot view” of system failures that allowed—and even encouraged—such experiments to happen.
“We've worked really hard to be transparent about the history of what occurred, to talk openly about how much it contradicted our values, to apologize openly for the role played by the department, and our failure to investigate this for so long,” Dr. Resneck said.
A preliminary report has been released that includes a letter (PDF) from Dr. Resneck.
“The work is messy. The work is uncomfortable, and you're going to encounter people who want to bury the past or skip this painful step,” Dr. Resneck said. “And at the same time, you're going to have others who hold you accountable for not moving fast enough. And I think that's all normal and to be expected.”
He noted that the experience has made him reflect on the words of Dr. Davis who called the AMA’s apology to the NMA a “modest first step.”
“What I'm really focused on now is that the reckoning can't be an end unto itself,” Dr. Resneck said. “It has to be followed by actions that actually stop ongoing harms and that move the needle on equity.”
Learn about the AMA’s strategic plan to embed racial justice and advance health equity, and explore the the AMA Ed Hub™ Health Equity Education Center.