Each act of gun violence should not be treated as an isolated incident and everyone who has experienced gun violence, including the emergency department physicians and trauma surgeons who treat its victims, ought to “step back and ask a ‘why’ question,” said Camara Jones, MD, MPH, PhD.
Dr. Jones is the research director on social determinants of health and equity in the Division of Adult and Community Health at the Centers for Disease Control and Prevention’s National Center for Chronic Disease Prevention and Health Promotion. Speaking to physicians at the 2016 AMA Interim Meeting during a session on gun violence, she argued that widespread availability of firearms accounts for the nation’s high overall death toll from guns but that the disparate racial impact of gun violence “has everything to do with racism.” Her talk came days before the AMA joined a "call to action" on gun violence and was one of several instances when attention at the meeting turned to issues of race and medicine.
“When I say the word ‘racism,’ I am talking about a system,” said Dr. Jones, whose three-year term as president of the American Public Health Association ended this month. “I’m not talking about an individual character flaw, or a personal moral failing, or even a psychiatric illness that some people have suggested. I’m talking about a system of power, and it’s a system of structured opportunity and of assigning value.”
Dr. Jones argued that physicians should take into account how systemic racism contributes to gun deaths and injuries as well as other health outcomes of concern in order to look for broader fixes that go beyond what they can address in a strictly clinical setting.
She noted that health disparities are found outside the U.S. too, and that perceptions of race are driven by local culture and history.
“I, here in Orlando, am clearly black. But in some parts of Brazil I’m just as clearly white. And in South Africa I’m clearly colored,” Dr. Jones said. “So here I am with the same physical appearance in those three settings, but the social interpretation of my appearance in each of those settings would assign me to a different racial group. And furthermore, if I were to stay in any of those settings long enough … my health outcome would probably take on that of the group to which I’ve been assigned, even though I’d have the same genes in all three places.”
It is widely understood that “racism unfairly disadvantages some individuals and communities,” Dr. Jones added. “But it shouldn’t take us long to recognize that every unfair disadvantage has its reciprocal unfair advantage so that racism is also unfairly advantaging other individuals and communities.”
Open or closed?
Studying late one night in medical school, Dr. Jones and her fellow students went into town to eat. Their food arrived around the time the restaurant closed to other customers. When Dr. Jones noticed the “Open” sign facing her, on the inside of the restaurant, she understood the two-sided nature of the sign.
To those on the inside already eating, the restaurant was open, so why wouldn’t the hungry people outside come in, sit down and eat? But to the people outside, the sign read “Closed.”
This translates to differential opportunities based on race. Those who have access are often not aware that racism creates a dual reality. You may be on the inside of the restaurant and unaware that there are those people who only see the “Closed” side of the sign and cannot access the same opportunities that are available to you.
Three levels of racism
Increases in asthma prevalence, homicide rates in young black men, obesity in certain communities and differences in cancer mortality are just a few of the health outcomes that racism affects, Dr. Jones argued. She outlined three forms of racism and what she sees as their effects.
Institutionalized. This form of racism is manifested in differential access to the goods, services and opportunities of society by race. Health care is just one example. Others include access to quality housing, education and employment opportunities, and a clean environment.
Personally mediated. More commonly known as prejudice and discrimination, this is the form of racism where prejudice means differential assumptions about the abilities, motives and intentions of others according to their race, and discrimination means differential actions toward others according to their race.
“That’s what most people think of when they hear racism: somebody did something to somebody,” Dr. Jones said. This form of racism can be found in examples of police brutality, shopkeeper harassment of minority customers and also in health care. For physicians, it could include fairly subtle, yet biased, actions such as “not giving the full range of treatment options because we might assume that patient couldn’t afford [them] or couldn’t comply or couldn’t understand.”
Internalized. This is when members of the stigmatized races accept negative messages about their own abilities and intrinsic worth.
Examples of internalized racism include “self-devaluation, feeling that maybe I’m not as good as, maybe I shouldn’t try to graduate from high school or apply to that college, try to become a physician or try to live in that neighborhood,” Dr. Jones said. She has written at greater length in the American Journal of Public Health on how acknowledging these forms of racism can inform public health research and advocacy.