From an editorial in the new issue of the New England Journal of Medicine (no link available):

By looking through a racially impervious lens, clinicians neglect the life experiences and historical inequities that shape patients and disease processes. They may inadvertently feed the robust structural racism that influences access to care, quality of care, and resultant health disparities. At times, we fail to make even the simplest efforts: for instance, even though Covid-19 disproportionately affects black Americans, when physicians describing its manifestations have presented images of dermatologic effects, black skin has not been included. The “Covid toes” have all been pink and white.

Racist photos of Covid toes? Who knew? More:

In the review of systems, we query patients about exposure to toxicants, but we never ask about one of the most dangerous toxicants: racism. The work of David Williams details the morbidity and risk of death related to perceived discrimination. Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on black Americans and other minority populations.

More:

As the vulnerability and inadequacy of our health care system are once again exposed, it is also time to reconceive that system, including the development of its workforce. Our actions must be driven by the data highlighting inequity in medical school admission and graduation rates, the dearth of black medical faculty, and the low grant-funding success rates for black biomedical researchers. We must also acknowledge past injustices and the persistent pain experienced by minority trainees and faculty, by listening and openly discussing racism and its health effects on rounds and at conferences and by broadening medical school curricula to include cultural sensitivity, cultural humility, and upstander training to equip students with advocacy tools to assist their patients and colleagues. Direct action to eliminate persistent health disparities obliges us to redouble our demands for a system that recognizes health care as a human right, providing an avenue to health equity for all.

Although effecting such fundamental transformation may feel impossible, the energy, idealism, and visions of young people have long fueled movements for change. Martin Luther King, Jr., was 26 when he led the Montgomery bus boycott and 34 when he delivered his powerful “I have a dream” oration. If we blend our voices with those of the newest members of our profession to advocate for the most vulnerable and to reinvigorate every aspect of their care, perhaps we can use our current public health crisis as a catalyst to, as Reverend Al Sharpton put it, “turn this moment into a movement.”

It quotes Rev. Al, so you know it must be Science.

Seriously, though, this makes me skeptical. Nobody can doubt that the stress that people who live in a society in which they have been historically discriminated against is bound to have physiological effects. Note, though, that David Williams talks about “perceived discrimination.” That is, the subjective impression of discrimination that a black patient has. Notice how the authors of the editorial (all physicians) elide from the perception of discrimination to describing the medical system as deformed by “robust structural racism.” That’s a terrible indictment. Is it true?

Here’s a detailed piece from NBC News about why there are so few black men in medicine. Turns out that there are fewer black men training to be doctors today than in 1978. Why are there so few? Excerpt:

Dr. Louis Sullivan, president emeritus and founding dean of the Morehouse School of Medicine and the secretary of health under President George H.W. Bush, believes that history plays a big role in the current shortage of male African-American physicians.

“Blacks, and especially black males, have always been underrepresented in medicine,” Sullivan told NBC News. “This stems from slavery and legally enforced segregation.”

But, he added, “cost is as much an issue as anything. Given that many black men come from low-income families,” the cost of attending medical school “is too high a burden to put on their families.”

Makes sense, but how many males from low-income white families go to medical school, or even think that it’s possible for them to become a doctor? Does the New England Journal of Medicine consider this to be a problem within the medical profession that stems from prejudice, such that the profession should engage in programs to repair the disparity? I’m not asking rhetorically; I really would like to know. Or are black kids the only  impoverished youth who merit the concern of medical reformers?

There’s no doubt that slavery and segregation put black men historically behind in the professions, but in what sense can you blame “robust structural racism” in medicine today for this? Again, I’m asking straightforwardly. This is such a broad claim. It seems to me likely that ideologues within the medical profession are using the George Floyd moment to medicalize issues that are social and political, and to justify it as merely a medical intervention.

I am sensitized to this because of a long conversation I had with a physician in reporting Live Not By Lies. Here’s what I write in the book about it:

A Soviet-born US physician told me—after I agreed not to use his name—that he never posts anything remotely controversial on social media, because he knows that the human resources department at his hospital monitors employee accounts for evidence of disloyalty to the progressive “diversity and inclusion” creed.

That same doctor disclosed that social justice ideology is forcing physicians like him to ignore their medical training and judgment when it comes to transgender health. He said it is not permissible within his institution to advise gender dysphoric patients against treatments they desire, even when a physician believes it is not in that particular patient’s health interest.

What I didn’t include in the final manuscript is this quote from our interview:

One of the most important questions in medicine now is what is the definition of normal. What is the definition of health – as opposed to wellness, which is about your subjective feeling of how you’re doing. Bad things die. No matter how much wellness you can report, if you are incapable of functioning, you’re going to die.

He elaborated on that point, explaining to me that the activist left within the medical profession are wrongly imposing radical subjectivity into medicine, for the sake of achieving political goals. This is bound to affect the quality of care, he said. As a physician, you cannot be heard to oppose any of this, or you risk being denounced as a bigot. The doctor only spoke with me after multiple assurances that I would not identify him, or give any hint of where he works. His Soviet background prepared him well for the kind of mind games one has to play to stay employed within a highly politicized profession.

Let me be clear: I don’t doubt that the experience of discrimination, perceived and actual, can have and does have a deleterious physiological impact on black people in this society. And I don’t doubt either that black people can exhibit particular physiological phenomena due to their genetic make-up, just like any other people. We should not be surprised by this, given what we know about human evolution.

That said, this editorial seems to be an example of activists using a crisis to advance a political agenda within the profession, in the same sense that Harvard Medical School last year removed portraits of distinguished faculty and alumni from its history, on the grounds that there were too many white men among them. One neurobiologist told NPR last year:

As she travels around the country to give lectures and attend conferences at scientific institutions, she constantly encounters lobbies, conference rooms, passageways, and lecture halls that are decorated with portraits of white men.

“It just sends the message, every day when you walk by it, that science consists of old white men,” says Vosshall. “I think every institution needs to go out into the hallway and ask, ‘What kind of message are we sending with these oil portraits and dusty old photographs?'”

Sexism! Racism! Those photographs are a threat to the health of non-whites and women!

More from that story:

At Yale School of Medicine, for example, one main building’s hallways feature 55 portraits: three women and 52 men. They’re all white.

“I don’t necessarily always have a reaction. But then there are times when you’re having a really bad day — someone says something racist to you, or you’re struggling with feeling like you belong in the space — and then you see all those photos and it kind of reinforces whatever you might have been feeling at the time,” says Max Jordan Nguemeni Tiako, a medical student at Yale.

He grew up reading Harry Potter books, and in that fictional world, portraits can talk to the characters. “If this was Harry Potter,” he muses, “if they could speak, what would they even say to me? Everywhere you study, there’s a big portrait somewhere of someone kind of staring you down.”

I’m sorry, but what? You feel oppressed by pictures that might talk to you and say something that hurts your feelings? So the portraits have to go so you can feel calmer? This is bizarre. But you see where I’m going with this, right? How can we tell the difference between unjust discrimination that can and should be fought, and left-wing activists within the profession medicalize their political views as a strategy of asserting and exercising power.

If you’re in the medical field, let me know what you think in the comments.

UPDATE: From a physician with whom I’ve corresponded in the past:

The NEJM opinion piece you refer to in “Medicalizing Racism” is absurd.  There is no “robust structural racism” in medicine—at least not directed at people of color.  As you know, I am a physician and have been heavily involved in medical education within both a major medical school and as the director of a residency training program.  We’ve previously corresponded on the zealous efforts, eager compromises, and generous accommodations that medical schools and training programs are making in order to pursue the dubious goal of statistical racial parity, even if it requires that more qualified applicants are passed over because of their race or sex in order to assist those historically underrepresented relative to their constituency within the population.  After benefitting from targeted recruitment programs, minimally qualified candidates from preferred groups (URiM—Underrepresented Minorities in Medicine) are explicitly privileged relative to applicants from non-preferred groups in interview invitations and admissions.  Even after admission, additional resources such as assigned tutors provided by the institution, broad assistance through the Offices of Diversity and Inclusion, and a kid-gloves approach from evaluators (professors, supervising physicians, and upper-level residents) provide them with every opportunity for success.  But such success, even on their own terms, has proven elusive.

Notwithstanding, the proudly woke medical educational establishment has been unsuccessful in achieving their goals regarding proportionate representation of Underrepresented Minorities in Medicine (URim), defined by the American Association of Medical Colleges (AAMC) as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”  (Interestingly, foreign applicants of color, such as African immigrants, are not included within this veil.)  This recalcitrant disproportion is certainly multifactorial.  One problem is that there are insufficient promising applicants, particularly of Black men, at the medical school or residency training level.  Those that are truly qualified are fiercely fought over by medical schools and training programs and are essentially able to write their own ticket—but this can’t actually change the overall statistics within medicine.  Increasingly, the more prestigious medical programs improve their racial statistics at the expense of less eminent institutions in a situation akin to the brain drain problem.  If you’re Harvard or Johns Hopkins you can have a graduating class that “looks like America” in which everyone has an IQ over 130, but only at the expense of all the state schools.  It’s a pipeline issue—there simply won’t be enough Black men going into medicine until there are more Black boys beginning to work towards this long-term goal through success in high school and college.  Fixing that supply problem is beyond my abilities and frankly, it’s presumptuous of me to tell anyone else how to raise their children or to what they should be encouraged to aspire.

Meanwhile, qualified White and Asian applicants know they’re being passed over because of their ancestry.  Increasingly, applicants from non-preferred groups (Whites and Asians) who previously would have been shoo-ins are attending the less prestigious osteopathic medical schools.  Apart from a D.O. after one’s name rather than an M.D., there is no substantial difference in training or in one’s ability to obtain a medical license, specialty training in residency, or a successful practice.  I suspect that the for-profit medical schools in the Caribbean will become increasingly meritocratic in that they are willing to admit anyone—even White men of privilege—who can pay the tuition and pass the exams.

Differential medical outcomes with COVID-19 and other diseases are to be expected given the genetic diversity between recognizable ethnic populations compounded by environmental and cultural factors.  Certainly, racism does not account for the disproportionate suffering of Blacks from genetic hemoglobin abnormalities (sickle cell anemia and thalassemia), Whites from auto-immune neurodegeneration (multiple sclerosis and ALS (Lou Gehrig’s disease)), Asians from nasopharyngeal carcinoma, and Ashkenazi Jews from a multitude of inherited errors of metabolism (Tay-Sachs, Gaucher, Niemann-Pick).

Your suggestion that “people who live in a society in which they have been historically discriminated against is bound to have physiological effects” is true, but does little to explain the current statistical inequities among groups in the U.S. population.  Did you know that Black women have a greater life expectancy than do White men (78.1 vs. 76.5 years in 2014? https://www.cdc.gov/nchs/products/databriefs/db244.htm) And what’s to be made of the profound disproportion in White male suicides?  The conventional medical wisdom well into the twentieth century was that Blacks were far less vulnerable to cardiovascular disease (heart attacks and strokes) than were Whites.  That was true—but only because Whites began suffering the medical consequences of prosperity (obesity, sedentary lifestyles, hypertension, atherosclerotic plaques) sooner while the Black population remained largely agrarian and engaged in manual labor prior to World War II.  As it turns out, Blacks are even more vulnerable to these lifestyle diseases (affluenza) than are Whites when matched for income, obesity, diet, and physical activity, but even more profound disproportions have been seen in other populations such as American Indians and Australian Aborigines (both of whom were treated deplorably) but whose medical problems also date to the material prosperity of the late 20^th century that their ancestors never could have imagined.  Can you think of an instance in which material prosperity has not been a Faustian exchange of one’s spiritual and cultural patrimony?  I can’t.

The funny thing about historical racial injustice in the United States is that we’re to believe that its effects increase in severity and prevalence with the passage of time and through subsequent generations.  It’s as if one were to toss a rock in a pond and the waves were to grow in height as they radiated outward.  The Thirteenth Amendment abolished slavery in 1865 (Now why didn’t the U.S. pass that amendment four years earlier in 1861 after all the Confederate States removed any opposition in Congress?  Hmm.) and the Civil Rights Act was promulgated in 1964.  Yet racial rancor is the worst it’s been in decades.  As you pointed out, there are currently fewer Black men in medical training than in 1978.  Clearly, the reflexive explanations (structural racism, lack of opportunity, no role models, etc.) are insufficient to account for the multitude of choices, individual and collective, that bring us to this pass.

Let me confess my privilege.  Since residency, my practice has focused on diseases that disproportionately affect women, minorities, and the poor.  I’m at work at 6:00 AM every day and my practice assists minorities at a rate far in excess to their proportion of the population.  I’ve been working through the pandemic at 50% of my salary so as to protect the staff from lay-offs.  I have no confidence that my children would be able to earn a fair shake in medical school admissions, but I doubt that I would support their entering the medical field in any event.  I love medicine and my job, but the outcomes-based approach to proportionate representation in American medicine will destroy the quality of medical education and practice just a few years before it undermines the public’s confidence in its integrity and efficacy.