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ALiEM Book Club: Medical Apartheid

2018-01-06T19:05:33+00:00

Rallies by white supremacists in Charlottesville, VA and the subsequent milquetoast response from the White House shocked many Americans. These events invoked a national discussion about how many of our public monuments, built to celebrate triumphs and critical moments from our country’s past, can also exhibit appalling acts of malevolence and cruelty, treatment that today is unacceptable. Similarly, our understanding of medical history has evolved. While many of us are aware of particular atrocities, such as the Tuskegee study or the nonconsensual obtaining of Hela cells from Henrietta Lacks, these stories are by no means isolated, and there are times in our country’s history in which harm was bestowed upon vulnerable populations, especially African Americans. Medical Apartheid unveils the long history of medical experimentation performed on African Americans and highlights some of the origins of our country’s health disparities.

Synopsis

In medicine, we have had a blind spot for racial biases. We blithely say that we provide the best care for all our patients and that it is evidence-based. We discuss decision making biases so extensively that is has become a field of study itself. However, rarely is racial bias and inequality addressed.

Harriet Washington’s Medical Apartheid goes beyond bias to discuss frank racism in the House of Medicine. The story is set in the antebellum South, and chronicles the excessive and unnecessary violence of Dr. Marion Sims, who has been hailed as the father of Obstetrics and Gynecology for developing a surgery to manage vaginal fistulas. However, he did not obtain consent from the women he experimented upon, including 3 women, at least 40 times without anesthesia, holding them in his infirmary for 4 years. Washington shares the history of black bodies on display: graverobbing for dissection, circus shows of abnormal anatomy, or display of a human being in the zoo. She traces how some of the physical features of blacks “discovered” in the 19th century, still directly and indirectly impact our practice today. For example, the baseless notion that black skin is not as sensitive to pain initially came from this period. A recent study found that current practices in pain assessment among physicians still reflect false beliefs that blacks have a higher pain tolerance than whites.1 In addition, a meta-analysis and systematic review, found a substantial difference in analgesic treatment among subgroup minorities, with African Americans experiencing the largest disparity.2 

It is tempting to think that racism in medical research ended after Tuskegee, in part, because that is the last ethics breach based on race to receive major media attention. However, Washington calls attention to the many, and in some cases ongoing, ethical issues that put black Americans uniquely at risk. Washington discusses studies designed to examine the utility of implantable contraception that were performed on junior high and high school girls without parental consent, despite evidence that black women face the highest rates of adverse events with these medications. She shares cases of research on siblings of children in the juvenile justice system. Parents of these children felt compelled to participate in the research because if they were able to be identified as a potential subject that meant those conducting the research could potentially impact the treatment of their child in custody. Most relevant to Emergency Medicine is her discussion of implied consent for critical care research in the unresponsive patient. In her conclusion, she suggests some vital ethical reforms to medical research; she also provides suggestions for black Americans to ensure they can confidently participate in research that is necessary for addressing health disparities, knowing that it has their best interest at heart.

About the Author

Harriet Washington began her career in journalism, focusing on health and the sciences. As her career progressed, she shifted her focus to medical ethics, winning several prestigious awards and research fellowships for her work.

Discussion Questions

  1. Does medicine owe the black and brown community reparations for past abuses? Why or why not? If yes, what kind of reparations do you think would be appropriate?
  2. What is your opinion of conducting research on unconscious Emergency Department patients based on “presumed consent?”
  3. How can we create educational and clinical environments where we recognize and call out these ethical violations, rather than becoming blind to the breach?
  4. What are the overt and subconscious things we do in the culture of medicine and medical education that prevent black and brown people from feeling welcome and/or climbing the leadership ladder?
1.
Hoffman K, Trawalter S, Axt J, Oliver M. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. [PubMed]
2.
Meghani S, Byun E, Gallagher R. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174. [PubMed]
Amy Walsh, MD

Amy Walsh, MD

International Emergency Medicine Fellow
Regions Hospital
St Paul, Minnesota