A direct line can be drawn between exploitative policies and poor health, even today
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Figure: racism, racial reparations, health care, emergency medicine, American Medical Association, health, inequity
The medical community has recently emerged at the forefront of the national discussion on racial reparations, with many arguing that racial justice and health justice are inextricably linked, so much so that its effects are still seen every day in every emergency department in the country.
The American Medical Association is pushing the issue to the forefront, debating it at its annual House of Delegates meeting this past June after its Medical Student Section wrote a resolution proposing the AMA study potential mechanisms of national economic reparations as well as reparations by the organization itself. It also called on the AMA to support federal legislation that facilitated the study of reparations.
Ultimately, the delegates voted to refer the resolution for further clarification rather than immediately adopt it, but its discussion still marks one of the first times that the leadership of a major U.S. medical association directly addressed the idea of racial reparations as a health initiative.
“Many healthcare disparities that exist today can be attributed to exploitative structural policies targeting minorities, especially the Black community, including disproportionate rates of incarceration, residential segregation, and unfair labor and employment policies,” the resolution stated. “The Black community is severely underrepresented in medicine, due to many societal barriers for success and the closure of all but two predominantly Black medical schools after the 1910 publication of the Flexner Report.”
A recent article noted that the U.S. health care system itself is deeply rooted in racial oppression, stating that physicians and scientists were “the architects and imagination of the racial taxonomy and oppressive machinations upon which this country was founded.” (Front Public Health. 2021;9:664783; http://bit.ly/3R59qJE.)
“This oppressive racial taxonomy reinforced and outlined the myth of biological superiority, which laid the foundation for the political, economic, and systemic power of whiteness,” wrote Avik Chatterjee, MD, MPH, an assistant professor of medicine at Harvard Medical School, and colleagues. “Therefore, in order to achieve universal racial justice, the nation must first address science and medicine's historical role in scaffolding the structure of racism we bear witness of today.”
A Path to Better Health
New York Health Commissioner Mary Bassett, MD, called reparations “a path to better health, and “not a far-fetched idea” in a lecture during Public Health Equity Week at Columbia University in October. Bringing a health perspective rather than simply an economic and social science perspective to the discussion of reparations is essential, she said.
“It's time to engage in a more direct reckoning with the U.S. legacy of 400 years of slavery and the Jim Crow laws that were enacted following the end of Reconstruction,” she said, “and to acknowledge that power, money, access to resources, good housing, better education, fair wages, safe workplaces, clean air, drinkable water and healthier food, which all translate into good health, have been systematically denied to people of African descent.”
Targeting health resources, such as neighborhood health centers, at marginalized communities is not enough, Dr. Bassett said. “The magnitude, the scope, and the scale of health interventions ... simply are not up to the task of eliminating the map of racial inequities,” she said. “I recognize that reparations will not end racism, but I believe that reparations could bring us closer to [that] goal.”
Health Gap and Wealth Gap
Eugene Richardson, MD, an assistant professor of global health and social medicine at Harvard Medical School and the chair of the Lancet Commission on Reparations and Redistributive Justice, said the wealth gap between Black and white people is directly linked to the legacies of enslavement, Jim Crow, redlining, lethal policing, and unfair housing and credit markets. The idea behind reparations, he said, is that eradicating the wealth gap will allow those marginalized for centuries to counteract the interpersonal racism that they face every day.
“Economic reparations will give people resources to intervene themselves on what the causes of the health inequities are in their own lives,” Dr. Richardson said. “It's not just about giving money to hospitals or committees or neighborhoods.”
One of the physicians advocating for the AMA to take on racial reparations at the House of Delegates meeting was emergency physician Sophia Spadafore, MD, a chief resident in emergency medicine in New York City and a member of the AMA Council on Legislation.
“Emergency medicine is the specialty that has our doors open to anyone, anywhere, anytime, and we see the effect of systemic racism not just on the health care system but our entire societal safety net,” she said. “We are the last stand before people lack any kind of health resources. When we are talking about economic reparations and how those might affect our patients and the health care system in general, emergency medicine should be one of the most influential players at that table.
“We are the ones caring for all of these people who have been marginalized and left out, not just by insurers but by society in general. We see not just one person's lifespan, but the generational trauma people go through, and the neighborhoods and communities we work in are often the ones affected most by these long histories of oppression and marginalization. We want to care for the patient in front of us and help them clinically, but we should also be involved in redressing these historic inequities.”
Dr. Richardson agreed, noting that emergency physicians have a particular stake in the move for reparations because they see the results of that wealth gap manifested in their patients every day.
“In the ED, you often encounter patients who were forced to let their disease go untreated for too long because they couldn't afford treatment at an earlier stage,” he said. “Economic reparations could literally transform the ability of these patients to get preventive health care.”
Reparation Proposals
The Affordable Care Act improved health insurance coverage, but the uninsured rate of Black Americans remains higher than that of white Americans, at 12 percent compared with nine percent. Black Americans are also more likely to report lacking a usual source of medical care, being worried about medical bills, and delaying prescription refills to save money, according to the Department of Health and Human Services. (Feb. 22, 2022; https://bit.ly/3XCtvcS.)
The resolution brought to the AMA by the Medical Student Section, which was also supported by its Resident and Fellow Section, focused specifically on economic reparations. One proposal would pay $850,000 to every descendant of enslaved people. Congressional Bill HR40—named after the broken post-Civil War promise of “40 acres and mule”—would establish a Commission to Study and Develop Reparation Proposals for African Americans, but does not specify what those reparations should entail.
Dr. Chatterjee and her colleagues suggested in their article that reparative policies need not consist solely of direct monetary transfers. They pointed to payment reforms such as expanding Medicaid coverage or new state-specific health insurance for non-white people. Pulmonary rehabilitation has also been found to be an effective treatment option for those with COPD, but it disproportionately benefits white Americans because not all insurance carriers cover it.
“This has led to disparities in COPD and other respiratory treatments, which are likely to be exacerbated during the COVID-19 pandemic,” Dr. Chatterjee said. “Reforming payment for effective treatments for diseases in addition to COPD that are more prevalent in minority populations, such as diabetes and heart disease, would also achieve greater justice.”
Economic reparations for racial injustice have solid precedence in recent U.S. history. Congress not only apologized in the Civil Liberties Act of 1988 for unjustly holding Japanese Americans in internment camps during World War II, it directed reparations of $20,000 to each person detained. The United States ultimately paid $1.6 billion in reparations to 82,219 Japanese Americans.
A Role for EPs
Dr. Richardson said emergency physicians can advance the conversation around racial reparations by supporting the diversity, equity, and inclusion movement at the hospital where they work.
“It's an essential move just to get to the very minimum of where we should be as far as equal representation and equal pay in the places where we work,” he said. “Then, you can get involved outside the hospital more politically. Vote for politicians who support reparations legislation. Get involved in voting drives. Look for non-governmental organizations that are doing this work in your area. If you don't have time to volunteer, contribute to the organization of your choice. Work on electing politicians that will get HR40 moving forward so that we can move the needle on eradicating the wealth gap.”
Dr. Spadafore acknowledged that medical organizations and individual physicians have limited resources, and some may resist the idea that economic reparations are an issue these groups should take on. “I never blame people for asking if something is really our lane and if it's a topic we should be leading the conversation on,” she said. “That's the first hurdle: helping people understand why reparations and health justice are so integral to our mission and what we do.”
But Dr. Spadafore said she is optimistic that the conversation will continue. “If you had asked me even five years ago whether there would be a discussion in national medical organizations around racial justice and repairing our part in racism and racial essentialism in medicine and acknowledgement that we participated and facilitated a lot of these racist structures, I would have laughed, and said, ‘No way are these groups ready for that,’” she said. “Yet here we are, funneling resources into scholarships and funds and research to start to reckon with our history and repair it.
“One year, something is laughed out of the room as something we would never consider discussing,” Dr. Spadafore said. “Two or three years later, at least there's a real debate and people are willing to study the issue, get more information, and think of concrete ways to move things forward. I believe that if we stay persistent and are dedicated to this question and create models for what economic reparations could look like and what they could mean to health justice, we can work on getting something implemented. That takes time.”
Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com. Follow her on Twitter@writergina.
