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Access to care is not the driving force in health equity. The driving force in health equity is the economy, which they worsen
Del Rio, 8-14, 20, Del Rio is Distinguished Professor of Medicine at Emory University School of Medicine and the executive associate dean for Emory at Grady. He is also professor of global health and epidemiology at the Rollins School of Public Health and co-director of the Emory Center for AIDS Research and co-primary investigator of the Emory Vaccine and Treatment Evaluation Unit, ContagionLive, COVID-19 and Its Disproportionate Impact on Racial and Ethnic Minorities in the United States, https://www.contagionlive.com/publications/contagion/2020/august/covid19-and-its-disproportionate-impact-on-racial-and-ethnic-minorities-in-the-united-states
Thus, it is important that we recognize that at the heart of most health disparities are concerns about social justice, and that without addressing policies and practices in housing, education, employment, health care, and criminal justice that foster racial discrimination, health disparities will never cease to exist Health Disparities in COVID-19 The coronavirus disease 2019 (COVID-19) pandemic has been characterized by enormous health disparities both in the United States and abroad. In the U.S., African Americans are contracting SARS-CoV-2 at higher rates, and they are more likely to die from COVID-19 than whites. Infection rates are more than 3-fold higher and death rates are 6-fold higher in predominantly black/African American counties compared with predominantly white counties.3 Hispanics/LatinX are also being disproportionately impacted. In California, LatinX represent 70% of all COVID-19 deaths in the group of people aged 18 to 49 years, despite making up just 43% of that population. Other historically marginalized communities, such as American Indians, are also experiencing some of the highest rates of COVID-19.4 Nationally, age-adjusted hospitalization rates for COVID-19 are approximately 5-times higher for American Indians, Alaska natives, and Blacks, and 4 times higher for LatinX persons, compared with non-Hispanic white persons (Figure). CDC data shows that LatinX people between the ages of 40 and 59 years have been infected at 5 times the rate of white individuals in this age category, but this difference is even more dramatic when looking at deaths of LatinX persons with COVID-19 who died, more than a quarter were younger than 60, although among white persons, only 6% were that young.6 Multigenerational households are also common among minority populations, resulting in an increased risk for older individuals living with grandchildren. These racial/ethnic disparities are not unique to the US. In the United Kingdom, Black and South Asian individuals are at higher risk of dying from COVID-19 compared with white persons after adjusting for other factors.7 There are many reasons that racial and ethnic minori- ties have been disproportionately affected by COVID-19, but social and economic disadvantages are likely significant contributors. A disproportionate number of minorities live in small apartments and houses in which it is difficult to isolate when sick; in addition, many are frontline service workers who don’t have the luxury of staying at home and teleworking. Poverty has long been recognized as a contributor to death and disease, but the striking differences in racial and ethnic impact of COVID-19 provide an opportunity to reaffirm the link between income and health. In the case of millions of the “working poor”—individuals who have a job that does not provide health benefits but make too much money to qualify for Medicaid—lack of access to health care is among the most serious challenges they face. However, health care accounts for some 10% to 20% of the determinants of health, while socioeconomic factors and factors related to the physical environment are estimated to account for up to 50% of the determinants of health.8 Furthermore, strong evidence linking income and health suggests that policies promoting economic equity may have broad health effects. Social vulnerability is a term that refers to the resilience of communities when confronted by external stresses on health such as a pandemic. CDC’s Social Vulnerability Index (SVI) uses 15 census track variables to help identify communities at greater risk.9 In an effort to quantify and better inform the relation- ship between community-level social disadvantage and incidence of COVID-19, investigators at Emory University examined the association of SVI scores with the case- fatality rate and incidence of COVID-19.10 Their data suggest that a higher SVI score is associated with a higher case-fatality rate, an association that strengthened after adjustment for age and for comorbidities. This association exists in more than 1 in 4 counties in the United States and suggests that these counties should be targeted by public policy interventions. The COVID-19 Health Equity Interactive Dashboard developed by the same group allows users to visualize the relationship between the virus’s health impact and social determinants of health at a county level.11 Health Equity Is the Road to Ending COVID-19 Health equity is the principle underlying the commitment to reduce and ultimately eliminate health disparities. It means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk or who have poor health because of social conditions. A potential “silver lining” of COVID-19 is that it could be seen as an impetus and opportunity to develop strategies that would begin to finally eliminate inequalities in health in the United States, thus achieving health equity. The first step is to acknowledge that health disparities related to COVID-19 are not the fault of those who are experiencing them, but rather the consequence of social policies and systems that create and perpetuate inequalities. As Williams and Cooper state in a recent Journal of the American Medical Association editorial, this is an opportunity to develop a new kind of “herd immunity.” By improving current policies and implementing new ones, making the investments necessary to decrease social determinants of health among the poor and disenfranchised, we will all be better protected from future pandemics.12
Turn — Mental health care is institutionally racist. Increasing access to it means more racism and more mental health problems
Medical News Today, July 3, 2020, https://www.medicalnewstoday.com/articles/racism-in-mental-healthcare-an-invisible-barrier, Racism in mental healthcare: An invisible barrier
Studies have shown that systemic racism often means that people of color and those belonging to other marginalized ethnic groups do not receive the mental health support they need. In this Special Feature, we explore the impact of racism as a public healthcare hazard in the mental health arena. In this Special Feature, we look at how racism impacts community-wide access to formal mental healthcare support.
Recently, Fiona Godlee — editor-in-chief at the BMJ — wrote a column in which she called racism “the other pandemic.” “Racism is suddenly and at last everyone’s business, and acting against it is everyone’s responsibility,” she points out. Action has been a long time coming. For years, studies from around the world have shown that systemic racism blocks access to healthful lifestyles and appropriate healthcare among consistently marginalized groups — particularly people of color. Despite this, decision makers have done little to address these inequities. In some of our recent features at Medical News Today — which are part of an ongoing series about race-related health disparities — we have discussed how and why the COVID-19 pandemic has disproportionately hit Black communities, and how the pandemic is likely to impact the mental health of people of color. Now, we look at how racism has forever been an obstacle blocking people’s access to appropriate formal mental healthcare among those in marginalized ethnic groups.We acknowledge that “people of color” is a very general term that encompasses numerous groups and identities, each of which has faced subtly different forms of racist discrimination. The same goes for the term marginalized ethnic groups. However, the aim of this feature is to provide an introduction to the impact of racism on mental healthcare. Future features will look at how racism has affected health and healthcare access in distinct marginalized groups more specifically. The impact of institutional racis Many forms of racism can be very subtle. Microaggressions, such as making assumptions about a person in conversation, often go unnoticed except by the person or people on the receiving end. In a personal essay called “On Becoming a Psychologist” — which appears in The Colour Of Madness, a book exploring the relationship between people of color and mental health — psychologist Cassie Addai wrote of experiencing such forms of aggression Growing up as a Black girl in a majority-white city, I can vividly recall examples of overt racism including being teased because of my ‘thick lips’ and being told to ‘go back/to where I ‘came from,’” she wrote. However, although people can identify and call out individual racist remarks more easily and spontaneously once victims and allies become acquainted with the forms it takes, this is more complicated in the case of institutional, or systemic, racism.A s Prof. Hannah Bradby, a sociologist at Uppsala University in Sweden, explains in a 2010 paper in Sociological Research Online: “The distinction between individual and institutional racism arose with the Black power movement in the U.S. when it was described as subtle and less identifiable compared with individual racism. ‘Respectable’ individuals can absolve themselves from blame for individually racist acts but nonetheless ‘support officials and institutions that perpetuate institutionally racist policies.’” Institutional racism upholds misconceptions and baseless assumptions about race and ethnicity, and it affects all official institutions, including those that offer mental healthcare. In the United Kingdom, for instance, a 2014 report — commissioned by the Lankelly Chase Foundation, Mind, the Afiya Trust, and the Centre for Mental Health — found that although Black people had lower rates of mental illness than other ethnic groups, they were “more likely to be diagnosed with severe mental illness and […] three to five times mor likely than any other group to be diagnosed and admitted to hospital for schizophrenia.” Rates of involuntary commission to psychiatric hospitals were also 2.2 times higher than the average for Black African individuals in the U.K., 4.2 times higher for Black Caribbean people, and 6.6 times higher for those who identified as “Black – other ethnicity.” At the same time, Black individuals were more likely than other community members to receive poor or downright harsh treatment in mental healthcare settings. ‘Circles of fear’ continue to be experienced by Black service users and communities in relation to mainstream mental health services,” the report notes. “Treatment is more likely to be harsher or coercive [for Black people] than that received by white service users and characterized by a lower uptake of primary care, therapeutic, and psychological interventions,” it continues. The same report notes that Black and other marginalized groups consistently found it difficult to access mental healthcare to begin with. ‘Serious, unconscionable disparities Similar situations occur in the United States and elsewhere in the world. “There are serious, unconscionable disparities in access to mental health for people of color in America,” said Nathan Greene, Psy.D., one of MNT‘s expert advisors. “African Americans, Latinx, and Asian Americans receive treatment of mental health challenges at 50–70% lower rates than white Americans in this country. This is the result of failures on individual and systemic levels,” he added. A 2019 study in the journal Health Services Research looked at the data of 1,237 Black adults in the U.S. who reported not having received formal support for a mental health issue for which they required support. The data in this study came from the 2011–2015 National Survey on Drug Use and Health. Its author, Sirry Alang, Ph.D., found that Black individuals reported mistrust in mental health service systems due to experiences of racism. Black respondents — particularly those who had been through higher education — reported that they had experienced stigmatization, and that professionals had minimized their mental health symptoms. This resulted in a lack of access to appropriate care. On May 29, 2020, Daniel H. Gillison, Jr. — the CEO of the National Alliance on Mental Illness — released an official statement acknowledging the extent of mental healthcare disparities in communities of color in the U.S. “The effect of racism and racial trauma on mental health is real and cannot be ignored,” he said. “The disparity in access to mental healthcare in communities of color cannot be ignored. The inequality and lack of cultural competency in mental health treatment cannot be ignored.” Stigmatization and cultural barriers The stigmatization of mental health issues can further amplify the effect of institutional racism on access to healthcare among Black people and other marginalized communities. It is also true that institutional racism can amplify internalized stigma. In an article for Columbia University, psychologist Thomas Vance, Ph.D., writes about the relationship between institutional racism and the stigmatization of mental health issues, particularly in the context of Black communities. “The lack of cultural responsiveness from the therapist, cultural mistrust, and potential negative views from the therapist associated with stigma impact the provision of mental health services in the Black community,” Vance points out. Speaking to MNT, psychologist Riya Patel, Ph.D.* — an assistant professor in the Faculty Research Centre for Intelligent Healthcare at the University of Coventry in the U.K. — further explained the role of stigma associated with mental health issues among communities of color and marginalized ethnic groups. “The first important [barrier in accessing mental healthcare] relates to how mental health problems are experienced, shared, and supported within diverse minority communities,” she told us. “Shame and stigma about poor mental health are common across societies, but these experiences may be amplified in some cultural settings and hold people back from reaching out for assistance,” she added. However, cultural differences can also be barriers, Patel noted. Mental health professionals who do not understand patterns of commun
ication characteristic of certain cultural groups may not understand the issue or provide appropriate support. “People from different backgrounds experience and describe symptoms of mental ill health in different ways, which do not always fit prevailing models of mental healthcare.” – Riya Patel, Ph.D. She added, “People have options within their own communities for getting help and may not perceive a need to access formal services.” “If people experience systemic discrimination when they do use mainstream services, this can cause secondary victimization, exacerbate their mental health status, and lead to distrust between community members and health providers,” Patel noted.
Increased mental health care results in racist social control and drawing Blacks into the criminal justice system
Matthews 1 David Matthews is lecturer, health and social care, Coleg Llandrillo, Rhos on Sea Matthews D (2015) Sociology in nursing 4: the impact of ethnicity on health inequalities. Nursing Times; 111: 44, 18-20.
The extent of racial prejudice in Britain is difficult to quantify, primarily because people may be unwilling to admit to it. However, the British social attitudes survey in 2013 showed that 30% of the British population described themselves as racially prejudiced (National Centre for Social Research, 2014). Direct experience of racial prejudice, or awareness that such attitudes exist, can have significant negative consequences for individuals’ health, particularly their mental health (Annandale, 2014; Barry and Yuill, 2011). Karlsen et al (2005) argued that experiencing racial prejudice increases the risk of anxiety disorders and depression, as it has among Caribbean, Indian, Pakistani and Irish minorities. Similarly, racially prejudiced attitudes can be embedded in how society operates, causing social structures and institutions to function in a racist manner. Rather than just focusing on the actions of individuals, we need to look at social structures and institutions that may operate in a discriminatory manner and influence the actions and attitudes of those within them. Institutional and structural discrimination can be found in health and other government services in the health sector; for example, it has been argued that the institutional attitudes and practices of mental health services and the criminal justice system have contributed to some of the ethnic disparities identified. The reasons for the over-representation of black individuals, especially young men, in mental health settings are hotly contested (Annandale, 2014) but one underlying reason is how mental health services and associated institutions respond to them (Rogers and Pilgrim, 2014). The likelihood of individuals being labelled as mentally ill increases in proportion to the cultural gap between those who are labelled and those who are labelling (Horwitz, 1983). Young Afro-Caribbean men are far more likely to come into contact with mental health services than other groups, especially via the criminal justice system; it is claimed this is because society – the wider public and criminal justice institutions – perceives them as a social threat (Barry and Yuill, 2011). As a result, the criminal justice system is more likely to interpret their behaviour negatively and, as that behaviour is more likely to be “visible” to criminal institutions working in collaboration with the health system, the individuals are more likely to be labelled as having a mental illness. In this respect mental health services can be viewed as institutions of social control (Rogers and Pilgrim, 2014), based on dominant perceptions of young Afro-Caribbean men exhibiting behaviour seen as a social threat. This is supported by research from the last three decades, which shows this group is more likely than its ethnic majority counterpart to be compulsorily admitted to mental health institutions and placed in locked wards (Rogers and Pilgrim, 2014). Suggestions of discrimination in the institutional practices of health services are contentious (Bradby, 2012). The purpose here is not to claim that those working in these services are racially prejudiced, but to suggest that the manner in which these services and institutions operate may discriminate against minority ethnic groups due to embedded norms, values and practices that impact on how their health status is understood.
The entire criminal justice system is racist
Dean Strang, July 12, 2020, https://www.dispatch.com/opinion/20200712/column-police-just-one-part-of-criminal-justice-system, Column: Police just one part of criminal justice system, Dean Strang is a criminal defense lawyer, law professor and author of two books of legal history. He is known for his role in the Netflix series “Making a Murderer.” This column was produced for the Progressive Media Project and distributed by Tribune News Service.
The calls for real transformation of policing are urgent and needed, but not enough. Transformation can start, but not end, there. The police, after all, are only the front end of the criminal justice system. Prosecutors’ offices are next in line; then courts, trial and appellate. Prisons and corrections departments are the back end. Together, these institutions compose a dehumanizing system, one that speaks invariably of “processing” cases. Racial disparities increase, rather than decrease, at each step. Disproportionately, people of color are stopped, harassed and arrested by the police; this is especially true for Black people. They and many other people of color also face racial inequities in terms of charging, plea bargaining and sentencing. By 2018, Blacks accounted for just 12% of the nation’s population but one-third of its prison population. African Americans are incarcerated at five times the rate of whites. In this form of systemic racism, prosecutors, courts and corrections departments deserve at least as much attention as police agencies. Recent years have seen the election of so-called “progressive” prosecutors. But only a few, including San Francisco’s Chesa Boudin and Philadelphia’s Larry Krasner, have attempted real structural changes in the system, beyond sloganeering. Overall, courts give structure and durability to systemic racism and antipathy toward the impoverished. Courts tolerate two subsystems. Those with money often can achieve relatively good outcomes, while the millions who are poor usually are consigned to overworked, underfunded indigent defenders and often “processed” into bad outcomes. In courts, an accused’s wrongs are “crimes,” but the wrongs of police, prosecutors and judges are “errors” routinely excused as harmless. This leads to impunity and a repetition of wrongs by emboldened government actors and a corresponding loss of public faith in police, prosecutors and the courts. Thanks to the courts, too, police officers who violate the U.S. Constitution in “good faith” usually are immune from liability. No criminal defendant gets a pass for good faith. Further, bad faith or the biases of police officers mostly don’t count. Even if the traffic stop was motivated by racism or a desire to snoop, by judicial rule it is fine if the officer claims a minor traffic violation. At the system’s back end, prisons are another obvious target for transformation. The land of the free and home of the brave, with less than 5% of the world’s population, has more than 20% of the world’s prisoners. A prison abolition movement, led by people as scattered as Angela Y. Davis in the United States and the sociologist Thomas Mathiesen in Norway, has been around for 50 years or more. It should be heard. Finally, legislatures are architects of the criminal justice system. They deliberately underfund much of it, especially the defense of the poor. They also have created the redundant layers of police agencies that threaten to smother whole segments of the American populace. Especially in communities of color, people are over-policed by a stack of police agencies that compete with one another for arrest statistics and prestige. These include a municipal police department, an overlying county sheriff’s office and sometimes a state police force. Many cities now pile on public housing police, public transportation police, port authority and airport police, park police, capitol police and campus police — most of these with broad policing powers that extend well beyond their core missions. We also have more than 90 federal law enforcement agencies, again assigned broad powers and overlapping authority. That’s right: nearly eight dozen nationwide police agencies created and run by the federal government, which in theory has no general police power at all under our Constitution. So yes, we should start with transforming the police. But it will be too little if that front end of the system — and thus of structural racism, antipathy to the impoverished and systemic injustice — is all that we transform.
Health care system full of microaggressions and racism
Tribune Content, 9-3, 20, https://www.gmtoday.com/health/how-microaggressions-in-health-care-hurt-minorities/article_2a63f7d4-ee34-11ea-9fb2-9f7c4aa1fd18.html, How microaggressions in health care hurt minorities
Far too often, when Sarah Perren went to a Philadelphia hospital for her regular diabetes care, her doctor gave her dietary recommendations that she never could have afforded. Just stepping into the office made the 59-year-old Black woman feel tense and self-conscious; she sensed that the doctor thought she was just lazy for not following his diet. One time, another doctor at the clinic literally jumped back when she took off Perren’s socks and saw her dry skin — a frequent consequence of diabetes. The doctor announced that she didn’t want any skin flakes to get onto her clothes. “I felt it was racial,” the West Philadelphia resident recalled. “You just have a feeling the way they talk to you. That’s when I told myself my health is more important somewhere else.” She has since established care with another hospital,but still feels the toll of what experts increasingly recognize as microaggressions — interactions that may not be obviously racist, but still feel dismissive or even hostile to patients of color.A growing body of research indicates that microaggressions can seriously harm patient care by making important communication impossible and turning people off entirely from getting medical care. Patients report feeling marginalized in a variety of ways. Perren recounts a time when she brought her son to the emergency room with severe stomach pain. They waited hours to get attention for what turned out to be appendicitis, while watching a white doctor and his wife jump to the front of the line in 15 minutes for no clear reason. And while Perren’s physician never bothered to learn whether she could manage the recommended complicated and costly dietary rules, other patients report that doctors assume they can’t afford the best therapy. One study found, for instance, that children of color with type 1 diabetes were much less likely than white children to get the most effective blood glucose monitors, regardless of their parents’ income. Microaggressions, despite the name, can have outsized impacts. “What they do is make patients feel marginalized,” said Georges Benjamin, executive director of the American Public Health Association. “Some (microaggressions) are more overt – people assume you’re having less pain than you actually are or you’re going to abuse pain medications so they give you just enough for the weekend.” A study from just a few years ago out of the University of Virginia’s psychology department found that racist myths persist among some white doctors and medical students, such as that Black people don’t feel pain as acutely as whites, or that their skin is literally thicker. Multiple studies have shown that Black patients are significantly less likely to receive pain medications for fractures in the emergency room, for example. Microaggressions erode the most important relationship in health care..
Medicare for All means rationing
Instiute for Policy Innovation, March 27, 2019, https://www.ipi.org/ipi_issues/article_detail.asp?name=what-medicare-for-all-supporters-wont-tell-you, What Medicare-for-All Supporters Won’t Tell You
All government-run health care programs ration care. Some rationing is subtle, some is blatant. But they all do it. When the government pays for health care, it must compete against other claims on government funding, such as welfare, defense and education. As a result, there is never enough money to go around. NEVER! So politicians look for subtle ways to limit health care spending that affect smaller populations to free up money for other claims on government funds. That means cutting at the margins, at least initially: the very old, the very young, and the very sick—i.e., people who typically don’t vote. Thus a 65-year old might be able to receive a pacemaker but perhaps not at 75 or 85. An otherwise healthy teenager hurt in a car accident might receive significant resources, while a premature infant with only a small chance to survive might not. It may sound cruel but it makes sense. Given a zero-sum game, where a dollar spent on one patient is a dollar that can’t be spent on another, maximizing the benefit is likely the best way to decide who receives how much. Another way to ration is through waiting. For years the Vancouver-based Fraser Institute has published an annual list of waiting times in Canada. Ironically, among single-payer systems waiting lines can be a feature, not a bug. When famed Canadian pediatric orthopedic surgeon Dr. Walter Bobechko invented a spinal clamp for children with scoliosis—known as the Bobechko clamp—that would help them leave the hospital in a few days rather than several weeks, he claimed hospital management criticized him.5 Those quicker departures opened up beds sooner, creating additional costs for the hospital’s limited budget. Dr. Bobechko eventually left Canada to practice medicine in Texas. The U.S., by contrast, generally has an open-ended health care spending system, even for the two largest government-run programs, Medicare and Medicaid. However, because both programs impose price controls, patients may be denied certain therapeutic options—e.g., more expensive medical devices or pharmaceuticals—and doctors’ offices may limit their Medicare and Medicaid patient loads, creating longer waits to see a doctor. While there is already rationing for both Medicare and Medicaid patients, it is often limited and subtle. Under M4A rationing will be open and explicit—and widespread.
Rationing denies care to the disabled
Patricia Williams, law professor, Northwestern, August 2020, Williams, Patricia J., The Endless Looping of Public Health and Scientific Racism (July 31, 2020). Burris, S., de Guia, S., Gable, L., Levin, D.E., Parmet, W.E., Terry, N.P. (Eds.) (2020). Assessing Legal Responses to COVID-19. Boston: Public Health Law Watch., Available at SSRN: https://ssrn.com/abstract=3681399
Rationing Care During the Pandemic Again, I raise these stereotypes in order to ponder the medical consequence of such epistemic foolishness at a moment when COVID-19’s disparate toll on black and brown bodies has directed much attention to “underlying conditions.” Careful commentators will point out that underlying conditions are not the same as innate predisposition: there is no known human immunity to this coronavirus. And while age and illness may diminish our immune system’s response to any pathogen, that greater susceptibility is merely a probability indicative of neither any human predisposition nor any natural immunity. Our universal susceptibility to it is underscored precisely by the virus’ being “novel.” It bears repeating that underlying conditions like rates of stress, diabetes, asthma, and crowded living conditions and overrepresentation in risky jobs are factors directly accounting for greater intensity of affliction. We know this—this is not a mystery. Given this, attention to the fate of people of color is both overdue and double-edged: it highlights inequities but also risks reinforcing hem as innate. For example, if the United States’ rates of infection are wildly off the charts compared to other nations, we do not generally blame it on the innate conditions of a peculiarly “American” biology; we know these numbers are the product of poor policy decisions. Just so, disproportionate deaths among communities of color must not be attributed to an imagined separateness of “African American” biology. Yet, that is precisely the risk! Amid a welter of misguided fantasies of “sub-species,” “bad blood,” and dissolute traits, we forget at our peril that the trauma and social factors disproportionately affecting people of color are also driving death rates among whites—if not to the same degree. Trap white people in crowded, poisoned, impoverished contexts and they die too. The proposal to use race or ethnicity as a marker of disease vulnerability performs its persuasive labor by appealing to life-saving potential where confined to the context of vaccine prioritization. But it remains to be seen how race will intersect with the usages of vulnerability for purposes of triage in hospital settings. COVID-19 reduces us all to frail, wheezing, non-essential, bare bodies. When we arrive at the emergency room, we are delivered as mere bags of bones among so many “burdening” the health care system. Anonymously quarantined in isolated wards, not visibly marked as a uniquely beloved soul with dear family and networks of friends—is bad enough without having race deployed as an additional cipher for poor outcome. With a shortage of ICU beds, such a cipher will likely be algorithmically weighted as well, for algorithms are more efficient than the Horae, and doctors are really quite busy these days. Recognizing the risks of bias in such emergency circumstances, the Department of Health and Human Services’ Office of Civil Rights issued a bulletin on March 28, 2020, restating a federal commitment to protecting “the equal dignity of every human life from ruthless utilitarianism.” Under both the Americans with Disabilities Act and the Affordable Care Act, people “should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities or age.” The underlying concern is exemplified by the case of Michael Hickson, a black quadriplegic whose COVID-19 care was withdrawn by St. David’s South Austin Medical Center after a doctor told his wife: “…his quality of life—he doesn’t have much of one.” His wife was recorded asking pointedly: “Because he’s paralyzed with a brain injury, he doesn’t have quality of life?” The doctor answered in the affirmative (Shapiro, 2020). The New England Journal of Medicine has run a number of articles about triage in the face of shortages of ventilators. Here is one such take: Triage proceeds in three steps: 1. application of exclusion criteria, such as irreversible shock; 2. assessment of mortality risk using the Sequential Organ Failure Assessment (SOFA) score, to determine priority for initiating ventilation; and 3. repeat assessments over time, such that patients whose condition is not improving are removed from the ventilator to make it available for another patient. (Shapiro, 2020). Number one covers the direst instances—crudely put, those who do not stand a chance. Number two, mortality risk, may encompass a lot of us who are older or who have disabilities or other pre-existing conditions. And since there is overlap between long-term stress, environmental poisoning, poverty, lack of medical insurance and such conditions, there is quite a perfect storm of collective mortality risk clustered by zip code and histories of real estate segregation. Number three, “repeat assessment” of whether to free life support for another patient is interpellated by availability of resources that will be in shorter and shorter supply as the numbers of sick and dying continue to climb. Ideally, such assessment is supposed to be done by committee, in conversation with family members or surrogates, and done with consideration of a patient’s Do Not Resuscitate orders. But, in a pandemic or other emergency, decisions to withdraw care are frequently up to a single doctor or resident or perhaps a nurse. In other words, given the mounting numbers, it will probably be up to a highly stressed, overworked, frightened, sleep-deprived human being who has no relation to you but the abstractions of your temperature, oxygenation rate, age, and whatever else that singular individual medical professional finds to read onto, into, or out one’s body.Discrimination against those with loosely defined disabilitiesis already quite common; the University of Washington MedicalCenter, for example, has argued for “weighing the survival ofyoung, otherwise-healthy patients more heavily than that ofolder, chronically debilitated patients” (Ne’eman, 2020). The reconfigured overlay of race as itself a debilitating, resourceconsuming morbidity-risk worsens the situation. Disability rights advocates have worked hard to push these concerns to the front burner, urging Congress to ban triage based on “anticipated or demonstrated resource-intensity needs, the relative survival probabilities of patients deemed likely to benefit from medical treatment, and assessments of pre- or post-treatment quality of life” (Solomon et al., 2020; see also Chapter 34). On July 22, the advocacy organization Disability Rights Texas filed a complaint withHHS against the North Central Texas Trauma Regional Advisory Council for its use of a rigid, point-based, algorithmic scoring system, which can automatically exclude from intensive care persons with a range of pre-existing conditions and disabilities without resort to individual assessment. Other states are beginning to reexamine their crisis rules in response to such concerns. Political Consequences of Treating Race as Biological Destiny Perceptions of disease, deviance, and disgust have always enabled time-worn and hypnotic constructions of embodied difference to be carried forward. When The New Yorker Magazine chose “The Black Plague” as a title for a really excellent piece about COVID-19 by the very insightful author Keeanga-Yahmahtta Taylor, there was a some pushback and rethinking of that as an unfortunate choice allowing some to think of the disease as not really affecting young white people partying on Florida beaches. M
ore obviously and more powerfully, when Donald Trump speaks of “the China virus,” he not only gives the disease a race and a place; true to his outsized colonial imagination, he gives it distance. It’s “over there,” not here, well removed from the conceptual possibility of “our” susceptibility. If “we” are afflicted, it is not just the illness thatdebilitates us but anger that we have been invaded by “them.” It is this form of displaced animus that one saw in the spikes of antiAsian prejudice that arose in the wake of outbreaks of smallpox in San Francisco’s Chinatown in the 1800’s and that culminated in the Chinese Exclusion Act of 1882. Anti-Semitic nativism targeted Jews after bouts of typhus in 1892 (Wald, 2008). Mary Mallon, or “Typhoid Mary,” was an asymptomatic carrier of typhoid fever; her arrest in 1907 on public health charges galvanized much anti-Irish sentiment in New York City, figuring them as immigrants importing unsanitary and slovenly habits (Wald, 2008; Schweik, 2009). When the AIDS epidemic first started spreading in the 1980’s, some people told themselves it was a disease conveniently localized to the bodies of “gay men.” And when Zika virus was carried from equatorial regions by mosquitos riding the waves of climate change, New York City health officials sprayed insecticide by zip code (focusing on East Flatbush, Bed-Stuy, Crown Heights and Brownsville in Brooklyn, and in upper Manhattan, in the neighborhood once known as “Spanish Harlem”) (Frishberg, 2016), as though those pesky identitypoliticking mosquitos could simply be red-lined (Denis, 2020). Instead of coming together around our shared vulnerability, time and again we have created a set of golems to stand in for a pathogen, divisive demons that direct our fears of inherent virulence, murderous voraciousness and leech-like parasitism. Asians. “
Any racial equality is offset with loss in the future
Hoag, August 2020, Alexis Hoag is an associate research scholar and lecturer at Columbia Law School and thevinaugural Practitioner-in-Residence at the Eric Holder Initiative for Civil & Political Rights at Columbia University. At the law school, Hoag teaches courses on abolition, capital post-conviction defense, and movement lawyering. Her scholarship explores America’s unfulfilled promise to Black people and its impact on the criminal legal system, particularly as it relates to due process and the right to counsel. Prior to Columbia, Hoag served as Senior Counsel at the NAACP Legal Defense and Educational Fund, Inc., and as an Assistant Federal Public Defender in Nashville, TN, primarily representing death-sentenced individuals in federal habeas and related state court proceedings. She is a graduate of Yale College and NYU School of Law, Harvard Law Review Blog, https://blog.harvardlawreview.org/derrick-bells-interest-convergence-and-the-permanence-of-racism-a-reflection-on-resistance/
Nothing about this moment — COVID-19’s disproportionate impact on Black people, Trump’s explicit anti-Black racism, or the mass demonstrations following lethal police use of force against Black people — would have surprised Professor Derrick Bell. These fault lines are not new; rather, these events merely expose longstanding structural damage to the nation’s foundation. A central theme of Bell’s scholarship is the permanence and cyclical predictability of racism. He urged us to accept “the reality that we live in a society in which racism has been internalized and institutionalized,” a society that produced “a culture from whose inception racial discrimination has been a regulating force for maintaining stability and growth.” Bell would have also foreseen Trump’s presidency as the likely follow-up to eight years of the nation’s first Black President. Any amount of racial advancement, Bell argued, signified “temporary ‘peaks of progress,’ shortlived victories that slide into irrelevance as racial patterns adapt in ways that maintain white dominance.”
Minority youth will not want mental health treatment. Those that do often end up in the criminal justice system
Rebecca Klisz-Hulbert is assistant professor in psychiatry and behavioral neurosciences at Wayne State University, August 15, 2020, Washington Post, Fewer Black teens seek treatment for depression, mental health issues than White counterparts, https://www.washingtonpost.com/health/black-youth-at-higher-risk-of-depression-mental-health-problems/2020/08/14/e28056ec-d66e-11ea-aff6-220dd3a14741_story.html?hpid=hp_national-right-4-0_hse-latest-feed%3Ahomepage%2Fstory-ans
Black youth in the U.S. experience more illness, poverty, and discrimination than their White counterparts. These issues put them at higher risk for depression and other mental health problems. Yet Black youth are less likely to seek treatment. About 9 percent of them reported an episode of major depression in the past year, but less than half of those — about 40 percent — received treatment. By comparison, about 46 percent of White youth who reported an episode were treated for depressive symptoms. nstead, some turn to suicide, now the second leading cause of death among Black children ages 10 to 19. That rate is rising faster for them than any other racial or ethnic group. Data from the Centers for Disease Control and Prevention show the rate of suicide attempts for Black adolescents rose 73 percent from 1991 to 2017. With schools nationwide grappling with how to offer instruction to students, principals and teachers need to be reminded that Black children have endured a distinctive kind of trauma since the pandemic began. They have had a different experience. The killings of George Floyd and Ahmaud Arbery — and what happened afterward — are just two examples. As an expert in child and adolescent psychology, I know that a multitude of barriers keep Black children, and their families, from receiving that treatment. They need help to deal with the pervasive poverty and racism that surrounds them. Studies suggest Black youth and their families may be less likely to identify their own mental health symptoms. If they do receive referrals for care, they may follow up less often than Whites. Delays in seeking care can lead to negative consequences, including emergency psychiatric hospitalizations and noncompliance with treatment recommendations. These youngsters may then become adults with mental health issues that remain unaddressed. Parents and caregivers should encourage treatment. But interviews with them done as part of one study revealed they sometimes obstruct the process. Many feared their child would be labeled “crazy.” Those caregivers, sensitive to social stigma, also relied on others in the community when deciding to pursue treatment for their sons. Sometimes they would receive support from those they spoke with; other times, they would not. Because of discrimination and abuse, Blacks have good reason to distrust the mental health system. Health-care disparities exist there just as they do in other health-care domains. Black adolescents are less likely than White teens to be treated with beneficial psychiatric medications, and more likely than White teens to be hospitalized involuntarily. Other reports suggest Black youth with psychiatric disorders are more likely to be referred to the juvenile justice system, while White youth are more often referred for mental health treatment.
Racism in many other areas
Hoag, August 2020, Alexis Hoag is an associate research scholar and lecturer at Columbia Law School and thevinaugural Practitioner-in-Residence at the Eric Holder Initiative for Civil & Political Rights at Columbia University. At the law school, Hoag teaches courses on abolition, capital post-conviction defense, and movement lawyering. Her scholarship explores America’s unfulfilled promise to Black people and its impact on the criminal legal system, particularly as it relates to due process and the right to counsel. Prior to Columbia, Hoag served as Senior Counsel at the NAACP Legal Defense and Educational Fund, Inc., and as an Assistant Federal Public Defender in Nashville, TN, primarily representing death-sentenced individuals in federal habeas and related state court proceedings. She is a graduate of Yale College and NYU School of Law, Harvard Law Review Blog, https://blog.harvardlawreview.org/derrick-bells-interest-convergence-and-the-permanence-of-racism-a-reflection-on-resistance/
Only after I started practicing did I cease seeing Bell as a pessimist and recognize him for what he was: a realist. Working on capital cases as an appellate defende in Tennessee, no federal judge wanted to acknowledge the gross racial disparities in death sentencing in a state where Black men convicted in a single county made up the largest subgroup on death row. The draconian rules of procedural default prevented these same clients from securing relief on otherwise meritorious claims of racial discrimination in jury selection. Later, as a lawyer at the NAACP Legal Defense and Educational Fund, Inc. (LDF), I inherited one of the Mississippi school desegregation cases that Bell filed with his colleagues Mel Leventhal and Marian Wright Edelman. Despite five decades of federal court monitoring, the public school district was still failing to adhere to the law established in Brown v. Board of Education. My colleagues and I reengaged members of the original plaintiff class, now grandparents of children enrolled in the same district. The district no longer operated a dual school system separated by race; instead, it operated a single, virtually all-Black, under-resourced school system that funneled children into the criminal legal system. In civil rights and the criminal legal system, I was fighting the same fight as my forebearers with similarly racist results. So, as Bell posed, “Now what?”
Health care not key to health outcomes
Darrouzet, 7-7, 20, Michael Darrouzet is the CEO of the Texas Medical Association. Jennifer Hanscom is the executive director and CEO of the Washington State Medical Association. Philip Schuh is the executive vice president and CFO of the Medical Society of the State of New York. All are board members of The Physicians Foundation, STAT News, Health care reform: The ‘new normal’ needs to go beyond clinical care, https://www.statnews.com/2020/07/07/new-normal-health-care-go-beyond-clinical-care/
Over the past decade, state and federal governments, health insurance companies, health care delivery systems, and physicians have struggled over who should bear the cost when patients get sick. The Centers for Medicare and Medicaid Services and private insurance companies have increasingly shifted this risk to physicians, holding physicians responsible for patients’ health through quality measures and financial rewards and penalties The problem is that these measures, incentives, and risk models focus almost entirely on clinical care. Yet social and environmental factors, such as access to healthy food, safe housing, and other social determinants of health, drive 70% of health outcomes.
Increasing access to NHI is the extension of anti-black eugenics. Appeals to a liberal ethic of care is the appropriation of black suffering for the benefit of the biopolitical state.
Jackson (Zakiyyah Iman, assistant professor of black feminist theory, literature, and criticism in the English department at George Mason University and a liate faculty in Women and Gender Studies. She has published articles in Feminist Studies and glq) 2016 (Losing Manhood: Animality and Plasticity in the (Neo)Slave Narrative, Qui Parle Fall/Winter 2016, Vol. 25, Nos. 1-2, pg. 95-135, Wake AD)
In Beloved, Morrison departs from and transforms the slave narrative convention of juxtaposing the degradation of slaves with that of animals in order to draw our attention not to the violence of dehumanization but rather to the violence of humanization. More specifically, Beloved suggests that animalization and humanization of the slave’s personhood are not mutually exclusive but mutually constitutive. In other words, the slave’s humanity (the heart, the mind, the soul, and the body) is not denied or excluded but manipulated and prefigured as animal, whereby black(ened) humanity is understood, paradigmatically, as a state of human animality, or “the animal within the human.” Morrison’s text recalls rhetorical strategies employed by Frederick Douglass, arguably the nineteenth century’s most iconic slave, that diagnose racialization and animalization as mutually constitutive violence under slavery. Douglass’s iconicity is perhaps precisely owed to his dexterous navigation of competing liberal humanist rhetorical modes and affective registers, in particular, sentimentality and religio- scientific hierarchy. While Douglass undoubtedly radically calls into question the biopolitical logics and practices of slavery with respect to both humans and animals, he does so in a manner that reveals the seemingly near-inescapable paradoxes of liberal humanist recognition to the extent that one is conscripted by its terms—appeals to discourses of sentiment and Self. Yet, both sentiment and the sovereign “I” return us to racialized, gendered master narratives of identity and feeling, which the rooster’s gaze in Beloved productively de-stabilizes.5 Mister’s gaze, or the exchange of glances between Mister and Paul D, offers a much-needed critical alternative to sentimental ethics—sympathy, compassion, protection, stewardship, care, and the humane—which has historically been conceived within the terms of a racialized, heteropatriarchal economy of sensibility. In what follows I examine how we might read Morrison as productively problematizing sentimentality as well as gendered appeals to discourses of the Self rooted in religio-scientific hierarchy, as both discourses have historically recognized black humanity and included black people in their conceptualization of “the human” but in the dissimulating terms of an imperial racial hierarchy. Re-constellating the slave narrative genre, Morrison opens up a new way to interpret the genre, not as one that exposes slavery’s de- humanization but rather as one that details the violence of liberal humanism’s attempts at humanization. Unsettling reified interpretations of history and literary slave narratives, Beloved identifies the violation of slavery not in an unnatural ordering of man and beast but in its transmogrification of human form and personality, as an experiment in plasticity and its limits therein. To put it differently, New World slavery established a field of demand that tyrannically presumed, as if by will alone, that the enslaved, in their humanity, could function as infinitely malleable lexical and biological matter, at once sub/super/human. What appear as alternating, or serialized, discrete modes of (mis)recognition—sub/super/humanization, animalization/humanization, privation/superfluity—are in fact varying dimensions of a racializing demand that the slave be all dimensions at once, a simultaneous actualization of the seemingly discontinuous and incompatible.
Can’t solve Black incarceration, which results in a massive deprivation of care
Pollock 14 [Anne, “On the Suspended Sentences of the Scott Sisters: Mass Incarceration, Kidney Donation, and the Biopolitics of Race in the United States,” Science, Technology, & Human Values, Volume: 40 issue: 2, page(s): 250-271, https://journals.sagepub.com/doi/full/10.1177/0162243914539569]
In Discipline and Punish, Foucault ([1975] 1995) theorized that prison’s obvious failure to rehabilitate is actually part of its function, playing a key role in constituting the delinquency it purports to seek to correct. In the profoundly racialized US prison system, the role of prisons in constituting a class of society that is excluded from society is particularly blatant (Alexander 2010). Indeed, in the post–Jim Crow era, as Loic Wacquant (2002, 55) argues, the “carceral institution…has been elevated to the rank of the main machine for ‘race making.’” No other country has an incarceration rate as high as the United States, and our prison system is rooted in our history of slavery (Davis 1998; Blackmon 2008). I refer to the US prison system as “our” prison system, at the risk of sounding parochial to non-American readers, to underscore the responsibility that I and others writing from this critical location must take for this moral emergency. In the wake of the fall of Reconstruction, the swelling prison system in the South did more than appropriate labor; incarceration and a prison record also became a mode of denying citizenship rights more broadly (Davis 1998). The Scott Sisters have themselves put their experience into this larger context of the social role of criminal justice in perpetuating racial inequality, for example, by participating in a town hall meeting at a Jackson church on the topic “Saving Black Boys from the Cradle to Prison Pipeline to Help Ourselves” (Thomas-Tisdale 2012). The Scott Sisters’ case is also embedded within the larger problematic of the public health consequences of mass incarceration (see Freudenberg 2002; Rich et al. 2012). In 1991, much earlier in the growth of mass incarceration, the American Public Health Association (1991) issued a statement decrying mass imprisonment on the grounds that “prisons disproportionately confine sick people…and…prisoners are subject to further morbidity and mortality in these institutions,” noting that this burden falls particularly heavily on poor people and people of color. More recently, amid scholarship showing that black/white health disparities are smaller among prison populations than amid the general population, Dumont et al. (2013, 85) point out that much of the impact on the social determinants of health appears after prisoners are released, creating “a perverse relationship between public health and incarceration: even as correctional facilities appear to provide a venue for addressing health disparities by accessing a high-need, medically-underserved, largely non-White population, incarceration itself ultimately perpetuates those disparities in the community.” Barbour’s notion of prison release as a way of saving money points to the peculiar character of the right to health care in the United States. As sociologist Tony Hatch (2010) has pointed out, in the United States, the only people with a Constitutional right to health care are prisoners: any state is perfectly within the law to disregard the health of any ordinary citizen. This peculiar structuring of the right to health care—such that deprivation of liberty and access to a right to health care are explicitly intertwined—is part of how biological citizenship is negotiated in the United States. The US Supreme Court has ruled that failure to provide adequate medical care to prisoners is considered “cruel and unusual punishment” under the eighth amendment: Mississippi is not legally allowed to disregard the health of a person in its custody in prison. In the 1976 ruling Estelle v. Gamble, the Supreme Court liberally cites a still-active provision of the Civil Rights Act of 1871, which provides federal recourse for those whose constitutional rights are being violated by a state (42 U.S.C. § 1983). The Supreme Court’s invocation of a Reconstruction-era law hints at the state and federal racial politics at stake in requiring states to care for their prisoners. By making the state’s release of the Scott Sisters conditional upon the state’s release from any obligation toward them at all, a perverse form of freedom is constituted. Mississippi officials have explicitly articulated medical release of prisoners as a means of shifting costs from state to federal obligation, pointing out that if released prisoners qualify for Medicaid, the state’s financial burden for their care is lowered to 25 percent, and if released prisoners qualify for Medicare, the financial burden is completely shifted to the federal government (Bakeman 2012). And in this particular case, the sisters were allowed to move to Florida, where their mother, children, and grandchildren were living, an unusual privilege for people on parole that is both quite correct and effectively diminishes still further any contribution by the state of Mississippi to their care. Any Medicaid or other state contribution for the Scott Sisters’ care will be paid for by the state of Florida, not by the state of Mississippi. Of course, even though prison confers a right to health care, in practice, prisoners are often very poorly cared for. That Jamie Scott is in such poor health—after spending essentially her whole adult life in the custody of the prison—points to the inadequacy of that care. The structurally racist criminal justice system is the context of both the organ failure and of its donation, in a way that resonates with Sherine Hamdy’s account of dialysis and kidney donation in Egypt. There, Hamdy posits that “disease processes” of kidney failure and survival are “already political,” and “contest the very opposition between the biological and the political” (Hamdy 2008, 563). Both Jamie Scott’s organ failure and Gladys Scott’s promise of organ donation have what Hamdy would flag as a “political etiology.” Dialysis itself provokes comparisons with incarceration among nonincarcerated people with end-stage renal disease, who describe themselves as “doing time” (Russ, Shim, and Kaufman 2005). In this sense, Jamie Scott’s kidney failure is its own life sentence. Even the prospect of a kidney transplant, from her sister or otherwise, would not free her from the obligations of disease management but would trade one intensive medical regime for a less onerous one. Prison is a particularly stark setting for what Alondra Nelson has characterized as a central tension in the health inequality of African Americans: poor black communities have long been “both underserved by and overexposed to the medical system” (Nelson 2011, 20). The Scott Sisters’ case becomes an individualized instantiation of this problematic: the medical system that cares so poorly for Jamie also demands bodily sacrifice from Gladys. After their release, the sisters cared for their ailing mother (since deceased), while striving to get themselves healthy enough for transplant surgery, for which they lack the necessary financial resources (Ma’at 2012b). Insurance (presumably Medicaid) would pay for Jamie’s surgery but not for Gladys’s. The inadequacy of health care for prisoners is in this sense continuous with the inadequacy of health care for racially stratified American publics.
Providing health insurance is useless because it doesn’t solve underlying causes of inequality and quality care isn’t available in communities
Hinkson and Ehlers 2017 – Leslie R. Hinkson is Assistant Professor of Sociology at Georgetown University and Nadine Ehlers, PhD, is an academic staff member of the School of Social and Political Science at The University of Sydney (“Conclusion: Freedom from Debt,” Subprime Health: Debt and Race in U.S. Medicine pp 183-186) bhb
Through framing race as biological and as the underlying cause of health disparities, architects of race-based medicine have laid the groundwork for a tripartite system of health care delivery, biomedical practice, and biomedical research that has simultaneously racialized disease and illness and rationed access to and quality of care along racial lines. This system has created a space for health disparities- rooted in slavery, settler colonialism, Jim Crow, and residential segregation-to grow, and for health-related costs and debt to accumulate to its victims. Such debts, as the chapters collected here explore, impose a financial toll in addition to emotional, psychological, and social costs. Several contributions in this volume have illustrated how race-based medicine has created monetary debts for minority subjects through limited access to affordable care and through a history of social and medical abuse and neglect that created health disparities. These disparities are costly to address-in pure monetary terms-and such costs are often squarely placed on the shoulders of racial minorities themselves. Additionally, race-based medicine has, in recent decades, augmented the creation of debt through the formulation of race-targeted treatments that are associated with larger price tags than those used to treat nonminority subjects with similar ailments. Are the terms of repayment any less onerous when the debt is conceived as a moral as opposed to a monetary one? In other words, does the United States as a whole suffer emotionally, financially, psychologically, and socially as a result of the moral or ethical debt burden associated with its historical role in helping to both create and maintain disparities in the health profiles of racial minorities compared with their White counterparts? The contributions of this volume suggest that it does. As many authors in this volume argue, race-based medicine today is often positioned as an attempt to redeem the nation’s less than virtuous past: it is framed as a means through which we might redress past injuries and repay this accumulated debt. However, race-based medicine often fails to address the conditions that created this debt in the first place, and rather than serving to defray that debt and alleviate attendant suffering, it often functions to maintain the status quo and thus entrench past injury. An enduring question that remains is, what are the problematics of framing race-based medicine as an adequate or even appropriate form of redress? Rather than ensuring that all people have access to affordable healthy food, for example, we provide them with race-targeted pharmaceutical treatments for hypertension and diabetes. Rather than pouring more resources into studying the social and environmental determinants of breast cancer, we invest more heavily in the search for race-specific genetic factors to explain the increased likelihood of African American women dying from the disease than their White counterparts. Rather than investing in increasing the supply of affordable, quality health care in minority communities, particularly where the inhabitants are lower income, we expand Medicaid coverage. But what use is health insurance if the health providers you are able to access view your coverage as inferior to other forms and so won’t accept it? Or, what if those providers don’t offer quality care, or are too few in number to serve everyone in the community requiring their services? Ultimately, such approaches all come with significant monetary costs, and all attempt to address health disparities in some way. Some have even been specifically crafted as a means of social redress for the existence of these disparities. However, none truly focuses on eliminating them. Thus, race-based medicine can be seen as a racial project that, in our contemporary era, is greatly influenced by the tenets of neoliberalism: it extends a meaning of race based in biology-which is used to rationalize the organization and distribution of both medical services and medical knowledge-without disrupting profit margins or shareholder value.1 Indeed, it yields the future promise of both better health outcomes for those who fall under the racialized biomedical gaze and greater wealth to those invested in its many forms of expansion. To date, however, wealth associated with race-based medicine has only accrued to a select few, and as the cost of health care rises, minorities continue to experience excessive rates of morbidity and mortality. Thus, the specter of guilt recursively haunts the conscience of the nation, and that guilt continues to keep the United States a nation divided. In examining race-based medicine through the lens of debt, the chapters in this volume return again and again to its main limitation: its rationalization and practice reveal a poor theorization of race. That race should be conceptualized as a biological reality, or even an admittedly crude-yet necessary stand-in for genetic variation, reveals an underdeveloped and ahistorical understanding of the concept’s past and present as a sociopolitical category. In a form of teleological reasoning, race becomes an explanatory variable—the supposed cause of racial health disparities—without much attention being placed on what race is or the casual [sic] mechanisms and pathways through which race operates as a predictor of health profiles. Such reasoning is indicative of a disturbing trend in biomedicine that may well disseminate across the rest of society: the reentrenchment of race as a biological “truth” in a field that is esteemed as a hard science, whose assumptions are in many ways seen as inviolable by many other academic disciplines and by the public, may serve to not only provide biological explanations for health and other racial disparities found in our society but to provide justification for them as well. The reentrenchment of the idea that race is biological makes for poor science. To be clear, it is to be expected that medical practitioners and researchers should focus on the body, on the biological roots of disease, and on the biological responses to external stimuli. The problem with race-based medicine, particularly as it relates to ethnopharmacology, is not that it focuses on the biological but in that it treats race as a possible biological determinant or root cause/trigger of disease as opposed to thinking of race as predicting the amount of exposure to a series of external stimuli that invoke certain biological responses. For example, African Americans are more likely to be diagnosed with nitric oxide deficiency than Whites. This condition can be caused by obesity, stress, diet, and lack of exercise, among other factors. In other words, the primary causes are external to the individual. Yet scores of scientific and medical journals recommend, given the higher probability of nitric oxide deficiency in this population, that beta-blockers are not an effective alternative pharmaceutical option when considering treatment for hypertension or congestive heart failure. If this deficiency is what explains the lack of effectiveness of the drug in individuals, why not simply test all patients with hypertension or congestive heart failure for nitric oxide deficiency in order to determine the best course of treatment? Why simply use race—whether self-identified or assumed by the health care professional—as a proxy for a specific biological process? In focusing on the racial category as opposed to low
levels of nitric oxide, the former becomes the focus of treatment, the deficiency to be overcome. Biomedicine, we would suggest, needs to focus more on what is broken in bodies and the pathologies to be found in biological processes, rather than biologizing what is broken and pathological in our society.
Insurance doesn’t mean care—racial biases in medicine mean that black people might get treatment, but never quality care
Hoberman 12 John Hoberman is a Professor at the University of Texas, PhD UC Berkeley and is social and cultural historian who has researched and published extensively in the fields of race studies, human enhancements, medical history, and globalization studies. Black and Blue: the origins and consequences of medical racism
Over the past 25 years. The most prestigious American medical journals have produced massive evidence confirming that racially biased diagnosis and treatments are a fact of life in American medicine. These analyses document racially biased behaviors and if prompted one official investigation and no disciplinary proceedings. Other professionals serving the public, such as policemen or professors, are not granted such immunity from scrutiny of their professional conduct. The racially motivated habits whose effects are presented in the medical literature and statistical data are so ingrained that some doctors do not deviate from them even when they know their interactions with black patients are being recorded for observation. Their personal eccentricities and the specific harms they cause their patients remain anonymous, buried in the statistics that make it into print. Concealed behind the sterile terminology will racial “disparities” and “cultural differences” are an unknown number of biased behaviors that in other social venues might be regarded as negligence or violations of the law. What evidence do we have the doctors employee racially motivated thinking when dealing with patients of color? The abundant data that indicate differential diagnosis and treatment for a wide range of diseases and disorders are one type of evidence. Their crucial disadvantage is that they portray collective behavior rather than the more detailed scenarios of private professional conduct that do not appear in the medical literature. The motives for some physician behaviors can be deduced on the basis of what is known about the history of racialist thinking by physicians. Deductions of this kind are indispensable to understanding racially motivated medical thinking and behavior, given the dearth of current survey data about physicians racial thoughts and fantasies. But they are open to the objection that what we know about doctors racial complexes from the overt medical racism of the past may not apply to modern practitioners who have supposedly absorbed socially sanctioned disapproval of racist speech and behaviors and conduct themselves accordingly. This books methodology is based on the premise that, to the contrary, significant aspects of the medical racial folklore of the pre-civil rights have persisted and adapted to modern circumstances, to a greater extent than many have assumed possible in an age of officially mandated racial equality and racially civil public discourse. There is, in fact, no reason to assume that medical students and doctors are less likely to absorb and act upon the racial fantasies that still suffuse modern societies. In 2001, for example, 3 white medical students at the University of Alabama at Birmingham were exposed by the news media. After they were black face to a Halloween party. One was dressed as Stevie wonder, the 2nd is a character from the fat Albert cartoon show, and the 3rd as a black woman. The medical school officials who handled this case, with whom I communicated, resolve this matter by accepting public apologies and devoting a data racial sensitivity training. The idea that this behavior demonstrated character defects that might make these individuals unfit to practice medicine apparently did not figure in the process that finally certified them is fit to treat black patients. This incident also raises the question of where cultural stereotyping ends and biological race fantasies begin. Blackface signifies a fantasy of racial transformation, just as cross-dressing signifies a fantasy of gender transformation. These medical students found gratification in taking on the identities of a blind singer, a comical cartoon image, and the generic black female who is traditionally ranked at the bottom of our racial hierarchy. These future positions regarded playing with distorted versions of the black body is a kind of entertainment. One can only wonder what the experience of public humiliation and a day of racial sensitivity training may have done to temper or redirect their fantasies about black bodies in ways that might serve the interests of the African-American patients who will someday consult them for medical treatment. The most thoroughly documented racial disparities concerning the diagnosis and treatment of heart disease, the leading cause of death in the United States among Blacks as well as whites. This book argues that the medical folklore about Blacks and cardiovascular diseases that was so evident throughout the 20th century has distorted some doctors responses to heart disease in black patients. The absence of this historical perspective. In the current medical literature illustrates the naïveté of medical authors who regard racially differential diagnosis and treatment of heart disease is a mysterious phenomenon whose causes have somehow eluded our understanding. Reading our way back to the relevant medical publications and coronary disease will help to clarify the mystery. At this point. Let us survey. The findings about racially disparate treatment of patients requiring therapy for heart disease, that of appeared since the late 1980s. As of 1989 white patients were undergoing one 3rd more coronary catheterizations and more than twice as many coronary angioplasties as black patients. In 1993. Researchers confirmed that white patients consistently underwent invasive cardiac procedures more often than black patients. In a 1996 editorial in the new England journal of medicine, H. Jack Geiger expressed deep concern about the unequal treatment of heart disease: “perhaps most consistent-and most disturbing-are the repeated findings that Blacks with ischemic heart disease, even those enrolled in Medicare or free care systems are much less likely to undergo in geographically, angioplasty, or coronary artery bypass grafting.” A 1997 report came to similar conclusions regarding bypass surgery; the altar called this finding “disturbing, because we also found that they were not due to differences in the severity of disease or to coexisting illnesses.” A 2000 report confirmed that “medical therapies are currently underused in the treatment of black, female, and poor patients” who have suffered acute myocardial infarction. “This variation was not explained by severity of illness, physician specialty, hospital, and geographic characteristics”– possible confounding factors. The study ruled out, leaving physician bias as the most probable explanation for why black patients were offered fewer therapeutic procedures. A 2005 survey of racial differences in the management of acute myocardial infarction covering between 1994 and 2002 found that racial differences and care had persisted rather than diminished during this period. Racially differential practices have also been found to affect the treatment of early-stage lung cancer. One research team wrote the following in 1999: “our analyses suggest that the lower survival rate among black patients with early stage, non-small cell lung cancer, as compared with white patients, is largely explained by the lower rate of surgical treatment among Blacks.” The same conclusion was reiterated in 2006: “black patients obtain surgery for lung cancer less often than whites, even after access to care has been demonstrated. They are likely not to have surgery recommended, and more likely to refuse surgery.” It is historically conditioned fear that causes some black patients to refuse surgery even when it would be in their best interest to consent. The medical literature refers to these decisions as examples of “patient preferences” as though these de
cisions to reject surgery were free and autonomous acts on the part of empowered medical consumers. In fact, black spheres of surgery persist because the medical profession is never address the consequences of its racist history and weight that might reassure African-Americans who feel strain from the medical system. Heart and cancer surgeries are generally regarded as desirable procedures that benefit patients, and that is why racially differential access to them is unjust. There are other kinds of surgery that are undesirable when better alternatives exist, and here too black patients have borne an extra burden of suffering. The effects of a hysterectomy, for example, are likely to be more of an ordeal for a black woman than for her white counterpart, since “black women are more likely to get the more invasive kind of hysterectomy, which doesn’t require a large incision. The vaginal operation is more expensive and harder, and studies have shown it is used more and women higher on the social economic scale.” It was reported in 1996 and 1998 that black patients with diabetes and circulatory problems were less likely than whites to have legs during surgery and are more likely to undergo the amputation of these limbs. Yet, precisely the reverse was true of the more beneficial type of operation, since Blacks were less than half as likely as whites to get hip replacements. Here, too, “patient preferences” dissuade some black patients from undergoing hip or knee surgeries because they “report less confidence in the efficacy” of such operations. Accepting such “patient preferences” as autonomous decisions is mistaken, since the black patients lack of confidence in the procedures is an expression of mistrust rooted in a group history of traumatic experiences involving the medical profession.
The aff traps black people into a racist system– Implementing NHI through an anti-black grammar leads to race-specific medical interventions – it creates racist disease surveillance that contains and securitizes black spaces because of structural factors that make their inhabitants predisposed to illness
Krupar and Ehlers 2017 – Shiloh Krupar is a Geographer and Provost’s Distinguished Associate Professor at Georgetown University, where she currently serves as Field Chair of the Program in Culture and Politics in the Edmund A. Walsh School of Foreign Service. Nadine Ehlers, PhD, is an academic staff member of the School of Social and Political Science at The University of Sydney (“Biofutures: Race and the governance of health,” Environment and Planning D: Society and Space 35:2) bhb
Second, and related to our first point, these biomedical targeting operations extract the conditions of black health and illness from the broader contexts of structural racism. Biomedical targeting generally fails to recognize the social conditions in which poor health emerges and, in the case of black subjects, how poor health, institutional racism, and the epistemology of anti-blackness are ontologically enmeshed. The targeting of black populations—specifically the two cases we explore here—does not simply direct resources to black subjects. Instead, in such operations, race is objectified as that to be targeted, meaning that race itself is not undone: That is, race as a stratifying mechanism that orders the social—a social order characterized by anti-blackness—is not called into question. Both BiDil and medical hot spotting demarcate populations, with supposedly distinct bodies, and name them as a political problem in need of specific health governance; black bodies and racialized spaces are targeted in order to manage the life of the population. Accordingly, BiDil might be seen to ontologize blackness as a corporeal truth for market accumulation, while medical hot spotting can be said to spatially ontologize structural racism in order to secure cost efficiencies of the health care system. BiDil is predicated on financial extraction; medical hot spotting is predicated on threat containment These biomedical targeting technologies reveal how health interventions do not necessarily support or achieve a better future for African Americans. Instead, they advance the epistemological violence of anti-blackness by concentrating the “problem” of black life in the U.S. at the scales of: (1) the racialized body (BiDil) and (2) space (hot spots), which both become objects of ever more heightened administration, financial exploitation, and securitization. BiDil positions African Americans as “problem bodies” that must take on responsibility for their own racialized embodied risk through the act of buying and consuming race-based medicine; here, anti-blackness operates through the black responsibilization of risk. Medical hot spotting tracks, maps, and fixes high-cost health care users in “problem spaces” that are positioned outside the populace; hot spotting locates and reifies the structural position of anti-blackness in space for the purposes of surveillance, anticipation of risk, and containment Third, contemporary biomedical targeting technologies are an endangering form of health administration exacerbated by the logics of neoliberalism. Under neoliberal conditions, populations previously excluded from the vital politics of the nation are now ostensibly being addressed. However, the two biomedical targeting technologies that we explore reveal a predatory power to demarcate race for purposes spanning financial extraction to threat containment—even as such “targeting” is advocated as the means for addressing the embodied and spatial effects of racial inequality. In neoliberal times, the color line no longer operates as a clear and obvious modality of exclusion, as Du Bois would have it (Goldberg, 2008). The neoliberal biopolitics of health increasingly emphasizes customizing health, the body, and life itself through biomedical practices (Clarke et al., 2003: 181–182). Our two case studies reveal how customizing health seems to be an operation of inclusion (directly or indirectly by race) within biomedicine: BiDil is a customized drug that attends to black health; it targets racial minorities supposedly to extend life. Medical hot spotting is also a form of customization through care delivery: It delineates “problem spaces”—where high utilizers of health care are located—in order to direct resources and generate efficiencies in health provisions. “Customizing” works in the first case through “color awareness” and marketing within biomedicine (i.e. the racialized spectacle of the body), and paradoxically in the second, through invisibilizing race at the level of “location”/space according to the so-called colorblind agency of the free market and cost–benefit analysis (O’Boyle, 2007). While both targeting technologies may attempt to alleviate racial health disparities, they simultaneously augment racial difference and exacerbate racial inequalities—but they do so in very different ways: thus emphasizing the importance of tracing out the empirically distinct means through which each technology resecures the epistemology of anti-blackness. BiDil highlights the neoliberal refusal to acknowledge the social production of risk, by casting health as an individual—not social—enterprise. Medical hot spotting disavows the historical and spatial processes of racial formation that structure the present and simultaneously shows that certain (racialized) subjects are positioned—in advance—as risk failures within the paradoxically “race-neutral future” of the nation. To begin exploring these ideas, we turn to the case of BiDil, the oft-disputed first pharmaceutical with a race-specific indication.
Black and other minorities will be targeted by drug companies who will patent products designed to treat individuals with certain new racial profiles. This commodifies race.
Roberts 10 [Dorothy, George A. Weiss University Professor of Law and Sociology and the Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights @ Penn Law, “Race and the New Biocitizen,” in What’s the Use of Race? Modern Governance and the Biology of Difference, pp.259-64]
Amy Harmon of the New York Times won a 2008 Pulitzer Prize for a prominent series of articles called “The DNA Age,” about the many ways genetic discoveries are influ- encing our lives. One of these articles, titled “Gene Map Becomes a Luxury Item,” quoted a millionaire, saying, “I’d rather spend my money on my genome than a Bentley” (Harmon 2008a, F1). Sequencing your genome can be quite pricey. Knome, in Cambridge, Massachusetts, charged private clients $350,000 to read their entire genome and provide a face-to-face, customized analysis of what it tells about them. Scientists predict that, in the near future, they will be able to map everyone’s personal genetic code at a more reasonable cost, allowing doctors to make more accurate predictions about our health and prescribe medications designed specifically to match each person’s individual DNA profile. In fact, several biotech companies already offer to genotype DNA sent to them by customers and provide personalized reports about their ancestry and risk for various conditions. Using the tag line “genetics just got personal,” the Silicon Valley company 23andMe is an online service that sends customers an at-home kit to collect a saliva sample and, based on a genetic scan, gives them quantitative estimates of their risk for certain diseases and traits based on research that has found genetic associations. The company also uses genotyping to “compare your genetic information to that of people from around the globe.”1 23andMe markets itself as a tool not only for gathering personal information, but also for creating social connections. Its Web site prominently displays “sharing and community” as a chief service, noting, “Seeing your own genetics is just the beginning of the 23andMe experience. Our features also give you the ability to share and compare yourself to family, friends and people around the world.”2 In September 2008, the New York Times style section carried a colorful splash about the celebrity “spit party,” hosted by Barry Diller, Rupert Murdoch, and Harvey Weinstein, at which the glitterati spit into test tubes so their DNA could be analyzed (Salkin 2008). Cofounder of 23andMe Anne Wojcicki explained that the company helps people use their genomes as a platform for social networking: “If you want to have a community around psoriasis, we’d like to be able to allow you to form a psoriasis-specific community” (Salkin 2008, ST1). But her vision of this new citizenship based on DNA is even grander: “We envision a new type of community where people will come together around specific geno- types, and these artificial barriers of country and race will start to break down” (Weiss 2008, A1). Sharing one’s DNA is becoming a civic duty as well as a basis for civil engagement. In October 2008, Harvard genetics professor George Church launched the Personal Genome Project (PGP), which will build the only public DNA database that links genes to diseases, physical traits, and abilities (Harmon 2008b). In exchange for having their genomes inventoried, PGP participants agree to make it all public, along with personal information about their health, ancestries, and habits. Ten people, called the PGP-10, initially volunteered, and Church appealed to 99,990 more of his fellow citizens to join him in donating their genetic material as part of the new civic responsibility to aid scientists in their mission to advance personal genomics. “We’re all at risk for everything to some extent,” Church said, “and so we need to have a rich set of data and we need to be sharing that data until we get a much deeper understanding of what all the risk factors are, environmental and genetic” (Nakashima 2008, A1). A key component of 23andMe’s services is similarly to put customers’ genetic information in a database for research. As the company explains on its Web site, “Because we believe 23andMe’s mission extends to the advancement of science, we intend to give you the opportunity to participate in research that could improve understanding of how genetics influences our lives.”3 The expansion of genetic research and technologies has helped us cross a threshold into a new type of biopolitics concerned with our capacity to control and manipulate human life. As British sociologist Nicholas Rose (2007) has shown, so-called biological citizenship is grounded in the unprecedented authority wielded by individuals over their well-being at the molecular level. According to Rose (2007, 40), “our very biological life itself has entered the domain of decision and choice.” Biological citizenship entails both individuals’ autonomy over personal welfare and a biosociality that links people together around their common genetic traits (Rabinow 1996). Genetic information enables individuals not only to manage their own health, but also to unite with others around their common health conditions, as revealed by DNA testing. Rose (2007, 4) and others celebrate biocitizenship because it enhances human agency, as patients “become active and responsible consumers of medical services and products ranging from pharmaceuticals to reproductive technologies and genetic tests,” and as they are empowered to form alliances with physicians, scientists, and clinicians to advocate for their interests (Franklin and Roberts 2006). The relationship between citizenship and biology entails far more than organizing around shared health concerns. Genetics becomes the basis for political relationships that extend beyond the family and that include a broad range of ties among citizens and with the state. Genetics provides novel means for reinterpreting existing political identities and creating new ones, for forming communities, for participating in civic life, and for imposing civic duties. We could describe the emerging category of biological citizenship without regard to race. Indeed, biological citizenship is supposed to transcend race. But I have been struck by the way race is fundamental to the new biocitizen. Race is treated as a key—even essential—classification in the genetic research and testing that informs biocitizens. Race is at the cutting edge of technologies that empower biocitizens. Race is integral to the public discourse about genetics that promotes biocitizenship. Why? Why is race, a category invented in premodern times, so central to the most modern scientific advances? What is the use of race in constructing the biocitizen and in pro- moting biocitizenship as the prevailing relationship among individuals, the market, and the state? I want to take up Rose’s (2007, 167) admonition to “locate the current debates over race and genomics firmly within the transformed biopolitics of the 21st century.” But just as we cannot apply the same old sociocritiques or paste the same label of eugenics on contemporary biopolitics, nor can we uncritically assume that the new biocitizen- ship necessarily fosters individual life and choice and necessarily intervenes on the consequences of inequality, rather than legitimizing inequality. By placing race at the foundation of biocitizenship, race appears more significant at the molecular level, precisely as it appears less significant in society. On one hand, scientists have recently claimed genetic confirmation of classical racial categories; pharmacogenomic researchers use race as a proxy for genetic difference in studies of disparities in health and drug response; and biotech companies market a variety of products that treat race as a biological grouping. On the other hand, the U.S. Supreme Court has affirmed a color-blind approach to social policy that rejects race conscious- ness as a tool for addressing inequality, while many pundits have declared the Obama presidency to be evidence of a postracial America. Scientists, politicians, and corporations are constructing biocitizenship in a way that not only
obscures the continuing social significance of race, but helps to promote post–civil rights mechanisms for preserving the racial inequality. The Expansion of Race-Based Biotechnology The emergence of biocitizenship is occurring at the same time as we are witnessing a resurgence in scientific and commercial interest in genetic differences among “races.” (Duster 2005). After World War II, the rejection of eugenics, which had supported sterilization laws and other destructive programs in the United States, generated a compelling critique of the biological basis of race. The classification of human beings into distinct biological races is a system of governance that arose out of European conquest, enslavement, and colonization of people in Africa and Asia. Biocitizenship did not really originate in the twenty-first century. Race has always been a form of biocitizenship: its function is to include or exclude residents from full citizenship according to their assignment to a political hierarchy based on invented biological demarcations and justifications. Social scientists’ conclusion that race is socially, politically, and legally constructed was confirmed by genomic studies of human variation, including the Human Genome Project. These studies showed high levels of genetic similarity within the human species. Genetic differences among human beings are “clinally distributed”—they appear gradually across geographic space; they do not fall into sharply demarcated groupings (Bolnick 2008, 72). On June 26, 2000, when President Bill Clinton unveiled the results of the Human Genome Project, he proclaimed that “human beings, regard- less of race, are 99.9 percent the same.” Most genetic variation occurs within popula- tions, not between them. Some scholars believed that the science of human genetic diversity would replace race as the preeminent means of grouping people for scientific purposes. In his manifesto against racial thinking, Against Race, sociologist Paul Gilroy (2000, 37) predicted that advances in genomic research would eventually discredit the idea of “specifically racial differences” by rendering race a useless way of classifying people. Similarly, Aravinda Chakravarti (2009, 380) wrote, in a recent issue of Nature, that “each of us has around 6.7 billion relatives. . . . The global picture of relatedness that is emerging from DNA studies stands to shatter many of our beliefs about ourselves.” Chakravarti is hopeful that by shifting the focus of genomewide studies from popula- tions to individuals, “we could test once and for all whether genetic race is a credible concept” (Chakravarti 2009, 381). Reports of the demise of race as biological fact were premature. Attention quickly shifted from the 99.9 percent genetic similarity to the 0.1 percent genetic difference, and that difference was presumed to encompass race. One of the first sites for resuscitating race was also an important aspect of biological citizenship: personalized medicine. By prescribing therapeutics that match each individual’s genetic predisposition to disease and response to drugs, scientists will enable people to manage and advocate for their own health more effectively. Key to the National Institutes of Health Pharmacogenetics Research Network, which studies how genes affect people’s response to drugs, is the belief that “it is important to understand the 0.1 percent difference because it can help explain why one person is more susceptible to a disease or responds differently to a drug or an environmental factor than another person” (National Human Genome Resource Institute 2005). Some researchers see race as a critical first step to producing personalized medicine because it can serve as a proxy for individual genetic difference (Tate and Goldstein 2004). The Raw Materials of Pharmacogenomic Research In her ethnographic study of two biopharmaceutical labs, medical anthropologist Duana Fullwiley (2008) discovered that race served as an unquestioned organizing principle for the collection, analysis, and reporting of genetic data. During a six-month fieldwork stay at the University of California, San Francisco, Department of Biopharmaceutical Sciences, Fullwiley interviewed researchers investigating the pharmacogenetics of cell membrane transporters, molecules that are vital to drug delivery. The human genomic DNA that provided the raw material for their research entered the lab already classified by race. The researchers purchased DNA from the Coriell Institutes for Medical Research Cell Repository, which identified samples according to self-reported race. Unsatisfied, they also sought a grant to build a genetic database specifically for their project that collected more “racially pure” DNA by “excluding anyone who reported racial mixing in their genealogies for the past three generations” (Fullwiley 2008, 159). The researchers not only assumed that African American and Caucasian DNA samples would have significantly different haplotype frequencies, but they also perceived each as the other’s “opposite race” (Fullwiley 2008, 162). When researchers found results that were inconsistent with their perception of racial categorization, instead of rethinking their presumptions about racial sameness and difference, they usually reacted against the data. So when African American genetic frequencies were too similar to Caucasian ones, the scientist concluded that the racially labeled samples must have been contaminated. The organizing principle of race has marked the very raw materials that go into creating the new biocitizen and shape the scientific conclusions researchers draw from them. Race at the Frontier of Personalized Medicine The promise of personalized medicine, matching drugs to each individual’s unique genome, hinges on race. Until pharmacogenomics can live up to this promise, race stands in as a surrogate for individual genetic variation. In June 2005, the Food and Drug Administration (FDA) approved the first race-based pharmaceutical, BiDil, to treat heart failure specifically in African American patients. BiDil was not designed only for black people. Jay Cohn, the University of Minnesota cardiologist who pat- ented BiDil, combined two generic drugs that have been prescribed to patients regard- less of race for decades and originally intended to market it to all suitable patients. Cohn and the biotech start-up firm Nitromed repackaged BiDil as a race-specific drug as a way to get marketing approval from the FDA and to extend the patent (Kahn 2004). What is more, the clinical trial that tested BiDil involved only African Ameri- cans. Because there was no comparison group, the researchers never showed that BiDil functions only or even better in black patients than in others. Yet the FDA permitted Nitromed to market BiDil as a drug for black people. Why do heart patients need a race-specific therapy? One theory supporting this need is that the reason for higher mortality rates among black heart patients lies in their genetic difference, either in the reason for getting heart disease or the reason for responding differently to medications for it. In its March 2001 press releases, Nitromed explained that BiDil’s efficacy stemmed from “a pathophysiology found primarily in black patients.” “Observed racial disparities in mortality and therapeutic response rates in black patients may be due in part to ethnic differences in the underlying patho- physiology of heart failure,” the company asserted (Kahn 2003, 474). The FDA simi- larly explained its decision to approve BiDil specifically for African American patients in a January 2007 article in Annals of Internal Medicine. “We hope that further research elucidates the genetic or other factors that predict the usefulness of hydralazine hydro- chloride-isosorbide dinitrate [the ingredients in BiDil],” the authors wrote. “Until then, we are pleased that one defined group has access to a dramatically life-prolong- ing therapy” (Temple and Stockbridge 2007, 61). In
the past, the FDA has had no problem generalizing clinical trials involving white people to approve drugs for everyone. White bodies function like human bodies. But with BiDil, a clinical trial involving all African Americans could only serve as proof of how the drug works in blacks. By approving BiDil only for use in black patients, the FDA emphasized the supposed distinctive—and substandard—quality of black bodies (Bowser 2004). BiDil is only one example of the growing trend toward what law professor Jonathan Kahn (2006, 1349) calls “the strategic use of race as a genetic category to obtain patent protection and drug approval.” The emergence of race-based biomedicine means that the pharmaceutical and biotech industries see blacks and other racialized groups as profitable markets and test populations, as companies are searching for new money- making drugs and as the expansion of biotechnologies increases demand for human subjects and sources of human tissue. Race is a key channel through which scientists and corporations convert biomedical research into biocapital. In this way, powerful market forces help to construct the new biocitizen along racial lines.
Impact – property relations are founded on and sustained by the violent erasure of black bodies
Leong (Diana, Assistant Professor of English & Environmental Humanities Graduate Program at Utah University) 2017 (The Salt Bones: Zong! and an Ecology of Thirst, Published January 4th 2016, Isle Journal, Volume 23 Issue 4, November 2016, C.A.)
The “Zong” case played a pivotal role in enabling British commercial law and modern finance capital to ensure/insure the fungibility of the slave. Scholars of its legal proceedings have pointed to the “general average” as the fundamental principle at stake in the appeal. Under the terms of this insurance precept, claims could be made for cargo that was deliberately destroyed if the act was absolutely necessary to secure the success of the larger enterprise. In these instances, all contracted parties (i.e., insurers and the insured) agreed to share in the loss and recompense of jettisoned cargo. In the case of “Zong,” the ship’s owners and crew invoked this clause to make a claim for the average value of the jettisoned slaves by speculating about the value they would have generated in their imagined exchange. But as Ian Baucom skillfully argues, the general average is also the “practice by which finance capital insures not only its objects, but, more importantly, its capacity to value (and to guarantee the value) of objects regardless of either their thingly existence or their actual market place exchange” (29). The “Zong” case is singular therefore not in the fact that it treated slaves as commodities, but because it formalized practices of speculative finance that successfully freed value from the material existence of the object. Value, in other words, no longer depended on the exchange and use values of objects, or even on the actualization of an imagined loss, but was instead conferred in the acts of insurance and speculation. “Insurances,” Baucom writes, “set the money-form of value free from the life of things” (30–31). What this means for our understanding of racial slavery is that the edifice of modern finance is built on a violent erasure of black bodies that is not only condoned but anticipated, producing “an economy in which blackness circulates precisely as a form of disappearance, a spectral blackness” (Sexton, “Captivity” 78). This circulation of blackness as money-form (i.e., currency) and spectral remainder occurs alongside and through the extraction of labor from the slave’s flesh, but is not necessarily bound to it. In this regard, the slave’s flesh is marked as excessive, which, as Philip reminds us, provides the generative locus for a certain legal order. ertain legal order. In “Zong! #2” of the “Os” section, we encounter the following clusters of words: the throw in circumstance the weight in want in sustenance for underwriters the loss the order in destroy the that fact the it was the were negroes the after rains Wafor Yao Siyolo Bolade Kibibi Kamau (Philip 5) In the context of the “Zong” case, “the loss” belongs to “the underwriters” of the ship’s insurance company for whom the systematic murder of slaves represented a contractual obligation. Within this framework, any recognition of the slaves’ former bearings, as sons, daughters, friends, and partners, is foreclosed. However, Philip declares “the Africans on board the ‘Zong’ must be named. They will be ghostly footnotes floating below the text … [the] idea at [the] heart of the footnotes in general is acknowledgement—someone else was here before—in Zong! footnote equals the footprint” (200). All twenty-six poems in “Os” contain a set of African names separated from the formal text by a thin line—footprints of a type of loss that cannot be accounted for within the confines of the law. In her analysis of “Zong! #2,” Shockley argues that we should read these names as additional “underwriters” of the text to counter the calculations of value necessary to speculative finance. The word cluster “the weight in want/in sustenance” also draws attention to one homophone that repeats throughout the collection: “want,” meaning “to desire or need,” and “wont,” meaning “one’s customary behavior in a situation” or “given to.” The word “weight” invokes, first and foremost, the heaviness of those black bodies cast into the sea and the value guaranteed by their deaths. The footnotes at the bottom of the page also bear the weight of lost kinship in want of recognition. In light of the absences that saturate “Zong! #2,” and the bar of the law that separates the lost from “the loss,” the phrase “weight in want,” or the “value in custom,” refers to captivity itself. Within the system of “Zong” as both text and historical instance, the “wont” or “custom” that provides “sustenance” for the “underwriters” of slavery is the eradication of black bodies. Acts of violence that verified the slaves’ material existence as excessive to the production of abstract value consequently begat an “order” that comes in and as “destroy.” Even though the treatment of the slaves as subjects of capital was assumed and uncontested, the court still ruled in favor of ordering another trial and overturned the initial awarding of compensation to “Zong’s” owners. According to the proceedings of Gregson v. Gilbert, “Zong’s” slaves were allegedly thrown overboard after the crew concluded that “a sufficient quantity of water did not remain on board … for preserving the lives of the master and mariners … and of the negro slaves” (Philip 210). However, during the appeals process, it was discovered that slaves were thrown overboard in groups over the course of several days. During this time, rainfall had re-supplied the ship with enough drinking water so as to make the further killing of slaves unnecessary. Nevertheless, slaves were still thrown overboard after the rains had fallen, begging the question of what, well beyond the captain’s morbid fiduciary self-interest, motivated the additional murders? The case was clearly never about the ethical significance or legality of these deaths or about the treatment of slaves as commodities. In fact, as Jeremy Krikler proposes, the Chief Justice, Lord Mansfield, may have deliberately “ignored [those] aspects of the law,” which contested the legality of the massacres because he was “fixed firmly on the questions of absolute necessity and the general average which he believed might now be weakened if the humanity of the slaves was introduced” (43). Mansfield’s well-documented ambition to rid British commercial law of ambiguity certainly guided his decision to safeguard its clarity. Once it became clear that the ship’s owners failed to meet the standards of absolute necessity, Mansfield’s refusal to consider the slaves’ humanity enabled him to shift focus toward the crew and away from the murders themselves. In so doing, the laws of absolute necessity and the general average were left intact, another paramount example of the “order in destroy” found in “Zong! #2” (Philip 5). Mansfield’s resolve to treat the “unnecessary” murders as nothing more than evidence of crew error works retroactively to confirm the slaves’ status as “‘empty bearers’ of an abstract, theoretical, but entirely real quantum of value” (Baucom 31). As such, both the law and the systems of speculative finance it scaffolds treat the slave as if she were already dead; until, as Mansfield’s anxieties suggest, they resurrect her to fortify the boundaries of the “hum
an.”
Impact – Racial battle fatigue causes chronic and mental illnesses, and increased rates of infant mortality.
Sullivan (Shannon, Chair and Professor of Philosophy at the University of North Carolina at Charlotte. She teaches and writes on feminist philosophy, critical philosophy of race, American pragmatism, and continental philosophy) 2017 (Setting Aside Hope: A Pragmatist Approach to Racial Justice, Chapter 13 in Pragmatism and Justice, Pragmatism and Justice Edited by SUSAN DIELEMAN, DAViD RONDEL, AND CHRISTOPHER VOPARIL OXFORD UNIVERSITY, https://www.academia.edu/27794394/Setting_Aside_Hope_A_Pragmatist_Approach_to_Racial_Justice_2017_, WAKE AD
While Warren’s argument against the politics of hope primarily targets its metaphysical nature, the destruction of black bodies that he analyzes is no mere abstraction. Neither, of course, are the intractable racial in- equalities described by Bell. In both cases, antiblackness involves “the literal destruction of black bodies that provide the psychic, economic, and philosophical resources for modernity to objectify, forget, and ultimately obliterate Being (nonmetaphysical Being)” (Warren 2015, 327). This occurred initially through the transatlantic transformation of human beings into things (slaves) and then subsequently through other social, legal, and extralegal ways of annihilating black people and communities, including political tactics such as poll taxes, literacy tests, and the convict leasing system (2015, 216). Recent developments in the medical health sciences reveal another material way to see how the metaphysical, legal, and economic destruction of black people via hope is both literal and physical. A concrete connection between hope and poor health and death exists for black Americans, and I now turn to that connection to bodily situate Bell’s and Warren’s accounts. Psychologists and other social scientists in the United States recently have focused on how African Americans cope with so-called mundane racism: not the big-booted racism of chattel slavery, lynching, or even legalized segregation, but rather the more mundane and subtle or ‘invisible” racial attacks that increasingly are being documented in post—Jim Crow America. Examples include the student who rolls his eyes in class when he realizes that the black woman at the front of the room will be his professor or the black person checking out at the grocery store who gets hassled to show several forms of identification to cash her check when the white person in front of her did not. In many ways, microaggressions such as these are minor in comparison to the major assaults that African Americans historically have experienced and still do experience. At mini- mum, racial microaggressions are not spectacularly horrific in the way that the overt violence of shootings and chokeholds is. But just because we tend not to notice the destructiveness of racial microaggressions does not mean they are trivial. Racial microaggressions can be deadly, although we (especially white people) often don’t recognize or want to acknowledge their violent effects. De facto white class privilege in the form of racial microaggressions contributes to people of color’s “racial battle fatigue,” which entails “the constant use or redirection of energy for coping against mundane racism which depletes psychological and physiological resources needed in other important, creative, and productive areas of life” (Smith, Hung, and Franklin 2012, 40). Racial battle fatigue has been linked empirically to depression, tension, and generalized anxiety disorder in African Americans, and the stress associated with all of these psychological problems also contributes to physiological weathering that harms black health, contribut- ing to high rates of hypertension, cardiovascular disease, pre-term birth rates, and infant mortality to name a few (Smith, Hung and Franklin 2012, 37, 40; D. Smith 2012). The effects of white racism literally get inside and help constitute the bodies of black people in harmful ways. They wear down the body’s various systems by creating a high allostatic load via stressors that accumulate over time. The results are health problems such as disproportionately high rates of pre-term birth, infant mortality, cardio- vascular disease, diabetes, and accelerated physiological aging (Blitstein 2009). Racism hurts—literally—and it also kills in ways that are subtler but no less deadly than the lyncher’s noose or the neighbor’s bullet (Drexler 2007). These effects, moreover, can be transgenerational, physiologically passed onto subsequent generations through various epigenetic changes (Sullivan 2013).
Antiblackness is a controlling impact. Increase in access cannot solve racial health disparities. The plan de-politicizes the conditions that produce these effects.
Sullivan (Shannon, Chair and Professor of Philosophy at the University of North Carolina at Charlotte. She teaches and writes on feminist philosophy, critical philosophy of race, American pragmatism, and continental philosophy) 2017 (Inheriting Racist Disparities in Health: Epigenetics and the Transgenerational Effects of White Racism, Critical Philosophy of Race, Volume 1, Issue 2, 2013, pp. 190-218 (Article) Published by Penn State University Press, WAKE AD)
A major health disparity between black and white Americans is found in preterm birth rates, and because of the extensive and often severe consequences of preterm birth, I focus on it here. Preterm birth, which occurs when a baby is born at least three weeks before full term (forty weeks), is a leading cause of infant death and mortality. It also is associated with numerous, subsequent health problems in both childhood and adulthood, such as respiratory and heart problems (including cardiovascular disease and related maladies), cerebral palsy, intellectual disabilities, vision and hearing complications, and feeding and digestive problems (Lu and Chen 2004, 692; Centers for Disease Control 2012; Mayo Clinic 2011; Kuzawa and Sweet 2009, 3). African American women are 1.6 times more likely than white American women to give birth prematurely (thirty-seven weeks or earlier), and 2.9 times more likely to give birth very prematurely (thirty-two weeks or earlier) (Lu and Chen 2004, 692; Mayo Clinic 2011). An African American baby is more than twice as likely to die in the first year of his or her life than a white American baby (Lu and Halfon 2003, 13). This gap has not improved since the civil rights movement and the end of Jim Crow, despite efforts to increase African American women’s access to prenatal health care (Lu et. al. 2010, 62). In fact, it only has widened in the past fifty years: from 1.6 to 2.3 times a greater risk of mortality for African American children than white American children in the first year of their lives (David and Collins 2007, 1191). As one neonatologist has put it, “There’s something about growing up as a black female in the United States that’s not good for your childbearing health. I don’t know how else to summarize it” (California Newsreel 2008, 1). What is this “something” that is so damaging to African American women’s health? The official if somewhat unhelpful answer provided by the U.S. Centers for Disease Control (2012) is that “the reasons for the differences between [the preterm birth rates of] black and white women remain unknown and are an area of intense research.” A significant portion of this research is searching for a “preterm birth gene” specific to African Americans (David and Collins 2007, 1191–92). Besides tending to work with an essentialist concept of race, this line of research is troubling because it “problematically conflates observed biological variation with inferred genetic contributions, and ignores evidence that social factors can have durable life course and transgenerational effects on health” (Kuzawa and Sweet 2009, 9). It wrongly assumes that “predisposition” means “genetic,” that is, that the fact that people are born with predispositions for particular health conditions demonstrates that those conditions must be genetic (Francis 2011, 55). The misguided assumption made by the quest for a preterm birth gene is that biology is both synonymous with genetics and antithetical to all things social.
The alternative is a refusal to affirm.
Ehlers & Krupar (Nadine, University of Sydney & Shiloh, Georgetown University) 2017 (Biofutures: Race and the governance of health, Environment and Planning D: Society and Space 2017, Vol. 35, (2), p.222–240, Wake AD)
The Du Boisian vision of alleviating the racial ‘‘cut’’ in the governance of life has yet to be realized. In the era of neoliberal biopolitics, black lives are especially imperiled in the very same moment that life is ostensibly affirmed. Biomedical targeting technologies are predicated on the laudable pursuit of attending to vulnerable populations and alleviating racial disparities of health. These technologies potentially address specific conditions that affect black life, in accord with Du Bois’ call to attend to the color line. In the contemporary era, race-based pharmaceuticals and medical hot spotting bring black subjects into the fold of the vital politics of life through customizing care at different scales of existence—the individual body and the environment of certain populations. Yet in doing so, as we have shown, these practices continue to ontologize those bodies and spaces as a problem. Thus, while they may not explicitly fortify the color line in the Du Boisian sense, they more ominously resecure anti-blackness through the supposed fostering of life. The targeting of specific bodies or spaces extracts them from broader relations of structural racism and customizes medical resources in ways that objectify race or racialized space as that which should be secured against. Ultimately such biomedical targeting recursively protects the reality that health optimization is an exclusionary anti-black project. Our main intervention has been to examine the epistemological underpinnings of antiblackness with respect to new health governance along the lines of race. Our two examples of BiDil and medical hot spotting show that biomedical targeting anticipates risk and failure and performs death-expectant interventions that ultimately expel African Americans from optimal health but do so in different ways. BiDil extols black responsibility of risk, enlisting African Americans in self-care for lived and embodied conditions of anti-blackness, that is, for violence against blacks and for historically accumulated disadvantage and ill-health from the positioning of African Americans outside of the category of Human. Medical hot spotting further demonstrates antiblackness as the structural positioning of African Americans outside the rest of the populace as demarcated ‘‘problem spaces’’ inhabited by ‘‘problem bodies.’’ The practice orchestrates violence through spatial abstraction and data-based mapping operations that contain and surveil race as a threat, and, like BiDil, it calls for individualized responsibility. In short, these biomedical targeting technologies fail to cultivate black futures. Instead, they ontologically secure blackness as nonfuturity. Futurity lies at the heart of biopolitical governance and practices, which intervene into life in order to control but also improve the prospects of the population. In a Foucauldian understanding, biopolitics exerts a positive influence over life, ‘‘that endeavors to administer, optimize, and multiply it, subjecting it to precise controls and comprehensive regulations’’ (Foucault, 1978: 137). Yet, if health, as we have shown, is an exclusionary antiblack achievement, it seems imperative to work to abolish race as an operation that biopolitically adjudicates. To this end, biomedical efforts that seek to organize reparative justice must work against reestablishing race as an ontology at the very same moment that we labor toward alleviating those very real social disparities predicated on race. As such, a just politics would need to address the epistemology of anti-blackness as the basis for health. Essentially, such a politics would refuse this world, precisely because it is structured through anti-blackness and ‘‘looks like no future at all’’ (Bliss, 2015: 93)