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Invited Commentary: From Unacceptable to Intolerable

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See also the article by Goldberg et al in this issue.

In an address to the Medical Committee for Human Rights on March 25, 1966, Dr Martin Luther King, Jr, stated the following: “Of all the forms of inequality, injustice in health is the most shocking and inhumane.” Over 50 years later, the United States and our profession continue to grapple with the impact of systematic and institutionalized injustice in the health care system. Finally, in 2020 after witnessing the disproportionate impact of COVID-19 on communities of color and the horrendous murders of unarmed Black people on national television, most notably George Floyd, the nation seems poised to finally find intolerable what was always unacceptable.

In their article “How We Got Here: The Legacy of Anti-Black Discrimination in Radiology,” Goldberg et al (1) present a historical framework for understanding both the persistently low representation of Black radiologists in the United States and the glaring health disparities encountered in Black communities. They effectively make the argument that these are the contemporary consequences of systematic legislated anti-Black discrimination. By describing the impact of anti-Black policies at the undergraduate, graduate, and postgraduate phases of medical training, the authors provide readers the opportunity to understand that Black Americans were actively excluded from the medical profession and professional medical organizations, understand the origin of the health inequities and disparities, and use this history to inform interventions to combat the legacy of anti-Black discrimination in medical education and health care delivery.

An examination of the intersection of race and health care in the earliest stages of this nation’s history must necessarily conclude that Black people were not seen as humans, so it was acceptable to treat them inhumanely. In the immediate post–American Civil War period, large numbers of the newly emancipated Black citizens succumbed to illnesses such as dysentery, cholera, and smallpox for want of appropriate clothing, sanitary housing, food, and medical care (2). The health and well-being of Black citizens, who died at a far greater rate than White citizens, was not a priority for the government (2). W. E. B. Du Bois opined years later in 1899, “The most difficult social problem in the matter of Negro health is the peculiar attitude of the nation toward the well-being of the race. There have, for instance, been few other cases in the history of civilized people where human suffering has been viewed with such peculiar indifference.”

Finally, in 1865 the Freedmen’s Bureau established a medical division that led to the founding of the first federally funded health care system in the nation and eventually Howard University College of Medicine in Washington, DC, in 1868 (1). In the decades that followed, Black students, who were systematically excluded from medical schools, could chose among seven medical schools that were explicitly focused on training Black physicians. However, in 1910, the American Medical Association (AMA) commissioned the Flexner Report ostensibly to increase the quality of medical education in the United States. The recommendations in the report led to the closure of 71% of Black medical schools compared with 40% of medical schools overall (1,3). This severely exacerbated the shortage of Black physicians and Black institutions, thus negatively impacting access to health care in Black communities (3). For example, Goldberg et al (1) highlight that in the 1950s, 90% of hospitals in Southern states refused to care for Black patients or did so in segregated wards.

Even after successfully completing medical school, Black physicians had to overcome barriers in obtaining residencies, with only 5% of hospitals in Southern states and 10% in the Northern states accepting Black applicants into training programs (1). The article by Goldberg et al (1) effectively connects the aftermath of the systematic closures of Black medical schools, the practice of utilizing quotas at several institutions in the mid-20th century, and the exclusion of Black trainees from postgraduate training to provide readers a reasonable explanation and historical context for the recalcitrant underrepresentation of Black physicians in medicine.

The obstructions for Black physicians extended beyond training to participation in professional medical societies such as the AMA founded in 1847 (1,3) and radiology societies such as the Radiological Society of North America (RSNA) founded in 1915 (1), the American College of Radiology founded in 1923, and the American Roentgen Ray Society founded in 1900. Furthermore, barriers were purposefully and strategically placed in the way of Black radiologists seeking board certification through the American Board of Radiology (ABR) (1). Goldberg et al (1) place a spotlight on William Edward Allen, Jr, MD, who became the first Black radiologist certified by the ABR in 1935 despite the obstacles placed in his way.

James Baldwin famously stated, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” With an aim to foster transparency and promote racial healing and organizational transformation, the AMA cataloged, studied, fully acknowledged, and apologized for its various racist actions and their impact on physicians and communities of color in June 2008 (3). This approach provides an example and template that radiology organizations can use to interrogate the impact of their participation in upholding and tolerating racism. The representation of Black physicians in radiology and particularly in academic radiology remains stubbornly low despite some improvement in female representation (47). Most recently, the American College of Radiology elected its very first Black (and second female) chair of the board in 2021, 98 years after its founding, and the RSNA elected its first Black at-large board member in 2021, 106 years after its founding. In addition, in 2020 several radiology societies convened the Radiology Health Equity Coalition to advance health equity in the radiology community. Although these are significant and important steps, certainly more structured, aggressive, and direct actions are warranted by medical and radiology societies, medical institutions, and radiology departments, as well as leaders in radiology education.

On April 17, 2018, a statue of Dr J Marion Sims, a prominent 19th-century obstetrician-gynecologist, the so-called “father of modern gynecology,” was removed following intense protests activated by the publication of Medical Apartheid written by Harriet A. Washington (8). These protests and the removal of the statue placed a spotlight on a particularly painful aspect of slavery, the unethical treatment of Black patients stemming from concepts of eugenics and medical inferiority. Dr Deidre Cooper posits that the first women’s hospital in the United States was not opened by Dr Elizabeth Blackwell in New York City in 1857, but rather it was the hospital owned and operated by Dr Sims on a small slave farm in Mount Meigs, Alabama, from 1844 to 1849 (9). During this period, Dr Sims performed painful experimental procedures on Anarcha, Betsy, Lucy, and other enslaved women. These women not only endured painful experimental procedures without the benefit of anesthesia, although available in a rudimentary form at that time, they were responsible for all the duties needed to maintain the progress of Sims’ inhumane experimentations (9). Against their wills, these women helped Dr Sims develop curative therapies for vesicovaginal fistulae (9).

The authors draw parallels between this unethical experimentation that occurred before emancipation and the Tuskegee Syphilis Study, which spanned a period of 40 years, post–Civil War, post–Civil Rights Movement, and even after the development of the Nuremberg Code (1). The possible connection between this painful history and the underrepresentation of Black patients in clinical trials presents an interesting topic for future investigation. Furthermore, the article offers examples of published scholarly work by Drs Marcus F. Wheatland and Allen (1). However, a deeper discourse on the legacy of discriminatory practices in the area of research and scientific publications and the subsequent impact on current numbers of Black academic radiologists or research scientists in radiology present other interesting perspectives that warrant future exploration.

A particular strength of the article is that it highlights the efforts of Black physicians to advocate for themselves and their communities in the face of unrelenting overt racism and discrimination (1). The National Medical Association was founded in 1895 to support Black physicians and other health care professionals who were actively barred from the AMA (1). Its founders, in direct contrast to the AMA, sought to create an inclusive professional society that was “[c]onceived in no spirit of racial exclusiveness, fostering no ethnic antagonisms, but born out of the exigency of the American environment…” (10). The authors describe efforts of Black radiologists Dr Wheatland and Dr Rudolph Fisher to provide access to imaging for the Black community (1). Dr Allen provided training opportunities and scholarships for students interested in radiology (1). Dr Lawrence D Scott was the first Black RSNA member, and he sponsored Dr Allen’s successful membership application. Dr Allen was not only the second Black member of the RSNA but the first Black member of the American College of Radiology and the first Black radiologist certified by the ABR (1). By using these examples, the authors reinforce the importance of representation in the fight against medical racism and health care disparities.

Goldberg et al (1) acknowledge that many of the solutions they propose in their article are resource intensive, which may be prohibitive for many hospitals frequented by Black patients (1). Indeed, compared with White patients, Black patients more often receive care at safety net hospitals, which face significant financial constraints and tend to rank worse on quality measures and outcomes (11). Imaging examinations may be of worse quality and performed on older equipment and by less skilled technologists (11). It would be elucidating to have a more robust discussion on the intersection of the legacy of medical racism, economics, and imaging disparities. Ultimately, the Black medical schools that closed as a consequence of the Flexner Report were forced to do so because they were unable to attract funding. Did this inability to attract funding extend to Black hospitals, and what was the impact on care delivery? Does this legacy manifest in the significant financial challenges hospitals that predominantly serve minority communities and historically Black medical schools encounter?

The article by Goldberg et al (1) successfully links the intolerable disparities in diagnostic imaging and underrepresentation of Black physicians in radiology we see currently to the historical unacceptable practice of medical racism and systematic discrimination. Although acknowledging these historic events is painful and uncomfortable, to disregard them would be injurious to the specialty and directly harmful to Black physicians, radiologists, and patients. The article provides readers a thought-provoking framework for understanding the impact of institutionalized anti-Black racism in medicine and radiology that is imperative as communities, institutions, and organizations attempt to combat health care disparities clearly evident in our society.

Disclosures of conflicts of interest.—Member of the RSNA Board of Directors.


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Article History

Received: Sept 21 2022
Accepted: Sept 23 2022
Published online: Jan 12 2023