NOVEMBER 6, 2020
IN THE DAYS AND MONTHS after the death of Civil Rights icon John Lewis on July 17, 2020, getting into “Good Trouble, Necessary Trouble” has become a clarion call for many of us. Backtrack 55 years and on March 7, 1965, known as “Bloody Sunday,” Lewis had been famously rendered nearly unconscious during the voting rights campaign in Selma, Alabama. As I watched his body slowly and ceremoniously carried in a horse-drawn carriage over the Edmund Pettus Bridge, I thought not just of the sacrifices made by Lewis himself in the name of equality but of the many other people involved in that struggle — in particular, the physicians and nurses who, on Bloody Sunday, flanked the protestors from the rear like a military auxiliary force.
Formed in 1964, the Medical Committee for Human Rights (MCHR) was an interracial coalition of health professionals that deployed direct action confrontation and sit-ins, both common during that era, to help desegregate the American Medical Association, American Dental Association, and numerous local medical societies that excluded Black physicians from membership, internships, and residency opportunities.  The organization also had a more pressing role: to provide medical attention to Civil Rights protestors injured by segregationists. The five ambulances in Selma used by African Americans, which incidentally also doubled as hearses, were brought to the voting rights march because of the anticipated violence. Along with tear gas, the peaceful marchers were hit with bricks, pipes, and fists as they attempted to cross the bridge. Alabama state troopers, wanting to prevent medical professionals and ambulances from accessing the protestors, confined them to the march’s outskirts. This meant the bloodied marchers had two options if they needed treatment: wait for state troopers to allow ambulances access to the bridge or make their way across several blocks to where the medical professionals were being guarded by the police. 
“May I join millions of Americans in their protests against refusal of law enforcement officers in Selma to permit first aid … to the injured on Sunday, March 7th,” wrote Dr. Emile Holman of Presbyterian Medical Center in San Francisco to United States Attorney General Nicholas Katzenbach. Irwin Kaiser, head of obstetrics and gynecology at the University of Utah, also wrote Katzenbach: “Certainly I would strongly favor the maximum efforts by our government to prevent this sort of official violence against our fellow citizens. Short of this, however, every effort should be made to see to appropriate emergency assistance for those injured in these unfortunate incidents.”  Similarly worded complaints arrived in Washington, DC, from other physicians of multiple backgrounds and ethnicities. Albeit largely invisible, physicians were in fact some of the most vocal advocates for civil rights in the 20th century. Who knew? Unbeknownst to many both then and now, medicine has never been apolitical.
In medical schools in recent years, there has been a broad push for more medical humanities training, and more particularly for understanding how poverty, environmental racism, ideologies of difference, and conscious and unconscious bias negatively affect African Americans and nonwhite populations in the clinical setting. How exactly can medical students benefit from active engagement with the humanities? Why would it help? Physician David S. Jones and plenty of others argue that the humanities can help build empathetic bridges between patients and clinicians. To give one example, reading fictionalized accounts of illness pushes physicians to think about disease in narrative terms and figuratively places them in the patient’s shoes. John A. Williams’s classic revolutionary text The Man Who Cried I Am (1967) is a case in point. Set during the Civil Rights/Black Power era, the main character, Max, is an African American man battling cancer while also fighting for equal rights. The pain of cancer is depicted as being on par with the social (and sometimes physical) pain of racism. “Max felt a sharp, gouging pain,” we are told, “and he gripped his glass tightly. Water came to his eyes and he felt sweat pop out on his forehead.”  Is it the cancer, racism, or both? The point is that physicians should understand both sources of pain when treating African American patients. Expressive mediums like painting, music therapy, and poetry have also been used by medical humanities scholars to bridge communication gaps and trigger empathy.
As legal and bioethics scholar Dorothy Roberts has made clear, political racial groups were central to the rise of Western science. Racial science, rooted in notions of immutable biological difference, was foundational to slavery; and post-slavery continued to frame discourses around disease susceptibility. Throughout the 20th century, scientific racism posited that so-called race was fixed and could serve as a proxy for different races supposedly suffering from different diseases. Diabetes, for instance, was considered to be a disease of “whiteness” until the mid-20th century, and so a marker of advanced biological civilization. Scientists argued that African Americans were biologically inferior in ways that somehow made them immune to the devastating illness. Later in the century, this presumed biological difference seemed to fade away with the shifting political realities of race. But biology continued to be destiny, at least for those intent on constructing racial difference through the lens of disease.  Race, however, is a political and social construction, and disease itself has never been neutral. The malleability of racial and scientific discourse is telling. Historian Samuel K. Roberts convincingly argues, for instance, that biological difference was not the cause of high rates of tuberculosis among African Americans in the early to mid-20th century, as defined by sanitarium officials of the time. Rather, structural racism — namely, the overlapping influence of housing segregation, poor sanitation, and poverty — made African Americans particularly vulnerable. 
Such ideas about biologically instantiated racial difference continue to infiltrate medicine and treatment. Historian Keith Wailoo’s work on pain shows how ideas stemming from 19th-century scientific racism buttress insidious assumptions about African Americans having a higher threshold for pain than whites. A recent University of Virginia research study is more specific, arguing that African Americans end up receiving less pain management than whites because many physicians assume they have higher pain tolerance due to thicker skin and less sensitive nerve endings. 
Such misguided beliefs have not gone away. Importing the history of medicine into medical humanities curricula can thus serve a critical function in exposing students not only to problematic assumptions around “race” but to the multifactorial causes of disease. Social scientists, too, have a role to play in such curricular objectives. Sociologist Didier Fassin, for instance, uses the theory of “cultural anesthesia” to frame the ways in which physicians and scientists can become numb to the pain of socially defined “others,” rendering their pain invisible and inconsequential in clinical encounters and public health. Other social science research is helpful in teaching students about how physicians and the offices they create are all too likely to reflect their own political, social, and cultural sensibilities regarding patient populations. One notable study by health researchers Michelle van Ryn and Jane Burke suggests that physicians tend
to perceive African-Americans and members of low and middle [socioeconomic status] more negatively on a number of dimensions than they [do] Whites and upper SES patients. Patient race was associated with physicians’ assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient’s likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians’ perceptions of patients’ personality, abilities, behavioral tendencies and role demands. 
In his work on the transformation of schizophrenic identity in the 20th century, the historian and psychiatrist Jonathan Metzl argues that physicians do more than respond to external stimuli: they help create the diagnostic tools and societal perceptions used to evaluate the sick, thereby determining who is deserving of sympathetic care as opposed to isolation and invisibility. With respect to yet another venue for the exercise of bias, the title of a study in the New England Journal of Medicine is especially revealing: “‘We Don’t Carry That’ — Failure of Pharmacies in Predominantly Nonwhite Neighborhoods to Stock Opioid Analgesics.”  Not stocking analgesics matters for multiple reasons, not least because physicians need to understand this broader context; their biases might lead them to assume negligence or incompetence on the part of patients when other factors, like unreliable access to medications, including opioid analgesics, might in fact be in play.
Those of us who work in the field of social disparities in public health and health care anticipated from the beginning the devastating impact the SARS-CoV-2 pandemic would have in minority communities. COVID-19 might be novel, but health disparities are generations in the making. For some, the global pandemic has pulled back the curtain on an epidemic of diabetes, heart disease, hypertension, asthma, stroke, and autoimmune diseases like rheumatoid arthritis, lupus, multiple sclerosis, and type I diabetes among African Americans. Racism and poverty are long-standing risk factors for disease disparities.
Over the course of a life racism can contribute to elevated stress levels. Stress releases cortisol, which in turn can increase blood sugar levels in diabetics. Epidemiologist Camara Phyllis Jones evocatively makes the case for the debilitating effects of racism: stress hormones, which result in a perpetual feeling of fight or flight, deteriorate heart valves, build plaque around artery walls, constrict blood vessels, and generally weaken the immune system. Scholars have called this the “weathering process.” It might as well be called the withering process. The COVID-19 pandemic is stressful for everyone, but for some people (e.g., essential workers with chronic underlying conditions who are also subject to discrimination), the added stress amplifies their vulnerabilities. Scholars have also researched the generational influence of structural racism and its impact on higher-than-average rates of pre-term and still-births among African American women. Stress hormones impact pregnancy by restricting blood flow via the placenta to the fetus, thereby prompting early delivery. Studies have found that those stress hormones can be passed from mother to child in ways that might predispose the child to chronic disease and poor health outcomes decades later.
Racism and health could thus hardly be more intimately intertwined. The Black Lives Matter movement has brought increased attention to the problem of medical citizenship, defined as unequal access to medical resources, technology, and information that shapes treatment. “White Coats for Black Lives” is a largely student-run national organization that capitalizes on that movement. Demanding more than simply the right to live, it demands the right to good health. Creating the conditions for good health, as we now know, necessitates understanding and addressing the broader problems of social and environmental structural inequality. These movements are promising developments on that score. They’re also arguments for the medical humanities.
Damon Tweedy’s outstanding memoir, Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine, provides yet more fodder, explaining the rationale behind why some physicians insist on connecting their identity as health care workers to broader social movements. Early in his medical school coursework, Tweedy narrates how his professor mistook him for maintenance staff. “Doctors,” he writes, are “like all other people, […] capable of prejudice and discrimination. While bias can be a problem in any profession, in medicine, the stakes are much greater.”  If students read such first-person texts, they are primed to examine their own biases and likely to become more empathetic practitioners of a humane form of health care. All this said, if we visit a physician for a ruptured spleen, we obviously want that physician to be the world’s foremost authority on ruptured spleens. Yet, as Black patients, we also, ideally, want that physician to have some training in the medical humanities, and enough empathetic discernment to be supportive of broader social justice movements that impact the health of patients. We want our doctors to understand the ways in which racism has historically influenced public health, which means we want them to be engaged in all the messy contextual complications of the healing process. That is getting into good trouble, necessary trouble.
 John Dittmer, The Good Doctors: The Medical Committee for Human Rights and the Struggle for Social Justice in Health Care (New York: Bloomsbury Press, 2009).
 Letter from Emile Holman, MD, Presbyterian Medical Center, Sponsor, Medical Committee for Human Rights to Attorney General Nicholas Katzenbach, Washington, DC, March 10, 1965; Letter from Irwin H. Kaiser, MD, Professor and Head, Department of Obstetrics and Gynecology, University of Utah School of Medicine to Nicholas Katzenbach, March 10, 1965. Collection on the Medical Committee for Human Rights, 1963–2004, manuscript collection 641, University of Pennsylvania Special Collections, Philadelphia, Pennsylvania.
 John A. Williams, The Man Who Cried I Am (New York: Signet Books, 1967), p. 8.
 Dorothy Roberts, Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-First Century (New York: The New Press, 2012).
 Samuel Kelton Roberts Jr., Infectious Fear: Politics, Disease, and the Health Effects of Segregation (Chapel Hill: University of North Carolina Press, 2009).
 Keith Wailoo, “The Pain Gap: Why Doctors Offer Less Relief to Black Patients,” The Daily Beast, April 11, 2016.
 Michelle van Ryn and Jane Burke, “The Effect of Patient Race and Socio-Economic Status on Physicians’ Perceptions of Patients,” Social Science and Medicine 50 (2000): 813–828.
 R. Sean Morrison, Sylvan Wallenstein, Dana K. Natale, Richard S. Senzel, and Lo-Li Huang, “We Don’t Carry That: Failure of Pharmacies in Predominately Nonwhite Neighborhoods to Stock Opioid Analgesics,” New England Journal of Medicine 342 (April 2000): 1023–1026.
 Damon Tweedy, Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine (New York: Picador Books, 2015), pp. 151–152.