Perspective

Institutional Problems, Individual Solutions ¡ª The Burden on Black Physicians

List of authors.
  • Alyssa M. Newman, Ph.D.

Article

The racially disparate impact of the Covid-19 pandemic has attracted increasing attention and concern. Black Americans have been disproportionately affected throughout the pandemic, and gaps replicating the same well-worn patterns of racial inequity are visible in the early rollout of vaccines. According to the Centers for Disease Control and Prevention, Black populations in the United States are nearly three times as likely to be hospitalized and twice as likely to die from Covid as White populations.1 Yet available data from about half the states reveal that only 5% of vaccine doses have gone to Black residents, with vaccination rates among White residents two or even three times those among Black residents in many states.2 This emergent vaccination gap is particularly troubling given that many Covid mitigation strategies, such as working from home or avoiding public transportation, have largely been inaccessible to low-income Black communities and therefore fail to protect them. Thus, vaccines are among the last remaining strategies for curbing the pandemic in disproportionately affected groups.

One factor often brought up in connection with low vaccination rates is Black mistrust of medical institutions and its current extension to Covid vaccines. The level of vaccine hesitancy is cause for alarm: polling from December showed that 35% of Black respondents said they probably or definitely would not get vaccinated, as compared with 27% of the public as a whole.3 Though an urgent response is clearly needed, it is important that the problem of mistrust and suggested remedies are accurately characterized and do not exacerbate racial inequities in medicine and health care. Such caution is warranted because the type of response demanded by the acute crisis is largely incompatible with addressing the long historical arc of medical mistrust.

One commonly proposed solution has been to position Black physicians and investigators at the forefront of vaccine-rollout efforts to provide more trusted and racially concordant messaging to the Black public.4 Rather than actually addressing the problem of Black mistrust, however, this solution attempts to circumvent it. Deploying a group representing only 5% of the medical profession is a strategy that hinges on favorable perceptions of these individual physicians, who must be seen as sufficiently personally trustworthy to overcome Black apprehension about medical institutions at large. The proposed solution responds to the problem of low vaccine uptake among Black Americans ¡ª not the problem of Black mistrust. Understanding this distinction is essential, because the response demanded by the immediate problem has critical implications for the future of Black trust and for equity in medicine and health care.

To be clear, I acknowledge that there are few other options for boosting vaccination rates among Black Americans at a moment when the country is facing acute racial inequities in the midst of a pandemic. In response to these dire conditions, Black physicians have earnestly taken up the work of encouraging vaccination within Black communities.5 But it is important to recognize that asking Black physicians to do this task creates an additional burden that their non-Black counterparts do not shoulder. It is significant that this extra labor is being asked of them on top of their everyday duties as physicians during a pandemic. Furthermore, it requires a contribution that extends beyond their professional identities, as they expose aspects of their private lives in the interest of relating to broader Black communities. This strategy is especially worrisome as a proposed solution to Black medical mistrust: Should a troubled relationship caused by a long history of mistreatment of Black patients by White physicians be resolved by the labor of individual Black physicians, who themselves are underrepresented in medicine because of racism?

The distinction between an emergency response and a true solution to long-standing issues within medicine is important. Black physicians can hardly refuse the many extra burdens they are tasked with during this crisis, but there are limits to how much they can carry, as well as consequences for their ability to pursue other aspects of their careers that are important to their future advancement. Although the crisis itself is temporary, the long-lasting detrimental effects of this emergency will again fall on the most marginalized populations.

Within this context, another crisis is brewing that threatens to intensify the underrepresentation of Black physicians ¡ª the same people whose work in recruitment and mentorship is essential to addressing this underrepresentation. At the very least, we must acknowledge the implications of what Black physicians are being asked to do: when we position their labor as a solution to Black mistrust, we are asking nothing of medical institutions themselves. After the pandemic passes, the mistrust will remain, and left in Covid¡¯s wake will be a field that is even more challenging for Black physicians. Already defying the racism that has limited their presence to 5% of the field, they will now have to contribute disproportionate labor while attempting to persist, succeed, and advance in the profession.

The emergency response is being conflated with addressing mistrust in part because of the effort to partition medical racism into aspects that can be treated immediately and those that can be postponed for a later, less urgent response. In essence, there is an attempt to separate out ¡°past racism¡± as ¡°immovable historical occurrences¡± from ¡°everyday racism¡± that ¡°can be tackled in the present.¡±4 But medical racism comprises both of these mutually reinforcing elements. Though every individual and community is different, Black Americans who encounter mistreatment from physicians rarely interpret those experiences in isolation. Rather, drawing on first-hand experience, the collective knowledge of their families and communities, and broader history, Black Americans understand these interactions as demonstrations of medical racism. These incidents are not simply representative of the relationship of the physician to the Black patient ¡ª they are a reflection of the relationship of the institution to the Black community. That relationship has been built over time, influenced by major historical inflection points, everyday experiences, and structural inequities. The direct experience of mistreatment by physicians does not itself create mistrust in medicine ¡ª it confirms that mistrust. And an institution that has built, earned, and reinforced a relationship of mistrust with the Black community over time cannot simply substitute the trustworthiness of individual Black physicians for its own; an actual resolution to mistrust can come only with the deep, historical reckoning and transformation that is long overdue.

Beyond emphasizing the importance of Black physicians, the urgency of the pandemic response and the widespread sense of outrage and concern over the disproportionate impact on Black populations demonstrate how medical institutions can ¡ª and always could ¡ª deploy targeted, direct, strategic interventions in service of Black communities and their specific health care challenges. This reaction has entailed recognition of the myriad factors, both within and outside medical institutions, that influence Black populations¡¯ access to, experiences of, and attitudes toward health and health care. This recognition, spurred by the current crisis, has catalyzed a response from within medicine that is attuned to these factors and adaptive to Black communities¡¯ needs and circumstances. Medical racism is one basis of the disproportionate Black suffering during the pandemic, but it is also part of a broader system of interlocking oppressions based on structural, economic, technological, geographic, and various other factors. In light of these linkages and the racial health inequities that persist across periods of crisis and normalcy, long-term solutions to medical mistrust must include intentional, targeted health care interventions that take into account broader systemic, institutional issues in order to ameliorate both inequities and mistrust.

Medical institutions have the responsibility of addressing racism and continued mistrust within Black communities. Positioning Black physicians as the solution both deflects from this institutional responsibility and generates systemic problems for Black physicians who are already overburdened and underrepresented, hindering their career advancement. Amidst a steep crisis with a particularly devastating impact on Black communities, our solution to the acute racial inequities of the present must not exacerbate the racial inequities of the future.

Funding and Disclosures

Disclosure forms provided by the author are available at NEJM.org.

This article was published on May 29, 2021, at NEJM.org.

Author Affiliations

From the Berman Institute of Bioethics, Johns Hopkins University, Baltimore.

Supplementary Material

References (5)

  1. 1. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Centers for Disease Control and Prevention, 2021 (https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html).

      Google Scholar
  2. 2. Doherty T, Kenen J. Just 5 percent of vaccinations have gone to Black Americans, despite equity efforts. Politico, February 1, 2021 (https://www.politico.com/news/2021/02/01/covid-vaccine-racial-disparities-464387).

      Google Scholar
  3. 3. Hamel L, Kirzinger A, Mu?ana C, Brodie M. KFF COVID-19 vaccine monitor: December 2020. Kaiser Family Foundation, December 15, 2020 (https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/).

      Google Scholar
  4. 4. Bajaj SS, Stanford FC. Beyond Tuskegee ¡ª vaccine distrust and everyday racism. N Engl J Med 2021;384:e12-e12.

  5. 5. Huang P. ¡®You can¡¯t treat if you can¡¯t empathize¡¯: Black doctors tackle vaccine hesitancy. NPR, January 19, 2021 (https://www.npr.org/sections/health-shots/2021/01/19/956015308/you-cant-treat-if-you-cant-empathize-black-doctors-tackle-vaccine-hesitancy).

      Google Scholar

Comment (1)