Where We Stand
Section: Public Health
Policy: Equity Task Force Recommendations
Appendix N

Equity Task Force Recommendations

 

EQUITY TASK FORCE REPORT: SYSTEMIC RACISM

  

PDF (DRAFT): Equity Task Recommendations , adopted as OMA policy

The Equity Task Force recommends:

That the OMA recognizes racism, in its systemic, cultural, interpersonal, and other forms, as a serious threat to public health, to the advancement of health equity, and as a barrier to appropriate medical care. Racism is part of American society and therefore part of American health care. Health care professionals have the ability and obligation to recognize and untangle the influence of racism and discrimination in medicine. 

That the OMA transform the Equity Task Force into a standing Justice, Equity, Diversity, and Inclusion (JEDI) Committee to address justice, equity, diversity, and inclusion in our practice, institutions, and industry. OMA will ensure that the committee has a diverse membership and is of sufficient size to perform the anticipated functions. The committee will immediately develop a charter covering membership, function, and scope (which is to extend beyond issues of race, to include, but not limited to, those involving gender, sexual identity, ethnicity, religion, immigrant status and experience, language, disability, old age, poverty, and rural location). The committee will address tasks in these areas which they deem appropriate, but including: 

Educating OMA members on the influence of institutional and individual racism and other inequities on the practice of medicine.

Advocating for policy changes that improve equity in the health care professions and practice of medicine in Oregon. This includes recruitment and retention of future physicians, physician assistants (PAs), and other healthcare workers from racially diverse communities and other underrepresented identities.

Recommending methods to reduce the impact of racism on public health and health outcomes. This includes recognizing, addressing, and reversing racially differentiated health outcomes for our patients.

Recognizing and addressing the major public health issue of violence against individuals because of personal characteristics. This includes identifying and supporting policies that reduce violent injuries and death among Black Americans and other people of color. In addition, especially during mental health crises, OMA will identify and support policies that improve police interactions with the community.

Promoting recognition of the inequalities in upstream social determinants (e.g., family wealth, housing stability, food security, employment, education) and their influence on the health and outcomes of our patients, in order to begin addressing these as public health issues.

Expanding advocacy to support policies that address these upstream social determinants.

That the OMA collaborate with other organizations to promote health equity, inclusion, and diversity. Examples of possible collaborations could include supporting the formation of an Oregon chapter of the National Medical Association (NMA), work on equity policies and solutions with other physician and PA organizations, and continuation of OMA engagement with the Oregon Health Authority, Oregon Health Leadership Council, and other organizations in efforts to promote medical outcomes and improve social determinants of health.

 

Systemic Racism Workgroup Background

In 2020, police (and members of the public claiming to act in a manner of authority) killed a number of unarmed Black people. The news of these events spread instantly and widely through news outlets and social media platforms due in large part to video recording capabilities of modern cell phones. The police killing of George Floyd on May 25, 2020—though not materially different from the others—spread widely and in full undeniable detail because it was daylight, in public, and clearly recorded from beginning to end. This led to ongoing and intense public outcry across the nation and worldwide.

OMA responds:

In June of 2020, the Oregon Medical Association President and the Chair of the Policy Committee asked the OMA Equity Task Force to expand its scope of work and address systemic racism as a public health issue. The Equity Task Force called together a diverse group of volunteers from around the state who gathered to develop a report and recommendations.

In the previous year, the OMA’s Executive Committee, at its retreat, drafted a new strategic plan for 2020 that included an update to the organization’s Vision, Mission and Values. The revised mission calls for OMA to speak as the unified voice of medicine in Oregon; advocate for a sustainable, equitable and accessible health care environment; and energize physicians and physician assistants by building and supporting their community. Among the core values were solutions-driven leadership with attention to systematic problem-solving to support and empower OMA members to build a healthier Oregon and inclusivity pursuing goals with a focus on equity diversity and inclusion.

Taking this into consideration and because racism is a complex problem with centuries of history and intergenerational fallout leading to ongoing disparities impacting the health of the community, the workgroup sought to answer a number of questions with its report: 

• What is racism? 

• How does it impact people and communities? 

• How does this relate to the health of our patients and communities? 

• What role have physicians and the medical community played in perpetuating this problem? 

• How is this a public health problem?

• What responsibility do we have to engage in solutions and how can OMA contribute? 

Discrimination grows from the unjustified prejudices one group of people has against another group of people based on certain characteristics such as race, sex, religion, disability, and more. Often times, such discrimination leads to purposeful divisions within society constructed by those with power. These lines of division can manifest in different ways, but all offer advantages to those who have power. Lines of division are maintained by an imbalance in social control and physical authority and are embedded into the fabric of society. Such lines eventually become normalized for the advantaged side, while those targeted for exclusion suffer the consequences of their dispossession. The experience of each disadvantaged group has its own history and unique features but there is significant overlap. The problems created are not self-correcting.

The size and complexity of the entire problem is daunting and the creation of an inclusive treatise for all disadvantaged groups would require an exponential expansion of the task force. An attempt at a single comprehensive treatise for all minoritized groups could also distract from the goals of demonstrating how discrimination leads to systemic injustices and ongoing disparities, and how the permanent nature of these makes it impossible to render change without effort. This report focuses on the Black experience as an example of how structural racism within national and state systems and institutions, including health care, impacts targeted people, with a close look at demonstrated impacts on the well-being and health of Black people and their communities. Events surrounding the Black community inspired the request for expanding the scope of OMA’s Equity Task Force.

Although the Black experience in this country provides a powerful example of how systems of racism work, we acknowledge that systemic racism has significantly affected other racial and ethnic groups, and that discrimination also exists related to sexual and gender identity, religion, language, country of origin, and disability. While we will not thoroughly explore the experiences of other minoritized groups here, their experience, like that of the Black community, needs to be examined closely and addressed in the future.

In addition, we recognize that evidence, statistics, and scholarly work inform this report, however, we would be remiss not to also tell some of the individual stories of the impact and damage of racism which our members and others have experienced. This combination of data and medical humanities storytelling give a better and more holistic picture of this very complex issue and its impact on the healthcare professions and the communities we serve. Systemic racism is understood through sundry events knitted together, all of which are unique experiences. Medicine has traditionally made use of case presentation to expand on the human dimension of experience, though it is not common in OMA reports. Individually, these events can be interpreted as mere anecdotes or exceptions, and with this they become invisible. We bring them to light and integrate them into the story of racism told here.

Systemic racism is a problem in the United States and has been since before the beginnings of slavery when race as a social construct was intentionally developed to justify abuse and maintain power. This report briefly details the history of anti-Black systemic racism in the United States with its impact on housing, employment, political power, financial independence, policing, and health care. Oregon’s systems and institutions are no exception.

The recent killings of Black people by police have thrust the issue of racism into national and international prominence. Attention has been focused on the public health impact of violent injuries and death at the hands of law enforcement and also on our model of community policing in general. Violence is a significant contributor to mortality rates for Black people and should be added to the list of major health problems. We discuss the complex contributors, rooted in racism, which set up the milieu for such violence.

We describe the impact of the War on Drugs in the Black community, including policies resulting in confrontational policing tactics and the rapid expansion of incarceration of Americans. These policies have disproportionately affected people of color, impacting individuals, families, and communities, and their health and wellness, as well as access to appropriate health care.

Black people experience bias in many aspects of life. Navigating the impacts of bias creates challenges in health care as well. There is a long history of inequitable access to health care and medical treatment. The racial disparities in health outcomes are rooted in all the impacts of cultural and systemic racism as well as racism embedded in care delivery systems.

Although the discrimination against any one particular group has its own unique history and complexities, social and public policy interventions addressing racism can be expected to be a rising tide that helps all disparaged groups. We build a case for the relevance of racism to the medical profession given downstream effects on health outcomes and resultant public health.

We call on the Oregon Medical Association to actively address issues related to race and offer the recommendations listed above for influencing policy, with a goal of improving health outcomes in all communities targeted by systemic racism and other related forms of discrimination, and for continuing to improve the environment in which we practice for all members of the health care community regardless of personal characteristics. Making our recommendations part of OMA policy will help us support and become leaders in the transformation of health care to an anti-racist industry.

A Chronology of Racism: The Black Experience

History, as nearly no one seems to know, is not merely something to be read. And it does not refer merely, or even principally, to the past. On the contrary, the great force of history comes from the fact that we carry it within us, are unconsciously controlled by it in many ways, and history is literally present in all that we do. It could scarcely be otherwise, since it is to history that we owe our frames of reference, our identities, and our aspirations.

James Baldwin, Ebony, August 1965¹

Racism can be considered to have three inseparable aspects. There is a longitudinal experience which stretches over generations. There is bias (aka. bigotry) which has perpetuated and maintained this experience. There is also contemporary life which has been infiltrated by this experience in manifold ways. In order to address the negative impact of systemic racism on health in the present, we must first describe how we got here. We begin with a historical summary of the American Black experience. Before the Civil War, systemic racism in the form of sanctioned slavery was woven into the fabric of the United States. We focus most of our discussion on the time following the Civil War, where more detail is provided. 

Historical Summary of the Black Experience in America

The “American Dream” of “Life, Liberty, and the pursuit of Happiness” in its original conception was reserved for white men with property. Expressly stating the intention of excluding people of color and all females was unnecessary as this was widely understood by those in positions of power and authority at the time this phrase was penned. 

The systems that provided preferential treatment to those in power remained in place for centuries and remain embedded where they have not been actively reversed. Therefore, systemic racism in its various forms has had a longitudinal, intergenerational impact for Black Americans, extending from 1619, when enslaved Africans were first brought to North America, through to the present day.²

Before the Civil War, the vast majority of Black Americans in the United States were enslaved.³ In 1860, there were about 400,000 free Black Americans, compared to four million enslaved Black Americans.³ The 13th amendment became law in 1865, abolishing slavery and abruptly resulting in millions of freed slaves entering the depressed postwar economy of the war-torn south without adequate resources for self-sufficiency.⁴ The Freedmen’s Bureau was a government agency established in 1865 to provide aid to former slaves but could not meet the demand.^5,6 While some slave owners were compensated for loss of slaves due to the emancipation proclamation, no former slaves were reimbursed for their many years of enforced uncompensated labor which predated emancipation.⁷

Post Emancipation period with Post-Civil War and Presidential Reconstruction: 1862-1867

The period immediately following emancipation was a predictably precarious time for recently freed men and women. It is estimated by Connecticut College historian Jim Downs, in his book “Sick from Freedom,” that approximately 25 percent of the four million freed slaves died or suffered significant illness between 1862 and 1870.⁴ Some received medical aid by a short-staffed Freedmen’s Bureau. They suffered from illnesses such as smallpox, cholera, and dysentery, in addition to malnutrition and exposure.⁴ Dependable statistical records regarding disease and mortality in ex-slaves during this time are not available. However, given the mortality rates of these illnesses (even with “medical treatment”) and the fact that many who had these illnesses were not treated, it can be concluded that the mortality rate was significant. Freed slaves were frequently attacked by bands of confederate guerillas, were spurned by many southern whites (who did not consider them to be citizens, or even fully human in some cases), and were without adequate support for basic needs such as food, clean water, and shelter.⁸

During this time, the South had no effective government. The south was policed by federal soldiers who were essentially an occupying army. Their focus was keeping the peace and dealing with confederate guerilla bands, not with attending to the needs of ex-slaves. Coming out of slavery, freedmen were mostly illiterate (teaching slaves to read and write was illegal due to Slave codes) and most had little understanding of the monetary value of their labor or how the economy worked. Employment opportunities were available, but employers had no obligation to reimburse those employed (14th amendment, affording citizenship and equal protection under the law, was not ratified until 1868). It is likely that there was a tendency on the part of ex-slaves to avoid long term employment, which was interpreted as laziness by southern whites.^4,9,10

When President Abraham Lincoln was assassinated at the end of the Civil War, Andrew Johnson, a former slave owner from Tennessee, became President. President Johnson had a lenient policy toward the ex-Confederate states, deferring to the state governments to determine the rights of freed slaves.¹¹ As a consequence, Black Codes, laws that circumscribed the rights of Black Americans, were enacted in the states that had been part of the Confederacy, severely restricting the rights of the newly freed slaves, adding to their struggles.^12,13 Black Codes in some southern states had the effect of providing inexpensive labor for white employers. Under Black Codes, many states required Black people to sign yearly labor contracts; if they refused, they risked being arrested, fined, and forced into unpaid labor. Black Codes limited what jobs Black people could hold, as well as dictating if or when they could leave their employment.^10,14,15

Congressional Reconstruction: 1867-1877

The Reconstruction Act of 1867 weakened the effect of the Black Codes by requiring all states to uphold equal protection under the 14th Amendment, particularly by enabling Black men to vote as citizens. Voting was further protected by the 15th amendment which more directly enfranchised all citizens of the United States.¹⁶ For a brief period following the elimination of the Black Codes and ratification of the amendments, Black people achieved considerable economic and political success. During Reconstruction, many Black men participated in politics by voting and by holding office. For example, there were as many as 16 Black congressmen elected from 7 different southern states.¹⁷ Many more Black Americans were elected to local public offices. Hiram Revels and Blanche Bruce, both Black men, even served in the U.S. senate.^18,19 Because there were skilled laborers among the ex-slaves, a number of “freedmen’s towns,” were constructed in an attempt to create an independent existence without dependence on white people or the government.²⁰

The removal of Black Codes and passage of the 13th and 14th amendments caused a white backlash and motivated the Ku Klux Klan.^21,22,23 A number of violent and deadly attacks on freed Black people occurred, as evidenced by the Colfax, Louisiana Massacre in 1873.²⁴ Congress passed the Enforcement Acts, also known as the Ku Klux Klan Acts (May 1870, Feb and April 1871), empowering the President to use military force to protect Black people. The Enforcement Acts were used by President Ulysses S. Grant to counter the violence and intimidation toward Black people.²⁵

The End of Reconstruction and the Preservation of White Supremacy in the Face of Constitutional Headwinds: 1877-1923

At the end of formal Reconstruction in 1877, an even more intensely violent anti-Black backlash occurred.²⁶ There was a return of large-scale disenfranchisement of Black people and segregation was mandated when southern states, counties, and cities enacted Jim Crow laws. Jim Crow laws were state and local statutes that legislated racial segregation. “Pig Laws”, similar to Black Codes and Jim Crow laws, resulted in harsh penalties for Black people. If a Black man did not have a job satisfactory to white law enforcers, he was incarcerated, and incorporated into a free Black labor force for white businesses. Additionally, “Pig Laws'' unfairly penalized poor Black people for crimes such as stealing livestock. Many trivial offenses and misdemeanors were treated as felonies with harsh sentences.^27,28,29,30 Black people had limited opportunities and lacked resources to assert their rights through legal challenges, but when they did, these efforts were unsuccessful.³¹

In 1896, the Supreme Court delivered the “separate but equal” ruling in Plessy v. Ferguson. This decision was applied to a man who by appearance was White, but who had a modicum of Black ancestry. He protested being forced to sit in the Black section of a train. He took his case to court, and it was eventually heard in the Supreme Court. The decision was a 7 to 1 ruling in favor of separation of the races on trains. Although this was thought to be a trivial ruling at the time, its impact was ultimately pivotal in that it provided a precedent for segregation and Jim Crow. This supported continuing segregation in the south, but also encouraged it in the north. Segregation of housing, schools, swimming pools, beaches, hospitals, government, bathrooms, water fountains, theatres, stadiums, public transportation, and other entities was now constitutional through this editorializing verdict of the Supreme Court. Segregation, which should have been unconstitutional according to the 14th Amendment, was now a sanctioned practice.^30,32 From that time until the Civil Rights Act of 1964, this form of dehumanizing discrimination was legal and enforceable.³³

Without the benefit of federal protection, many towns founded by Black people were ultimately destroyed by white people with the inhabitants brutally murdered. Prominent examples include the Wilmington Massacre in North Carolina in 1898³⁴ and the Atlanta Massacre in 1906.³⁵ Without the ability to own land, life for many Black people in the south was reduced to sharecropping and other dependent, subordinate means of existence.³⁶ This was the beginning of Black incarceration contributing to a statutory racial caste system, which resulted in additional loss of protected rights and access to the privileges of citizenship for many in the Black community.²⁷

Overt forms of systemic racism, such as Black Codes and Jim Crow laws, later gave rise to less overt and more insidious policies. One example of such policies was the grandfather clause, which stated that a man could only vote if his ancestor had been a voter before 1867.³⁷ Because the 14th Amendment was ratified in 1868, this essentially prevented any Black man from voting. Additional discriminatory tactics included the literacy test and poll taxes. The literacy test was applied by the county clerk, who was white and would intentionally give Black voters extremely difficult legal documents to read as a test, while white men received easier texts. Poll taxes effectively excluded many Black and poor people from being able to vote. Finally, in many places, white local government officials physically prevented potential voters from registering. These policies ensured that Black people were not proportionally represented in government and prevented them from having any political power to impart change.³⁸

These policies were extremely effective in achieving their goals. During Reconstruction, Black people were a majority of the registered voters in Mississippi, Alabama, Florida, Louisiana, and Georgia.³⁹ At that time, the percentage of Black voting-age men registered to vote was greater than 90 percent. By 1940, the percentage of eligible Black voters registered in the South was only three percent.³⁹ Examples of voter suppression still exist today.^40,41,42,43

Northward migration of Black people was welcomed during World War I (WWI), as an expanded workforce was necessary to provide the needed equipment and weapons for fighting the war.⁴⁴ However, the approximately 40,000 brave Black men who fought in combat overseas for the United States during WWI were met with racism and discrimination both in the military and upon returning to civilian life.⁴⁵ Although the volunteer "'colored regiments" were disbanded after the Civil War, segregation remained in official military units.⁴⁶ During WWI, there were four all-Black regiments led by white officers. There were more Black volunteers during WWI to fill the numbers needed for these units, and so additional units were made with Black officers. However, there were still efforts to bar Black individuals from serving in the Marines and efforts to prevent Black service on top of segregation.⁴⁶ Black men were instructed to mark their registration cards in order to be drafted separately from white men.⁴⁶ In addition, many individuals were falsely accused of dodging the draft and arrested when postal workers conspired to withhold their registration cards. Many Black WWI heroes never received the Medal of Honor for their recognized acts of valor as a result of racism.⁴⁵ Black soldiers faced countless acts of disrespect, discrimination, and received subpar equipment and accommodations.

The United States military was not ordered to desegregate until 1948.⁴⁵ A lack of diversity in top military positions and reports of continued racism in the military are still seen in recent years.⁴⁷ The U.S. House Armed Services Committee held a hearing on the "Alarming incidents of white supremacy in the military—how to stop it?" in 2020, further demonstrating the continued presence of racism within our nation’s military.⁴⁸

As white and Black soldiers returned to the United States, Black employment was met with resistance. Black workers were seen as competing with whites for jobs.^49,50 Returning Black soldiers were met with increased violence from white civilians with documented increases in race riots and lynchings.⁴⁶ Tensions over civil rights and social and political rights of Black people led to the East St. Louis and Newark massacres in 1917, and race riots across the country, most notably in Washington, D.C. and Chicago in 1919.⁵¹

In Chicago in 1919, a young Black man, Eugene Williams, was swimming in Lake Michigan and drifted into an area tacitly reserved for white swimmers. He was pelted with stones and drowned. A disturbance ensued and ultimately, a riot and destruction of property; 38 died (23 Black citizens, 15 white), 537 were injured, and 1,000 were made homeless.⁵² Ironically, these events occurred in a town founded by a free Black immigrant from Haiti, Jean Baptiste Pointe DuSable.⁵³

In 1919 alone, there were 25 riots and 97 lynchings of Black people including the killing of up to 100 African Americans by white law enforcement officials and vigilantes in Elaine, Arkansas after Black sharecroppers tried to organize a union asking for better working conditions.^54,55 The summer of 1919 has been called the “Red Summer,” a term coined by James Weldon Johnson in an article written for the National Association for the Advancement of Colored People (NAACP).⁵⁵

The period from 1917 to 1923 saw some of the worst racial terrorism with numerous incidents of white mobs attacking Black people and their communities.^55,56 Black soldiers returning from fighting for the United States in WWI had proudly risked their lives and shed blood for democracy, to fight for the side of life, liberty, and the pursuit of happiness.⁵¹ They felt they deserved to participate in the American Dream at home. This was met with lynchings and a resurgence of the Ku Klux Klan.⁵⁰ In the early 1900s, Greenwood, Oklahoma, a mostly Black section of Tulsa, Oklahoma, became the home for a thriving community known as “Black Wall Street“. During the post-war period of white racial unrest, this prosperity changed. In 1921, thirty-five city blocks of Greenwood were burned to the ground, and 300 people were killed and 800 injured at the hands of white mobs.⁵⁷ Similar episodes of destruction of other prosperous Black communities extended from Tulsa to Washington, D.C.⁵⁵

The 20th Century

The zeitgeist of the first half of the 20th century was one of tolerance for the racial terrorism and legalized exclusion of Black Americans from significant participation in the economy, in other aspects of society, recreation and the politics of the United States. It was essentially a U.S version of apartheid, which, though most intensely applied in the southern states, actually carried an impact in all aspects of American life.

The original construct of Social Security excluded domestic and agricultural workers, an exclusion that disproportionately affected Black Americans.⁵⁸ Following World War II, federal mortgage lending programs helped white Americans buy homes building generational wealth, while having policy that stated the presence of a Black resident in the neighborhood reduced the value of the homes in that neighborhood.^59,60,61

Black people faced social, professional, commercial, and legal discrimination. Laws were enacted to support a segregated social structure based on race. Theaters, hotels, and restaurants segregated Black people in inferior accommodations or refused to admit them at all. Shops served them last.⁶² Hospitals usually had segregated wards if they admitted Black patients.⁶³ People who fought against these rules were jailed or worse.^64,65 The models of segregation in the United States were so effective they were ultimately used by Hitler and served as a basis for the construction of apartheid.^66,67,68 Segregation of accommodations - not just in the south, but also in places now considered progressive like San Diego and New York - made travel difficult for Black people. In 1937, The Negro Motorist Green Book, a travel guide, was first published. It listed establishments where Black travelers could expect to receive unprejudiced service.⁶⁹ Segregated public schools meant generations of Black children often received an education inferior to that of white children—with worn-out or outdated books, underpaid teachers, and lesser facilities and materials.⁷⁰

Oregon Was No Exception

Slavery in the Oregon Territory was prohibited in 1843; however, Black Exclusion Laws which were first enacted in 1844 attempted to prevent Black people from settling within the borders of the territory and eventual state of Oregon. In 1859, Oregon became the only state admitted to the union with a Black Exclusion Law.⁷¹ Black Exclusion Laws legalized public whippings of Black individuals who entered Oregon until the penalties were later changed to force Black individuals into physical labor instead. White individuals who settled on Native land in what is now the state of Oregon further benefited from the 1840 Donation Land Act which provided white citizens with free land. These laws are a few of the many reasons why there is a lack of overall diversity in the state, a significant racial wealth gap, and related health inequities.

Racist laws continued to be made in the territory, including making it illegal for Black residents to own real estate, make contracts, vote, or use the legal system. Oregon also banned interracial marriage, a law which was not repealed until 1951. The 1857 exclusion law remained in the Oregon Constitution until 1926 when it was repealed by a ballot measure. The Fifteenth Amendment, ruling that Black Citizens could vote, was passed by Congress in 1869. The Amendment was rejected by Oregon in 1870 and not ratified in the state until 1959, 90 years after adoption in the United States.⁷²

The 1920s saw a resurgence of white supremacy with the KKK in Oregon also. In 1923, the Oregon Chapter of the Ku Klux Klan had 35,000 members. The Oregon KKK was a mainly anti-Catholic organization as the Asian American and Black populations in the state were not large enough to mount a significant campaign against racial minorities. The Klan collapsed by 1925, with exception of the Tillamook branch, which lasted through 1928.⁷³ Black Exclusion was repealed in 1926, but its impact is long lasting.^74,75 The racist language in the Oregon State Constitution persisted for several decades more. The last vestige of racist language was finally removed from the Oregon State Constitution in 2002, just six years before Barack Obama became the nation’s first Black president.⁷¹

Although the 14th Amendment was ratified in 1868, conferring equal protection under the law for all citizens and affirming that Black people are full and equal citizens, interpretation by the Supreme Court was restrictive until the second half of the 20th century. Segregation was made legal through the Plessy v. Ferguson decision (see above), thus allowing continued disruption of Black neighborhoods and enterprise through land use rules and other laws and covenants, contributing to a cycle of poverty.⁷⁶ Oregon has its own examples of this in the displacement of Black people from their homes during the expansion plan for Legacy Emanuel in 1970, which is discussed in more detail below.

Dr. DeNorval Unthank (December 14, 1899 - September 20, 1977) was a Black physician who moved to Portland in 1929. He and his family settled in the all-white neighborhood of Westmoreland, but they were violently harassed. Their house was pelted with rocks, and ultimately, they were driven from their home. They were forced to move four times before being able to settle. Dr. Unthank was not allowed privileges in any Oregon Hospital and delivered babies in his home. He took care of many thousands of patients of all races. He was the only Black physician in Portland in the 1930s. He became the first Black member of the City Club of Portland in 1943. He founded the Urban League of Portland in 1945 and served as president of the Portland NAACP chapter. There is a park named after him in the Boise neighborhood.^77,78

In Portland, the Albina neighborhood was the only area in Portland where Black individuals could own a house as a result of racist codes put in place by the Realty Board of Portland.⁷⁵ In 1948, the “National Realtor Code'' permitted Oregon realtors to deny homes to individuals “of any race or nationality whose presence will be detrimental to property values”.⁷⁹ The Oregon Fair Housing Act was passed in 1957; however, the discriminatory denial of loans in the form of redlining continued in Portland during the 1970s and 1980s, further preventing minority citizens from owning property throughout the city.⁷⁵ The gentrification of North Portland began in the late 1980s and continues to this day, with many Black individuals and families forced to move as a result of rising housing prices in this historically Black community.

Medicine Was Not Exempt

Professional medical organizations, hospitals, and medical schools were not exempt from these discriminatory practices.^80,81 Rather than leading society away from tolerating racial exclusion, they followed the path of the country. The American Medical Association’s (AMA) policy of tolerating racial exclusion by its member organizations was pivotal in contributing to a two-tier system of medicine in this country.^80,82

Previously admitting only white physicians, the AMA later opened its membership to people of color but did not acknowledge past harms done to Black physicians and their families and patients until 2008, when AMA Immediate Past President Ronald Davis met with the National Medical Association (NMA), an organization for Black physicians, in Atlanta, offering a formal apology. Racial exclusion has many downstream effects and “the medical profession, which is based on a boundless respect for human life, had an obligation to lead society away from disrespect of so many lives.”⁸²

A direct line can be drawn between acceptance of white supremacy and segregation to the Flexner report and then to the subsequent racial divide in medicine. The 1910 Flexner report on medical schools examined medical school entrance requirements, the size of endowment and tuition, the size of laboratories, and the availability of teaching hospitals and their clinical teaching staff in order to standardize admission requirements and design medical school curriculum to include both basic science and clinical exposure.⁸³ A direct result of this report and subsequent changes in medical programs led to the closure of 5 of 7 then-extant Black medical schools.^84,85 Flexner’s conclusion that these Black medical schools were “in no position to make any contribution of value”⁸⁶ further exacerbated their chronic funding challenges and resulted in the subsequent erasure of up to 35,000 Black physicians from the hallways of United States hospitals who could otherwise have been trained at these five-medical schools from the time they closed to the year 2019.⁸⁷

To the Present, With Some Conclusions

The conditions of the postbellum period were made insufferable for Black people through incessant, cruel, racist attacks against their very existence and the forceful removal of any pathways for improvement of their situation. According to economists Robert Williams Fogel and Stanley L. Engerman in their book, Time on the Cross, “...the life expectations of Black people declined by 10 percent between the last quarter century of the antebellum era and the last two decades of the nineteenth century. The diet of Black people deteriorated. Studies of the diet of Black sharecroppers in the mid-1890s indicate that they were protein and vitamin starved. The health of Black people deteriorated. Sickness rates in the 1890s were 20 percent higher than on slave plantations. The skill composition of the Black labor force deteriorated. Blacks were squeezed out of some crafts in which they had been heavily represented during the slave era and were prevented from entering the new crafts that arose with the changing technology of the last half of the nineteenth century and the first half of the twentieth. The gap between wage payments to Black and white workers in comparable occupations increased steadily from the immediate post-Civil War decades down to the eve of World War II.”⁸⁸

Apart from racism, the basis of these attacks, at least in part, was due to the fear that this four-million strong workforce, much of which was skilled in crafts ranging from carpentry, blacksmithing, coopering and metal works, to farming, pottery, tool making, and production of clothing, would be strongly competitive in the marketplace. The choice of Black labor during slavery was not just because it was free, but because slaves were hardworking, efficient, and capable. The threat of workforce competition from Black people was virtually eliminated through restrictions on land ownership, licensure laws, and education. Taxes and fiscal policies were used to transfer income from Blacks to whites which made it impossible to accumulate wealth and invest in the future.^88,89

The laws supporting Jim Crow, segregation and the resulting racist societal structure were actively challenged by civil rights advocates including the legal team of the NAACP, an organization which was formed in 1909 for this very purpose.⁹⁰ These laws began to topple in 1948 with Truman’s Executive Order 9981, desegregating the military.⁹¹ In 1954, the Supreme Court declared discrimination in education unconstitutional in Brown v. Board of Education of Topeka, but it would take another ten years for Congress to restore full civil rights to minorities, including protections for the right to vote.³⁰

Racist language was removed and replaced within state and federal legislation over the next 20 to 30 years, making school, job, hotel accommodations, hospital, restaurant, and institutional segregation illegal.^92,93 Discriminatory real estate and hiring practices were outlawed,³⁰ but discriminatory practices still exist, and consistent enforcement of these laws is still needed today.⁹⁴

In the early to mid-1960s, Black communities, frustrated with the effects of systemic racism, including unfair policing policies, biased justice system, poor or inadequate housing, poor public education, high unemployment rates, voter suppression, and various forms of discrimination, erupted in riots across the nation.^95,96 Many newspapers at the time propagated a view based on racism, blaming the riots on Black people and “Black anger”.⁹⁶ However, the 1967 presidentially appointed Kerner Commission concluded that white racism, not Black anger, was at the root of the violence.⁹⁶

A tremendous amount of effort was needed to create and sustain systemic racism. Over the years, Jim Crow was finally overcome by way of a long and arduous struggle culminating with the civil rights protests of the 1960s. Legal segregation was shown to be in conflict with the constitution and its amendments. However, this recognition de jure, does not imply that racism has been excised de facto from our institutions and structures.⁹⁷ Unravelling the effects of slavery and systemic racism will continue to take a tremendous amount of effort, courage, and focused cooperative intention. The long-term impact of living under a system of oppression is significant, and newer challenges have evolved.

 

Effects of Racial Bias in Society

In the remaining sections we discuss the scope and complexity of the present situation. We will show that segregation and discrimination continue in our society and its institutions. Racism is robustly embedded in our social structures, having been created and supported by the history described above. Ultimately, disparities in health and outcomes result. Control over the imagery and story of a people impacts their ability to take control of and mold their future. Ideas of racial superiority have been used to rationalize the brutal treatment of other human beings.⁹⁸ In order to justify slavery, white slave traders, owners and enablers had to depict and view Black people as “other” or “less than.” Today there are many examples of the perpetuation of this narrative of racial inferiority, with devastating outcomes.⁹⁹

TS, a 41-year-old Black woman who worked as a supervisor of social services in San Francisco, had a history of breast cancer in remission. She went to the emergency room with severe chest pain. EKG and lab work were unremarkable. She was seen by the ER doctor. Her concerned husband, a tall, muscular Black man, was with her. Her care team concluded that perhaps her husband was beating her, and that she might have a broken rib. Social work was called. Ultimately, she was sent home and told to take Tylenol. She returned a few times with the same pain, now worsening, but the results did not change. A few months later, another ER doctor saw that the history of breast cancer had been listed and ordered a CT-scan of the chest that revealed large metastases invading the sternum. The patient later died. (Stories like this one are shared and known within affected communities, impacting the community who is targeted and further contributing to distrust, but often lost to general knowledge by the public. This story was shared by a contributing member of the OMA Equity Task Force.)

A clinician’s assumptions have a direct impact on care. The racially biased assumptions in TS’s case delayed her diagnosis and negatively impacted her care. While explicit bias (a.k.a. bigotry) has declined in the past 50 years and is now considered unacceptable in general society, implicit or unconscious bias is common and persistent.¹⁰⁰ It is found in our health system still today, and can prevent people of color from receiving adequate, equitable care or benefitting from access to care.¹⁰¹ There is evidence that implicit bias results in disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy.¹⁰² Stories like the one above, shared within the community, underpin expectations of biased care, and impact the trust and bias that patients bring with them to a clinical encounter.

Such implicit bias occurs as a result of stereotypes and prejudices, and in medicine, this bias can cause a difference in care and treatment based on a patient’s race, age, gender, weight, or other physical characteristics. In 1998, Project Implicit was founded and Implicit Association Tests (IATs) were created and made publicly available.¹⁰³ These tests attempt to measure the often-unspoken attitudes or beliefs of individuals and educate test takers on their personal implicit biases. IATs are commonly used by medical schools and healthcare institutions to increase bias awareness. A 2015 systematic review of IAT results amongst healthcare providers found low to moderate levels of implicit racial/ethnic bias and identified a resulting impact on the patient-provider interaction, treatment decisions, treatment adherence, and patient health outcomes.¹⁰¹ However, the test alone has not always been shown to identify or reduce implicit biases and it is recommended that these tests be paired with other training.¹⁰⁴

As a field, health care must move beyond IAT training and start incorporating training based in critical race theory in order to address systemic racism in our institutions. Critical race theory was created and promoted by civil rights scholars to address the root causes of racism including societal structures and cultural assumptions. It incorporates race consciousness, societal dynamics, and centers the perspective of socially marginalized groups.¹⁰⁵ Critical race theory is already being used in many fields, including public health, to address racial health inequities.

Effects of Bias Outside Health Care

Bias against people of color starts outside the field of health care. Stereotypes of Black people have evolved over the years, always serving the best interests of their creators. The enslaver who used violence to compel slaves to work needed justification for this behavior. Black people were depicted as docile and lazy -- the “Sambo” stereotype. White society embraced this notion which could assuage guilt about slavery as it seemed to follow that Black people needed the direction of the slave master.¹⁰⁶ After slavery ended and Black people began seeking independent existence, whites engaged in the violent suppression of these aspirations. The white portrayal of Black men shifted to that of the “brute savage.” This was meant to justify the ferocious attacks and lynchings of Black people and to support segregation. 1915 saw the release of “The Birth of a Nation,” a film that depicted the Ku Klux Klan as heroic and honorable, depicted Black men as savages attacking white women, and paved the way for the racist narrative that continues to paint Black men as dangerous and predatory to this day.¹⁰⁶

More recently, American media (which is largely owned and controlled by whites) has contributed to and continues to contribute to Black criminal imagery through subtle use of words, pictures, videos, and entertainment that suggest that Black people tend toward criminality. This kind of subliminally suggestive programming is particularly harmful because people are unaware of it. Without realizing the racist undertones, a white person might call the police because a Black person is walking down the street in their predominantly white neighborhood. They might cross the street or grab their purse or wallet more tightly when a Black person approaches. The person may not even be aware of these actions. But this kind of thinking, fueled by bias, can be dangerous, especially when it influences how individuals and institutions—especially the police—interact with Black people.^107,108,109

Paul Butler is a law professor at Georgetown University Law Center and is author of the book Chokehold where he writes, “The bottom line is that it is not crazy or racist for a person to think she is more likely to be the victim of a street crime perpetrated by an African American man than a man of another race. It is just that it is unlikely that either event will occur. The person who is at most risk from a Black man is another Black man, and even this risk is relatively low. For the most serious crimes—homicide and rape—whites are much more likely to be victimized by white people they know than by Black strangers.”¹¹⁰

Negative stereotypes that dehumanize and degrade a group of people can be internalized and the dominant group ideology accepted as deserved and inevitable, causing additional harm by precipitating poor self-concept.¹¹¹ When Black children internalize negative stereotypes about themselves, it affects school performance which in turn impacts the work and socioeconomic opportunities and the communities they live in later.⁹⁹

These societal biases also influence judicial sentencing patterns. Jennifer Eberhardt, Stanford Professor of Social Psychology and McArthur Award recipient, conducted a study that found that “suspects with stereotypical African features have tougher jury verdicts, longer prison and death sentences, and a greater probability of mistaken identity.”¹¹² Pamela Newkirk commented on these findings and others in her book “Diversity Inc: The Fight for Racial Equality in the Workplace,” observing, “The problematic perception of Black barbarity mirrored in mass-media representations then becomes a self-fulfilling reality that serves to normalize the hyper-criminalization of Black people in society.” As Newkirk explains, biased portrayals of Black people in the media have real-world repercussions and serve to disadvantage Black people in many areas of society, perhaps most notably within the criminal justice system.¹¹²

The struggle to coexist with the constant existential threat of the negative imagery mentioned above is not unique to Black men. Black women have also fought to maintain their individual identities in the face of pejorative images since the advent of slavery over 200 years ago.¹⁰⁶ Data show that the majority of women on welfare, such as SNAP (Supplemental Nutrition Assistance Program) are white, though the label of “Welfare Queen” has been effectively attached to Black women through the voices of media and politicians.^106,113,114 The use of the label “Angry Black Woman” is particularly damaging as it is often used with women in important positions to demean them and devalue their opinions when they speak up about injustice in the workplace.¹¹⁵ Former President Trump applied this term to Vice President Kamala Harris because of her intense questioning of Supreme Court Justice Brett Kavanaugh during his confirmation hearing.¹¹⁶

The prevalence of this imagery that has populated American media for centuries have served to minimize the worth and ridicule the plight of Black men and women, impacting their own and others’ attempts to combat racial injustice. When these narratives influence how individuals and institutions interact with Black people, it increases their negative impact.¹¹⁵ Such stereotypes also influence political and legislative decisions.^106,115,117 For example, most crack users were and still are white, but sensationalized media depictions of “crack whores,” “crack babies” and violent “crackheads,” were portrayed as primarily Black. These were effective in recruiting political support and steering the War on Drugs into communities of color.^118,119,120 The consequences are evident in policy and enforcement; in particular, differences in law enforcement practices have a significant impact on communities of color.

Discrimination in Decision-making and Outcomes in Oregon

A real-world example of the repercussions of housing discrimination is found in the story of the Vanport community. The Vanport community was a 1942 WWII temporary housing project that became a majority Black community as a result of discriminatory housing policies. Despite rising water levels due to heavy rainfall in 1948, residents of Vanport were not warned that the neighborhood was at high risk of flooding and the dikes were failing. When the region flooded, it resulted in the death and abrupt displacement of thousands of Black Oregonians. It was already difficult to find a home as a Black Oregonian and the only option for Black families at this time was to move to the overcrowded Albina District.¹²¹ These Black families then experienced further displacement due to the expansion of Legacy Emanuel Hospital in later years.

It is clear that Oregon has been no haven from individual and systemic examples of racial discrimination. Examples are seen in employment, schooling, housing, welfare, recreation, and policing; this was recognized fifty years ago by the City Club of Portland.¹²²

The City Club arrived at the conclusion that city government engaged in projects and made policy decisions that neglected the input of affected citizens when Black neighborhoods were involved. The gentrification of North Portland in the 1970s is a good example of this governmental neglect and lack of citizen input.¹²³ Many Black people were displaced when white city leaders pushed through major plans without making effective attempts to communicate with the people living in the impacted neighborhood. The expansion of Emanuel Hospital in 1972 led to the destruction of 22 city blocks containing between 200 and 300 homes and businesses in the primarily Black neighborhood of Albina. The owners were reimbursed far below market value for their property. People with limited resources were displaced. Homes were capriciously demolished, despite the fact that Congress ultimately failed to fund the entire project. Tragically, there are still vacant lots around the hospital and much of this land remains empty.^124,125,126 The consequences are clearly devastating and long lasting when systems are set up and decisions are made without inclusion of those directly impacted.

Exclusion from power and minimizing the voices of the people impacted has a direct impact on the well-being of the community. In the United States, economic disparities are ongoing: median household income for Black Americans is about $46,000, compared to $63,000 for white people. Home ownership is a major source of wealth and savings, but just a third of Black people own their homes, half the rate of white people. Black people still find it more difficult to get loans.^127,128

The schools in Portland, Oregon, remain relatively segregated. Black high school students are twice as likely to be expelled or suspended. Sixty-eight percent of Black students graduate from high school on time, as compared to 85 percent of white students. Black/white performance in school is fairly even initially for math and science, but the gap widens over time. Of Black 10th grade students, 60 percent do not meet reading standards, 75 percent do not meet math standards, and 63 percent do not meet writing standards. Black people with four-year college degrees make $11,000 less than their white counterparts.¹²⁹

The problems Black Oregonians have faced parallel what Black Americans have experienced elsewhere in the United States. Generations of life under systemic racism have impacted the resources, self-image, and opportunities of Black Americans, and made the cycle of poverty more difficult to break. The small number of Black people in Oregon makes it difficult for Black Oregonians to reclaim and redirect their own stories or change the imagery that promotes bias and continues to have real, lasting consequences.

 

Public Health Issue No.1: Law Enforcement in the Black Community and the Disproportionate Loss of Black Lives to Violence

On May 25th, 2020, George Floyd, a 46-year-old Black man, was arrested for alleged use of a counterfeit $20 bill and killed by a police officer. Several video recordings detailed the incident.¹³⁰ He was handcuffed and was lying face down. He presented no threat to officers or bystanders. Other police officers stood by without intervening. Onlookers appeared helpless to do more than protest and express their distress as events unfolded.¹³⁰

Following this event, ongoing protests erupted across the United States and worldwide.¹³¹ The tragic episode of George Floyd’s death is evidence that systemic racism, the motivation behind the March on Washington nearly six decades ago, continues to be a problem today.

Police Violence in the Black Community

The killing of George Floyd is not an isolated event. The probability of extrajudicial killing of Black citizens by law enforcement is 2.5 times that of white people. Hispanic men are also disproportionately impacted with a rate nearly two times that of white men.¹³² Black men face a one in 1,000 risk of dying at the hands of a police officer in their lifetimes.¹³³ For white men, the risk is lowest at 39 per 100,000.¹³³

Loss of life due to police shootings in this country occurs at a relatively constant rate of about 1,000 citizens per year.¹³² This is a very high rate compared with the rest of the world, and it affects all races.¹³⁴ For perspective, in England and Wales (with a population of 56.9 million) there were 55 fatal police shootings in the last 24 years. In the United States (with 316.1 million people) there were 59 fatal police shootings in the first 24 days of 2015.¹³⁵ The vast majority of police officers in the United Kingdom do not carry firearms, so this may be viewed as an unfair comparison. That said, it is a comparison that emphasizes there are other effective ways to police that are less deadly to citizens. Differences in law enforcement tactics are likely tied to the UK’s laws limiting the availability of firearms.¹³⁶

Gun violence occurs in significant frequency in our society, and a significant number of the police killings may be arguably justified individually on the basis of self-preservation and protection of others. This raises the question: how dangerous is it to be a police officer?

When examined statistically, policing has become a safer profession over the last five decades. Prior to 1980, an average of 115 police officers per year were killed feloniously (killed as a result of a criminal act) in the line of duty. From 2006 to 2015, the annual average number of felonious police deaths was 49.6.¹³⁷ Between 1970 and 2016, the number of line-of-duty deaths has fallen by 75 percent.¹³⁸ The number of police officers has increased over time and there are about a quarter of a million more officers working today than there were three decades ago.¹³⁷ Despite declines in death rates, policing remains a risky profession. Between 2014 and 2019, 1,467 law enforcement officers were shot with 249 fatalities (245 shot per year with 42 deaths per year on average).¹³⁸

In summary, there has been a significant drop in the number of police officers killed in the line of duty. While each one of these is tragic, the numbers do not seem to be consistent with the high and nearly constant rate of civilian fatality at the hands of the police. Furthermore, it does not explain the divergently higher rate of police killings of Black and Hispanic people.

In 2015, the number of citizens killed by the police was 994; 94 of which were unarmed. Of the unarmed people killed by police, 38 were Black, and 10 were suffering from mental illness. The incidence of fatal encounters was 18.6 per million and 1.7 per 100,000 for unarmed persons overall. The incidence of fatal encounters for unarmed Black men was 6.1 per million, while that for Hispanic men was 2.8 per million and white men was 0.9 per million. The killing of unarmed Black people at the hands of the police is 7 times the rate for white people.¹³² Police use of force is a leading cause of death for Black men in their mid-to-late 20s, and while this risk is highest for Black men it is measurably elevated for Black women and other people of color as well¹³⁹

In 2015, an estimated 53.5 million (about one in five) persons aged 16 or older experienced some kind of contact with the police during the previous 12 months.¹⁴⁰ In citizen-initiated contacts, the police were felt to have improved the situation in the majority, and this was true for white, Black, and Hispanic subgroups independently. Close to 90 percent of each of these subgroups were more or as likely to contact the police again. However, approximately 2 percent or 1 million people experienced nonfatal threats or use of force from a police officer. Men were about three times more likely than women and Black and Hispanic people were about three times more likely than white people to experience this.¹⁴⁰

Lloyd Stevenson was a 31-year-old off-duty security guard, father to five, and a former Marine. He was in a 7-Eleven store in Northeast Portland when it was robbed in April of 1985. He helped the employees stop the thief, but then got into a fight with a witness in the parking lot. A police officer put him in a ”sleeper hold.” Stevenson was pronounced dead 45 minutes later at a Portland hospital.¹⁴¹ An inquest jury reached a verdict that the cause of death was criminally negligent homicide, but a grand jury refused to bring indictments against any of the officers.¹⁴¹

When law enforcement officers enter a neighborhood in which they perceive a higher threat of violent crime or higher density of firearms, they might carry a higher level of anticipation and suspicion. Researchers have explored and identified racial bias in decisions to use deadly force. Black Americans are more likely to be perceived as dangerous and warranting such a response.^142,143,144 In a racially segregated Black neighborhood, if an officer anticipates a higher threat level, it may blur the lines between suspects and innocents; this can also contribute to perceptual distortions as events unfold.^145,146,147

In law enforcement training, officers are taught to prioritize victims and innocent bystanders over themselves. On the other hand, the perpetrator's life is of lesser concern than the lives of the officers.¹⁴⁸ Law enforcement professionals are also taught about perception time and reaction time. Reaction time is perception time plus action time. Perception time is that time needed to discern a threat. Action time is the time it takes to raise a weapon and fire after a threat is realized.¹⁴⁹

Reaction time is therefore always greater than action time, generally putting officers at risk in violent situations. In practice, environmental factors weigh in, such as distorted light with shadows and reflections, noise, weather conditions, etc. Officers may seek to eliminate the action time, and simply be ready to act preemptively. Reaction time experiments demonstrate that a police officer encountering an armed suspect, even when their own gun is ready and aimed at the suspect, will not be able to fire faster than a suspect who initiates action and chooses to shoot the officer.¹⁵⁰

These factors complicate the interaction of police officers with suspects. Anticipation, in a situation which is perceived to be dangerous, can be lifesaving. But this puts the suspect, who is presumed innocent until proven guilty, at potentially higher risk. When this risk is multiplied by a large number of similar interactions, this risk approaches reality.

A history of poor interaction between a neighborhood and law enforcement may lead to some defiance on the part of the neighborhood’s citizens, which can intensify the anxiety and tension on the part of the officer. The interactions between officers and citizens can be quite complex under these circumstances.^151,152

Confrontational policing tactics, such as “Stop, Question, and Frisk'' (SQF) and racial profiling, have additional social cost and further erode trust in agents of law enforcement.¹⁵³ Such tactics reduce the sense of safety within the targeted population; incidents of police brutality (experienced directly or indirectly) can contribute to trauma and PTSD.⁹⁹ New York City’s SQF tactics in 2002-2013 resulted in nearly 5 million stops. No arrest was made in 88.1 percent of these stops. There were large differences across demographic groups in their experience of innocent stops with almost 25 percent of all stops targeting Black men aged 14-24 years, despite this group representing only 1.9 percent of the city’s population. “Proactive” policing tactics hence perpetuate significant differences in perception of policing with 77.6 percent of whites reporting that “police behaved properly” in their interactions, whereas for Blacks, the percentage was only 37.7 percent.¹⁵³ Law enforcement officers’ expectations and biases, and the lack of trust of Black citizens when interacting with police, may contribute to rapid escalation and physical aggression or violence in these interactions.

Policing and the Crime Rate in the Black Community

In one narrative that attempts to justify the high level of police violence against Black Americans, it is suggested that the increased mortality rate for Black people at the hands of the police is due to higher police presence leading to increased contact, which in turn is related to higher crime rates in Black communities.¹⁵⁴ This may be a logical argument; however, it begs the question of why the higher police presence and increased numbers of contacts with the members of the Black community is not producing a lower crime rate.

Black people account for close to half the country’s homicide victims despite representing only 13.4 percent of the population.¹⁵⁵ Black Americans are six times more likely to be murdered than are white Americans.¹⁵⁶ For young Black men this disparity is even greater, with Black boys and men between the ages of 15 and 34 experiencing homicide rates 15 times those of white boys and men of the same age.¹⁵⁶ Homicide is the second-most important contributor to the racial gap in life expectancy. If this discrepancy were eliminated, it would do more to equalize life expectancy by race than the elimination of death by any other cause except only cardiovascular disease.¹⁵⁶

Interpersonal violence is a major cause of death and disability among young Black men.¹⁵⁷ In the age group of 1-19 years, homicide is the leading cause of death for Black males, at 35.2 percent. It is also the leading cause of death for Black men ages 20 to 44, at 28.9 percent.¹³² Unfortunately, this risk especially impacts people at a time in their lives when education and productivity is most important, contributing to the significant toll that violent death and injury take on the community. Deaths at the hands of police cause additional harm with resultant spillover effects in these communities, including on mental health.¹⁵⁸

Lack of police presence in Black neighborhoods is not the problem. Black communities are simultaneously “over-policed” and underserved by police. The disproportionate use of SQF (described above), Special Weapons and Tactics (SWAT) teams to carry out drug arrests, and the use of no-knock warrants (which will be described later), all represent “proactive” or confrontational policing tactics that are oppressive to all members of the community, including those not involved in criminal activity.¹⁵⁹ At the same time these tactics can actually contribute to lower clearance rates (identification and removal of perpetrators) for homicide, leading to these killers acting with impunity, and greater preemptive killing in the community to protect self and family.¹⁶⁰ This style of confrontational policing also creates a rift and an atmosphere of distrust, reducing community members’ willingness to cooperate with the police and making it difficult to find witnesses, prosecute perpetrators, and clear dangerous criminals. The dilemma is clear: ineffective policing leaves members of the community in danger which results in justified fears of retaliation for cooperating with the police. This further prevents those who might be willing to bear witness and perpetuates deficiencies in policing outcomes.

Focusing on the crime levels in Black neighborhoods as a cause for increased police presence and contact deflects attention from the core issue of how these neighborhoods have developed higher crime rates and maintained them despite that police presence. Poverty and joblessness (exacerbated by high incarceration rates and its impact on employability) have led to crime as an alternate pathway for survival. Brendan O’Flaherty and Rajiv Sethi, Professors of Economics at Barnard College and Columbia University respectively, report in their book, Shadows of Doubt, that criminal activities are secured by more criminal activity, which can lead to murder. Murder rates are exacerbated by fear of murder in an atmosphere where killers have impunity from the law.¹⁶⁰ If the policing goal is serving and protecting, then this form of policing is a predictable failure. It has been debated whether increasing police presence is effective at reducing crime. While community style policing (in which the police embed themselves in the neighborhood, walk the beat, and get to know neighborhood residents) might help to deter crime,¹⁶¹ a large body of evidence supports a greater need for global investment in communities to improve public safety.^162,163

In another narrative that attempts to justify the high level of police violence against Black Americans, it has been argued that in regions of higher gun violence police will tend to be faster to draw and use their weapons.¹⁶⁴ This again oversimplifies the problem and distracts from the reasons behind the high levels of gun violence. The argument ignores the role of America’s lack of legislated restrictions on firearms in contributing to the heightened risk of police killings in this country^165,166 and absolves the police of their role in racialization of poor law enforcement outcomes. At its worst, this argument appears to place the blame on the people living and dying in these communities for the circumstances contributing to violence within the communities which include residential segregation, higher incarceration rates, lower educational attainment, poor economic indicators and employment status.¹⁶⁷ The risk of death from police interactions is higher for Black citizens compared with white citizens presumably because of underlying bias towards Black people and Black communities.^{142,143,144,167,168,169} Addressing bias in law enforcement must be a part of the solution, but correcting the upstream systemic social and economic contributors is also necessary to reduce violence within a community.

Communities that lack economic opportunity and access to resources foster opportunities for criminal activity to arise, and protection of this activity is done violently, creating “hotspots” of crime.¹⁷⁰ In his book, A Great American City, urban sociologist Robert Sampson notes that “even though the city of Stockholm has far less violence, segregation, and inequality than the city of Chicago, in both cities a disproportionate number of homicides occur in a very small number of very disadvantaged neighborhoods.”¹⁷¹ This implies that the criminal activities of a relatively small subgroup can raise the risks for those living in the vicinity of one of these hotspots. Significant regional variation of the homicide rate is noted between states, with the highest three being Missouri at 46.21, Wisconsin at 37.57 and West Virginia at 36.86 per 100,000 in 2016. The lowest three states that year were South Dakota, Vermont, and Montana all of which had rates of 0.¹⁷² Oregon sat at 8.02 per 100,000. Violent Crime has been shown to be localized to geographic hot spots which are mostly urban locations.^173,174

In her book, The New Jim Crow: Mass Incarceration in the Age of Colorblindness, Michelle Alexander, writer, civil rights lawyer, opinion columnist for The New York Times, and visiting professor at Union Theological Seminary, offers the following explanation for violence within Black communities: "What a growing number of sociologists have found ought to be common sense: by locking millions of people out of the mainstream legal economy, by making it difficult or impossible for people to find housing or feed themselves, and by destroying familial bonds by warehousing millions [in prison] for minor crimes, we make crime more—not less—likely in the most vulnerable communities.... When given a choice, most people in the ghetto, like anywhere else, would prefer to be able to work, support their families, and live without fear of harm or violence, if given the chance.”¹¹⁸ Seeking to control this violence with increased police presence does not correct the source of the problem and can contribute to the risk that police presence might add to the already high rates of violent death within the community.^{156,159,160,175}

Violence as an Outcome

Identifying all the root causes of violent crime is challenging. The list includes poverty; segregation with inequality; joblessness; residential instability, foreclosures, vacancy rates, and evictions; and land use issues. In the Black community, these are the result of a long history of systemic racism. Not surprisingly, communities with effective policing, strong social organization, job opportunities, access to resources to solve community problems, and residential stability have lower rates of violent crime.¹⁷⁰

Violence represents a public health issue for people of color.¹⁷⁶ The stunning statistics demonstrate that homicide is the leading cause of death in Black men between the ages of 1 and 44. Police use of force contributes to risk of death for Black people, but this problem cannot be viewed in isolation. Despite the increased police presence in Black neighborhoods, the lack of effective policing leaves criminals unhindered and contributes to an insecure environment. Confrontational policing tactics broadly targeting Black citizens and policies focused on controlling, rather than healing or protecting the community, contribute to risks of violence. To eliminate violence, policing must engage the community and evolve to effectively combat crime. At the same time effort must be directed at transforming social and political policy to promote an environment of wellbeing for these communities.¹⁷³

 

Public Health Issue No. 2: The War on Drugs

Just two months prior to the death of George Floyd, Breonna Taylor, a 26-year-old emergency medical technician, was killed when three Louisville Metro Police Department officers forced entry into her apartment under the authority of a “no-knock” search warrant for drugs and drug money. Gunfire was exchanged because Taylor’s boyfriend thought someone was breaking into the apartment. Ms. Taylor, who was unarmed, was shot eight times, and died. No drugs or drug money were found in the apartment.¹⁷⁶

Public awareness of this event has prompted concern about the policies and procedures that led to Taylor’s unnecessary death. Much of the legislation and the associated procedural changes that allowed for this circumstance began after the War on Drugs was officially declared in 1971 by the Nixon administration, and later again in 1982 by the Reagan administration, despite the fact that illegal drug use was actually on the decline.¹¹⁸ The effect of the War on Drugs was to increase the size and presence of federal drug control agencies, start mandatory sentencing, and allow no-knock warrants. Arrests and convictions for drug offenses skyrocketed, especially among people of color.

Politics and Criminalization of Substance Use

Believed to be politically motivated by many, the War on Drugs has ravaged Black and Hispanic communities.¹¹⁸ John Ehrlichman, Domestic Policy Chief for the Nixon Administration, exposed the administration's intent on using the War on Drugs to harm the Black community: “You understand what I’m saying? We knew we couldn’t make it illegal to be either against the [Vietnam] war or Black, but by getting the public to associate the hippies with marijuana and Blacks with heroin—and then criminalizing them both heavily—we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”

Ultimately, incarceration of people who are caught in possession of drugs demonstrates indifference to the possibility of an underlying substance use disorder. The laws do not adequately account for the medical situation. The unanswered question at the root of mass incarceration concerns our definition of crime and further stigmatization of substance use for political gain. Incarceration of people with substance use disorder does not improve their access to appropriate and needed medical care and inflicts people with the permanent label of convicted felon. Formerly incarcerated people with substance use disorder, which may be untreated or undertreated during incarceration, have a very high incidence of accidental overdose on returning to the community.¹⁷⁷ At the time of reentry into society, stress, lack of support, poor access to healthcare, and difficulty finding work (often a consequence of their conviction history), heightens the risk of relapse into drug use, re-incarceration, overdose, and death.¹⁷⁸ Investment in mental health and substance use disorder services during and after incarceration has been shown to help break the cycle of re-incarceration by reducing relapse into drug use.¹⁷⁹

Further complicating this situation are mandatory minimum sentences which eliminate a judge’s ability to apply discretion and have forced judges to harshly punish nonviolent drug offenders despite the low risk of physical danger to the community. This rapidly increased the prison population after the 1984 Sentencing Reform Act.¹⁸⁰ The impact has been both direct, through mass incarceration, and also indirect, through the impact on family members and bystanders.

No-knock warrants result in forced-entry, military-style police raids on individual homes and apartments.¹⁸¹ These raids have had a terrible impact on entire neighborhoods. Forty-two percent of SWAT team raids targeted Black people and twelve percent targeted Hispanic people. Sixty-one percent of all the people impacted by SWAT raids in drug cases were minorities. Stark, often extreme, racial disparities in the use of SWAT for search warrants were found when the issue was studied by the American Civil Liberties Union. These raids result in property damage and often use violent tactics and equipment that unnecessarily risk bodily harm and death. SWAT teams have been deployed despite the presence of children in the home.¹⁸² Errors have been made and the homes of innocent people raided. Such a mistake was made in the case of Breonna Taylor. Although there is currently no community oversight and collection of data, it is believed that no-knock raids occur at least 20,000 times per year.¹⁸³

Militarization of Law Enforcement

Policing in Black urban neighborhoods has often been confrontational, but after the militarization of the police with the War on Drugs since the early 1980s, paramilitary tactics and high-grade military weapons started to be used to conduct domestic criminal investigations in searches of people’s homes, an approach similar to those of an occupying army. The weapons are provided to local and state police agencies through programs such as the 1033 Program, launched in the 1990s, which authorizes the U.S. Department of Defense to transfer military equipment to law enforcement agencies. Additional funding is provided through programs such as the Edward Byrne Memorial Justice Assistance Grant, established in 1988, which provides funding to enforce drug laws. This funding is used to purchase numerous types of weapons.¹⁸²

Drug possession, an activity that can be viewed as victimless or nonviolent, has been treated like a highly dangerous violent crime. The influx of federal funds was on the order of $15.4 billion into law enforcement in association with the War on Drugs, and the Iraq wars made acquisition of the latest in military surplus available at low cost.¹⁸² Despite white and Black people having similar rates of using and/or selling drugs, the prime focus of the War on Drugs has been on poor vulnerable Black neighborhoods, driven by the focus on crack cocaine rather than the powder cocaine that was more popular in white neighborhoods.¹¹⁸ In essence, the police may behave like a militarized invasion force, raiding the homes of people or stopping and searching them in the streets, creating the impression of an occupying army with little concern for the inhabitants.¹⁸⁴

SWAT began in 1964 for the purpose of addressing imminent threats such as riots, hostage situations, barricaded suspects, and active shooter or sniper scenarios.^185,186 In 1975, there were 500 SWAT teams nationwide and they were used sparingly. However, SWAT teams have now increased by 15,000 percent, with 80 percent of their activity devoted to executing search warrants, many of which are “no knock” warrants, often for small amounts of drugs.^187,188 This activity does not directly curb violent crime. Federal funding and grants are distributed based on enforcement of the War on Drugs. Law enforcement also garners resources from asset seizures resulting from drug related arrests. There is no equivalent incentive encouraging the investigation of murder and/or robbery to compete with the lucrative incentives provided to police departments by the War on Drugs. This may help to explain why, despite all the police activity, there is still a high murder rate in Black neighborhoods.^{184,188,189,190}

The War on Drugs is not a battle with pills on one side and people on the other. From its initiation, it has been a war targeting communities of color, a manifestation of structural racism. The use of the word “war” is appropriate, given the use of military hardware and SWAT teams, in addition to spontaneous unannounced searches that cast a wide net inflicting harm on innocent civilians. The decision to concentrate on “crack” cocaine, most prevalent in the Black community, was deliberate. The criminalization of drug use and possession as opposed to addressing drug dependence with rehabilitation was also intentional. This is in significant contrast to the approach taken toward drug dependence in white communities where rehabilitation is the mainstay.^118,119,120 The impact has been devastating. Although drug use and/or sale by Black people has never been shown to exceed that by whites, law enforcement’s unbalanced attention to the Black community, accompanied by inflexible mandatory sentencing, in a context of bias in court decisions, has resulted in disproportionate conviction rates (detailed in the next section). The impact is not restricted to those currently in prison, but also affects all who pass through prison and carry the label of convicted felon; there are spillover effects on families and friends. The decision to focus on permanent punishment rather than medical care and rehabilitation for those affected has resulted in tragic consequences, especially for young people just beginning their lives. This constitutes a public health crisis.

 

Public Health Issue No. 3: Incarceration Rates and Correctional Institution Health Care

Likely we could point to no better example of systemic racism than the mass incarceration evolving in the wake of the War on Drugs, which led to a massive expansion of Black imprisonment. Presently, 2.3 million people in total are incarcerated in the United States, which is greater both in total number and in percentage of the population than any other country.^191,192 With only five percent of the world’s population, 25 percent of the prisoners in the world are in the United States. Between 1970 and 2003, state and federal prison populations grew sevenfold to 1.4 million convicted felons. Offenders in county jails accounted for another 700,000 by 2003. Another 4.7 million people were under probation or parole supervision, so that the correctional population in 2003 was nearly seven million. This accounted for six percent of the adult male population.¹⁹³ 450,000 people are incarcerated for nonviolent drug offenses on any given day, and one in five incarcerated people are locked up for a drug offense.¹⁹⁴

Of 1.5 million drug arrests in the United States in 2016, more than 80 percent were for possession only. Prosecutors are twice as likely to pursue an offence with a mandatory minimum sentence for Black people as for white people arrested for the same offense.¹⁹⁵

The Black population has been hit especially hard. Black people have been more likely to be imprisoned since the 1920s, when prisons were used to enforce Jim Crow laws. With the declaration of the War on Drugs, special attention to the epidemic of crack, a cheaper form of cocaine, directed policing resources into Black communities, which, due to long years of housing discrimination and poverty, were often concentrated in very localized areas of cities and towns. This siege on Black communities, combined with the removal of judicial discretion in sentencing and the 100:1 disparity of sentencing for crack cocaine as opposed to powder cocaine, tremendously expanded the rate of United States Black male confinement to four times the rate of incarceration of Black men in South Africa under Apartheid.¹⁸⁴

The three-strikes rule, and other habitual offender laws further exacerbated the problem, such that a person with three nonviolent, victimless offenses could end up with unusually severe punishment of long imprisonment. In October 2020, a Black man in Louisiana was informed by the Louisiana Supreme Court that the life sentence handed down for his last offense (stealing hedge clippers), an offense which followed four prior convictions, had been upheld. He was convicted in 1997 and has been in prison ever since.¹⁹⁶

Black people represent 13 percent of the United States population, but as of 2020 constitute 35 percent of the municipal jail, state, and federal prison population. This figure represents an improvement, as the Black imprisonment rate dropped by 33 percent over the 12 years from 2006 to 2018. As of 2016, Black people made up 48 percent of the life sentences, 56 percent of sentences of life without parole, and approximately 42 percent of death row inmates.¹⁹⁷ In 2006, Black people were eight times more likely to be incarcerated, on average. The incarceration rate for Black Americans in 2014 had come down to five times that of white Americans.¹⁹⁸ Nationwide, Black children represent 32 percent of children who are arrested, 42 percent of children detained, and 52 percent of children whose cases go to criminal court, while representing only 14 percent of children in the United States.

Oregon follows the national trends with similar statistics. As of August 1, 2020, there are 1,306 Blacks and 9,833 whites in Oregon prisons, out of a total of 13,694 prisoners.¹⁹⁹ With Black people accounting for 9.5 percent of the prison population but only 1.91 percent of the general population of Oregon, this amounts to a Black-to-white incarceration ratio of 5.9.²⁰⁰ This constitutes a 24 percent improvement compared to 1990.²⁰¹ Although Black people in Portland, Oregon are seven percent of the population of the city, 45 percent of Portland’s homicide victims are Black. Fully 77 percent of Black youth referrals are adjudicated as compared to 46 percent of white youth referrals.¹²⁹

Formerly incarcerated people often lose the right to vote and have difficulty finding employment, and are denied business loans, student aid, public housing, and other public assistance. One of six Black men between the ages of 25 and 54 have disappeared from typical daily life from either death or incarceration, and one in thirteen Black people of voting age are denied the right to vote because of laws that disenfranchise people with felony convictions.¹⁹⁵

Health Risks Accompany Incarceration

Incarceration has been associated with premature death. There is increased risk of heart disease, stress-related illness such as psychological problems, hypertension, drug overdose, and cancer among those who are incarcerated.²⁰² Acquiring infections in prison such as HIV, HCV, tuberculosis, sexually transmitted infections, methicillin-resistant Staphylococcus aureus, and now COVID-19 is also a significant risk.^{202,203,204,205} The COVID-19 pandemic has disproportionately affected individuals in United States prisons; they have 5.5 times the case rate and 3.0 times the death rate (adjusted for age and sex) when compared to non-incarcerated United States citizens.²⁰⁶

In 1994, voters amended the Oregon Constitution by passing Ballot Measure 17. Also known as the Prison Reform and Inmate Work Act, Measure 17 requires that all able prisoners work 40 hours each week; the legislation also states that 20 of those required hours can be used for unpaid job training.^207,208 In 1999, Oregonians passed additional legislation, in the form of Ballot Measure 68, in order to allow for the creation of Oregon Corrections Enterprises (OCE) under the Department of Corrections to help fulfill the work obligations created by Ballot Measure 17.²⁰⁹

The moral argument for divesting from OCE is amplified in light of the COVID-19 pandemic. Prisoners are already at an increased risk of infection as a result of the inability to maintain social distancing in cells or group spaces.^210,211 In addition, many prisons are requiring individuals to make masks and hand sanitizer for the healthcare providers during the pandemic without consistent access to their own protective equipment.^212,213 OCE workers in contact with contaminated laundry from Oregon hospitals may be at an even higher risk for infection. The exploitation of prisoners to handle biohazard material is unethical—especially when the transmission of a novel virus is still being studied. The manager of the OCE laundry plant has also acknowledged that the private sector has automated commercial laundry as a result of COVID-19, which raises further ethical concerns for the direct handling of contaminated laundry from hospital systems.²⁰⁸ Oregon has had at least one case of COVID-19 in an inmate that worked in a laundry position for OCE.²¹⁰ While unstudied, the use of inmates for hospital laundry during the pandemic may be in part responsible for outbreaks within prisons.

As of March 2021, nearly 400,000 people incarcerated in prisons have had COVID-19. Ninety out of the 100 largest outbreaks of COVID-19 in America reported in 2020 took place in jails or prisons. The number of COVID-19 cases has been reported to be 5.5 times higher among people who are incarcerated compared with the general population.^214,215,216 Inmates of the correctional setting do not generally receive health care that meets public health standards, further compounding the risks of adverse outcomes. Health care interventions and prevention efforts in correctional facilities have the potential to directly impact the health outcomes of inmates and the communities to which prisoners return.^202,204

The Breadth of the Problem and Its Impact

At present incarceration rates, one of every three Black boys born today can expect to be sentenced to prison. This compares to one of every six Hispanics and one out of every 17 white people.¹⁹⁸ Those not graduating from high school are particularly susceptible.¹⁹⁷

Black and white people use drugs at similar rates, but the imprisonment rate of Black people for drug charges is almost six times that of whites.¹⁹⁸ Mandatory sentencing was applied to crack users in the 1980s through 2000s, but when the more recent opioid epidemic impacted a broader portion of the population (including many white people), it was viewed more as a public health crisis.²¹⁷ Additionally, the mandatory sentences for equivalent doses of crack versus powder cocaine are significantly harsher for the form of the drug historically more commonly used in Black communities. Even after this discrepancy was improved with the Fair Sentencing Act in 2010, the ratio remains 18:1 (reduced from 100:1) for sentence length.²¹⁸

Children whose parents are involved in the criminal justice system suffer psychologically and are six times more likely to be involved in criminal activity. One in nine Black children has an incarcerated parent, compared to one in 57 white children, and 2.7 million children are growing up in United States households in which one or more parents are incarcerated. Two-thirds of these parents are incarcerated for nonviolent offences, including many with drug law violations.²¹⁹ Partners of incarcerated people often suffer depression and economic hardship.²²⁰

Our understanding of the health effects of the penal system on individuals, communities, and society is in an early stage, however evidence is emerging in this past pandemic year. Sociologists and public health researchers have already demonstrated a host of significant adverse outcomes for both incarcerated and formerly incarcerated people and the families and communities to which they belong. This suggests a need for future research and policy development. The adverse effects of the penal system are disproportionately experienced by Black communities and other people of color in this country due to racial differences in law enforcement and justice.

 

Public Health Issue No. 4: Race-Based Disparities in Health Outcomes

Background on Race in Health Care

Dr. Esther Choo, an emergency medicine physician in Oregon, said about her interaction with a patient's family: “I told them what was going on quickly and asked if they had any questions. And this is what they said. They told me he worked for [a well-known company]. That he was on his way to work. That he is loved in the community. A good brother and son. That he was well dressed before the blood soaked his clothes. Nothing in recent memory has broken my heart as much as gradually realizing that a family of a shattered man whose chief concerns should have been—when can I see him, when does he get out of surgery, do you know his meds and allergies, his mama gets to go in first—had to worry that the racism inherent in the system and in people everywhere meant they had to spend their few moments with me putting him in a favorable light, shifting any possible implicit negative frame I had (e.g., “hoodlum” or “criminal”) to get him the care he deserved. What is the goal of all our antiracist pledges over the past summer? It’s that this family can walk in with full confidence that their loved one is valued and cherished here and that we will fight for his life with everything we have, no questions asked.”²²¹

Dr. Choo’s experience illustrates the reasonable fear on the part of many Black Americans that they will not receive equitable or sufficient care from the United States healthcare system, that implicit bias can be assumed to always be a part of care, and that bias must be worked around and minimized as much as possible. This mistrust has been cultivated by centuries of healthcare providers and a system that characterizes race as a biological variable. There is no biological basis for race.²²² Race is a social construct that served at one point in history to distinguish enslaver from enslaved.²²³ We must acknowledge that “race” characteristics are a continuum. Health outcomes will improve when we recognize that categorizing patients into a single race serves as a dangerous proxy for biological variation. The belief in biological differences between socially constructed races has served as a catalyst for ongoing inequities in provision of care and abuse at the hands of medical professionals.^220,224

The historical record provides stories of Black patients being abused by white clinicians. Dr. Marion Sims, the so-called “grandfather of gynecology” performed surgical experiments on unanesthetized Black enslaved women in the mid-1800s. Dr. Sims observed that white women could not tolerate the painful procedures. The enslaved women had no option but to submit to the long, agonizing surgeries.²²⁵ John Brown, an escaped slave, documented his experiences of abuse at the hands of another physician, Dr. Thomas Hamilton, in the mid-1800s. In an attempt to find a cure for sunstroke, Dr. Hamilton repeatedly confined Mr. Brown in a heated pit until he lost consciousness. Dr. Hamilton was also curious about the thickness of Black skin, and induced blisters to Mr. Brown’s hands, legs, and feet.²²⁶

The belief that Black people are less sensitive to pain, established by white physicians working with slaves, persists in modern medical practice and decision-making.²²⁷ Black patients experience disparities in pain management across medical specialties, from treatment of long bone fractures in the emergency department to perinatal care.^228,229 According to one study published in the American Journal of Emergency Medicine in 2019, Black patients were still 34 percent less likely to receive opioids for acute pain than were white patients, and Hispanic patients were 13 percent less likely to receive opioids for acute pain.²³⁰ While physicians and physician assistants aim to improve the health and quality of life in our communities, we cannot claim that we treat our patients without bias. Implicit bias, which has unconscious influence on our decision-making, affects every member of society. These biases are influenced by the communities in which we grow up and by our medical training.¹⁰⁴

Examples of abuse at the hands of clinicians and researchers did not end with the abolition of slavery. A U.S. Public Health Service Syphilis Study was performed at the historically Black Tuskegee University between 1932 and 1972. Six hundred Black men were entered into a study without their informed consent and were told they were being treated for “bad blood.” The original project was to last six months but continued for 40 years, ending only after the study was revealed by the Associated Press and public outcry demanded an investigation. The participants did not receive proper treatment for the disease, even when penicillin became the drug of choice in 1947 and was widely available, in order to observe the natural progression of syphilis.²³¹

There are other examples of medical exploitation of human subjects in pursuing research, scientific discovery, medical device development, and commercial enterprise. One such example is found in the history of HeLa cells, the story of how Dr. George Gey of Johns Hopkins University developed a durable and prolific line of cells for research. He used Henrietta Lacks’ tissue without her knowledge or consent, and without informing her family. Prior to her death in 1951, she provided the first immortal human cells ever grown in culture; these cells continue to be used in research but are best known for providing an essential tool in the development of the polio vaccine. These cells have been instrumental in the development of a multi-billion-dollar medical industrial complex.²³²

These examples demonstrate a few of the many reasons why Black individuals and communities may mistrust the U.S. medical system. The fears of being used as non-consensual research subjects has caused mistrust in public health programs and medical treatments, including needle exchange programs, sickle cell screening programs, birth control programs, and protease inhibitors for HIV.^233,234

Beyond research exploitation of the vulnerable there are also examples of societal devaluation of life with quiet collaboration by the medical community. In an attempt to decrease or eliminate “undesirable” features in U.S. society, sterilization laws were enacted in 30 states, culminating in 60,000 forced sterilizations that targeted immigrants, minorities, and impoverished people.²³⁵ Between 1970 and 1976, 25 percent of Native American women were sterilized, often without full informed consent, and Black and Latina women were also targets of coercive sterilization.²³⁶ In 2013, the Center for Investigative Reporting found that female inmates in California were sterilized without consent, and in 2017 a Tennessee judge issued an order offering prison inmates a sentence reduction if they agreed to permanent birth control.²³⁷ Allegations of sterilization of vulnerable populations without full informed consent continued in 2020.²³⁸

A diverse healthcare workforce is critical to achieving health equity.²³⁹ The persistent underrepresentation of Black medical professionals is multifaceted but can be attributed, at least in part, to historical lack of access to training and exclusion from professional organizations. There were a limited number of Historically Black Colleges and Universities with medical schools at the turn of the last century when the white medical schools would not admit Black people. The majority of these schools closed down within a decade of the 1910 Flexner Report due to pressures related to more stringent credentialing requirements and inadequate funding, reducing the number of Black physicians educated and available to the Black community.²⁴⁰

Like the medical schools, the AMA did not admit Black physicians until 1965, after legislation required it to do so. The NMA was formed in 1868 by an integrated group of physicians at Howard University, a historically Black university. The NMA requested admission to the AMA at the time but was voted down 114 to 82. The AMA denied the vote had been about race for more than 100 years, but ultimately a letter of apology was written to the NMA and was carried over and read to the NMA in 2008.⁸² We do not have documentation as to whether the OMA followed the bylaws and guidance of the AMA in regard to race.

Oregon healthcare leaders have recognized the need for improved diversity in the workforce. Efforts to recruit diverse students and trainees to the state already exist in training programs; notably, Oregon Health Sciences University has made effort in this area for over 25 years through medical school and residency admissions processes with some successes. In 2017, the Oregon Legislature enacted House Bill 3261, directing the Oregon Health Policy Board to conduct regular assessments of the health care workforce needs of the state. Increasing the diversity and cultural competence of the health care workforce in the state of Oregon has been recognized as a tool to address the growing racial, gender, and ethnic diversity of the state.²⁴¹ Nonetheless, our health care workforce continues to lack needed diversity in many areas and ongoing investment in strategies for change is needed.²⁴²

Disparities in Health Outcomes

After a history of abuse, inequity, and a lack of representation in medicine, Black people have many reasons to doubt they will receive equal care.²⁴³ This ongoing mistrust of the U.S. healthcare system contributes to lower care utilization by Black Americans.²⁴⁴ Black Americans receive less preventative care and chronic care and have higher rates of chronic disease-related hospitalizations.²⁴⁵ They are more likely to die when they receive treatment, they have lower survival rates from treatable diseases, they die more frequently during childbirth, they have increased risk of dying prematurely in childhood when compared with white Americans, and collectively Black Americans have a lower life expectancy.^{246,247,248,249} Even after correcting for socio-economic status and insurance, these disparities in health outcomes still exist.²⁵⁰ These outcome differences exist as far back as race-based data have been collected.²⁵¹

Racial disparities in health outcomes are truly disturbing. Black children are 50 percent more likely to be born with low birth weight. Infant mortality is 2.3 times higher for the children of Black mothers than for those of white mothers. Black infants are 3.8 times more likely to die from complications related to low birth weight and two times more likely to die from sudden infant death.²⁵² Additionally, Black, American Indian, and Alaskan Native women are two to three times more likely to die from pregnancy-related causes than are white women. For women older than 30, this ratio becomes four to five times as high.²⁵³

The incidence of hypertension in Black people is 42 percent, while that in white people is 25 percent. The diabetes rate in Black people is 13 percent, compared to white people at six percent. Black death rates from diabetes (73 per 100,000) are higher than for whites (29 per 100,000). Black death rates for stroke (85 per 100,000) compare unfavorably to those of whites (56 per 100,000). Black people are significantly more likely to die from heart disease, stroke, diabetes, or cancer compared to whites.¹²⁹

It is well documented that these inequitable health outcomes are not limited to Black Americans. According to the 2018 National Healthcare Quality and Disparities Report, racial and ethnic disparities in care were getting smaller from 2000 through 2016-2017, but persist, especially for poor and uninsured populations. Blacks, American Indians and Alaska Natives (AI/ANs), and Native Hawaiians/Pacific Islanders (NHPIs) received worse care than whites for about 40 percent of quality measures and disparities were improving for only 4 measures for Blacks, 2 measures for AI/ANs, and 1 measure for NHPIs.²⁵⁴ Black Americans and other communities of color experience a lower life expectancy than white Americans.²⁴⁷

Despite the best intentions and efforts of clinicians who try to provide care to each patient equally, differences in how care is made available and delivered by medical systems (independent of social determinants of health) may contribute to inequitable outcomes. Commonly used race-based medical research contributes to sustaining race-based medicine and may play a role in worse outcomes for Black patients. One example is the race-adjusted laboratory value for eGFR, a marker of kidney function. Originally attributed to differences in muscle mass, this race-adjusted value may overestimate kidney function, leading to later initiation of advanced treatments, delays in listing for renal transplant, and possibly worsening outcomes from kidney failure in patients categorized as “Black.”²⁵⁵ In another example, the American Heart Association guidelines assign additional points for heart failure risk for anyone who is “non-Black” resulting in all Black patients being categorized as lower risk and potentially delaying diagnosis and treatment.^255,256,257

Further examples of differences in care abound. A 2007 study reported that pulse oximeters, routinely used in medicine and surgery, are less accurate at low oxygen saturations for patients with dark skin.²⁵⁸ This inaccuracy may have a significant and adverse impact on medical decision making. Another example is BiDil, the heart failure drug marketed for Black people whose clinical testing included self-reporting race without any genetic evidence of differences in CHF between Black patients and other races.²⁵⁹

These examples of race-based medicine and research highlight the need for clinicians and scientists to replace race with factors measurable by clinicians and develop biologically based approaches to care and research unless the sociopolitical forces are directly pertinent.^{256,257,260,261} Additional effort is needed to alter how race is portrayed during medical education and training so that embedded racism is not perpetuated inadvertently by being passed on to the next generation of physicians and PAs.²⁶² Finally, medical training and practice must account for the impact of historical and personal traumas on the care experience and clinicians must learn to provide trauma-informed care.²⁶³

As has been described above, racial differences in American healthcare begin even before patients enter clinical care. In addition to the ways race affects social determinants of health and the delivery of care, unlike most other industrialized nations American access to health care depends critically upon a patient’s employment, age, education, and ability to pay. As a consequence, Black Americans and other communities of color are more likely to be uninsured,²⁶⁴ to have unaffordable deductibles and copays if they are insured,²⁶⁵ to be less likely to seek care when needed, and to be more likely to have incurred complications before they receive care.^266,267 Obstacles to health insurance compound pre-existing problems endured by Black Americans through inequitable access to education, police protection, employment, and housing, as well as the complicated relationship Black Americans have with the medical system because of historical betrayals of trust.²⁵⁰

Social determinants of health enumerated in earlier sections of this document and lower rates of access and utilization of healthcare services are contributors to the disproportionate impact of epidemics on the health of Black people. Events of 2020-2021 have underscored these effects. Significant and pervasive differences in outcomes from COVID-19 have been documented for Black Americans.²⁴⁸ In one study of a large cohort of patients in Louisiana, 70.6 percent of those who died of SARS-CoV2 were Black while they comprised only 31 percent of the local hospital system population.²⁶⁸ In another example, this one of adults aged 45 to 54, Black and Hispanic COVID-19 death rates were at least six times higher than those of white people nationally.²⁶⁹ 

A 2021 mid-pandemic systematic review of racial and ethnic disparities in COVID-19 related infections, hospitalizations, and deaths has demonstrated that Black and Hispanic populations experience disproportionately higher rates of infection and mortality but similar rates of case fatality, more likely due to exposure-related factors. These factors, in turn, represent one health risk and demonstrate the impact of the environments in which these individuals live and work.²⁷⁰ 58 percent of our population depends upon employment and ability to pay to access health care,²⁷¹ thereby exacerbating adverse public health consequences in communities of color that experience simultaneous loss of employment, income, health insurance, and good health.²⁴⁸

Adverse history, unsatisfactory experiences, and limited means creating limited access define the Black experience with health care. These have resulted in longstanding health outcomes disparities, which COVID has further emphasized over the last year. Correcting health outcomes for a community whose circumstances define their risk can only be successful by altering the sociopolitical factors that limit opportunities, environment, and access to care. This is an ongoing public health crisis.

 

A Call to Action

There are clear racial disparities in health care delivery and outcomes. Racism in this country has an intergenerational impact with varying manifestations. Systems influenced by racism affect safety within Black communities and interactions with law enforcement. They reduce access to educational opportunities, acquisition of wealth and secure housing, and result in bias in society affecting our media and systems of justice. Current policies of law enforcement and justice place lives and health at risk. Other ethnic and racial groups targeted by systemic racism have a similar experience.

White patients fare better than do patients of color. Decades of reform attempts have not changed this at the state or national level. An institution that generates worse outcomes for Black people and other people of color must be considered a “racist” institution. Based on our nation’s history of race in medicine and persistent racial disparities in health access and outcomes, the American healthcare system is racist.

Until recently, physicians, PAs, and other healthcare allies have not taken a stand in opposition to racist public policies even when the downstream effects on health and access to health care are seen. Historically, the healthcare system in this country has played a role in perpetuating and participating in systems of racism even if individual clinicians have tried to resist. Health outcomes are predictably worse for people affected by racism in this country. The scope of the problem is large; the social and economic determinants of health cannot be separated from our country’s racist history. Thus, there are many areas outside healthcare requiring change for health outcomes to improve.

The responsibility for change is both individual and institutional. Examples of institutional changes were the 13th, 14th, and 15th Amendments. Though these provided a framework, the full fruition of these amendments remains to be realized, as described above. If hearts and minds do not change in parallel with institutional change aimed at eliminating disparities, or worse, if there is backlash, racist outcomes will persist. Individuals, including members of the OMA, must acknowledge that passive tolerance of racist outcomes or active resistance to institutional change will perpetuate disparities.

Our healthcare institutions, with sustained and unrelenting race-based outcomes, must acknowledge the role of structural racism. Structural racism in healthcare is not simply the sum of individual actions- these are not the main drivers of racially differentiated outcomes- but reflects racism incorporated into our professional institutions. Racism may not always be intentional, but it remains actively at work. Centuries of white domination produced a healthcare system that reflects white interests. Close scrutiny reveals that racist policies are embedded in our profession. Dismantling racism begins with individual self-reflection, yet primarily requires large-scale institutional change in policies including those affecting access to and delivery of health care. This may require including new voices when creating those health care policies. The OMA must provide leadership for institutional changes to be embraced. These changes must reduce or eliminate our racially differentiated outcomes to be considered successful.

As representatives of Oregon’s medical community, we commit ourselves to reversing the manifold health consequences of our country’s history of racism. The OMA cannot assume the associated guilt of centuries of racist oppression in society and medicine, but we must assume responsibility for change. We know that social inequities persist in American society. Therefore, the OMA will advocate for policies that improve the health of our communities and provide health care access to all races in order to mitigate and reverse these preexisting social inequities.

We as clinicians need to learn to see not only race, but the person beneath the surface. We need to work against the tendency to oversimplify people using stereotypes, either consciously or subconsciously. Deliberate suppression of racial awareness is not truly possible, nor is it useful. A racial lens exists in all of us, and it is best to be conscious of it. Race awareness is the first step toward generating equitable outcomes through our practice, profession, and institutions.

The OMA starts by publicly acknowledging the racially differentiated outcomes in health care and the impact of racism on health in our state; by increasing the awareness within our professional community that our own practices may inadvertently contribute to inequitable outcomes; by focusing on structures and policies within our institutions that determine who gets care, who pays for care, who delivers care, how healthcare resources are allocated, and who allocates those resources; and by accepting that significant change in outcomes requires significant change in our healthcare system, our government, our laws, and our practice.

We have the responsibility to focus on these problems, to contribute to finding solutions, and to help heal the harms done by racism. The OMA must advocate for the interests not just of our profession and our patients, but of our society.

Definitions/Terminology

Ally: “An ally is any person that actively promotes and aspires to advance the culture of inclusion through intentional, positive and conscious efforts that benefit people as a whole. Everyone has the ability to be an ally as privilege is intersectional -- white women can be actionable allies to people of color, men can be allies to women, cis people can be allies to members of the LGBTQ+ community, able-bodied people can be allies to those with different ability, economically privileged people can be allies to those who are not and so on.”¹¹⁸

Allyship: “A lifelong process of building relationships based on trust, consistency, and accountability with marginalized individuals and/or groups of people. Not self-defined -- work and efforts must be recognized by those you are seeking to ally with. An opportunity to grow and learn about ourselves, whilst building confidence in others.”²⁷²

Antiracism: “Active process of identifying and eliminating racism by changing systems, organizational structures, policies and practices and attitudes so that power is redistributed and shared equitably.”²⁷³

Antiracist: “One who is supporting an antiracist policy through their actions or expressing an antiracist idea.”²⁷⁴

Black vs. African American: We use the term “Black” to be inclusive of all those who experience current systems of racism against those with dark skin as this experience is shared by both those who are descended from enslaved Africans brought to North America and others who have more recently immigrated from African, Caribbean, and other countries. The term African American may be more appropriately applied to those who have been in this country for generations and who can often trace their roots to the enslaved people who helped build this country.²⁷⁵

Color blindness: “Civil rights leaders are quick to assure the public that when we reach a colorblind nirvana, race consciousness will no longer be necessary or appropriate. Far from being a worthy goal, however, color blindness has proved catastrophic for Black people…. Our blindness … prevents us from seeing the racial and structural divisions that persist in society: the segregated, unequal schools, the segregated, jobless ghettos, and the segregated public discourse -- a public conversation that excludes the current pariah caste…. We have become blind, not so much to race, but to the existence of racial caste in America.”¹¹⁸ While intention when aspiring for color blindness may have been good, the effect has been to be blinded to the impact of racist systems and implicit bias on the lives of people of color.

Implicit bias: “The attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control.”¹⁰⁹

Microaggressions: "The everyday verbal, nonverbal, and environmental slights, snubs or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership.”²⁷⁶

Public health issue: “For a health problem or condition to be considered a public health issue, four criteria must be met: 1) the health condition must place a large burden on society, a burden that is getting larger despite existing control efforts; 2) the burden must be distributed unfairly (i.e., certain segments of the population are unequally affected); 3) there must be evidence that upstream preventive strategies could substantially reduce the burden of the condition; and 4) such preventive strategies are not yet in place.”²⁷⁷

Racism: “A system of dominance, power and privilege based on racial group designations… where members of the dominant group create or accept their societal privilege by maintaining structures, ideology, values, and behavior that have the intent or effect of leaving non-dominant group members relatively excluded from power, esteem, status and or equal access to societal resources.” ²⁷⁸

Racist: “One who is supporting a racist policy through their actions or inaction or expressing a racist idea.”²⁷⁴

Social determinants of health: “Our health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be.”²⁷⁹

Source: Moreland-Capuia A. Training for Change: Transforming Systems to be Trauma-Informed, Culturally Responsive, and Neuroscientifically Focused. Springer; 2020

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Systemic Racism Workgroup Members

Jenny Silberger, MD

Fred Williams, MD

Monica DeMasi, MD

Olivia Fuson, Student

Amy Jones, Student

Dave Kinzie, MD

Larry Krupa, MD

Emily Lane, Student

Rowena Manalo, MD

Mollie Marr, Student

Samuel Metz, MD

Lillian Navarro-Reynolds, PA-C

Dana Parker, Student

Jim Reuler, MD

Reva Ricketts-Loriaux, DO

 

Consultants:

Leslie Gregory, PA-C

Gwendolyn Turner