A Black Physician’s Analysis Of The Legacy Of Racism In Medicine

JOHN DANKOSKY: This is Science Friday. I’m John Dankosky.

KATHLEEN DAVIS: And I’m Kathleen Davis Uché Blackstock always knew that she wanted to be a doctor. Her mother was a physician at Kings County Hospital in Brooklyn. Uché and her twin sister Oni would often visit their mother at work, seeing her in action taking care of patients. And they loved to play with their mother’s doctor’s bag.

And later, Uché and Oni became the first Black mother-daughter legacies to graduate from Harvard Medical School. In her new book, Dr. Blackstock reflects on this legacy and grapples with the long history of racism in American medicine. Dr. Uché Blackstock is an emergency physician, founder and CEO of Advancing Health Equity, and author of Legacy– A Black Physician Reckons with Racism in Medicine. She is based in Brooklyn, New York. Dr. Blackstock, welcome back to Science Friday.

UCHÉ BLACKSTOCK: Kathleen, thank you so much for having me. I’m excited to be back.

KATHLEEN DAVIS: Thank you so much for being here. You write so lovingly about your mother. Tell me more about what you learned about medicine from her.

UCHÉ BLACKSTOCK: Well, I refer to her as the original Dr. Blackstock. I had a very unusual childhood in that my mother was a Black woman and that she was a physician, but she also really left a huge impact on both my twin sister and me. She grew up here in Central Brooklyn, where I live, but under very different circumstances.

She was born to a single mom. My mom also had about five other siblings and was raised on public assistance. So she had a really, really difficult life. But with some fortune, determination, strong work ethic, she ended up being the first person in her family to graduate from college, attended Brooklyn College, had a chemistry professor there who encouraged her to apply to medical school.

And she ended up at Harvard Med. And she could have gone anywhere after that, but she came back to Central Brooklyn, worked in a city hospital and state-run hospital here, essentially taking care of her neighbors, friends, and family. And so growing up, that was my influence. And she also did some work with local Black women physicians, community health fairs, diabetes screenings, doing what we call health equity work at a time in the ’80s and ’90s when it really didn’t have that expression or term that was used.

KATHLEEN DAVIS: Your mother was diagnosed with a form of leukemia, and she passed away at the age of 47. And in your book, you write people often talk about going to war or the fight to combat the disease. But we hear less about how the war and fight a person endures before they get visibly sick may have contributed to a physical diminishment of the body. This really made me think about cancer and disease in a way that I hadn’t before. Can you expand a little bit on this?

UCHÉ BLACKSTOCK: I think, especially in my mother’s situation, she was someone who took amazing care of herself. She ran daily. She started running in medical school, and she’d run like two marathons.

KATHLEEN DAVIS: Wow, incredible.

UCHÉ BLACKSTOCK: Yeah, she’s this very, very disciplined woman. But in thinking about and doing the research for this book, why she was diagnosed at 46 with this disease that really doesn’t usually impact Black women and then died at 47 after a brief battle with it, and I look back. And many of the neighborhoods that my mother grew up in were superfund sites.

So there were sites where there was toxic dumping. When we took her for a second opinion to Dana Farber Institute, the oncologist actually said it looks like your chromosomes– it’s like you’d been exposed to radiation at some point early on in your life.

KATHLEEN DAVIS: Wow.

UCHÉ BLACKSTOCK: This idea that it’s very likely that whatever it was brewing in my mom’s blood cells for a while, and it had me really thinking about environmental racism. We know that toxic dumping and other sorts of associations with environmental racism occur often in Black communities, and they impact health in ways that we don’t really know.

KATHLEEN DAVIS: And I want to talk about that in just a moment. But I’m curious, did your understanding of your mother’s life and career change as you got older?

UCHÉ BLACKSTOCK: Yes, it did. My sister and I we were only 19 years old when she died. We were sophomores in college. And so really, when I was writing the book and now a mother, I’m now a full-fledged physician I had a career in academic medicine that I left because I didn’t feel like I was in an environment where I could thrive. I actually felt like I was silenced as a Black woman faculty.

And thinking about the conversations that I would have had with my mom if she was still alive. I always thought she was an amazing woman. I was always incredibly impressed by her but more so now, carrying all these different roles that I carry, like, wow, not only was she amazing.

But I wish she could have given herself a little bit of grace. I wish the road could have been easier for her. I wish that she didn’t have to work so hard to get to where she was– where she ended up. And I wish she could have lived longer to see the fruits of her labor.

KATHLEEN DAVIS: In the book, you detail how structural racism operates in medicine. How are racial health inequities overlapping but also distinct from factors like geography or income?

UCHÉ BLACKSTOCK: A lot of times, what I like to use is, for example, something like redlining. Redlining policies– a policy that came out of the 1930s as part of the New Deal, what it actually led to was neighborhoods being graded A, B, C, or D based on who lived in those neighborhoods, what the racial and ethnic composition was.

And if you lived in a neighborhood that was white and affluent, you got an– it was an A grade, and so you were likely, if you applied for mortgage or mortgage insurance that was federally backed, you were more likely to get it than if you lived in a D neighborhood that was mostly racial and ethnic minorities.

I use that example because when we look at formerly redlined areas, those areas today are the same areas that have the very worst health outcomes, have the highest maternal and infant mortality rates, the highest asthma rates. And when you look at it, these are neighborhoods that have been essentially chronically disinvested in because, when you have discriminatory housing policies, where people are not able to purchase property, they can’t build generational wealth.

We know that property taxes go towards schools, so we know that actually inhibits the quality of education within schools. We know that businesses don’t want to come there because people don’t have income to spend. If businesses don’t come, jobs don’t come.

And so we call all of those the social determinants of health, and systemic racism is, really, a key determinant of those. And so that’s why we still– that’s why we see today, almost 100 years later after these policies went into effect, we see them accounting for a large part of the health inequities that are currently present in our country.

KATHLEEN DAVIS: You mentioned maternal health. I want to circle back to that. We hear a lot of statistics about maternal health, about how Black women are much more at risk for complications than their white counterparts. As a physician, who I’m sure was well aware of these stats, how did that affect how you approached your own pregnancies and birthing experiences?

UCHÉ BLACKSTOCK: I have to say, for me, being pregnant both times was incredibly anxiety provoking because the stats that I knew about. A stat that I often share is like even me, with my Harvard undergrad and medical degree, I’m still five times more likely to die of pregnancy-related complications than my white peers. The people would say, why is that the case? You have access to great insurance. You have access to great doctors. But then I think it’s important to bring up the conversation of there’s several factors.

One, we know that– and I write about this in the book. We know– and we have data that when Black patients go seek care, often their concerns are ignored or dismissed, unfortunately. We’ve seen that implicated in even someone like Serena Williams, who is the greatest athlete of all time.

She went through this experience of where she had a previous blood clot. In her second pregnancy told them that she was having symptoms similar and, unfortunately, was not listened to. And that blood clot then embolized. It moved to her lungs, and she could have died.

And so that’s one piece of it, where we see that Black patients are just not listened to as much. And that is we call implicit bias because I think health professionals would want to say, no, I treat every patient with respect. And I listen– I give every patient my best care in terms of listening. That’s not always happening. The other piece of it is the impact of everyday racism that actually professional level of attainment or educational level doesn’t protect Black birthing people from.

And so there’s a term called weathering that the public health researcher Arline Geronimus talks about how the stress of either living in poverty or the stress of everyday racism causes a wear and tear on people’s bodies that actually ages them prematurely and makes them more susceptible to developing disease, or delivering their babies earlier, or having complications. And so when looking at rates like the Black maternal mortality rate, we have to think about how all those factors really inform the statistics that we’re seeing today.

KATHLEEN DAVIS: One of the things that some people say will result in a really positive birthing experience are doulas or midwives, and I want to touch a little bit on some medical history. I learned reading your book that there was once a group of highly trained Black midwives in the US. Can you tell me a little bit about that and also why that changed?

UCHÉ BLACKSTOCK: For a very long time in this country, midwives or birth workers were the ones that performed deliveries. They were primarily the health care providers, and obstetric gynecologists were not as involved. And we had what we called the granny midwives in the South that actually would go door to door and help people deliver babies, both Black and white. And we know that, even in the early 1900s, we had data that midwife-mediated deliveries had very positive outcomes.

But what happened in the early 1920s was an act called the Sheppard-Towner Act. And essentially, w that did was a campaign essentially that portrayed midwife care as being unsanitary and unhygienic and associated with worse complications of the birthing process. And what it also did was it forced midwives to have to fulfill certain, more regimented criteria and licensure to become midwives.

And so what that did actually was it erased the number of Black midwives because we know at that time Black midwives did not have the same access to educational spaces as white midwives. But it also led to the decrease in white midwives as well. And it medicalized the whole birthing process because it portrayed obstetrics gynecologists, who were mostly white men at the time, MDs, to be the ones that should be the chosen health care provider for deliveries.

And so fast forward to 2024, we’ve seen, really, an increase in the number of birthing centers as people have become more informed about this issue and don’t want in-hospital delivery. They want it either at a birthing center or at home because we know that’s correlated with better outcomes. We also know that having a doula, someone who is specially trained but to help support the birthing person, can also have very, very positive outcomes and help lead to a decrease in complications during the delivery process.

KATHLEEN DAVIS: Only 5.6% of physicians in the US are Black, but about 12% of the population is Black. You point in your book to the Flexner Report, which was published in 1910, as part of the reason for this disparity. Tell me a little bit about this report and why it had such a profound effect.

UCHÉ BLACKSTOCK: My goal for this book was to help people connect the dots to why we’re seeing the numbers we see today. And the Flexner Report was a report that was actually commissioned by the American Medical Association, which is the oldest and largest association of physicians and actually has its own history, troubled history, with bias and racism. But the AMA and Carnegie Foundation commissioned a man named Abraham Flexner, who was an educational specialist, to do an assessment of all 155 US and Canadian Medical schools.

And just so people know a context, Abraham Flexner, he in his writings believed that Black students, Black people were inferior. So that probably also informed his recommendations. But essentially, he went around to all of these medical schools and compared them against the standard, which were Western European schools and US Johns Hopkins.

And so he was looking at the number of physician scientists at the schools, the laboratory facilities, the admissions criteria. So it led to the closing actually of a number of medical schools. But at the time, there were only seven historically Black medical schools, and those were the medical schools that were training essentially all of the Black physicians. At that time so it led to the closure of five out of seven of those schools and leaving behind Howard and Meharry, which still put out the most number of Black medical students to this day, Black physicians, rather, to this day.

But it’s estimated that– in a study that was actually published in the Journal of American Medical Association, if those schools had not closed, they would have educated between 25,000 and 35,000 Black physicians.

KATHLEEN DAVIS: Wow.

UCHÉ BLACKSTOCK: And when you think about that number, I actually cried when I read that report because I thought about the tremendous loss to our communities, not just in the number of physicians but the number of patients that could have been cared for, the research that could have been done, the students and trainees that could have been mentored. And so I thought it was really important to talk about this report in Legacy so that people really understand that policies from the 1910 actually can impact the numbers that we see today.

KATHLEEN DAVIS: As we’ve talked about, so much of this discrepancy and these inequities are just baked in. What needs to change in the education of the next generation of doctors? What are your recommendations?

UCHÉ BLACKSTOCK: So obviously, we need to think about how medical schools are training medical students and to make sure that we’re talking about the history. We are addressing how it’s being taught because, either explicitly or implicitly, there is this notion that Black bodies are somehow different biologically. And we learned that about kidney function, about lung function.

So we really need to tease out these myths that are deeply, deeply rooted in our system. So that’s one thing, looking at the curriculum and how our students are educated. We also need our faculty to receive continuing education about these issues. A lot of times, the students know more than the faculty.

And I think, for health systems and hospitals, they need to have standardized protocols and policies for tracking these health metrics to make sure that patients are not being treated differently, that there aren’t, for example, different prescribing habits for pain medications by health professionals, so tracking that in real time and then also intervening as necessary. And finally, I actually make a call to action in the last chapter to policymakers that think about health in all policies.

Health is not just about health care. So yes, we want everyone to have access to quality health care and culturally responsive health care. But also we want to think about education, employment, access to healthy foods and green space, what we call the social determinants of health. So investment in those two will also make people even healthier.

KATHLEEN DAVIS: Doctor Blackstock, thank you so, so much for this conversation. I really appreciate you being with us.

UCHÉ BLACKSTOCK: Thank you so much for having me.

KATHLEEN DAVIS: Dr. Uché Blackstock, emergency physician, founder and CEO of Advancing Health Equity, and author of Legacy– a Black Physician Reckons with Racism in Medicine. She is based in Brooklyn, New York.

If you’ve enjoyed this conversation, you can keep it going by joining the Science Friday Book Club. Legacy is our book club pick for next month. So go to sciencefriday.com/legacy to find out more and to read an excerpt of the book.

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