A System of Fear

by Stephen C. Nelson, MD

In addition to training and consulting with Hackman Consulting Group, Stephen Nelson is currently a physician specializing in the treatment of Sickle Cell Disease at Children’s Hospital in Minneapolis, MN. Dr. Nelson received a Bush Fellowship in 2009 to study the role of racism in the treatment of patients with Sickle Cell Disease, and regularly trains and presents on racism in medicine, provider bias, and transforming racial disparities in health care.

As I listen to conversations about the events surrounding the homicides in Ferguson and Staten Island at the hands of the police, I am struck by some similarities that I encounter in healthcare. Too often, it appears we get stuck on single, isolated incidents at the expense of appreciating the “big” picture. By focusing on individual acts, we lose sight of broader systems that may be affecting these individual acts.

I was especially disheartened to hear a particular conversation on NPR on the way home from work the other evening. I was listening intently to the interview on December 5th with civil rights attorney Constance Rice on how she built trust with police. I was particularly frustrated to hear her say:

“Cops can get into a state of mind where they’re scared to death. When they’re in that really, really frightened place they panic and they act out on that panic. I have known cops who haven’t had a racist bone in their bodies and in fact had adopted black children, they went to black churches on the weekend; and these are white cops. They really weren’t overtly racist. They weren’t consciously racist. But you know what they had in their minds that made them act out and beat a black suspect unwarrantedly? They had fear.”

I was frustrated to hear her use the word” racist” when talking about these individual white cops. This makes racism an individual act and not a broader system of oppression. What I believe she really meant to say was that these white cops were not prejudiced. By focusing on the individual police officers, she failed to acknowledge the systems of racism and white supremacy in our society that led these police officers to fear black men. I absolutely believe that many white cops fear black men. But, she didn’t discuss why this is true.

White people are scared of black people. Just admit it. We are. We are not proud of it.

This is how we were raised. This is how we were taught. This is “just the way it was”, especially in the South, especially in Virginia where I grew up in the 60s and 70s. But this miseducation didn’t stop in the 60s and 70s. It continues today.

So, if I am honest with you I will say that I still have some fear of black people. Think about it… Use the “dark alley” scenario, or “walking down the street alone” and you hear foot steps behind you. Are you relieved in either situation when you realize the person behind you is white?

As with many of us, we learn this fear at a very young age. For me, it was when our family was in Atlanta visiting friends. I had finished 7th grade. It was the summer of 1973. Dad got tickets for us to see the Atlanta Braves play the New York Mets. He was especially excited because Tom Seaver was pitching for the Mets that night. We were driving to Fulton County Stadium and some neighborhood children had placed a detour sign to force traffic down their street. The goal, as I discovered, was to give you directions to the parking lot and then ask for money. When we turned down that dark street, my mother reached around and locked all of the doors to the car. She was afraid. So I was afraid. The boys giving us directions were black. We were in an all black neighborhood at night in Atlanta in 1973. It was subtle. It was very quiet. But, it reinforced a feeling deep inside me that I carry to this day. I was to fear black people.

We have a college friend who apparently does this a lot. Every time she would lock her car door her husband would ask “Did you see a black person, Linda?” My husband Peter and I would start asking each other the same question if we locked our door. “Did you see a black person, Linda?” We’d ask friends or family when they locked their car door “Did you see a black person, Linda?” We thought it was funny. This was before I started recognizing my white privilege, before I started to understand how racism really works in our society, and before I began to look at my world with a critical race lens to see, to really see how people of color are treated in our country.

This fear is now automatic. Thanks to the ingenuity of the American automobile industry, we don’t have to think about it anymore. Our car doors lock automatically. Sure, this is for our own safety, right? Or is it so we don’t have to ask “Did you see a black person, Linda?”

This fear is ingrained. It is automated. It is immediate. It is engaged even if we are not conscious of it. We don’t have to do anything to make it happen. It just does. Just like my car doors locking; my stereotyping, bias, and fears play out automatically. Sometimes I’m aware of this, and sometimes I’m not.

Stereotyping, unconscious bias, and fear have affected, in such profound ways, the care that I have given to my patients and families of color. Like my car doors, I was unaware. It just happened. I never even noticed it.

Turns out, my patients and families noticed. How do I know this? Dr. Hackman and I asked. Race matters. Race and racism affect the delivery of health care. To learn more you can read our manuscript published last year: “Race matters: Perceptions of race and racism in a sickle cell center.” Pediatr Blood Cancer 2013;60:451–454 as well as our chapter “Dismantling racism to improve health equity” in Health Disparities: Epidemiology, Racial/Ethnic and Socioeconomic Risk Factors and Strategies for Elimination. Nova Publishers, New York, 2013, Chapter VI, 147-160.

Physicians and health care providers, for the most part, are good people. We go into medicine to give quality care and to help patients and families. We like to think that our healthcare system somehow functions in a vacuum, outside of our highly racialized society. We are not taught how the structure and systems of our society (racism) affect the social determinants of health such as poverty, education, incarceration, homelessness, unemployment and insurance. The disparities seen with these social factors in people of color are partly to blame for the profound racial health inequities seen in the United States.

Some of the blame also lies with us, the healthcare system itself. We are overwhelmingly white. According to 2010 U.S. Census data, Minnesota is now 5.2% black and 4.7% Latino/Latina. However, of the 13,083 licensed physicians in Minnesota only 261 are black and 313 are Latino/Latina. The numbers are even more disparate when looking at the nursing workforce. Of the 57,639 RNs in Minnesota, only 105 are black and 30 are Latino/Latina. And, of the 220 graduates from the University of Minnesota Medical School in 2013, one was black.

The education and miseducation I received growing up that led to my fear of blacks was not very different from my medical education. Who teaches us in medical school? Whites. Only 4% of American medical school faculty are from under-represented minorities (black, Latino, Native American). What are we taught? Evidence-based protocols developed by majority white researchers, using majority white patients, carried out by the majority white health care system.

What are we not taught? We are not taught about the social determinants of health and how racism affects these as well as health outcomes. We are not taught to see our own unconscious biases and stereotyping.

Just as police officers may fall prey to their own biases, stereotyping and fears; so too may the health care provider. In both cases, the result may be deadly for people of color. While the presence of more significant training for providers regarding racism may help to lessen the racial disparities in health care, the opposite is also true. The absence of substantial training on issues of race and racism will serve to perpetuate and potentially exacerbate racial health care disparities. Until racial issues are honestly addressed by the health care team as well as the judicial system, it is unlikely that we will see significant improvements in racial disparities for Americans.

Fear is real. But, we can lose it.

Here’s wishing for a less fearful and more joyful 2015 for all of us!

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