Be Quick, but Don’t Hurry Toward ‘Anti-racism’

“We see the need for nonviolent gadflies to create the kind of tension in society that will help men rise from the dark depths of prejudice and racism to the majestic heights of understanding and brotherhood.”

—Martin Luther King Jr., “Letters from a Birmingham Jail,” 1964

As physician gadflies bring our attention to racism in medicine as a health care crisis, stewards of health care work quickly to address systemic racial health inequity. But systemic racism proves complex, since highlighting racism for people in power violates rules governing racial caste and challenges diversity and inclusion values central to medicine. While our resulting discomfort spurs us to respond expediently, we must also welcome and protect perspectives from stakeholders lower on systemic hierarchies, lest we exclude data essential to genuine anti-racist assessment.

Responding quickly within hierarchy usually means convening leaders proximal to power. For example, a hospitalwide increase in IV line infections compels senior leadership to convene a nimble anti-infection task force composed of clinical leaders. Clinical protocol and evidence inform target, scope, process, and intervention. Process measures like time to plan implementation and outcome measures like reduction in IV line infection define success. Existing structures beget corrective measures.

However, treating systemic racism like IV line infections might serve only to reinforce systemic racism. Hierarchy conceals racism. Its hidden enormity—evidenced by its uncommonly known but important history—means leaders underestimatethe requisite effort to achieve anti-racism. Action requires leadership to acknowledge that racism thrived unchecked on their watch. Anti-racism efforts have little precedent, so few proven anti-racist processes and interventions exist.

While any robust anti-racist effort will measure health equity outcomes systemwide, hurriedly approaching systemic racism exposes its problematic power dynamics. When leadership uses traditional approaches to systemic racism, they might exclude less powerful stakeholders in the name of expedience. No assessment of systemic racism is complete without the student, trainee, patient, and community perspectives revealing hidden and egregious racism datapoints. Often underestimated and discounted, less powerful stakeholders observe and suffer from systemic racism most often since they lack the power to counter transgressions. Once included, these vulnerable members of the organization must be protected from invalidation of their accounts and other retailation for speaking truth to power. Any ethical anti-racist process will provide these protections when soliciting these essential perspectives. Anything less guarantees systemic racism’s survival.

For example, in the 19th century, new medical diagnoses such as dysaesthesia and drapetomania framed profitable enslavement as protective and thus beneficial to slaves, thereby dissolving the cognitive dissonance between chattel slavery and American notions of dignity such as “all men are created equal.” In the 1960s, President Johnson blamed “the breakdown of the Black Family” for racial disparities in income and infant mortality.

Indeed, anti-racist efforts that exclude stakeholders may ultimately join this flight of racist ideas. Anti-racist trainings that focus on provider attitudes toward patient care and colleagues will appear anti-racist, improve outcomes, and ease discomfort in leadership. However, trainings alone overlook racism in other system contexts, including patient admission policies, hiring practices, and other, yet unknown areas. Over time, residual racism will mutate, spread, and eventually re-conceal itself in our denial.

To take our best step against its adaptations, we must not swat away gadflies or only salve their bites, but rather grow comfortable with racism so exposed. If health system leaders want to go fast toward “anti-racism,” they should go alone. If they want to go far toward authentic anti-racism, they should go with all stakeholders together. ■