Inequality is killing us—some of us more than others. David R. Williams, a professor at Harvard’s Chan School of Public Health and world-renowned researcher on the social determinants of health, studies just how racism and its intersection with class and gender have detrimental health effects. In a recent talk on “How Racism and Inequality Makes us Sick” at my home institution of Duke, he explained how racism impacts the health of people of color and the delivery of and access to quality care. As the discussion unfolded, Dr. Williams made reference to the 2003 Institute of Medicine Report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, on which he was a prominent committee member. Even though there is a greater awareness as to how racism is a public health problem, after 20 years not much has changed regarding its findings.1
Addressing racism in medicine and health disparities along racialized lines is a tall order, and even more so when placed in the context of larger social and systemic dynamics that directly and negatively impact health and human well-being. In the US, the prevailing fourth wave of public health introduced a focus on health as a social phenomenon.2 Within this paradigm, public health policy and practice are driven by a focus on social determinants of health (e.g. education, transportation, housing, access to medical care, access to technology, access to recreation, proximity to pollution, etc.). A fifth wave is focusing on systemic and upstream drivers of the social conditions in which we live that stifle health promotion and human flourishing, such as the role racism has played in shaping our common life. These, then, become the focus and targets for change.3 This paradigm recognizes that health can only be achieved through a culture of health—which emphasizes collective action in addressing these systemic drivers and a cultural reimagining of health, health equity, and our collective life together.4
So, what is the responsibility of medical schools and their hospital systems in the formation of professionals to address the negative effects of racism on their patients’ health outcomes and their ability to deliver quality health care to communities of color? Some clinical health care professionals may think this question is misguided. Even if they lament these conditions, they think the responsibility of addressing them lies outside their purview and expertise. After all, how can they, with the specialized training they’ve received, address such large-scale upstream drivers that stifle health and human well-being? This simply asks too much of medical professionals. Or maybe this asks too much of them alone.
I actually think that healthcare professionals, schools, and systems can make a contribution to addressing this colossal problem. It requires embracing and cultivating solidarity, a value and a virtue that is a hallmark of social ethics. As a firm commitment to the common good of all people, solidarity calls us to confront inequalities in health outcomes and advocate for the those on the margins.5
A commitment to solidarity requires both individual and communal introspection. Individually, solidarity “invites us to consider whether our own behaviors and mentalities demonstrate a concern with those on society’s margins.”6 Communally, “solidarity challenges us to ask whether the social organizations of which we are a part strengthen the bonds of human friendship, especially the bonds between those with and those without sufficient resources.”7 If our medical schools, health care institutions, and associated organizations are not doing this well, then we must seek systemic changes that improve our capacity to enable such relationships, especially since so much data points to the deleterious effects of racism on health care and health outcomes.
The cultivation of solidarity as virtue and a value in medicine and health care systems cannot be left to personal, familial, and communal contexts. As a social practice, medicine should take seriously the responsibility to form its professionals in ways that promote solidarity individually and communally.
The Duke University School of Medicine, where I serve, has entered into this space. I reference our program not so that it can be held up as “the” model for such work; rather, I highlight it because it is the context where I work and am trying to make a contribution. We have sought to implement systemic changes to dismantle racism and advance equity, diversity, and inclusion in the school of medicine, identifying five major areas of priority:
- Cultivate an anti-racist environment,
- Nurture, reward, and attract outstanding talent,
- Advance education and training to support an anti-racist workforce,
- Develop anti-racist equity centered and community engaged research practices, and
- Ensure sustainability by strengthening leadership capacity and organizational accountability.8
Each of these priorities have a number of action steps, guidelines, and dedicated committees to ensure the operationalization of these priorities.
Considering the systemic nature of the problem, ways forward require both individual and communal responses. The cultivation of the virtue of solidarity moves these efforts from being merely perfunctory gestures to fulfilling the ethical demands required of health justice. To be sure, this commitment requires leadership to incorporate these elements into its organizational structure and other processes related to its strategic initiatives. And it requires a level of reciprocity on the part of all working in these spaces to create and maintain a culture of health at the institutional level if we are to address upstream systemic drivers of health disparities. I think this can be done. These efforts are one medical school’s approach to nurture and embrace solidarity as a value and a virtue to motivate collective action towards health justice. That kind of medicine might just move us to a kind of healing we all need.
- Camila M. Mateo and David R. Williams, “Racism: A Fundamental Driver of Racial Disparities in Health-Care Equality,” Nature Reviews, (2021) 7:20, pp. 1–2.
- Sean A. Valles, Philosophy of population health: philosophy for a new public health era (New York: Routledge, 2018).
- S. C. Davies, E. Winpenny, S. Ball, T. Fowler, J. Rubin, and E. Nolte, “For debate: a new wave in public health improvement,” The Lancet (2014), 384(9957), 1889–1895.
- Patrick T. Smith and Jill Sonke, “When Artists Go to Work: On the Ethics of Engaging the Arts in Public Health, Hastings Center Report (Forthcoming).
- Brian Matz, Introducing Protestant Social Ethics: Foundations in Scripture History, and Practice (Grand Rapids: Baker Academic, 2017), p. 194.
- Ibid., p. 193.
- Dismantling Racism and Advancing Equity, Diversity and Inclusion in the School of Medicine, Duke University School of Medicine, June 2021. medschool.duke.edu/sites/default/files/2021-08/dismantling_racism_and_advancing_equity_diversity_and_inclusion_ADA.pdf.