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The Syndemic of Racism and COVID-19 and Its Implications for Medical Education Joshua Freeman, MD

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The Syndemic of Racism and COVID-19 and Its Implications for Medical Education Joshua Freeman, MD COMMENTARY Something Old, Something New: The Syndemic of Racism and COVID-19 and Its Implications for Medical Education Joshua Freeman, MD (Fam Med. 2020;52(9):623-5.) doi: 10.22454/FamMed.2020.140670 wo seismic issues, racism and COVID-19, African Americans, have far higher rates of have engaged the United States in the most chronic diseases, which makes them more last several months, acting together to vulnerable both to becoming infected and for T 1— create what is known as a syndemic a set of worse outcomes when infected. Even before linked health problems that interact synergis- COVID, African Americans had mortality rates tically to contribute to excess burden of dis- much higher than those of Whites, particularly ease in a population—that seriously impacts for the most common chronic diseases: diabe- the health of all of us. Racism is old; it has tes, cancer, heart disease, and stroke.5,6 always been a defining characteristic of our People of color are not more vulnerable, and country. Triggered by episodes of police kill- do not have more chronic disease as a result ing of people of color, particularly the murder of genetics or biology.7 The genetic variation of George Floyd, we have seen extraordinari- among people of the same race is at least 10 ly broad discussion about it. The Black Lives times that between races.8,9 The true causes Matter movement reminds us of the history of of population health disparity are collectively racism in the United States, from slavery, to known as the social determinants of health lynchings and Jim Crow segregation, to mass (SDH): factors such as adequate housing, food, incarceration (the “New Jim Crow”2), and the income, and education, to provide the basis inequity that begins at birth for every Black for a reasonably healthy life. In the United child as a result of the social constructs of race States, racism is a major SDH. People of color and racism. are overrepresented at lower socioeconomic COVID-19 is new, the biggest world-wide levels; Black families have an average wealth pandemic at least since the 1918 influenza of less than 10% of that of White families.10 pandemic. While it started in China, the Unit- Chronic stress is a critical outcome of the SDH, ed States has become the world epicenter of whether from worrying about whether you can the disease with the most cases and deaths feed or house your family, or from fear that (over 5 million cases, more than a quarter you, or your spouse, or your children, may be of all those in the world, and nearly 200,000 killed or jailed at any time, when simply walk- deaths as of this writing).3 As everywhere, ing down the street or driving your car can the disease has hit the poorest, sickest, and put you in danger.11 Racism has placed people most vulnerable communities the hardest; in of color, over generations, in the situation of the United States that has meant minorities, in whom the infection rate is at least twice 4 From the Department of Family and Community Medicine, that of Whites. The causal virus SARS-CoV-2 University of Arizona College of Medicine, Tucson, AZ; and does not discriminate, but the society in which the University of Kansas School of Medicine, Department it occurs does. People of color, and especially of Family Medicine. FAMILY MEDICINE VOL. 52, NO. 9 • OCTOBER 2020 623 COMMENTARY having worse SDH. This makes them chroni- from basic science lectures to clinical rounds to cally less healthy, more likely to have chronic the informal or hidden curriculum. Seminars disease, less likely to have adequate health addressing unconscious bias are good, but we insurance, and more susceptible to the effects must have zero tolerance for conscious bias, ca- of a pandemic such as COVID-19. It is this sual racism, and comments about people and impact that creates and perpetuates the cur- false assumptions about populations, just as rent syndemic. we should for sexual harassment. We must em- While SDH have a huge impact on the pres- power those who challenge such statements or ence and severity of disease, medical outcomes behaviors, and protect them, even when it is are often tied to access to treatments impacted the most junior student challenging the most by the quality of a person’s insurance. A uni- senior attending. Why do we teach students to versal single-payer health insurance system open their presentations with race: “The pa- would obviate that disparity, because everyone tient is a 53-year-old Black male”? In general, would be covered, and when everyone is in the most references to race are inherently racist. same system everyone has access to the same They certainly are never “just a joke.” options for diagnosis and treatment. The performance of our medical schools and Medical education also occurs within this academic health centers should be evaluated racist reality. LaShrya Nolen, a medical stu- on how they actually perform in four key ar- dent writing in the New England Journal of eas: Medicine, uses the fact that early Lyme dis- ease only appears as the characteristic bulls- 1. Diversity: Does the school produce a eye lesion of erythema migrans on white skin health workforce that looks more like to suggest that the failure to recognize it may America by enrolling and supporting a cause later diagnosis and a greater likelihood group of students that is truly diverse in of advanced Lyme disease in people of color. ethnicity, gender, socioeconomic status, and More importantly, she makes the general point geographic origin? that “normal” is consistently assumed to be 2. Social determinants of health: Does the “White”.12 Recently, the practice of adjusting school teach and carry out programs estimated glomerular filtration rate levels for aimed at addressing the SDH? Does it African Americans has been questioned, and a require every patient presentation to ad- number of major hospitals have abandoned it.13 dress the SDH equally with the traditional Several recent articles address the continuous medical content? Do students make home experience of racist and derogatory comments visits to understand first-hand the con- from physicians and patients alike, the pre- text of people’s lives? How much student sumption of a greater likelihood of self-destruc- training occurs in community and primary tive behaviors by members of minority groups, care settings? and the degree to which such comments are 3. Disparities: Through its programs of edu- often not only unchallenged but assumed to cation and community intervention, and be normative.14-18 its research agenda and practice, does the One paper in particular, from a group of school explicitly work to reduce disparities medical students, provides an outstanding in health care and health among popula- review of both the deep roots of racism in tions? Do its graduates practice in spe- medicine and the current practice in medical cialties and areas of need, and thus help education of using race to create shortcuts and reduce health disparities? heuristics that are frequently wrong, as well as 4. Community engagement: Does the aca- racist. The authors succinctly state that “The demic health center clearly identify the imprecise use of race—a social construct—as community it serves? Does it involve the a proxy for pathology in medical education is a community in determining the location of vestige of institutionalized racism,” and make training, the kinds of programs it carries a number of suggestions for amelioration.19 out, and in identifying the questions that Additional curricular strategies for addressing need to be answered by research? racism in medical education can also be found in the Family Medicine special issue from Jan- These changes are not going to happen easi- uary 2019.20 ly, quickly, or without offending anyone. Indeed, For medical education to successfully ad- it is quite possible that they will not happen, dress racism, it must start by examining ev- or not happen as broadly and deeply as they ery area in which teaching and learning occur, need to, if left to the same people who have 624 OCTOBER 2020 • VOL. 52, NO. 9 FAMILY MEDICINE COMMENTARY been running the existing medical education 10. Hansen S. Here’s What The Racial Wealth Gap In America system. They strike at the heart of our tacit Looks Like Today. Forbes. June 5, 2020. https://www.forbes. com/sites/sarahhansen/2020/06/05/heres-what-the-racial- assumptions of normal. But normal is not the wealth-gap-in-america-looks-like-today/#5f0667c0164c. same as adequate. To achieve health equity, Accessed September 1, 2020. and a healthy and safe society, we all need to 11. Derrick CB. Sirens: 4 decades of harassment by the police. take this on, students, faculty, and patients. Guernica. July 27, 2020. https://www.guernicamag.com/ sirens/. Accessed September 1, 2020. We need to take it seriously, and take it to 12. Nolen L. How Medical Education Is Missing the Bull’s- the limit. eye. N Engl J Med. 2020;382(26):2489-2491. doi:10.1056/ NEJMp1915891 CORRESPONDENCE: Address correspondence to Dr Joshua Freeman, [email protected]. 13. Zoler ML. Dropping Race-Based eGFR Adjustment Gains Traction in US. Medscape. July 6, 2020. https://www.med- scape.com/viewarticle/933418. Accessed September 1, 2020. References 14. Tweedy D. Medical Schools Have Historically Been Wrong 1. Merrill S. Introducing Syndemics: A Critical Systems Ap- on Race. New York Times. July 27, 2020. https://www. proach to Public and Community Health. San Fracisco: nytimes.com/2020/07/27/opinion/sunday/coronavirus-med- Jossey-Bass; 2009: 304.
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