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T wo weeks after a Staten Island grand jury decid-ed not to indict the police officer involved in thedeath of a black man, Eric Garner, I delivered a lectureon the potential for partnership between academia

and health departments to advancehealth equity. Afterward, a groupof medical students approached meto ask what they could do in re-sponse to what they saw as anunjust decision and in support ofthe larger social movement spread-ing across the United States underthe banner #BlackLivesMatter.They had staged “white coat die-ins” (see photo) but felt that they

should do more. I wondered whether others in the medicalcommunity would agree that wehave a particular responsibilityto engage with this agenda.

Should health professionals beaccountable not only for caringfor individual black patients butalso for fighting the racism —both institutional and interperson-

al — that contributes to poorhealth in the first place? Should we work harder to ensure thatblack lives matter?

As New York City’s health com-missioner, I feel a strong moraland professional obligation to en-courage critical dialogue and ac-tion on issues of racism andhealth. Ongoing exclusion of anddiscrimination against people of

African descent throughout theirlife course, along with the legacyof bad past policies, continue toshape patterns of disease distri-bution and mortality.1  There isgreat injustice in the daily vio-lence experienced by young blackmen. But the tragedy of lives cutshort is not accounted for entire-ly, or even mostly, by violence. In

New York City, the rate of prema-ture death is 50% higher amongblack men than among white men,according to my department’s vitalstatistics data, and this gap re-flects dramatic disparities in manyhealth outcomes, including cardio- vascular disease, cancer, and HIV.These common medical condi-tions take lives slowly and quiet-ly — but just as unfairly. True,the black–white gap in life ex-pectancy has been decreasing,2 and the gap is smaller among women than among men. Butblack women in New York City arestill more than 10 times as likely

as white women to die in child-birth, according to our 2012 data.Physicians, nurses, and public

health professionals witness suchinequities daily: certain groupsconsistently have much higherrates of premature, preventabledeath and poorer health through-out their lives. Yet even as researchon health disparities has helped

 #BlackLivesMatter — A Challenge to the Medical and PublicHealth CommunitiesMary T. Bassett, M.D., M.P.H.

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to document persistent gaps inmorbidity and mortality betweenracial and ethnic groups, there is

often a reluctance to address therole of racism in driving thesegaps. A search for articles pub-lished in the  Journal over the pastdecade, for example, reveals thatalthough more than 300 focusedon health disparities, only 14contained the word “racism”(and half of those were book re- views). I believe that the dearthof critical thinking and writingon racism and health in main-stream medical journals repre-sents a disservice to the medicalstudents who approached me —and to all of us.

The World Health Organiza-tion proclaimed in 1948 that“Health is a state of completephysical, mental and social well-being and not merely the absenceof disease or infirmity.”3  Today,both individual and social well-

being in communities of colorare threatened. If our role is topromote health in this broadersense, what should we do, bothindividually and collectively?Many health professionals whoconsider that challenge stumbletoward inaction — tackling rac-ism is daunting and often viewedas divisive and requiring action

outside our purview. I would liketo believe that there are at leastthree types of action through

 which we can make a difference:critical research, internal reform,and public advocacy. In reflect-ing on these possibilities, I addto nearly two centuries of callsfor critical thinking and actionadvanced by black U.S. physi-cians and their allies.

First, it’s essential to acknowl-edge the legacy of injustice inmedical experimentation and thefact that progress has often beenmade at the expense of certaincommunities. Researchers exploit-ed black Americans long beforeand after the infamous Tuskegeesyphilis study.4 But there is roomfor optimism. Over the past twodecades, for example, we’ve seen a welcome resurgence in social ep-idemiology and research docu-menting health disparities. Where-as stark racial differences in

health outcomes have sometimesinappropriately been attributedto biologic or genetic differencesin susceptibility to disease or badindividual choices, new methodsand theories are allowing for morecritical, nuanced analyses, includ-ing those examining effects ofracism. By studying ways in whichracial inequality, alone and in

combination with other forms ofsocial inequality (such as thosebased on class, gender, or sexu-al preference), harms health, re-searchers can spur discussionsabout responsibility and account-ability. Who is responsible for poor

health outcomes, and how can we change those outcomes? Morecritical research on racism canhelp us identify and act on long-standing barriers to health equity.

There is also much we can doby looking internally at our insti-tutional structures. Though theU.S. physician workforce is morediverse than it was in the past,and some efforts have been madeto draw attention to the value of

diversity for improving healthoutcomes, only 4% of U.S. physi-cians are black, as compared with 13% of the population, andthe number of black medicalschool graduates hasn’t increasednoticeably in the past decade.5 Renewed efforts are needed tohire, promote, train, and retainstaff of color to fully representthe diversity of the populations we serve. Equally important, weshould explicitly discuss how weengage with communities of col-or to build trust and improvehealth outcomes. Our target“high-risk” communities, oftencommunities of color, have as-sets and knowledge; by heedingtheir beliefs and perspectives andhiring staff from within thosecommunities, we can be moreconfident that we are promoting

the right policies. The converse isalso true. If we fail to explicitlyexamine our policies and fail toengage our staff in discussionsof racism and health, especiallyat this time of public dialogueabout race relations, we may un-intentionally bolster the statusquo even as society is calling forreform.

#BlackLivesMatter

University of Vermont Medical Students during a “Die-In” Protest.

   W   i   l   l   i  a  m   J  e   f   f  r   i  e  s ,

   P   h .   D .

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In terms of broader advocacy,some physicians and trainees maychoose to participate in peacefuldemonstrations; some may writeeditorials or lead “teach-ins”; oth-ers may engage their representa-tives to demand change in law,

policy, and practice. Rightfully ornot, medical professionals oftenhave a societal status that givesour voices greater credibility. Af-ter the grand-jury decision lastNovember not to indict the policeofficer who shot a black teenagerin Ferguson, Missouri, I wrote tomy staff noting that in this timeof public outcry, it is importantto assert our unwavering commit-ment to reducing health dispari-

ties. We can all do at least that.As a mother of black children,

I feel a personal urgency for soci-

ety to acknowledge racism’s im-pact on the everyday lives of mil-lions of people in the UnitedStates and elsewhere and to actto end discrimination. As a doc-tor and New York City’s healthcommissioner, I believe that

health professionals have muchto contribute to that debate andprocess. Let’s not sit on the side-lines.

Disclosure forms provided by the authorare available with the full text of this arti-cle at NEJM.org.

From the Office of the Commissioner, NewYork City Department of Health and MentalHygiene, New York.

This article was published on February 18,2015, at NEJM.org.

1. Krieger N. Discrimination and health in-equities. In: Berkman LF, Kawachi I, Gly-mour M, eds. Social epidemiology. 2nd ed.

New York: Oxford University Press, 2014:63-125.2. Harper S, MacLehose RF, Kaufman JS.Trends in the black-white life expectancy gapamong US states, 1990-2009. Health Aff(Millwood) 2014;33:1375-82.3. Preamble to the constitution of the WorldHealth Organization as adopted by the Inter-national Health Conference, New York, 19-

22 June, 1946: signed on 22 July 1946 by therepresentatives of 61 States (official recordsof the World Health Organization, no. 2, p.100) and entered into force on 7 April 1948(http://who.int/about/definition/en/print.html).4. Washington HA. Medical apartheid: thedark history of medical experimentation onblack Americans from colonial times to thepresent. New York: Doubleday, 2006.5. Diversity in the physician workforce:facts & figures. Washington, DC: Associa-tion of American Medical Colleges, 2014(http://aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce/).

DOI: 10.1056/NEJMp1500529

Copyright © 2015 Massachusetts Medical Society.

#BlackLivesMatter

The New England Journal of Medicine

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