- Structural Racism and Practices of Reading in the Medical Humanities
The notion that race is biological has been exhaustively refuted in both the humanities and the social sciences, and over the past two decades increasing numbers of scientific and medical experts have joined the attack. In 2000, the Human Genome Project (HGP) was applauded for providing definitive evidence that race has no biological foundation. Around the same time, medical journals called for increased scrutiny, if not outright dismissal, of racial classification and profiling in the clinic and in research.1 Yet even as race has been delegitimized by these authoritative voices, its use in the clinical setting is still common, with rationales ranging from its adequacy as a tool for categorizing people to the exigencies of prescribing race-based pharmaceuticals.2 It is also still alive in the well-documented conscious and unconscious forms of race bias that play out in clinical interactions. In its less-recognized incarnation, biological concepts of race that reigned in earlier decades persist in how medicine conceives of the organs and disorders of African Americans as differing from those of other groups.3 Science’s delegitimizing of race has not, in other words, brought an end to race’s life in medicine, where its continued presence has material effects on how people of color are diagnosed and treated.
In the late 1990s and early 2000s, health care responded to problems of bias by issuing cultural competency guidelines. Medical school education boards followed suit, issuing their own sets of objectives for a cultural competency skill set that would counteract “evidence of racial . . . disparities in health care.”4 Such skills are intended to help medical school students understand that patients of diverse cultural backgrounds “perceive health and illness and respond to various symptoms, diseases, and treatments” differently, and to “recognize and address gender and cultural biases in health care delivery” toward the goal of improving [End Page 25] physicians’ interpersonal skills with patients of diverse backgrounds.5 Yet for all their noble intentions, cultural competency courses and the skills they aim to impart do not get at the root of racial disparities in health care—that is, structural racism. Racism is not simply enacted in select interpersonal interactions; it is inscribed in the institution of medicine, and no amount of re-training individual physicians will fix an institution. Additionally, when we examine whether cultural competency curricula are achieving their stated goals, it is hard to see their effect. As John Hoberman argues, there is little evidence that cultural competency courses have been ubiquitously integrated into medical school curricula; there is less evidence that such courses are having an effect on the culture of medicine; and there is no evidence they are reducing students’ bias.6 Perhaps most significantly, cultural competency courses do nothing to enlighten physicians-in-training about structural racism, which causes the very diseases and conditions they observe in their patients.
What role have the medical humanities and narrative medicine fields played in this situation? In general, the fields have promoted a pedagogical agenda based on “fixing” poor interpersonal skills through engagement with discrete literary works. Hoberman, for one, has vociferously criticized both the privileging of the single work and the aim of fostering identification, asserting that this approach should be replaced with sociological or anthropological analyses that illuminate social context.7 This article argues instead that literary studies (and the study of single works) do have a place within an anti-racist medical humanities and narrative medicine practice, provided the fields shift toward methods of interpretation that foster structural competency.8 An idea elaborated by Jonathan Metzl and Helena Hansen, structural competency recognizes that bias in the clinic derives from the stereotypes and stigmas health care professionals learn from the culture at large, stigmas that are themselves the product of structural racism. In other words, “stigmas are not primarily produced in individual encounters but are enacted there due to structural causes,” and so it “follows that clinical training must shift its gaze from an exclusive focus on the individual encounter to include the organization of institutions and policies . . . if clinicians are to impact stigma-related health inequalities. . . . [M]edical education needs...