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Ethics Talk: Hacking Structural Racism in Health Care

Learning Objectives
Identify key ethical values or principles at stake, as described in the program
0.25 Credit CME

In this video edition of Ethics Talk, journal editor in chief, Dr Audiey Kao, talks with organizers of MIT Hacking Racism in Healthcare about design thinking as a way to find solutions to combat structural racism and advance health equity.

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.25 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.25 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.25 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.25 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Video Transcript

Audiey Kao: Hello and welcome! I'm Audiey Kao, Editor in Chief of the AMA Journal of Ethics. Thank you for joining us for this episode of Ethics Talk. I'm here with Harriet Washington, a noted ethicist and author of Medical Apartheid: The Dark History of Experimentation From Colonial Times to the Present, which won a 2007 National Book Critics Circle award for nonfiction. Ms. Washington is a writing fellow in bioethics at Harvard Medical School and also a fellow of the New York Academy of Medicine. Today, we will be talking about the impact of environmental racism on health during this COVID-19 pandemic and beyond.

Harriet, thanks for being a guest on Ethics Talk.

Harriet Washington: It is my deep pleasure. Thank you, Audiey.

[music slowly fades away]

Kao: So, the COVID-19 pandemic has further exposed racial and ethnic inequities in health. And it's just the latest example of what you have described as environmental racism. Can you explain to our audience what you mean by environmental racism?

Washington: If you ask 10 people for a definition, you'll get 10 different definitions. I look on it quite simply: it is nothing more than the disproportionate exposure of people of color in this country to noxious substances, in particular industrial chemicals, heavy metals, pathogens, even vermin. All these things have a direct bearing on human health. All of these things either foster disease outright, or they increase one's vulnerability to disease. And frankly, the policies of this country like segregation, which is still very much in effect, and housing discrimination, economic biases, and just utter frank racial biases have served to heard people of color into areas that become sacrifice zones where they're bombarded with these exposures.

My book focuses on, unlike other works on the subject, my book focuses on the cognitive effects: how this exposure affects intelligence, brain development, neurological problems. It's quite profound. The evidence is increasing at a prodigious rate. And we're learning more and more about how much these horrible ailments and how much cognitive and psychiatric problems owe to disproportionate environmental exposures.

Kao: So, given that description, what do you see as the role of health professionals in advancing environmental justice?

Washington: The role of health professionals has always been very important. They are the sentinels. They are the ones equipped and trained and with the desire to identify potential sources and actual sources of poisoning, and to insist upon governmental action, industrial action. In the early days of public health, organized public health in this country, was universities and public health institutions that would confront industry, would confront government, and say, “This is a nexus, a node of disease. You have to do something about it. It's got to be eliminated.” But more recently, public health is focused upon approaches to personalized responsibility, which is important but isn't terribly useful in the sphere where individuals have almost no power to change their exposures.

But medical intervention is even more important. Now, it's critical because in my opinion, the government has largely abdicated its responsibility. One cannot expect corporations to safeguard the public health when it runs contrary to the bottom line. It's a capitalist society, you know, and they're simply not, can't expect government—it's great when they do—but you can't expect corporations to spend money they don't have to spend, lose profits they don't have to lose in order to protect human health. But that is government's role. That is what we expect from government. And the EPA in the last four years has abdicated, in my opinion, abdicated that responsibility. We've had people at the helm who have decided to foster business interests rather than environmental sanity. And as a result, the burden falls very heavily on the shoulders of medicine and public health.

Kao: Right. So, in October 2017, the AMA Journal of Ethics published the theme issue on safe water access.

Washington: Yes.

Kao: Now, six years removed from the Flint water crisis, it should come as no surprise that Flint residents remain deeply skeptical about the safety of the water supply, given repeated false assurances from government officials, including health professionals. So, how should we hold individuals in positions of authority accountable for their failures to address environmental harms, including its long-term negative health consequences on children and adults, many of whom are people of color?

Washington: It's my take on the issue that Flint doesn't have a water pollution problem, no more than Newark does or Baltimore or Washington or New York City. America has a water pollution problem. America's waterways are flooded with heavy metals and other poisons. And the internal waterways are plumbing, and in cities since the early 1920s, has been ferried by lead pipes. Which were, you know, it was known then that lead was a toxin that was going to be a problem. And it is a problem. So, it's not, it's really an American problem we're looking at. And we need an American solution.

It's really interesting that, as I said, the industry can't be expected to clean this up and stop their behavior when it's going to cost them a lot of money. And that makes it incumbent on the government and medical personnel experts, public health experts to apply pressure to industry. But what's happened is that it's actually not a new pattern. For a very long time, city governments have had a history of knuckling under to corporate interests. In the 1920s, when public health officials warned that lead plumbing should not be used to carry water, that lead poisoning was the inevitable result. It was the inevitable result when we began adding lead to gasoline rather than alcohol as an anti-knock agent. All these things were foreseen by public health, and cities were warned. But they decided to listen to industry instead, which used its own scientists to portray a fictitious portrait of these chemicals as being harmless.

So, the first thing we really need to do is stop listening to industry. When it comes to deciding the science, we have to understand that industry scientists are indeed highly-trained scientists, but they also have divided loyalties. They are not going to be industry scientists very long if they begin issuing reports and recommendations that are not in line with corporate interests. So, we need to use government scientists and academic scientists who do not have relationships with industry that might pose a conflict of interest. I don't see that we've begun doing that.

The other thing that's necessary, too, is that we need to have an agency, whether it's the EPA or something new, devise a central national agency to look at this national problem. And it needs to be able to issue penalties that are real. It needs to be able to control the behavior of industry. We also need better testing. Philippe Grandjean at Harvard University has released a great deal of studies showing how intensely flawed the testing of industrial chemicals are. We've got 160,000 industrial chemicals that've been inadequately tested or not tested well at all. They pose threats to human health, many of them, but we're not even aware of these. We can't rely on corporate assessment that a chemical can be safely used near human beings. It's simply proved not to be reliable throughout history.

So, we need to rethink how we address this. And we need to find a way of investing in agency, a government agency, that's independent of industry with teeth, legislative teeth and the ability to issue meaningful penalties to control the behavior. That's how I see it. I think it's really important. And of course, we need leadership at the EPA. I think it's important to note that since the Nixon administration, the EPA had been making steady progress in addressing some of these problems. But when the new administration came in, there was an appointee whose stated goal was to destroy the EPA. And from what I've seen, he's done a pretty good job in the past four years. So, those are the things that I would really very much like to see done.

Kao: Yeah. So, given what you've just said, it seems like leadership from everyday people are critical. And so, there's been many stories written about the contributions that citizen scientists played in exposing critical evidence about contamination in the Flint water supply. So, what do you see as some of the important contributions that citizen quote-unquote “health scientists” can make to expose and respond to environmental racism?

Washington: Actually, I must demure. I don't agree that it's the role of citizen scientists to make these changes. I do agree absolutely that they have done important work and can continue to do important work. And we should encourage that, yes. But this job is too immense for individuals. It's not realistic to expect them. First of all, they may make discoveries, but do those discoveries translate into action that's going to preserve health? That's not in their power. And frankly, there's a limited ability of citizens. Not every citizen has the training, the inclination, or frankly, the time to invest in doing this work. The people who are affected by environmental racism are largely people who are expending most of their energy to survive: holding down jobs, trying to protect their families and children. And although they do and should invest time in community work that tries to identify and get attention to hazards, it's not, in my opinion, fair to expect them to take on this work.

It's actually we're at critical levels in many communities, and we need to see real action. And that's why I prefer to think about investment and work done by government and appointed experts, professional experts to do this. I think that would be much more efficient. And that having been said, when communities get together and organize, they can make a great deal of difference in their own communities. They cannot solve this national problem. They probably cannot solve the problem even in one city. But they certainly can and have banded together and made big steps with the cooperation and help of catalysts: groups like Earthjustice, who provide lawyers, the Sierra Club and Nature Conservancy, who, aside from the preservation of the wild and clean water and the things that they are known for, are also invested in the quest for environmental justice, in maintaining healthy communities. So, using these groups as partners, as I detail in the last chapter of my book, a community can indeed make some strides. But I do not ask these communities to work on solving the problem. As I said, the problem is too immense to ask them to take on.

Kao: Yeah. No, I appreciate those points. And as we near the end of our conversation today, I want to return back to what you were speaking to near the start of our conversation. Your latest book, published in 2019, examines the link between environmental racism and cognition. So, what should health professionals know about the thesis in this book?

Washington: There are a lot of things that health professionals already know, but there are some that I think they could do well to rethink, depending on their specialty and the degree of their knowledge. One of the very common mythologies held by scientists as well as laypersons is the nature, for example, of IQ. There's a wide supposition that IQ somehow measures the potential intelligence of a person, that it's immutable, doesn't change over their life. And among hereditarian scientists, the message is very widely promulgated that this is genetically transmitted and racially tied, that people of color have an average, African-Americans, for example, average 15 points lower IQ than whites. Hereditarians say that's because IQ is inherited. And by that, they mean intelligence is inherited. But they're wrong on both counts. And I think it's important to understand that. Because if one doesn't understand, it's very easy to be taken in by these beliefs such as hereditarianism: the inheritance of intelligence.

Instead, what we do see very clearly supported by increasing precision of evidence, we do see that environmental toxicity is closely tied to intelligence in a myriad of ways, from simply deranging the neurological development of children who are exposed in utero, to really subtle changes that are brought about by exposures at different stages of life. And it's all very well documented. But somehow it hasn't coalesced into a wider understanding that environmental racism is posing a direct threat to the mental health and the psychological development and intelligence of groups of people of color who are herded into these exposure zones. And I'd like for medical people to get a greater understanding of that and to apply it in their practices.

Kao: Well, you've certainly given our audience a lot to think about. So, I'd like to thank Harriet Washington for sharing her expertise and insights with our audience today. Harriet, thanks again for being a guest on Ethics Talk.

Washington: Oh, thank you for having me. It's been a pleasure, a deep pleasure.

[theme music plays]

Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at journalofethics.org. And finally, to our listening audience out there, be safe and be well. We'll see you next time on Ethics Talk.

Video Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

AMA CME Accreditation Information

Credit Designation Statement:  The American Medical Association designates this Enduring Material activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to: 

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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