Medical Reparations: A Resolution Paper

Introduction

Medical Reparations build on the longstanding call for slavery reparations by focusing on the specific debts owed to Black people in healthcare settings. It is a response to the health effects of racism writ large as legacies of slavery that persist today and that call for repair. Despite the abolition of slavery and the inclusion of former slaves and their descendents as equal citizens, the generation-wide life expectancy gap between Black and white Americans has not significantly narrowed since antebellum times. Racial disparities are entangled with poverty, class, and social power in myriad forms, and these contribute to unequal health outcomes. Healthcare institutions have harmed Black people through unequal access to medical care, racialized medical theories, histories of experimentation and institutionalized biases in clinical care.

We draw here on reparations as informed anti-racist praxis, but also acknowledge that racism exists in numerous forms. The continued dispossesion of Indigenous peoples from their native lands, and the presence of anti-BIPoC (Black, Indigenous, and People of Color) racism, are all rooted in historical trends that persist, including in medicine. We agree with former National Medical Association President Dr. Rodney Hood’s suggestion that this “slave health deficit” endures because its original wounds have never been sutured, and have rather become a foundation upon which race-based inequality persists. The recent creation of a Lancet Commission on Medical Reparations and Redistributive Justice signals the ongoing need to address possible modes of reconciliation in medicine and the health sciences by way of reparations.

We also seek to acknowledge the Ramaytush Ohlone people, who are the traditional custodians of the land on which UCSF is built today. We pay our respects to the Ramaytush Ohlone elders, past, present, and future who call this place their home. We are proud to continue their tradition of coming together and growing as a community. We thank the Ramaytush Ohlone community for their stewardship and support, and we look forward to strengthening our ties as we continue to develop a relationship of mutual respect and understanding.

Over the course of the 2020-2021 academic year, the UCSF REPAIR Project sponsored a series of campus forums, teach-ins, student reflection events, and curricular reforms in order to facilitate discussions on medical reparations. With scholars from the medical and social sciences and members of the community, these efforts helped clarify the justification for medical reparations and generate proposals for their concrete implementation. 

In this resolution report, we provide: (1) the evidence base for medical reparations, drawing from past and contemporary examples; (2) deliberations over how reparations might work; (3) the REPAIR Project’s suggestions for reparations at UCSF. 

The Evidence-Base for Reparations

The notion of slavery reparations in the US dates back to the end of the Civil War—initially conceived by white abolitionists and Black Baptist and Methodist ministers and formalized in calls by the Union General William T. Sherman (Gates: https://www.pbs.org/wnet/african-americans-many-rivers-to-cross/history/the-truth-behind-40-acres-and-a-mule/). The initial proposal was to grant newly freed slaves forty acres of southern US lands and a mule at the end of the war. The order for reparations was taken up by President Lincoln but was swiftly overturned by his successor, Andrew Johnson, who opted to instead give this reparative land to Confederate soldiers and their families. The insult-upon-injury caused by this early refusal to grant reparations has haunted US society for nearly two centuries.

While reparations have since been provided for several communities, including some Native American tribes, some Japanese-American citizens, and victims of the U.S. Public Health Service Syphilis Study at Tuskegee, reparations for descendants of formerly enslaved individuals have remained elusive (https://www.crf-usa.org/brown-v-board-50th-anniversary/reparations-for-slavery-reading.html). It should be noted that reparations are not a solution or a fix for racism, but rather a symbolic and material gesture through which institutions can move towards cultivating spaces of belonging grounded on anti-racist and abolitionist frameworks. Anti-asian racism, among other forms of racialized hate and violence, persist to this day. However, the unrepaired wounds of slavery have aggregated over time, reproducing inequity and anti-Black racism in various forms of segregation, discrimination, incarceration of Black communities in the US and measurable disparities in health. For this reason, we argue that reparations are not a one-time gesture, nor a single action – they are an aggregate process, and one which is incomplete for many communities of color.

Although calls for reparations have persisted since the end of the Civil War, these calls have gained momentum more recently with the ascendency of the Black Lives Matter movement and other anti-racist activism around the United States. This has coincided with increased media coverage of the murder of Black people by the police, and greater attention given to the Senate hearings on Reparations Bill HR 40 in June, 2019. At the 2019 hearings, Rev. Eugene Taylor Sutton testified before the US House of Representatives subcommittee about this bill and reparations in general, noting that generations of enslaved Black people were bred, used, and sold for the purpose of attaining wealth for white people. Any contemporary structure built on this broken foundation, he said, cannot hope to stand. It must be repaired, the wrong reconciled. The call for reparations, in other words, has been pulled into the 21st Century, provoking impetus to consider what this might mean in the medical context.

The rationale for medical reparations begins with a recognition that American science and medicine have played a part in sustaining racial harms. The growing list of these harms is being documented by many clinician-activists, including Derek Ayeh, Jason Silverstein, Eugene Richardson, Mary Bassett and Brittany Butler et.al. The work of these clinicians builds on generations of non-clinical social science scholarship describing different kinds of racial harm. Through four campus forums and a Teach-In series at UCSF, we produced ample evidence of anti-Black racism in American medicine. For instance:

Plantation roots of biomedical research

The emergence of scientific medicine in the 19th century envisioned the plantation as a research site [qua living laboratory] for biomedical knowledge production (Medical Apartheid; Krieger). Physicians exploited enslaved black people to further the medical profession, their own careers, and increase the profits of plantation owners. Scientific findings from these practices were later published in medical journals and taught in medical schools. Freed Black Americans were denied quality healthcare while being used to further the medical profession since the mid 19th century, with deleterious health outcomes (Reverby; Roberts). The rise of modern American medicine as a respected profession could not have happened without coexistence with slavery.

Medical experimentation on Black people

The unequal treatment of Black people in medical experimentation has a long history, as Harriet Washington and Dierdre Cooper Owens have shown, from the U.S. Public Health Service Syphilis Study at Tuskegee (Sacks) to the forced sterilizations of women of color as “population control,” (Lira), and their use in pharmaceutical testing of contraceptives. Black men were used to study the effects of plutonium radiation  in the 1950s and 60s. Non-consenting incarcerated African Americans were used in dermatology studies by UCSF researchers as recently as twenty years ago.  

Racialized Diagnostics

Biomedical sciences have also long contributed to discrimination through racialized diagnostics, including the pathologizing of protest behaviors of Black men by labeling them as schizophrenic (Metzl]. The belief that Blacks have a higher pain tolerance emerged under regimes of slavery to justify brutality and the torture of slaves (Hogarth) but these logics persist in contemporary racialized practices of pain management today (Hoffman et.al.). From big data technologies to the most carefully calibrated diagnostic machines, racial prejudice can be reproduced even as we strive for more precision and personalized medicine (Brown). The flawed calibration of pulse-oximeters for dark skin, and the consequent under-diagnosis of Black and Brown persons with severe COVID-19 symptoms is but one recent example of this.

Race as a Category

The continued use of race as a biological category in medicine leaves unexamined the problematic fact that race itself was a colonial era-social construct unrelated to any fixed biological givens other than highly misleading phenotype (Vyas et.al.) In other words, race is not a biological given, it is a socially-constructed mode of categorizing people as different based on unreliable assessments of skin color. Medical use of genetic ancestry is unable to escape the pitfalls of racism when entangled with such racial categories. Today, racial categories continue to be reified through new technologies such as genetic arrays that, invariably, reflect socially-meaningful distinctions (such as ancestry, geographic origin, self-identification) but not biological givens. Still, the effects of racism on health are profound at both the individual and community level.

Medical institutions' Contribution to Segregation.

The 1910 Flexner Report on Medical Education justified the closure of five of the seven Black medical schools, leaving only Meharry Medical College and Howard University. In the report, Flexner suggested that while Black physicians did not have the capacity to treat all Black people who were sick, they were probably able to treat enough Black patients, which kept whites safe from infection and contagion. The closure of Black medical schools meant medical education in the US disproportionately took place at predominately white institutions (PWIs) for over a century. If the 5 medical schools that were closed were able to remain open, the US would have been able to train around 10-30,000 Black doctors, based on the fact that Black doctors were almost exclusively taught at historically Black colleges and universities (HBCU) until the 1960s (Kendall et.al.).

Racial Discrimination in Admissions

Blatant discrimination in admissions and residency programs has long stymied the careers of Black medical students and, despite rectifying the discrimination of many others who were also excluded from medical careers (Jews, Catholics, women), a recent report by the AAMC shows that admissions of Black men into medical school has remained stagnant since the 1970s. In medical education, long-standing cultural barriers have impeded black enrollment for decade. As an example, the 1984 Eastern Virginia Medical School yearbook entry showed Virginia Governor Ralph Northam’s cohort sporting blackface and Ku Klux Klan attire. The undisrupted presence of these hostile behaviors in the social world of medical schools needs to be addressed alongside the persistent low enrollment of Black men in medical schools to further understand the persistent harm of slavery in health, healthcare, and medical education.

Criminalization of Black People

Medical diagnoses and clinical care can augment surveillance and incarceration of Black people. Abolitionist social theory and politics call for cessation of policing in hospitals and clinics, and a refusal of diagnostic practices that selectively criminalize Black people for medical problems, including addiction and mental health disorders. Racialized carceral practices perpetuate systems of the failed project of emancipation of Black people by reproducing unpaid and low paid labor through the prison system. When medical practices wittingly or unwittingly contribute to surveillance and incarceration of Black patients, they perpetuate these forms of inequality in the same ways that harsh sentencing laws do (such as ‘three strikes’ laws). The call for medical abolitionism goes hand in hand with the call for reparations.

The REPAIR Project and Medical Reparations

The REPAIR Project held four campus forums featuring a scholars with expertise in the evidence base for medical reparations, elucidating the central role that science and medicine have played in pathologizing notions of racial difference about Black people and other communities of color. Dr. Rana Hogarth described how notions of inherent racial pathology culminated in (but did not begin with) the eugenics era. Dr. Natale Lira documented how evolutionary sciences constructed racial taxonomies that presented white people as genetically superior and authorizing sterilization of people of color. Dr. Tina Sacks elucidated the ways that descendants of the U.S. Public Health Service Syphilis Study at Tuskegee continue to experience mistrust of the medical system.

The REPAIR Project’s Teach In series in collaboration with UCSF White Coats for Black Lives was entitled “Honoring Black History, Imagining Black Futures.” This series complemented and enhanced existing graduate and health professional school anti-racist curricula, establishing and  strengthening relationships with community organizations in San Francisco. The first, “Honoring Black Community Hospitals” taught histories currently excluded from medical education by learning from experts in medical anthropology, sociology, history of medicine. The second teach-in, featuring Cleo Silvers of the Black Panther and Young Lords Parties, emphasized the history of community health programs and the need to restructure teaching hospitals to provide exemplary healthcare to communities in need rather than prioritizing trainee learning at the expense of racialized bodies. The healthcare academy would benefit from a shift away from competence-based models and toward praxis-driven models for health equity, including redistributing funds directly to those communities. The third teach-in “Racism and Housing Injustice” brought together UCSF medical students with expertise in advocacy for the health of unhoused communities, community organizers with Code Tenderloin, the National Harm Reduction Coalition, and scholars from the UCSF Department of Humanities and Social Sciences. At the time of writing this report, a fourth session on “Black Lives and Food Insecurity” is in development with Grocery Cooperatives in Oakland.

Deliberating Reparations

Although reparations as a concept emerged as compensation for the wrongs of slavery, some have argued that medical reparations must cast a broader net to include those people and activities that reveal harm from racial bias in relation to medicine. Debates over how to deliver reparations are numerous. A few questions that arise in these debates include the following:

Should reparations be reserved for descendants of slaves only?  Or should reparations be made to others and in other ways that compensate for the harms incurred because of legacies of slavery?

Some have argued that reparations in the form of compensation should be exclusively paid to those whose families were wronged by slavery because slavery was the original wrong, inflicting the original harm. Thus those who are descendants of slaves have been living in a position of deficit that needs to be addressed and rectified.

Others have argued that the legacies of slavery in the US have impacted all Black Americans, thus reparations should be focused on eliminating anti-Black Racism and providing compensation to all Black Americans (including those whose families were never slaves). In other words, reparations should not only compensate descendants of slaves but also funding efforts to root out and eradicate ongoing forms of institutional racism, namely the lack of people of color at every level of the socio-economic hierarchy. Here, the goal of reparations is to create a more racially equitable and just society. Reparations can help push forward efforts that reach beyond compensation to descendants of slaves.

Should reparations be narrowly defined as monetary compensation as presented in the original order (as forty acres and a mule)?

The debate here is whether or not reparations for slavery should be solely the offer of cash payments to slave descendants calculated as the modern day value of what forty acres and a mule was worth at the end of slavery in the US. This amount is calculated differently, with some based on the original debt compounded for current day values, some calculated around the wealth gap between Black and white Americans, and some based on the value of labor that was unpaid during the life of a typical slave. In some calculations the goal is to compensate not just for the original debt that was never given, but also for two centuries of lost earnings. In other words, the goal is to compensate for the capital deficit that was set in motion by the original debt and has accumulated over 200 years as a generationally augmented effect (Powell; Darity and Mullen).

Thus, one estimate is of $3 billion in unpaid slave labor in 1863, translating to $1.4 trillion in reparations for Black descendants of enslaved people (based on the amount of wages earned by non-enslaved workers between 1620 and 1840, subtracting costs related to the care of slaves in food, housing, care, etc.) (Neal). Others calculate compensation based on the compounded interest on that amount (calculated for 1983) bring the total to roughly $240,000 for each Black American (Ralph).

There are precedents for monetary reparations. They have been offered and delivered by the German government to survivors and survivor families of the Holocaust (as payment for labor, lost lives and lost property), [add more here]. In the US, the Marshall Plan helped ensure that Jews received cash and land reparations for the Holocaust. Also in the US, reparations were made to former internees of the Japanese internment camps during World War II,  after President Ronald Reagan signed into law the Civil Liberties Act of 1988 which apologized for the internment on behalf of the U.S. government and authorized a payment of $20,000 (equivalent to $43,000 in 2019) to each former internee who was still alive when the act was passed. There are also examples of woefully inadequate reparations to Native Americans in the form of land and money.  

Using this definition of slave reparations--that they should only be in the form of cash or equivalent payouts to slave descendants--other kinds of diversity/equity initiatives already in place at many institutions would not necessarily count as forms of reparation. 

Others argue that this definition of reparations is too limited and undermines the true goals of reparations that are aimed at evening the playing field by rectifying the deficit caused by slavery not just in socio-economic but also in cultural/moral terms. This view argues that the funding of programs that selectively augment Black prosperity and end racial injustice could serve as forms of reparations. This view is often tied to arguments that giving cash payments as compensation to descendants of slaves in the US will not be possible to arbitrate fairly or with consensus, and that cash compensations would not ultimately make a measurable difference in creating an even playing field for people who experience the harms of racism. Some scholars also argue that giving cash payments invites Black participation in financial systems of banks/credit/capitalism that have historically worked to indebt or enslave Black people in ways that whites have not experienced, thus deepening the prosperity gap all over again. This view argues that so long as larger structural and institutional forms of racism enmeshed in capitalism persist, even cash payments will not enable Blacks citizens to collectively thrive in the US.

This view promotes the idea that we should expand the view of reparations as more than cash compensation to slave descendants. This might mean considering the global reach of slavery initiated by the US and the need for reparations in global contexts (including immigrants from American colonies and territories where slavery was a basis for the economy) (Lewis). Reparations in this view might also take the form of a multitude of efforts to eradicate racial injustice, race-based socio-economic apartheid and anti-Black institutional racism in a variety of ways. A robust effort to re-map the meaning of reparations so that they specifically reach to communities of color in a variety of different, local, and locally-beneficial efforts (including direct cash payments, funding community resources and investments, etc.) (Lucas).

Will reparations undo ongoing institutional and individual racism or will they only make these problems worse?

Similar to ongoing debates about Affirmative Action, scholars and activists have pointed to the need to think through reparations carefully in relation to their possible negative side effects in the form of hardened institutional and implicit racism. The concern here is not simply that reparations will ratchet-up pre-existing assumptions about moral deservingness along race hierarchies—such as often occurs in public and legislative debates over affirmative action. The concern is also with how reparations may augment institutional racism by giving white people the ability to wash their hands of further efforts to eliminate racial bias by assuming reparations have taken care of the problem. These two issues, which operate at individual and institutional level, work hand in hand.

Some have argued that reparations would not go far enough to eliminate ongoing racism, and that even with cash reparations the system would reproduce itself within a generation without more significant actions (Henry).

What Form Might Reparations Take at UCSF?

UCSF, like other medical schools in the country, has a robust history of activism by BIPoC students aimed at drawing attention to racism. In the 1960s, the campus’ Black residents organized one of the first Affirmative Action Offices in a United States medical school and established free clinics for the underserved Black community in San Francisco. The Black Caucus continued to fight for fair treatment, increased enrollment, and workers’ rights, including anti-apartheid mobilization efforts in the late 1980s. In 2016, UCSF medical students sparked the activist collective called White Coats for Black Lives that is now a national organization with more than thirty chapters. Staff, clinicians, and students from across the schools of medicine, nursing, pharmacy and dentistry later formed the Do No Harm Coalition, which organizes health professionals into advocacy campaigns against racial injustice. Currently, UCSF is developing a longitudinal “Anti-Oppressive Curricular Initiative” and a “Policy on Response to Learner Concerns About Content and Delivery of Educational Activities,” which seek to identify and address medical racism in educational materials and pedagogy.

The scholarly and activist communities that have flourished at UCSF in recent years have provided a foundation from which to conceive of a project for medical reparations. As discussed throughout this white paper, reparations should be thought of in a capacious and creative manner. While several strategies can be employed in pursuing a project of repair, fundamentally they must be grounded in acknowledging and countering the medical establishment’s complicity with racism towards BIPoC communities, and anti-Black racism in particular. Moreover, reparations will be most successful when implemented as a series of permanent institutional and structural reforms. As several reparations scholars warn, short-term strategies run the risk of replicating inequalities. With these considerations in mind, we offer this preliminary list of potential strategies for implementing reparations at UCSF.

A list of possible reparations:
  • Free tuition for Black students and Native Californian Students (members of the Indigenous Peoples of California)
  • Fully funded, tenure track faculty positions for Black scholars
  • Funding for curriculum revisions across four schools and Grad Division to incorporate topics of social justice, anti-racist frameworks, and health disparities and equity
  • Cash reparations to families who were sterilized, experimented upon by UCSF researchers
  • Increased access to publicly subsidized clinics serving Black communities in San Francisco
  • Changes in accreditation requirements to respect the legitimacy of non-European medical traditions, especially for Native Californian Students
  • Increased funding and grant opportunities for local community members to develop health-care interventions

 

*This paper was originally intended as a White Paper, intended to move forward discussions of policy goals toward implementation of medical reparations.  However, we note that the title raises the question of  the use of ‘White’ in White Paper. The Stanford Law School offers some clues about its etymology: “A white paper is an authoritative report or guide that often addresses issues and how to solve them. The term originated when government papers were coded by color to indicate distribution, with white designated for public access. Thus, white papers are used in politics and business, as well as in technical fields, to educate readers and help people make decisions. In commercial use, the term "white paper" has also come to refer to documents used as a marketing or sales tool.” There are also Green Papers (a government report of a proposal with no commitment to action), and Pink Papers (federal and state agencies with limited circulation). (https://www-cdn.law.stanford.edu/wp-content/uploads/2015/04/Definitions-of-White-Papers-Briefing-Books-Memos-2.pdf). One could say the etymology of the term ‘White’ in White Paper is not explicitly or obviously racial. And yet, if one considers the qualities attributed to whiteness: freedom of access, mobility, authority, denoting the least restricted kind of knowledge and information, then one might want to consider the ways that this title does actually carry a certain cultural baggage that reinforces notions of whiteness as a site of privilege. Thus we use the term Resolution Paper.