As psychological anthropologist Nat Kendall-Taylor recently noted, When the College Board revised the draft African American studies curriculum, it removed the word “systemic.” The result: To discourage students from learning and thinking “critically about the connection between the design of our institutions and the uneven way in which opportunity and resources are meted out in America.”
Among the lessons that recent protests should have made patently clear is that social, economic, political, and cultural systems and institutions can perpetuate and reinforce inequalities, regardless of the intentions or beliefs of individuals within those systems. Thus, racial and class bias can be embedded in the policies, practices, and norms of institutions and organizations, and can result in unequal access to opportunities, resources, and power for individuals and groups. Systemic and structural bias are often manifest in disparities in education, healthcare, housing, employment, and criminal justice.
Instead of pitting individual or structural or systemic racism as opposites, personal beliefs, attitudes, and actions and systemic or structural factors are often interconnected and mutually reinforcing.
Case in point: Healthcare. Black babies die at twice the rate of white babies. Blacks in every age group have significantly higher rates of diabetes, strike, heart disease, and death. African Americans “live sicker and die quicker.”
In her 2022 study of the toll of structural racism and prejudice on African Americans’ physical and mental health, Linda Villarosa, a former executive editor at Essence magazine and a contributor on race, health, and inequality to The New York Times Magazine, shows that racial disparities in life expectancy cut across class lines.
Strikingly, a Black woman with a college education is as likely to die or nearly die in childbirth as a white woman with an eighth-grade education. Even more striking are two striking facts. One is that Black teenagers have lower infant death rates than those in the 20s. A second is that while Black immigrants from Africa or the Caribbean have lower levels of maternal and infant mortality, the longer they or their children live in the United States, the rates grow higher.
Why is this the case? It’s not genetics nor is it about individual behavior, educational attainment, diet, marital status, place of residence, of household income. In part, it’s because of disparate treatment that is a byproduct of persistent physiological myths and fallacious assumptions rooted in the past as well as conscious or unconscious bias. It’s also partly because of “allostatic load” -- chronic levels of physical, mental, and emotional stress and environmental demands and pressures that Black women experience. Systemic or structural racism, in short, inflicts a physiological medical, mental, and emotional toll.
There is a real danger that ideas about systemic or structural racism will lead to fatalism – to the profoundly pessimistic belief that the structures and systems that perpetuate inequality are so deeply ingrained that progress is impossible. The most hopeful, powerful, and empowering antidote to such cynicism and negativism can be found in Ricardo Nuila’s stunning debut study of Houston’s publicly funded Ben Taub county hospital, the safety net for the Houston’s indigent, uninsured, and undocumented.
An associate professor of medicine, medical ethics, health humanities, and health policy at Baylor College of Medicine and director of its Humanities Expression and Arts Lab, who also moonlighted for McSweeney’s, the non-profit publishing house, Nuila is the son of a Salvadoran immigrant. The People’s Hospital is everything that reviewers have said. Written “in the tradition of Bryan Stevenson’s Just Mercy and Atul Gawande’s Being Mortal,” the book is “inspirational and gut wrenching, thrilling and scrupulous, damning and hope-filled.”
His account focuses on five patients: a restaurant franchise manager who can’t afford the cost of his cancer treatment, a college student who can’t get an accurate diagnosis of debilitating knee pain, a 36 year old suffering liver failure and who is disqualified from Medicaid, an undocumented immigrant whose severe gangrene leaves will require the amputation of all four limb, and a mother whose high risk pregnancy endangers her and her fetus’ lives.
This book, however, is not yet another account of the inadequacies of this nation’s healthcare safety net. Rather, he shows how a public healthcare system can be just as effective as those medical centers ranked as the nation’s best. In fact, Ben Taub has a better record treating blood clots than any other hospital in the country. It's also the go-to place for trauma care.
As he explains, private hospital care is characterized by excess and waste, and a lower-cost model can be equally successful if it adopts a truly patient-centered approach.
Don't get his argument wrong. Hospitals are expensive and need sufficient funding if they are to fulfill their vital role. But much too often hospital spending, like higher ed expenditures, funds items that don't contribute directly to the outcomes we seek.
Ben Taub replaced an earlier charity hospital, Jefferson Davis (yes, named for the Confederate president) that was the subject of a gut-wrenching 1962 expose by the Dutch playwright, novelist, and anti-Nazi resister Jan de Hartog, who served for 9 months as an emergency room orderly. Jeff Davis was a typical big city charity hospital -- understaffed, overcrowded, short of supplies and equipment – where patients waited hours on end to see a physician, where the linens were filthy, and the floors covered with vomit and blood.
Why was Jeff Davis such a monument to misery. It wasn’t simply penuriousness or racism. It was also because it was a teaching hospital. Pedagogy, not patient care, was the primary concern, as two later observers wrote:
“Care for patients was an incidental, sometimes optional, side effect. From the medical school's perspective, the emergency room at the public hospital was "the best school in suturing a man could have in peacetime." Where else could a young physician find ‘such a generous and constant supply of stabbed, shot, fractured, lacerated, burnt and otherwise insulted living tissue for his training’?”
Hartog’s The Hospital made Houston a national embarrassment at a time when the city was trying to raise its image by building the Astrodome, the first domed stadium, and what would become the Johnson Space Center. Hospital administrators, the hospital board, city council members, and county commissioners, came under an intense national spotlight, and ultimately decided to support the creation of a county-wide hospital district with independent taxing authority. The budget rose from $9.5 million in 1964 to $180 million in 1987 and three new hospitals were built and eight community clinics were built.
There is much that higher education can learn from Dr. Nuila’s passionate, poignant, and exceptionally perceptive and powerful account of a “charity” hospital. His overarching message resembles that offered in a recent book by Leo Lambert and Peter Felten: That impact is ultimately about rich human relationships.
To improve patient outcomes, the hospital district radically reduced the number of patients that each doctor would see each day and established mechanisms to supplement emergency room care with regular outpatient care for the chronically ill. We in higher ed need to do something similar: Provide our students with more intimate, hands-on, mentored learning opportunities.
When I served as a senior advisor to the president for student success at Hunter College, one of the City University of New York campuses, I saw firsthand how even an underfunded campus could transform undergraduate lives. The key was a strategy that placed as many students as possible in supportive learning communities: in a cohort, honors, opportunity, research, or veterans program, or in an arts or business or healthcare or math or science center or a fellowship preparation program – each with a dedicated mentor and experiential learning opportunities.
This wasn’t cheap, but it wasn’t excessively expensive either. It was largely a matter of shifting institutional priorities.
The journalist, novelist, and playwright George Packer recently called our time “a golden age of fatalism,” and cited as evidence the host of historical scholarship consumed with the evils of this country’s past and the misguided myths that continue to distort Americans’ thinking and public policy. He explains the impact of such an approach with words that I wholeheartedly endorse:
“Historical fatalism combines inevitability and essentialism: The present is forever trapped in the past and defined by the worst of it.”
Packer’s goal isn’t to whitewash, sanitize, conceal, or cover-up the past – as too many conservative politicians apparently want to do – but to remind us that this country’s history is marked by “slow, fitful progress” that is the product of controversy, conflict, contention, and coalition building.
To my delight, he concludes his piece by commending a recent book by one of my former Columbia students, George Washington University’s Timothy Shenk, whose Realigners is a model of what cutting-edge history can offer. Without in any way minimizing the horrors of the past, Shenk “rejects ‘skeleton-key histories’ such as the new fatalism that draws “a straight line from slavery in the seventeenth century to systemic racism in the twenty-first” and shows that the real struggle in American history is to forge coalitions that can bring about meaningful change.
Building such majorities is an extraordinarily difficult and demanding task that depends “on the convergence of public sentiments, historical events, political talent, institution building, and luck.” But coalition building is essential if genuine improvements are to take place.
An unlikely, unexpected coalition in Houston, of all places, created an independent county hospital district that dramatically improved care for the indigent and the undocumented by emphasizing patient needs rather than revenue generation. Dr. Nuila quite rightly calls this a national model . Can’t we, in higher ed, do something somewhat similar? We need to place mentoring and relationship building first. I can’t think of a better way to address the retention and graduation challenges, equity and achievement gaps, and mental health problems that beset higher education. Time is of the essence.
Steven Mintz is professor of history at the University of Texas at Austin.
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