Tag: racism

Don’t Scapegoat Immigrants for the COVID-19 Pandemic Surge

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This post is a part of our Bioethics in the News series

By Larissa Fluegel, MD, MHS, and Sean A. Valles, PhD

The U.S. COVID-19 pandemic summer surge has inspired a public search for answers as to why wide vaccine availability has not been sufficient to prevent a new wave of infections. Certain answers are plausible, such as blaming the surge on some combination of the more infectious delta variant spread, vaccination rates remaining too low on average and excessively low for some populations, a relaxation of formal disease control restrictions, as well as more nuanced informal social habits such as diminished mask-wearing, more indoor parties, etc. Yet others cast blame onto a much less plausible target: immigrants.

Florida Governor Ron DeSantis blames President Joe Biden for being too lax on the southern U.S. border immigration enforcement, suggesting that Biden has been “helping [to] facilitate” the pandemic. Governor Greg Abbott of Texas took things further, ordering that state law enforcement could “begin pulling over vehicles whose drivers are transporting migrants who pose a risk of carrying COVID-19.” Both of these responses to the pandemic spread are unethical, incoherent, and ineffectual. Accusations against Latin American immigrants are unethical and misguided.

For many reasons, blaming those immigrants crossing the southern U.S. border for negative health outcomes is problematic. Such targeted blame is dehumanizing to immigrants—it promotes negative stereotypes that perpetuate discrimination, mistreatment and health disparities, and by extension, it is detrimental to non-immigrants’ health. Moreover, it is a form of blame shifting that prevents authorities and the public from effectively taking responsibility for community-wide problems.

Image description: a black and white photo of an individual holding a sign that reads “Hamilton was an immigrant. Einstein was a refugee.” They are wearing a long jacket and a tricorne hat. Image source: Victoria Pickering/Flickr.

Blaming immigrants is dehumanizing

There is a long history of dehumanizing immigrants to the U.S., although such dehumanization is generally done selectively. Immigrants such as Charlize Theron and Albert Einstein are treasured, while others are despised for having the “wrong” skin color, accent, occupations, and so on. Dehumanizing and targeting immigrants has been part and parcel of U.S. history, from 19th century church-burning riots that terrorized Irish immigrants, and the overtly racist Chinese Exclusion Act, to current cases of medical abuse and neglect in migrant detention centers. Philosopher David Livingstone Smith traces these sorts of systemic cruelties to a process of dehumanization in which we find ways of convincing ourselves to think of certain groups of people as somehow less than human. To convince ourselves we seek justifications such as depicting immigrants as vermin infecting or invading a country. According to Livingstone Smith, such depictions then give us permission to act aggressively against those groups and to “exclude the target of aggression from the moral community.”

In sum, we find ways to give ourselves permission to dismiss the ethics of how we treat certain groups of people. With such misplaced permission, we decide that certain groups, in this case select immigrants, don’t count as fellow humans worth caring about, and so abuse doesn’t really count as abuse. It’s this sort of misguided logic that also explains Governors Abbott and DeSantis’ school mask requirement bans. Paradoxically, their purported attempt to reign-in government restrictions on individuals simultaneously reveals disregard for the ways in which harsh immigration enforcement strategies negatively impact the lives of immigrants.

Blaming immigrants promotes unrealistic, unhealthy negative stereotypes

Blaming immigrants promotes negative stereotypes that perpetuate discrimination, social mistreatment, and unjust health disparities. Since early in the pandemic, anti-Asian racism and xenophobia mixed in with COVID-19 politics has led to a worldwide phenomenon of hate crimes against anyone appearing to be of Asian descent, and vicious expressions of misguided blame directed at anyone from the same vague region as where the pandemic originated. Historically, and erroneously, people in the U.S. have associated immigrants with human disease and contagion. Immigration authorities have long scrutinized immigrant health when deciding who can enter or remain in the U.S. Additionally, there is a false perception that immigrant illnesses are predominantly acquired before entry to the U.S.; it is instead most often the case that immigrants tend to struggle with worsening health as they spend more time adopting U.S. cultural norms, including unhealthy eating habits.

Stereotypes about “unsanitary” immigrants represent cruel and unjustified blame shifting. For example, consider meat processing plants which have been hot spots for COVID-19 outbreaks. Staffed predominantly by an immigrant workforce, those workers face abusive and unsanitary working conditions (an open secret in the industry for over a century) that foster disease outbreak. Laying blame for this suffering on immigrant workers, or immigration generally, is a horrendous ethical mistake. Statements by public figures like Governors Abbott and DeSantis contribute to morally skewed views about immigrant health.

Unhealthy negative stereotypes hurt people and cost all Americans a lot of money

Another pragmatic consideration is how those immigrants who do fall ill interface with the U.S. health care system. Negative stereotypes about immigrants among health care providers lead to substandard and/or improper care. In fact, the anticipation of being mistreated coupled with fear among those with an undocumented immigration status serve to dissuade immigrants from seeking needed care. Such fears might even discourage some from getting the COVID-19 vaccine. In this way, blaming immigrants contributes to worsening the pandemic. (A related irony is that nearly 1 in 3 doctors are themselves immigrants.)

There is a public health concern to this sequence. Delaying or avoiding care harms immigrants as well as those around them. To avert transmission, contagious diseases need to be treated in a timely manner. Not doing so leads to an underestimation of actual disease distribution and burden. A correct estimation is necessary to determine the right amount of resources and timely measures necessary to contain them. It is a waste of public resources to have those in need use emergency rooms for care that, if identified and delivered in a timely manner, could have been averted before the situation worsened. Part of the motivation for the Affordable Care Act was to  increase access to regular necessary care, yet undocumented immigrants were excluded from benefitting from the Act, despite the fact that providing coverage would have improved public health and probably saved the public money as well. For example, consider strep throat, a condition that is easily treatable with inexpensive antibiotics. Left untreated, strep throat can get complicated and potentially cause serious long-term heart problems. Untreated strep throat might drive a person to seek care in an emergency department. Yet another example is an untreated dental cavity that might lead to a dental abscess or a deep skin infection of the mouth and neck, again possibly resulting in an emergency room visit. Once there, correct diagnosis would require fluid cultures and expensive MRI or CT imaging. The cost of delayed care is borne by all of us. Some combination of insurance companies, hospitals, or government pay those excess fees, passing along costs to everyone else.

Speaking out

It is unfortunately fashionable across the U.S. and Europe to blame immigrants for social problems. Economic and social problems are quickly blamed on immigrants. Conversely, the available evidence points to immigrants being economically and socially beneficial to their respective new country.

We, the authors, come to this issue as people who have committed their professional lives to making healthcare and health policy more humane—seeking to help our future physicians and our colleagues treat patients as complex human beings deserving of care, rather than revenue streams to be maximized. Similarly, we see immigration discussions falling prey to the same mistake so common in healthcare, wherein powerful decision-makers, such as politicians, lose sight of their shared humanity with the people whose lives depend on them. We need to demand better from our political leaders and importantly, we need to speak out when politicians dehumanize immigrants.

Larissa Fluegel photo
Sean A. Valles photo

Larissa Fluegel, MD, MHS, is an Assistant Professor with the Center for Bioethics and Social Justice and the College of Human Medicine at Michigan State University where she teaches social context of clinical decisions.

Sean A. Valles, PhD, is Associate Professor and Director of the Michigan State University Center for Bioethics and Social Justice. He is author of the 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era (Routledge Press).

Join the discussion! Your comments and responses to this commentary are welcomed. The authors will respond to all comments made by Thursday, September 2, 2021. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Continue reading “Don’t Scapegoat Immigrants for the COVID-19 Pandemic Surge” →

White Horse, White Faces: The Decriminalization of Heroin Addiction

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

The U.S. is in the grips of an opioid addiction crisis. According to the CDC, the rate of opioid (prescription and heroin) overdose deaths has quadrupled since 1999.

Consider the following:

Economic Impact of the Opioid Epidemic:

  • 55 billion in health and social costs related to prescription opioid abuse each year
  • 20 billion in emergency department and inpatient care for opioid poisonings

On an average day in the U.S.:

  • More than 650,000 opioid prescriptions dispensed
  • 3,900 people initiate nonmedical use of prescription opioids
  • 580 people initiate heroin use
  • 78 people die from an opioid-related overdose

There is a strident call for prevention, treatment, research, and effective responses to quell this modern day public health scourge. The Obama administration is calling on Congress to 1) expand access to medication assisted treatment (MAT); 2) improve prescription drug monitoring programs; 3) advance prescriber education; 4) encourage safe pain management; 5) accelerate research on pain and opioid misuse and overdose; 6) expand telemedicine in rural America; 7) safe disposal of unneeded prescription opioids; and 8) improve housing support for those in recovery.

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Image description: An individual is shown injecting their arm with a syringe. They are seated and shown from the chest down. Image source: Flickr user Urban Seed Education.

Along with these initiatives, expanded use of naloxone is deemed critical as a lifesaving measure for first responders and others to reverse drug overdose. Injection clinics, where users can inject heroin (illegal drugs) in a safe environment is regarded as a reasonable and appropriate response to the problem.

Undoubtedly, there is a striking difference in tone about this “new” heroin epidemic compared to the old epidemic of crack cocaine, which affected predominately black, poor, and urban communities. The difference is that young white people are addicted and dying, reflecting a shift over the last 50 years in the demographic composition of heroin users. A New York Times analysis found that young white adults are dying at rates not seen since the AIDS epidemic. This new epidemic is predicated on addiction to prescription painkillers and people turning to heroin and fentanyl as cheaper alternatives with no administrative barriers (contracts, doctor visits, prescriptions).

The current narrative goes something like this: “…[B]ut these are people and they have a purpose in life and we can’t as law enforcement look at them any other way. They are committing crimes to feed their addiction, plain and simple. They need help.” So, when young white people become heroin addicts they are “people with a chronic health problem” and thus are deserving of patience, tolerance, and help. Coming from middle-class and suburban environs, they are portrayed as high achievers from exceptional families, and so the addiction is not their fault—it is not a personality flaw or character deficit.

In contrast, at the height of the crack cocaine epidemic in the mid-80s, black people were branded as pathological, unsympathetic “superpredators” and therefore deserved disdain and incarceration. Black crack addicts had several personality flaws—lazy, stupid, it was their fault that they became addicted—their addiction was the result of a moral failure.

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Image description: An individual is shown injecting heroin into another individual’s hand with a syringe. Their faces are not shown. Image source: Wikimedia Commons.

Racism is in full effect in this new public health scourge. Of course, addiction requires medical intervention and all the social resources needed to help those afflicted. BUT, let’s not have a conversation about the new heroin epidemic in a vacuum with scant if any attention to the racist underbelly of the discourse. Minority and poor people were junkies and criminals deserving nothing more than a jail cell. Today’s addicts are not even called addicts. The goal is to avoid stigmatizing language and so language conveying a chronic illness is preferred such as substance abuse disorder. Addiction is a serious public health issue and it is encouraging to see the change in strategy to treat those afflicted. We know that mass incarceration is not an effective public health response.

It is problematic that we are having a white washed conversation about opioid addiction. This new conversation is occurring in an ahistorical vacuum. The goal is not to incarcerate young white heroin users, but to help them. However, this new enlightenment is a sting for black and Latino families who suffered the same problems, but they were not deemed “people with futures” or “people who deserved help.” They were junkies and criminals. Ironically, black people are suffering less from this new epidemic because of pervasive racial stereotypes whereby doctors are reluctant to prescribe painkillers to minority patients believing they will sell them or become addicted.

It is disingenuous to frame the conversation ahistorically. The current responses and narratives surrounding the heroin epidemic shows that it indeed matters who is in the grip of addiction: “White heroin addicts get overdose treatment, rehabilitation and reincorporation, a system that will be there for them again and again and again. Black drug users got jail cells and “Just Say No.”

The new white face of heroin addiction has changed the discourse of addiction from criminalization to public health, and the change is welcomed. However, it does give me pause that the white face was necessary to enact humane responses for a health problem that affects us all.

kelly-blake-crop-facKaren Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 4, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Racism and the Public’s Health: Whose Lives Matter?

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Karen Kelly-Blake, PhD

“Strange Fruit”

Southern trees bear a strange fruit
Blood on the leaves and blood at the root
Black bodies swingin’ in the Southern breeze
Strange fruit hangin’ from the poplar trees

Pastoral scene of the gallant South
The bulgin’ eyes and the twisted mouth
Scent of magnolias sweet and fresh
Then the sudden smell of burnin’ flesh

Here is a fruit for the crows to pluck
For the rain to gather, for the wind to suck
For the sun to rot, for the tree to drop
Here is a strange and bitter crop

– Billie Holliday, recorded 19391

In order to create the conditions that allow for health and well-being for all people in the US, we must boldly address the causal relationship between racism, discrimination, bias and poor health.3,4,5,6,7 As a medical anthropologist, I must clearly state that race is not a biological fact, but instead is socially constructed. Having satisfied that disciplinary requirement, let me be even clearer—an individual’s lived experience in the world from birth to death is shaped by the color of their skin (as so hauntingly illustrated in the “Strange Fruit” lyrics above). Over the past year, there has been a seemingly endless stream of media images2 of black people being killed or brutalized: Trayvon Martin, Michael Brown, Walter Scott, Eric Garner, Freddie Gray, Tamir Rice, Renisha McBride, and the Emanuel Nine. The images starkly illuminate the profound relationship between racism and black people’s health. Unfortunately, these events are not new nor are they anomalies in the US, but they have captured national attention. The hidden subtext of these events is the extent to which racist social interactions and institutional structures affect the daily lives of millions whose suffering is not broadcast on the nightly news.

Justice for All March - Dec. 13, 2014
Image Description: an individual is holding a sign above their head that reads, “We revolt simply because, for many reasons, we can no longer breathe.” Image Source: fuseboxradio on Flickr

A growing body of literature highlights the ways in which racism and discrimination affect the health status of people of color.3,4,5 The American Journal of Public Health6 and the DuBois Review: Social Science Research on Race7 devoted entire issues to those concerns. Note a few examples. Persistent discrimination in housing and mortgage lending effectively sustain residential segregation which in turn restricts access to educational and employment opportunities, nutritious food, safe spaces to exercise, and high-quality medical care.8 The widening wealth gap—for every dollar of wealth held by white households, black households held 6 cents, and Latino households 7 cents.9,10 Research has shown that black people, when compared to whites, are less likely to be offered the latest health care treatments for cancer,11 heart disease,12 and depression.13 Studies also reveal significant bias in the criminal justice system, leading to higher arrest, conviction, and incarceration14 rates for black people for similar crimes and at higher rates than whites. Data indicate that self-reported incidents of discrimination are psychosocial stressors that negatively affect physical and mental health.13,16 In sum, racism is a public health problem.15,16,17,18,19 It contributes to higher levels of stress, greater exposure to risk factors, reduced access to medical and social services, and ultimately to excess levels of disease, disability, and death.5

So, whose lives matter? Georges Benjamin, Executive Director of the American Public Health Association argues that “good intentions and good science are no longer enough”.20 Public health has the capacity, the tools, and the knowledge to connect and act on the ways in which racism and discrimination in all their forms become personified and observable as health inequities.21 Essential to the mission of public health is the capacity to analyze and promote social justice and health equity and inform the interconnected call for social justice, racial justice, economic justice, environmental justice, community justice, and climate justice.17,22

We are perhaps at an inflection point. Unlawful police killings, exemption, and health inequities are not new phenomena, nor is the related struggle to counter them.17 Public outrage and the cries for social justice demand that we move beyond antiseptic bromides about “diversity,” “cultural competency,” and the inane claim that we live in a “post-racial” society. Such a move requires accountability, open discussion, and candid self-assessment, of individuals and of our institutions, about the complex realities of racial injustice and the resulting historical trauma.20 The ability to unpack and forthrightly address the causal relationship of racism and discrimination to disease, disability and death is part of the charge and responsibility of public health programs. Equally, it is incumbent on medical schools to transmit that knowledge to future practicing physicians and public health experts and prepare them to address racially generated contemporary public health issues.15

Justice for All March - Dec. 13, 2014
Image Description: A person speaking at a podium is surrounded by a crowd of people, some of whom are holding signs that read “I Can’t Breathe,” “Hands Up Don’t Shoot,” and “Black Lives Matter.” Image Source: fuseboxradio on Flickr

If we want to truly achieve social justice and health equity, these recent high-profile incidents, and the rising social movement,23,24,25 might create an opportunity to confront and acknowledge the racist, discriminatory, and biased legacy of our history. To that end, we must be ready and willing to dismantle the systems that perpetuate inequality.20 The time to achieve these aims is now, and if not now, then when?

kelly-blake-crop-facKaren Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 6, 2015. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Racism and the Margins of Respect for Autonomy

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Doug Olsen, PhD, RN

The recent allegation that a father at a Michigan hospital requested and was granted a change of nurse for his newborn son, based on the assigned nurse’s race, has created a stir in the professional and national public media (Articles in USA Today, Washington Post, Lansing State Journal, and reports on MSNBC.) The initial gut reaction has been overwhelmingly negative, to the point of horror, that the hospital would accede to such a request. The strong reaction seems related to the accusation that the father’s request arose from hateful racism; he is alleged to have brandished a swastika tattoo while making the request.

This initial reaction is understandable, and ethical analysis must account for these concerns. The values of diversity, inclusiveness, fair access to work, and the elimination of inappropriate bias in distribution of care are essential to ethical healthcare.

However, the overall situation of patients requesting clinicians based on personal characteristics is more complex than this initial reaction indicates, because in addition to the values leading to outrage, our professional values also include allowing and encouraging autonomy of patient choice in the goals of treatment and the method of service delivery, and also maximizing the ethical therapeutic clinician-patient relationship. Better clinician-patient relationships are more trusting, have greater mutual respect, better communication, and have more clinician empathy and result in better clinical outcomes and patient satisfaction (Atlas et al., 2009; Thom et. al, 1999; Larson, Yao, 2005). Optimum clinician-patient relations are essential for the moral discernment essential to ethical care, including shared decision making and patient-centered care.

Choice of clinician is recognized as an emotional issue: U.S. insurance health-plan marketing often cites broad choice of clinician in their public advertising, government interference in patient choice is a bogeyman of health-care politics, and patients state that they prefer choice (Harris, 2002). In addition, some requests, such as those for same-gender providers, are routinely considered appropriate and granted.

If we take the values of patient autonomy and importance of relationship seriously, denying a patient’s request for a different provider requires specific, strong justification. The clinician finding the patient’s motives as reprehensible isn’t enough by itself. A clinician’s duty to provide optimum care isn’t limited by personal judgments of the patient, just as a firefighter shouldn’t decide whether the homeowner is worthy before responding.

Justifications to limit a patient’s choice of provider based on personal characteristics include feasibility – that granting the request would unfairly disadvantage other patients or that the request arises as a consequence of a patient’s disorder and granting it would negatively affect treatment; or that granting the request would unduly harm the involved clinicians or other employees.1

In this particular case, the two potential justifications are adding to patient pathology and harming employees by creating a hostile workplace. Membership in a hate group and fringe politics is not, in and of itself, a mental disorder. But as a mental health clinician, my ears perk up at extreme inflexibility and antisocial views. However, in this case the nature and duration of the relationship make invoking this justification unlikely.

The best justification for denying this father’s request is a potential for harm to employees by creating a hostile workplace far outweighing any expected benefit of granting his request. Race-based requests for providers have been held to contribute to a hostile work environment. The Seventh Circuit Court of Appeals held that a nursing home’s policy to honor residents’ requests for white certified nursing assistants, along with methods of enforcing the policy and “racially-tinged comments and epithets from co-workers,” created a hostile work environment for an African-American employee (Chaney v. Plainfield Health Center, __ F.3d __ (No. 09-3661, July 20, 2010)). The court’s finding was based in labor law and not in relation to patients’ rights which seems appropriate to this justification.

Still there may be circumstances when a race-based request can be honored without harm to others. Indeed, there is no good to be had in forcing a patient into a relationship which will be less therapeutic than possible, or forcing a clinician to care for a patient who brings hateful feelings to the relationship.2

Regarding the clinician requested by the patient, providers are often called upon to treat patients whose personal views and lifestyles are repugnant, and patients have a right to optimum care whatever their personal characteristics or opinions. This is clear in the American Nurses Association (ANA) code of ethics. Provision one of the ANA code of ethics (2001) states, “The nurse, in all professional relationships, practices with compassion and respect… unrestricted by considerations of social or economic status, personal attributes or the nature of health problems.”

While physicians retain the right to choose their patients, the American Medical Association Code of ethics (2001) principle six states, “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve,” the latitude of the “physicians’ prerogative” to choose patients is clarified and limited in their code’s Opinion 10.05:

“(2)…(b) Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination. . . nor can they discriminate against patients with infectious diseases.

“(c) Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat…”

When it is clear that racism or some other socially unacceptable reason is the basis for the requesting a change of clinician, certain limitations and understandings must be made clear to the patient: First, the patient needs to be told that the decision to grant the switch is based solely on providing the patient optimum care by providing a clinician with whom the patient can form a therapeutic bond. Second, allowing the patient to switch clinicians does not indicate the institution’s endorsement of his or her views; the patient needs to be told that the institution specifically does not recognize race or other analogous factors as the basis of any decision, and that the institution values and strives for a diverse workforce. Third, the patient’s desire for clinicians with certain characteristics may not be met at all points in time, for example, in emergencies or when no clinician with the desired characteristics is available. In addition, the patient should be assessed for an underlying pathology as extreme views may be related to a psychiatric disorder, and treatment should be offered if a disorder is diagnosed.

1Lack of decision-making capacity is the most common reason for limiting patient choice in many areas, but I am assuming that most patients who can make such a request and be consistent about the request would meet criteria for decision-making capacity.

2An argument could be made that the society and possibly the hateful individual benefits from forcing confrontation with the hated group, as this is a sometimes an effective way of breaking barriers, but this would be paternalistic, in that the patient would be forced to do something for his or her own good.

References:

  • American Medical Association. Code of Medical Ethics. 2001. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml
  • American Nurses Association. Code of ethics for nurses with interpretive statements. Washington, DC: The Association; 2001. http://www.nursingworld.org/ethics/code/protected_nwcoe303.htm.
  • Atlas S, Grant R, Ferris T, Chang Y, Barry M. Patient–physician connectedness and quality of primary care. Annals of Internal Medicine. 2009;50: 325-335.
  • Chaney v. Plainfield Health Center, __ F.3d __ (No. 09-3661, July 20, 2010).
  • Harris K. Can high quality overcome consumer resistance to restricted provider access? evidence from a health plan choice experiment. HSR: Health Services Research. 2002;37(3): 551-571.
  • Larson E, Yao X. Clinical Empathy as Emotional Labor in the Patient-Physician Relationship. Journal of the American Medical Association. 2005;293(9): 1100-1106.
  • Thom D, Ribisl K, Stewart A, Luke D. Further Validation and Reliability Testing of the Trust in Physician Scale. Medical Care. 1999;37: 510–517.

OlsendougDoug Olsen, PhD, RN, is an Associate Professor in the College of Nursing at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, March 22. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.