Systemic symptoms: Privilege and advantage in “antiracist” medicine

The implausibility of meaningful change in educational achievement at the group level

Photo by Raimond Klavins on Unsplash

By Anonymed (an anonymous Canadian Doctor)

“I hate to break it to you, but there is no big lie. There is no system. The universe is indifferent.” - Don Draper, Mad Men

At this point it ought to be clear that the terms “systemic” and “structural” racism are intentionally nebulous. In our benighted times they are primarily deployed by ideologues as an unfalsifiable retort to anyone questioning the Diversity, Equity & Inclusion (DEI) takeover of our culture and institutions. Like many in the antiracism world, when pressed, medicine’s weekend red guards typically define them by pointing to any (negative) disparity in outcomes for “people of colour” - usually in the particular areas of life they have been told best illustrate their point (they don’t sweat diversity in basketball, bricklaying, garbage disposal, etc). Most people spouting the terms seem to know little more than that, repeating non sequiturs as if they spoke no other language (which they don’t). But let’s give the devil his due. Is talking about “systemic” racism in medicine entirely nonsensical?

When medical institutions self-flagellate about the profession’s history of racism and the perils of living in a white supremacist superstate, I hope they are actually referring to very specific and durable discrepancies in professional recruitment (otherwise god knows). Certain gaps do exist, but rather than ask why they have proven intractable despite years of efforts to “diversify”, medical bureaucrats tend to take their lead from the most shrill activists, who themselves tend to parrot the Ta-Nehisi Coates narrative that there is nothing wrong with [insert community] that ending white supremacy wouldn’t fix. 

The term thrown around most often these days is “representation,” by which people usually mean the degree to which a given institution’s members reflect the population. It isn’t always clear what counts as the population, given that the demographic distribution changes dramatically from one part of the country to another, and from urban centres to rural and remote parts of the country. But let’s not quibble for now.

It has always seemed curious that the demographic categories we care most about are sex, race and ethnicity when we know that economic status is a better predictor of advantage. Regardless, some survey data is available to answer the question of just how racist medical recruitment currently is.

In 2020, Khan et al published randomly sampled demographic data from more than a thousand medical students. We will address the alleged sexism of the profession in another article, but in terms of race, their study suggests that Asian and South Asian minorities are overrepresented, and white, rural, black and Indigenous students are generally underrepresented. The study didn’t break it down, but I imagine there would be additional differences seen between, say, Nigerian Canadians (who are among the most successful immigrant groups in the country) and those of Caribbean or Somali background. We could also expect differences between Indigenous applicants based on whether or not they come from a reserve and, if so, where the reserve is located.

Data like this is annoyingly general and can be presented in different ways according to the bias of the reader. But there are some takeaways that are hard to deny: Those of Asian and South Asian background are thriving, rural and poor people get the short end as they always do, and there is a persistent underrepresentation of Black and Indigenous students in our ranks.

That “Asian” cultures are succeeding to the point of overrepresentation in a profession like medicine is generally unsurprising. Indian and Chinese immigrants in particular have succeeded everywhere they’ve gone throughout history, from Malaysia to America to Fiji (which puts the lie to the racist slur that their success stems from their “white adjacency”). There are many reasons for this - from family dynamics to cultural commitment to education to their propensity to not commit crimes or have children out of wedlock - but internalizing white supremacy isn’t at the top of the list (what kind of supremacists would we be if we let others beat us at our own game?). And if systemic racism is to be judged by crude equity outcomes, then you’d have to conclude it is these minority groups who are doing most of the discriminating. Just saying.

The plight of the rural and poor (and often rural-poor) is nothing supernatural. The divide is as old as time. Rural white people in particular are viewed as the backward bigots of society and their woes largely fall on deaf ears. As a woke colleague of mine used to say, “it’s not up to them anymore.” C'est la vie.

As an aside, the Khan study does hint at the role played by class. By the numbers, medicine is no longer a man’s game. And it is no longer a white people profession. But it does, unequivocally, remain an occupation of the affluent. How else do applicants find the time to do all that DEI volunteering and book trips to go take pictures with Ghanian orphans? Even among our most disadvantaged, class rules. I mean no disrespect when I say that next time you hear an inspirational story about the first Black, Mi'kmaq, Inuit, etc person becoming a heart surgeon, put your money on the relative means of that person. They may not be rich and powerful by national standards, but to most they will be “privileged”. 

The discrepancy in Black and Indigenous candidates is one place where the diversity establishment at least has a shred of a point. Broadly speaking, they are underrepresented. There are nuances therein, but fair enough. What do we do with that information? It was as though COVID and George Floyd erased all memory of the pre-2020 world. People somehow forgot that medical schools, along with law schools, graduate schools, and every other department of higher education in the country, have been seeking qualified applicants from minority communities (and black and Indigenous ones in particular) for decades. At this point, when activists say that we have to “dismantle” and “diversify” and “include” and all the rest of the Newspeak, what they’re actually saying is that we should disrespect members of these communities by lowering the standards for them (more than has already been done) and pretending that this has no impact on them or on the people they will ultimately serve. If you want poignant examples of this mindset, consider that Harvard discriminated against qualified Asian applicants because they were too competitive, California is getting rid of the SAT in favour of a “multi factor” admission score (which intentionally adds subjectivity to the process), and public schools are changing the way grades are assigned in order to rig the game in favour of those failing to keep up.

A less racist and condescending solution might be to address the things that make people fall behind in the first place. This, too, has been attempted for decades, with varying degrees of success. Laws like the much-promoted American No Child Left Behind Bill Act - which sought to bring poor and minority students up to a certain proficiency level through negative reinforcement on the schools themselves - met with mixed reception and even mixier outcomes. It just isn’t that easy to meaningfully and sustainably change educational achievement at the group level, no matter how well-intentioned the effort. The evidence would suggest that the success of Asian and other minorities in the medical profession (and the lack thereof in Black and Indigenous communities) reflects the power of cultural norms, and highlights the difficulty in finding true solutions, rather than the intractability of white supremacy. 

So what do we do? Unfortunately I don’t have anything especially novel to say. These problems have deep historical and cultural roots and have proven less than amenable to silver bullet solutions. But what we can do is try at all costs to avoid making things worse. Lowering standards to attract those from minority groups has a long and sordid history of compounding the problem and benefiting those who least need the help (the old lament of the Critical Race Theory types is that the greatest beneficiaries of Affirmative Action programs are actually white women). What’s more, our patients and profession deserve the best, and attempting to socially engineer at the level of acceptance to professional schools is the wrong point of contact with the problem. By all means, put resources into such communities to improve primary and secondary education (but do it intelligently!). Recruit bright and promising students early and mentor the living hell out of them. And, sure, if there are two applicants with comparable qualifications based on objective criteria, choose the one from the historically disadvantaged group if you must. But stop with all the white supremacy nonsense and recognize that the profession and our patients are too important to play these games.

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Thanks for reading. For more from this author on wokeism in medicine, read Of gods and (medicine) men

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