Race & Health: History of medical racism

Race and racism are based in history, and how humans thought about the physical differences. Early conceptions of these differences were focused on physical adaptations across geographies around the world. This thinking evolved over time: explanations for these differences changed as human history and science evolved. The associations between disease and race grew closer over time, however the extent to which this can be explained by science is limited. Listen to learn more about this evolution, and the impact that this has on today’s medical practices.

Guests include Erica Charters, Professor of the Global History of Medicine at the University of Oxford, Carlos López Beltrán, Senior Researcher at Instituto de Investigaciones Filosóficas, National Autonomous University of Mexico, and Alexandre White, Assistant Professor in the Johns Hopkins Department of Sociology and in the Department of the History of Medicine.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Delan: Hi everyone, welcome to the Race & Health Podcast, partnering with Lancet Voice. My name is Delan Devakumar, Professor of Global Child Health in University College London. In this series, we'll be picking up topics from the previous Lancet series on racism, xenophobia, discrimination and health. And in this episode, we're talking about the history of race and racism and how it relates to health and the impacts that it continues to have now.

In our conceptual model in this series, at the core of how racism leads to health are the structural causes and history is fundamental to this. So I've got three wonderful guests to talk about this and to really to educate me in particular. First I have Professor Erica Charters who's a professor of global history of medicine at the University of Oxford where she's also the academic lead of medical humanities.

Her research examines the history of disease and its relationship to British and French imperialism and the long history of tropical medicine. Then we have Professor Carlos López Beltrán, who is a senior researcher at Instituto de Investigaciones Filosóficas, the National Autonomous University of Mexico.

He's a historian and philosopher of biological and anthropological sciences, working on the historical and conceptual roots related to biopolitical notions such as hereditary race, mestizaje, between 1700 and today. And then finally we have Dr. Alexandra White who is an assistant professor in the John Hopkins Department of Sociology in the Department of the History of Medicine and is also an associate director for the Center for Medical Humanities and Social Medicine.

His work examines social effects of epidemic outbreaks in both historical and contemporary settings and the global mechanisms that produce responses to outbreak. Can I open with a very broad question just tell me about The historical roots of race and racism, Erica, if I can come to you first, please.

Erica: Yeah, thanks, Dan. I think thinking about the history of race to me is actually one of the reasons that I became a historian, not so much just to focus on race, but partly because I think history can sometimes open up these different avenues of examining questions and examining views that we take for granted today.

So one of the things I find very interesting, especially the period that I research most intensely, is 1700s, so before the 19th century. And in some ways we can think about this as a period before the rise of racial thought. And not so much that people don't, say, notice things like skin color, or physical identifiers, but there's a different way of thinking about what those mean.

Very often I find in the writings I look at, people are much more interested in thinking about religion, say, as a kind of category of identity, and even a physical category of identity. So I think it's a thought process for us where we can use history to say, okay, what do we think of as being?

Most important identifiers, but also why do these change? The other point I'd want to stress is also thinking about how people understand bodies very differently in the past. And again, this is what interests me, is how things we take to be so basic and in some ways kind of firm and tangible, actually had different interpretations in the past.

So one way of capturing this is that what I like to call the pre modern body is much more flexible and adaptable and malleable. People really did think that bodies themselves adapted and changed in response to environments and climates. In someone's own lifetime, and the implications of this is that very often people assume that the reason why there's all these different looking people in the world in different races is simply because it's a response to living in different parts of the world, and so if I moved from Britain to India, my body would actually physically change in my lifetime to adapt to that climate and adapt to those diseases, but therefore also become physically different.

And our notion of race, which I would say is something a bit like having fixed, heritable, corporal differences, and those stay the same throughout our lifetime, that's actually not present through all of our historical record. 

Delan: Thank you. And of course, this was a time before kind of understandings of Genetics and heredity, and I don't know if you have the answer to this, but when did those kinds of concepts come in?

Erica: So I know Carlos and Alexandra will have some of their answers on this. One thing which I find very interesting is, of course, a lot of European theories of thinking about bodies as being more fixed, even if there's not necessarily our modern understanding of, say, genetics. It really does start to align with experiences of colonialism.

So when Europeans are going overseas and partly as a response to the observations they have when they think about, all right, why are bodies responding in these different ways? Why do they respond differently to different types of disease? And how should we interpret that? So in my research, I argue it happens somewhere around the 1700s.

Other people have argued it happens earlier in different contexts and this is where we can think about how it's as much the kind of social and political and cultural context that are shaping these medical and scientific theories and so it can also vary depending on where we are in the world.

Delan: Thank you. Carlos Alexandre? Carlos? 

Carlos: I've been interested exactly in the period Erika is, pointing towards. That is when heredity starts becoming to an important notion to understand bodies and diseases. Somehow it, it's a main factor, heredity, to consolidate our modern notion of race.

So disease and race are two notions that become intimately connected after the 1700s. So race in this modern physiologically and anatomically based notion was seen was began to be seen as the consequence, the existence of races began to be understood as a consequence of hereditarily transmitted physical traits.

A typical character would be skin color, but there were many colors associated to The emerging races that were seen as not good or not perfect and as somehow different from the typical well constructed body of the Europeans. African groups, for instance, were described as being the consequence.

Of accumulation of hereditary diseases or of the skin, or of different parts of the body. This was asserted by many authors. For instance, blooming ba, who is considered the father of physical anthropology stated that black skin color was originally a disease that beca became incorporated to a whole continent and and it became, as he said, a second nature. So the 18th and 19th century notion of degeneration became to be used to describe this drifting away from away from the typical to European white body of of the different races that populated the different continents.

And basically it was Seen as as analogous to drifting away from the right path. 

Delan: Thank you. So that's really interesting. And this idea of the typical person or the typical body being the white European person. And then a deviation from that to everyone else. And that's fascinating.

And this sort of hierarchy is built into that coming in the 1700s. Alexandra, would you like to take this one? 

Alexandre: Yeah, I think the as everyone's once said, I think really what in the 1700s is really this emergence in particular in certain ways of an ideas of particular races as we could say, biologically constituted in particular ways.

But I think what's important to recognize, especially as we move from the 1700s to the present and really into the 19th century and 20th century, especially is that. Signifiers of racial difference tend to transform and shift and are not are not stable categories, right? So we have in, Linnaeus's, for instance, taxonomies on, on, on different races we have the blurring of both what we might call Physiological characteristics with notions of cultural or psychological differences, behavioral differences.

He references that, Africans are governed by caprice, for instance, right? Which is a claim that is not, we would not necessarily see as biological, but is something that in which, behaviors are tied to innate characteristics that can be linked to particular racial groups. And I think that as you see, moving into the 19th century, With the emergence of not only eugenics, a form of accepted science at the time around pop the perfection we could say of population according to particular racial groups, as well as the assu assumed erasure of other groups over time through evolution or in other spaces with racism in the space of medicine, more particularly, especially in colonial settings.

ideologies and concerns about the capacity of infectious disease to spread from colonized groups in Africa and Asia and elsewhere to colonial populations were linked to both ideologies and concerns about presence of disease within certain populations, but also the fact that something innate to Colonized cultures were fundamentally risking the lives of colonial populations and also putting their health in danger.

So we see the ways in which as Stuart Hall might say, that race is a floating signifier in that it's racial difference is constituted by somewhat a grab bag of what we might see as negative traits that are contributed to this wider racist feelings and sensibilities. 

Delan: Can I press you a little bit on that interaction between science and the kind of colonial powers, because it seems like race was used by the colonial powers in their advancement of their empires.

Is that right? How deliberate was that? 

Alexandre: I'm very deliberate. I think that, we have to think about, first, we have to think about kind of European imperial projects as somewhat being total projects which involved the accumulation of vast amounts of knowledge for the purposes of colonial control in in colonial sites, not just in the fields of politics and the military or what we might call colonial statecraft, but also in areas of science in anthropology and medicine itself.

What I mean there is that and a host of historians of anthropology have written about this, but the ways in which cultural knowledge was produced for imperial actors or in terms of, how anthropological knowledge about different cultures, different populations in colonial sites was produced, Was meant to serve the practices of empire, serve the tools of governance.

And similarly with medicine, you saw similar things. In, in many cases, especially across across Africa in the late 19th century, you saw racial segregation. Of colonial cities being justified explicitly along concerns for infectious disease spread, potentially in Cape Town in 1901, where I've written about this, racial segregation was imposed through quarantine camps in response to an outbreak of an epidemic of play of bubonic plague, for instance, in West Africa, similarly in French colonial cities.

Distinctions were drawn in terms of who can live where in terms of residential segregation along perceived risks of malaria spreading from indigenous populations to colonial populations and there are many examples of this. 

Erica: Yeah, I wanted to add to Alexandra's. I think this broader question about what is the relationship between science or scientific medicine and colonialism, especially European colonialism is a big one.

It's obviously a very hot topic. And I think one way of thinking about this question for historians is whether you can actually separate out scientific and medical knowledge from broader frameworks of understanding the world, right? And that's not to say that we think. Science is constructed, but I think it's another way of thinking about the role of scientific frameworks and how they're shaped also by broader ways of thinking about the world.

So I think one another example to add to Alexander is when we think about the category of tropical medicine and the category of tropical disease. So Coming back to how in some ways this built on again, these observations that people had about how tropical climates these environments called tropical seem to have their own types of disease.

And again, this is partly, it's definitely based on observations that are tangible, but it's also based on shifting disease ecologies in different parts of the world, right? With cholera, In India, and you have the decline of plague in Europe, people notice that there seems to be diseases associated with locations.

This feeds into different theories. And what then you result the end result in some ways is this framework of thinking about the world where geographies are partly geographies of disease. They then map onto you. Different kinds of colonial endeavors, right? There's a, there's an interesting overlap between areas that are called tropical and areas that are part of European colonies.

And I think the implication then, if we think about this for medicine, is not only that it's shaping these categories, right? So who should study? Those diseases, how should they be interpreted? Who do they affect? But also these broader questions about how do you solve the problem of disease, right?

Because if you suggest that actually disease is part of a climate, then there's also this suggestion that therefore, okay, as long as you can't change the climate, those places will always be disease ridden. And so I often think this is a really nice way of how this framework of race is also tied into broader questions.

frameworks about geography, about disease causation, and even today, our notions of global health, right? Global health doesn't mean everywhere in the world. We use global actually to talk about certain places, and it's also an argument about methodologies. Is it about climate? Is it about ecological conditions?

Is it about socioeconomic conditions that we think of as being the causes behind uneven rates of disease? Because clearly some parts of the world have greater burdens of disease than others. Part of this is a debate over what explains those differences. 

Carlos: I'd like to exemplify this notion of the way medical science and the sciences in general are constructed, the way they are developed and conceived, did have after the 17th century.

An inbuilt colonial racially motivated bias. This can be exemplified very easily if we think that in the Americas had a previous colonial time frame than other parts of the world. Even after the our region became independent politically independent from Europe, our local elites Adapted and adopted the sciences and the medical sciences, many of the physicians were trained first in France and then in North America and created a situation which we describe as internal colonialism.

There were some people that were thinking that probably the best way to understand Bodies and diseases that were present in the different regions, for instance of Mexico, would be to incorporate local knowledges and local therapies, etc. But that was not, for a long time, a general idea. Usually, the mental frame and the approach was a colonial approach that was adopted by the local elites.

from European scientific development, so in a way, the colonial situation persisted for a long time. 

Delan: Thank you. If I can take you on a little bit, and all of you have talked about health and health outcomes, tell me a little bit more on how these concepts of race and underlying racist ideologies resulted in differences in health outcomes.

Alexandre? 

Alexandre: Yeah, I'd be happy to provide, a particular example, I think, especially from the United States, where We have significant issues with certainly with health disparities along racial lines in, in, in the U. S. And I think this is something that has become much more evident in the public eye recently, but it's been something that many of us have been studying and trying to Respond to in both social scientific, historical and clinical spaces over many years.

But I think, the one example we can look at is the ways in which, especially in the late 19th and early 20th centuries beliefs about racial difference led to fundamental assumptions in medical spheres about the physical differences in human bodies along racial lines. And one example would be related to the The work of Samuel Cartwright and spirometry and pulmonary health, in particular.

Cartwright conducted a number of experiments during the Civil War, especially on enslaved and formerly enslaved peoples during, in the late 19th century. And came to the conclusion that black people had fundamentally different differential lung capacities than white populations.

Later this belief of this was taken up by eugenicists like like Hoffman and others to suggest that actually that this indicator of Ostensibly black lungs having limited air lung capacity and the prevalence of tuberculosis within African American populations was fundamentally an indicator of the race itself would eventually die out and that.

Genocide by disease and by physical insufficiency would have, would be the result now at the same time, I want to stress also that for all of this seeming to be purely settled science, there were always those who were resisting and responding and fighting against. These arguments are a variety of ways and resisting kind of the science, what was seen at the time as a scientific status quo or the Genesis status quo scholars like W.

B. Du Bois Kelly Miller and others destroyed many of the statistical arguments that propped up eugenics, though, their their arguments may not have been widely accepted we would say that, mathematically they were Easily confirmed and resisted these eugenical arguments, but very much we see ways in which racial difference came to mean actually fundamental physiological difference in a number of different ways to race scientists and clinicians and doctors of the period that would lead to differential diagnosis.

Care and treatment and when in many ways we still see the legacies and effects in this in physician bias today, as well as in some aspects of how medical algorithms are constructed to account for racial difference. We have in the United States, especially particular ways in which organ function tests are.

Are corrected according to racial difference. Now, in, in some cases, this has been as a result of attempting to actually ameliorate disparities in health, but in cases like the pulmonary function test, we can in, in many ways, trace certain forms of race correction in, in pulmonary function back to that late 19th century period when it was believed to be it was believed that Black people's lungs were fundamentally different and inferior to those of the white population.

Delan: Thank you. We have an episode, I think it's a fifth episode in the podcast on kidney disease that explores some of these renal race correction algorithms that lie behind renal function. Carlos? 

Carlos: I'd like to use this phrase that Alexander used, that disease is being distributed or separated along racial lines.

In the Americas and in Mexicos particularly, we have this peculiar situation where these racial lines are within individual bodies. So at some point, due to both demographic and biopolitical debates in our region during the 19th century people landed on, on the notion of the admixed body, the mestizo as a.

Characteristic of our region is very common to, to hear the phrase, we are all mesti no matter what our ancestors are. So what began happening is that the racial lines as I said are in individual bodies. So the pathologization, the racialized pathologization. Use the Mestizo as as a site.

Very early on some people have called the diagnosticators of the region began ascribing to the Amerindian or the African and Amerindian side of our bodies all the negative elements and so that all these eugenic programs of trying to purify or to better the races by bringing in European migrations or by Why is a eugenic weddings coming together, but and that has carried on to our day.

So every time there is a some health related problem, national problem, or regional problem. Physicians tend to try and situate in the dark side, in the Amerindian or the African side of our bodies, the origins of these ills or these diseases. The most recent example is the epidemics of diabetes we've been having.

This notion of the the thrifty genome has been used to explain why our bodies accumulate more body fat and are more predisposed to, to diabetes. And this is because our Amerindian ancestors while they were migrating into these regions, they went through several periods of famine and scarcity and that there was an adaptation to that sequence where this genetic predisposition To accumulating and holding on to fats and a and this hypothesis has been proved not to be very empirically supported, but it's used com continuously to point towards the genetic composition of AM of our aminian side.

To explain why we are more, uh, predisposed to these diseases, obesity, diabetes and in a way that moves the gaze away from other more obvious environmental or nutritional factors that probably would explain a bit better what's going on. 

Delan: Thank you. And that's important, isn't it?

And how these ideas of race and behavioral characteristics can take people's understanding away from what might be happening, be it nutritional causes, environmental pollution, other exposures, and people blame it on someone's race. They should or could be putting their emphasis somewhere else. 

Alexandre: I think it's I think it's important to note that also um, the knee jerk reaction to you could say the kind of racially motivated knee jerk reaction to assume disease prevalence or lack thereof in certain certain regions or within certain communities as a function of racial difference still exists today in the, um, in the early periods of the COVID 19 pandemic in the U.

S. and elsewhere, there were arguments about, potentially the

the resistance of African Americans in the United States to COVID itself and to, and of Africans to COVID itself in a host of different articles that was ultimately proven false once collected, once more data was collected and it's in the United States, especially separated by by racial groups as understood by the U.

S. Census. But we see, time and time again, these assessments about especially certain infectious diseases and prevalence in, or prevalence being affected by racial classification kind of emerge, especially during moments of kind of acute. Epidemic spread. 

Delan: Yeah. And we go into these concepts a little more in the first episode of the series, which is about COVID 19 pandemic and the reality, at least in the UK, which I think was mirrored in the US was higher mortality amongst black populations and other ethnic groups.

Erica: I will say that Carlos and Alexander, I think, have covered this point extensively. And maybe just to add, a few points here, because I think Alexander's point. point at the outset about the kind of conflation of race and culture is really important, as I think we're all saying, and also these theories of causation so maybe there's observable differences in one way or another, and then the question becomes, how is this interpreted?

And I think, again, for historians, This is why it's not only an interesting point to try to define what we mean by race, but to think more generally about how medical frameworks, right? Medicine is done by humans, and humans have culture, we're social animals, we're cultural animals, and so one of the things often to think about is how these medical practices, therefore, necessarily are also part of cultural frameworks.

And I think this is why then when we look at modern theories, right? So you can see how broader notions Of even public health and very often things which we might think of as being you're having good motivations, having humanitarian concerns about improving the health of others about improving the health of, say, the poorest communities in our society, whether it be, say, In Japan, or whether it be in the Americas, all of this relies on different theories and questions about causation.

The one thing I'd add, which I find very interesting, is in the 19th century, you also get, in some ways Medical practitioners trying to push back against some of these theories, right? And I think that's another thing to keep in mind is medicine doesn't just spread around the world as a kind of blanket.

And everyone simply takes it. You have a lot of people who take that and then adopt it and use it also for their own ends. And so I think a kind of nice overlap here is where you see medical people thinking about. New ways of physical categories and race and health according to nationalism. So you have this pushback, say, in Brazil in the 19th century the tropicalistas that want people to look at nutrition rather than say, again racial types.

And so using this medical knowledge that they've actually acquired very often in European medical schools and reinterpreting it in new ways. So it's a very dynamic process in, in, in many ways. 

Carlos: When we were doing research on genomics, especially human genomics in Mexico and Latin America, we frequently came across this problem that was pointed us.

to us by researchers, the way they were classifying and categorizing the research groups often using the local racializations, the Mestizo or the different regional the designators for the different groups. But the problem they had is that when they tried to publish their results.

In journals, especially in important journals, most of them are in the north. They had to translate into what would be accepted and understood as a proper racial category by the referees of those journals. For instance, Mexican researchers have to use admixed Mexican populations as a general category that does not exactly capture how they were thinking about the different groups.

And I, this, I think this creates a kind of perverse cycle where once these papers are published, then people start using those designators that are not adequate to understand how people understand themselves. I think it was Bourdieu who called this the cunning of empirical, imperialist reason, where, the way the United States has constructed a racialized set of categories is influencing constantly how other people describe and racialize their regions.

Delan: Thank you. I wonder, Erika, you mentioned that you worked on British and French imperialism because at least nowadays, French take a very different path in not collecting this kind of data. Do you have any thoughts on that? 

Erica: And again, I think this is this interesting point. And Carlos is, as he's saying is the categories and language, right?

Language here is shaping not only categories, but then thinking about which data is collected. And you're right that the French are this interesting case, especially because of the impact of the French revolution and how, again, We can think about how race is one category, religion is another category, it's a very interesting point, therefore, about when we're collecting data, when we're putting together those surveys, which categories are used what the, what terminology is used, and then of course how that's going to shape not only what's collected, but the interpretation of it.

And I do think it's very interesting, you have these case studies in some places of how Locations in parts of the world where one part has been a British colony and one has been a French colony and how in some ways then you get very different interpretation of the same kind of health context.

Not only in terms of those categories, but also in terms of causation. I think, again, this, to me, it's a nice point about how the historical record isn't flat, right? That there's these variations, not only when we want to talk about empire, I notice we tend to think about European empires only, but also to think about differences within Those Western empires too, and how they function and how they play out in different levels.

Just to talk more broadly about history, because I feel like, especially over the past few years but if you're a historian, especially of race and medicine, very often part of your role has been to talk to medical students, medical practitioners, and in some ways to try to explain what's a very complex.

And say five minutes before an anatomical class is taught or something like that. And one thought I had is very often what this means is that I, History becomes a repository of problems, right? And one of the things I'd want to try to get us to think about is, it's not just that everybody in the past, therefore, was racist.

And we've conquered that because now we understand what racism is, or even that History becomes this area where you go back and you collect horrible stories, because I see two issues with this, right? One is, I think, what historians call a kind of genealogical version of history, where what happens in the past is thought to cause directly outcomes today, right?

So we can see this when people talk about the history of, say, a medical invention that, one person is doing this in the laboratory and then today you have penicillin. And I think historians very often are unhappy with that kind of notion because it suggests that there's this direct causation between one act to where we are now.

And I think we want to think about how that can also be the case when we're thinking about the role of race and health, right? I think what's much more helpful is to think about history as showing us how medicine is a process and that therefore the line from A to B is not always direct.

There's a number of individuals who are involved, not only, say, in laboratory developments, but even in these theories. And partly also I think that helps us to see how saying Okay, these bad formulas, this bad framework is out there. Now we've figured out where it is, and rather to think about how very often a lot of these ways of thinking incorporate Some racial frameworks and other things that are not some things that are problematic and other things that are not and so we can't simply get rid of history and then simply move on with the happy present with our kind of modern enlightenment, because I would say, of course, that's also what a lot of The European imperialists thought that they had progressed beyond those before and now we're in an enlightened age.

Yeah, 

Carlos: I would ask the question how much history do physicians and medical people need to know in order to orient themselves and their choices and which paths lead astray and with which paths. I think that's would be better taken. Usually the, especially for physicians the amount of things they need to learn is so much that they leave too little space for humanistic subjects.

And I think that could be corrected. 

Alexandre: I think, I completely agree. I think that, what part of doing historical work. Especially, when it's historical work on histories of race and racism, we have to recognize the incredible durability. Of these ideas and concepts to persist, to mutate and transform into, as over time and we see these traces in many different places around the world and perhaps with different routes, but they, their emergence or the reemergence, um, maintains in particular ways in our present.

And we need to take that very seriously. 

Erica: I also think one way of thinking about this is I often think it, like I said, I always feel like it's empowering in some ways to know. The past in the sense of to make part of history is that actually people were very different than we are today.

So for example, this notion that your body is so malleable and flexible. I think the power of that it is it lets us realize that there's a number of avenues for future thinking, right? It opens up our possibilities, partly because we don't see a straight line trajectory from the past to today.

So I would say Maybe this is less about having very specific historical knowledge but rather thinking about how when we can see that there's a number of opportunities, a number of roots that were taken and roots that were not taken in medical research in the past, then that also lets us think about opening up different ways of thinking about how research should be conducted and which questions are used, partly because there actually isn't an obvious way 

Delan: Thank you very much.

So I, history is crucially important to our understanding, and I learned very little history, in fact. I'm going back to my schooling, let alone in medical school. I think it's fundamental to how we think about what happens today and moving forward as well. So thank you very much to all of you.

This has been fantastic and I've learned a 

lot as well.