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Department of Radiation Oncology, University of Michigan, Ann Arbor, MichiganCenter for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
Recent events have reaffirmed that racism is a pervasive disease plaguing the United States and infiltrating the fabric of this nation. As health care professionals dedicated to understanding and alleviating disease, many radiation oncologists have failed to acknowledge how structural racism affects the health and well-being of the patients we aim to serve. The literature is full of descriptive statistics showing the higher incidence and mortality experienced by the Black population for health conditions ranging from infant mortality to infectious disease, including coronavirus disease 2019 (COVID-19). Acknowledgment that the root of health disparities experienced by Black people in this country are based in racism is essential to moving the nation and the field of radiation oncology forward. With this lens, a brief overview of structural and institutional racism shapes a discussion of what radiation oncologists and the organizations that represent them can do to address this scourge. As members of a technological field, we often harness the power of data to advance human health and approach challenging diseases with optimism that multidisciplinary effort can produce cure. A few principles to mitigate the longstanding issues of Black marginalization within the field have been recommended via the ATIP (Acknowledgment, Transparency, Intentionality, and rePresentation) and LEADS (Learn, Engage, Advocate, Defend, Support) approaches. However, additional introspection is encouraged. Just as individuals, practices, and organizations rallied to determine how best to address the issues related to the COVID-19 pandemic, the same investigational fervor must be applied to the issue of racism to combat this sinister and often deadly disease.
Introduction
A Black man was killed by police, inciting protests around the world. In what some would call a “postracial” America, watching George Floyd asphyxiate to death, his life slowly choked from his body, will not soon be forgotten. Nor should it be. Anti-Black racism is a pervasive disease that plagues the United States and infiltrates the fabric of this nation. As health care professionals dedicated to understanding and alleviating disease, so many have failed to acknowledge how structural racism affects the health and well-being of the patients we aim to serve.
A 2016 perspective published after the police killing of another Black man, Philando Castile, admonished that “as clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism.”
And although health care workers who decided to take a knee for 8 minutes and 46 seconds to speak out against racial injustice are to be applauded for at least acknowledging the issue, when will substantive change happen?
As the world acknowledges the deadly consequences of systemic racism, many professional organizations have issued statements of support and solidarity. The American Society of Clinical Oncology was direct in the condemnation of the treatment of communities of color and called upon its members to “confront and address complex forces and systems that have created disparities in cancer prevention, diagnosis, treatment, and research.”
So it was disappointing to see the lackluster response issued by the American Society for Radiation Oncology (ASTRO), an organization that claims diversity and inclusion as a core value.
ASTRO's “All Lives Matter” confession dilutes the message and fails to speak directly to anti-Black violence or to acknowledge the problem of systemic racism within radiation oncology. It sanitizes the murder of George Floyd as an “unnecessary death” and weakly conflates it with multiple social issues while failing to give weight to any of them. Their response left many Black radiation oncologists pointedly asking “Do we matter to you? Do you see us?” The message was tone-deaf; the end result highlighting that one of the most evidence-based specialties in medicine has grossly ignored the evidence.
Violence Against Black People Is Not New
Rodney King was viciously beaten by 14 Los Angeles police officers in 1991 while a civilian recorded the incident from a neighboring balcony. Even with the incriminating video, the 4 officers charged with excessive force were acquitted owing to insufficient evidence. Almost 30 years later, Black people continue to suffer brutality and murder at the hands of racist Americans in addition to the men and women charged to protect and serve.
For Black Americans, the consequence of racist policing is death (Table 1).
Eric Garner repeated the words “I can’t breathe” 11 times; those same words haunt us as we watched a handcuffed, unarmed George Floyd pinned to the cement, saying “I can’t breathe” and calling out to his deceased mother. Emmett Till must have also called out to his mother, who could not protect her 14-year-old son from being kidnapped, tortured, and lynched in Mississippi in 1955 after being accused of whistling at a White woman.
Sixty-five years later, similar acts of violence continue to plague Black victims.
Table 1Deaths of Black Americans due to lethal force by law enforcement is not new: Chronical of several incidents of racist policing
Victim
Date
Location
Status
Circumstances of death
Outcome
Oscar Grant (age 22)
1/1/2009
Oakland, California
Unarmed
Murdered by a transit officer in Oakland, California while he was pinned to the ground in a train station
Guilty of involuntary manslaughter; sentenced on 11/5/2010; released on 6/13/2011
Eric Garner (age 43)
7/17/2014
Staten Island, New York
Unarmed
Killed by officers when he was put in a chokehold and pinned face down on the sidewalk by multiple policemen. He pleaded with the officers, repeating the words “I can’t breathe” 11 times
No indictments
Michael Brown (age 18)
8/9/2014
Ferguson, Missouri
Unarmed
Unarmed, shot and killed by police officer
No indictments
Tamir Rice (age 12)
11/22/2014
Cleveland, Ohio
Replica toy gun
Shot by police offers within 10 feet while at a local park
No Indictments
Walter Scott (age 50)
4/4/2015
North Charleston, South Carolina
Unarmed
Motorist shot in the back and killed by a White police officer in South Carolina after a routine traffic stop for a defective brake light
Charged with second degree murder and sentenced to 20 years in jail
Samuel Dubose (age 43)
7/19/2015
Cincinnati, Ohio
Unarmed
Motorist shot and killed during a traffic stop for a missing front license plate
Indicted for murder and voluntary manslaughter; after 2 mistrials the charges were dismissed
Christian Taylor (age 19)
8/7/2015
Arlington, Dallas
Unarmed
College student shot by police after trespassing at a car dealership
No indictments
Philando Castile (age 32)
7/6/2016
Sant Paul, Minnesota
Declared licensed firearm
Pulled over for nonfunctioning brake lights. The victim declared the licensed firearm to officers when asked for license and registration. Shot close range, hit with 5 of 7 bullets with girlfriend and 4-year-old daughter in the vehicle at the time of the shooting
Charged with second-degree manslaughter and acquitted
Stephon Clark (age 22)
3/18/2018
Sacramento, California
Unarmed
Shot and killed by officers in the backyard of his grandmother’s house. Twenty rounds fired, including 8 bullets that murdered him; 6 of them in his back
No charges filed
Atatiana Jefferson (age 28)
10/12/2019
Fort Worth, Texas
Unarmed
Neighbor called nonemergency number after noticing the victim’s door was open. Police arrived and shot and killed her through her window
Officer indicted for murder
Breonna Taylor (age 26)
3/13/2020
Louisville, Kentucky
Unarmed
Emergency room technician killed in her home after police enter without warning or identifying themselves, using a no-knock warrant. Eight bullets entered her body
In this regard, the cell phone camera has been one of the most impactful civil rights tool of the past decade, as evidenced in the case of Ahmaud Arbery, whose murder was filmed unceremoniously; or of Christian Cooper, whose camera captured a woman weaponizing the police against an unarmed Black man–her masterful performance a clear illustration of her awareness of systemic racism and her willingness to evoke the injustices in the police system as her personal weapon.
The Importance of Centering Black Issues
“All lives” cannot matter if Black lives do not. In this vein, it is time for our organizations and their membership to devote dedicated time and solutions to addressing anti-Black racism. Equity of all types is absolutely critical, but aggregating issues into a single diversity and inclusion bucket allows people to avoid the challenging work of confronting racism. Meaningful action to address racism, personally and professionally, has been perpetually delayed. We must place racism front and center to legitimately begin the work of reducing the primary risk factor for poor health outcomes among Black Americans in the United States.
Naming Racism as the Root of Health Inequity
Racism is the belief that one’s race imbues an inherent superiority over others, a belief that has been parlayed into a complex social, political, and economic system established centuries ago to benefit Whites at the expense of others.
This country was built upon the backs of African slaves who were corralled into submission by violence that would make the actions of the officer who killed George Floyd appear docile.
The apologists who claim slavery was not racist because some slaves were not African deny the fact that the US government, led by White men, enacted laws in 1705 that made slavery a race-based institution, rendering White skin better than Black.
This is where the whitewashed history taught in schools, colleges, and universities has stunted progress toward removing the stain of slavery and racism from our country. Although overt bigotry and hatred are certainly more egregious manifestations of racist behaviors, one can be antiracist and still benefit from the tenets of racism. We cannot begin to heal until the racist underpinnings of this nation are acknowledged and repaired.
More apropos to this discussion is how persistent racism, both individual and structural,
is the root of health disparities experienced by Black people in this country. The literature is full of descriptive reports parading statistics of the higher incidence and mortality experienced by Black people for health conditions ranging from infant mortality to infectious disease, including coronavirus disease 2019 (COVID-19). The same structural barriers that make the Black population more susceptible to COVID-19—endemic poverty, poor access to high quality education and healthy nutrition, and inequities in the health care system—have created an environment that breeds disparate health outcomes for Black people. Yet these inequities are so pervasive that many, particularly those in positions of influence, cannot see past their own biases, the inherent individual racism, to see that a problem exits. Stating there is no racism in the police force is a prime example. Understanding the historic and current fact of racism, the structural inequities facing Black people, and coming to grips with one’s own conscious and unconscious biases will be crucial to moving this nation forward and improving health care for all.
How Anti-Black Racism Destroys the Radiation Oncology Workforce
The lack of Black representation in radiation oncology stems from racism; it has been documented for years and harms our patients and mission.
The Sullivan Commission Missing persons: Minorities in the health professions. A Report of the Sullivan Commission on Diversity in the Healthcare Workforce.
More recent articles have reviewed data on implicit bias and has highlighted improved outcomes when minority patients are treated by care providers from similar backgrounds.
More representation is needed. The term “underrepresented” is grossly inadequate, as non-White health care professionals “are largely excluded, and when included, it is within systems that disadvantage and discriminate against nonwhites.”
It may be uncomfortable to read the word racism in this context, but misnaming the problem leads to inappropriate and inadequate solutions, and “the consequence is a deepening division.”
Black people are excluded from radiation oncology by an educational system steeped in racism. Despite comprising 12% of the US population, Black people only comprise 6.6% of the medical school population.
The systematic exclusion of the Black people from medical school is directly attributable to residential segregation, unjust educational funding structures, and numerous other factors that decimate Black children. It is therefore no surprise that half of those who could have otherwise become medical students are eliminated. Similar inequities lead to a decrease in Black representation in radiation oncology residencies.
The residency selection process disregards the well-documented racism against Black students, purporting to judge individuals based on “merit” but with significant subjectivity in the process. Additionally, the veil of racism allows some to disregard the hidden costs associated with medical education that limit entrance into radiation oncology.
The end result is delayed scientific progress and rampant cancer disparities that disproportionately affect Black people.
In light of recent events, any noncommittal response to collective Black trauma is unacceptable; it is time for each of us individually to acknowledge that anti-Black racism is a critical systemic disease. The sequelae include police brutality, health disparities, educational and economic inequality, and professional inequity. It is time for professional organizations to address the deleterious effect of anti-Black racism on the professional lives of its members and commit to implementing needed change.
Practical Steps Forward for Radiation Oncologists
As members of a technological field, we often harness the power of data to advance human health and approach challenging diseases with optimism that multidisciplinary effort can produce cure.
The systemic disease of racism is a glaring exception. Systemic racism continues to have devastating effects on the health and well-being of Black people across the socioeconomic spectrum. Unfortunately, ASTRO has done little to tangibly address this long-standing crisis with the rigor and commitment it merits. When COVID-19 struck, ASTRO, along with radiation oncologists in private practice and academic settings, rallied to address the pandemic and to determine the best pathway forward. Should not solutions to the long-standing epidemic of anti-Black racism be undertaken with the same vigor?
ASTRO and other organizations representing the field of radiation oncology have left their Black members to tackle systemic racism and implicit bias by themselves under an organizational gaze that appears to harbor no true commitment. Issues of health disparities and workforce diversity are often approached by organizations as insurmountable, intractable, and unsolvable.
This perspective must be rectified so that we can propel our professional organizations forward with true inclusivity.
Progress begins by acknowledging the existence of systemic racism both individually and collectively as an organization of radiation oncology professionals. Just as other challenging scientific enigmas allure clinicians and researchers to seek solutions, the same fervor must be offered to diversity, inclusion, and equity. Although this work should not be relegated to a single organization, because ASTRO is the largest body representing our practice and has a stated core value of diversity and inclusion in its 2017 Strategic Plan, we suggest a few principles to mitigate the longstanding issues of Black marginalization within the field using the ATIP approach: acknowledgment, transparency, intentionality, and representation (Table 2). We also suggest principles that individual radiation oncologists and departments can consider via the LEADS approach: Learn, Engage, Advocate, Defend and Support (Table 3). Several concrete steps are outlined herein, but the true hope is that individual and institutions alike will take time for self-reflection and that every organization representing us will similarly invest the necessary time and funds to develop their own way forward.
Table 2ATIP principles recommendations for ASTRO and other medical societies to mitigate Black marginalization and to promote equity
ATIP principles
Concrete recommendations
Acknowledgment
•
Acknowledge that anti-Black racism exists and underpins health disparities
•
Acknowledge that implicit bias exists and is deleterious to the success of Black ASTRO members
•
Acknowledge that ASTRO has historically failed to commit sufficient resources and attention to the problems of racism and implicit bias within its membership
All elected and appointed leaders must participate in training on unconscious bias, microaggressions, and strategies to mitigate the destructive effects of racism
Transparency
•
Transparency in determining pathways to joining the ranks of ASTRO leadership and board representation
•
Transparency about data on ASTRO’s platforms and priorities
•
Transparency about funding and resources devoted to organizational priorities
ASTRO must provide an annual report to the membership body that details the activity and resources spent and available for DEI initiatives
Intentionality
•
Establish diversity, inclusion, and equity as a major area of focus within the ASTRO strategic plan
•
Cultivate a Black leadership pipeline from the undergraduate through faculty levels
•
Require demonstrated commitment to equity and inclusion as a prerequisite for ASTRO leadership positions
•
Dedicate resources toward understanding and eliminating health disparities in radiation oncology
•
Position diversity, inclusion, and equity activities in high visibility time slots and locations at ASTRO meetings
Elected leaders must demonstrate commitment to diversity, equity, and inclusion. Candidate statements for all leadership positions and elections must include specific plans for improving diversity and addressing health inequities
ASTRO’s advocacy lobby must address health disparities in addition to issues of reimbursement
rePresentation
•
Commit to inclusive representation with critical mass, not tokenism
Create a position on the board representing healthy equity from a racial/ethnic group UIM
Abbreviations: ASTRO = American Society for Radiation Oncology; ATIP = Acknowledgment, Transparency, Intentionality, and rePresentation; DEI = diversity equity inclusion; UIM = underrepresented in medicine.
and departmental policies that perpetuate racial inequity
•
Review track record on workforce diversity from staff through faculty
•
Examine recruitment, hiring policies and retention rates
•
Develop policies that clearly condemn and reject anti-Black racism
Support
•
Invest in success of Black colleagues
Quote their research. Nominate them for positions of leadership
Volunteer for their committees and help them produce great results
•
Donate to organizations that support equity and Black advancement (eg, United Negro College Fund)
•
Develop a diversity, equity, and inclusion task force with actionable mandate within the practice. Ensure there is racial diversity within the group, if possible. If the department lacks diverse members, collaborate with other departments that have more success
•
Fund disparities research, especially by Black researchers with particular understanding of these issues
•
Encourage NIH-funded faculty to support Black students via NIH diversity supplement
Abbreviation: NIH = National Institutes of Health.
Medical societies and individuals alike must acknowledge their roles in creating systems of exclusion that perpetuate inequities and support a status quo of the privileged majority. To reduce the burden of anti-Black racism, leading organizations such as ASTRO must prioritize justice and racism and set the example by addressing anti-Black racism directly, seeking appropriate counsel and expertise as needed. The murder of George Floyd is symbolic of what Black people have long been conveying to deaf ears: we die a thousand deaths throughout our lives and careers as a result of anti-Black bias, both blatant and implicit. Our professional environments require that we stifle the challenges of our lived experience to maintain the comfort of our non-Black colleagues. The implication is always that outing anti-Black bias will be detrimental to our success. With this statement, we are standing up and speaking out. George Floyd and the many other Black people sacrificed to deadly racist targeting demand that we stand up and be acknowledged. We are radiation oncologists (Fig 1). Please see us, acknowledge us, advocate for us because our Black lives matter.
Figure 1We, too, are radiation oncologists. Clockwise from top left: Drs Christina Chapman, Darlene Gabeau, Chelsea Pinnix, Curtiland Deville, Iris Gibbs, and Karen Winkfield.
On behalf of the American Society for Radiation Oncology (ASTRO) Board of Directors, I thank Dr Chapman and her colleagues for their article in this edition of Advances in Radiation Oncology discussing racism in radiation oncology. The ASTRO Board of Directors stands resolutely with the authors against anti-Black violence and racism and welcomes the recommendations put forward in the article.
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