January27,2014

TranscriptforInterviewWithRobertBaker
Interviewer:ThisyearsthemeforNationalHistoryFairDayisRightsandResponsibilities, andsocouldyoudiscusshowthedenialofAfricanAmericansintheAMAimpactedtherightsof AfricanAmericanmedicalpractitioners? Baker:BeingamemberoftheAMA,atthetimethatthishappened,roughlyfromthe1870s straightupuntilthe1960s,soalmostacentury,andduringthatcentury,beingamemberofthe Americanmedicalassociationwasessentialforgettingyourprivilegesandhospitalsgivingyou accesstoallkindsofeconomicbenefits,givingyouadvancementsinthefield.Justlikeduring thatperiodtherewereAfricanAmericanbaseballteamsthatsortofplayedinsecondrate stadiumsandneverquitegotthelimelight,soAfricanAmericansphysiciansweredelegatedto secondratehospitalsandnevergotthechancetohavethekindofeconomicsuccessthatthe comparablewhitedoctorshad.Youhavetoremembertheexclusionwasonthestatelevel,the exclusionwasprimarilyinthestateofthesouthandconfederacy,instateslikeNewYork, AfricanAmericansquicklywereadmittedtotheAMAanddidalotbettertothelocalmedical societiesanddidalotbetterineducationstatusandachievementthantheircounterpartsinthe south. Interviewer:Canyouelaborateontheresponsibilitiespromisedfromthetwoethicalprinciples mentionedinyourbook,collectiveprotectionandfairopportunity? Baker:Itsunethicaltodiscriminateagainstanybody,itsunethicaltoviolatethehumanrights andpersonaldignityofanybody.Ifyouprecludethemfromjoiningyoursocietysimplybecause ofthecoloroftheirskinortheirgeneticbackgroundandfortoolong,especiallyintheSouthofthe UnitedStates.AfricanAmericanswerentprovidedequalopportunitytoriseintheirprofession. Thethingthat'sneataboutmedicine,isthatifyourreallygoodyoucanrisetothetopofyour field,andthethingsthatshorribleaboutwhathappenedtoAfricanAmericanphysicians,wasthat alotofthemweretalentedandyettheywerenotabletorisetothetopofthefieldsimply because,asIsaid,thecoloroftheirskinandtheirracialbackground. Interviewer:CanyoudiscussthedenialofAfricanAmericanrightsinthe1847AMACodeof Ethics? Baker:Soyouhaveacodeofethicsthatareappliedequallytoeverybody,sowhathappensis thatnobodysaidbecauseyouareanAfricanAmericanyoucantbeamemberofthemedical society.TheyfoundundergroundwaystoexcludeAfricanAmericans.Theysaidtheyhadntgone topropermedicalschools,theyrelabwasntpracticedinmedicalschools,andsowhat happenedwasthephysiciansfromHowardandothermedicalhospitalsthatadmitted AfricanAmericanswerepresumedtobesecondrateandbecausetheywerepresumedtobe secondrateornotqualified,theywereexcluded.Itscalledinstitutionalracism,nobodysayswe aredoingthisbecauseyoureanAfricanAmerican,whattheydoisfindsomeothervaluerthat

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theyimposethathasthesameeffect.ItexcludesAfricanAmericans,andofcourseitwasunfair toAfricanAmericanpatientswhowantgoodqualityandtoeverybodywhobelieveseverybody shouldbetreatedequally.

Interviewer:Howinfluentialdoyouthinkthecodeofethicsareregardingtreatmentofpatients ofAfricanAmericandescent? Baker:Extraordinarilyinfluential.Illgiveyouanexample,whentheaidepidemicbrokeoutinthe 1980s,justbysheeraccent,theprovisionintheAMAcodeofethics,whichrequiresphysicians totreateverybodywhowassick,withrespecttoallthedangertothephysician'sownhealthor life.Thebasicideaisthat,ifyou'reasoldieryouhavetofightevenifyourlifesatrisk,ifyourea firemanyouhavetoputoutfireseventhoughyouputyourlifeatrisk.Ifyou'reaphysicianyou havetotreatpeopleduringtimesofepidemic,evenifyouriskyourownlife.Thatlinewastaken outoftheAMAcode,inthe1980swhentheaidsepidemichitlotsofphysiciansrefusedtotreat peoplewithaids.Therewasasecondarycode,adifferentcodeforphysicianswhopracticed infectiousdiseasetreatmentsorinternalmedicinethatwillhavethatlineinit.Whenyouchange theAMAcodewhathappensisphysiciansactdifferently.Thethingthathappenedinrespectto AfricanAmericans,isthatpeopleinterpreteditinadiscriminatoryway.Theyactuallyfollowedthe originalcodetherewouldhavebeennodiscrimination. Interviewer:CanyoudiscussthehistorictreatmentofAfricanAmericanpatientsanddoctorsin themedicalfield? Baker:Thecountrywasfoundedinthe18thcentury,andoriginallytobecomeadoctoryouhave togettrainedoutsidetheUnitedstatesbecausetheirisnotrainingofregulardoctorsintheU.S andafewAfricanAMericansdidgettrainedinEuropeandtrytopracticemedicine.What happensisintheNorthweknowthatsomeofthemgetadmittedtoregularmedicalsocieties andtreatAfricanAmericansandwhitepatientsandtheyareacceptedinthecommunity.What beginstohappenintheSouthisthemedicalsocietiesdonotrecognizethesephysicians,so theyareexcludedfromthemedicalsocieties,thebetterhospitals,andthebetteropportunities fortraining.Andtheyaretreatedassecondclassdoctorsandoneofthenastythingsthat happensinthattheyhavethesedirectoriesthattellpeoplewheredoctorsofficesarelocated andforalongtimeupuntilthe1940sthesedirectoriesusedtohavealittlecbythenamesof theAfricanAmericanphysicians,soanyonewouldknowthattheseareAfricanAmerican physicians,itstoodforcolor.Andthatwasapoliteusageatthetime.Bottomline,therewas exclusioninthemedicalschools,therewereexclusioninthemedicalsocieties,thereforethere werefewAfricanAmericanphysiciansavailableandtheAfricanAmericancommunitieswere gettingsecondratemedicalcareandtheAfricanAmericanphysicianswerebasicallyhelplessto providethemwithbettercare.Thatcomestoanendinthe1950swhenthecivilrights movementhits. Interviewer:Howhasthegovernmentinthepastbecomeinvolvedintheefforttoend

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discriminationinhealthcare? Baker:Welleverybodygetsinvolved.ThegovernmentgetsinvolvedintheCivilRightsActs, whichdirectlybansdiscrimination,anditreachesintothehospitalsandthemedicalschools throughmedicareandmedicaid,andissuestatementsthattheywillnotgivemoneytoany hospitalthatdiscriminatessince,medicareandmedicaidandareamajorformoffinancial supportformedicaltraining,andforhospitals.ThehospitalsbasicallyallovertheUnitedStates begintoenddiscriminationagainstpatientsandagainstphysicians.Soitsamassivething,it happensthe1960sandearly1970sanditspartofcivilrightslegislationandisimplemented throughthemedicareandmedicaidprogram.Atthesametime,bythe1970stheAmerican MedicalAssociationrespondstothecivilrightsmovement,andtotheNationalMedical Association,whichwasAfricanAmerican,andbeginstochangeitspolicies.Bythe1980stheres amajoreffortbytheoldmedicalassociationsoftheUnitedStates,bythegovernment,to addresswhattheycallhealthcaredisparities,differentialdatastatisticstreatmentsbetween AfricanAmericansandtherestofthepopulation.Atthesametime,thereslotsofsponsorships forAfricanAmericanstogetmedicaltraining.Itwasamassivemovementstartinginthe1960s intothe1990stotryandcorrectthepast.In2008,theAMAformallyapologizestowardspast historyofdiscrimination. Interviewer:Canyouelaborateontheracialbiasinducedduringmedicalstudies,andisthis biasstillprevalenttodaytoadifferentextent? Baker:Theanswertothatistoacertainextent,yes.Thebiasisstillaroundtoday,andtheway weknowitisthefollowing:notgettingpeopleintomedicalschools,butratherinthewayinwhich patientsaretreated.OneofthemythsaboutAfricanAmericansisthattheyhaveagreaterpain tolerancethanwhitepeople.Itturnsoutthatthatsjustamyth,nottrue.Oneofthethingsyou wanttofindouttoseewhetherornotthestereotypeaffectsmedicalcareisyouaskdoctorsto filloutaquestionnaire,inwhichyoudescribeapatientsufferingfromangina,whichisakindof heartpain,andyouask,whatkindoftreatmentwouldyougivethispatient,whetheryoudrefer themtoacardiologistorspecialistinheartcareornot,andifyougiveindicationsthatthepatient iswhitetheyaremuchmorelikelytotreatthepain,andrefersomebodytoacardiologistthanif yousuggestthatthepatientisblack.Thecuriousthingisthatstudyholdsforwhetherornotthe physicianbeingassessedisanAfricanAmericanorwhitephysician.Sodoweknowthatthere isbiasinthesystem?Yes,wedoknowit.Doesitexistinthekindofheavyhandedoverwaythat itexistedinpriordecades?Clearlynotbecausemedicalschoolsaretryingtogooutoftheirway toopentheirdoorstoAfricanAmericans,andatthepremedicallevelandthecollegesthereare allkindsofprogramsthatextendawelcominghand,givesupport,includingfinancialsupportto AfricanAmericanstudentsthatwanttogotomedicalschool.Soyouvegotasocietytryingto apologizeforpastdiscrimination,tryingtomakeeverythingbetterontheonehand,andyetsome oftheseoldbeliefsaboutracialdisparities,aboutthetworacesbeingdifferentstilllingeronin peoplesminds. Interviewer:Doyouthinktheseprogramsaredoingenoughtohelpwiththesedisparities?

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Baker:Thatsaninterestingquestion!Theyarecertainlymakingabigdifference.Those disparitiesstilllinger,andsoaslongastherearethosedisparitiesyouwanttodomore.Sohow doyoumakeabetterprogramormakethemworkmore?Imeanthatsnotmyexpertise,butI reallywishtheydidworkbetter. Interviewer:Soinyouropinion,youdontthinktheyresufficient? Baker:Theracialdisparitiesstillexist.ThereshouldbemoreAfricanAmericanphysicians, nursesetc.inhealthcare.Thereshouldbefewerlingeringracialstereotypes.Therearemore cominginandthestereotypesarebeingeroded,buttheresstillracialdisparities,andaslongas thereareracialdisparitiesyoushouldbedoingmoretoeliminatethem. Interviewer:Canyoudiscusstheamountofsaypatientshaveonthehealthcaresystemtoday? Baker:Patientshavemorerightstodaythantheyhaveeverhad,however,ifyourasickperson oraworriedpersonyourgoingtobetreatedtodaybetterthaneverbefore,butyouwonthavea lotofsay,no. Interviewer:Whodoyouthinkhasthemostsayregardinghealthcare? Baker:Twogroups:1)Healthcareprofessionals2)Namelessbureaucratsthatdevise programslikemedicareandmedicaid. Interviewer:Describethechangeinthecodeofbioethicsregardingracehistoricallyto currently? Baker:Afterthe1960s,virtuallyeverycodeofmedicalethics,AMAandelsewhere,prohibited discrimination.Oneofthegreatchangesisthattherewasnothinghiddenaboutracial discriminationespeciallyintheSouth,priortothe1960s.Therewereseparateseatingareasand buses,separateplacestoeat,separatetoilets,separatewaterfountains,separateschools,and itwasnthidden.Whathappenedwasfromthe1960sthatbasicallybecameagainstthelaw,and becamebadformitwasnotthethingyoucouldsayordo,andyoucouldntusetheNword.So itwasafundamentalchange,thatwasradicallydifferent.Whatwasslowertochangein medicineandeverypartofsociety,waspeoplesactualattitudes.Ithinkyourgenerationhas gottenmoreopportunitiesandmorepossibleavenuesofmobilitythananygenerationofAfrican Americansinthehistoryofthecountry,buttheresstillhiddenvaluesthatImsureyouwill encounterinyourlifetime.Theressubtleandnotsoeasilycorrected,andthebigbarriersthatwe bulldozeddowninthe60sand70s. Interviewer:Andlastlyisthereanythingelsethatyouwanttoadd? Baker:No,IhopeIveansweredallyourquestionsandhavebeenusefultoyou.