Rahul Biljani, MD

“A virus drove us indoors. A violent death drove many of us into the streets.”

-G. Gabrielle Starr, President of Pomona College

Overall, racism exists and racial disparities in deaths due to police brutality or COVID-19 present important opportunities to consider the role of race, systemic, and systematic biases in medicine. The codes of ethics for physicians, major medical organizations (eg, American Psychiatric Association), honorific societies (eg, 

), and police officers (eg, The International Association of Chiefs of Police) speak to an implicit social contract with the public. Since Hippocrates, physicians have taken a binding oath to guide the moral and ethical treatment of patients while law enforcement officers take an oath to protect and serve. It is a physician’s and police officer’s duty to respond in a medical and public health emergency. Racism, disparities, and police violence against unarmed black men (and women) represent public health epidemics deserving immediate responses.

When the COVID-19 pandemic ignited and spread like wild-fire, the health professions robustly responded. As stated in the Hippocratic oath, physicians are asked to do more and to promote healing.

“I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing . . . Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of 

Hence, we must ask whether our clinical spaces are safe spaces for all (or some)? How do we reconcile that a leading cause of death for black men is police violence? Where is the help we promised the community? Where is the leadership needed within our institutions and professions?

In the Fall of 2014, Black undergraduates across US college campuses engaged in 

regarding racism (eg, #BBUM; Being Black at University of Michigan).

 Following the deaths of unarmed black men, they held die-ins and medical students engaged in “White Coats for Black Lives die-ins.”

 Unfortunately, in 2020 these same groups were again compelled to protest and new hashtags were launched to 

racism, including one focused on faculty and those working within academic settings (#BlackInTheIvory).

 Faced with ongoing racism, violence, and protests within a pandemic, we looked for authentic and empathetic leadership to help heal the nation’s pain. Often, we found delayed corporate messaging, perfunctory leadership, silence, or resignation (ie, a problem “too big to fix”).

There are ethical considerations and societal implications when physicians are deaf, silent, and fail to act. Two examples of ethical lapses involve Nazi 

 In general, the failure of physicians (and the psychiatric community) to respond to Nazi atrocities during World War II is well described. Less well known is Mr Steven Biko’s story where physicians providing care for him failed to intervene after he was beaten by South African police for anti-apartheid activity. Specifically, physicians allowed a semi-comatose Biko to be driven more than 700 miles to a South African prison (and not a hospital), alone, handcuffed, and naked on the floor of a police vehicle. Mr Biko died in detention the following day—the medical community failed to respond. When someone says “I can’t breathe” the medical profession is duty bound to respond. This is a transformational time and physicians can no long sit on the sidelines of indifference; they must act.

There will be continuing surges in COVID-19 cases and deaths as well as a 

in mental health problems due to COVID-19 and police violence.

 Unfortunately, the unequal physical burden, economic hardships, and emotional costs due to (and following) COVID-19 and police brutality will continue to be disproportionately borne by racial and ethnic minorities, low income individuals, and marginalized and vulnerable populations. 

Without mental health, there is no health.

 Thus, psychiatrists are uniquely positioned to make certain this moment is not lost. As physicians, we are ethically bound and it’s our job to advocate for the human being in the human experience, regardless of personal feelings.

We are at a turning point for law enforcement and the health professions where we must ask whether our silence implies consent. Every human body (including black and brown bodies) deserve respect. Every person should have an opportunity to go as far as their hard work and talent can take them. Black and brown people who die before their time due to racism, COVID-19, or police brutality 

more than prepared remarks, notes of sympathy to the family, and delayed and sanitized statements that can be viewed as a perfunctory and fleeting obligation.

 Action can no longer be delayed. We need relevant action-oriented leadership from the psychiatric community to heal this country’s open wounds. Anything less is meaningless.

On June 1, 2020, there were 1,783750 million COVID-19 cases and 98,536 deaths due to COVID-19 nationwide.

 The US began to loosen stay at home restriction while the CDC warned us about additional COVID-19 spikes and hotspots. On June 9, 2020, protests continued as the families of Ahmaud Arbery, Michael Brown, Eric Garner, Botham Jean, Trayvon Martin, and Pamela Turner gathered to attend Mr Floyd’s homegoing funeral. Mr George Floyd was buried next to his mother. Unfortunately, there have been and will be other 

for other unarmed black people to follow Mr. Floyd’s.

This moment in history cannot be lost. When you ask us if we are okay, be prepared to hear us say we are not . . . and never have been. Then be prepared to do more than you have before. Tell us what you plan to do as an ally and 

. We conclude with 7 specific recommendations.

In the end, we will remember not the words of our enemies, but the silence of our friends.”

1. Recognize that racism, disparities, and police violence occur within societies tolerating them. Commit to denouncing discrimination.

 Commit to be an antiracist by condemning groups who spread racist rhetoric, including those purported to be in “jest.” Commit to reviewing and incorporating these antiracist tenets into the patient bill of rights and within APA ethics documents as appropriate. Commit to sharing these tenets with other professional societies and accrediting bodies. Believe that we can eliminate disparities and police violence.

2. Recognize that implicit, conscious, and unconscious bias operates at the individual, systemic, and institutional level; leading to suboptimal health care access, quality, treatment, and outcomes including mental health care.

 Develop and create metrics, and collect and share data focused on the social determinants of health and racial and ethnic disparities to: improve health care quality and patient outcomes; inform and execute policies for hospital administration; improve organizational effectiveness; and share with those accrediting and regulating (eg, JCAHO [Joint Commission on Accreditation of Healthcare Organizations], CMS [Centers for Medicare & Medicaid Services], APA [American Psychiatric Association]) health care organizations and health professionals. Incorporate key components into the learning plans for training programs, continuing medical education, maintenance of certification, and accreditation and recertification activities. Commit to eliminating disparities in psychiatric care and ensure high quality care for minority people by data sharing with other disciplines and developing a robust research agenda using a race equity lens.

3. Medical decision-making is highly idiosyncratic, and minorities report less trust and involvement in their care. 

Furthermore, recognize how implicit, conscious, and non-conscious bias, stigma and stereotyping, verbal and non-verbal communication styles, and cultural differences influence how people express themselves in good and bad times (eg, grief) and may influence the clinical interaction and decision-making. Understand trust is earned and easily lost. Incorporate security standby requests data and other measures related to patient care as part of the continuous quality improvement process and commit to auditing your institution’s data. Educate yourself about types of privilege and bias, and how this influences interactions with people with your ecosystem (including patients).

4. APA statements have addressed the lack of minorities in psychiatry and have expressed concern about the pipeline.

 Commit to make additional investments in activities designed to diversify and enhance the psychiatric pipeline. The National Academy of Medicine and others speak to the importance of what minorities bring to the quality of the science. Ginther and colleagues5 have reported on race-based differences in funding of NIH Grants. Commit to an inclusive culture by recruiting, mentoring, and retaining minorities within psychiatry, academy, and scientific pipeline. Support minority, marginalized, and vulnerable members in our professional communities and societies for inclusion and leadership (even if their scholarship is “different”) by sponsoring and nominating them for awards, honors, and appointments. Commit to extinguishing racism from the scientific review process. Commit to finding the leadership in your midst by looking to see who is on your committees. If they are not representative or do not include diverse voices, work to change them.

5. Work to build trust via robust truth and reconciliation processes such as dedicating plenary talks and conducting a full day seminar within the annual meetings to address these issues. 

Examine psychiatry’s legacy including historical wrongs and missed opportunities for the full participation of black psychiatrists as well as harm done to minority patients and their communities. Acknowledge how the field of psychiatry may have benefitted from discrimination, racism, and racist behaviors, and apologize to those impacted and affected. Commit to broadly disseminating what you learned to the mental health community (eg, psychologists, social workers etc) as well as current and future patients and clients.

6. Enhance the quality of psychiatric care by removing barriers to care. Commit to enhancing capacity and access to high-quality psychiatric care while ensuring high-quality psychiatric care for racial and ethnic minorities. 

Commit to addressing race-based micro-aggressions and macro-aggressions and learning about race-based trauma. If needed, seek resources within and outside your community. This will require learning to be comfortable with being uncomfortable and committing to be a health care partner to optimize patient and population health and well-being. Commit to actively listening to the patient’s story without interruption.

7. Recognize it is not the victims’ job to educate you. 

Commit to doing the hard work over the long run.

The authors thank Michelle B. Riba, MD, professor of psychiatry at the University of Michigan for her ongoing inspiration and support. We acknowledge those who have come before us, the ancestors whose stories have prompted us to write our own, and those who will come after us. We acknowledge those doing ongoing work towards social justice in word, verse, and song.

Above all, we acknowledge the lives of those known and unknown lost before their time.

1. Hardeman RR, Medina EM, Kozhimannil, KB. Structural racism and supporting black lives: the role of health professionals. 

2. Byng R. #BBUM Hashtag sparks dialogue about diversity at the University of Michigan. 

. November 20, 2013. Accessed August 19, 2020. 

http://www.huffingtonpost.com/2013/11/20/bbum-university-of-michigan-black-students_n_4310790.html

3 Tracy M, Southhall A. Black football players lend heft to protests at Missouri. 

. November 8, 2015. Accessed August 19, 2020. 

http://www.nytimes.com/2015/11/09/us/missouri-football-players-boycott-in-protest-of-university-president.html

4. Charles D, Himmelstein K, Keenan W, Barcelo N. White coats for black lives: medical students responding to racism and police brutality. 

5. Ginther DK, Schaffer WT, Schnell J, et al. Race, ethnicity, and NIH research awards. 

6. Peck E. The Reckoning over workplace racism has begun. 

. June 9, 2020. Accessed August 19, 2020. 

https://www.huffpost.com/entry/like-me-too-but-for-racism_n_5edfee15c5b64843bde220d0

7. Moodley K, Kling S. Dual loyalties, human rights violations, and physician complicity in apartheid South Africa. 

8. Lindert J, Stein Y, Guggenheim H, et al. How ethics failed: the role of psychiatrists and physicians in Nazi programs from exclusion to extermination, 1933-1945. 

. January 2013. Accessed August 19, 2020. 

https://www.researchgate.net/publication/260437078_How_Ethics_Failed_-_The_Role_of_Psychiatrists_and_Physicians_in_Nazi_Programs_from_Exclusion_to_Extermination_1933-1945

9. Meyer R, Madrigal AC. A devastating new stage of the pandemic. 

 June 25, 2020. Accessed August 19, 2020. 

https://www.theatlantic.com/science/archive/2020/06/second-coronavirus-surge-here/613522

10. Starr GG. After George Floyd’s killing, what academics can do. 

. June 1, 2020. Accessed August 19, 2020. 

https://www.chronicle.com/article/After-George-Floyd-s/248890

11. Lutton L. Coronavirus case numbers in the United States: June 1 update.

 June 1, 2020. Accessed August 19, 2020. https://www.medicaleconomics.com/view/coronavirus-case-numbers-united-states-june-1-update

12. Faussett R, Dewan S. Police decisions are scrutinized after Rayshard Brook’s fatal encounter. 

June 18, 2020. Accessed August 19, 2020. 

https://www.nytimes.com/2020/06/18/us/rayshard-brooks-police-tactics.html

Articles

This moment in history cannot be lost. When you ask us if we are okay, be prepared to hear us say we are not . . . and never have been. Then be prepared to do more.

Racism, Policing, and COVID-19 Disparities: We Need Action!

The very serious function of racism . . . is distraction. It keeps you from doing your work. It keeps you explaining, over and over again, your reason for being.


Many envision a world of equality, freedom, and inclusion for all. Beyond slavery’s brutality (where many physicians enslaved people), the US Constitution – 14th Amendment (July 9, 1868) specifically addresses citizenship rights and guarantees equal protection under the law. The 14th Amendment continues to figure prominently in landmark civil rights racial discrimination cases (eg, Brown v Board of Education of Topeka; 1954). Yet, minority Americans continue to be discriminated against based upon their race (as well as their ethnicity). Moreover, medicine with its problematic history is not blameless: James Marion Sims (considered the “father of gynecology”) experimented on enslaved black women (without anesthesia), tolerated segregation (including public facilities and hospitals), discriminated against African American physicians, experimented on black people without their consent (eg, 

), and allowed unacceptable, unequal, and lower quality health care for racial minority people.

Although separate was deemed not equal in 1954, the American Medical Association remained silent during the 1964 Civil Rights Act deliberations and policy-making process. It wasn’t until 1997 when President Clinton apologized for Tuskegee and 2008 when the American Medical Association apologized for excluding African American physicians from membership. Conversations regarding the ethics and status of James Marion Sims “contributions” to science are ongoing.

Racial and ethnic minorities (including African American physicians) are at increased risk for accruing race-based micro-aggressions (eg, explicit, implicit, and daily discrimination; unfair treatment; racism) as well as race-based macro-aggressions (eg, physical, social, emotional, generational trauma) over the lifespan in and outside of clinical and educational spaces.

 Within and outside of health care, the persistence of these aggressions highlights the negative impact of stereotyping, bias, and marginalization yielding decreased quality of life and life expectancy, increased comorbidities, and disparities in the quality of health, pain, and primary care for racial and ethnic minorities. These aggressions intersect with patient satisfaction as well as health care quality and delivery. The urgency in addressing race-based bias, discrimination, and stereotyping within educational and health care institutions, is underscored by the physical and psychological harm caused to learners, trainees, patients, and others in the education and health care ecosystem, including the perpetrator.

Racial disparities in health and health care are well described.

 Even when matched by socioeconomic and insurance status, embedded in the disproportionate morbidity and mortality rates are historical and continuing practices in the US (eg, segregation) yielding lower quality health care and poorer health outcomes for minority patients.

 This is best demonstrated via a social determinants of health framework where unequal and suboptimal access, distribution, and utilization of resources as well as variability in clinician decision-making contribute to socio-political and health challenges associated with diminished health and well-being.

It is not surprising to find that populations at risk for health disparities are disproportionately and negatively affected by COVID-19, in large part because of the inequitable environmental and social conditions shaping health behaviors. Multiple other issues also contribute to the observed disparities such as having more chronic health conditions, decreased access to health care, increased health care costs, and prejudice directed at minority patients within the health care system. For those with or without exposure, COVID-19 has had an impact on overall physical, social, and mental health and well-being.

Specifically, black people account for 33% of the hospitalized COVID-19 cases and 23% to 25% of COVID-19 deaths (nearly 2-3 times their percentage in the population).

 Black, brown, and minority people are also disproportionately essential workers (eg, bus drivers, nursing home aides, grocery workers, taxi and delivery drivers), live in urban environments, and are more likely to be furloughed, laid off, and unemployed compared with white people. (Of note, the 

  is cost prohibitive for many low-wage essential workers: the price for masks escalated from $1 per mask in January 2020, to $7 per mask in April 2020, and $15 per mask in May 2020.

Moreover, in an increasingly apprehensive and fearful society, black and brown people (especially men) may be at increased risk for stereotyping and racial profiling when wearing face masks; putting them at further risk for negative consequences including disparities due to COVID-19 and negative interactions withlaw enforcement.

Unheard stories: our collective trauma and PTSD

There is no greater agony than bearing an untold story inside you.

Experiencing and witnessing trauma can cause deep spiritual and psychological wounds. Video evidence of police brutality against Blacks is not new nor are national protests following unarmed black men being brutalized or killed by police or surrogates: Rodney King (Los Angeles, CA, 1991) and 

 (Sanford, FL, 2012). However, 2014 was a pivotal time when national outrage intensified. Specifically, the escalating number of unarmed black men dying due to overzealous police brutality (with accompanying protests) across the country: Eric Garner (NYC, NY, 2014), Michael Brown (Ferguson, MO, 2014), Tamir Rice (Cleveland, OH, 2014), Laquan McDonald (Chicago, IL, 2014), Walter Scott (North Charleston, SC, 2015), Samuel DuBose (Cincinnati, OH, 2015), Freddie Gray (Baltimore, MD, 2015), Philando Castile (Falcon Heights, MN, 2016), and so many others whose story have yet to be told.

The number of black men dying in the hands of police became one of the leading causes of their premature death. As the national context intensifies, the literature reveals an increase in community mental health challenges following the deaths of unarmed black men.

 Unfortunately, psychiatric capacity under the best of circumstances is insufficient and the ability to deliver psychiatric culturally appropriate psychiatric care is also lacking. In 2018, Dr Altha Stewart, the President of the American Psychiatric Association reported only 7% (2000) of psychiatrists (28,000) were black, thereby supporting pleas for increased diversity in the sciences, medicine, and academy.

The ugly truth regarding these police brutality stories (and other cases yet to be revealed) is the qualified immunity from accountability that police have. Specifically, official narratives come from the police and a counter narrative is needed. Dashcam and bodycam videos were instituted to stop problematic policing behavior, protect police officers, and document the person being policed. Although these cameras can be a neutral and unimpeachable witness, they must first be turned on. Without a victim’s narrative, their dead body speaks via the autopsy. Nevertheless, autopsy reports and witness statements can and will be questioned, the video can go missing or never be created. We know many police officers are caring and community focused, and we also know the they generally get the benefit of the doubt (especially when the victim is black). We also are fully aware that degrees from elite universities and prestigious awards do not come easily and don’t protect us.

Overall, physicians tend to be rational and quantitative. However, does this mean we should allow or rationalize the existence and disproportionality of police violence? For instance, hypertension is a common gateway disease to cardiac disease and metabolic syndrome and is extremely common in African Americans. Mr Floyd had hypertension, a fact that was initially used to rationalize his death. Regardless of the presence or absence of comorbidities, criminal behavior, or illicit drug use—Mr Floyd died before his time due to police brutality—in the United States of America in 2020.

The epidemic of police violence directed at unarmed black men reflects societal ills. As the US diversifies, the racial and ethnic diversity of college campuses, health professional schools, and health care systems have not kept pace. Considering the emergent nature of addressing police brutality, racism, and disparities, institutional and structural inequalities within health care must be addressed.

The deaths at the hands of police are not just relevant to city officials, they’ve occurred in universities and hospitals where we seek (and expect) respite, care, compassion, and education. Considering their primary purpose, attention needs to be given to why and how hospitals and universities are frequently deciding to arm security services.

, a 57-year-old African American woman went to Calhoun Liberty Hospital in Florida for abdominal pain.

 When Ms Dawson refused to leave after being discharged, she was arrested and handcuffed by the police. Despite pleading to stay and telling the staff and police multiple times “I can’t breathe,” Ms Dawson was forcibly removed (dragged) from the emergency room until she collapsed (and became “dead weight”) in the street. Unresponsive and not breathing, Ms Dawson was readmitted to the emergency room where efforts to revive her failed; she was pronounced dead an hour later. The autopsy revealed she died of a saddle pulmonary embolus. The police dashcam video and audio documenting the final 20 minutes of Ms. Dawson’s life, her last words, and her death are chilling.

Outside hospital settings, mental illness and cognitive impairment is often used to rationalize mistreatment by law enforcement. In 2016, Mr Alan Pean a 26-year-old unarmed Haitian and Mexican American man with bipolar disorder went to a hospital in Houston, TX, for psychiatric treatment and was admitted to a surgical floor.

 Naked and delusional in his hospital room, hospital security (who were also off duty police officers) was called. Mr Pean never saw a psychiatrist prior to being shot and critically wounded—he survived.

In 2012, Mr Darren Rainey, a 50-year-old unarmed black man with schizophrenia was incarcerated in a Florida Dade County prison mental health unit. Correction officers locked Mr Rainey in a shower (where the controls were located in the next room) under 180-degree water for almost 2 hours.

 Mr Rainey died from his injuries. The investigation into his death cited, “complications of schizophrenia” as a contributing factor.

disparities in hospital security standby requests

 (calling security for present, imminent, or perceived incident/threat) for patients and their visitors was published in 2018.

 The 8 years studied shows black patients and their visitors had security called on them at more than twice the rate of white patients and their visitors. The article raised important issues: (1) How often non-threatening situations were escalated due to negative perceptions and stereotypes of black patients and their visitors; and (2) The role of diminished employee resilience, tolerance, and cultural humility, awareness, and competence, especially with regard to stressful situations (eg, extreme grief, fear, and loss; critical and emergent illnesses) that leads to security being called on black patients and their visitors more so than whites. All in all, these examples again reveal the disproportionate over policing of black and brown people They also underscore the need to examine the why, while identifying root causes, trends, and interventions.

Too often we watched the lives of unarmed black men taken in seconds by the police. We saw Mr George Floyd’s life slowly extinguished in 8 minutes and 46 seconds while in police custody. As minority and African American physicians, we acknowledge these macro- and micro-aggressions continue to negatively affect our health and well-being. Psychiatrists are in a unique position to actively address the collective trauma caused by the confluence of rampant and persistent race-based disparities in health care and police violence. A fundamental tenet of the oath we take as physicians is 

 (first do no harm). Thus, it is important to realize the dangers of over-policing do not stop at hospital doors; black and brown patients face similar threats to their person even when seeking care. If we aim to “do no harm” we cannot ignore this reality.

In the final article of the series we discuss the importance of physician action by noting historical examples where we failed to do so. We conclude with brief recommendations on what physicians can do to capitalize on this moment and how we can all help to create lasting change. Click here to read the first article in this series, “

Policing and COVID-19: Discrimination, Racism, and Xenophobia

 is Professor, Department of Anesthesiology, Professor, Department of Obstetrics and Gynecology; and Professor, Department of Health Management and Policy, University of Michigan School of Public Health; Faculty Affiliate, Program for Research on Black Americans, Resource Center for Group Dynamics, Institute for Social Research and Faculty Associate, Institute for Health Policy and Innovation, University of Michigan; and Attending Physician, Back and Pain Center, Michigan Medicine, Ann Arbor, MI. 

 is a Doctor of Medicine Candidate, Class of 2021, University of Michigan Medical School. 

 is Interventional Pain Medicine Fellow, Back and Pain Center, Michigan Medicine, University of Michigan. The authors report no conflicts of interest concerning the subject matter of this article.

1. Wall L. The medical ethics of Dr J. Marion Sims: a fresh look at the historical record. 

. 2006;32:346-350.
2. Washington H. Apology shines light on racial schism in medicine. 

. July 29, 2008.
3. American Medical Association. 

The History of African Americans and Organized Medicine

. AMA History. 
4. Centers for Disease Control and Prevention. US Public Health Service Syphilis Study at Tuskegee. Presidential Apology; May 16, 1997.
5. Zielinski S. Cracking the code of the human genome: Henrietta Lacks’ immortal cells. 

. January 22, 2010.
6. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. 

The Immortal Life of Henrietta Lacks Reconsidered

. 2014. 
8. Gamble VN. Subcutaneous scars: a black physician shares what it feels like to be on the receiving end of racial prejudice, despite a successful career. 

. 2000;19:164-169. 
9. McCabe J. Racial and gender microaggressions on a predominantly-white campus: experiences of Black, Latina/White undergraduates. 

. 2009;16:133-151.
10. Ansell DA, McDonald EK. Bias, black lives, and academic medicine. 

. 2015;372:1087-1089.
11. Kessler R, Mickelson K, Williams D. The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. 

. 1999;40:208-230.
12. Smedley BD, Stith AY, Nelson AR, Eds. 

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

. Washington, DC: The National Academies Press; 2003.
13. Green CR, Anderson KO, Baker TA, et. al. The unequal burden of pain: confronting racial and ethnic disparities in pain. 

. 2003;4:277-294.
14. Marmot M. Social determinants of health inequalities. 

. 2005;365:1099-1104.
15. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease. 

. 
17. Centers for Disease Control and Prevention. 

COVID-19 Data from NCHS. Weekly Updates by Select Demographic and Geographic Characteristics

. 
18. Maremont M, Hufford A, McGinty T. US pays high prices for masks from unproven vendors in coronavirus fight. 

. April 18,2020. 
19. Mullins B, Pulliam S, Forrest, B. A chaotic gray market determines who gets coronavirus gear-and who doesn’t. 

. May 8, 2020. 
20. Kovaleski SF. Trayvon Martin case shadowed by series of police missteps. 

. May 16, 2012.
21. Bosman J, Fitzsimmons EG. 

Grief and protests follow shooting of a teenager: police say Mike Brown was killed after struggle for gun in St Louis suburb

. August 10, 2014. 
22. Dewan S, Oppel RA. In 

Tamir Rice case, many errors by Cleveland police, then a fatal one

. January 22, 2015. 
23. Galovski T, Peterson Z, Beagley M, et al. Exposure to violence during Ferguson protest: Mental health effects for law enforcement and community members. 

. 2016;29:283-292.
24. Varghese F, Israel T, Seymour G, et al. Injustice in the justice system: reforming inequities for true “justice for all.” 

. 2019;47:682-740.
25. Rossman S, Etters K. Bristol woman dies while being kicked out of area hospital. 

. December 23, 2015. 
26. Rosenthal E. When the hospital fires the bullet. 

. February 12, 2016. 
27. Hawkins D. Florida inmate dies after being locked in a scalding shower for 2 hours; guards won’t be charged. 

. March 20, 2017.
28. Green CR, Wayne R McCullough WR, Hawley JD. Visiting black patients: racial disparities in security standby requests. 

Psychiatrists are in a unique position to actively address the collective trauma caused by rampant and persistent race-based disparities in health care and police violence. 

Racism, Policing, and COVID-19: How Do We Justify Racial Disparities in 2020?

Does it dry up
Like a raisin in the sun?
Or fester like a sore—
And then run?
Does it stink like rotten meat?
Or crust and sugar over—
like a syrupy sweet?

ince early 2020, the US has been in the midst of a worldwide pandemic due to a deadly coronavirus disease (COVID-19). Physicians, per their oath, “leaned in” to serve on the front line, prevent further spread, and treat the sick. To date, COVID-19 continues to challenge public health infrastructure, out-pace hospital and physician capacity, make people ill, and kill on a global scale. Much the same can be said about the not so novel racism virus. Its current and tragic toll upon generations of racial and ethnic minority Americans (eg, African Americans, Arab Americans, Asian Americans, Hispanic and Latino Americans, and Native Americans and Pacific Islanders), continues to make our society sick, contributing to accelerated aging and premature morbidity and mortality.

Although the US was founded on “liberty and justice for all,” discrimination, racism, and xenophobia existed worldwide prior to the country’s birth and continues to persist. One can argue racism is a much deadlier, more virulent, and more pervasive disease than COVID-19. Like crabgrass and thorny weeds in a beautiful perennial garden, both must be extinguished for the US to reach its full promise. Considering the changing demographics in the US: an increasingly minority, female, and aging society (ie, a minority majority society), it is our imperative to do so.

Under the emerging coronavirus shadow and as the US rapidly ascended the COVID-19 climb curve, young and old people became infected and died, including people without predisposing conditions. No person or community was immune as health professionals and scientists primarily focused on developing COVID-19 public service announcements, flattening the curve, and inventing an effective vaccine.

On February 23, 2020, there were 53 cases of COVID-19 in the United States.

a 25-year-old unarmed African American man went jogging

 in his Glynn County, Georgia neighborhood when he was pursued, confronted, and fatally shot by two armed white residents, as another white resident detained him and videotaped the encounter, and a racial slur was uttered.

 The Georgia Bureau of Investigation released the autopsy results revealing that Mr Arbery was shot 3 times—his death was ruled a homicide and charges were filed against the perpetrators 74 days later. The circumstances surrounding his death and subsequent delay in filing charges were almost overlooked.

On March 13, 2020, there were 565 cases and 8 deaths due to COVID-19 nationwide.

 Like others across the country, our university and clinics began to shutter and a “stay at home” order was implemented. In Louisville, KY, just after midnight, a no-knock narcotics raid was conducted on the home of Ms Breonna Taylor, a 

 EMT, emergency room technician, and aspiring nurse.

 Ms Taylor was in bed with her boyfriend, Mr Kenneth Walker. Despite already having the primary suspect in custody, police elected to use a battering ram to forcibly enter Ms Taylor’s home. Mr Walker feared for their lives and shot in self-defense—wounding one officer. Ms Taylor was shot at least 8 times and died. Of note, the police assert they knocked and identified themselves prior to entry, no drugs were found in Ms Taylor’s home, Mr Walker had a permit to carry a gun, and the initial charge of attempted murder of a police officer filed against Mr Walker was dismissed.

On May 5, 2020, there were 1,173,257 cases and 62,806 deaths due to COVID-19 nationwide.

 Mr Arbery’s death finally received national attention when the video began circulating on social media. Like Mr Arbery, the circumstances surrounding Ms Taylor’s death was delayed until shared on social media.

Two defining moments occurred on May 25, 2020. There were 1,592,599 cases and 92,762 deaths due to COVID-19 nationwide.

 and Harvard alum was birdwatching in Manhattan’s Central Park.

 He noticed an unleashed cocker spaniel digging up shrubbery and disturbing the bird sanctuary, and asked the dog’s owner, a white woman, to comply with park rules and leash the dog. Instead, she stated, “I’m going to tell them (the police) there’s an African American man threatening my life.” She called 911, feigned hysterical fear as Mr Cooper videotaped their interaction and her conversation with the police dispatcher. Although her dog was taken away, to date no charges were filed against her for filing a false police complaint. The New York Commission on Human Rights started an investigation and her dog was returned to her care.

Reminiscent of fiction (eg, Harper Lee’s book 

) and consistent with real cases (eg, 1921 Tulsa riots), Mr Cooper’s experience was the latest in a long familiar pattern of a white person making troubling false accusations associated with serious crimes (eg, theft, rape, and murder) against black people (especially black men), leading to further criminal injustices including trial, criminal convictions, and imprisonment (eg, Central Park 5).

 There are numerous false accusations associated with everyday activities made against minorities across the age (including black children), gender, and income spectrum, which prompted several hashtags: #Driving/WalkingWhileBlack, #BarbequeingWhileBlack, #GolfingWhileBlack, #SellingLemonade/WaterWhileBlack, #SwimmingWhileBlack, #DrinkingCoffeeWhileBlack, #StudyingWhileBlack, and eventually 

 All provided additional support for the 

 campaign as African Americans’ lived daily experiences were increasingly reduced to hashtags.

 Each event and demonstration was thought to be the tipping point. Most minorities continue to hold their breath waiting for change and relief from the unequal burden of racial discrimination. We continue to wait to breathe free.

May 25, 2020, was also the day an unarmed 46-year-old African American man, 

Mr George Floyd was accused of using a counterfeit $20 bill

 to pay for items at a convenience store in Minneapolis, Minnesota.

 Shortly after 8 pm CST, the owner called the police. Mr Floyd was sitting in his vehicle across the street from the store when the police arrived and arrested him. Claustrophobic and with his hands cuffed behind his back, Mr Floyd—who was approximately 6-feet 4-inches tall and 223 pounds—did not attempt to escape or resist arrest, but he had difficulty getting into the back of a police cruiser. Mr Floyd lay prone on the pavement with his head next to the cruiser’s wheel. He could see the gathering crowd as a white police officer (a training officer with nearly 20-years on the Minneapolis Police force) deliberately and forcefully kneeled on Mr Floyd’s neck for 8 minutes and 46 seconds; two officers restrained his legs and another officer prevented onlookers/witnesses from intervening to help. (Of note, it was the fourth training day for two officers and the practice of chokeholds including putting a knee on the neck is no longer taught in most police academies.)

They and onlookers listened as Mr Floyd pleaded, “please, please, please . . .” and “I can’t breathe” (a familiar refrain) more than 17 times, called for “Mama” (who died 2-years before), and stated, “they are trying to kill me” multiple times.

 The last 3-minutes, Mr Floyd lay pulseless and motionless as the officer (with his left hand in his uniform’s pants pocket) rocked his knee into Mr Floyd's neck and defiantly looked into the camera and eyes of onlookers. The officers made no attempt to revive Mr Floyd and prevented the EMTs from doing so. Attempts to revive him once in the ambulance failed; Mr George Floyd was pronounced dead at 9:45 pm CST in the hospital.

It has been said that a child will lead us; and this time it was a courageous 17-year-old, 

 Although the police demanded she stop videotaping, Ms Frazier (and other bystanders) captured the events surrounding Mr Floyd’s suffocation at the hands of police on videotape and posted the video on a social media platform. The initial police press release stated Mr Floyd “died of a medical incident during a police interaction” and resisted arrest. However, video evidence from surveillance cameras dispute these assertions and show that Mr Floyd complied with the officers’ orders.

Protests erupted in the streets of Minneapolis and the 4 officers involved were fired on May 26, 2020. Two different autopsies determined Mr Floyd’s death was a homicide and revealed he had COVID-19 antibodies. The training officer had 18 misconduct complaints, several officer-involved shootings, and was disciplined on 2 occasions for excessive force. He was arrested and charged with third-degree murder and second-degree manslaughter on May 31, 2020.

In the meantime, protests (often peaceful) erupted across the rest of the US and continued across the globe (eg, Australia, France, New Zealand, UK) in response to Mr. Floyd’s and the many other deaths of black people due to police brutality. On June 3, 2020 the other 3 officers were arrested and charged with lesser crimes—aiding and abetting second-degree murder and aiding and abetting second-degree manslaughter—associated with Mr. Floyd’s death and the training officer faced a new charge of second-degree murder under Minnesota’s felony murder statute. This prompts the question, what would have happened if the cameras weren’t there?

Police officers are given the presumption of innocence, while black and brown people must prove theirs, even when there is video evidence of police violence directed at them. Deeply disturbing, there is something wrong and strangely familiar in watching the innumerable videos of unarmed black men dying due to police violence; revealing not only man’s inhumanity to man but how black people are devalued and dehumanized.

Although in 2019, black people represented 13% of the population, they represented 24% of the 

 When compared with white people, black people are three times more likely to be killed by police and 1.3 times more likely to be unarmed. From 2013 to 2019, only 1% of killings by police officers have resulted in officers being charged with a crime.

Sleep deprived, but not post-call, on Sunday, May 30, 2020, we were weary, exhausted, and tired to the bone, but awakened early for our zoom research meeting to write a paper focused on the social determinants of health, disparities, and COVID-19. We’d been there before, and simultaneously acknowledging the familiar without words, confessed our angst, and processed our grief, sadness, and ongoing PTSD from witnessing another unarmed black man be dominated by police violence, murdered by police, and die alone in the middle of a city street. There were no good words. Although our numbers remain small, our shared phenotypes and history as minorities and physicians made it easier to understand and explain our feelings to each other regarding the police extinguishing Mr Floyd’s dreams and life, but it wasn’t okay.

We watched as the world attempted to process the erupting global protests against police brutality and racism. And, we witnessed peaceful protestors tear gassed and shot with rubber bullets in the US. As these major events intersected, large crowds gathered despite a global pandemic to voice their collective pain and frustration at continued violence toward black and brown people. We were in the midst of a perfect storm within an imperfect world where black and brown bodies are devalued, dehumanized, and criminalized; and where our phenotype, regardless of class, prompts over-policing, bad-policing, and criminal-policing in many of our communities; further magnifying health and educational inequities. It was a continued insult to injury within minority communities; and if we were honest with ourselves, we too feared being targeted when exercising, driving, or shopping, facing false accusations in the classroom and workspace, and ongoing discrimination and decreased opportunities within organized medicine, professional societies, scientific community, and academy.

We realized we were not just sick and tired of being sick and tired, but were exhausted from the silence, systemic oppression, and structural and institutionalized racism. How could we be safe when our brown and black brothers, fathers, uncles, and other relatives (including women and children) were not safe in the world? Were we deluding (or protecting) ourselves by wearing short or long white coats to shield us from the silencing, suffocation, killing, and execution of black and brown people as repeatedly witnessed on media? Yet, we witness or experience the same figuratively in the classroom, the boardroom, and in clinical spaces daily. We knew what could happen without the privileged white coat to shield us (maybe). What happens when we are just like any other black or brown person and perceived as being in the wrong neighborhood? Continued silence was no longer an option as we witnessed the disproportionate impact of educational, health, economic, and social injustices.

We intrinsically understand why minority communities have diminished trust in the police, health professionals, and health care systems via our lived experiences; we are them. Nonetheless, we lived on to share our narratives and perspectives, express our anger, and continue to carry unequal burdens and unheard stories. We believe, the medical community must not tolerate racist behavior in our society and must take an active role in understanding (and preventing) racism to promote healing.

The circumstances surrounding the death of Mr George Floyd and so many other unarmed African Americans by police as well as other ongoing disparities in the midst of the 

 pandemic caused us to pause and reflect on our own situation as African Americans and physicians. This country is once again at a crossroads of race relations. As we reckon with this historical moment, the field of medicine must not be left behind, sit on the sidelines, and be held blameless.

As physicians we have a responsibility to ALL of our patients; embracing a social determinants framework requires that we treat the parallel diseases of COVID-19 and racism as equally detrimental to the health and well-being of our patients. The second article in the series, “

Policing and COVID-19 Disparities: How Do We Justify Racial Disparities in 2020?

” discusses race-based injustices and disparities throughout the history of medicine that continue to the present day. We discuss the ways in which police violence against black people intersects and overlaps with medical practice, necessitating intervention from all health professionals.

1. Jernigan DB. Update: public health response to the coronavirus disease 2019 outbreak: United States, February 24, 2020. 

. 2020:69:216-219.
2. Fausset R. What we know about the shooting death of Ahmaud Arbery. 

. June 24, 2020.
2. Wootson C, Brice-Saddler M. Attorney for man accused of killing Ahmaud Arbery says ‘this is not just another act of violent racism. 

. May 15, 2020. 
3. Haines E. Family seeks answers in fatal police shooting of Louisville woman in her apartment. 

. May 11, 2020. 
4. Stewart N. The white dog walker and #LivingWhileBlack in New York City. 

. May 30, 2020.
5. Keyes A. A long-lost manuscript contains a searing eyewitness account of the Tulsa race massacre of 1921. 

. May 27, 2016. 
6. Harris A. The Central Park Five: “We were just baby boys.” 

A social determinants framework requires that we treat the parallel diseases of COVID-19 and racism as equally detrimental to the health and well-being of our patients.

Rahul Biljani, MD

Articles

Racism, Policing, and COVID-19 Disparities: We Need Action!

Racism, Policing, and COVID-19: How Do We Justify Racial Disparities in 2020?

Policing and COVID-19 Disparities: Discrimination, Racism, and Xenophobia