More Than Diverse: Race as an Insufficient Proxy of American Historic Lived Expertise

SPECIAL REPORT: DIVERSITY

As an Ethnic Black American psychiatrist, I believe this famous quote by Albert Einstein can help American psychiatric clinicians navigate today’s rapidly changing landscape of diversity-based frameworks: “Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.” I interpret this saying to implore clinicians and academics to never stop critically interrogating extant health care knowledges and practices. As a compass to navigate these lines of questioning, Einstein instructs us to first learn from the past. History books and lecture halls are certainly one way of learning about health care’s inequitable past. Yet, worthwhile histories of American health care harm are not limited to the realm of secondhand academic knowledge or documented disparities. Rather, we can learn about the past directly from the individuals carrying firsthand, living perspectives of American history.

As a medical educator and originator of the sociohistorical justice (SHJ) framework, I have dedicated my career to helping health care systems, clinicians, and educators disaggregate and honor the individuals bearing historic lived expertise: knowledges born from direct and multigenerational experiences of enduring and overcoming American medicine’s storied past. Lived experts differ from academic experts in their epistemological approach to knowledge, which is the way that experts know what they know. Academics often assess knowledge credibility through normative metrics like seniority, publications, and degrees. In contrast, the epistemological credibility of lived and/or living experts is established through direct experience; they know what they know because they lived or are still living it for themselves.

Yet, knowledge construction is not a socially neutral process: Groups unequal in power also have unequal access to academic knowledge, like possessing enough resources to obtain a formal education or to become a credentialed educator themselves, especially one who is freely spoken within the academe.¹ Because knowledge is not neutral, lived experts frequently hold firsthand subjugated knowledges of how minoritized groups survive oppression, and these subjugated knowledges know the realities of social oppression in personalized ways that vicarious knowledge can never replicate or achieve.¹ Indeed, Patricia Hill Collins, PhD, once spoke of the epistemological advantages of lived experts: “Those individuals who have lived through the experiences about which they claim to be experts are more believable and credible than those who have merely read or thought about such experiences.”¹

Let us now return to the meaning contained within Einstein’s words of wisdom: Hope for the future begins with learning from the past. Despite the present controversy of diversity-based frameworks, we are still accountable to innovate knowledge that prevents future disparate outcomes. Moreover, according to Einstein, the knowledge required to truly understand today’s inequitable practices is largely rooted in the past. However, because experiencing health care inequity is a form of social minoritization in itself, only lived and living experts are epistemologically equipped to offer firsthand, subjugated knowledge of American medicine’s shortcomings.

Identifying Living Experts

Identifying living experts of present-day harm can be relatively straightforward, since they are alive to speak for themselves. In contrast, identifying living experts of American historical harm may sometimes seem impossible because many of history’s original victims are no longer alive. Indeed, many of the harmful historic acts that still detriment modern medicine’s functionality occurred many decades or centuries ago. For instance, historic acts of educational segregation, like the Flexner Report of 1910, generationally deprived educational opportunity to over 35,000 doctors to Black Americans with lineages established in the US by 1910, being Flexnerian-Deprived Black Americans (FDBAs).^2-4 Discrete acts of medical racism also directly contribute to historic Black Americans’ adaptive distrust of health care systems, like the medical exploitation of Black men during the Tuskegee syphilis study, whose public exposure in 1972 instilled so much rational avoidance of health care systems among Black men that it literally reduced their lifespan by 1.5 years.⁵ If the original living experts of historic harm are deceased, how, then, can we learn from lived experts with firsthand knowledge of American medical history?

Thankfully, living experts of American historical harm are all around us: They are individuals who inherited yesteryear’s subjugated knowledge from their elders as they transmitted their wisdom of surviving American health care’s oppression across generations through storytelling. Nonetheless, identifying living experts of American historical experiences is trickier than identifying living experts of present-day experiences, especially regarding historic acts of racism. This complexity arises because, due to the welcomed voluntary migration of diverse populations, Americans bearing a present-day racial identity do not automatically possess direct (vs vicarious) familial ties to a defined historic harm, even if that historic harm was executed along racial lines. Allow me to explain.

All Black Americans share a present-day racialization due to similar physical features, and most carry present-day lived expertise of American racism and historic lived expertise of colonization and/or race-based harm rooted to diverse national contexts across the wider African diaspora. Notwithstanding, Black Americans are not a historical monolith in their epistemological perspectives to timelines of American medical harm. To begin, FDBAs represent the 90% ethnic (historical) majority of Black Americans with ancestry originating within foundational American history, conceptually termed Ethnic Black Americans within the SHJ framework. The other 10% of Black Americans are non-FDBAs who do not possess familial ties throughout foundational American history due to voluntarily establishing their lineage within American society many centuries later, over half of whom arrived within the last 20 years.^3,4,6,7 Therefore, FDBA lineages are the historic living experts of the missing 35,000 Black doctors caused by 115 years of ongoing Flexnerian educational segregation.^3,4,7 FDBA lineages equally carry the historic lived expertise and subjugated knowledge of surviving every moment of American anti-Black racism since 1910, including Tuskegee, the American Civil Rights movement, and so much more. However, compared with prior decades, the representation of FDBA doctors has acutely declined, including by roughly 50% for FDBA men, despite institutional claims of accountability to their problematic history through diversity-based programs.⁴ Some medical school classes have no FDBA epistemological or living representation among their Black-identifying students at all. Historic lived expertise is misconceptualized and decentralized within present-focused, diversity frameworks, thereby limiting the infusion of historically corrective subjugated knowledge into the academe. The historical homogenization of distinct, contemporarily minoritized groups within prevailing frameworks sustains this inability to optimally learn from America’s past.^3,4,7

The diverse lived expertise of all individuals experiencing presently mediated discrimination must still be prioritized. Truly, in the spirit of Einstein’s guidance, he instructs us to “live for today,” and diversity frameworks shine in these present-focused subtypes of equity work. Yet, in addition to being inclusive of diverse living histories of worldwide experiences, if American health care institutions truly wish to “learn from yesterday,” they must specify and honor the historic lived experts bearing subjugated knowledges of surviving their own institutional harm.

Sociohistorical Justice Framework

Institutional historical accountability sometimes overlaps with modern-day notions of racial diversity. However, race is an insufficient proxy of subjugated knowledge born of American historic lived expertise: Race is a fluid construct that changes as the sociopolitical, geographic, and temporal context changes. Thus, the equity work of institutional historical accountability requires attunement to concepts stably anchored to place and time, for which the SHJ framework was crafted.^3,4,7 Socio honors the unique sociopolitical construction of discrimination within a defined geographic region and/or nation (including but transcending notions of race), and historical differentiates the temporal aspects of endured harm for contemporary minoritized persons (like ancestry, ethnicity, chronicity of endured harm within a given social context). SHJ is a 5-step, history-based equity framework that helps institutions build locally relevant, lineage-based, restorative equity endeavors in historically, racially, ethnically, and nationally diverse societies. SHJ achieves this goal by (1) naming a historic discriminatory act, (2) defining the geographic footprints and generational timelines of that historic harm, (3) interrogating the sociopolitical constructs that marked the original victims, (4) disaggregating present-day populations to identify the modern descendants of original victims bearing direct and continuous—not vicarious—historic harm, and (5) measuring success only by how precisely those modern descendants benefit from a given historic equity effort.³

SHJ provides institutions the vernacular and nuance required to respectfully disaggregate contemporary groups in relation to American history. SHJ’s insistence upon historic lived expertise by no means competes with diversity-based frameworks for present-day accountability or lived experiences. However, SHJ does assert the irreplicable epistemological strength of historic lived expertise at the helm of medical knowledge interrogation, production, and validation.

Concluding Thoughts

In hopes of building a brighter tomorrow, we must stand in solidarity as a unified—though historically distinct—contemporary body of clinicians, researchers, and educators to innovate solutions to today’s health care inequities. As we forge paths forward in this tumultuous climate of health equity, let us use these periods of critical self-reflection to center the recruitment, representation, and retention of historic lived experts within the epistemological construction of new health care knowledges.

Dr Black is an adult psychiatrist, associate professor at the University of Connecticut, and vice chair of education at the Institute of Living, one of the country’s oldest psychiatric hospitals.

References

1. Hill Collins P. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. 2nd ed. Routledge; 2000.

2. Campbell KM, Corral I, Infante Linares JL, Tumin D. Projected estimates of African American medical graduates of closed historically Black medical schools. JAMA Netw Open. 2020;3(8):e2015220.

3. Black C, Temple S, Acquaye A, et al. Sociohistorical justice: a corrective framework to mend the modern harms of medical history. Lancet Reg Health Am. 2024;38:100874.

4. Black C, Brinker M, Acquaye A, et al. Beyond race-based ideology in HPE equity attempts: a framework and vocabulary for sociohistorical justice. Teach Learn Med. Forthcoming 2025.

5. Alsan M, Wanamaker M. Tuskegee and the health of Black men. Q J Econ. 2017;133(1):407-455.

6. Tamir C, Anderson M. One-in-ten Black people living in the U.S. are immigrants. Pew Research Center. January 20, 2022. Accessed June 16, 2025. https://www.pewresearch.org/race-ethnicity/wp-content/uploads/sites/18/2022/01/RE_2022.01.20_Black-Immigrants_FINAL.pdf

7. Black C. How do we know what we know? centering lived experiences in health equity knowledges. Teach Learn Med. Forthcoming 2025.