The Racial Capitalism of Care

U.S. society is marked by deep inequities in the distribution of care, from unpaid care work inside the home to the disparate treatment and impact of various government agencies and programs. This event, moderated by Ruha Benjamin, examined how racial capitalism—the intertwined operation of race and class—shapes two major systems of care in the United States. Drs. Michelle Morse and Bram Wispelwey discuss their advocacy work on racial inequalities in medicine, while Dorothy E. Roberts discusses her new book on the child welfare system Torn Apart. Together, they ask how we got here and how we can build a more just world.

Ruha Benjamin: Welcome everyone. It’s really my honor to get us started. Let me start with a short bio of our three panelists in the order they will speak.

Michelle Morse: Thank you so much, Ruha, and wonderful to see everyone virtually this evening, or morning, wherever you are in the world. We wanted to share a little bit about some of the trajectory of work we’ve been doing around racial inequities, so I’m just going to kick us off by sharing a little bit about the context in which some of our work emerged. And again, the opportunity that we have to be in dialogue with all of you to keep deepening that work as well.

So our hospital in Boston, at Brigham and Women’s Hospital, there was a really, really important moment in recent years, where the work of organizers and activists and community members all across this world, as a part of the Black Lives Matter movement, created a window of opportunity for a new kind of conversation around racism at our institution. And it’s not to say that that was the first time, of course, that that conversation was happening. There had been, I would say, waves of interest in racial justice and health equity over the many years that I had been at Brigham and Women’s Hospital as a trainee and as a faculty member.

But in 2016, in particular, the summer that Philando Castile and Alton Sterling were murdered by police, really led to another kind of window of openness. And mostly because trainees, medical students, nursing students, folks at the hospital were saying, “We have to do better. Black Lives Matter is not something that’s happening out there. This is something that applies to our work and the way that we take care of patients as well.”

And so that window of opportunity really led to a new kind of question that was being asked, and that question was, how is racism operating in our hospital? And one of the things that trainees and students were demanding was, they said, “We want to see more action on health equity. We want to see more investments in health equity, and we want to see a new kind of conversation, an honest conversation, about how racism actually shapes the way that we deliver care.” And I should say, not just racism, but also racial capitalism. I mean, as many of us know, the way that payment systems work in our healthcare system, they very much incentivize sick care, and unfortunately, because of the history of settler colonialism and structural racism in this country and enslavement, the people who are the sickest are of course people of color.

And so anyway, with all of that context happening, we started asking some new questions, and some of those questions were really generated by us looking at critical race theory and public health critical race practice, to ask better questions about why racial inequities were so persistent at our hospital. And one of the questions that we started asking was really about heart failure care and how heart failure care was operating, because it was one of the most common diagnoses for patients, and as many of you know, one of the flashpoints for racial inequities is cardiovascular care. So I’ll pass it over to Bram to share a little bit more about what that led to.

Bram Wispelwey: Perfect, and that’s just the context of the noticing that really happened around that time, 2015-2016, because of all these other events going on, where we started looking around. And at that time there were a number of us who were trainees, who were residents, and we were working on multiple services. And what we were noticing with heart failure patients in particular is that patients of color, Black and Latinx patients, were more likely to be seen on this general medicine service, as opposed to the specialty cardiology service.

And so, starting noticing that and asking around, we looked into the data, and then sure enough, we looked at ten years of data and later found out actually there had been prior data even before that, internally showing that our impressions were correct. In fact, that we had essentially segregated care for our Black and Latinx patients in the hospital for heart failure patients.

The context there is so important because when you think about public health, when you think about medicine, there are a couple of core areas of tension when you try to bring in something like critical race theory and public health critical race practice, which was developed by Chandra Ford at UCLA and Collins Airhihenbuwa, dating back about twelve years now. And those tensions are, this idea which we have in medicine and public health that science is objective, that these empirical findings that we have, they’re not particularly influenced by bias and that we’re just kind of fashioning new information. So that’s number one. And number two is that the best way to progress in our knowledge is to use our own core discipline and all the techniques we have. Critical race theory really forced us to acknowledge that in the entire history of the United States, always the norms around race and racism have completely infiltrated health sciences and medicine.

And so, they’ve proven over time to not be impervious to all the social and political norms of the time. So that was number one. We have all this empirical evidence that in fact, science is not objective, that the way we do medical science is not objective. I think that part was key, and also that we needed to look outside of medicine. We needed to look outside of public health in order to make actual leaps in the way we’re thinking about race and racism. Even recent literature in academic medicine is littered with explicitly, or implicitly, the idea that race has a biological meaning or genetic meaning, as opposed to sociopolitical construction, which we know.

That was really I think the core insights of getting us to that point of saying, “Hey, we’re going to look at this in a certain way. We know race is a social construct. We’re going to analyze this.” The knowledge production is going to be influenced by that. Monitoring and evaluation are going to be influenced by that.

But then we got to the point where we had these results showing that we had institutional racism. And then the question was, what do we do about it? And we sort of surveyed around, like what is an approach to something like this, which is a patient safety emergency, as far as our patients of color are concerned. And we weren’t really satisfied with what we had. It was a lot of checklists, objective, race-blind kind of implementation efforts that had been done in the past. And so, I’ll go ahead and pass it over to Michelle to kind of tell the story of then where we got to at that point.

MM: Exactly. I think we were really trying to figure out what’s the most effective intervention we can start with? Not to say we’re going to get it right from the beginning. But where do we start in fixing this problem? And I think so many people are talking now about the fact that it’s been twenty years since Unequal Treatment, which was the Institute of Medicine’s landmark national report documenting extensive racial and ethnic inequities in healthcare outcomes in this country. And twenty years later, we have very little progress to show for it.

And so what we started to think about was, knowing that that’s the context, knowing that there is obviously no silver bullet for institutional racism, and certainly no silver bullet for racial health inequities. But we felt it was incredibly important to come up with a race-conscious intervention that really targeted the fact that we were propagating cycles of institutional racism in heart failure care in our patients. And we should also say, this is just one example. Brigham and Women’s Hospital is not the only hospital that has examples of institutional racism, and certainly heart failure is probably not the only example, even at Brigham and Women’s Hospital. But what we started to do was to think about a framework that would allow us to really get at the heart of the issue. Race-conscious interventions for a system of racism that is clearly race-explicit.

And so what we started to do was we looked at social science literature, we learned a lot from Sandy Darity and Kirsten Mullen and the frameworks that they’ve created around reparations. We looked at reparative justice and applicative justice, and we came up with a framework called the Healing ARC, with “A” being acknowledgement, “R” being redress, and “C” being closure. And the idea is using that reparations framework that Sandy Darity and Kirsten Mullen developed many years ago and really applying it to health, healthcare, public health. And so that’s kind of the genesis of the Healing ARC framework.

And what we started to do at our hospital was say, “OK, well, what is actually happening right now to the Black and Latinx patients who come in with heart failure?” And I’ll say two things that we found. We found that, based on a survey of the providers in the emergency department, the providers clearly stated, actually, that white patients were more likely to advocate for themselves, to go to the cardiology service, and that that influenced the decision about where the patient went, which is a really important acknowledgment about how white privilege can be operationalized and perpetuate institutional racism. And then what we also did was, we decided to focus on that part of the problem. So for those of you who are in the clinical, medical world, you know we have these electronic medical systems, and we can basically put together these alerts that come up when you’re seeing a certain patient or taking care of a certain patient in the electronic medical record. And so we created a best practice alert in Epic, which is our electronic medical record system, to say, “Hey, this is a patient who’s from a group that has been historically excluded from the cardiology service at our hospital. Think about where you’re sending this patient and consider sending them to the cardiology service.”

So it’s just a start, but it’s race-conscious because it’s specifically focused on Black and Latinx patients and making sure that the provider is aware, is acknowledging that this pattern has existed at our hospital for at least twenty years, and possibly longer. And so I’ll pass it over the Bram to share a little more about what happened after we started that work.

BW: Yeah, so one of the things we did to talk about this process, is we wrote about it, and it was just over a year ago now that it was published in Boston Review, “An Antiracist Agenda for Medicine.” And we talked about essentially the story that we’re telling now. And part of that was really to put it out there and to kind of see the response. Because there are certain reasons we could talk about later why this hadn’t explicitly been attempted before.

And something that happened pretty quickly, though, is that, and it really started on social media for Michelle, and on Twitter, is that there started being intensive backlash from white supremacists and it started going quicker and quicker. We started seeing it in different right-wing media outlets, white supremacist outlets, editors who were part of publications that are known to produce work on discredited race science and things like that started blasting it out to their followers, and it ended up on Fox News.

And suddenly we were getting all sorts of hate mail, threats, racist and genderist slurs to Michelle’s accounts, and even our hospital was receiving threats of violence, their social media handles were being attacked. Patients were asking questions. And so we found ourselves in the middle of this firestorm of the backlash against what’s using the term critical race theory, this very manufactured backlash that’s become extremely popular and is still ongoing by different right-wing actors.

This really led us to do serious security work around it. You know, again, we’re describing a single pilot based on documented racial inequities and what is based out of fairness and justice. And this was the response we received. And so things calmed down for a little while, but then when Trump spoke in January in response, actually, to some of the work Michelle and others had been involved in, in New York, and in Minnesota, of considering race-conscious approaches to access to things like monoclonal antibodies and antivirals with COVID due to racism impacting COVID outcomes, then he spoke at a rally in Florida. Things sort of heated back up again, and ultimately neo-Nazis, white nationalists, came to our hospital just this past January, passing out fliers with our picture on them, and passing out propaganda to really create a chilling effect for anyone who wants to do this work, who was pushing for racial equity in healthcare.

So that was last year. But simultaneously, we’ve continued the work. The process Michelle just mentioned, we’ve already started that process in our electronic medical record system. We’re working with community wisdom councils, so Black and Latinx community members and leaders, to think about what does appropriate acknowledgment look like? What does appropriate redress look like? What does closure look like? And so we’re making all that progress there. And at a bigger scale, we’re trying to figure out, how do we protect, how do we promote race-conscious efforts as opposed to race-blind efforts, which is the default approach, which can often exacerbate health inequities right now. That’s our current organizing effort that we’re right in the middle of.

RB: Thank you. And so, I will have some follow-up questions, especially around that last point. But first, before we get to that, I want to invite Dorothy into the conversation. This is going to be my first time hearing her talk about Torn Apart. I’ve just been following the book tour online, so I’m about to geek out. Several of you just joined me, so we can hear a little bit about Torn Apart, and then we’ll broaden the conversation to your other works as well.

Dorothy Roberts: Sure, sure. And thank you so much. It’s great to be back in touch with you, Michelle, and nice to be in connection with you, Bram, and always Ruha, just a delight to be in your presence and engaging with you. So thanks so much.

I just have to say, though, on your last point, Michelle and Bram, about the white supremacist reaction to race consciousness that most of the work I’ve done with Michelle has been around race correction, which is explicit, you know, adjustments, like corrections for race, blatantly in the diagnostic tools. So how anyone could complain about race consciousness when it’s done all the time in medicine, is real hypocrisy.

But anyway, it is interesting that I know Michelle, and we’ve worked together on promoting racial equity in healthcare, and so it’s interesting that I am now going to be talking about a different topic. But maybe later we can talk about how they’re very much related, which is abolishing the so-called child protection services or the child welfare system or foster care, which I lay out a case for in my book, Torn Apart.

And I like the way both of you, Michelle and Bram, sort of gave a history of how you came to the work. And so maybe I’ll just give a brief history, which is that I wrote a book twenty-one years ago called Shattered Bonds: The Color of Child Welfare, that documented the huge racial inequities in the child welfare system and argued that they were a form of racial oppression, and that there was a need for radical change in the system.

And I then spent twenty years very engaged in reform efforts to try to change this system. I was an expert among four others who were appointed by Washington State to try to fix the foster care system in the state of Washington after a judge found that, in a big class-action lawsuit, the state was violating the constitutional rights of children in foster care. I wrote articles. I participated in lots of meetings and workshops. I gave trainings to social workers. I met with heads of child welfare departments. I worked on task forces. I wrote reports. I traveled all over the country. And I came to find twenty years later that the problems I wrote about twenty years ago still exist. And they still exist because this is a system that is designed to uphold racial capitalism, and as long as it’s designed that way, it is not going to be able to be fixed.

You know, as abolitionists say, there’s no malfunction in these systems. They’re functioning the way they were designed, and so I have become an abolitionist on this issue. I think the only way to truly support families and keep children safe is by dismantling what I’m calling the family policing system, and replacing it with an approach that isn’t rooted in racial capitalism, that is truly about equitably and humanely caring for children, meeting families’ needs, and keeping people safe, preventing violence, not reacting to it after it already occurs.

And so let me just say a little bit about what I mean by that. How does the so-called child welfare system or family policing uphold racial capitalism? Well, it was designed from the very beginning to be a way of dealing with the needs of people who were disadvantaged, excluded, suffering from the impact of racial capitalism. So we would have to begin with the separation of families during the slavery era, and then we could move forward to after the abolition of slavery, the efforts of white supremacists to re-enslave Black people, to put them back to work for white people, and part of that was apprenticing Black children back to former enslavers, through the courts, with petitions by white people that Black parents were neglectful, and judges ordering them to be apprentices, sometimes for their very own former enslavers, by the thousands upon thousands of children. And this was a way of forcing them back into labor for white people, along with the convict leasing system and chain gangs and all of those precedents for the mass incarceration we have today.

And it also was a weapon of war against indigenous tribes. In the 1800s, the United States was waging an actual war against native tribes to dispossess them of their land, and even to commit genocide against them. And in the late 1800s, they turned to child removal as a weapon of war, a military tactic to separate native children from their families and tribes. And that turned later int a federal adoption policy to take native children on grounds that they were neglected, under child welfare laws, and place them in white-run orphanages and get them adopted by white people.

And then the system was always designed, from the very beginning, to deal with the needs of impoverished families, mostly white impoverished families, by putting them in poor houses, and then eventually that was reformed into orphanages and foster care and orphan trains where children were taken from their families and put on trains from the East Coast to work on farms in the Midwest and the Southwest.

So the whole foundation of our so-called child welfare system today is based on oppressing politically marginalized people who suffer from the results of an unequal racial capitalist system, and blaming them for the hardships that their children face, instead of dealing with what we know are the main harms to children, which are structural racism and poverty and other forms of structural inequalities.

We can also see the connection between capitalism and white supremacy in more recent history of the entanglement of the end of welfare and the welfare entitlement, and the emphasis on adopting children out of foster care and speeding up the termination of parental rights. So in the 1990s, after Black families began to be more present on welfare rolls as a result of activism, largely by Black mothers fighting for entitlements to welfare, which they were not given prior to the civil rights movement, welfare became more stingy, and it became connected to foster care, because Black mothers were routinely taken off welfare benefits on grounds they didn’t have suitable homes, and then there was a federal rule passed, the Flemming Rule, that they then would have to be taken from their homes if they didn’t have suitable homes. To receive welfare, they couldn’t, then, have their children safely at home. So we already see this connection between capitalism and of welfare and the buildup of foster care, mostly based on inclusion of Black people into these systems.

Eventually, in the 1990s, based largely, or fueled on negative stereotypes about Black people as criminals, and also Black mothers, in particular, as welfare queens, having children just to get a welfare check, it helped to lead to the end of the federal entitlement to welfare in 1996, signed by Bill Clinton, and then in 1997, Clinton signed the Adoption and Safe Families Act, just one year apart where the Congress sped up termination of parental rights, and incentivized through bonuses, cash bonuses to states, to put more children into foster care.

And so there’s a tight, very tight entanglement of capitalist approaches to the welfare of children, and white supremacist incursions into Black communities and indigenous communities in particular. Part of the way this operates, and this is a $30 billion apparatus, where most of the money is spent on taking children away, maintaining them outside their homes, away from their family caregivers. This happens in part because neglect statutes are defined to confuse poverty and neglect. They’re defined as failing to meet the material needs of children, and this mostly happens because parents can’t afford to meet all the material needs of children. And most of the children in foster care are there because of allegations of parental neglect.

There’s also lots of documented evidence of racial bias in child welfare decision making, including, and maybe we can get to this later, by doctors who are some of the primary mandated reporters who routinely report, suspect, and report Black mothers far more than anyone else, and this is part of the reason why, along with teachers and police officers and other mandated reporters, we see these disparities in rates of involvement. And by the way, recent studies show that more than half of Black children in America will be subject to a child welfare investigation by the time they reach age eighteen.

So to sum up where I got after realizing how the system operates, and how it was designed, and how it continues to rely on accusing, investigating families, separating families, terrorizing families in a way that blames them for the disadvantages their children experience because or racial capitalism, and thereby supporting racial capitalism by diverting attention away from social change, radical social change, toward disparaging mostly impoverished families, but especially in Black and indigenous communities. I came to the conclusion, along with members of a growing abolitionist movement, that the system must be dismantled, and we need to simultaneously, as we’re dismantling it piece by piece, by doing things like ending mandatory reporting, giving family caregivers actual legal rights or defending their rights, and other kinds of legislative change. But just as important is providing the kinds of material concrete resources that families need, and also developing better ways of preventing domestic violence, including transformative justice. And more broadly, creating a society that truly and equitably cares for people, that keeps people safe and provides for human needs without caging people, without arresting people, without putting people in coerced detention, and without separating families.

RB: Thank you, Dorothy. We’re going to give the panelists just an opportunity to have a little cross-talk. I’m going to ask Michelle if you’d like to respond to Dorothy, and Dorothy, if you have anything, in some ways your segway was a response, but if there’s anything else, I’ll give you an opportunity now.

MM: And yeah, Dorothy, I can’t even tell you how much you have a fangirl and boy of progressive providers and professors. So we always just learn so much from you, and so thankful for your courage in the ways that you write and analyze and research these kinds of topics that have to be central to the conversation about how we transform our communities and our society. So I’m just so thankful for you.

And the thing that I wanted to kind of respond to, there were so many parts of what you described that I think are so synergistic. There are so many parallels that we see in medicine and public health, and you know, the thing that came to mind, in particular, was your description of policing poverty, policing people of color, and targeting unfortunately these communities based on racism, white supremacy, and using policy to do so. And really, in so many ways, blaming the victim. And the way that that has shown up in medicine for me, or one of the ways that came to mind for me, was even in our heart failure work, there has been a lot of attention to how patients might come into the hospital for heart failure, but then they get readmitted and readmitted and readmitted, and often what we do as providers is, we say, “Oh, that patient’s not taking their medication,” and “Oh, those Black patients especially. They don’t take their medication. And they eat too much salt.” Right? We have all of these awful racist tropes about patients of color in particular, and we often blame them for what are health outcomes that we, in fact, have created, because of our sick care system that is built around racial capitalism.

What we found in the work that we were going at Brigham actually was that when you look, when you were on the cardiology service, again, this specialty service, the readmission rates were the same between Black, white, and Latinx patients. So the racial inequities actually went away when you got this specialty care and all the wrap-around services that go along with it. And so in fact, we should not be blaming our patients at all. We should make sure that they have both the specialty care and the wrap-around services, the support at home that comes with, again, some of these more well-resourced services, like cardiology. So another example of how blaming the victim is a part of the system of racial capitalism, and who gets sick, and who has access to the best care and not.

DR: Responding to what you just said, Michelle, and again, I feel honored and just joyful about being with all of you.

So absolutely the whole way that the family policing system operates, but we see these kinds of stereotypes and blaming in healthcare professions as well, and healthcare institutions ignore the way in which structural impediments are actually the reason why people can’t provide housing for their children, or can’t comply with the doctor’s orders. And there’s just so many ways this parallels in family policing.

One thing that comes to mind right away is that the answer to families when they are separated because of inadequate housing or food or clothing or education or healthcare is to give them a set of mandated tasks they have to perform. And those tasks often have absolutely nothing to do with the needs of the family. And so, if they don’t fulfill all those tasks, they are at risk of not only their children staying in foster care, but their parental rights being terminated and their legal relationship, anyway, being ended. And it’s not because of any evidence that the child is at risk. It’s because they didn’t comply.

So this idea of compliance is so great in the family policing system, and the stereotypes about not complying, especially among Black mothers. You know, the notes in case files about how they’re angry, that they’re resistant. Any complaint, which is actually a concern for their child, is seen as not wanting to recognize their deficits, not being rehabilitatable, that sort of thing. So that’s definitely a commonality.

And the other that I’m thinking of, stemming from what you just said, is how, when there are actually equitable resources, and people are valued equally, there are better outcomes. And a big part of the family policing system is that it is only designed for the most marginalized people. It isn’t designed for wealthy people, because wealthy people have the resources and because they’re in charge of who’s going to get punished. But part of the justification for this punitive approach towards impoverished and working-class families is that their children need this. And wealthy people’s children don’t. Well, that’s because wealthy people’s children have the benefit of resources that can address the needs that they have.

You know, it’s not as if wealthy families don’t have problems. It’s not as if they don’t have conflict. It’s not as if their children are never neglected. That has nothing to do with it. It’s that, first of all, they’re perceived as being better parents, but also, they do have resources, private resources, that they can pay for on the market, and this is, again, the capitalist approach. If you can pay for them, we’re not going to punish you. If you can’t pay for them, we will punish you. And that’s also related to what you were saying about how these inequities happen in healthcare institutions as well.

RB: Yeah, that last point, Dorothy, brought to mind the recent high-profile case of the Penn student whose abuse wasn’t believed precisely because of the middle-class trappings and whiteness in suburbia. And so the underside is that, certain kinds of abuse are not legible precisely because of these distorting lenses of racism. You could see the parallel with the opioid crisis as well in terms of people who have access to things that are killing them, precisely because they are not policed in the same way.

DR: Yes, yes, and just to add a footnote to that case, her mother in the end got off because she could hire a high-powered lawyer to reopen the case and challenge the findings. You know, impoverished people or working-class people can’t afford lawyers. That’s also a part of what leads to these huge, huge disparities and inequities.

RB: There’s some great, really great questions coming in the chat. I want to make sure I get to them. I just want to ask a couple of follow-up questions from those opening comments. First, maybe Bram, if you could just go back to that white supremacist backlash that you described, and just to note that it’s not only the kind of cultural backlash, the social media backlash, but also in terms of law. So what are some of the legal challenges to race-conscious work in healthcare that take on a more official, codified structure?

BW: I mean, this is really one of the reasons why the backlash is so effective, actually, because of how the law’s been interpreted, especially in recent decades. And so a lot of the laws that were designed to protect Black folks against discrimination, thinking about how Title VI or the 1964 Civil Rights Act, is now being used to prevent race-conscious efforts to address racial inequities because the law has been interpreted only looking at intent, rather than disparate impact. And it’s very difficult to prove intent.

And so any corrective measure, like ours, where we have this racial inequity in heart failure admissions, could be seen, according to the law, laws that were designed for very different purposes are now being used to actually prevent race-conscious interventions. And so we’ve been threatened to be sued. Public health departments, like Minnesota, were threatened to be sued when they did something similar, and they backed off including a race-conscious effort. The State of New York, and Commissioner Mary Bassett, are being sued.

This is the way the law is being used now by white supremacists in order to avoid any challenging of the status quo. And I think about why we think this backlash happened, in our work, and it really touches on a lot of what Dorothy was discussing. It’s something that, I saw someone mention in the chat, W.E.B. Dubois, almost one hundred years ago talked about why poor white people were not acting in their class interest and joining with poor Blacks against white elites. And he talked about the wages of whiteness. This unearned status and sense of superiority that come from understanding yourself as white in a society where that fiction of whiteness has a lot of real benefits, psychologically and materially.

And so that’s a big part of why, directly we’re going to challenge that in our intervention, and that’s what I think in particular has led to that backlash, which also has these legal ramifications.

RB: One of the really important distinctions I think you all made, again, towards the end of your comments, Michelle, I believe it was, between race-conscious and race-based medicine. I think a lot of times when we’re confronted with the role of racism, how racism infects any arena, medicine, education, business, the alternative is often pitched at, well, if racism is a problem, we should ignore race. Let’s have a colorblind approach as the next sort of seemingly logical alternative. And of course, we know for a variety of reasons, ignoring a problem, trying to erase a problem doesn’t magically make it go away. And so, the alternative really is a race-conscious approach. Could you talk a little bit about some of the race conscious efforts in your own work as New York City’s Chief Medical Officer?

MM: Yeah, no, this is one of those kinds of key critical tensions that can be very confusing, and I myself continue to be kind of on this journey of building my consciousness around it as well. But you know, I think it’s helpful to think of race-based medicine as a kind of medicine that assumes a biological difference between the races.

So, an example of race-based medicine is something that Dorothy and I have been working on for a few years now, is how we “correct” kidney function for the Black race and dichotomize humanity into Black and non-Black, and then actually automatically add a multiplier to a kidney function result if you are, “Black.” And you know, again, that is race-based medicine. That is using race in a way that’s biological. And what we know, in fact, from lots of research by health equity scholars, including Professor Roberts, is that actually, that “corrector” delays care for Black people. And the study personnel assigned race. It wasn’t even self-identified race.
And so again, that brings into question so many of the past research studies, and all of this work that has happened in the history of medicine around “race-based medicine” or using race as a biological variable.

Now, contrast that with race-conscious approaches to health justice, health equity, racial justice. Race-conscious approaches are really about acknowledging the starting point, acknowledging the fact that people of color are systematically excluded from healthcare, from other systems, from rightful access to treatment in many different realms. So it’s starting with that acknowledgment of the way our society is actually constructed, the way we have a racial hierarchy determining so much of what people’s day-to-day lives are like, especially for people of color.

So race-consciousness is saying, “Well, this is the starting point.” Right? The starting point is white supremacy. And knowing that, we have to actually be explicit and clear about making sure that the people who’ve been left behind, whether it’s, poverty, whether it’s people of color, being race-conscious is knowing where we’re starting from and actually being clear in naming racism as one of the drivers and actually making sure that people of color, specifically, who have been harmed by it are centered in the solutions.

One of the things that we’re doing in New York City, is, and Professor Roberts is a part of this, we developed a coalition called the Coalition to End Racism in Clinical Algorithms. And part of what we’re doing in that coalition is not only saying, “We have to end race adjustment or race correction,” which again, is race-based medicine, but then we also actually need to develop a plan to engage patients of color whose care has been delayed or impacted by race adjustment, identify them, so when it’s kidney function, these are the Black patients. Where are the Black patients? Have they seen a specialist? Have they been evaluated for a kidney transplant? So it’s specifically saying, “We know that Black people’s care had been delayed by this. We need to identify the Black patients and make sure that they get the care that they deserve,” and that is a part of being race-conscious, reparative, and corrective.

RB: Thank you so much, Michelle, for that thoughtful, in-depth response. I’m going to turn now to a number of the questions that are coming to me in the chat. I’m going to kind of guess who can respond to them, but if someone else wants to try, feel free.

So I’m going to actually start here with a question to Dorothy, asking if you’ve encountered in your research the way that the foster case system or the family regulation system has affected undocumented families living in the U.S., leading to family separation, criminalization, deportation.

DR: Yeah, so you know, we’ve talked a little bit about how the family separation system is connected to the healthcare system, and I also saw a note about saying more about how doctors are involved, and I would just emphasize again that doctors are intimately involved because they are one of the chief categories of so-called mandated reporters who report suspected child abuse and neglect. And they do it in extremely racially biased ways.

They are, for example, much more likely to suspect Black mothers of drug use while pregnant and report them than white mothers, and same thing, they don’t report wealthy white mothers, especially, and so, or affluence white parents in general. They’re less likely to be suspected of committing abuse, and even when there is evidence of drug use, which is not evidence of bad parenting. Let me make that clear. But they rarely report that. And that’s one reason why this idea of mandated reporters is not real, because none of these reporters really thinks they’re mandated to report all their suspicions. They’re actually agents of the state to report on marginalized families. And when I say that, I think of Governor Abbott’s directive to child welfare workers to report the parents of trans children who have had gender-affirming care, another connection between the healthcare system and family policing.

So this system is also deeply entangled with the deportation system and with the criminal punishment system. I mean, they’re all intimately involved. I think we’re more likely to think of how immigration enforcement is connected to criminal law enforcement, but both of those are connected to the family policing system. And so, they share information across all of these systems.

And by the way, child welfare departments are increasingly entering into big contracts with computer companies like IBM and SAS and building up huge databases that are designed to monitor the, again, the most politically marginalized communities, but with tremendous amounts of information about children and their families and their whole social networks that can be shared with ICE and with police departments, and is shared across these different domains. If there is an allegation of child abuse or neglect against an undocumented person, who gets into the child welfare system, that enhances their chances that they’re going to be deported.

And also, it’s important to recognize that the agents in all these policing kinds of systems work together, and so they may go to a home to inspect it for child maltreatment or for immigration violations, or for suspected criminal offenses together, or they may report to each other. Caseworkers, often when they go into Black neighborhoods, bring police officers with them in order to terrorize families and get them to cooperate or get them to let them into their homes without a warrant or probable cause.

So yes, there is definitely a connection between the surveillance and searching for and deportation of undocumented people, noncitizens in the United States and family policing, along with police departments and other aspects of criminal law enforcement. And in Torn Apart, I call it a “giant carceral web,” because they all have carceral logics. They operate in carceral ways. They’re designed to punish people and to, again, deal with human needs.

I saw someone put in the chat about the emphasis on not providing children their material needs and not emotional needs. And that is very true. And one way this manifests is how the reaction to a child whose material needs aren’t met, like they don’t have adequate housing or clothes or food, is to separate them from their families, ignoring the emotional trauma, which does have health effects as well on children. And this is so accentuated when it comes to Black families.

So with Black families in particular, because of this longstanding narrative that Black people don’t have loving bonds with each other, that Black children are better off outside of their families and communities, that Black fathers are absent. They don’t care about their children at all, and Black mothers are neglectful and are bad role models for their children. You know, these stereotypes that began during slavery and have continued in the Black welfare queen and the Jezebel, and the crack baby, so called “crack baby,” which by the way, doctors helped to promote that lie as well. So all of these devalue the bonds that Black families have, and therefore, that emotional trauma is often ignored completely and is seen to not matter, and that the goal should be just to get these children outside of these homes that are presumed to be dysfunctional. I think one reason why we see these huge racial disparities in doctors reporting abuse and neglect, is that they already have this idea that Black children are going to be harmed in their homes, or their parents won’t have what they need to take care of them. And so when there’s a positive drug toxicology, they’re more likely to call up CPS.

I once gave a talk in Chicago about this, a long time ago. This was after writing Shattered Bonds, and a doctor, he was dressed in that doctor’s uniform, whatever they’re called, scrubs or whatever, I don’t know. And he was a white guy who was sitting by the door, kind of looking in. And he said, “Yes, I actually do report my Black patients more than white patients.” And he says, “But it’s because I can just tell that they’re not going to be safe when they go home. And it’s not because of their race. It’s because of this sense I have.”

RB: Racist spy sense.

DR: Exactly. It operates cowardly in this system.

RB: Well, you mentioned the data, the companies’ collusions in terms of really strengthening this web and allowing this information to flow. So I just want to come back to Bram and Michelle and ask about technology in the healthcare setting as well. But in this case, how technology can be or is potentially used to undo these harms, or subvert the status quo, perhaps moving towards redress. And this is also an invitation for this last stretch of our conversation to also seed some of the lines of action, the organizing, the ways that people who are listening can think about how to intervene and work towards abolition. So Bram.

BW: I think that this is something you touch on really brilliantly in Race After Technology, this idea that despite all the different ways that technology can perpetuate through race-blind or racist mechanisms, that also there’s the potential to be creative. There’s a potential to subvert the status quo and expose the existence of systemic inequality. I think you mentioned holding up this black mirror to society, and I think in our small way, with this electronic medical record, that’s what we wanted to do. We wanted to acknowledge this, have providers confront it at that moment when they’re trying to admit a Black patient to general medicine instead of cardiology to confront and say, “Hey, we as a hospital, as a system, have this racist practice, and put that forward.” Right?

And I think the hope is that that is a use of technology, a use of medical technology that all physicians and other workers, health workers are using every day, that we can be creative, we can subvert these systemic inequities because the systems are built this way. The hospitals are built this way, only integrated because they had to with Medicare, not that long ago, a few decades. So I think that’s an example that has a lot of synergy, and obviously beyond medicine as well.

RB: What I really love about it, I love a lot of things about it, but one is that it’s really getting us to reckon with how our habits of thinking, the things that are just slightly above the unconscious, the things we don’t really dwell on. And it’s intervening at that level of like, how can we change our habits of thinking, unwittingly sort of reproducing these assumptions, and to use technology in that way, this thing that you have to go to, like it’s part of the routinization of racism and healthcare. But here you’re trying to routinize antiracism.

And one of the things that just reminds us that the kinds of changes we need to engender at the level of culture, that is, the norms and behaviors and habits in institutions, they can’t simply be legislated. Like, we can create policies that invest in these types of things, but we’re talking at the level of culture, how do we begin to change our habits of thought and action? And to me, this intervention, it’s powerful because it’s so small and simple. Rather than a grand statement or a symposium on antiracism or all of the things that these institutions do. It’s like, “No. What are you doing, just part of your job?” Like, your every day that you don’t even think about, that you get trained to do, and it’s at that level that we begin to see different ways of approaching and interacting and recommending treatment, etc.

So with that, we have a couple of questions here about kind of the follow-up to what you all did. And so I’m going to ask two questions at once. Andrew asks, “Has there been follow-up data collection regarding the cardio service allocation, whether improvements have been observed?” And Hubert asks, “Is Brigham and Women’s Hospital supportive of this initiative by Bram and Michelle?”

BW: And so we’re collecting the data now. So we really only just started to roll this out, really only actually, due to a lot of the challenges we discussed. But having had to look into the data, make sure the tech pieces were working right, I know for a fact that it has worked on a couple of occasions, and actually just being able to look in a patient’s chart and see that there were a couple of instances where it changed practice. You know, it kind of broke that heuristic, like you were talking about, Ruha, was really incredibly exciting after, six, seven years of this work, to be at that stage where we’re seeing this changed patient care, I felt pretty amazing, and that’s the stage we’re at now. So there is data being collected. We will report on this ultimately, but it will take really a number of months.

MM: Exactly. And I think, to follow up on that, you know, if it works, to get to Dorothy’s point as well, who’s to say that we can’t have something similar for the way drug tests are ordered in the emergency room for a patient who’s coming in? And you know, there are so many other potential applications of this kind of alert. And it’s also to not say, “It’s enough.” This is a start. This is the beginning of a process of repair. And so I think we’re also excited to think about where else we can go and continue to build on this, because we need to do more, right?

But just to the question about whether or not Brigham and Women’s has been supportive of this, it’s such an important question. It’s such an important question, because it can be very threatening to have neo-Nazis walking on your lawn, and tons of right-wing media coverage saying that you’re racist. But for the wrong reasons. But what we have seen, so there’s a new president at the hospital. It’s the first time Brigham and Women’s has had a Black president. So Dr. Bob Higgins, actually, had just started only about maybe like a month before the neo-Nazis were marching on Brigham’s lawn. And he’s been a huge support to Bram and I, to our work, and I think really sees the opportunity to say, “Actually, we can do better. We know how to do better. And we’re going to show that we can do better,” and then continue to build on it. So I think that that has been a shift under his leadership, to have that kind of support. And we’re really excited to keep collaborating with Dr. Higgins as president of the hospital.

RB: Thank you for that. So I’m going to pose now a question from Tamara, who is a doula in Wisconsin. This is for Dorothy, I think. So Tamara says, she’s a doula in Wisconsin and has done years of grassroots organizing with a mission towards addressing increasing Black maternal and infant deaths by creating community-based models of care that are race-conscious. Her question if framed around her frustration with practicing capitalism under duress, since volunteerism is not sustainable, and direct for-fee service models make my important work vital work a commodity for affluent people. So she asks, “How, then, can we organizers eliminate being part of a nonprofit industrial complex where we compete for funding dollars and perpetuate the insidious ways philanthropists and corporations influence, coopt or sabotage our movement for reproductive justice?” It’s a million-dollar question.

DR: I know. Why did you give me the hardest question of the night? That is such a difficult question. Let me say that one of the things I’m working with organizers in the movement to abolish family policing is an easier question, perhaps. I’m not trying to deflect, but I’m building up. Which is, do we disconnect entirely from the current system? And one possibility would be to say, don’t work in that system at all, or even engage in contracts with the system at all, because it is, as I’ve said, fundamentally designed to harm people, and when you connect resources, community-based resources, like the one that Tamara is asking about, to this system, it completely destroys it, because people are afraid of even accessing those caring services because they could potentially turn into part of the surveillance system.

And this is one of the most toxic aspects of family policing, and this is part of mandatory reporting as well, that the very people and networks and communities and places that could be supportive, turn into arms of the state to surveil. Can you have a visiting nurse program when the nurses are hired by the child protection agency and are required to report back to them what they see. Of course, families that engage in those are going to be fearful. I saw a question about undocumented people being fearful to participate. But in general, families are fearful of participating in what the meager amounts that are provided because it could lead to them losing their children. And so there’s definitely those kinds of things I think most of us have decided you just cannot be connected to this system, because it’s going to ruin what help you could give.
And there are more complicated questions, though, about people have asked, should I be a foster care giver? Should I even go into the social work profession? I think the answer to that is, let’s radically change social work. We shouldn’t abolish the possibility of people having, oh gosh, it’s so hard to even describe it without relying on capitalist logic and language. I mean, as you were saying, Ruha, we’d need fundamental changes in culture, in ways of thinking.

Anyway, but that wasn’t the question. The question was about nonprofits, and I have to say, it’s something that there have been so many meetings about this policy, it’s very hard, because you need funds to be able to provide the care that you want to provide. You need some kind of support. And so, the best kind of support would be community-generated, without relying on systems like the family policing system, and without relying on institutional, other kind of nonprofit private institutional supports, but we’re talking by definition about communities that are already struggling and strapped to even meet their basic human needs. And so, it’s difficult to imagine how to do it now.

I think one possibility is to put more pressure on funders not to create these kinds of processes where it ends up that only the most privileged are able to use the care that she’s providing. There are funders who have made more of a deliberate effort to fund community-based organizations and networks, and not just the ones that are prominent and that are used by more privileged people. I’ve seen that work with some funders. So that’s one possibility.

And the other is, we have to think about other ways that we can support each other, really imaginative ways of maybe sharing resources. In other words, again, it’s hard to even think of the words, but I’m sure someone has thought of the right words for this, and I just haven’t been educated about it. But you know, reciprocal kinds of giving. You know, I can provide this. You could provide that. And we can find a way as a community that we can provide for each other.

RB: Mutual aid?

DR: Mutual aid, yes, that can also work. Mutual aid that allows for us to be able to support each other. I did know the word “mutual aid.”

RB: I know you did. I know you did.

DR: But I was trying to think of this process where everybody shares their skills, their resources, their knowledge. Do you know what I mean?

And definitely, mutual aid. There’s a terrific article by Anna Arons at NYU, that was part of the “Strengthened Bonds Symposium” at Columbia, which was honoring the 20th anniversary of Shattered Bonds. It was a wonderful gathering of people dedicated to abolishing the family policing system. And Anna Arons wrote an article, this is published in the Columbia Journal of Race and Law, and she argued and documented the there was an unintentional abolition during the lockdown in New York during the early months of the COVID pandemic, because the Administration for Children’s Services, ACS, their CPS arm, basically shut down. They weren’t going into people’s homes. The court system wasn’t separating as many families. And at the same time, children were staying home with their caregivers. And there were these dire warnings that there was going to be a huge increase in child abuse because CPS wasn’t investigating, and children were trapped at home with their pathological parents. And Arons points out that that didn’t happen at all. There was no increase in child abuse during that period. And even the director of ACS admitted that in a hearing or meeting before the city council. And she says that the reason why was because mutual aid networks sprang into action and distributed, diapers, and mental health care, and groceries. They delivered groceries to people, like thousands of deliveries of groceries. This was a massive action by many mutual aid networks that were able to provide what families needed. And then, at the same time, families were getting concrete supplements to their income because of the CARES Act, which has been shown to have reduced child poverty while these child tax credits and checks were going out, and are predicted now to throw children into poverty when Congress, or maybe Congress has stopped them already.

So it was this combination of cash in people’s hands that they could use to care for their children, no strings attached. You don’t have to give up custody of your children. You don’t have to be subjected to investigation. And just as importantly, mutual aid. And so we know from that, and lots of other examples, what can work without relying on either being entangled in these systems and without relying on big funding from nonprofit organizations.

RB: It’s possible. So we have a wonderful question here to end on. And the reason why I love this question is because often times when we talk about systems, harmful systems, whether it’s medicine or child welfare or policing, we forget about the system in which we’re embedded, which is the university system, and the complicity, often, of universities and ideas, not just the institutions, but the ideas that bolster so many, and justify and legitimize so many of these, whether we’re talking about scientific racism, or we’re talking about all of the various ways in which tech solutionism comes into play.

Allen asks a great question that gets us to look inward. He says, “Here in Brazil, we believe that universities have a fundamental role in the deconstruction of these racist practices in different fields of knowledge.” So he asks, what in our view is the role of universities in deconstructing all of this in the US? He’s thinking of the initial continuing training processes, for example, of health and educational professionals to get started. So maybe Bram and/or Michelle can tackle it, and Dorothy, if you have anything to say, we can start to close out.

BW: One of the phrases from one of our dear friends and mentors who’s sadly passed away, Paul Farmer, just a couple of months ago, is that in any analysis of a situation of understanding, you have to be historically deep and geographically broad. And the first thing that comes to mind for me is that, when I think about at least the American universities represented, that we’re affiliated with her in the panel, you’re thinking about institutions, maybe from the seventeenth century, that were founded by European settlers while they were committing genocide against indigenous peoples in New England and down the East Coast. And so that these institutions were founded as these fundamentally colonial ones, and, for example, at Harvard Medical School, the first president, the first dean of the medical school was an avowed, severe anti-black racist. And that’s the history, and the history of enslavement as part of these institutions.

So it’s not just the potential for a role, but it’s the deep, deep responsibility, and that conversation has just catapulted a little bit to a new level, right, just the last couple of days here at Harvard, with a little bit more of this recognition that we need to be historically deep and geographically broad when we think about what our own role has been and continues to be. I’ll at least start there, but I don’t know if someone else wants to jump in.

MM: The only thing I’ll add is I think that is Allen Britto, who is from the Brazil chapter of the Campaign Against Racism. So, hi, Allen. That’s such a great question. That’s all I wanted to say.

RB: Dorothy, I know you’ve been teaching generations and cohorts of people that have gone into many, many different professions. So just seeding these ideas is just a powerful way of contributing to the transformations we seek.

DR: I ran into this session because I just taught my last class at Penn for this semester, and it was a course called Race, Science, and Justice for undergrads. And in fact, we read your article on informed refusal, that was one of the texts that we read for this week. And we ended on this powerful note. I said, you’ve learned about all these racist ideas, as Bram was saying, that are embedded in science and medicine from the 1600s until now.

Penn, for example, is the first medical school in the nation. It trained Samuel Cartwright, who argued that Black people’s lungs were weaker, and therefore they had to be enslaved to be healthy. Samuel Morton, who collected almost a thousand skulls to prove his ideas of racial difference, and that Black people were the least intelligent race, and white people the most intelligent race. Penn is steeped in this history of racial thinking. You know, there’s also the experimentation on Black people’s bodies. But as well, the racist thinking of biological differences between people of different races that has justified huge inequities, structural inequities, and it still plays that role today. You know, pinning the reason why we have racial and other inequities and injustices is because of some innate differences within people’s bodies, whether it’s poor people or Black people or indigenous people, or people with disabilities, this idea that the suffering that they experience because of social inequality, actually stems from their physical impediments and impairments and defects.

And I think that is the thinking that ties across all of what we’ve been talking about today, and links together family policing and medicine and science and the criminal punishment system, and they’re all based on that idea of blaming the people who are the most impacted by structural inequalities for their own suffering, and then intervening on them as the solution. So yeah, I think we in universities do have an obligation to redress, repair, and radically change these ways of thinking that came out of universities and were promoted by universities.

And I’ll just mention one other thing, which is that we have an obligation to use the privilege we have of being in universities to engage with, and even take leadership from people in our surrounding communities, which very often, for Penn, maybe less so for Harvard and Princeton, but definitely Yale, University of Chicago, you know, so many universities that are not only bumping up against the most impoverished and oppressed parts of their cities, and in fact encroaching on them, using them as research subjects, and far from even taking leadership from them, not even treating them as equal human beings so often. And that, I think, also has to be part of what universities need to do to account for their long history of collaborating in and promoting racist and racial capitalist ideas.

RB: Absolutely. The only other thing I would add to what has been said in response to Allen’s terrific question is that for me, part of that responsibility entails both the training that is mentioned, the critical tool kit, and the ability to see what’s wrong, but also a kind of creative capacity to imagine how things could be otherwise, building on the robust idea of abolition as both bringing things down and growing things up.

So practically speaking, what that means for me in my own classes is that almost always I have a speculative component to the assignments, to the discussions where we’re critiquing, and we’re trying to imagine and create other ways of organizing social life and interacting as human beings, and as a teacher, those are often the most interesting, enlivening, and just keep me hopeful, is when I see students using their design skills, creative skills, even those who don’t think of themselves as artists, but just using their imagination, because we have to understand that as a muscle, that if it’s not practiced, if you don’t use it, you never develop it. So you can see what’s wrong, but you can’t see any way out of it.

And so I would just encourage anyone in that role, whether as a teacher, a parent, an organizer, to take imagination seriously as part of this tool kit that we need in order to seed other ways of organizing social life. And Dorothy’s heard me get on this enough.

DR: Yeah, well, you know, one of the readings that I have my students do, along with yours, Ruha, was Octavia Butler, and with a slide that says, “There’s nothing new under the sun, but there are new suns.”

RB: Yes, I wholeheartedly agree. Thanks for adding that.

DR: Imagining something radically different, if you can do that. And I say, look, race was invented. If it was invented, we can invent something else.

RB: Exactly. Let us end there with new suns, with invention, and just thank everyone for staying tuned for an hour and a half. Thank you wonderful panelists, Michelle, Bram, and Dorothy. Have a great night, everyone.