In June 2021, the American Academy of Neurology (AAN) recommending the prohibition of neck restraints in law enforcement. Around the same time, the American Medical Association (AMA) issued a statement denouncing the pseudoscientific and racist concept of "" and categorized racism as a . In 2018, the American College of Physicians (ACP) released a position paper , sparking the notable "" movement.
Police brutality, racism, and gun violence: These are not the typical issues that medical organizations deliberate on.
Some healthcare professionals feel that we are ; others feel that we have an to use our status and expertise to focus on broader public health issues. But physician activism is not a novel idea. In fact, medical organizations have had overarching influence and have taken positions on a wide variety of social issues for decades. Not all of these positions have been positive however; many of our professional organizations have directly and indirectly contributed to racism, sexism, gender bias in medicine, and the .
Looking back at our history provides a basis for understanding present-day advocacy, as both our actions and our silence have long-standing ramifications on the health and well-being of society.
A Look Back at Earlier Medical Advocacy
In 1910, the AMA commissioned a study by educator Abraham Flexner to take a critical look at medical schools in the U.S. in an effort to standardize medical education and shift toward evidence-based medicine. The was instrumental in shaping modern-day medical education by increasing the prerequisites required for admission, focusing on the scientific method, and improving clinical education. The report is widely lauded and credited with closing many substandard schools and elevating the field to where it is today. However, the report was also the impetus for closing all but two of the historically Black medical schools, sparing only Howard University and Meharry Medical College. The report noted that students at those two institutions should concentrate on "hygiene rather than surgery" and stated that "the practice of the negro doctor will be limited to his own race."
The closing of Black medical schools in conjunction with the AMA's barring of the organization significantly limited the number of Black doctors in the workforce. These exclusionary policies were not unique to the AMA; other professional organizations also had similar . These actions had a ripple effect on the lack of diversity in the medical profession, which still today. But the effects are more insidious than just a lack of diversity in medicine; the exclusion of Black people from a prestigious, well-paying profession contributed to discrimination, lack of social mobility, and the increasing wealth gap.
What About Inaction or Silence?
The example above has a clear message: Medical organizations should not endorse regressionist or discriminatory policies. But should they be silent on societal issues? That is also not the answer. Too often silence is misconstrued as tacit approval. For too long, inaction and silence has allowed the racist concept of excited delirium to propagate.
Charles Wetli, MD, a forensic pathologist, coined the phrase excited delirium in 1985 to explain the deaths of 32 young Black women in 1980s Miami. He theorized a syndrome that affected cocaine users, consisting of psychosis, sexual promiscuity, aggression, and leading to eventual death. He cited historical evidence of for this supposed syndrome, even though the cases were nothing alike. Those deaths were eventually attributed to a , but the concept of excited delirium proliferated, even though there was no or physiologic evidence for its existence.
From the onset, the term was racially charged, with a in deaths involving Black males. Over the years it has evolved to its modern-day form of , positing a baseless syndrome that predisposes young Black men to die in police custody. This syndrome has been advanced by the , and the legal and law enforcement community. However, except for the American College of Emergency Physicians (ACEP), most of the medical field did not take any public position on excited delirium. Though it wasn't recognized by the AMA, World Health Organization, American Psychiatric Association, or listed in the Diagnostic Statistical Manual of Mental Disorders (DSM), no professional organization denounced the diagnosis. Instead, most remained silent.
After the murder of George Floyd there was an outcry by , and in June 2021, the AMA released denouncing the diagnosis. However, this diagnosis is still being misappropriated and used to justify police brutality, retroactively explaining away deaths in police custody. The silence of the general medical community at large has been instrumental in the proliferation of this baseless diagnosis.
Medicine Does Not Stop at the Bedside
We've seen the extremes of medical advocacy, from direct action leading to greater discrimination and segregation, to silence leading to police brutality and discrimination in law enforcement. But there are also numerous examples of positive change, such as the AMA and National Medical Association denouncing the of Black and white blood donations during World War II. Some medical organizations have also their own internal histories.
Medical advocacy is not a new concept but is inherent to our profession. Medicine does not start and stop at the bedside -- all factors that contribute to the health and well-being of our patients are "in our lane." Our advocacy should be evidence-driven and reason-based, conducted in the same way as our clinical work. AAN is comprised of experts in both the brain and vasculature of the brain; thus, it follows that they should have a position on circumstances and practices that lead to direct injury of those organs. Similarly, gun violence affects all our patients; in the same way we promote exercise and a healthy diet, we should promote the safe usage of firearms.
We also need to remember that silence and inaction are distinct stances. Medical organizations and physicians have an obligation to further the field through advocacy, not only to advance the health of our patients, but also to prevent medicine from being distorted by others to further their own agendas.
is a Neuro-Oncology Fellow at the Dana-Farber Cancer Institute and Massachusetts General Hospital, and is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University. He is an active member of both the AAN and the AMA.