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Just Medicine: A Cure for Racial Inequality in American Health Care, Dayna Bowen Matthew

Reviewed by Nancy López


In 1903, sociologist W.E.B. Du Bois argued that the problem of the twentieth century was the color line. More than a century later, an Institute of Medicine report titled Unequal Treatment (2003) painstakingly documented the continuing presence of a color line in health care delivery. Regardless of income, wealth, or education levels, visible minorities still receive unequal care. What is paralyzing a profession like medicine, which is dedicated to ethical treatment and social justice, from eliminating documented racialized inequities?

In Just Medicine: A Cure for Racial Inequality in American Health Care, Dayna Bowen Matthew makes a bold argument: implicit bias and unconscious racism are the elephants in the room that no one seems to want to talk about. As enduring social structures and fundamental causes of unjust, inevitable, and avoidable racialized injustices in health, implicit bias and unconscious racism must be named and confronted by all stakeholders. Matthew supports these arguments by reviewing the vast interdisciplinary social science research evidence base on the causal mechanisms linking implicit bias and unconscious racism to the delivery of unequal health care for stigmatized minorities in the United States. To contextualize these findings, Matthew also conducts informal interviews with physicians, nurses, and patients.

Perhaps the most potentially transformative ontological contribution that Matthew makes is her conceptualization of the “Biased Care Model.” As a heuristic device for research and praxis (a tool for ongoing dialogue, reflection, and action), Matthew's framework provides a necessary visualization of the problem and a theory of change. The Biased Care Model illustrates three intervention points for disrupting avoidable disparities: pre-encounter, during the encounter, and post-encounter. At the macro level, Matthew provides a practical structural policy prescription for eradicating the implicit bias and unconscious racism malady plaguing our nation: revisions to civil rights law (Title VI) to include implicit bias and unconscious racism.

Matthews's arguments dovetail nicely with the tenets of critical race theory, which simultaneously point to the permanence of racism and white supremacy but also shine a light on potential transformation leverage points. For example, according to critical race theory, small gains in racial justice are possible when they overlap with the interests of the powerful. The language of implicit bias and unconscious racism may provide an opening narrative that can strategically engage providers and policymakers to listen, reflect, and act in the service of racial justice. The Biased Care Model provides a model for necessary intersectional knowledge projects that examine how implicit bias and unconscious racism may be experienced and manifested differently depending on the particular configuration of structural race-gender-class inequality at play in a given local municipality or rural.

Finally, the policy prescriptions allude to a way forward for cultivating synergies by stakeholder groups, including social scientists, providers, lawyers, and policymakers, as well as patients, to work together to eradicate implicit bias dovetails nicely with community-based participatory research methods in public health and potentially research practice partnerships in education, criminal justice, and other policy arenas.

Just Medicine is necessary reading for all who envision a society in which health equity is a moral imperative. I would place Matthew's contributions on the scale of Michelle Alexander's transformational book, The New Jim Crow: Mass Incarceration in a Time of Colorblindness (2010). Matthew not only documents the problem of color-blind racism but also provides solution-oriented road maps for a way forward. These contributions are transformational for interdisciplinary race scholars as well as for health practitioners, policymakers, and patients who have a vested interest in changing the status quo of paralysis in the elimination of unconscious racism in health care.

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