Twelve years ago, SETMA went to the HMO with which we work and requested that our patients have a zero co-pay to see a primary care provider in order to eliminate all economic barriers to care.  We can now demonstrate statistically that our patients with a zero co-pay have a better outcome than our fee-for-service Medicare patients who are still responsible for their 20% payment.

Our practice, patients and partners are made up of African American, Oriental, Asian, Middle Eastern, Indian and other racial, ethnic and national groups.  Collectively, we are the solution to the problems which together we all face.

White People

It was very disappointing to hear the reference at the conference to “white people.”  And, the term was used derisively.  Why can’t we eliminate the phrase “white people?”  I have never seen a "white man."  My shirts are white; my skin is not!!  I and all men and women are "colored."  Some, like me, are Caucasian with skin tone which vary from light brown, to slightly pink, to dark black.   Others are Mongoloid which has more to do with physiognomy than skin color. Others are Negroid, which varies from dark brown to black.  

In reality, we are all "colored."   If more proof is needed, I offer the following observation. Pakistanis are Caucasian, yet some have skin tones darker than any African-American.  There is no uniformity between skin color and ethnicity.  Denzel Washington played the role of Steve Biko (one of my heroes) in the movie, Cry Freedom.  In Steve’s trial in a South African court, the judge asked, "Why do you people call yourself black, you are browner than you are black?"  Steve responded, "Why do you call yourself white, you are pinker than you are white?"  To which the judge responded, "Precisely!"  If we are going to refer to Caucasians by a color, let’s agree to call them “pink,” or “brown,” or “black.”  All apply.

The foundation of racism

In 1970, I was in a medical meeting in Los Angeles   In a plenary session of 1,000+ people, an African American professor assumed the microphone and began to address her theory of the foundation of racism. She argued that prejudice is produced in people who resent others having something which they don't.  She opined that white people were missing melanin and resented it.  

When she finished, I was recognized. I said that the absence of melanin is not the issue of racism as Caucasians only have a relative, not an absolute, melanin deficiency. I said that the absence of melanin which resulted from a metabolic abnormality did not result in Caucasian-ism but albinism.  At that time, I quoted verbatim and correctly the biochemical pathway for the production of melanin, pointing out the point of the blocking of its production resulting in albinism.  (I could do that 46 years ago; today I can't.)  Needless to say, my observations won the day. 

Now, here we are 46 years later, still fighting the same fight of skin tone but blaming “white people” for all of societal ills, and as we now know, “white people,” really don’t exist.  It is implied that it is because of white people that others don’t have dental care.  And, it is the responsibility now of “white people” to provide dental care for everyone.  Both propositions are false.

Social Justice and Healthcare Equity

Studies of “justice” and of “social justice” are long and tortuous. It is a canon of progressivism, 20th Century Liberalism, Socialism, and Communism - which are not used as synonyms but which may be a linear “procession” -- that “social injustice” exists in any setting, where there is a difference in wealth and/or of the fruits attached thereto.  The clear implication is that any disparity in distribution of any goods, whether a process or a product, is ipso facto the result of injustice.

The political model of “social justice” does not allow for differences in personal choice and assumes injustice at the root of all differences in resources.  This creates simplicity and a uniformity which demands the stifling of initiative, creativity, ingenuity and/or industry in a society.  All differences among people are reflective of an evil influence even though one worked hard, created utility (in the John Locke scheme) and received a reward, while another opted for lassitude or at least lesser expenditure of effort, discipline, or energy, and consequently received a lesser return.  It is one of the pernicious theories of the “big four” above - progressivism, liberalism, socialism and communism - that the resulting differences are evidence of and proof of the presence of injustice which must be eliminated by the artificial and societal elimination of those differences.

On the other hand, one asks, “Are there inequities and/or injustices in society?”  Absolutely!  Is the fact that more African-American men are executed for murdering a Caucasian than Caucasian men are for murdering an African-American evidence of injustice?  If you support the death penalty, which I do not, it certainly is highly suggestive.  Is it injustice that when I was a college student, an African America student could not attend the same school?  Absolutely!  On May 6, 2016, when I gave the Commencement Address at my undergraduate University, I was introduced by an African American graduating senior.  After his introduction, I embraced him and commented that 51 years before, he could not have attended that school and that the proudest moment of my life in a commencement ceremony was being introduced by him.  We have a long way to go, but having experienced the consequences of supporting civil rights in the South in the 1960s, I know we have come a long way.

The concept of justice requires a moral judgment of a behavior and/or of an outcome to call it injustice, and in the context of “social justice,” it is required that the negation and/or correction of that behavior must produce justice in order to prove that the outcome was the result of injustice.  It is unclear whether all differences in human experience and/or differences in resource distribution are the result of a morally deficient process which would be judged as injustice.  Injustice requires an intentional, willful and/or premeditate act which injures another in which injury was the goal.

Sociology versus Injustice

I would argue that sociology identifies many more reasons for societal differences than injustice. And, that while some of those sociological determinants qualified as injustice, all do not.  Progressives and their fellow travelers, while rejecting absolute values held by others, believe absolutely that injustice is at the root of everything they want changed.  While all of us would like to eliminate poverty, and while at times poverty has been the result of criminality and injustice, all of us do not believe that all poverty is the result of the evil intent of others.  It is equally unclear to me that “blame,” the determination and the declaration that a certain deficiency is the result of an intended negative attitude or action, is a part of the solution unless the “injustice” remains as a legal, structured barrier to equality, justice and equity.

A Subtle but Real Dilemma

There is another problem with the philosophical foundation of this conference.  That is that the emphasis upon “social justice” and/or “health equity” takes on the appearance that the solution to societal problems is not the elimination of discrimination and injustice but it is to reverse the roles so that those previously oppressed become the oppressors.  This collectivist mentality tends to place ultimate value upon the class rather than upon the individual.  In my value system, it is the elimination of disparities, prejudice and injustice for all that is of value, not simply changing the roles of different groups in the society.

As described in SETMA’s Model of Care (see above), the primary emphasis is upon the health of an individual and the health of the group is of concern but is subordinate to the person.  The group is used as a model for how to promote individual health but the quality of care is measured by the well being of the individual.  In the collectivist model the individual is almost a pawn in the intended remodeling - in the manipulation - of the group to produce an outcome which is not based on the well being of the individual but upon the change in appearance of the group.  This is unspoken and perhaps even unseen but it is nevertheless true.  A System and a solution which will be successful and satisfying are focused on the individual primarily and only incidentally upon the group.