What's Behind Social Hatred

By Laurie Jo Moore

This book provides an analysis of the individual and social dynamics of racism and hatred, an analysis of the specific characteristics of the most malignant leaders and monsters in history as well as social analyzes of why huge populations of people have chosen to follow these monsters.  Their conclusions come back to the existential issues

• Language: English
• Publisher: Laurie Jo Moore
• Release date: Jun 8, 2020
• ISBN: 9781792329937

Laurie Jo Moore

Dr. Moore has devoted her life to understanding suffering. She was instinctively interested in understanding social movements and fortunate enough to complete her undergraduate degree cum laude at the University of California at Berkeley in 1969. This began her social education with the Black Liberation Movement that went on to inspire the Women's Movement, the Gay Liberation Movement, the Elder People's Movement, the Disabled People's Movement, the Liberation of the Mentally Unwell and liberation movements across the world. At the same time all the young men in her generation were being drafted into the Vietnam Conflict, nine million to be exact. Berkeley was one of the most prominent universities in the War Resistance. This and her experience with SE Asian refugees were the motivation for writing her first book The Secret Fire; When the Land of a Million Elephants Turned Red. It tells the Lao Allies' stories about twelve Lao men who survived the Pathet Lao Death Camps for an average of ten years. Following university, she studied at the Oregon Health Sciences University (OHSU), completing medical school, an internship in the African American community, worked in a migrant labor clinic and then two free clinics, one a former Black Panther clinic and the other supported by the Unitarian Church. For the next seven years she was the primary doctor for the county health department urban semi-emergency street clinic, the alcohol detox center, the men's, women's and children's jails, oversaw the operations of the Venereal Disease and Tuberculosis Clinics and visited the pediatrics clinic. In 1982 she entered the Psychiatry Residency at OHSU where she was an American Psychiatric Association Public Psychiatry Fellow, a Chief Resident and then a faculty member of the Department of Psychiatry. She was triple boarded in General Psychiatry, Addictions and Geriatric Subspecialties and followed these interests as well as cultural interests that took her to New Zealand for fifteen years and the Australia for five years. In these countries new cultures offered further opportunities for clinical work and study including the Pacific Peoples, the Maori, the Aboriginal people and the many migrant people who came to these countries escaping persecution in their homelands. Dr. Moore has had a strong interest in social psychiatry, trauma, addictions, bipolar disorder, personality disorders, existentialism and new emerging treatments for trauma that touch the unconscious. She has become especially interested in the unconscious and how this has been a neglected area of investigation and intervention. She has studied and practiced Eye Movement Desensitization and Reprograming (EMDR) and Davanloo or Intensive Short-Term Psychodynamic Psychotherapy (ISTDP) completing special work with Dr. Allan Abbass, the world expert in Halifax, Nova Scotia. She is a brilliant scholar and a gifted clinician and teacher. It is easy to become swept away by her passion for understanding the causes of human suffering and a desire to find a better way for humanity to restore human dignity.

Book preview

Chapter 1

Overview of the History of Slavery

Summary by Laurie Jo Moore

History of slavery. (2019). In Wikipedia. Retrieved from:

https://en.wikipedia.org/w/index.php?title=History_of_slavery&oldid=926921144

Any discussion about social hatred requires a summary of the history of slavery, a topic which has been largely ignored by the education system and neglected by mental health professionals. It is with a deep sense of gratitude that I offer the following overview taken from a summary provided by Wikipedia. (The 467 references cited will not be repeated.)

Slavery varied in social, economic and legal manifestations across cultures, religions, and nations. It was rare among the hunter-gatherer populations and began to develop under conditions of social stratification as far back as 3500 BCE in the first very early civilizations such as Sumer in Mesopotamia. The Mesopotamian Code of Hammurabi (c. 1860 BCE) refers to slavery as an established institution. It became common in Europe throughout the Dark Ages and continued into the Middle Ages (476 AD-1492). The Byzantine-Ottoman Wars in Europe (14th to 20th Centuries) resulted in the capture of Christian slaves in large numbers. The Atlantic Slave Trade began in the 15th Century and lasted for over 500 years. The Portuguese, Spanish, Dutch, French, British, Arabs, and Americans all participated in this massive holocaust. David P. Forsythe, a historian, noted that at the beginning of the 19th Century almost three quarters of all people were trapped in some kind of bondage with slavery or serfdom.

Slavery probably proliferated after the invention of agriculture during the Neolithic Revolution, about 11,000 years ago. It was practiced in almost every ancient civilization, including Ancient Egypt, Ancient China, the Akkadian Empire (first empire of Mesopotamia), Assyria (now northern Iraq and southeastern Turkey), Babylonia (present day Iraq), Ancient Iran, Ancient Greece, Ancient India, the Roman Empire, the Arab Islamic Caliphate and Sultanate (Supreme Religious and Political Rulers who at the dawn of the 16th Century involved Three Empires, the Ottoman, the Safavid and the Moghul to control North Africa, Southern Europe and the Indian Subcontinent) Nubia (an area along the Nile River between Egypt and Sudan), and the pre-Columbian civilizations of the Americas.

Vikings

The Viking era began around 793 and Norse (another name for the Vikings referring to the Germanic people who settled Scandinavia during the Viking Age) raiders captured and enslaved Franks (Germanic people along the middle and lower Rhine River), Frisians (Germanic people in northwestern Germany and the coast of the Netherlands), Anglo-Saxons, and both Irish and Britonnic Celts as well as taking slaves from German, Baltic, Slavic and Latin countries. Irish slaves were sent to colonize Iceland.

Mexico, South America and Native American Indians

Slavery in Mexico dates back to the Aztecs, in South America the Incas, in Brazil the Tupinanba, in Georgia the Creek, in Native American cultures the Comanche.

China and Korea

The Han Chinese enslaved during the process of the Mongol invasion. Before the Three Kingdoms of Korea slavery was probably more important than in any other East Asian country but by the 16th Century it was no longer necessary.

Eastern Europe

Slavery largely disappeared in Western Europe in the Middle Ages but persisted in Eastern Europe in the Byzantine Empire and Muslim world where pagan Central and Eastern Europe people along with the Caucasus and Tartary were important sources of slaves. Viking, Arab, Greek, and Radhanite Jewish were all important merchants of slavery during the Early Middle Ages.

During the Islamic invasions starting in the 8th Century hundreds of thousands of Indians were enslaved by the invading armies.

Southeast Asia

In Southeast Asia there was a large slave class in the Khmer Empire who built Angkor Wat. One quarter to one-third of the population of some areas of Thailand and Burma were slaves between the 17th and early 20th Centuries.

The Philippines

In pre-Spanish Philippines slavery was practiced by the tribal Austronesian people. The neighboring Muslim states conducted slave raids along the coastal areas of Thailand and the Philippines from the 1600s to the 1800s.

Crimea

The Crimean Khanate (the northern coast of the Black Sea in Eastern Europe once part of the Soviet Union and now part of the Ukraine) frequently mounted raids on the principalities of the Danube River, Poland-Lithuania and Muscovy. Until the early 18th Century the Crimean Khanate maintained a massive slave trade within the Ottoman Empire exporting two million slaves from Russia and Poland-Lithuania between 1500 to 1700.

Hawaii

Ancient Hawaii had a caste system and the Kauwa were the outcasts or slaves. They are believed to have been captives of war.

New Zealand Maori

Before the arrival of Europeans in New Zealand in the 1700s each Maori tribe considered itself a separate entity and prisoners of war became slaves, or were ransomed or eaten. The children of slaves remained slaves. In the early 19th Century slavery seems to have increased.

The Africa Slave Trade

In Africa slavery was endemic and part of everyday life with court slaves, slaves in the armies, working on the land, as couriers and intermediaries and as traders. During the 16th Century Europe became more prominent in the export of slaves from Africa to the Americas replacing the Arab world that had dominated trade before then. The Dutch imported slaves from Asia to South Africa.

The map below shows the African countries involved in the slave trade in the 13th Century. In Senegambia between 1300 to 1900 about one-third of the population was enslaved. The same was true of the early Islamic states of Western Sudan, Ghana (750-1076), Mali (1235-1645), Segou (1712-1861) and Songhai (1275-1591). In the 19th Century, almost half the population consisted of slaves in Sierra Leone, Duala of the Cameroon, Igbo and other regions of the lower Niger, the Kongo, the Kasanje kingdom, and Chokwe of Angola. Roughly one-third of the population were slaves in Ashanti, Yoruba, Kanem and Bornu. In Fulani jihad between 1750 and 1900 between one to two thirds of the entire population consisted of slaves. In the 19th Century in northern Nigeria and Cameroon, a population of the Sokoto califate, half the population were slaves and the same was true in Madagascar. Up to 90% of the Arab-Swahili Zanzibar were enslaved. Slavery persisted in Ethiopia until the emperor Haile Selassie abolished it August 26, 1942. For the benefit of the Muslim countries over at least ten centuries (9th to 19th) Africa was bled of its human resources. Roughly four million Africans were taken across the Sahara through the Red Sea and then from Indian ports across the Atlantic, another four million through the Swahili ports of the Indian Ocean, and the other route was along the trans-Saharan caravan where nine million were taken including eleven to twenty million that were sent across the Atlantic (up to 37 million).

Prior to the 16th Century the bulk of slaves were exported from Africa to the Arabian Peninsula and Zanzibar became the leading port. Arab slave traders would conduct raiding expeditions themselves sometime entering deep into the continent and they preferred female slaves. When the Europeans became rivals along the East Coast of Africa, the Arab traders concentrated on the overland caravan routes across the Sahara.

The Middle Passage was the name given to crossing the Atlantic endured by slaves chained in rows in the holds of ships engaged in by the Portuguese, Dutch, Danish-Norwegians, French, British and American. The peak of the Atlantic slave trade was late in the 18th Century involving raiding expeditions into the interior of West Africa. These were usually carried out by African states including the Oyo Empire (Yoruba), Kong Empire, Kingdom of Benin, Imamate of Futa Jallon, Imamate of Futa Toro, Kingdom of Koya, Kingdom of Khasso, Kingdom of Kaabu, Fante Confederacy, Ashanti Confederacy, Aro Confederacy and the Kingdom of Dahomey. The people captured were shipped by European traders to the colonies of the New World. After the War of Spanish Succession, the United Kingdom gained a monopoly on the transport to Spanish America. Over the centuries twelve to twenty million people were transported from Africa through the Middle Passage to the Americas but also to Europe and Southern Africa.

Brazil

Slavery in Brazil was a mainstay of their economy in both mining and sugarcane production. More than one-third of all the slaves in the Atlantic Slave Trade went to Brazil (4 million, 1.5 million than any other country).

British and French Caribbean

Slavery was common in the Caribbean, the Lesser Antilles islands of Barbados, St. Kitts, Antigua, Martinique and Guadeloupe. This trade was controlled by the British and the French. England had sugar islands in the Caribbean maintained by slaves in Jamaica, Barbados, Nevis, and Antigua. The British victory in War of Spanish Succession (1702-1714) allowed England to enlarge its role in the slave trade. Queen Anne of Great Britain negotiated a secret agreement with France to obtain a thirty-year monopoly on the Spanish slave trade called the Asiento. Queen Anne would get 22.5 % and King Philip of Spain 28% of the slave trade sales to Spanish colonies from the Caribbean to Mexico as well as the British colonies in the Caribbean and North America.

The French imported approximately 13,000 Africans for slavery every year.

The United States of America

Plantation owners in the mid-1600's were recognized in Virginia, Massachusetts, Connecticut, Maryland, New York, New Jersey, and North and South Carolina.

At the time of the Civil War the slave population in the United States stood at four million. The vast majority, 95%, lived in the South and comprised one-third the population as opposed to 1% in the North. In the 1850s the central political issue was the extension of slavery into the western territories. This was opposed by the Northern states and became the cause of the Civil War. President Abraham Lincoln issued the Emancipation Proclamation order on January 1, 1863 that allowed any slave who could escape from the control of the Confederate government to become legally and actually free.

Contemporary Slavery in Africa and Islamism

Slavery is no longer legal anywhere in the world but human trafficking remains an immense problem especially in Asia where between 25-40 million people were enslaved in 2013. Slavery is epidemic in Sudan. In the Second Sudanese Civil War (1983-2005) people were taken into slavery. In the late 1990s systematic child-slavery and trafficking was prevalent on cacao plantations in West Africa. More than half a million Mauritanians, up to 20% of the population remain enslaved, many in forced labor. Slavery persists in the 21st Century in Islamic countries.

The trading of children into sex slavery has been reported in modern Nigeria, Benin, Ghana, and Togo. Slavery is prevalent in Niger, common in the Democratic Republic of Congo, in the cacao and chocolate plantations in West Africa.

Commentary

This overview presents information that is largely unknown except to historians, the perpetrators of slavery or the people affected by these egregious violations of human integrity and dignity. The practice of slavery coincided with the development of authoritarian patriarchal society that became preoccupied with economic survival and development but also was very clearly carried out for the aggrandizement and accumulation of wealth and power by a wide variety of peoples. With this transition to an authoritarian patriarchy, there was also a loss of the psychological and spiritual connection with the interior self that had devastating consequences for humanity.

Tribal and religious themes are evident as well as the racist devaluation of peoples that perpetrators used in treating them as objects. Arabs and Europeans dominated this exploitation. There is not one corner of the earth that was not involved in the enterprise of slavery including the Africans selling their own people and all the countries that benefited from slave labor and the sexual violation of peoples stolen from their homeland.

It is startling but not surprising that this evil side of human history has remained in the shadows. It manifests in many of the themes in the chapters to follow that shed light on the familiar underlying dynamics in this horrifying persecution of innocent human beings.

Marx was a sociologist and his work intended to improve the suffering of humanity. The exclusion of a psychological understanding of human nature, however, led to the use of his ideology as a major source of cruelty and oppression of the freedom of the individual in the name of the sanctity of the state.

Chapter 2

Psychiatric Contributions to Understanding Racism

By Laurie Jo Moore

Moore, L. J. (2016). Psychiatric Contributions to Understanding Racism. Transcultural Psychiatry, 37(2), 147–183. https://doi.org/10.1177/136346150003700201

This article reviews the theoretical contributions of psychiatrists to understanding racism. Racism is poorly understood because it is a tool of socio-economic oppression and it serves those in power to obscure its nature. Confounding factors are examined from several perspectives including coercive behaviors characteristic of unequal relationships, ethno- centric blindness, ignorance about socioeconomic oppression and the racialization of poverty. The damaging effects of racism on physical and mental health are reviewed, as well as the complicity of medicine and psychiatry in dominant cultural racist practices. Despite this complicity, psychiatry has contributed to psychological theories of the origins of racism. Psychoanalytic perspectives argue that racism is not a problem of certain people, but a problem intrinsic to human character and unconscious dynamics.

Considering the magnitude of human misery created by racism, few psychiatrists have contributed to its understanding (Fernando, 1988; Group for the Advancement of Psychiatry, Committee of International Relations, 1987). This article discusses the contributions psychiatrists have made toward clarifying the nature and existence of racism. Studies from other professions are included only when necessary to allow a sensible analysis. I begin by discussing factors that contribute to obscuring racism. I then review studies that demonstrate the socio-economic realities of racism and the damaging effects it has on physical and mental health. Next, I show how racism is extended by the complicity of doctors and psychiatrists in dominant cultural racist practices. The second half of the article reviews theoretical contributions that help in understanding racism. I discuss the principles of totalism and sociogeny and review psychoanalytic perspectives on racism, including the tendency to dichotomize, the central role of individual and group identity and factors that increase the need to hate.

Racism is poorly understood. Dominant cultural beliefs present a superficial view of racism as simply the psychological phenomenon of prejudice. Racial or ethnic prejudice is described as a psychological state, feeling or mental attitude, felt and/or expressed as an antipathy based upon an erroneous, inflexible generalization (Allport, 1954). However, racism, is much more than prejudice. Racism is associated with the overt and covert forceful establishment and maintenance of power by one social group over another. Slavery, colonialism and neocolonialism are all forms of racism that impose social, economic and cultural domination. The social and economic residua of these power dynamics persist within the structure of societies to perpetuate and maintain discrimination and inequality along racial lines. Once racial practices are imbedded in the structures of society, racism becomes an institutionally generated inequality. This institutionalized form of racism is covert because it is hidden by dominant cultural beliefs that represent institutions as democratic (Fernando, 1988, 1991; Wellman, 1977).

Sociologists used the term ‘racialism’ to refer to the acting out of racial prejudice by individuals toward individuals, or more generally to racially prejudiced behavior (Richardson & Lambert, 1985). They distinguished between racism as ideology (cultural racism akin to group psychological prejudice), racism as social structure (institutional racism) and racism as practice (racialism). On closer examination these categories fail to define distinct separate entities and the term ‘racism’ is accepted as inclusive of all these phenomena (Fernando, 1988).

Racism is defined most broadly within the social and political context by Bulhan (1985) following Memmi’s (1968) definition as ‘the generalization, institutionalization and assignment of values to real or imaginary differences between people in order to justify a state of privilege, aggression and/or violence.’ Racism thus, includes the ideas and actions of individuals, the goals and practices of institutions, and the cultural symbols, structures and myths that accentuate real or imaginary differences of race, and validate the absolute, differential (superior/inferior) and spurious nature of these differences. Most importantly, racism includes the use of these beliefs or practices to justify and maintain inequity, exclusion or domination.

Factors that Confound the Understanding of Racism

Dominant cultural groups describe and order reality intentionally to maintain a position of dominance. This frequently involves the socio- economic, political and cultural domination of one racial or ethnic group over another. Promoting and maintaining ignorance about the nature of racism and racial inequality is an extremely effective tool for confusing and disempowering people. This phenomenon is examined from several different perspectives, beginning with an overview of socially coercive behaviors that are characteristic of dominant groups toward subordinants. Next, I describe ethnocentrism, a useful concept from the field of anthropology. I then review in-depth studies that clarify common misunderstandings about the role and nature of socio-economic oppression in racism.

The Dynamics of Inequality: Coercive Behaviors Characteristic of Dominant Groups

Certain behaviors and ways of thinking are characteristic of unequal relationships. These include: cognitive schemas that describe reality in ways that support the power imbalance; psychological defenses, such as denial and minimization, that reinforce these positions; the social ordering of roles and acceptable behaviors; and the institutional enforcement of these inequalities. These characteristics have been described succinctly by J. B. Miller (1978) and her account is summarized here.

Dominant groups tend to label subordinants as defective or substandard along various dimensions. The actions of dominants toward subordinants tend to be destructive. Dominants usually proscribe acceptable roles for subordinants including work that obviously no dominant would choose to perform. These include many roles in the service industry and the provision of bodily comforts, e.g. cleaning up for and after dominants, providing comfortable surroundings, feeding, etc. Functions that dominants prefer and value are closely guarded and kept within a domain inaccessible to subordinants. Subordinants are encouraged to develop characteristics that the dominants prefer, such as submissiveness, passivity, docility, dependency, lack of initiative, inability to act, decide or think. Subordinants that adopt these values are considered well-adjusted. The development of other characteristics is considered abnormal. Dominants impede the development, freedom of expression and action of subordinants and attempt to minimize the existence of any inequality. By virtue of occupying a dominant position, the dominant group promote a belief system that incorporates myths supporting its dominance. This includes developing an overall cultural outlook, philosophy, morality, social theory and even science, all of which include distortions and rationalizations that legitimize the unequal relationship. The dominant group becomes the model for what is normal, and tends to believe that both dominants and subordinants share the same interests and experience. Dominants are usually convinced that the way things are is right and good not only for them, but especially for subordinants. Members of the dominant group find it difficult to understand why subordinates who speak out are so upset and angry and react with surprise and disbelief to complaints about injustice. The subordinate group is necessarily more concerned with survival, so subordinants tend to avoid direct and honest reaction to destructive treatment. Since self-initiated action is dangerous, subordinates tend to develop indirect and disguised ways of acting that accommodate and please dominants. Subordinates usually know much more about the needs of the dominants than vice versa; indeed, subordinants may know more about dominants than they do about themselves. Some subordinants imitate dominants, internalize their beliefs and attempt to ‘pass.’ The dominant group intentionally obscures the true nature of the unequal relationship and the very fact that an inequality exists (J. B. Miller, 1978). These principles refer generically to the dynamics of unequal relationships. They apply to unequal racial relationships and explain some of the common distortions that dominants support.

Ethnocentrism: Color Blindness

The ignorance that produces and accompanies racism is representative of an ethnocentric level of psychological development; ‘ethnocentric’ meaning that a person or a group assumes that their view of the world is central to all reality. This level of development is characterized by a belief system that accepts unquestioningly the dominant group’s cultural stereo- types and beliefs. An individual at this level of development knows little or nothing about the beliefs or culture of any subordinate group. In its purest form ethnocentrism is the denial of cultural difference (Bennett, 1993). A person who denies the existence of cultural differences perpetuates the mistruths of the dominant culture by virtue of their lack of understanding of the actual history and situation of any subordinate groups. Because this type of blindness to reality is imbedded in a network of beliefs that is indifferent to truth value, people at the ethnocentric level of development experience this blindness as normal and are usually not receptive to new information about reality. This behavior creates a smoke screen with which the dominant group tends to cover its tracks and justify aggression. The complex cognitive schemas and carefully woven lies and distortions confound and confuse people and maintain a state of ignorance or blind- ness to reality.

Thomas (A. Thomas & Sillen, 1972) described this in the U.S. as ‘color blindness,’ implying that when people look at subordinate groups of people of color, they do not see them with any depth as human beings with their own history, culture spiritual or socio-economic realities.

It is not surprising, that for example, the enormity of destruction and genocide of ethnic or racial groups, perpetrated during the Atlantic slave trade has been largely kept secret in the American education process. The slave trade lasted roughly 450 years and forced somewhere in the region of 10 million Africans into slavery in the U.S. (H. Thomas, 1997). These were the survivors, however, and other authors estimate that the number of people abducted and destroyed in this massive enterprise of human bondage was somewhere between 60 and 150 million Africans (Bulhan, 1985). The 10 million First Nation peoples in North America alive in 1492 were reduced by massacre and illness to fewer than 1 million in the 20th century (Zinn, 1980). Textbooks and general historical references used in public education have rarely discussed the nature of these genocidal activities. The lack of this essential information is an example of the attempt to obscure the truth, deny the existence of inequality and ignore the destructive behaviors used to maintain it.

The obvious racism of slavery and war are, however, only a part of the story of the oppression of one group of humans by another. The less immediately visible effects of systematic colonial and neo-colonial domination and institutionalized racial oppression define the essential realities of most of the people in the world. Over 800 million people – one-fifth of the world’s population – have become a global underclass. They are illiterate, impoverished, malnourished and have sky-rocketing mortality rates. This underclass reflects the extremes of reality for a large proportion of people displaced by development and the unjust distribution of resources. Urban areas in Third World countries grew from 4% in 1920 to 41% in 1980 (Bulhan, 1985). Although the media would have us believe that these phenomena are natural occurrences, in reality they are manmade: 30% of the world’s grain is fed to livestock when just 2% of that grain would eliminate starvation. Equally, an investment of $40 million a day would establish clean water supplies across the world when over $1.4 billion a day is spent on weapons research and arms, exceeding $500 billion a year (Eckholm, 1982). How do we explain such grotesque contradictions? How do we make sense of the violence perpetrated by one group of humans upon another? And why is it that we have such a dearth of knowledge about issues that determine the lives of billions of people? The lack of understanding of the nature of social and economic oppression and the role it plays in racism is a profoundly important part of ethnocentric ignorance.

Socio-economic Oppression: The Realities of Racism

Socio-economic oppression is the major social vehicle of establishing and enforcing racial inequality. The dominant group confounds any under- standing of the nature of socio-economic oppression and uses the results of poverty (such as violence and self-destructive behaviors) to justify racism. Few people understand the complexity of the relationship between socio-economic discrimination and racism, and this ignorance serves the purposes of the dominant social group. For example, until the 1980s no vital statistics were published about blacks in South Africa who were living in the homelands (Susser & Cherry, 1982). This information was simply left out of the statistics for the Republic of South Africa. Similarly, the U.S. does not collect mortality statistics by socio-economic class (Navarro, 1990). This undermines any attempt to make sense of the effect that socio-economic oppression has upon mortality.

Because we cannot see all the ways a society enforces socio-economic oppression and racial discrimination – in part because societies intentionally conceal this information – we must infer this from other measures. The following discussion presents some data from the U.S. and South Africa that help us unravel the realities of socio-economic oppression and clarify how poverty is racialized.

Irrespective of race, class or ethnic background, poverty results in increased rates of violence, criminality and physical and mental illness. In the U.S., based on data from the 1970 Census Bureau it has been shown that every 1% rise in the unemployment rate is accompanied by a 2% increase in mortality rate, a 5–6% increase in homicides, a 5% increase in imprisonment, a 3–4% increase in first admissions to mental hospitals, a 5% increase in infant mortality and a 2% rise in cardiovascular deaths.

While poverty contributes to violence and illness irrespective of race, racism is manifested in economic oppression. By almost every measure of social or individual well-being, African-Americans are at a marked disadvantage compared with white Americans due to socio-economic disadvantage. The 1980 U.S. Census Bureau estimated that a vastly disproportionate number of blacks lived in poverty: 31% of blacks, 42% of black children and 66% of black children with a female head-of-the-household live below the poverty level (Kovel, 1984). These figures are more than three to six times their representative proportionate numbers by census data. White families earn almost twice as much as African-Americans (Wellman, 1977). The unemployment rate of African-Americans is double that of white Americans. (Richardson & Lambert, 1985)

Poverty is associated with an increase in violence of all kinds – social, interpersonal and intrapersonal. The fact that African-Americans are disproportionately more socio-economically oppressed causes them to be over-represented in prisons. African-American men accounted for 46.6% of all male prisoners in the U.S in the 1980s. Blacks accounted for 50–75% of the prison population in 18 states, over 50% of persons who have been executed and 58% of those awaiting execution on death row (Bagley, 1971).

Poverty is associated with an increase in death by all causes.¹ During a study that spanned seven decades from 1900 to 1970, African-American males had the highest rate of homicide, reaching 77.1 deaths per 100 000 compared with 8.7 per 100 000 for white males (Hemsi, 1967). Homicide is the leading cause of death among African-American men aged 15–44 and African-American women aged 15–35, a rate six times that for whites (Bell, 1992). There has been a dramatic increase in suicide in black youth in the last three decades (Dillay, 1989; Spaights & Simpson, 1986), with a peak for black males and females between the ages of 25 and 44 (Baker, 1990).

The pervasiveness of the effects of poverty and socio-economic oppression is reflected in the rates of alcoholism and drug abuse. One-third of all African-American adults and one-half of all African-American youth use and abuse alcohol (Dean, Walsh, Downing, & Shelley, 1981; Littlewood & Lipsedge, 1981b; Shaikh, 1985). Alcohol is the primary or secondary cause of at least one death in ten in the U.S. and more than 50% of murders and 50% of accident-related deaths in black Americans involve alcohol (Cochrane, 1977; Gary, 1981). Blacks die from alcohol-related illnesses three times more often than whites. The repercussions of alcoholism on a community are suggested by the fact that every alcoholic is a serious menace to at least five to seven persons around him (Dean et al., 1981).

With regard to the relationship between mental illness and socio- economic status a longitudinal study of poverty and psychiatric status from the National Institute of Mental Health Epidemiological Catchment Area study showed that respondents living in poverty had a two-fold increased risk of an episode of at least one psychiatric disorder as defined by the Diagnostic Interview Schedule using the Diagnostic Statistical Manual III. The effects of poverty did not differ by sex, age, race or history of psychiatric disorder (Bruce, Takeuchi, & Leaf, 1991). Similarly, somatization, depression and anxiety are significantly greater in the unemployed (Linn, Sandifer, & Stein, 1985).

These health effects of poverty are aggravated by racism, which affects both the employed and unemployed. Pierce (1988) showed that when blacks are employed, regardless of the site of the workplace, most of them ‘suffer special stress as a result of threatened, perceived, and actual racism’.

An epidemiological study in Florida (Ulbrich, Warheit, & Zimmerman, 1989) of 2115 adults showed that socio-economic status interacted with race to increase psychological stress after undesirable life events or economic problems.

Discrimination can appear to be hidden when it is institutionalized, although it is not usually hidden from the person who is subjected to it. Dominant cultural beliefs pretend that institutions function in a democratic, impersonal way. What usually occurs, however, is that the dominant group’s discriminatory practices are incorporated into the institution’s value system. For example, in a recent general accounting office study, young blacks were denied Supplemental Security Income (SSI) and Social Security Disability (SSD) benefits more often than whites (Okpaku, 1993). Lindsey and Paul (1989) found that American blacks were over- represented in involuntary commitments to mental institutions.

Several studies from the U.K. confirm that socio-economic oppression places members of racial minorities at increased risk of violence (Fernando, 1988, 1991). West Indians in the U.K. were 36 times more likely to be the victims of an interracial attack than whites, and Asians were 50 times more likely to be attacked. Black patients were four times more likely than whites to have reached the hospital by way of the police. Black patients were twice as likely as Whites to have been transferred to hospital from prison and twice as likely to be detained under mental health legislation.

Studies from South Africa that predate the official end of apartheid provide an opportunity to examine the most overtly racist practices this century that were officially sanctioned by a dominant culture.2 Apartheid in South Africa was held by the South African Institute of Race Relations [SAIRR] to have produced the highest rates of homicide, divorce, family dislocation and imprisonment per capita in the world (Cooper, Horrell, & Streek, 1983). A World Health Organization (WHO) report documented the following patterns of mental disorders in South Africa, which it considered the direct result of apartheid: a high incidence and prevalence of retarded psychomotor development in African, Coloured and Indian children due to severe malnutrition; a high incidence of organic brain syndromes arising from preventable causes, unusually high rates of alcoholism and related psychiatric disorders among Africans and Coloureds (World Health Organization, 1983). South Africans had the highest suicide rate on the continent (World Health Organization, 1983) and the highest rates of alcoholism and capital punishment in the world (Van Niekerk, 1979). ³

Bulhan summarizes the issues concisely:

Every social order of course dispenses rights and privileges unequally. An oppressive social order deepens this inequality in how it dispenses life and death to its citizens. Data on the United States and South Africa show that blacks carry an inordinate burden.⁴ By almost every measure of social and individual well-being, they are at a marked disadvantage, compared to whites. They die earlier. They suffer greater poverty, disease, and dislocation. They have higher rates of incarceration, execution, and industrial accidents. Their space, time, energy, mobility, and bonding are curtailed, exploited, and abused. The consequence of this structural, institutional, and personal violence is a greater rate of physical, social, and psychological death.

The extensive effects of racialized poverty on health and mental health have been documented by other authors in the U.K. and South Africa (Dommisse, 1986; Kovel, 1984). We can thus conclude that socioeconomic oppression is a major vehicle of enforcing racism and that this has devastating effects on health and well-being by increasing all forms of violence, morbidity, mortality and mental illness.

Racism in Medicine and Psychiatry

Medical doctors and psychiatrists have contributed to the already devastating effects of socio- economic oppression by participating in racist practices. Many early psychiatric articles perpetuated distorted cultural myths of white supremacy by attempting to document that black people suffered higher rates of mental retardation, were genetically inferior in intelligence, were hypersexual and hyperaggressive and developed pathological family structures inadequate for adequate child-rearing. Sabshin, Diesenhaus, and Wilkerson (1970) examined the dimensions of institutionalized racism in the U.S. and took particular note of the distinct under-representation of blacks in psychiatry. Alexander Thomas, an American psychiatrist and his colleague, Samuel Sillen, a psychologist, comprehensively analyzed the unfounded, spurious nature of these myths, confronted the profession with its racist practices and revealed the extent to which psychiatry had been a willing servant of the institutionalized racial prejudice of the dominant culture (A. Thomas & Sillen, 1972). Suman Fernando (1988), replicated this analysis in the U.K. These authors stressed that psychiatry had an ethno- centric, racist heritage and had been used as a vehicle of implicit and overt racism. Fernando noted with regret that the emerging field of transcultural psychiatry had essentially ignored the struggles of black Americans and offered little hope of altering the ethnocentric blindness of psychiatrists. He hoped that psychiatrists in the future would be able to identify and eliminate their complicit participation in the dominant, racist cultural practices.

Since the 1960s there have been numerous studies examining medical practice in the U.S. that have helped us develop a more reality-based understanding of the nature and extent of racism in medicine and psychiatry. First, I review the studies relating to medicine.

Disparities in Health and Health Care between Blacks and Whites

A series of studies has confirmed that when patients who are socially or economically disadvantaged are compared with other patients there are inequalities in regard to access to care (Aday, Andersen, & Fleming, 1980; Aday, Fleming, & Andersen, 1985; Blendon, Aiken, Freeman, & Corey, 1989; Eggers, 1988; Kjellstrand, 1988) use of services (Burstin, Lipsitz, & Brennan, 1992; Epstein et al., 1988; Epstein, Stern, & Weissman, 1990; Goldberg, Hartz, Jacobsen, Krakauer, & Rimm, 1992; Wenneker & Epstein, 1989; Wenneker, Weissman, & Epstein, 1990; Yergan, Flood, LoGerfo, & Diehr, 1987), and clinical outcomes (Braveman, Oliva, Miller, Reiter, & Egerter, 1989; Burstin et al., 1992; Lurie et al., 1986; Sorlie, Rogot, Anderson, Johnson, & Backlund, 1992).

The Council of Ethical and Judicial Affairs of the American Medical Association in 1990noted significant disparities of care between blacks and whites in America. Black men suffering from a myocardial infarction were half as likely to undergo angiography and one-third as likely to undergo bypass surgery as white men, while mortality rates suggested that the there was an equivalent severity of heart disease. A subsequent study of patients surviving acute myocardial infarction showed that blacks were 33% less likely than whites to receive coronary angiography, 42% less likely to receive coronary angioplasty and 54% less likely to receive coronary bypass surgery. (Peterson, Wright, Daley, & Thibault, 1994). The Council also discussed the findings of several studies showing that blacks with kidney disease were less likely to receive long-term dialysis or kidney transplant (Council on Ethical and Judicial Affairs, 1990). The American Society of Transplant Physicians’ Patient Care and Education Committee (1991) (Gonwa et al., n.d.; Kasiske et al, 1991) concluded that although end-stage renal disease is more common in racial minorities than in whites, fewer blacks were accepted as candidates for transplantation. The problems with racial and ethnic inequality were even worse for other organ transplantation. (Gonwa et al., n.d.; Kasiske et al., 1991).

Racial disparities have been documented in the quality of treatment provided by general internists. In a rigorous assessment of the quality of care of 9932 Medicare patients in 297 acute care hospitals in five states, patients who were black or from poor neighborhoods received poorer quality of care and were more unstable at the time of discharge (Kahn et al., 1994). In another study, all hospitalized patients with pneumonia were reviewed between 1970 and 1973 in 17 different centers. After controlling for clinical characteristics and income, black patients were less likely to receive medical services, particularly intensive care (Council on Ethical and Judicial Affairs, 1990). In a study of emergency room treatment, Hispanic patients with pain received unequal and inadequate analgesic treatment compared with white patients. This was not associated with any difference in the physicians’ awareness of the severity of pain (Todd, Samaroo, & Hoffman, 1993).

The incidence of AIDS in the U.S. among racial and ethnic minority groups, particularly African-Americans and Hispanics, is vastly disproportionate to their numbers in the population. Black patients with HIV were found to be significantly less likely to receive anti-viral therapy of PCP prophylaxis upon referral to an HIV clinic (Moore, Stanton, Gopalan, & Chaisson, 1994).

Racism and Psychiatric Diagnosis

Despite evidence suggesting that there are no essential differences in the clinical presentation of psychiatric disorders in black and white Americans (Helzer, 1975; Pierce, 1988; Raskin, Crook, & Herman, 1975), a series of studies shows that the racial bias of clinicians affects their clinical judgment (Littlewood, 1993). In a public sector study, Strakowski, Shelton, & Kolbrener (1993) showed that black patients were significantly more likely to be diagnosed with schizophrenia than white patients with similar clinical presentations. Mukherjee, Shikla, Woodle, Rosen, and Olarte (1983) found that black and Hispanic (Puerto Rican) American bipolar patients were at higher risk than whites for misdiagnosis as schizophrenic, especially if they were young and experienced auditory hallucinations during an affective episode. In a sample of 192 hospitalized patients, schizophrenia was diagnosed significantly more often in black American patients and affective disorders more commonly in white patients (Simon, Fleiss, Gurland, Stiller, & Sharpe, 1973). Snowden and Cheung (1990) found that blacks and Native Americans were more likely than whites to be hospitalized and diagnosed with schizophrenia instead of an affective disorder, that black Americans were diagnosed with schizophrenia at almost twice the rate of whites, and that Hispanics were diagnosed with schizophrenia at one and a half times the rate of non-Hispanic whites. In contrast, Asian Americans and Pacific Islanders were less likely to be admitted but remained in state and county hospitals for longer periods (Snowden & Cheung, 1990; Yergan et al., 1987).

Adepimpe (1981) found that black Americans were at an increased risk for misdiagnosis, and Neighbors, Jackson, Campbell, and Williams (1989) concluded that the evidence was especially convincing for the over-diagnosis of schizophrenia and under-diagnosis of affective disorders among African- Americans. Steinberg, Padres, Bjork, and Sporty (1977) found that American blacks were almost twice as likely as white patients to be diagnosed with paranoid disorders. In a study of 2279 patients visiting the emergency room, Gross et al. (1969) found that the behavior of female patients who required hospitalization was more often seen as neurotic if the patient was white and psychotic if the patient was black.

In community-wide surveys after World War II, the rate of mental illness among African Americans was no higher than that of other groups when socio-economic variables were controlled (D. H. Williams, 1986). Spurlock (1975) contends, and others agree, that the over-representation of African- Americans in some diagnostic categories is indicative of faulty assessment that is sometimes rooted in institutionalized racism (Spurlock, 1982; A. Thomas & Sillen, 1972; Wilkinson & Spurlock, 1986).

Loring and Powell (1988) examined the role of institutionalized racism in the overdiagnosis of paranoid schizophrenia and paranoid personality disorders in American blacks. They used a written analogue approach presenting the vignettes of two patients, but altering the sex and race of the patients to determine what effect this had on diagnosis. The sample included 488 psychiatrists of known race and sex from the American Psychiatric Association membership roster and 290 returned the questionnaires (59.4%). A covering letter indicated that the study was to evaluate the reliability and validity of the DSM-III but made no mention of the importance of sex or race. Respondents were asked to make Axis I and Axis II diagnoses. The actual patients suffered from undifferentiated schizophrenia and dependent personality. Diagnoses were influenced by cultural stereotypes with black males being more likely to be termed paranoid schizophrenic and black males and black females being most likely to be diagnosed on Axis II as having paranoid personality disorder. Clinicians tended to ascribe violence, suspiciousness and dangerousness to black clients even though the case studies for white patients were identical. Black clinicians seemed to have internalized these cultural views because they also assigned paranoid schizophrenia to black men, although less frequently. The authors speculated that white females were inclined to make less serious diagnoses of white female patients because of social and political movements that emphasized the social causes of mental illness in women (Loring & Powell, 1988).

In an article on culture and diagnosis, Good (1992) concluded that these diagnostic difficulties were not just seen in the care of American blacks, but were prevalent among all members of American subcultures and ethnic minorities, and that these problems deserved urgent attention. There is little doubt that racism has affected the ‘nonjudgmental empathic’ attitude of American psychiatrists in diagnosing patients of ethnic minorities.

Studies in the U.K. have also confirmed the overdiagnosis of schizophrenia among blacks. Cochrane (1977) studied hospital admissions in England and Wales in 1971 and found an overrepresentation of schizophrenia among most immigrant groups (born outside England and Wales) most marked for West Indians and Pakistanis. Carpenter and Brockington (1980) found that immigrants were given the diagnosis of schizophrenia more often than natives, especially West Indians, Africans and Asians. Hemsi (1967) and Bagley (1971) found that Afro-Caribbean, African, Indian and Pakistani patients at Camberwell Psychiatric Register showed a similar preponderance of schizophrenia. In south-east England, Dean et al. (1981) found that the diagnosis of schizophrenia on first admission was five times the expected number for immigrants from the West Indies, four times the expected number for African immigrants (mainly ethnic Asians), and three times that expected for Indian immigrants. Littlewood and Lipsedge (1981b) examined case notes for 250 consecutive patients admitted to a hospital in a London borough with a relatively large proportion of ethnic minorities and found that schizophrenia was diagnosed significantly more commonly in West Indians and West Africans and less frequently in Indians from the subcontinent. Shaikh (1985) compared a group of white British-born patients with a group of Asians matched for age and sex and found that schizophrenia was significantly over-diagnosed in the Asians. In a study of legally detained patients in Birmingham, McGovern and Cope (1987) found that two-thirds of West Indian migrants and British West Indians compared with one-third of whites and Asians, and 8–16% of West Indians were diagnosed as suffering from cannabis-induced psychosis although this diagnosis was not given to whites or Asians. Littlewood and Lipsedge (1981a) studied patients with religious delusions and suggested that patients with acute psychotic reactions were misdiagnosed as schizophrenic more readily if they were born in the Caribbean than those who were born in the U.K.

In an extensive study of admissions to psychiatric hospitals in Bristol, Ineichen and colleagues (Harrison, Ineichen, Smith, & Morgan, 1984; Ineichen, Harrison, & Morgan, 1984) reported that black people were over- represented among compulsory admissions, and the authors attributed this to discriminatory public attitudes and police behavior. Similarly, Rogers (1987) suggested that discriminatory public attitudes combined with police behavior resulted in the excessive use of force to apprehend black people in the U.K. under the Mental Health Act. Immigrant and British West Indies male patients were overrepresented in patients detained compulsorily in Birmingham in 1987, with West Indians aged between 16 and 29 having 17 times the risk of being detained as whites (McGovern & Cope, 1987).

Harrison et al. (1984) found that, compared with whites, West Indians were more likely to have drawn attention by causing a public disturbance even though staff perceived them prior to admission as less likely to be violent. In a study in South London, Bolton (1984) found that West Indian, Indian and African patients recognized as uncooperative, but not aggressive, were more likely to be sent to locked wards compared with white English patients; this was unrelated to diagnosis. A national mental health study in London confirmed that three times the expected number of Afro-Caribbean patients were placed under mental health papers (Rogers, 1987). Norris (1972) found that 92% of non-whites compared with 64% of whites were diagnosed with schizophrenia in Broadmoor Hospital between 1974 and 1981 and, although these patients’ lengths of stay did not vary, the non-white group were contacted by police more often after discharge. This suggested that the non-white patients were seen as more criminal and lesssick. Littlewood and Cross (1980) studied the use of ECT in a hospital in east London. They found that black immigrants were more likely to have been diagnosed as psychotic, to