COMMITTEE REPORTS

Juneteenth: A Celebration of Freedom and a Reminder of the Ongoing Fight for Justice

By: Mia Kang and Marie Angele Theard 

This year many of us who practice Anesthesiology in the United States will have an opportunity to work one day less in June due to a relatively recent declared federal holiday, Juneteenth.  Juneteenth commemorates June 19, 1865, the day that Union General Gordon Granger signed General Order No. 3 in Galveston, TX.1

So, what was General Order No. 3?

General Orders No. 3.

The people of Texas are informed that, in accordance with a proclamation from the Executive of the United States, all slaves are free. This involves an absolute equality of personal rights and rights of property between former masters and slaves, and the connection heretofore existing between them becomes that between employer and hired labor.

The freedmen are advised to remain quietly at their present homes and work for wages. They are informed that they will not be allowed to collect at military posts and that they will not be supported in idleness either there or elsewhere.1

Upon first reading, General Order No. 3 appears to be a very progressive document in declaring that the formerly enslaved people would have “absolute equality of personal rights and rights of property.”1 This is no doubt a reason for celebration! However, the second paragraph of the general order highlights the grim reality that true equality would be elusive for many of the formerly enslaved and that they would be on their own without much tangible political or economic support from the United States government.2 These historic challenges continue even in healthcare.

As noted in the Spring issue of the Newsletter, the economic and political injustices Black Americans have faced historically continue to result in significant health disparities in outcome. To improve outcomes after stroke, shortening time to treatment is critical. However, in a systematic review of stroke treatment between racial minorities and White patients, Ikeme, et al. found that Black patients received delays in treatment as compared to Whites in 6 out of the 8 studies. White patients were more likely to be referred to a secondary hospital and more likely to be evaluated by a stroke team as compared to Black or Hispanic patients. In 13 out of 18 studies, the rates of tPA and mechanical thrombectomy (MT) were lower for non-White patients as compared to White patients. Even after adjusting for race, income, primary payer, and other potential confounders, researchers have found that race is still an independent predictor of less frequent use of EVT as well as poor outcomes.4

Not surprisingly this pattern is replicated globally with health outcomes of indigenous peoples lagging behind those of non-indigenous peoples. An analysis of 28 populations in 23 countries found that life expectancy at birth was lower in 16 out of 18 populations, infant mortality was higher in 18 out of 19 populations, educational attainment was lower in 26 out of 27 populations, and economic status was lower in 15 out of 18 populations.5 Neurotrauma in Canada disproportionately affects indigenous peoples,  and a recent scoping review cites: “inadequate resources available, social problems in indigenous communities, and challenges within the health care system” as reasons.8 The World Health Organization (WHO) has long been calling for increased awareness and efforts to address health equity, noting the importance of structural determinants of health which it defines as “social norms and institutional processes [which] shape the distribution of power and resources determined by the conditions in which people are born, grow, live, work, play and age.”6 In response to the tremendous impact of the COVID pandemic, particularly on people who were most economically disadvantaged, the WHO dedicated World Health Day 2021 to addressing the issue of health disparities, declaring “that we [should] commit to building a fairer and healthier world by taking health equity much more seriously than before – and meet head-on the social and economic factors that cause health inequities.”7  

The paucity of studies investigating disparities in patients including neurosurgical patients is due in part to inadequate research funding and poor representation of diverse groups in research.9 Our success in improving outcomes will be best informed by more community-based research supported by scientists who reflect the communities they serve, a more diverse group of participants, training to promote understanding, and importantly increased funding for health equity on par with biomedical reserach.9  

Despite the freedom and equity that General Order No. 3 promised, institutionalized and structural bias posed tremendous challenges for the newly emancipated Black citizens of Texas.  The language of health equity must be regarded like the release of General Order No. 3 as a moment of great celebration, but also a beginning towards needed change. Juneteenth gives us an opportunity to celebrate the hard-won freedoms of Black Americans but should also serve as a humbling reminder that the work for increased health equity continues.

This piece of history is an important part of US history that serves as the origin of a myriad of health inequities that we are all striving to rectify.  Understanding our patients and our colleagues is an important step in promoting change. In an effort to gain the valuable insights of our SNACC membership, the EDI committee invites you to share your history and insights so that we may move closer to appreciating our differences and the value we bring to medicine.

References

  1. https://en.wikipedia.org/wiki/General_Order_No._3
  2. Gordon-Reed, Annette. “On Juneteenth.” New York: Liveright Publishing Corp. 2021.
  3. Ikeme S, Kottenmeier E,  Uzochukwu G, et al. Stroke 2022;53(3):370-79.
  4. Mehta AM, Fifi JT, Shoirah H, et al. AJNR 2021;42(9):1576-83.
  5. Anderson I, Robson B, Connelly M, et al. Lancet 2016;388:131-57. doi: https://doi.org/10.1016/S0140-6736(16)00345-7.
  6. https://www.who.int/health-topics/health-equity#tab=tab_1 (accessed 4/17/2023)
  7. https://cdn.who.int/media/docs/default-source/world-health-day-2021/health-equity-and-its-determinants.pdf?sfvrsn=6c36f0a5_1&download=true (accessed 4/17/2023)
  8. Salaheen Z, Moghaddamjou, Fehlings M. Neurotrauma in Indigenous Populations of Canada–Challenges and Opportunities at a Global Level: A Scoping Review. World Neurosurg 2022;167:213-21.e2. doi: 10.1016/j.wneu.2022.07.108. Epub 2022 Aug 2.
  9. Boulware LE, Corbie G, Aguilar-Gaxiola S, Wilkins CH, Ruiz R, Vitale A, Egede LE. Combating Structural Inequities – Diversity, Equity, and Inclusion in Clinical and Translational Research. N Engl J Med. 2022 Jan 20;386(3):201-203. doi: 10.1056/NEJMp2112233. Epub 2022 Jan 15. PMID: 35029847.

 

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