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Lancet Reg Health Am
Lancet Reg Health Am
Lancet Regional Health - Americas
2667-193X
Elsevier

S2667-193X(24)00201-1
10.1016/j.lana.2024.100874
100874
Comment
Sociohistorical justice: a corrective framework to mend the modern harms of medical history
Black Carmen carmengblack@gmail.com
abc∗
Temple Shavonne d
Acquaye Amber c
Fields Christopher c
Konopasky Abigail e
a Institute of Living at Hartford Hospital, Hartford, CT, USA
b Morehouse School of Medicine, Atlanta, GA, USA
c Yale School of Medicine, New Haven, CT, USA
d Authority Health, Detroit, MI, USA
e Geisel School of Medicine, Dartmouth University, Hanover, NH, USA
∗ Corresponding author. Institute of Living at Hartford Hospital, Morehouse School of Medicine, Yale School of Medicine, USA. carmengblack@gmail.com
24 8 2024
10 2024
24 8 2024
38 10087410 4 2024
12 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcDiversity, equity, inclusion, and antiracism (DEIA) frameworks aim to repair the modern harms of medical history. Delivering justice requires interrogating how nationally minoritised populations change between present and historical contexts. Sociohistorical justice concepts inform DEIA like history informs modernity, particularly in racially, ethnically, and nationally diverse populations. We illustrate sociohistorical justice's five-step, history-based framework through the American Medical Association (AMA) Strategic Plan to increase the representation of historically excluded American physicians1 (Fig. 1).Fig. 1 Four-step framework and vernacular of sociohistorical justice.

The AMA Strategic Plan intends to ensure the representation of Black Americans, improve race/ethnicity categorization, and amplify “invisible-ized” voices because “some voices and not others have historically been centered.”1 One notable AMA injustice is the Flexner Report of 1910.2 It closed five of only seven schools admitting Black Americans and created admissions criteria requiring societal privilege.2

Lev Vygotsky, the creator of sociohistorical learning theory, said: “To study something historically means to study it in the process of change.”3 Sociopolitical minoritisation—including racism—historically changes. The American Psychological Association (APA) defines race as “perceived shared physical traits that result in the maintenance of a sociopolitical hierarchy” and vary “owing to changing social contexts.”4 America's contemporary racial category, “Black or African American,” sociopolitically contextualises people by phenotypic features stereotypically associated with Blackness, not ancestry. Victims of historical racism are identified by racialised sociopolitical conditions belonging to another place and time, not present-day conditions. The Flexner Report closed five Black medical schools in the southern United States from 1910 to 1923.2 Thus, the geographic footprint of Flexner's attributable harm is restricted to the continental United States and timestamps to 1910–1923.

Sociohistorical lineage adds continuous, multigenerational nuance to geographic footprints and timestamps of historic harm. Without Flexner, Black Americans descended of 1910—being Flexnerian-Deprived Black Americans (FDBAs)—could have benefitted over 35,000 physicians, including family-oriented and community-based perks of physicianhood such as financial stability, private school, role models, and academic aspirations/inspirations.2 Yet, today's FDBAs cannot be solely identified as “Black Americans” because the sociopolitical context of American racism has changed. Identifying FDBAs requires disaggregating Black Americans in relation to American history, a concept likened to ethnicity versus race.

The APA writes that ethnicity characterises people by “a shared culture … related to common ancestry and shared history.”4 Being racialised as “Black American” in 1910 nearly exclusively identified sociohistorical lineages descended from American slavery because over half of voluntary Black immigrants to America arrived after 2000.5 In contrast, today's sociopolitical terminology of “Black or African American” may include anyone of African ancestry with certain phenotypes.

Black American immigrants often maintain their external tribal and/or national identities to distinguish historical origins. Indeed, Jamaican immigrants might identify as both Jamaican American (historical/national/ethnic origin) and Black American (race). Similarly, ethnic Yoruba immigrants from Nigeria may simultaneously identify as Yoruba (ethnicity), Nigerian American (historical/national origin), and Black American (race).

Given Black Americans’ historical/national/ethnic diversity, descendants of American slavery particularly embody living histories of all-American anti-Black oppression and resistance: human trafficking, severed African ancestral ties, Jim Crow, redlining, the Civil Rights movement, Southern gospel and the blues, mass incarceration, state-sanctioned racialised violence and terrorism, and others. American history demanded descendants of American slavery be traumatically reborn and forge new origins within the country they originated: The United States. Yet, compared to racialised peers of external historical/national/ethnic origins, the originators of Black America—the only “Black Americans” implicated by many historical contexts—lack a name claiming their internal, all-American historical/national/ethnic origins. The originators of Black America are Americans by ethnicity, hereafter called Ethnic Black Americans. Furthermore, contemporary FDBAs are Ethnic Black Americans (EBAs).

Ironically, the AMA is apologizing for historical anti-Black medical racism, yet by counting any “Black or African American” matriculating student, they are substituting race-based “cures” for history-based injuries. Race-based equity attempts make history invisible, which may perpetuate historical trauma through institutional and structural segregation. Sociohistorical representation disaggregates contemporarily minoritized populations by sociohistorical lineages of discrete harm to ensure proportionality by sociopolitical ancestry rather than race. For example, by ethnicity, Black Americans are overwhelmingly EBAs.5 By history, only EBAs carry centuries-long American educational deprivation, like the Flexner Report. From our experience, nonetheless, diversity-minded and race-based recruitment reduces EBAs to a shrinking minority of Black American medical students. Sociohistorical validity removes anachronistic outcomes from DEIA efforts by demanding that historically corrective success is only measured by how well restorative efforts precisely benefit the sociohistorical lineages most directly and continuously (versus vicariously) deprived by the named historic act.

Conclusions

Present-focused DEIA frameworks blur accountability to national history. Sociohistorical justice concepts correct and complement DEIA by disaggregating racially/ethnically/nationally diverse societies according to geographic footprints and generational timelines of discrete harm. Historical disaggregation empowers restitution to lineages directly and continuously harmed by history.

Contributors

CB was lead investigator on the research project that inspired the original concept of sociohistorical justice. CB also created the original written manuscript and figure. ST and AA were medical student research assistants on the research project who contributed to designing the theoretical framework. CF and AK contributed significantly to refining the theoretical framework. All authors contributed to manuscript revisions and refinement.

Declaration of interests

Authors report no conflict of interest in the preparation and submission of this manuscript.
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References

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3 Vygotsky L.S. Cole M. Mind in society: development of higher psychological processes 1978 Harvard University Press
4 Race and Ethnicity American psychological association dictionary of psychology. Washington DC: American Psychological Association [cited 2024 Apr 10]. Available from: https://www.apa.org/topics/race-ethnicity
5 One-in-ten black people living in the U.S. are immigrants 2022 Pew Research Center Washington DC [cited 2024 Apr 10]. Available from: https://www.pewresearch.org/race-ethnicity/wp-content/uploads/sites/18/2022/01/RE_2022.01.20_Black-Immigrants_FINAL.pdf
