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Caste: The Origins of Our Discontents

2022; Elsevier BV; Volume: 61; Issue: 6 Linguagem: Inglês

10.1016/j.jaac.2022.03.022

1527-5418

Balkozar Adam,

Early Childhood Education and Development

The depth, rigor, and honesty that Pulitzer-Prize winning author Isabel Wilkerson brings to her book Caste: The Origins of Our Discontents is so powerful that there were times I had to put the book down to catch my breath. Over the last 2 years, society and our field have asked a lot of difficult questions about the structures that build and sustain racism and intersectional discrimination. How did we get here? How did we get to a place where unarmed Black men are still being killed by police? How are people wearing khakis and carrying tiki torches openly rallying in the defense of white supremacy? How are the lives of Black Indigenous and People of Color (BIPOC) viewed by some as less valuable? How is it that many of us, who were around for the Civil Rights marches of 1960s, felt transported back in time after seeing the response to Black Lives Matter protestors in Washington, DC? How does a supposedly “colorblind” pandemic have a disproportionately higher impact on communities of color? Closer to our field, how might research and treatment practices actually discriminate against the very people they purport to help?1Lane Jr., A. Gavins A. Watson A. et al.Advancing antiracism in community-based research practices in early childhood and family mental health.J Am Acad Child Adolesc Psychiatry. 2022; 61: 15-22https://doi.org/10.1016/j.jaac.2021.06.018Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Wilkerson, a former New York Times reporter and winner of the National Humanities Medal, devotes her book to answering these types of questions. Caste is not filled with conjecture or hypotheses, but is a well-researched, evidence-based account. Her book, which she began writing well before George Floyd’s death, the pandemic, Charlottesville, or the Capitol Riots, strikes me as prescient. It brings to mind a quote (variably attributed to Edmund Burke, Georges Santayana, and Winston Churchill) that “those who fail to learn from history are doomed to repeat it.” Caste shows how our inadequately addressed past wreaks havoc on the present. At the most basic level, caste is defined by Wilkerson as “the granting or withholding of respect, status, honor, attention, privileges, resources, benefit of the doubt, and human kindness to someone on the basis of their perceived rank or standing in the hierarchy” (p 70). Casteism and racism are not the same, although it can be hard to differentiate the two. They often overlap. Caste elevates certain groups at the cost of others, with a zero-sum game mentality to how society ought to work: one group is kept in a low position so another can rise above. Wilkerson deftly explains how the United States—while wrapping itself in the language of Enlightenment philosophy “casting” itself as an egalitarian ideal—actually created and sustained a caste throughout our history. Of course, the United States is not the only “caste society.” Perhaps the most well-known caste system is in India, where the Dalits, the lowest group, share a position similar to that of African Americans. Both groups were exiled, oppressed, and forced to work in brutal, dirty, disgraceful conditions for individuals who placed themselves in the position of master. Wilkerson also explores how the caste system thrived in Nazi Germany. In these pages of the book, I found myself feeling ill reading how Hitler studied America, praised the near genocide of Native Americans, and worked to emulate our Jim Crow laws. Like African Americans, Jews in Nazi Germany were restricted from working in government or in high-status professions such as medicine or law (p 83). In the pages of Wilkerson’s book, I was also shocked to learn that the Nazis considered some American laws too harsh (p 84). This is not a history taught in schools, but it should be. Caste ought to be required reading for high school, college, and medical students and is a key companion to curricula on critical race theory (CRT). Again, we ignore the past at our own peril, a lesson that CRT opponents should heed. CRT requires us to confront our shameful past and acknowledge how it has manifested in our hospitals and clinics, our criminal justice system, the schools we send our children to, the neighborhoods we go home to every night. CRT forces us to see how those systems have protected and advantaged White people while harming and disadvantaging BIPOC. As Wilkerson writes: “You were born to a certain caste and remained in this caste, subject to the high status or lower stigma it conferred, for the rest of your days and into the lives of your descendants” (p 105). We can admit our monumental failures as a country while still taking great pride and feeling deep love for our country, recognizing the many features that make it such a wonderful place to live. One of the “eight pillars of caste” that Wilkerson outlines in her book is “dehumanization and stigma” (p 140). Medical advances have been built on this atrocious pillar: the act of seeing African Americans as subhuman. Black people, given neither consent nor anesthesia, had their bodies mutilated in the name of medicine (p 147). The discoveries of James Marion Sims, heralded as the father of modern gynecology, were built with the bodies of enslaved women. In the 19th and early 20th centuries, medical schools relied on bodies stolen from cemeteries—many of them Black—for dissection.2Nuriddin A. Mooney G. White A. Reckoning with histories of medical racism and violence in the USA.Lancet. 2020; : 949-951https://doi.org/10.1016/S0140-6736(20)32032-8Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar From the Tuskegee experiment, which withheld treatment for syphilis from Black men, to the forced sterilization of thousands of Black people in North Carolina, to the use of Henrietta Lacks’ cancerous cells without her knowledge to advance medical research, our history is riddled with example after example of Black Americans being tortured, abused, disenfranchised, and harmed by a system this is supposed to heal them. It is offensive and foolish to act as if the actions of our past have not invaded our present. As child and adolescent psychiatrists, we must recognize, address, and destroy every fragment of the caste system we see. It is our ethical and moral responsibility to examine the impact of the caste system on our own interactions and the care of our patients harmed by the caste system, which disproportionately affects African Americans, Hispanics, and Native Americans. We saw an alarming increase in the number of suicides by Black youth during the pandemic, a tragedy from which we may never recover.3Sheftall A.H. Vakil F. Ruch D.A. Boyd R.C. Lindsey M.A. Bridge J.A. Black youth suicide: investigation of current trends and precipitating circumstances.J Am Acad Child Adolesc Psychiatry. 2022; 61: 662-675https://doi.org/10.1016/j.jaac.2021.08.021Abstract Full Text Full Text PDF Scopus (40) Google Scholar Our commitment to deliver equitable healthcare to all whom we are entrusted to care for must go beyond verbal affirmations. Mental healthcare in this country is in a crisis. While cardiology suites, cancer institutes, ortho offices, and dermatology clinics occupy prime real estate at our healthcare institutions, psychiatric units are often in freestanding, dilapidated buildings. Out of sight, out of mind? It’s not hard to figure out what care is prioritized. We can change that, and dare I say, we have started to. When doctors and nurses were experiencing unprecedented levels of despair after having lost so many patients to COVID, it was often psychiatrists, therapists, and social workers—the hidden frontline workers—they came to see. But with so few of us—we are facing an extraordinary shortage of psychiatrists that is only getting worse—we often are relegated to the role of pill prescriber. This occurs to the detriment of forming the kinds of relationships that allow us to promote other types of interventions with our patients. This, unfortunately, can exacerbate the disparities we see in care. For example, Black youth and youth in foster care receive disproportionately high prescriptions for antipsychotics.4Dosreis S. Yoon Y. Rubin D.M. Riddle M.A. Noll E. Rothbard A. Antipsychotic treatment among youth in foster care.Pediatrics. 2011; 128: e1459-e1466https://doi.org/10.1542/peds.2010-2970Crossref PubMed Scopus (82) Google Scholar Casteism in psychiatric practice ensures that the privileged get psychotherapy, others just a prescription. We need to examine how the caste system has affected our patients’ trust of the medical system; their access to mental health care; the stigma they are forced to overcome; the resources that do not exist in their communities; and the disinvestment that has replaced well-paying jobs, healthy living, and stability with trauma, anxiety, and death. The burden of caste extends beyond our patients to us as clinicians. Wilkerson notes that many people of color, those of the non-dominant caste, are not expected to reach such heights and, as a result, often face discrimination or are passed over for promotions (p 307). Their opportunities may be blocked because they are not perceived to deserve them. We can work to change that. Being doctors puts us in a position of authority that we are entrusted with when dealing with our patients, their families, and our colleagues. Our upbringings, either in the dominant or non-dominant caste, have left an indelible mark on us. What caste inspires us to consider is how we can use our upbringings to transform our future. Unless we reckon with our past, we cannot expect to move forward as a people, a profession, or a country. I am thankful to Wilkerson for giving us the opportunity to reflect and encouragement to act.