A More Just World

My boys have dark brown curls and mischievous smiles. They speak with clarity and confidence. They move with boundless energy but also with unexpected grace. They enjoy playing with their lovies, reading with their daddy, and dancing with me, their mommy. They were born in St. Louis, but their great-grandparents were born in Africa, Asia, and Europe. They are six and eight. They represent the best of America. And I am scared for their future.

I am a surgeon and health-services researcher who studies disparities in breast cancer. I am interested in the potentially modifiable factors that contribute to ethnic and racial inequities, including how well or how poorly our patients feel (e.g., psychological distress) and how well or how poorly we clinicians treat them (e.g., implicit bias). Black women are less likely to get breast cancer than white women but are also more likely to die from it. Black women are more likely to be diagnosed with an aggressive variant of the disease known as triple-negative breast cancer.

These disparities reflect a messy web of ancestry and access, biology and bias that belies the social constructs of race we use to organize and categorize the people around us. Much space in the scientific literature has been devoted to describing disparities, but only more recently has research focused on concrete efforts to address the root causes of these differences. A plethora of toolboxes and smartphone apps and decision-making aids are being generated to promote enrollment of racial and ethnic minorities in clinical trials, to facilitate patient communication with clinicians, and to help patients become more active participants in their own health-care decisions. We clinicians are also being trained to recognize the biases we bring to our work, and I’m optimistic about the growing consensus that this trend doesn’t spring from political correctness but from the need to practice better medicine.

I am committed to the goal of eliminating ethnic and racial health disparities but, perversely, it is unclear whether and how the work I and others do will help my boys. They are mixed race.

I’ve watched them blend into crowds of brown people in Bermuda and in Houston. I’ve seen the puzzlement on people’s faces as they try to figure out or simply blurt out, “What are they?” I’ve looked at their health records; I know that whether they are listed as “black” or “white” depends on whether I or my husband brought them to their first appointment. One of my boys already refers to himself as black while the other resists—even as he swears that he loves my skin.

As both a black mother to biracial boys and a surgeon-scientist who examines race, I am conflicted about what box(es) to check lest I bias the statistics one way or another. Yes, in America and in the U.K., where my husband is from, most people will consider them black. In Nigeria, where my family is from, they will be referred to by the antiquated term of half-caste and—to my chagrin—be celebrated for it. At their public school, in a system with one of the largest racial achievement gaps in the country, I actually do not know whether they are included in the roughly 10 percent of students who are listed as African American or the roughly 10 percent of students who are listed as being of two or more races.

A large part of me wants them included among the black students because it is important to examine the intersection of class and race when we interrogate interracial achievement gaps, which persist even when black and brown wealthy children with well-educated parents are compared to white, similarly situated peers in many of the “best” school districts in this country. But my bias toward including them with the black kids is not wholly logical: Part of me hopes that their strong grades and test scores will narrow local achievement gaps by raising the averages for black children. But part of me also— irrationally— dares to hope that the social confidence and easy acceptance they take for granted might somehow be contagious and transmitted to the brown and black children grouped with them. That those who feel as “othered” as I did, growing up in a mostly white town, might somehow feel more included and more valued than I did and they do.

At the same time, I also worry that my boys’ categorical inclusion will provide false hope, will offer unrepresentative examples of black kids thriving in a place where they all too rarely do. That their success will allow the school system to pat itself on the back and place even less focus on addressing disparities in achievement.

But beyond how their stats affect school rankings, I think about how their complex racial heritage—and the complex racial heritage of most people who identify as black or Hispanic or Native American in the United States—could affect their ability to someday get a bone-marrow transplant, with matches being harder to achieve for people of color and mixed race. I think about the non-randomness with which the growing numbers of multiracial people in America will identify as black or white or Asian or Hispanic, depending on where and by whom they are raised and how these decisions will bias both resource allocation and the outcomes of clinical trials.

In short, I worry that our ability to practice good medicine will be challenged by the browning of America, by the increasing ethnic and racial complexity of this country at a time when the structural racism in our country’s culture and institutions is more entrenched than one would expect more than fifty years after the Civil Rights Movement. My boys were born just a couple of years before and ten miles away from where Michael Brown was killed in Ferguson, Missouri. They have borne witness to growing social divisions in this country and rising populism across the world. They have attended more political demonstrations before ten than I did before thirty-five. They know more about politics than six- and eight-year-old boys should. They have had “The Talk,” and they know why I won’t buy them toy guns and why their actions may not be viewed in the same way as the hijinks of their white friends.

I am committed to providing a more just world for my sons, and I—more than many—am equipped with tools and blessed with privileges that facilitate my being an active participant in the betterment of our country and our world.

But as their mother, I worry. As a disparities researcher, I worry. As a surgeon, I worry. And as an American, I worry.

Fayanju is a surgical oncologist whose clinical practice and research centers on the care of patients with benign and malignant breast disease.