Commentary by Billy Thomas, M.D.

Kacee Daniel’s Pain Lives in Both Misery and Joy reminds me of the concept of “Double Consciousness,” first presented by W.E.B. Du Bois. It is evidenced in the lines “Force feeding me a game that destroys me by design, I swallow every bite and ask for more.”

In 1903, during the post-Reconstruction period and more than four decades after the passage of the 13th Amendment, W.E.B. Du Bois introduced the term “double consciousness” to describe the internal conflict that existed in newly freed enslaved Black persons as they struggled to survive and assimilate into an environment dominated by a white majority. Du Bois states: “One ever feels his twoness – an America, a Negro; two souls, two thoughts, two unreconciled strivings; two warring ideals in one dark body, whose dogged strength alone keeps it from being torn asunder.” These two warring ideals—to either join mainstream society or to reject it and define the world and relate it entirely from a Black perspective—are at the core of double consciousness, resulting in a struggle to establish one’s identity (Du Bois, 1903; Bonner, 2006). Black Americans lived in two worlds: one composed of like individuals who shared ancestry, culture, religion, values, and experiences and another world dominated by a white majority and a culture in which there were very few shared experiences, ancestry, or values—namely, a world in which Black Americans were not considered truly human, only property. In order to survive, formerly enslaved people found themselves in a position in which they had to conform and assimilate into a white society. In order to assimilate and progress socioeconomically, Black Americans were forced to take on the values, manners, ideologies, and the religion of a people that were foreign to them and, according to the ruling majority, pre-ordained as the only true human beings, creating an aspirational level or standard of humankind to be achieved by Black Americans. As is the case with many minority populations, this overwhelming internal struggle may give way to the adoption of the dominant group’s values and ideals, resulting in the dilution or even the erasure of the minority group’s values and structure—in this case Black Americans—leading to the loss of personal and group identity.

How does one make the transition to fit into a social structure that historically has been discriminatory, polarizing, and abrasive to individuals who are different from the dominant group? Black Americans were torn between trying to retain their true heritage, culture, and values as human beings (i.e., personal and group identity) and conforming to a system that demanded shedding all that was representative of their personal identity and culture in favor of adopting ways of life and thinking that were foreign to them and based on the norms, values, religion, and ideologies of a white majority.

In many ways the poem highlights the ongoing inner struggles of coming to grips with one’s efforts to become part of a culture and educational environment in which minority and marginalized people have historically been less valued. It is about retaining one’s personal identity in an ongoing struggle to assimilate and progress through an educational system and a society that was developed by and in many ways favors the dominant majority. It is about the day to day pain and exhaustion of attempting assimilation and navigation of social structures and educational systems along with the ongoing struggle to find one’s personal identity in a political, economic, and educational landscape normalized to the dominant majority. It is about an ongoing quest for knowledge and assimilation at the risk of losing one’s self.

Double consciousness is not unique to Black people and applies to any minority group of people who seek to integrate and assimilate into a large homogeneous majority population. It likewise applies to the large number of people who have immigrated to this country from around the globe. In many cases the difference in the level of assimilation has been determined by skin color as a proxy for race. The very visual evidence of skin color has been used to deny access at multiple levels. Although this affects all people of color, its overall impact is more pronounced on Black Americans whose ancestors were bought and sold as slaves and whose basic make-up has been shaped by generations of enslavement, discrimination, and marginalization. The result is a deep internal conflict with one’s self and a continuing struggle to overcome the internal racism, low self-esteem, and loss of self-created by systemic racism. Perhaps the best illustration of internal racism, the lack of identity, and the feeling of inferiority produced by racism is a series of experiments conducted by Drs. Kenneth and Mamie Clark in the 1940s in which Black children between the ages of 3 and 7 were asked to identify the race of dolls and which dolls they preferred. A majority of the children preferred the white doll and assigned positive characteristics to it. The study concluded that prejudice, discrimination, and segregation created a feeling of inferiority among Black children and damaged their self-esteem, resulting in a loss of self-identity and creating what we now consider internalized racism (Jones, 2000; Clark & Clark, 1939; Green, 1997).

Researchers have applied the term “toxic stress” to the effects of persistent adverse life circumstances—such as racism, discrimination, and poverty—that may influence the genetic predispositions that affect an individual’s emerging brain architecture and long-term health. Toxic stress has been shown to have a pronounced effect on those areas of the developing fetal brain that primarily function in our critical thinking, behavioral responses, cognition, linguistics, and ability to respond to stressful situations (Shonkoff J P, 2012). Long-term effects have been shown to be intergenerational. Historically, Black Americans are the descendants of a population that was subjected to an environment and culture of constant stress and fear of being beaten, killed or lynched, and sold at the whim of their owner (Blight, 2011). Along with the unmeasurable trauma of separation of families, this produced a level of chronic toxic stress that may manifest itself as both implicit and explicit changes in behavior, critical thinking, and ambiguity about one’s true identity. These long-term changes could serve as defense mechanisms and operate at the core of double consciousness. Black Americans continue to conform in an attempt to assimilate into a majority world that, in many cases, continues to be unfair and marginalizing. As our understanding of the long-term biological effects of toxic stress improves, we may be able to identify an unconscious and biological basis for double consciousness.

While double consciousness maybe the internal manifestation of biological processes (i.e., epigenetic) that have become deeply engrained in Black Americans and profoundly affects critical thinking and behavior, code switching may be considered the superficial manifestation of double consciousness. It can be unconscious or deliberate, and it may play a significant role in our daily behavior and activity. The foundation of code switching is based on linguistics (or language variations) and situational behavioral changes during social interactions (McCluney et. al, 2019; Nilep, 2006). Code switching is ubiquitous throughout society, more specifically in minority communities, and is a conscious effort to fit in or conform. It is controlled and applied at will and is readily used to fit into daily interactions, events, and environments. Although superficial, it creates a baseline level of chronic stress.

As long as there are dominant and subordinate groups, remnants of double consciousness will remain. Our goal should be to look at double consciousness from a historical perspective and try to understand its manifestations in Black, Indigenous, and People of Color (BIPOC). In order to do this, we must first try to understand the mitigating circumstances of slavery, segregation, institutional racism, and their generational effects on Black and White Americans in creating dominant and subordinate classes based on race. We must realize and take ownership of past wrongs and move to change. In order to move forward, the possible origins and realities of double consciousness must be recognized, put in context, and applied to our current state of racial tension. How did we get here?

Behavior is not fixed (nature) and is influenced a great deal by the surrounding environment (nurture) (Jones, 2000). Individuals and populations exposed to continuous toxic stress develop specific responses that can be heavily influenced by their support systems—such as families, communities, religious leaders, teachers, health care providers, and mentors—resulting in an increased awareness and understanding of existing social structures along with the development of skill sets that allow individuals to overcome social barriers and progress in a majority-dominated world. (Hughes, 2006). As is the case with many minority and marginalized groups, BIPOC must strive to overcome the barrier of double consciousness in order to find a place in which the very soul is at peace, where self-worth overrides external factors that could create barriers to attaining consciousness of self, development of personal and professional identity and fulfillment.

The intent of this commentary is to increase awareness, educate and promote change. As an African American male who has spent an entire career in academic medicine I’m very aware of and have experienced the external barriers and internal struggles that result from assimilation into an educational environment with very few or no minorities. I’m also the product of a segregated, and later, integrated public school system. Neither of these facts makes me an expert on poetry or an authority on the genesis, biological basis, and reality of double consciousness, but as one with a lived experience that encompasses many of the conflicts highlighted in the poem, it does give me a very unique perspective and insight surrounding the behaviors, perceptions, and perhaps critical thinking of students and faculty of color as they seek to become part of the medical community. Over the years my role as a faculty member as evolved from one as primarily a clinician and researcher to one as a teacher, advisor, mentor and coach. As a faculty member part of my responsibility (duty) is to share my perspectives and past experiences and possibly give meaning and basis for the feelings of isolation and ambiguity experienced by many students and faculty as they struggle to find themselves and develop their personal and professional identity. This has given me the opportunity, privilege and honor to be involved in the personal and professional lives of multiple students and faculty. Needless to say, it has shaped me personally and professionally.

Lastly, and maybe more importantly, the poem highlights the value and critical need of an institutional awareness and culture along with transitional programs and support systems that serve to mitigate the experiences of minority students and faculty as they adapt and maneuver through an academic environment that may not be inclusive and nurturing. In spite of what may seem an overwhelming struggle, I remain optimistic as local and national health professions institutions continue their efforts to address the lack of diversity in medicine through the creation of leadership positions in diversity, equity and inclusion and organizations like the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education continue to institute policies and provide guidelines and strategies that seek to increase diversity and ultimately change the culture of medicine (Association of American of Medical Colleges, 2020).

Notes

• Association of American Medical Colleges. Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments. Academic Medicine. December 2020 Supplement, Volume 95, Number 12. S1 – S177.
• Blight D W. Race and Reunion: The Civil War in American memory. The Belknap Press of Harvard University Press. Cambridge Massachusetts, and London England. 2001.
• Bonner F A II. The Temple of My Unfamiliar. In Faculty of Color. Teaching in Predominately White Colleges and Universities. Staley CA, ed. Anker Publishing Company, Chapter 6, pp – 80-99, 2006.
• Clark K B and Clark M K. The Development of Consciousness of Self and the Emergence of Racial Identification in Negro Preschool Children. The Journal of Social Psychology Volume 10, 1939, issue 4. 591-599. https://doi.org/10.1080/00224545.1939.9713394
• Du Bois W.E.B. The Souls of Black Folk. Penguin Books, 1903.
• Green C D. Classics in the History of Psychology. Clark K B, Clark M K. The Development of Consciousness of Self and the Emergence of Racial Identification in Negro Preschool Children. Journal of Social Psychology Bulletin 10 591-599. https://psychclassics.yorku.ca/Clark/Self-cons/
• Hughes D et. al. Parents’ Ethnic–Racial Socialization Practices: A Review of Research and Directions for Future Study. Developmental Psychology. 2006, Vol. 42, No. 5, 747–770
• Jones C P. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000 August; 90(8): 1212–1215. PMCID: PMC1446334
• McCluney CL, Robotham K, Lee S, Smith R and Durkee M. The Cost of Code Switching The Big Idea Series/Advancing Black Leaders. Harvard Business Review. November 15, 2019. https://hbr.org/2019/11/the-costs-of-codeswitching
• Nilep C. “Code Switching” in Sociocultural Linguistics. Colorado Research in Linguistics, Volume 19 (2006). https://scholar.colorado.edu/cril/vol19/iss1/1
  DOI: https://doi.org/10.25810/hnq4-jv62
• Shonkoff JP, Leveraging the biology of adversity to address the roots of disparities in health and development. PNAS, 17302-17307, October 16, 2012, vol. 109, suppl 2. www.pnas.org/cgi/doi/10.1073/pnas.1121259109