The underpinnings of medicine are based in science, but its practice—like all human endeavors—is bound up in history, sociology, philosophy, and ethics. These have traditionally been considered concerns of the humanities, and medical education now formally embraces humanities training.1–3 However, there are criticisms of the current approach to narrative-based medical humanities training. Banner4 has argued that humanities and medicine have paid insufficient attention to race, choosing instead to be apolitical. Adams and Reisman5 have called for prioritizing the intersection of humanities with structural racism. The blind spots are made clear when some medical humanities advocates call for reform of humanities teaching in medical schools by finding “common ground” with the 1910 Flexner report on medical education reform.6,7 These calls conveniently gloss over the fact that the author, Abraham Flexner, argued for the closure of most Black medical schools: “A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an M.D. degree is dangerous.”8 A devastating real-world consequence of the Flexner report was that all but two extant Black medical schools soon closed, leading to approximately 35,000 fewer Black physicians in the United States.9 An inclusive medical humanities program could have prevented such embarrassing “advocacy” by humanities experts.
RESHAPING THE CANON
If we are to truly diversify the medical humanities curriculum, as we must, how should the canon be reshaped? One way would be to continue relying on narratives from conventional spaces, but with an intentional emphasis on voices from communities of people of color. For a more truly inclusive approach, however, one does not have to look too far: hip-hop, an art form only a few decades old, has evolved to become a voice for the oppressed in many different societies and cultures worldwide.
One of the most well-known pioneers of hip-hop is Shawn Carter, known professionally as Jay-Z. He grew up in the Marcy housing projects in Brooklyn, NY, initially pursuing crime before being redeemed by the rewards of his art. Author Zadie Smith has described Jay-Z’s works as “showrooms of hip-hop, displaying the various possibilities of the form.”10 On a superficial level, Jay-Z’s lyrics celebrate his successes and transformation from poverty to enormous wealth. But the key to a deeper reading is to understand the form of hip-hop itself. Many object to the focus on materialism, but braggadocio is as integral to hip-hop’s form as romance is to sonnets. Indeed, as Smith says, “Asking why rappers always talk about their stuff is like asking why Milton is forever listing the attributes of heavenly armies.”10
This surface-level story—“the hustler’s story”— serves as a stand-in for the struggles of life. As Jay-Z explains it, hustling is “the ultimate metaphor for […] the struggle to survive and resist […] to win and make sense of it all.”11 An alert reader who looks past this surface-level celebration of consumerism will be rewarded with truth-telling about the pathologies of poverty, crime, and American society and their interaction with health inequities. As Jay-Z himself states, “To tell the story of the kid with the gun without telling the story of why he has it is to tell a kind of lie.”11 Or more poetically, “Marcy raised me, and whether right or wrong/Streets gave me all I write in the song.”12
A large body of literature describes the association between racism and racial health inequities.13 Both structural and interpersonal racism can impact the care of individual patients, including their mental health,14,15 but clinicians may fail to see the application of these findings to their own practice. Individual narratives carry greater power to inform and persuade. In Jay Electronica’s song “Shiny Suit Theory,” the narrator (like Jay-Z) reports how he has gone from undercover drug dealer to being featured on the cover of a business magazine alongside billionaire Warren Buffett.16 He seeks help for (presumably) past trauma but runs into a disbelieving psychiatrist: “In this manila envelope, the results of my insanity/Quack said I crossed the line ‘tween real life and fantasy/Went from warring to Warren, undercovers to covers/If you believe in that sort of luck, your screws need adjusting.”16 Instead of listening to his patient, the physician responds by cutting the visit short with a prescription: “Aw, the doc interrupted/He scribbled a prescription for some Prozac, he said, ‘Take that for your mustard/Boy, you must be off your rocker/It takes a lot to shock us but you being so prosperous is preposterous.’”16 Note the hostility generated in the narrator in response to the curt dismissal of his lived experiences, as he calls the psychiatrist a quack. Encounters like these do little to engender trust in the larger medical establishment. Writer Michael Eric Dyson describes this narrative viewpoint by Jay-Z as placing “psychiatry itself on the couch” and giving it a “rousing psychoanalytic read.”17
The perspectives offered by Jay-Z’s work extend beyond interpersonal racism to structural racism in public health policy. When many Americans were shocked by the terrorism of 9/11, Jay-Z’s lyrics provided the perspective of Black Americans who have been suffering from state-sponsored terrorism for centuries: “Bin Laden been happening in Manhattan […] back when/Police was Al ‘Qaeda to black men.”18 In “Beware,” he goes a step further, provocatively juxtaposing an American president with the terrorist leader: “Before bin Laden got Manhattan to blow/ Before Ronald Reagan got Manhattan the blow.”19 These lyrics pun on the word blow, using it as both a synonym for explosion and as slang for cocaine. Thus, the poet here uses a single wordplay to highlight that the crack epidemic, attributed in mainstream media to cultural issues within the Black community, may have had its roots in the involvement of the Reagan administration in financing the drug trade in Central America.20 Jay-Z’s artistry also often experiments in form. In the song “22 Twos,” he gives us exactly 22 plays on the words two and too,21 and its sequel “44 Fours” does the same for phonetic equivalents of four and for.22
BELOW THE SURFACE: LAYERS OF MEANING
Certainly, hip-hop is not without critique: the glorification of violence, consumerism, misogyny, and toxic masculinity plague the genre. However, this critique is itself subject to criticism as being selectively applied to hip-hop and not to other artistic genres, and in many ways reflects systematically biased ways of approaching art. Misogyny is also rife in the works of Hemingway, Updike, and Mailer (who famously stabbed his wife), yet they remain canonical.
However, even if we take the criticism of misogyny in hip-hop at face value, it is crucial to understand that the words critics are objecting to have layers of meaning and context. Sometimes the lyrics are the words of a character who is misogynist. Sometimes they are provocations to identify disingenuous listeners. Sometimes they are used ironically. And sometimes they are truly misogynistic. An illustration of superficial reading by critics is one of Jay-Z’s best-known songs, “99 Problems,” which uses what may be thought of as a misogynistic word—but only if you don’t read the full verse. If you do, you will realize that at no point does the artist refer to a woman. It is, as Jay-Z says, “a deliberate provocation to simple-minded listeners.”11 He elaborates: “The art of rap is deceptive. It seems so straightforward and personal and real that people read it completely literally, as raw testimony or autobiography … It’s all white noise to [critics] until they hear a [curse word] and then they run off yelling, ‘See!,’ and feel vindicated…But that would be like listening to Maya Angelou and ignoring everything until you heard her drop a line about drinking or sleeping with someone’s husband and then dismissing her as an alcoholic adulterer.”11
In any case, the hip-hop form is evolving toward a more self-critical phase. In “Minority Report,” an elegy for the predominantly Black lives lost in the flooding that followed Hurricane Katrina in New Orleans, Jay-Z initially identifies systemic racism as the cause of the neglect and “otherization” of the victims: “And the next five days, no help ensued/They called you a refugee because you seek refuge.”23 But then he recognizes his own culpability as a person of means who donated but did not truly volunteer to help: “Silly rappers, because we got a couple Porsches/ MTV stopped by to film our fortresses/We forget the unfortunate/Sure I ponied up a mill, but I didn’t give my time/So in reality I didn’t give a dime, or a damn.”23 In “4:44,” he admits obliquely to straying in his marriage and confesses openly about the shame he feels that his daughter will grow up to discover his faults as a husband and father: “My heart breaks for the day I have to explain my mistakes/And the mask goes away/And Santa Claus is fake.”24
Perhaps most heartrendingly, Jay-Z confronts his own past misdeeds in “Beach Chair,” worried that his then-unborn child will pay the price: “See I got demons in my past/so I got daughters on the way/If the prophecy’s correct/Then the child should have to pay/For the sins of a father So I barter my tomorrows against my yesterdays/In hopes that she’ll be okay.”25 This piece, written in the form of a will, finds the narrator hoping to ensure financial security for her, but also praying that she will have more serenity in his life than he did: “I will prepare/A blueprint for you to print/A map for you to get back/A guide for your eyes…/My last will and testament I leave my heir/My share of Roc-A-Fella Records and a shiny new beach chair.”25
EMPATHY WITHOUT BOUNDARIES
The purpose of medical humanities is to provide physicians and healthcare providers in training or otherwise with alternative perspectives on life, and to engender empathy for the suffering and lived experiences of our patients. When we restrict humanities curricula to what feels comfortable, we are by definition restricting ourselves to points of view we wish to appreciate and empathize with. When we only embrace literary experiences that align with certain social classes or race, we send the message that our empathy has boundaries that align with social class or race.
Physicians carry considerable power in the patient-physician relationship. Opening our minds to the viewpoints of others diffuses some of that power and grounds us in the communities we serve. This is needed. As the poetry and poets of hip-hop evolve outside the confines of academia, leveling the playing field for countless oppressed voices worldwide, it is past time for literature in medicine to evolve as well—to listen to and reflect upon these voices that, in turn, reflect all facets of our societies and represent the worldview of all of our patients.
DISCLOSURES
The author has disclosed consulting for Anthos, Bayer, BMS, Genzyme/ Sanofi, and Pfizer.
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