“First Do No Harm:” Don’t Ignore Race in Medicine
"Colorblind" has become the buzzword often used by white people who mistakenly believe ignoring race proves they are not racist. In reality, ignoring race as a factor in social conditions is inherently racist. Although race is a human construct, the effects of racism are very real. This especially plays out in the healthcare field. Negative social determinants of health due to systemic racism play a crucial role in health outcomes for people of color. Health care workers must therefore consider racism and social determinants of health as the cause of health disparities to work towards equal access and treatment in healthcare.
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Nonmedical factors relating to circumstances in which people are born, grow up, and live -known as social determinants of health- influence health outcomes. Poor people have more negative social determinants of health, such as less access to healthcare care and quality nutrition, and more toxic living environments.
According to the CDC, "health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations."
Jo Phelan and Bruce Link explain the association between poverty and worse health outcomes with their Theory of Fundamental Causes, which details a direct correlation between "resources such as knowledge, money, power, prestige, and beneficial social connections” and health.
Epidemiologist Parisa Tehranifar adds, "it is the persistent association of socioeconomic status with overall health in the face of dramatic changes in mechanisms linking socioeconomic status and health that led Link and Phelan to call socioeconomic status a ‘fundamental’ cause of health inequalities."
Since many social determinants result from structural racism in the United States, making it difficult for people of color to escape the cycle of poverty based poor health outcomes, people of color make up a disproportionate number of the poor. In 2019, the poverty rate for white people in the United States was 10.5%, while the percent of Black people in poverty was 18.8%. Thirty-three percent of African American children live in poverty. Because people of color are overrepresented among the impoverished, they are more likely to receive poor health care and live in environments that foster illness, leading to deficient health outcomes. Racial inequality and systemic racism play a critical role in the delivery of sub-standard healthcare and wellness. The system is not colorblind.
Outside of socioeconomic status specifically, Americans of color are less likely than white Americans to get adequate medical and surgical services across various clinical settings. The list of racial health care inequities is lengthy: inferior pain treatment, lower rates of procedures for heart attacks, fewer prescriptions for beta-blockers after heart attacks, less timely administration of antibiotics for pneumonia, less optimal care for diabetes, fewer prescriptions for inhalers in children with asthma, fewer cancer screening tests, and many more. These health disparities are linked to systematic racism. Black people experience higher rates of hypertension due to chronic stress from racism. Physicians are even found to have high rates of implicit bias, thus causing damaging interactions with black patients. These trends have continued through the COVID-19 pandemic, as people of color are at a higher risk of getting sick and dying from COVID-19.
Appalling healthcare for Black Americans is far from a new phenomenon. The Tuskegee Syphilis study of 1932 is a prime example. Doctors monitored the progression of syphilis among Black people but did not tell subjects their diagnosis or treat the disease, even after the discovery of penicillin. As recently as 1996, Clarence Grim tried to use slavery to hypothesize high rates of hypertension among African Americans. Grim argued that Black people developed a genetic variation due to chronic salt shortages on slave ships. This claim was disproven as there was virtually no evidence to support it. As stated before, chronic racism - not a genetic deficiency - is responsible for the stress that leads Black Americans to higher hypertension rates. This long history of healthcare abuse also leads to distrust. This deeply rooted systematic oppression manifests itself through lack of access to high-quality medical care, food deserts in poor neighborhoods, exposure to environmental toxins, high incarceration rates, and experiencing the stress of racial discrimination.
To fight health disparities, physicians must take social determinants of health into account in clinical settings. Western medicine often focuses on providing care when necessary rather than offering preventative care. Physicians should consider race and socioeconomic status at the patient and practice level. Physicians should inquire about social and living conditions at the patient level and provide referrals to services when necessary. At the practice level, physicians should offer culturally safe services and make sure their clinics are accessible. This can be accomplished by providing bus fare or child care services for hard-to-reach patient groups. Although many health disparities result from deeply rooted systematic inequality, having physicians work to combat health disparities is a step in the right direction.
First, we need to increase awareness that racial inequity in healthcare exists. The “colorblind” population wants to believe all is well. It is not. This will come from education and community action. We must guarantee affordable and accessible health care. The Affordable Health Care Act, implemented under former President Obama, is a step forward. It should to be expanded and made more robust in order to reduce the impact of toxic environments that plague communities of color. Steps forward can be accomplished by the news media regularly exposing these deleterious living conditions.
A colorblind approach leads to racist outcomes. To make progress, it must recognized that the healthcare and wellness system in this country is broken for people of color. This is the only way to begin making progress towards a more equitable system.