Hello everyone! Today I am hoping to discuss racism in public health. According to the American Public Health Association, “racism is on ongoing public health crisis,” and as a public health professional, I hope to spread awareness and help advocate for meaningful, lasting change.
What is racism?
Racism is a social system or structure in which a dominant racial group, based on an ideology of inferiority, ranks people into social groups or ‘races,’ and uses these categorizations to devalue, disempower, or disenfranchise members of certain groups.
Racism plays a role in many inequities, including housing, educational and professional opportunities, access to financial and social resources, environmental exposures, and access to healthcare and medicine, among others.
I’d like to acknowledge that I am a white person, and therefore, I cannot comprehend the experience of racism, nor an I know what the experience is like. I wrote this post to help teach myself and others about the seriousness of racism as a public health issue, and to list some resources for those looking to learn more. Please feel free to comment with additional resources if you have them.
Below I have outlined a few examples of how racism impacts various issues of human health. This is absolutely not a comprehensive list, rather, it is meant to serve as a small survey of the different ways in which racism impacts health. I encourage you to read and learn more about this topic.
I also want to make it very clear that any health disparities mentioned in this post are a result of systemic and systematic inequalities, a lack of disproportionate exposures to risk factors, combined with inadequate access to resources due to our country’s systemic history of unequal treatment of minority populations, and absolutely not the fault of the populations that experience them.
Racism in America’s History and Health History:
Racism is deeply rooted in American history and culture. After all, much of the United States was built on salvery. And while slavery may be outlawed today, racism is still very real. It shows up nearly everywhere – from disproportionate levels of Black Americans facing mass incarceration, to the racially-driven wage gaps, medical bias, and segregated neighborhoods, racism persists as a driving force behind a multitude of inequities.
Racism has played a role in the US healthcare history. For example, the infamous Tuskegee Study of 1932 was an example of racism in medical research. The research team set out to investigate the course of syphilis over 6 months. They recruited 600 Black participants, and without informed consent or choice to leave the study, and studied their disease course over 40 years, and withheld known available treatment (penicillin), allowing participants to suffer and some to die, without their consent, for the sake of the experiment.
A second example: Dr. J Marion Sims, known as the “father of gynecology,” experimented on enslaved Black women without anesthesia. Much of what was known early on in gynecology was a result of the experiments this doctor performed on slaves.
These are just two examples of racism in the US healthcare system from years past. To learn more about racism in medicine, I highly recommend checking out this video.
Jumping ahead, modern medicine also has racial issues to confront. There is documented racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Black and white patients. A 1999 study found that physicians treated white and Black patients differently, even when their medical charts were statistically similar.
And a study of 418 medical students found when presented with false beliefs about Black patients and their health, many endorsed false beliefs, including the ideas that Black individuals have thicker skin than white people, and that their blood coagulates faster. These ideas came about years ago when people tried to justify enslaving Black peoples.
And in 2017, a nursing textbook was pulled after backlash for containing untrue information about different minority groups, many of which are based on stereotypes.
Given the above information, it’s not surprising that research suggests that there may be some biases in the practice of medicine. Whether or not these are intentional, they impact the patient experience and need to be addressed.
Clinical research also has racial disparities: a 2018 ProPublic analysis found that minority groups were underrepresented in clinical trials for new medications.
As you can see, racism has remained a persistent public health issue, and systemic issues that perpetuate racism impact a multitude of health outcomes, by exposing minority communities to more environmental threats (lead, pollution, etc), paying them lower wages so that access to healthcare, nutrition, and preventive care are less attainable, failing to provide equal access to insurance and medical care, and exposing minority communities to racist comments and microaggressions, which can take a toll on physical and mental health.
One example of these systemic institutions that perpetuates racial inequities is segregation. Segregation is itself a primary factor in reduced economic status by adulthood, lesser access to quality elementary and high school education with less preparation for higher education and employment opportunities, and higher rates of poverty.
Poverty is an independent risk factor for a multitude of poor health outcomes, as it impacts the individual’s ability to afford safe and healthy housing, nutritious food, and healthcare, among others. When this is combined with lower rates of income due to unequal pay and biases in medicine, people who experience racism are at a stark disadvantage for optimal health outcomes.
As you can see, these are complex, deeply rooted issues that demand attention and justice, on a system-wide level, which will take the work of everyday citizens, policy makers, public health and health professionals, among others.
Now, read on for a few select examples of documented racial inequities in health outcomes.
General mortality:
Racism is detrimental to health outcomes. A 1997 study found that for every 1% increase in prevalence of those believed Blacks lacked innate abilities compared to whites, there was an increase in all-cause Black mortality of 359.8 per 100,000 peoples.
Put another way – states with higher levels of racism also have higher levels of Black people dying from all causes.
Heart disease and hypertension:
Non-Hispanic Black people in the United States have higher rates of heart disease and death from heart disease compared to non-Hispanic White people, Hispanic people, and Asian or Pacific Islanders. They are also more likely to develop hypertension (high blood pressure).
OB-GYN:
Black women are three to four times as likely to die from maternal mortality compared to white women, even after controlling for socioeconomic status.
Infant mortality rates for infants are also 2.3 times higher for Black compared to non-hispanic white individuals. They are also at higher risk for sudden infant death syndrome, birth complications, and low birth weights.
Diabetes:
Diabetes diagnoses differ by race. Notably, non-Hispanic Blacks, Hispanics, and American Indians have higher rates compared to Asian Americans and whites.
And while many factors contribute to the development of diabetes, it’s worth noting that soda companies often target advertisements in low-income communities and communities of color.
Mental Health:
Racism can take a toll on mental health, and can increase risk of anxiety disorders and symptoms, among other mental health ailments.
When it comes to diagnosis, Black people are found to be more likely to be diagnosed with schizophrenia and less likely to be diagnosed with depression (likely due to failure of providers to recognize the problem) but more likely to suffer from more prolonged, chronic and severely debilitating depression.
Children and adolescents who have been exposed to racism are also more likely to develop mental health conditions. Yet, Black children are less likely to be diagnosed with ADHD compared to white children.
Proper diagnosis is important for proper treatment so individuals can function optimally with minimal mental distress impairing daily life.
It’s also important to recognize that microaggressions – or subtle, indirect or unintentional discriminations – can also cause mental distress.
Anesthesia:
Research shows that Black patients are less likely to be given pain medications by their physicians for similar problems.
In ER settings, Black patients are also less likely to receive analgesics compared to white peoples for extremity fractures, despite similar pain reports.
Younger Patients:
Children and adolescents also experience racial bias in medicine, and it has been documented to impact the care they receive, as well as their emotional and physical health outcomes.
Environmental Racism:
Environmental racism or unjust refers to inequalities between predominantly white and Black neighborhoods and their exposures to certain toxins and other environmental exposures.
Several studies have found higher levels of particulate matter exposure for BIPOC peoples and communities of color compared to white peoples (to learn more about PM 2.5, see this post).
Black people are also more likely to be exposed to toxic waste sites, which can impact air and water quality, and therefore, impact health outcomes.
Furthermore, Black children have higher levels of lead in their blood compared to white children, once again, likely due to neglect of these communities (which, by the way, Flint, Michigan still does not have clean water). And segregation is been found to increase risk of cancer related to hair pollution.
A recent study in New York City found higher levels of traffic, air pollution, wastewater treatment plants and industrial cites in the South Bronx (a community of color) compared to the rest of the city.
Furthermore, Black individuals are at a higher risk for developing asthma, likely as a result of the disproportionate exposures they face.
COVID-19:
Even though there has been less media focus on the pandemic and several states have reopened without any real plan, the COVID-19 pandemic is indeed still happening. And it’s disproportionately impacting certain populations.
According to NPR, African-American deaths from COVID-19 are nearly double the rate that wound be expected based on their share of the population at the national level, and in some states, the rate is 3 plus times as high. Hispanic and Lantios also make up a greater share of confirmed cases compared to their share of the population; up to 4 times greater in some status.
These differences are likely due to disproportionate access to health care and resources, and have quickly exposed the tragic inequities in our healthcare system in real time.
Moving forward:
There are some proposed solutions to work towards racism as a public health issue. Reducing segregation, abandoning immigration policies that act as mechanisms of structural racism, and training health care professionals (and heck, if you ask me, all professionals and people) to be anti-racist, are among them.
Others have suggested ‘communities of opportunity,’ in which there is equal access to childhood development resources, policies that reduce childhood policy, and work and income supports for adults, and ensured access to healthy housing and neighborhood conditions, should be developed to minimize the adverse impacts of systemic racism.
It has also been proposed that the healthcare system needs new emphasis on ensuring access to high quality care for all, strengthening preventive health care approaches, and addressing patients’ social needs as part of healthcare delivery. Diversifying the healthcare workforce has also been suggested.
As a public health professional, I feel it is essential for me to personally work to ensure a healthier, more just, and equitable world for all. I urge my fellow public health professionals to push for sweeping, multi-level systemic changes that will elicit equal opportunities, access to health care, and health outcomes for all. In addition to working through the resources mentioned in this post, I am ordering the book Racism: Science & Tools for the Public Health Professional.
I will report back once I have read it! In the meantime, if you’d like to learn more about racism in public health, I’d suggest looking through the American Public Health Association’s page on racism and public health.
And, I wanted to emphasize this again, as mentioned in this piece by one of my former professors, I think it’s important for all of us public health professionals, scientists, and health care works to be sure we add adequate context when reporting or discussing health disparities. Without appropriate context, the article argues, we risk perpetuating health myths and misunderstandings that may sustain racial misperceptions about marginalized groups.
Oh, and of course, vote for politicians who support justice and equity!
Take home: Racism is a public health crisis
Racism is deeply rooted in America and is an ongoing public health crisis that impacts physical and mental health. To create a equitable, healthy and just society, we must address this issue at intra and interpersonal, community, organizational, community, and public policy levels.
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