Twenty years ago the National Academy of Medicine published a landmark report showing that race-based disparities in healthcare were widespread. As Brian Smedley, PhD, Equity Scholar at the Urban Institute and a co-author of the report, explained: “There was no disease area or clinical service where we [saw] equitable treatment between people of color and whites.”
Dr. Smedley’s comment about the report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, was part of his keynote speech at a recent symposium hosted by the GPH Center for Anti-racism, Social Justice, & Public Health. His message was clear: While some progress has been made, much work remains in order to undo the structures and systems that create inequality.
Dr. Smedley began by recognizing the many municipal public health departments, non-governmental organizations, and professional institutions — including the APHA and the federal Centers for Disease Control — that have formally cited racism as a threat to public health. It’s good that “the movement has taken root,” he said. But while people’s health is altered by what they eat, whether they exercise or which doctors they see, it’s also influenced by society’s policies and practices, our cultural narratives, and who and what we value. “And it’s clear,” he said, “that in this country we have not historically valued people of color.”
Dr. Smedley identified four pathways through which racism infiltrates American society:
- Structural racism involves systems that produce cumulative, durable inequalities and set the stage for poor health. An example is residential segregation that situates Black or Native communities near environmental threats like air, water or soil pollution, or locates them far from access to healthy food.
- Institutional racism has a disproportionate impact on people of color by limiting their access to opportunities for economic advancement. Consider law enforcement’s aggressive use of “stop and frisk,” a policy that targeted Black and brown men even though they were no more likely to carry contraband than whites. Harms to health can occur just from the stress of interacting with the police, not to mention the risk of getting ensnared in the criminal justice system.
- Individually mediated racism, perhaps the most well-known pathway, arises from those who treat people of color with animus or in a discriminatory way, again resulting in harm to their health.
- Internalized racism describes members of marginalized populations who accept the negative beliefs and stereotypes that permeate our society. Even if they don’t subscribe to them, it may lead to perceiving oneself as worthless or powerless, and can affect how they think and respond.
Dr. Smedley also discussed how the health-harming pathways of racism are mutually reinforcing. For instance, at the doctor’s office biases are more likely to arise due to time pressure (no time for physicians to talk or get an accurate history), resource constraints (they can’t order desired diagnostic tests) and cognitive complexity (patients have multiple health challenges). These same conditions are often present in “safety-net” health care settings, where people of color are more likely to be found. In turn, they’re reinforced by a view of health care as a market commodity, rather than a human right. This is how racism becomes a social determinant of disease, entangled with an unequal distribution of resources.
Identifying these pathways was one of the most significant contributions of the Unequal Treatment report, said Dr. Smedley. It asked: when patients of color and white patients enter a healthcare system and the only difference is the color of their skin, what kind of treatment do they receive? The conclusion was that patients of color receive lower quality healthcare even after controlling for differences in access, such as insurance status or income to pay for out-of-pocket costs.
Some critics said those differences were not due to racism; they were an artifact of socioeconomic differences. But the report’s authors reviewed hundreds of studies with undeniable results: even in the same healthcare systems, with the same health insurance, and with the same health problems, patients of color had a lower quality of healthcare.
Now it’s 20 years later, said Dr. Smedley, yet racial and ethnic disparities persist. Their measures have narrowed slightly, on average by less than ten percent, so there’s some movement. But little progress has been made toward closing the gaps in healthcare access and quality, as well as in outcomes. “We're stuck,” he said. “We're stuck. We're not making a difference and we're not moving the needle, despite awareness of the problem.“
He cited five primary factors associated with this stagnation. First is “medical apartheid” -- our nation’s separate and inequitable healthcare system, in which healthier, wealthier communities have more healthcare services and professionals than poorer, sicker communities. Second is our tiered health insurance system, in which people who can afford better insurance receive better care. The third factor in the lack of improvement is the prevalence among clinicians of biases that are ingrained in us through socialization; clinicians are no less vulnerable to biases than other people. (One study found that 70 percent of medical students believed that black people had a higher tolerance for pain, despite the fact that race has no biological basis.) The fourth reason for the persistence of disparities was the use of race-based clinical decision support tools; at their core are algorithms that duplicate racial biases. This costs lives; for instance, some algorithms used to determine eligibility for a kidney transplant require a higher risk score for black patients than for white ones -- a fact that Dr. Smedley described as a “stunning injustice.” The fifth cause was a lack of diversity among healthcare providers; he noted that our nation’s healthcare professionals do not accurately represent its population, due to higher barriers to entry for people of color.
Dr. Smedley concluded his presentation by identifying ways to resolve these inequities. He first called for structural equity to fix our nation’s “maldistribution of resources,” including universal healthcare coverage and equitable reimbursement from all insurance providers. He next called for institutional equity, so that healthcare systems would be located and supplied according to need. His third call was for clinical equity, to focus on ending the inaccurate use of race as a biological factor. Lastly, he called for a more diverse population of healthcare providers. In fact, a 2005 study he edited, titled In the Nation’s Compelling Interest: Ensuring Diversity in the Healthcare Workforce, offers strategies to increase diversity in the health professions by changing admission policies to schools, deemphasizing standardized testing, and reducing financial barriers.
Dr. Smedley’s parting thoughts offered encouragement. “We can't let the pathogen of racism continue to cause havoc in our communities, if we ultimately want to live in a productive, healthy, equitable society. It's a struggle, but we will ride through it and get to a point where we can have these conversations about racism and understand the responsibility that we all have for dismantling it.”