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The impact of COVID-19 has underscored what health statistics have shown for decades: When it comes to serious illness in the United States, nonwhite people are likelier to die than white people. This phenomenon is often attributed to poorer health among low-income minorities, but on closer inspection, this explanation falls short.
Our team at Yale University has researched treatment disparities in gastrointestinal cancers, including cancers of the pancreas, colon, liver and other organs of the digestive system.
Our findings
, published recently, show that Black cancer patients do not receive the same quality surgery and follow-up therapies as white patients. This subpar care is not attributable to the patient’s medical condition. It is attributable to the patient’s skin color.
We can say this with confidence because our research is both wide and deep, encompassing 565,124 patients and a variety of cancers and controlling for differences in insurance, income status and
co-morbid conditions
. We found Black patients are less likely than white patients to have “negative surgical margins,” in which no cancer cells are found in the border of tissue removed during surgery. They are also less likely than white patients to have adequate lymph node removal during surgery. And they are less likely than white patients to be offered chemotherapy or radiation after surgery.
As a result of these treatment disparities, Black patients are likelier than white patients to die. As there are no clinical or financial explanations for the treatment disparities we observed, the inescapable conclusion is that structural racism — embedded in health care systems and physicians’ psyches (unconsciously, we believe) is responsible.
The question raised by our research is how — against all evidence of how to save lives — racism became so deeply embedded as to be mistaken for normal. One plausible answer is that racial biases take root before treatment decisions are made. Recall that a catch-all “explanation” for the higher mortality of Black cancer patients is that they’re sicker to begin with, likelier than white patients, for example, to smoke or be obese. These circumstances trigger a
range of reactions
among the public, including physicians — from compassion to blame-the-victim, from “how sad,” to “you did this to yourself.”
Whether charitable or harsh, such reactions miss the fact that the relatively poorer health of Black patients is itself evidence of structural racism in terms of less access to education, health care, fresh food and outdoor activity, and more exposure to social, financial and environmental stress. Seen in this light, Black patients are misjudged from the start and treatment disparities are the continuation of this initial misjudgment, essentially, a failure to recognize and avoid the racist dimensions of health care, including surgery, in the U.S.
The medical and scientific establishment know there’s a problem. The National Institutes of Health established the
UNITE initiative
to identify and address structural racism in biomedical research. Included in this initiative is guidance to the NIH to address long-standing health care disparities and issues related to minority health inequities, and to provide a roadmap for the allocation of federal research dollars. Scientists and physician-scientists need to grasp opportunities such as this to prioritize the study of disparities. Professional organizations such as the
American College of Surgeons Commission on Cancer
could also further their support to CoC-accredited hospitals for such analyses.
At the same time, research universities and health care systems need to engage community leaders of underrepresented racial and ethnic groups in quality improvement campaigns, include calling out evidence of the disparate treatment of patients of color. In addition, medical schools and research universities need to recruit and retain underrepresented minorities. To that end, federal aid needs to prioritize diversity in the awarding of support.
It stands to reason that physicians of color would be less likely to harbor biases against patients of color, though that said, all medical students should have mandatory training in relationship-centered communication, as recommended by the
Academy of Communication in Healthcare
. Learning to listen and respond to what patients actually say could be a powerful antidote to bias.
A hallmark of structural racism is that it’s pervasive. Health care is no exception. Accordingly, awareness of it and efforts to combat it must also pervade how doctors and hospitals approach patients of color.
Dr. Sajid A. Khan is an associate professor of surgery and section chief of hepato-pancreato-biliary and mixed tumors at Yale School of Medicine.
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