Racism and Health Equity – The Hastings Center

From Bioethics Briefings

Framing the Issue

Racism has been declared a threat to public health by public health and medical organizations like the U.S. Centers for Disease Control and Prevention, the American Medical Association, and the American Public Health Association. This recognition came largely in response to the disproportionate infections, hospitalizations, and deaths among Black, Latinx, and Indigenous people during the Covid-19 pandemic, as well as high-profile cases of police killing Black Americans like George Floyd. During the pandemic, there has also been an increase in racially motivated discrimination against Asians and Asian Americans. By declaring racism a threat to public health, organizations formally recognize the research that attests to racism’s detrimental health effects on people of color. Additionally, they acknowledge that the poorer overall health of people of color is not necessarily a matter of choice, and it is not the result of inferior biology, but it is often a matter of external social and political forces, including racism. Declaring racism a public health issue also affirms that when people of color have less access to health than other racial groups, their health equity is seriously compromised. In fact, health equity in general is compromised when any group doesn’t have the resources needed for health, as the Covid-19 pandemic has shown. Racism is especially a threat to the health of people of color, but as public health teaches us, we are all connected, and thus racism is a threat to everyone’s health.

Many people of color experience different forms of racism in their everyday lives. They can experience interpersonal racism, such as racial slurs from individuals, including people they know like peers, bosses, and co-workers, and people unknown to them like strangers they encounter on a daily basis. They can also experience institutional racism, such as employment discrimination and biased government policies. People of color can also experience racism within clinical settings, for instance, when physicians and nurses rely on racial biases to treat patients. Racism in clinical settings, though, can be considered interpersonal and institutional racism, depending on the encounter. But, more importantly, whether racism is experienced before or during a clinical visit, racism contributes to people of color’s disproportionately poorer health outcomes in birthing mortality, cardiovascular disease, diabetes, organ transplantation, and many other areas, jeopardizing their health equity.

Bioethicists often frame their research, teaching, and advocacy work around principles that are directly related to health equity, like social justice, respect for persons, beneficence, nonmaleficence, and protecting vulnerable populations. Racism threatens each of these foundational principles, and yet it is often an afterthought in bioethics work. To remain true to the principles of our profession and remain relevant in a time when expertise is frequently undermined, bioethicists must make it a priority to address racism’s threat to health equity.

Interpersonal Racism and Health

Interpersonal racism is the racism that people experience from individuals. Examples are  a Black person being called a racial slur by a White person, a Latinx person being followed by an employee while shopping in an expensive store, and an Asian person’s family restaurant being vandalized with anti-Asian graffiti. Interpersonal racism can be seen in individual acts of discrimination based on racial biases and stereotypes. Although it occurs at the individual level, it should not be dismissed as trivial; it can cause stress for the person on the receiving end, which researchers believe contributes to racial disparities in health, including disparities in people’s quality and quantity of sleep, rates of hypertension and cardiovascular disease, and mental and emotional health. Stress has even more impact on health when it is prolonged. Stress associated with interpersonal racism is also a contributing factor to increased poor pregnancy outcomes among Black people.

People of color also experience interpersonal racism from health care providers. Like the general population, physicians, nurses, and therapists have racial biases, but their biases are especially harmful because they can reduce the quality of care given to their patients of color. For example, studies have found differences in the ways that health care providers treat Black and White patients. Some health care providers  filter their clinical interactions, including how kind they are  and how closely they listen, through their racial biases. Experiencing racial bias from clinicians can lead patients of color to mistrust their providers and discontinue necessary care. Health care providers can also rely on racial biases when making care recommendations. For instance, Black people who come to the clinic with chest pain are less likely than White people to be referred for in-depth diagnostic testing. Research has also documented anti-Black racial bias in the assessment and treatment of pain more generally.

Bioethicists often research the relationship between individual health care providers and their patients, as well as health care systems and their relationship with patients. This kind of research, however, would be incomplete without consideration of the serious threat that racism poses to these relationships. To ignore racism and its effects on people of color’s health would be to ignore a great injustice. And this would go against bioethics’ commitment to justice and inclusion.

Institutional and Structural Racism and Health

Institutional racism is racism that is built directly into the institutions and systems that govern people’s lives. Individuals don’t need to be racist for people’s lives to be influenced by racism. For example, health care providers’ racial biases are often attributed to biases taught in medical education and modeled in practice. But the social determinants of health, like education, social stability, employment, access to clean air and water, housing, and access to health care, are clearer examples of institutional racism because they are shaped by large-scale systems with racist policies that affect people of color’s health. What makes institutional racism especially problematic and sometimes difficult to expose and eradicate is that its roots are often historical and political.

Institutional racism is intertwined with other forms of oppression like sexism, classism, or ableism. For example, Indigenous people and Black people have the highest rates of disability in the U.S. Disabled people, as well as Black and Indigenous people, face more barriers than other groups to accessing quality education and health care. Additionally, disabled people make up a large portion of police killings, by some estimates up to one-third to one-half of police killings. Although most discourse on police killings is about Black men, given that they are disproportionately victims, Black disabled people are frequently the subject of police violence. Police killings are at the intersection of racism and discrimination against disabled people.  Therefore, when examining the effects of racism on health we need an intersectional lens that also examines other identities subject to discrimination.

Black, Latinx, and Indigenous people also have higher rates of exposure to environmental pollutants in the air and water, partially because facilities that emit pollution are more likely to be located near their jobs, schools, and homes. Many of the people who live near these facilities are in these neighborhoods because of historical racist housing laws, like redlining, legal segregation, and government seizure of Indigenous people’s land. These federal, state, and local laws have left people of color in economically poor and under-resourced neighborhoods and with little political power to change their conditions. On the other hand, the U.S. government subsidized White neighborhoods and segregated White families into resource-rich areas. Because of the inferior location of their homes and their proximity to toxic facilities, people of color have had property that was devalued, leaving them without enough equity to fund things like their children’s college or their own retirement. Furthermore, many people of color haven’t been able to afford to move to more affluent areas.

The legacy of legal housing segregation still affects where people of color live and raises ongoing issues of environmental injustice. Places like “Cancer Alley” in Louisiana and Mississippi, as well as Flint, Michigan, and parts of Baltimore, Houston, and Appalachia, have high levels of air and water pollution and a disproportionate number of  marginalized residents in poor health. Despite environmental toxins contributing to cancer, respiratory disease, and other chronic illnesses, individuals’ efforts for environmental justice have been no match for the deep-seated injustices in the institutions and policies that govern our housing and environmental health. People cannot have equitable access to health if their very neighborhoods are poisoning them and they can’t rely on institutions to properly assist them and their families.

 Additionally, the harmful effects of institutional racism on people of color can compound over time, making it difficult to see that institutional racism is part of our social and political systems. It can also be difficult to see how institutional racism leaves legacies of disadvantage for future generations, including poverty, incarceration, and poor health. These are examples of structural racism, or the totality and intertwined effects of all forms of racism. Institutional racism, particularly as it contributes to structural racism, has long-term effects on individuals and future generations of people of color, making addressing racism a matter of health justice.

Conclusion

Racism is itself a social determinant of health that can affect our access to health equity, but racism can also influence our access to other determinants of health like safe housing. Bioethics as a field concerned with health, health care, and justice, particularly for the least well-off, has a moral responsibility to respond to the longstanding harms that racism has posed to the health and well-being of people of color. Bioethicists’ work must begin with a comprehensive view of health, which includes a social and political understanding of health and the ways that racism and other forms of oppression contribute to health inequity. Additionally, for people of color to trust bioethics, bioethicists can’t ignore how interpersonal and structural racism put burdens on them that other people don’t have to endure when maintaining their health or seeking health care. Disregarding these burdens would mean further marginalizing groups that are already marginalized. As bioethicists, we have to continuously grapple with how our work contributes to or dismantles racism and health inequities. We have to teach racism’s effects on health equity in our courses, fund health inequities research, and be advocates for social and political policies that work to eradicate racism at all levels. This may mean changing how we research, how we teach, and how and with whom we collaborate so we can achieve racial equity in all aspects of bioethics work and prepare the next generation of bioethicists to do the same. These kinds of changes are necessary for improving people of color’s access to health and health care. Racism poses a threat to health equity, and only by addressing it head-on can we live up to what makes bioethics a profession built on principles.

Keisha Ray, PhD, is an associate professor at the McGovern Center for Humanities & Ethics at UT Health Houston where she also serves as the Director of the Medical Humanities Scholarly Concentration.