Are health care disparities more about race or racism?
The US health care system has made significant progress in recognizing the inferior health outcomes experienced by African Americans. Since former Health and Human Services Secretary Margaret M. Heckler commissioned the landmark Report of the Secretary’s Task on Black and Minority Health, released in 1985, there have been countless initiatives and official government reports about the problem.1-3 Following the “Heckler Report,” the National Institutes of Health (NIH) established the Office of Minority Programs in 1990, which 10 years later became the National Center National Center on Minority Health and Health Disparities. With the passage of the Affordable Care Act (ACA), there is now a dedicated institute, the National Institute on Minority Health and Health Disparities (NIMHD). Despite increased awareness and appreciation for health care disparities since the Heckler Report 30 years ago, disparate outcomes for African Americans persist.
As a physician who also studies public health and public policy, I’m routinely confronted with the shocking health care disparities that exist in the US health care system. No matter the disease, whether it be cardiovascular, kidney, psychiatric, or cancer, outcomes are significantly worse for African Americans compared to Whites. While race is a rough proxy for social class, education, and culture it does not tell the whole story. In fact, in many instances, even after adjustment for factors associated with race such as social class, insurance status, and level of education, the health disparities gap persists between Whites and Blacks.1,4,5 This has been shown repeatedly, leaving many researchers searching for answers.6
An uncomfortable truth not often embraced by physicians and public health researchers is that a significant reason may be racism. While race and racism are related, they are not necessarily interchangeable. Racism is a system of racial prioritization and bias that systematically disadvantages certain groups of individuals based upon race, while race is a social construct with no basis in biology used to categorize people.
Instead of assigning racism as the culprit for persistent outcome gaps, many researchers often look for other reasons such as “culture” and “genetics,” thereby biologizing and pathologizing the black body, which is as American as apple pie. The effort to biologize racial differences has a long history in America. It is built upon the seemingly innocuous but flawed idea that race has a scientific basis, which can account for the differences between Blacks and Whites. From the eugenics movement in the early 1900s to the controversial Black heart medication, Bidil, assigning biological significance to race is routine in America. Interestingly, members of the Black Panther Party were keenly aware of this and fought Governor Ronald Reagan’s effort to form the Center for the Study and Reduction of Violence at UCLA in 1973. The Party feared that the center would simply be a vehicle through which researchers could find ways to assign biological relationships between race and violence.7
Biologizing race gives credence to the notion that adverse outcomes are somehow predetermined and hardwired into the genetic makeup of black people. This becomes problematic in medical research because it makes it easier for many investigators to minimize the effect of structural racism.8 As a result there is a missed opportunity for true elimination of health care disparities.
As more studies document racial disparities in health care, it is becoming increasingly clear that a significant amount of racial disparities may have nothing to do with biology, but are a result of inherent bias within the health care system and society at large.
While measuring race is important in highlighting disparities, race alone cannot fully explain poor health outcomes. Health outcomes are more strongly determined by societal factors such as poverty, proximity to healthy food, community safety, access to decent education, and access to physicians—all of which are reinforced by structural inequities due to racism. It should be unsurprising that a person’s zip code is a better predictor of their health status than just about any other factor, including race.
As we continue to become more sophisticated in our understanding of science, medicine, and genetics, we cannot discount our tendency to overlook the ubiquitous and insidious effect racism continues to have on the health outcomes of millions of Americans. Racism must be part of the dialogue when discussing racial health care disparities. I look forward to the day that we stop describing health care disparities and finally start designing successful interventions to do something about them.9
References:
In: Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC)2003.
"Roadmap to success": AHRO reports on quality, disparities, and the state of American healthcare. Qual Lett Healthc Lead. 2004;16(2):10-12, 11.
Moy E, Dayton E, Clancy CM. Compiling the evidence: the National Healthcare Disparities Reports. Health Aff (Millwood). 2005;24(2):376-387.
Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients' preferences on racial differences in access to renal transplantation. N Engl J Med. 1999;341(22):1661-1669.
Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med. 1996;335(11):791-799.
De Lew N, Weinick RM. An overview: eliminating racial, ethnic, and SES disparities in health care. Health Care Financ Rev. 2000;21(4):1-7.
Nelson A. Body and soul : the Black Panther Party and the fight against medical discrimination. Minneapolis; London: University of Minnesota Press; 2011.
Gee GC, Ford CL. STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions. Du Bois Rev. 2011;8(1):115-132.
Lurie N. Health disparities--less talk, more action. N Engl J Med. 2005;353(7):727-729.