Sometimes structural racism surfaces in a way that even those of us who would like to be “color-blind” cannot help but see.
In the spring of 2020, the video-recorded death of George Floyd (who was Black) at the hands of a law enforcement officer (who was white) brought millions of witnesses to the kind of hostility that is all-too-familiar to individuals of color. Individuals, many non-white, took to our nation’s capital in protest; there, they met a clear demonstration of force by individuals in military garb. In the fall of 2020, our presidential election included legal votes from a larger proportion of individuals of color than ever before. False cries of fraudulence ensued. On January 6, 2021, a group of individuals, many white (some carrying the flag of the explicitly racist Confederacy), breached our nation’s actual Capitol Building to protest the election. Congress was in joint session, presided over by the vice president. The individuals met many fewer, less severe immediate consequences than would seem justified.
As Roxanne Jones writes in an opinion article, “To be Black in America is to live with constant trauma … Black folk across the nation watched that siege and we knew in our souls that had those rioters been Black they would have faced deadly force long before they got inside …”.
Decades of robust evidence point to disparate health outcomes, with worse Black and Latinx outcomes than for white patients. We work to add some sensitivity trainings, but health care delivery remains largely unchanged – and biased. Once privileged eyes learn to see structural racism, it becomes visible in the very fabric of our institutions, even the ones grounded in “objective science.”
When I was an intern, one of my clinic supervisors first-authored a study finding differential recommendations by experts regarding acute coronary chest pain interventions in a simulated setting. Even in clinically identical situations, men of color and all women were statistically less likely than white men to receive the best evidence-based treatment. I recalled lessons about lifestyle factors and biological predispositions, but they were at odds with this clear evidence of broad, race-based decisions that could harm patients.
Many years later, reviewing data for a quality improvement project, I found evidence that Black and Latinx patients were more likely than white patients to be treated in the emergency department’s special locked area and transferred to the state mental hospital. The optics of this segregation in medical care are disturbing on a number of levels. I looked at that evidence and saw structural racism, and I called attention to it. It should not have surprised me (and clearly would not surprise individuals aware of these disparities throughout their lifetimes) that “It’s hard for people to accept that you are calling them racist,” and “Those differences may not be statistically significant” were common responses.
It would be tempting—and we may have absorbed lessons that give us permission—to cite biological or “sociocultural” differences as reasons for which individuals of color are more likely to have hard-to-treat psychosis or higher rates of underinsurance. We can reassure ourselves by citing higher rates of violence among Black individuals and then correlating violence with mental illness. However, such explanations only perpetuate myths that fly in the face of decades-old evidence of clinician bias. Even with validated diagnostic criteria, we are more likely to diagnose individuals of color with schizophrenia and white individuals with bipolar disorder. We are more likely to assign Black and Latinx children diagnoses of psychosis and behavioral disturbances than white children. We are giving our patients of color diagnoses that carry worse prognoses – and creating a self-fulfilling prophecy.
Ironically, physicians or diagnosticians without the lens of history may assume that expressions of well-earned distrust are actually delusions or psychotic symptoms. Medical mistrust, prevalent among individuals of color, is an important contributor to health disparities. For decades, the infamous Tuskeegee Study assessed the natural history of syphilis by lying to Black enrollees about (not giving them) treatment. According to Rebecca Skloot’s The Immortal Life of Henrietta Lacks, her cancer cells were cultured and marketed for others’ profit. Harriett Washington’s book Medical Apartheid details many egregious aspects of medical treatment endured by individuals of at the hands of the American medical system. It is a wonder that any individual of color feels safe with any physician trained in our institutions.
How does systemic racism influence individual patients? Is it real? A young Black man needs limb-salvaging surgery and attention to wound care but is discharged against medical advice, to the relief of unit staff who misinterpret his bipolar mania as the aggressive sociopathy of an angry Black man. A middle-aged Black man in needs amputation and is scared and angry; instead of recognizing predictable expressions of grief, the team interprets anger and refusal to sign consent. Harm ensues. Would treatment of my (white) male family members be the same? Unfortunately, I really doubt it – and this answer outlines exactly the kind of distrust we have earned in health care as well as in society.
It is not enough to say we are anti-racist; we have to modify our systems to recognize that we have placed individuals of color at risk of poorer outcomes. Lack of insurance, lack of finances, or even the presence of certain diagnoses may reflect less about the person and more about our society, our infrastructure, and our systems. As members of smaller communities and a larger society, we must make adjustments in our attitudes and knowledge as well as the services we provide to individuals who have experienced harm by insidious but ever-present racist structures.
Glaring disparities in treatment aren’t only happening in protests. They are happening in all of society, and in our hospitals. Only when we address systemic racism will we be able to realize the ethical imperatives of safe and equitable health care for all.
The views expressed here are my own and not those of my employer.
Jane Gagliardi is an internal medicine physician and a psychiatrist.
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