Why physicians should care about structural racism

This year marks the 50th anniversary of the passage of the Fair Housing Act, which formally outlaws racial discrimination in the sale and rental of housing. The Act, passed in the wake of the assassination of Dr. Martin Luther King Jr., had, at its core, the goal of affirmatively promoting equitable and integrated housing across the United States.

Earlier this year, however, the current presidential administration announced that it would suspend an Obama-era extension of the Act, one that would require communities to support housing desegregation in addition to barring discrimination.

The administration’s actions are in line with prior remarks made by current Department of Housing and Urban Development Secretary Ben Carson, who has described attempts at promoting affordable, desegregated housing as “experiments” in “social engineering” that “often make matters worse.”

As a physician, Dr. Carson should know better. Rather than making matters worse, policies aimed at alleviating racial disparities in housing represent some of the most effective ways we have of combating structural racism and its attendant health consequences.

The term “structural racism” (also called institutional or systemic racism) refers to a set of formal and informal policies relegating a certain racial minority to an underprivileged status within society. It functions to preserve the unequal racial status quo through laws, norms, and social institutions.

In the United States, structural racism against blacks is rooted in the practice of slavery. But even after abolition, blacks in the United States have been subjected to various forms of exclusion. And nowhere is this more evident than in the area of housing. Inequalities in where — and how — blacks and whites live persist to this day, and they reflect our country’s deepest racial divides.

The fact is, as a consequence of decades-long, government-sanctioned discriminatory practices in real estate and lending, blacks in many metropolitan areas continue to reside under conditions of persistent segregation and concentrated poverty.

And as many others have written, when it comes to health, your zip code is, in many ways, more important than your genetic code. It is through this lens that we can understand structural racism’s relationship to health.

Large-scale studies have revealed, for instance, associations between racial segregation and systolic blood pressureobesity, and cardiovascular disease — associations that persist even after controlling for family income and neighborhood poverty.

Moreover, black families are more likely to reside in shoddy, poorly-maintained housing. Many black families, as a consequence of where they live, are less likely than the overall population to be able to access critical resources such as clinics and grocery stores. And, as the water crisis in Flint, Michigan illustrates, black communities are exposed to harmful environmental pollutants at alarmingly high rates.

What are the implications of these findings for the medical profession? One answer is that the corrective measures that seem to be recommended most often, such as implicit bias training and increased diversity in the healthcare workforce, don’t go far enough.

These interventions, though well-meaning, ignore the historically grounded underpinnings of black-white health disparities in this country. Health is intricately related to place, and in the United States, place is very much related to race.

It’s time for clinicians — specialists and generalists alike — to abandon their misguided assumptions. Enduring health disparities between blacks and whites in the United States are not simply the result of interpersonal racism (e.g., prejudiced treatment of a black patient by a white physician). Nor are they, as some continue to believe, due to purported genetic differences between blacks and whites.

They are the result of structural racism.

We must begin to regard residential segregation, inadequate housing, and neighborhood disadvantage as treatable — even preventable — health exposures.

In the clinic, all physicians can implement screening tools to interrogate our patients’ housing needs. At the state level, physician organizations can lobby for Medicaid to expand its scope to include residential support. And when it comes to deciding how federal research dollars are spent, we must be vocal: channel funds into studies examining the effect of targeted housing interventions on marginalized populations’ health.

Famed civil-rights activist Stokely Carmichael stated that, compared to other forms of discrimination, structural racism “is less overt, far more subtle, less identifiable in terms of specific individuals committing the acts, but is no less destructive of human life.”

Longstanding racial inequities in housing constitute a potent form of structural racism with measurable effects on health; the current Administration’s political rhetoric notwithstanding, it is incumbent on our profession to work toward dismantling them.

Akshay Pendyal is a cardiologist and can be reached on Twitter @APendyal_MD.

Image credit: Shutterstock.com

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