Dissecting systemic racism in health care

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A couple of months ago, I had a lecture on the “Principles of Epidemiology and Public Health.” I remember looking at the graphs taken from the American Heart Association and noting that the incidence of developing coronary heart disease or myocardial infarction was higher in black men compared to their white counterparts. I thought to myself, “So this means that race is a risk factor in heart health.” At the time, I took the information that was presented to me at face value and didn’t bother reading further or asking myself why that was the case. I finally realize that maybe race isn’t a risk factor after all, but racism could be.

Higher premature mortality rates in the black community aren’t due to an inherited genetic flaw present in people of African descent, but rather a result of institutionalized racism present in the health care system. This may be because the health care system was built on an ideology designed to disproportionately discriminate on the basis of race. Credible institutions such as the American Heart Institution suggest the slavery hypertension hypothesis as a possible link to higher blood pressure in African-Americans. This theory argues that Africans have evolved to inherit genes that favor sodium retention to survive in the dry climates of their original habitat, but enhance underlying pathology when they migrate. However, pathophysiological data has shown that salt-resistant individuals retain just as much sodium as their salt-sensitive counterparts, but do not develop hypertension. Moreover, having higher sodium levels is not enough to cause hypertension alone. This shows that genetic explanations for health disparities between races stem from a racist ideology. Furthermore, by grouping certain disorders with certain races, physicians may implicitly employ racial signifiers that can lead to falsely diagnosing pathologies.

Biological racism persists in almost every field of medicine. The glomerular filtration rate (GRF) is a measurement used by clinicians to assess renal function and diagnose kidney-related diseases. The GRF is estimated through equations such as the CKD-EPI and MDRD, which take into account factors such as sex, age, weight, serum creatinine, and race. Including a racial coefficient to calculate the GFR is problematic because it estimates that the GFR is closer to normal for a black person compared to a white person of the same age, weight, and creatinine level. This creates a lower disease severity for black people, resulting in them being diagnosed with end-stage renal disease much later than their white counterparts, leading to higher disease mortality. Race is used in these equations as a proxy for muscle mass (crucial for estimating creatinine levels), without a concrete explanation for why race may be related to an individual’s muscle mass. Why can’t medical students be taught how to calculate muscle mass instead of using equations embedded with medical racism?

In a statement made by black neurosurgeons in the U.S. regarding the outrage and unrest reflected in recent protests, it is made evident that racism is a public health crisis. Through anecdotal evidence, they highlight a vicious circle in which members of the black community are intentionally subjected to neurotrauma, causing death or damage to the brain or spinal cord, which can result in a life-long commitment to surgical procedures. This widens the pre-existing socioeconomic gap by increasing unemployment rates and limiting access to insured health care in the black community. This made me wonder if biological hypotheses for racial disparities in health were a cover-up for a much bigger issue, i.e., the public health system.

Take the COVID-19 pandemic. During this time of uncertainty and unpredictability, one thing has been certain in the U.S. health care system: Black lives are being lost at a disproportionate rate. African-Americans make up 13 percent of the U.S. population and account for 24 percent of COVID deaths where the race is known, a rate that is two times higher than their population demographics. However, these statistics are not surprising for many researchers. Dr. Marcella Nunez-Smith, who is the director of the Equity Research and Innovation Center at Yale School of Medicine, states that these COVID-19 racial disparities were “expected” and a result of “pre-pandemic realities.” This makes it apparent that the black community was already at a disadvantage prior to the start of the pandemic.

The system was intricately built to put certain races at a disadvantage, so the first step in dismantling racist policies and practices would be to educate medical students about it. Since we are the future of health care, it is our duty to better the system for our black patients. One way of doing this would be by revising what is taught in medical schools. Instead of implying that Africans are genetically inferior, we should be taught about the racial bias that stems from this hypothesis and how it may negatively affect our patients. In a study published by PNAS in 2016, it was found that about half of the medical students and residents endorsed false beliefs about biological differences between black and white patients, such as “black people’s skin is thicker than white people’s skin,” resulting in a flawed assessment of pain perception and treatment in black patients. This shows us how rooted racial biases may result in inaccurate treatment outcomes. In order to uproot these biases, medical trainees must be taught to recognize and address them first. The willingness to learn and revise our beliefs will bring us one step closer to vanquishing racism in the field of medicine.

If I could simplify it to one equation, this is what it would look like: lack of access to quality health care + social inequities + higher mortality rates + underrepresentation in health care jobs + genetic explanations for biological inferiority + unimportance of acknowledging racial biases medical school curricula + using race as a risk-factor = systemic racism in health care.

It’s time to change the equation. Let’s start to view race as a social construct, not a biological one. Let’s develop plans to address the social determinants of health and prioritize equal access to health care for everyone. Let’s raise awareness about systemic racism in health care and confront racist policies. Let’s educate medical students about racial biases and the impact they can have on patient care. Let’s start having conversations that make a difference. Let’s aim for health equity.

So the next time medical students look at graphs of the incidence of developing heart disease, they do not just see race as a risk factor but instead understand the structural racism from where it stems.

Rhea Raj is a medical student and can be reached on Twitter @rhearaj123.

Image credit: Shutterstock.com

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