Racism and health: the life expectancy gap

Since the national election of 2020, racism at the polls has become a hot topic that Democrats hope soon to remedy with the election reform bill, H.R.1. I imagine many health care practitioners are wondering what is wrong with so many of our political leaders that they can promote laws restricting voting access disproportionately to people of color. Surely, if they took a look at how we handle things in the world of health care, they would learn a thing or two about racial equity. Right?

Actually, not so much. It turns out that when it comes to racial disparities, we in health care have a lot of work ahead of us. How about this for a defining metric? When I was born, my white male life expectancy was six years greater than that of a Black male born at the same time. Six years! After fifty years of racial “progress,” the gap remained exactly the same. Six years.

It appears that being Black is just as bad for your health as being a smoker. Must be a genetic thing, right? Guess again. Although white and Black people have different genetic risks for different diseases, the gap in overall life expectancy is not explained by heredity. It’s due to a myriad of social factors, such as socioeconomic deprivation, harmful environmental exposures, inferior health care, and even to bias in treatment by well-meaning clinical providers. In other words, to racism. Let’s take a look at the facts, starting with COVID-19.

The pandemic is continuing to ravage the country, with more than a half-million Americans dead so far. When we look closely at the numbers, though, we find evidence of something even more troubling. Black Americans are dying from COVID-19 at about 3.6 times the age-adjusted rate of white Americans. More than triple the mortality risk.

We should not be surprised that racial disparities appear in COVID survival. After all, Black adults are more likely to die from heart disease, strokes, and breast cancer. Black mothers are more likely to die in pregnancy and childbirth. And Black children are ten times as likely to die from asthma. Believe me, nothing puts a crimp in your life expectancy like dying in childhood. As the CDC puts it, “African Americans are more likely to die at early ages from all causes.” That really doesn’t sound like a genetics thing, now does it?

Which brings us to the pain point: the health consequences of individual bias. Let’s start with heart disease – still the number one cause of death in America. If you have coronary disease, you might need a diagnostic procedure called a cardiac catheterization, but Black people are less likely to get this than white people. And if they do get it, they are less likely to receive treatment of the obstruction. A multitude of studies have demonstrated this bias.

The clincher was an ingenious study done at a hospital in Cleveland. They created a committee of physicians who would review every cardiac case to decide if catheterization was required. The members had access to every piece of information about the patient except one: their race. When decision-makers were blinded to the patient’s race, the race bias disappeared. So, if I don’t know that you are Black, I will give you the same treatment that white patients get.

Are there any other examples of a racial health disparity? Oh, my goodness! There is a vast body of research on this topic and it all points in the same direction. Doctors and nurses treat patients differently based on nothing more than their race, and it puts Black people at a severe health disadvantage. This bias has been demonstrated in a host of conditions: congestive heart failure, pneumonia, lung cancer, childhood asthma, cardiac procedures, psychiatric diagnosis in adolescents, colon cancer treatments, the use of clot-buster drugs, hip and knee replacement surgery, treatment of Medicare patients, cancer research, provision of kidney transplants, the doctor-patient relationship, treatment of HIV, diagnosis of schizophrenia, screening for breast cancer, treatment of dialysis patients, use of psychiatric medications. treatment of pain in the emergency department, and life-saving treatment in the ICU, among many others.

Is there any nook and cranny in our world of medicine where health care professionals practice without racial bias? It doesn’t seem so. In fact, this is one of the most well-proven conclusions that I have ever seen in my evidence-based medicine career. With this much bias, I am surprised that Black people even make it to adulthood!

And what is especially notable is that most doctors and nurses are not trying to be racist, and would be shocked to learn they behave this way. This is a great example of subconscious bias and it is widespread and potent. Even more painful is the realization that I am not immune to this subconscious bias and must have surely practiced this way myself. It is a hard truth to accept. Yes, we may say that all lives matter, but we don’t behave, most of us, as if Black lives matter, whether we realize it or not.

Is there anything we can do about this? Well, for starters, we can get off our high horse about those racist politicians. We can come to terms with the subconscious racial bias that affects our behaviors and permeates the health care industry. And we can make racial equity a major priority for our work.

And we have a wonderful metric for our progress. When the six-year life-expectancy gap melts away, when a Black baby boy or girl has the same shot at living to a ripe old age as a white child, then we will know we have climbed the mountain. Let’s climb it together.

Nate Link is chief medical officer, Bellevue Hospital, New York City, NY, and author of  The Ailing Nation: Lessons from the Bedside for America’s Leaders.

Image credit: Shutterstock.com

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