Alessia Caputo, Federica Franceri
Abstract
Why do African-Americans have a death rate that is 1.6 higher than white people? Why are they disproportionately affected by many of the leading causes of death such as heart disease, stroke, cancer, hypertension, and obesity? If you do not have an answer, just keep reading.
The article disentangles the several causes of racial inequality and discrimination in healthcare systems today. From income inequalities to neighbourhood segregation, from implicit bias to measurement errors, racism is known to be systemic in American society. Inequalities in Socio-economic status (SES) conditions often translate into disparities in health outcomes among ethnic groups. Furthermore, the health care system seems to be inclined to systematic bias in medical professionals and technology. Addressing those inequalities and racial biases is a necessary effort to improve the overall health of the society, as well as ensuring equal treatment for all people.
According to the Oxford Dictionary, racism is defined as “prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is a minority or marginalized”. In other words, racism is the ideology that justifies the unequal treatment of specific categories of individuals that are judged to be inferior. Williams (1999) argues that “this ideology of inferiority may lead to the development of negative attitudes and beliefs towards racial outgroups (prejudice), but racism primarily lies within organized institutional structures and not in individual attitudes or behaviours”
Today, even by only reading the news or retracing the country’s history, it is unequivocal how racism is a systematic feature of American culture, with repercussions on people’s well-being and physical health. Furthermore, in the middle of a public health crisis that collides with numerous protests for racial justice, these concerns are real and should be addressed as quickly as possible.
Why so?
The impact of racism on health outcomes
Data and research have shown that health and inequalities are interconnected. Psycho-social status hierarchies and relative, rather than absolute, income disparities are some of the determinants explaining this relationship. It is important to notice that individual income should not be viewed only with reference to money. Indeed, it is a broader category, which also embraces the individual's ability to fully participate in society and to have control over his or her life (Marmot, 2004). Sen (1992, cited in Marmot 2004) claims that it is more relevant what we are capable of doing physically, psychologically, and socially with the income rather than the amount of income we have.
Systematic racism impacts health outcomes through income inequalities, social stratification, and psychological factors. Some estimates show that white families have the highest levels of both median and mean incomes and wealth, while Black and Hispanic families are considerably poorer. Data from the Board of Governors of the Federal Reserve System highlight that in 2019, median and mean wealth of Black families is less than 15% that of White’s (respectively $188,200 and $983,400 for White families vs $24,100 and $142,500 for Black ones).
Thus, the main wealth gap between these ethnicities remains evident. Indeed, systematic racism has constrained socioeconomic achievements by limiting access to education, employment opportunities, and active participation in society. A consequence effect of these aspects is residential segregation. Diez-Roux and Mair (2010) stressed that, because the place of residence strongly rests on social position and ethnicity, neighbourhood features could be important determinants of inequalities in health. The Multi-Ethnic Study of Atherosclerosis Neighbourhood showed that lower levels of social cohesion, aesthetic quality and higher levels of violence are associated with higher levels of depressive symptoms in a large sample of adults. As a consequence, since ethnic minorities live, on average, in impoverished and poorly equipped neighbourhoods, residential environments impact health outcomes and penalize African-Americans.
Despite the huge improvements in narrowing down the life expectancy gap between Black and White Americans thanks to safety-net programs and improved access to health facilities (Schwandt et Al. 2021), according to the New York Times in 2020 Hispanic and Black Americans experienced a steeper drop in life expectancy fuelled by the Covid-19 pandemic.
Still today, African Americans (or blacks) have an overall age-adjusted death rate that is 1.6 times higher than that of the white population (Williams, 1999).
Neonatal mortality is another commonly used measure of racial disparities in health in the United States. A study conducted by Hauck, Tanabe, and Moon concluded that black infants are 2.5 times more likely to die in infancy compared to non-Hispanic white new-borns. Also, according to the CDC, black mothers in the U.S. die at three to four times the rate of white mothers from any cause related or aggravated by pregnancy and its management (NPR, 2017).
Understanding discrimination in healthcare settings is particularly important for different reasons. Firstly, the healthcare sector has the moral obligation to provide equal care to patients regardless of their ethnicity, gender, sexual orientation, etc. Secondly, poor healthcare provision may undermine patients’ trust in the system, negatively affecting the health of the entire community. Thirdly, quoting Wilkinson & Pickett (2009), “national standards of health are substantially determined by the amount of inequality in society” It is, therefore, necessary to take the second factor into account as a social determinant of health when designing targeted policies to improve a country's health.
Through which channels does racism translate into poor health outcomes?
It goes without saying that eliminating racial and ethnic biases is essential for an equal and safe service, that actually deals with the problem of poor health outcomes among ethnic minorities. But this is easier said than done.
First of all, racism is systemic in many American environments, including the workplace: healthcare professionals’ behaviour may be driven by partisan attitudes towards different racial and ethnic groups. Too many physicians today have explicit puzzling reactions towards black people. As a result, they treat these patients with condescension, as if they are less likely to respond positively to medical care (Tello, 2017). Secondly, even when the physician is not explicitly or consciously racist, some implicit biases stemming from subconscious prejudices come into play (Tello, 2017).
By definition, implicit attitudes occur outside individuals’ awareness and are consequently difficult to acknowledge and control. The problem occurs when racial and ethnic biases lead to unconcerned prejudicial behaviour, such as voice tone while approaching patients or shorter diagnoses that will perpetuate inequity and discrimination. More in detail, actions that result from biases “compromise quality of care through error, miscommunication, no referral or inappropriate referral to specialty care or medical procedures, and misdiagnosis of medical conditions” (King & Redwood, 2016). This means that while public avoidance of explicit action could symbolize an attempt to solve disparities, latent outlooks will, despite unintentionally, keep the problem alive.
Still, poor health outcomes among ethnic minorities do not only stem from the systemic racism that affects US society. They are also the result of measurement errors that lead to misguided clinical decisions.
Two years ago, the New England Journal of Medicine published a study that proved how the pulse oximeter overestimated the blood-oxygen saturation more frequently in black people than white. Healthy human-being should have a blood saturation of 92-96%, but some of the patients who participated in the study on the accuracy of the oximeter had real saturation, measured with arterial blood gas, of 88%. In particular, for black participants, incorrect diagnosis happened 12% of the time, at a rate three times larger than white participants. Michael Sjoding of the University of Michigan, the study’s leader, observes that this number can often make the difference between being or not admitted to the hospital. It follows that this concern becomes particularly relevant during a global pandemic for pulmonary infectious disease.
The device works by passing two beams of light, one red and one infrared, through the tissue of the finger they are clipped to and then calculating the amount of absorption of each lightbeam. Oxygenated and non-oxygenated blood absorbs the light differently, but the measuring process must be calibrated for all skin types. Dark skin absorbs more light than white skin, thus weakening the signal.
Yet, the pulse oximeter is not the only example. A study on Science by Obermeyer et Al. (2019) demonstrated the presence of a racial bias in an algorithm used to allocate medical resources to those in need. The US health system heavily relies on commercial algorithms to help patients with complex pathologies, but results show that this specific computation for funds exhibited systematic racial bias. Indeed, the software gave white people priority over black people as funds were allocated according to prior medical expenses used as a proxy for medical needs. Given the unequal access to care and lower expenditure levels of African-Americans compared to white people, black patients with the same requirements as other white patients were disadvantaged by the algorithm.
Of course, these cases do not fully capture the complexity of the issue. However, the big picture is that medical staff and technology should be respectively trained and designed to be free from racial biases. It follows that all kinds of race labels must be rigorously disrupted and eliminated from our institutions for better clinical practices. If the race is “not only buried but buried alive” (Duster, 2003) in the cornerstone of medicine, then we have to start digging. It all starts from acknowledgement.
References
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