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Systemic Racism Produces Public Health Crisis

Systemic Racism Produces Public Health Crisis

Racism is not just an affliction of the mind and heart. Rather, racism, or should I say systemic racism is a public health crisis. One area that receives a great deal of attention is death by policing. 

Michael Brown, Eric Gardner, Sandra Bland, Freddie Gray, Philando Castile, Breonna Taylor, and George Floyd. The names that I just listed off are the names of Black Americans who have had their lives cut short due to the actions of the police. Those who are here to “protect and serve.” The truth is, for Blacks, policing in America is not a story of protection, but of harm. The state sanctioned violence perpetuated by the police on Black bodies has been very costly. Indeed, a recent study published in the Journal of Epidemiology & Community Health shows that a disproportionate number of total years of life lost due to encounters with the police were experienced by Black and Brown folk. 

Now as a Black man, this is not surprising to me. This is not news. And I would reckon that for many, if not all of you, that this is not news. The reality is, violence against Blacks is not the exception, it is the rule. Indeed, violence against Blacks in the United States is as American as apple pie and baseball. However, it is important to understand the there does not exist one institution in our society that does not perpetuate violence against Blacks. The focus on police brutality is justifiable, but ignoring the other sources of violence can have deadly consequences.

You were likely able to identify the faces listed on the previous slide. They received quite a bit of attention. And indeed, the protests that we are seeing today across this country are due in large part to the violence caused to the Black community by the police. But Kira Johnson, the woman pictured here with her husband and infant child, was not killed by the police. She died shortly after delivering her second child. She died in the hospital. She died after receiving inadequate care from those who swore to “do no harm.” 

Now, it is important to say that maternal death is not unique to Black women. In America, we have a higher rate of maternal mortality than in countries like Iran, Turkey, and Kazakhstan. However, as with many outcomes, we find that Blacks are hit hardest. The director of the Centers for Disease Control and Prevention’s Division of Reproductive Health, Wander Barfield, stated quote: “A well-educated African American woman with more than a high school education has a five-fold risk of death compared to a white woman with less than a high school education.” This is not a matter of class. This is a matter of race. The Institute of Medicine published Unequal Treatment that focused on the racial disparities in health outcomes. 

Maternal mortality is but one outcome. Obesity, breast cancer, diabetes, cardiovascular disease. These chronic diseases disproportionately impact Blacks. They are more common, and they are more deadly for people with Black skin. We currently see this with COVID-19.

This chart shows the proportion of Blacks in several states, and also shows the proportion of COVID-19 cases that are Black. Across each of these contexts, we see that a disproportionate number of Blacks are afflicted by this disease. I might add, that they are also more likely to suffer from severe illness. In general, Blacks die quicker and live sicker than whites. 

So why do we see this? Why is race such a profound determinant of one’s health? Biological distinctions between Blacks and Whites have been debunked, though the idea is still alive in well in the American consciousness. If we conclude as social and medical scientists have, that race is indeed a social construction, then racial inequities in health are socially constructed as well. 

Often you will hear that racial disparities in health come down to differences in health behavior across racial lines. Take Type II Diabetes, for example. Eat well, exercise, visit the physician regularly, and you will be able to prevent this chronic disease. The idea here is that one’s health outcomes is the product of their individual choices, so if one is sick, it is because they failed to take proper action to keep themselves healthy.

In the context of racial disparities in Type II Diabetes, given that Blacks are more likely to suffer from the disease, what that would mean is that Blacks are predisposed to make unhealthy choices thus leading to higher prevalence of the disease. Educated folks tout this position all of the time. Included the Surgeon General of the United States, Dr. Jerome Adams.

We will return, briefly to COVID-19. When Adams was speaking to reporters and addressing the fact that Blacks are hit harder by the virus, his advice was that blacks should avoid alcohol, drugs, and tobacco. Excellent advice, however this advice fails to acknowledge the fundamental cause of these health related behaviors. And in so doing, it hides the role that systemic racism plays in shaping the health and wellbeing of African Americans.

Now it will be foolish to think that our individual actions have no connection to health. They do. However, any real analysis of health behaviors would be incomplete if we did not consider the social contexts in which people are embedded. A classic idea in sociology is that we as individuals have agency. However, our social structures both permit and constrain our agency. We can eat healthily, but how do we accomplish that if we have the misfortune of living in food deserts, which, by they way, is the reality for a disproportionate share of Blacks. We can visit the physician, but how can we do that without adequate health insurance?

Medical sociologists turn to what is referred to as fundamental cause theory, which argues that our health behaviors, these so called proximate determinants of disease, are influenced by more distal causes. And the reality is that in America, race, or more appropriate to say ‘racism,’ is a fundamental cause of poor health in America. Redlining, residential segregation, housing discrimination, all of these policies meant to keep Black folk out of well-resourced communities has contributed to an environment, a context in which many Blacks find themselves unable to engage in the very things that may save their lives. Racism is a fundamental cause of poor health. In order to address the inequities, racism must be abolished.

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I want to turn my attention now to medical care providers. As a macro sociologist, I pay a lot of attention to social structures and tend to not really care about what goes on in people’s heads. However, I have enough knowledge of social psychology to be able to discuss the process by which individual physicians and healthcare providers more broadly fail to uphold their oath to “do no harm” to their Black patients. 

This medical racism has deep roots.

J. Marion Sims, regarded as the Father of Gynecology, regularly experimented on slave women in the mid 1800’s. Operating on them without consent and without anesthesia. These experiments were justified because Blacks were viewed as inhuman.

More recently, the government’s commissioned Tuskegee Syphilis Study ended only in 1972 targeted Blacks in the south, withholding effective treatments for syphilis among Black patients to see how the disease progressed. Of course, it is difficult to see how this act could be carried out on fellow human beings. The solution? Blacks are inhuman.

Flash forward to today. Black bodies are deemed biologically different than their white bodies. A 2016 study conducted by Hoffman and colleagues found that a majority of white medical professionals held the belief that blacks have a higher threshold for pain. That they are biologically stronger. The study went on to find out that these false beliefs lead to differences in pain treatment and management across racial lines. Specifically, physicians tend to underestimate the pain experienced by Black persons which leads to under treatment and the subsequent suffering of Blacks. This bias combined with views of Blacks as susceptible to addiction and media representations of Blacks as drug addicts and dealers is partly responsible for the reluctance of medical professionals in subscribing effective pain medications to their Black patients.

Pain is the way that the body communicates to us that something is wrong. It helps us to avoid harmful situations. But if that pain is not recognized by those trained to heal us and make us well, pain is just uncomfortable and debilitating.

If we return to Ms. Kira Johnson, she experienced excruciating pain which was ignored over and over again by physicians. By the time they addressed her issues and proceeded with an operation, they found her abdomen full of blood and were unable to save her life. Had she been listened to, had her pain be taken seriously, perhaps she would still be here.

To be clear, I do not believe that all physicians are racist. Excluding, of course many of the founding fathers of modern medicine. Moreover, the implicit bias or unconscious bias that leads to this disparate treatment is just that, unconscious. However, the long standing view that Blacks are less than human, the outright refusal of Whites to recognize the humanity of Black people has put us in a situation where the medical institutions are failing to heal and care for Black people.

What is the solution?

Dayna Matthew’s book Just Medicine: A Cure for Racial Inequality in American Health Care primarily focuses primarily on legal solutions, for example easing the burden of proof on plaintiffs attempting to prove implicit bias and negligence on the part of their physicians. However, this book also addresses structural solutions and changes in medical training. We know what we have to do. If we were to eliminate residential segregation, we would get rid of Black-White differences in education and income, resources important for maintaining health. Research indicates that first year students hold less implicit racial bias than fourth year medical students, but by the time they complete their medical training, the difference disappears.

What does this say?

Well it says that there is something about medical school and training that acculturates and socializes physicians into adopting harmful attitudes and biases toward their Black patients. And it is important to note that these implicit biases are present even in Black physicians. So simply diversifying health care providers does not fix the problem. We must change the institution of medicine which perpetuates racial bias.

But this takes work. This takes advocacy. It takes protests, donations, voting. It also takes outrage. Outrage at the status quo and the belief that things should be better. But change will not come from Black outrage alone. It is crucial that White folk use their privilege to help change these institutions. It is not enough merely to know about these inequities and health. It is not enough to share a Tweet or Facebook post. Changing this system requires active engagement. It requires a commitment to anti-racism, the active dismantling of systems of oppression. It starts with reparations where the economic and living environments for Blacks are made equal to their more privileged peers. It requires a revamping of medical training that focuses on reducing implicit racial bias, or at least preventing implicit biases from manifesting as differential treatment. Only then will we be able to live in a society where physicians can truly claim that they are upholding their Hippocratic oath. Only then will we be able to mitigate racisms role in the ongoing public health crisis.

Dr. Kyler Sherman-Wilkins