It’s time to acknowledge the role of racism in medicine in the United States. It’s not just the racism of George Floyd that we witnessed on video at the hands of police, it’s the daily traumatizing experiences of Black Americans at our hands as well in the US healthcare system.
While most physicians and other clinicians do not think of themselves as racist, we operate in an inherently racist system, known as structural racism. Structural racism has been defined as the “confluence of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups,”1 as I learned from Hardeman et al. in the New England Journal of Medicine.2 I am grateful that the tumultuous days since George Floyd’s murder have reminded me of racism, as measured by health inequities, in our practice of medicine.3
Despite our best efforts as clinicians, we are confronted by disparate outcomes for different races in nearly all areas of chronic disease. Here are just a few:
- Black people die of Covid-19 at 3.57X the rate of White people. Latinx are at 1.88X.4 Learn more at covidtracking.com/race, which is a collaboration between Ibram X. Kendi, his Antiracism Research Center, and others5—they collect, analyze, and publish data daily from the US.
- Blacks are 3X more likely to get their limbs amputated. A recent article highlighted the limb preservation efforts of Dr. Foluso Fakorede, while shining a troubling spotlight on the racial disparity that exists among those afflicted with this peripheral artery disease (PAD). Dr. Fakorede is on a mission to reverse the high number of amputations in the Mississippi Delta region where he runs his private practice. Racial disparity is evident in the rates of PAD and related numbers of limb amputations. PAD is often a complication of diabetes—and Black people are 1.4- to 2.3-fold more likely to be diagnosed with diabetes compared to White Americans and twice as likely to die. Amputations are probably one of the most preventable surgeries in the U.S. Across the US, the mean risk of amputation is 2-3 per 1,000 patients with diabetes and PAD, but the rate is up to 8X higher in specific places.6 But it’s not only medical reasons that factor into the higher amputation rates among African-Americans. Race does, too.7 Several studies point out this fact; one in particular states, “Non-medical factors—primarily socio-economic and geographic factors, such as race and where patients live—can have a dramatic impact as well on amputation rates,and Black patients with diabetes are at the highest risk for amputation.”8 According to THE SAGE GROUP, a leader in PAD research, “The probability of undergoing major amputation depends on who you are and where you live.”
- Black people have double the rate of Alzheimer’s disease.9 When you divide risk based on genetics, it’s different. Among non carriers of APOE4, Blacks had 2.3X the AD risk. Among carriers of APOE4, risk was not significant. When investigators looked at cognitive decline, years of education accounted for a large portion of disparities in cognition—again, part of the systemic injustice that we need to identify, dismantle, and rebuild. Meanwhile, let me ask how many Black physicians, researchers, and activists do you know in the fields of brain health, cognitive function, neurology, and neuroscience? know about the California Surgeon General, Nadine Burke Harris, M.D., a pediatrician, and her work with Maria Shriver on the California Governor’s Task Force with Alzheimer’s Prevention and Preparedness, but I would love to listen to and learn from more Black voices and resources in this important area.
- Black women are more likely to die of breast cancer. Breast cancer death rates in the most recent time period (2012-2016) are about 40% higher in Black women compared to White women, according to the American Cancer Society’s Cancer Statistics, 2019.10 Breast cancer affects 1 in 8 women, which is an increase since 1 in 11 in 1975. Breast cancer mortality rates have declined in White women but continue to grow in Black, Hispanic, and Native American women. In fact, death rates are 40-42% higher in Black women than in White women (DeSantis, 2016; American Cancer Society, 2019),11 even though incidence is lower (Howlader, 2016). Black women have 2X the rates of triple-negative breast cancer (an aggressive subtype) compared with White women.12 Overall, Black women are less likely to get better treatment compared with White women (Hirschman, 2007). Finally, Blacks have a 33% greater risk of dying of cancer than Whites.13 While we need to define, understand, and correct these disparities, the most recent facts and figures suggest we are making modest progress: the overall 5-year relative survival rate for breast cancers diagnosed in 2008-2014 was 81% for Black women compared to 91% for White women (CA: A Cancer Journal for Clinicians, Cancer Statistics, 2019). Recently, researchers found that lack of private/Medicare insurance and unfavorable tumor characteristics were the most important factors contributing to the higher risk of death among Black breast cancer patients under age 65 with early-stage disease, but they explained only one-third and one-fifth of the disparity, respectively.14
- Maternal mortality is 3-4X higher in Black women. Maternal mortality refers to the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes—and maternal mortality is rising in the United States in Black women.15
Racism in Medicine, Myths and Racial Health Disparities
As I’ve been posting about these health disparities and racism in medicine over the past few weeks, I am shocked by the number of comments blaming Black people for behavior or where they live. I learned from a Perspective in the New England Journal of Medicine that these comments are based on common myths. In this article, titled Racial Health Disparities and Covid-19 — Caution and Context, authors Chowkwanyun and Reed point out that when racial disparity is highlighted, we must explain the causes (or what’s not the cause but thought to be).16 They write: “Disparity figures without explanatory context can perpetuate harmful myths and misunderstandings that actually undermine the goal of eliminating health inequities. Such clarifying perspective is required not just for Covid-19 but also for future epidemics.” I learned a lot from this paper about my own biases and myth-based interpretation. As The Atlantic staff writer Graeme Wood put it: “If all we know is that disparities exist—and that is indeed all we know—then prepare for racist explanations to rush in to fill the gap.” Yep.
Chowkwanyun and Reed explain the dangers in discussing racial disparity. First, don’t jump to the conclusion that there’s biological difference, a common myth. Ms. Layla Saad emphasizes this point in her New York Times bestseller, Me and White Supremacy:17 based on the human genome project, < 0.01% of our genes are reflected in external appearance or what we talk about as race. “However, because race is a deeply held social construct and because of the existence of White supremacy, you and I are not treated the same. You hold White privilege. I do not.”
Chowkwanyun and Reed’s second point: don’t rush to assume it’s racially-driven differences in behavior. Third, don’t write it off as affecting only certain locations, i.e., Detroit, Chicago, New Orleans. Instead, we need to understand the resource deprivation associated with low socioeconomic status, stress (“weathering”) caused by racial discrimination, and place-based risk. These are public health problems. When we make the mistake of writing these health inequalities as racial, and therefore only of interest to supposed minority interest groups—policy continues to promote unstable or substandard housing, food insecurity, and unemployment. Last words to Chowkwanyun and Reed: more holistic analysis “will not only allow for more robust explanations of the patterns that have ignited so much commentary over the past few weeks, but will also guard against the dangers we have outlined here.”
Other areas of inequality include representation. Black women make up only 2% of active physicians in the United States. I looked into it further and realized that only 5% of US physicians identify as Black or African American. Yet Blacks are 13% of the population. 56% of physicians identified as White, 17% Asian, 6% Hispanic. The rest were unknown, or perhaps mixed race like me. The first Black woman to become a physician in the US was Dr. Rebecca Lee Crumpler, who earned a medical degree from the New England Female Medical College in 1964. At that time, 300 of 54,543 physicians were women, all White. That made Dr. Crumpler <1% of practicing physicians. So in 156 years, Black women physicians went from <1% to 2%?! We have a lot of work to do to create representation.
Now 51% of medical students in the US are women. 60% of physicians <35 are female. We are making progress in sex and gender disparity, but we have a long way to go to create racial representation. We know from rigorous research that patient-clinician racial and gender concordance has many benefits. My primary care doctor is a Black female physician. My daughter’s pediatrician is a Black woman. But we all need to go much further.
The Greatest Threat to Black People
As Nancy Oriol MD, one of the Associate Deans at my alma mater taught me, the “greatest health threat to Black men, women and children is inequality in health care and this is both a symptom and a cause of economic inequality, which is a threat to everyone.” Representation is a first step. Dr. Shepherd is an OB/GYN who posted today about 7 steps we can take to make change. Please read her post. There are many other inspiring Black women physicians in the image to the right:
Please let us know about more of them. Listen generously to them. Follow them. Be a true ally (i.e., not an optical ally because it’s on trend). Amplify their voices and share with your friends, so that young Black girls can be inspired and see themselves represented. Unite around representation. Educate yourself how you can do more to be an antiracist without asking them for help.
It’s Time to Act: Providing Respectful Healthcare to People of Color Is Not Enough
Dr. Hardeman urges us to act: “We believe that in Minnesota and throughout the country, health care professionals have an obligation and opportunity to contribute to health equity in concrete ways. Addressing violence against Black communities can start with antiracist practices in clinical care and research. Do we have the courage and conviction to fight to ensure that Black lives do indeed matter?”
Structural racism is a public health problem, and those of us in the field of medicine and health are responsible for dismantling it. As my friend and colleague Deb Cohan MD, a member of the faculty at the University of California at San Francisco and lifelong advocate for women of color, put it: “What am I, an obstetrician, doing about the disproportionate burden of maternal mortality and other poor reproductive outcomes among Black women? How am I confronting the underlying forces that facilitate increased suffering and death among certain groups because of their skin color? Although it’s necessary, it is not enough for me to provide respectful health care to pregnant women of color.”19
To address racial disparities in health outcomes, we need to define and understand the problem more comprehensively. We need better research into underlying risk factors and biomarkers. We need to point out where structural racism exists and dismantle it. We need a systems medicine approach, and we need better ways to address health disparity. We need to improve health outcomes in racial and ethnic minorities. Most of all, we need Black and Hispanic leaders and medical professionals to be represented in decision making regarding research.
In the words of Layla Saad, author of Me and White Supremacy, “Here’s to doing what is right and not what is easy.”
Jones CP. Confronting institutionalized racism. Phylon 2002;50:7–22
- Hardeman RR, et al. Structural Racism and Supporting Black Lives — The Role of Health Professionals. N Engl J Med 2016; 375:2113-2115.
- Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105(12):e60-e76; Williams DR, Wyatt R. Racial bias in health care and health: challenges and opportunities. JAMA 2015;314:555-556; James SA. The strangest of all encounters: racial and ethnic discrimination in US health care. Cad Saude Publica 2017;33(Suppl 1):e00104416-e00104416.
- https://www.medrxiv.org/content/10.1101/2020.05.07.20094250v1.full.pdf, accessed June 6, 2020.
- Note that the COVID Tracking Project was originally built by The Atlantic journalists Robinson Meyer and Alexis Madrigal, together with Jeff Hammerbacher at Related Sciences, and Alexis Madrigal now leads the work. Learn more at covidtracking.com
- Dartmouth Institute of Health. Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease. A Dartmouth Atlas of Health Care Series https://www.dartmouthatlas.org/downloads/reports/Diabetes_report_10_14_14.pdf, accessed June 1, 2020.
- Young BA, et al. Effects of ethnicity and nephropathy on lower extremity amputation risk among diabetic veterans. Diabetes Care 2003;26:495–501
- Newhall K, et al. Amputation Rates for Patients with Diabetes and Peripheral Arterial Disease: The Effects of Race and Region. Ann Vasc Surg. 2016;30:292‐8.e1.
- Weuve J, et al. Cognitive Aging in Black and White Americans: Cognition, Cognitive Decline, and Incidence of Alzheimer Disease Dementia. Epidemiology. 2018;29(1):151‐159. doi:10.1097/EDE.0000000000000747
- https://www.cancer.org/latest-news/gap-in-cancer-death-rates-between-Blacks-and-Whites-narrows.html, accessed June 4, 2020; DeSantis, C.E., et al. (2019), Cancer statistics for African Americans, 2019. CA A Cancer J Clin, 69: 211-233. doi:10.3322/caac.21555 https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21555;
- DeSantis CE, Fedewa SA, Goding Sauer A, Kramer JL, Smith RA, Jemal A. Breast cancer statistics, 2015: Convergence of incidence rates between Black and White women. CA Cancer J Clin. 2016;66(1):31‐42. doi:10.3322/caac.21320
- Dietze EC, et al. Triple-negative Breast Cancer in African-American Women: Disparities Versus Biology. Nat Rev Cancer 2015 Apr;15(4):248-54; Anstey EH, et al. Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers. Am J Prev Med. 2017;53(3S1):S40‐S46. doi:10.1016/j.amepre.2017.04.024
- Yedjou CG, et al. Assessing the Racial and Ethnic Disparities in Breast Cancer Mortality in the United States. Int J Environ Res Public Health. 2017;14(5):486. Published 2017 May 5. doi:10.3390/ijerph14050486
- Jemal A, et al. Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women with Breast Cancer Between 2004 and 2013. J Clin Oncol. 2018;36(1):14-24.
- Howell EA, et al. Site of delivery contribution to Black-White severe maternal morbidity disparity. Am J Obstet Gynecol. 2016;215(2):143‐152. doi:10.1016/j.ajog.2016.05.007; Creanga AA, et al. Pregnancy-Related Mortality in the United States, 2011-2013. Obstet Gynecol. 2017;130(2):366‐373. doi:10.1097/AOG.0000000000002114; Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol. 2018;61(2):387‐399. doi:10.1097/GRF.0000000000000349; Owens DC, Fett SM. Black Maternal and Infant Health: Historical Legacies of Slavery. Am J Public Health. 2019;109(10):1342‐1345. doi:10.2105/AJPH.2019.305243; Collier AY, Molina RL. Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews. 2019;20(10):e561‐e574. doi:10.1542/neo.20-10-e561
- Chowkwanyun M, Reed A, Racial Health Disparities and Covid-19 — Caution and Context.
NEJM May 6, 2020 DOI: 10.1056/NEJMp2012910 https://www.nejm.org/doi/full/10.1056/NEJMp2012910?query=featured_home
- Layla Saad, Me and White Supremacy (Sourcebooks, Naperville, 2020)
- https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018, accessed June 2, 2020.
- Cohan D, Racist Like Me — A Call to Self-Reflection and Action for White Physicians. N Engl J Med 2019; 380:805-807 DOI: 10.1056/NEJMp1814269