Structural racism — racism embedded in our society’s policies and institutions — has a significant impact on health. Segregation in our hospital systems; the lack of investment in housing, nutrition, and education in communities of color; environmental racism; and inequality in access to care are just some of the many ways that racism makes us unhealthy.
Clinicians and policymakers have recognized the need to adjust certain methods of care delivery to ensure that people of color get the same access to high-quality care as white patients. At the same time, others have called out clinical algorithms for including race as a risk factor inappropriately. Why is it equitable to take race into account sometimes but not others? The answer lies in the distinction between race and racism.
In a recent piece in JAMA Health Forum, Dave A. Chokshi, Mary M. K. Foote, and Michelle E. Morse of the New York City Department of Health explain the difference. When race is used as an adjustment in clinical algorithms, it is usually based on some assumption of biological differences between people of different races when no evidence of such difference exists.
For example, the standard algorithm for determining kidney function automatically produces a higher value for anyone identified as Black, based on the assumption that Black people naturally have more creatine in their blood. By using race as a blanket adjustment instead of using patients’ actual creatine levels, the algorithm not only contributes to delays in needed care for Black patients with kidney disease, but it also perpetuates the idea of race as a biological, rather than social definition.
“Even though race is a social construct, exposure to racism has biological consequences. The goal of using race and ethnicity as a social risk factor is to improve health outcomes of individuals from historically marginalized groups.”
Dave A. Chokshi, Mary M. K. Foote, and Michelle E. Morse, JAMA Health Forum
On the other hand, processes that adjust for structural racism can be necessary for equitable care. For example, doctors at the Brigham & Women’s Hospital in Boston realized that Black and Latinx patients with heart failure in their hospital were experiencing worse outcomes because they were less likely than white patients to be admitted to the cardiology unit. This was not because of biological differences between white patients and people of color, but in factors driven by structural racism: minority patients are less likely to have a cardiologist as an outpatient, white patients are more more likely to advocate for themselves to get specialty care, and implicit bias of doctors in the hospital also may play a role. To address this inequity, the hospital launched a pilot program including an alert in the electronic medical record that flagged Black and Latinx patients with heart failure and suggested that providers admit them to the cardiology unit.
Policies like this are not without controversy. The Brigham program sparked hateful pushback from white supremacists, while medical professionals and some societies have pledged their support for antiracist initiatives in response. However, as Chokshi et al. point out, the alternative to adjusting for racism is to keep letting health disparities persist, which is unacceptable:
What is the alternate approach for redressing racial inequities? If there is agreement that racial inequities are persistent and unacceptable, what is the solution? The onus must be on those arguing against race-conscious strategies for providing that alternative. The status quo for Black, Latino, Asian, Pacific Islander, and Indigenous communities cannot be tolerated.