US history is littered with instances of racism and it has creeped into not only social, political, and economic structures of society, but also the US healthcare system. Racism is the belief that one race is superior over others, which leads to discrimination and prejudice against people based on their race or ethnicity (Romano). Centuries of racism in the United States’ social structures has led to institutionalized or systemic racism”policies and behaviors adapted into our social, economic, and political systems that reinforces racism and racial disparities (Cobbinah and Lewis 996).
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Systemic racism can also be seen in the United States’ medical care system where it has contributed to different health outcomes among different races, most notably in doctor-patient relationships. If we want to improve individual health and population health, then we must address racism as a fundamental cause of health outcomes and a root cause of racial health disparities“an approach that seems to be lacking within the medical and public health realm.
A brief historical review of the US medical care system, starting from the times of American colonialism, and its relation to racism will give us an overview on how it contributes to systemic racism seen today. Analyzing racial impacts on doctor-patient relationships and minorities’ distrust of the medical profession will show the different levels of racial discrimination in the US medical system and shed light on why racial disparities are so wide. Many medical and public health professionals acknowledge race as a factor in health disparities, but most are reluctant or refuse to acknowledge the role of racism within the U.S. medical system, and its impact on individual and population health. This paper will show evidence of the relation between structural racism and Americans minorities’ health outcomes.
Since the American colonial period, U.S. institutions have reinforced each other to give undue advantage to white Americans and put them in a place of power over non-white Americans. Starting from the genocide and enslavement of Native Americans to the enslavement of African Americans, there has been a substantial shift in power and wealth favoring white Americans over non-white Americans, thus changing the social determinants of health (conditions in which people are born, grow, live, work and age) for each racial group (Cobbinah and Lewis 996). Consequently, this shift in power and wealth towards white Americans”which still persists today”changed U.S. population health and encouraged racial health disparities. Along with it came dehumanizing experimentation on Americans of color in order to find safe treatments for whites. Unfortunately, most medical and public health communities are unwilling to research or even acknowledge the impact of past racially-charged medical practices and experiments seen in today’s medical culture (Feagin and Bennefield).
However, many social scientists have found that these dehumanizing experimentations had a hand in creating the imbalance of health disparities between race that we see today. Although these experiments are not revered, medical history also does not ostracize them. In fact, the doctors and scientists who conducted these experiments are often exalted for their achievements and ignore the atrocious experiments they conducted on Americans of color. For example, in the 19th century, James Marion Sims conducted surgical experiments on black infants he took from their mothers. He was convinced that a neuromuscular disease”caused by vitamin/mineral deficiencies”was due to skull bone misplacement, so he made incisions in the scalp of the infants and used a cobbler’s tool to pry and change the positions of the skull bones, without any use of anesthesia (Feagin and Bennefield). Sims also conducted experiments on three enslaved women who each underwent 30 painful operations. In one instance, one of the women was held down by whites while Sims inserted a speculum into her vagina attempting to close ravage openings by abrading and suturing. He went on to perform the same surgery on whites”with anesthesia”once it was perfected. Despite all the atrocities he’s committed, James Marion Sims is honored as the father of gynecology (Feagin and Bennefield). Unfortunately, he was only one of the many scientists who used Black slaves as subjects of dissection and medical experimentation during the 19th century (Gamble 1774). Even after slavery was abolished, many Black people were afraid of being kidnapped at night and brought to a hospital to be killed and experimented on by white doctors. Anthropologist Gladys-Marie Fry did not find any evidence of this to be true but believes that white Americans, especially in the South, spread this kidnapping rumor in order to keep an oppressive control over the Blacks and discourage them from moving North (Gamble 1774). This is a perfect example of how racial discrimination has negatively impacted the overview of the medical profession from a minorities’ perspective. Not only was the past fear of painful experimentation still looming over African Americans’ head, but it was reinforced by white Americans’ racial discrimination.
Unjust medical experimentation did not stop there however. The design of past experimentation on slaves set up later discriminatory experimentation on minorities in the 20th century. The Tuskegee experiment is probably the most infamous and notable study conducted on African Americans of modern times. Started in 1932, the Tuskegee experiment sought to study how syphilis manifested in African American men. Back then, doctors believed that syphilis affected the neurological systems of white American men but only affected the sexual organs of African American men because they had primitive brains and strong sexual desires. Even after an efficient treatment for syphilis was discovered, researchers lied to the men about giving them treatment for syphilis so that they can examine how the disease progressed in their bodies. Many died due to the disease and/or passed it on (Gamble 1774).
In 1951, Henrietta Lacks went to John Hopkins hospital for vaginal bleeding. Upon examination, doctors found a tumor on her cervix and collected a sample without her knowledge. They treated her with radiation, but then sent her home with antibiotics. She passed away within the same year. Her stolen cells were given to Dr. George Gey who, upon realizing that her cells can grow indefinitely, commercialized them for a profit. Since then, her cells have been key to developing a polio vaccine and researching cancer. However, neither Lacks nor her children ever saw a penny from the multi-million dollar distribution of her cells (Feagin and Bennefield). In 1945, another scandal involving Americans of color was the Human Radiation Experiment. White scientists from the Atomic Energy Commission injected patients of color in hospitals with plutonium without their consent to observe the bodies’ reaction to radiation. Just like in the Tuskegee experiment, follow-up care was not given and many of them died (Feagin and Bennefield). Ill-informed and unfair conduction of these medically unethical experimentation has negatively impacted American minorities’ views on the medical profession.
Some people would argue, however, that since the civil rights movement and enactment of civil rights laws in the 1960s, racial discrimination is no longer an issue in U.S. institutions. These people, unfortunately, fail to see that there is still an everlasting effect on U.S. institutions from past racial discrimination. The ignorance of the racially charged history of the U.S. medical field in medical schools and public health schools also reinforces systemic racism and white-framing of the medical system.
In The Spirit Catches You and You Fall Down, we see how the American doctors’ and nurses’ racial discrimination towards the Hmong jeopardized little Lia Lee’s life. The mistrust between the Lia’s doctors and her parents was in part due to the stereotypes the doctors believed to be true about the Hmong. The doctors and nurses believed that Lia can only get better if they employ their methods and treatments, and were appalled by the Lee’s own cultural efforts to help their daughter. The doctors’ stereotypes and assumptions led them to believe that Lia’s parents were neglecting her health intentionally and decided it would be best if she were put in foster care. Removing Lia from her parents’ custody, however, worsened her health and the doctors’ soon realized their mistake. Although racism is not as evident in this example as in the others, this shows how systemic racism can cause negative health outcomes among minorities.
Nowadays, racism is found deep under the rules and practices of medical institutions along with the persistence of white authority, norms, and framing as medically correct. Even if it’s not as apparent as intentionally causing harm to a minority in the name of science, you can still find racial discrimination when you see the difference of treatment between a white patient and a non-white patient. There have been numerous studies and reviews that show African Americans, Native Americans, Latinos, and Asian Americans receive poorer quality of health care. The Center for Medicare Services (CMS) found African Americans, Native Americans and Latinos who were enrolled in Medicare Advantage plans received worse care compared to white Americans in getting needed care, managing care coordination, and getting appointments and care quickly in 2016. One study asked 720 physicians to look at black and white patient data, diagnose, and recommend treatment. It was found that the doctors were less likely to recommend standard catherization to African Americans than white Americans, even when both patients shared similar occupations and medical histories (Feagin and Bennefield). In 1999, another study found that African American patients were less likely to receive kidney transplants than whites and attributed it to physicians’ unconscious, or subconscious, bias and financial disincentives (Feagin and Bennefield). Similar results were found when researchers compared physicians who had a patient pool of more than 50% of minorities and physicians who had a patient pool of more than 50% white Americans. The latter group was more likely to recommend testing and the best treatment available than the former group (Feagin and Bennefield). In 2011, researchers found emergency rooms gave more attention and faster care to white children who had bone fractures than minority children who had sickle-cell disease (Feagin and Bennefield).
These studies and many more have shown evidence that most physicians give little attention to patients of color to the extent that they sometimes discredit their pain and offer them less than optimal treatment and care. Therefore, it is only obvious that we see minorities continuously suffer from poorer health outcomes when compared to white Americans. In 2010 it was found that, African-American women are more likely to die of breast cancer than women of any other racial or ethnic group. American Indians are nearly three times as likely to be diagnosed with diabetes as White Americans. Eighty-two percent of the pediatric AIDS cases¦ consisted of African-American and Latino children (Association of Medical Colleges). The gap between the quality of care and health outcomes between races indicates that systemic racism has a negative impact on minorities’ health. For example, African American women are more likely to die from breast cancer because of the lack of screening and effective treatment offered to them, even though they are less likely to develop breast cancer than white Americans (Cobbinah and Lewis 996).
When nurses and doctors were asked why there were such huge gaps between races, most blamed the patient for not actively seeking care, not speaking up about their health, and not following treatment plans as white Americans do (Williams). Others blamed the patient of color for distrusting healthcare professionals (Feagin and Bennefield). Most research studies attribute failing health outcomes of minorities to communication problems and trust issues between doctors and patients, however, they don’t dive into why these issues seem to persist specifically in minority groups. Joe Feagin and Zinobia Bennefield conceptualize this physician bias, either unconscious or implicit, as one of the main reasons why there is a communication issue in doctor-patient relationships. Several studies have examined doctors’ implicit association tests (IAT)”a test that analyzes a person’s unconscious stereotypes”and found that most white doctors preferred white patients over non-white patients, while most African American physicians had no preference. The studies have also shown that white doctors increasingly associate minorities, especially African Americans, with negative character traits. Dr. Max J. Romano described an incident during his medical residency where a young African American man came in with gun shots and died during surgery. Post-death, one of the hospital staff members removed two cellphones from the body. Immediately, another resident voiced his opinion that the young man must have been associated to drug dealing”as he saw in a fictional T.V. show that drug dealers carried two phones with them. The atmosphere then changed from nervous cleaning to nervous laughter. Later on, Dr. Romano realized that this incident was a reflection on the deep-seated racism and white-framework found in the U.S. medical system (Romano). The resident stereotyped the young Black man as a drug dealer based on one vague fact he saw in the media and no one seemed to think it was necessary to correct his perception. This shows the underlying racial bias of the resident and the rest of the hospital staff. Thus, it is not fair to solely attribute the poor health of American minorities to their lack of communication or involvement with their healthcare provider.
Furthermore, there are also trust issues perpetuating from both sides of the doctor-patient relationship. While doctors don’t seem to trust their patients to follow treatment plans they prescribe, patients of color don’t always trust their doctors. This distrust could also be a reason why minorities seem to be receiving a lack of quality healthcare and why racial gaps exist. In one study, physicians were less likely to trust non-white HIV patients and researchers suggested that this lack of trust from the physician could explain why there are patients of color who receive less pain management than whites (Feagin and Bennefield). Patients of color can sense the lack of trust from their physician in the way the physician interacts with them, and will, unconsciously or consciously, withhold important health information about themselves. If you couple these negative interactions with the past medical atrocities against Americans of color, it’s no wonder why patients of color mistrust their health care providers. Even when white physicians did not overtly show racist bias towards their patients, IATs showed that there were innate pro-white biases (Feagin and Bennefield). The bias and lack of trust shown by doctors interactions and the lack of acknowledgement of medically unethical practices of the past reinforces systemic racism in the U.S. medical system.
To improve doctor-patient relationships and racial stereotypes, many U.S. medical institutions have turned to employing cultural competence training in their schools and hospitals (Kleinman and Benson e294). Cultural competence care is, care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors, according to the U.S. Department of Health and Human Services (DHHS). There are two general approaches institutions have taken to teach their members about cultural competence: one, programs aimed at improving group-specific knowledge, and two, programs that apply cultural competency programs that apply generic or universal models (DHHS). Although, cultural competent training does not explicitly combat structural racism, it does include it. The goal is to teach doctors and doctors-in-training about being culturally aware of one’s patient and to incorporate it into your diagnosis and treatment. However, there are many problems with cultural competence that Kleinman and Benson point out in their article. They point out that cultural competence training has three issue: first, it suggests culture can be compacted into a technical skill that can be taught over a course of lessons; second, it reinforces homogeneity among racial groups, like, all Mexicans believe this, all Blacks believe that, and so on; and third, it causes physicians to overlook other practical aspects of health-causing agents, and mistakenly chalk up a health problem to a difference in cultural understanding (Kleinman and Benson e294). For this purpose, Kleinman and Benson suggest that ethnography should be taught in place of cultural competence. However, even if you employ ethnography training instead of cultural competence training, it is still a one-level approach to combating doctor-patient relationship and racial stereotypes. The approach is not sufficient to combat this issue; and it is definitely too small of an effort to combat structural racism in the U.S. medical system as a whole.
Structural racism is a complex issue that touches many areas of U.S. society and institutions, so it only makes sense that structural racism in health care would be just as complicated. To combat racial discrimination in U.S. health care will require a multi-faceted approach. The first and most important step is for U.S. society to be aware and recognize that structural racism is evident in our society and that it is having an adverse effect on U.S. population health. Recognizing that racial medical practices has taken place in U.S. history and its lasting effects on today’s medical culture will allow for a broader discussion of what can be done to combat this issue. Next, a look at all the different occurrence of structural racism in healthcare is required as this paper only touches upon a few. For that, more research is required as there are still very few studies that directly approach racial discrimination in the U.S. health care system as an issue. Finally applying the information learned about structural racism and health into policies, medical training, health surveillance, research design, and hospital and clinical culture is key if we want to decrease the impact of institutionalized racism on the millions of minorities living in America.
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