Charles E. Binkley, MD
Charles E. Binkley is the director of bioethics at the Markkula Center for Applied Ethics. Views are his own.
Justice, the ethical mandate that every patient is treated the same so as to achieve equivalent outcomes, is at the normative core of medicine. Or it should be. In the United States, for almost every disease state or health category measured, Black Americans fare worse than white Americans. This is not a new finding, but the COVID-19 pandemic has brought this disparity to the attention of the nation. As of June 12, 2020, age-adjusted COVID-19 hospitalization rates are five times higher for Black compared with white patients, and Black people are dying from COVID-19 at a rate two and one-half times higher than white people.
Why do Black Americans Have Far Worse Health Outcomes?
One of the most stark racial disparities between Black and white Americans is in maternal and fetal mortality. It is also one of the better studied areas of health disparity, and may offer some insights not only into why the disparities exist, but what needs to be done to bring justice to the system and to society.
In 1850, the reported Black infant mortality rate was 340 per 1,000 births, compared to the white infant rate of 217 per 1,000 births. In contrast to 1850, the Black infant mortality rate in the U.S. in 2016 was 11.3 per 1,000 for Black babies compared to 4.9 per 1,000 for white babies, a racial disparity greater than during the time of chattel slavery. Besides infant mortality, pregnancy related maternal mortality in the U.S. is three to four times higher for Black when compared to white women.
Social Determinants of Health
Research has often focused on issues such as economic inequality, housing, education, food insecurity, and transportation in order to better understand health disparities. Certainly the two-tiered public/private health system in the U.S. reflects deep economic disparities where those with private insurance are able to access private hospitals, and patients with Medicaid and the uninsured receive their care at public facilities. Just as these two systems reflect economic differences, not surprisingly they often also have marked differences in quality metrics and overall outcomes.
Social factors also affect access to health care, even for those who are insured. For instance, paid sick leave policies often benefit those with higher paying jobs and greater overall economic security. In addition, public transportation is often more time consuming than private vehicles, and most outpatient care is delivered during work hours. These considerations can negatively affect an individual’s decision to take time off work for medical care, particularly prenatal care.
Social factors have also been used to justify and perpetuate racial stereotypes about behavior patterns. Issues such as smoking, drug use, obesity, and poor nutrition have been assigned to Black women based only on race. Some stereotypes, such as obesity, trace their roots to slavery wherein enslaved people were seen as beholden to their own sensuous pleasures.
However, economic injustices and educational differences do not explain all health disparities in fetal mortality rates. Infant mortality rates for middle-class Black women with a professional or advanced degree are higher than for low-class White women with an eighth grade education. This suggests that there are elements besides social status that influence health outcomes.
“Weathering” is a biopsychosocial model that seeks to explain the effect that racism has on the physiology of Black women and how it affects infant mortality. According to this theory, persistent toxic stress induced by discrimination, insults, doubt, and similar racist attitudes toward Black women triggers the premature deterioration of Black womens’ bodies. Along with overlapping epigenetic theories, this research links racism to biological processes. It also explains the increased infant-mortality observed in Black women independent of education and economic status.
While “weathering” and epigenetic theories offer great promise at understanding how racism affects physiology, it is essential not to conflate the physiological effects of stress induced by racist attitudes with racial genetic or biological factors. In attempting to explain racial differences in outcomes, some researchers have proposed that there are inherent genetic differences that explain the disparities. For instance, the search for a “preterm birth gene” has persisted since the 1950s to explain racial differences in infant mortality, and has been unsuccessful. The data supports social determinants that have physiological effects rather than inherent genetic differences; not the genetics of race but the lived experience of racism.
System Determinants of Health
Medicine has a long and ugly history of explicit racism. Unfortunately, some of that legacy has been inherited by today’s medical institutions. One example, put forth in a medical journal in 1811, was the theory that enslaved Black people were less sensitive to pain due to their genetic inferiority, a belief that persists even today. An article published in 2016 found racial bias in both pain assessment and treatment recommendations. Researchers discovered that these assessments were grounded in false beliefs about biological differences between Black and white people that still exist in the health-care system today.
Not only do explicit racist stereotypes find their origin in slavery, but so too does implicit bias. A recent study found a positive correlation between pro-White implicit bias and geographic concentration of enslaved people as measured in 1860.
Another example of racism pervasive throughout the health-care systems is with interpersonal communication between Black patients and clinicians, particularly white clinicians. Black patients report not being believed, receiving worse service, being treated as unintelligent, and having their questions and concerns ignored by white doctors and nurses. Tennis star Serena Williams describes having a doctor dismiss her concerns about having a pulmonary embolism after the birth of her child, despite Williams’ medical history and experience with pulmonary embolism. If racism negatively affects the ability of clinicians to trust Serena Williams, their relationships with other Black patients must be significantly more uneven.
Transitional justice provides a basis for reconciling past racist practices through reparations. As such, medicine must work both to draw attention to the physiologic harms of racism, and also address the racist beliefs and practices in its own institutions. The two-tiered health system must be leveled such that there is a single, comprehensive, and just standard of care that everyone receives. Large academic medical centers must stop the racist practice of sending their trainees to public hospitals in order to get hands-on experience that would not be tolerated at private facilities.
Advances in maternal-fetal health may be instructive on how to address this chasm. Doulas are individuals trained in childbirth who act as patient advocates and “navigators”, bridging the relationship between mothers and their clinicians. Research suggests that doulas may have positive effects when it comes to minimizing racial health disparities. Utilizing culturally appropriate navigators, similar to the current use of medical interpreters, may be an effective tool to improve clinical relationships and level out health disparities.
Another opportunity is the use of systems to detect manifestations of explicit racism and implicit bias. The electronic health record gathers vast amounts of information that can be analyzed to detect racial differences in performance measures and quality outcomes. These data can then be used to implement corrective action at the individual and system levels.
Looking to the future, medicine must also assure equal access to emerging technology such as precision health care and genomics. Economic disparities leading to health disparities must not be allowed to deprive Black people of cutting edge advances in medicine.
If there is any good to come from the simultaneous COVID-19 pandemic and the Black Lives Matter movement it is the moral edict that medicine correct its racist practices and ensure one standard of care and outcome for everyone.