National Public Health Week Part 3: Racial Disparities in Healthcare

I'd like to close out NPHW with one more topic inspired by an amazing doc and eloquent storyteller who we were fortunate to meet at our public health conference this past week.  Dr. Camara Jones is a well-known family physician, epidemiologist, and research director on Social Determinants of Health & Equity at the CDC.  While many people have a general idea that racial/ethnic minorities generally experience poorer health care and health outcomes, Dr. Jones really helped us understand the roots of some of this by explaining the multiple levels of racism that can lead to health disparities.

1. Institutionalized racism:
This is a systemic issue of what Dr. Jones refers to in her article as "inherited disadvantage", which can manifest in various ways, including, "differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment."


Dr. Jones brought up a thought-provoking concern to us, challenging a tradition that is quite familiar to us medical students - including race within the chief complaint of a case presentation, chart note, etc.  For example, A 52-year-old African-American male presents with shortness of breath and chest pain for 30 minutes.

Dr. Jones suggests that race is an appropriate factor to include in the social history, but it becomes problematic when it is paraded around like a beacon from the start.  Certainly, there are different conditions that may be associated with different races or ethnic groups.  But when race/ethnicity becomes a defining factor of the patient, it has the tendency to conjure up racial stereotypes and assumptions.  And furthermore, it encourages a perspective of race as having a biological foundation rather than being understood in its true form as a social construct.  It is these types of flawed perspectives that further strengthen the foundation of systematized racism as it exists in our society.


2.  Internalized racism:
This is experienced by those of minority groups who, subconsciously or otherwise, begin to accept negative stereotypes about their self-worth, capacity, and agency.   That is, a sort of fatalistic perspective may be adopted by minorities - I'm a failure, I'll never amount to anything, I might as well give up.  Feelings of hopelessness and internalized beliefs about their limitations due to their racial/ethnic background lead to self-fulfilling prophecies - school drop-outs, risky health behaviors, etc.

3. Personally mediated racism:
This refers to individual perspectives rooted in prejudice, which leads to differential assumptions based on race, followed by differential actions based on these assumptions (read: discrimination). As an example, I encourage you to read about the tragic story of Anna Brown, a homeless woman who presented to the ER with a swollen and severely painful calf.

Anna had a negative ultrasound, which is the typical initial test when there is high suspicion of a DVT (deep vein thrombosis, or leg clot).  However, due to the high probability based on her clinical presentation, she should have been kept longer for observation and serial testing, but was instead released in handcuffs due to her refusal to leave.  Fifteen minutes after being placed in a jail cell, she was found dead - the DVT hadn't been picked up, and had migrated to her lungs, causing a fatal pulmonary embolus.

Would the outcomes have been different if she were white?  Or not homeless?  Did personally  mediated assumptions about her race/social status lead health care providers to believe that her pain wasn't real, that she was just seeking narcotics, that she didn't deserve an extensive work-up despite the warning signs?  We may never be sure, but it certainly challenges clinicians to examine their own biases and strive to treat every patient equally, providing quality healthcare that is a basic right of ALL individuals.