The burden of most major chronic diseases in the United States falls more heavily on racial and ethnic minorities than on other populations. These disparities are not new, but the COVID-19 pandemic has highlighted many of the ways in which structural inequities in our society adversely affect the health of racial and ethnic minority communities. Together, these disparities, and the rise in racial tensions due to the heightened visibility of inequities in criminal justice, have led to a closer examination of our broader society as well as our health systems.
Health disparities are those differences in disease incidence and outcomes between groups that would not exist if our society were equitable and fair. The major societal resources that influence health — education, housing, employment, wealth, access to care and more — are commonly called the social determinants of health. Enduring adverse conditions in these areas, as well as psychosocial stress and personal mediated discrimination, lead to what is termed “weathering” — the wear and tear of belonging to a marginalized and oppressed group.
How did we get here? We got here through a prevailing system of structural racism that locks populations into a straightjacket of disadvantage. When presented with evidence of widespread discrimination and inequities in our country, many Americans say the system is broken. The system is not broken. In health care, we are very familiar with the saying, “Every system is perfectly designed to achieve the results it gets.” The design of the system that created and maintains inequities in the social determinants of health in the United States is structural racism.
But how can there be structural racism in America when the 1964 Civil Rights Bill put an end to federally supported racism? What many people are not aware of is that much of the racism in America persists, but in more subtle ways; and structural racism can, and does, persist in governmental and institutional policies, even in the absence of individuals who are explicitly racially prejudiced. A major barrier to addressing racism is our nation’s inability to embrace and address its roots when it memorialized race — how people look — as a tool to justify chattel slavery. These overt historical actions and more subtle contemporary discriminatory practices, from post-slavery Jim Crow laws that included forced sharecropping to redlining in housing, among other injustices, have created and maintained racial castebased inequities in our society. While no one today has owned a slave or created structural racism, everyone can choose to support structural racism and maintain race-based inequities, actively or passively, by doing nothing, or they can choose to help to dismantle it and finally begin to bend the arc of the moral universe toward justice.
IN HEALTH CARE, DISPARITIES ARE THE DIFFERENCES between groups of people based on inequities in such areas as access to and quality of care, as well as implicit biases among some providers. As a profession, we in health care often lament our inability to reduce health disparities. But should we really be surprised?
We believe that our call to attend to and heal the sick leads us to rise above individual prejudices and to provide the best care to all of our patients. But studies that test for implicit bias show that the opposite often is true. Harvard University’s Implicit Project finds that, even as we strive to rise above, our biases continue to follow us. While the average score for an American is a borderline medium-high implicit or unconscious anti- Black bias, and lawyers and doctoral-level researchers score medium, physicians score high on the scale. Yet, there is nary a physician who believes that he or she harbors any implicit biases, nor that any such biases could affect the care they deliver. Harvard’s conclusions are further supported by other studies that suggest provider bias, in conjunction with other social-determinants-of-health factors, contribute significantly to health disparities.
How to move forward? Ultimately, the only way is to dismantle structural racism and create an equitable, fair and just society in which every American has similar opportunities and resources to achieve a fulfilling life. The World Health Organization has identified three major principles to achieve health equity: Create equity in living and working conditions so that every person can achieve his or her full health potential; reorganize society so there can be an equitable distribution of power, money and resources; and educate the health care community and the broader society about the social determinants of health and how social inequity drives health disparities.
AS HEALTH CARE PROVIDERS, IT IS INCUMBANT UPON US TO LEARN from our patients. They have told us what they want: They want to be treated as respected human beings. This isn’t rocket science — or, in our case as physicians, brain surgery. Speak directly and with civility to patients; work in partnership with patients; take the time to answer their questions and concerns; and, finally, make it possible for patients to get in to see you within a reasonable time.
But we also must be cognizant that our society has created structures that impede the ability of a disproportionate number of people in racial and ethnic-minority communities to keep appointments, to be timely and to adhere to recommendations. And we also must be mindful of the high level of mistrust that has been engendered as a consequence of historic and contemporary mistreatment. When we see our minority patients struggling with adherence to recommendations, we should not first ask what is wrong with them or with their community, but ask what we have done to them or to their community that has impeded their ability to comply. By doing that, we are practicing anti-racism.
If we embrace the tools of cultural humility, mindfulness, compassion, empathy and self-reflection, we can begin to break down barriers and start a movement toward truly reducing disparities in care. And if we bring these same values to our daily lives, we may have a chance to start to dismantle structural racism and to help create a society that is grounded in equity and justice. Only then can we truly start to eliminate health disparities and improve health outcomes for all Americans.
Dr. Keith C. Norris is professor of medicine and vice chair for equity, diversity and inclusion in the UCLA Department of Medicine.