The disparities have long been documented. Black people are more likely than white people to die from cancer. They are more likely to suffer from chronic pain, diabetes, and depression. Black children report higher levels of stress. Black mothers are more likely to die in childbirth.
Those findings are part of a mountain of research cataloguing the complex and widespread effects that racism has on the health — and the medical care — of Black people in the U.S. Those effects stretch back centuries and take different forms, from discriminatory diagnostics to institutional barriers to care, all of which affect a person’s health.
But while the problem has been studied for decades and improvements have been made, many disparities persist unchecked.
The demonstrations sparked by the killing of George Floyd in Minneapolis have prompted a reckoning over racism and police brutality. But, among those in the medical communities, there have also been calls for urgent action to address the role that systemic racism plays in health disparities among Black people.
“Health disparities still exist because nothing has truly changed,” said Ashley McMullen, an assistant professor of internal medicine at University of California, San Francisco.
The Covid-19 pandemic has only made those disparities — and the structural discrimination they are rooted in — all the more apparent. Black Americans have been dying at about 2.4 times the rate of white Americans. As medical anthropologist Clarence Gravlee put it in Scientific American: “If Black people were dying at the same rate as white Americans, at least 13,000 mothers, fathers, daughters, sons and other loved ones would still be alive.”
“People of color right now are more likely to be infected, and we’re more likely to die. What we’re seeing here is the direct result of racism,” said Camara Phyllis Jones, an epidemiologist who recently served as president of the American Public Health Association. “That’s the thing that is slapping us in the face. Actually, it’s lashing us like whips.”
The systemic discrimination that has impacted Black health so inordinately dates back to the first ships carrying enslaved Africans that crossed the Atlantic. The colonial narrative of hierarchy and supremacy exists to this day, Jones said, and has translated, centuries later, into gaping health disparities.
Today, Black people in the U.S. are more likely than white people to live in food deserts, with limited access to fresh fruit or vegetables. They are less likely to be able to access green spaces, and more likely to live in areas without clean water or air. Black children are more likely to grow up in high-poverty areas. Black adults are more frequently exposed to greater occupational hazards, often working in frontline jobs across many fields.
The list goes on. All of these factors shape health, and all are shaped by structural racism.
“The air you breathe, the food you eat, the visual representations of what your future could look like — all are distorted by structural racism.”
Jessica Isom, psychiatrist and researcher
“The air you breathe, the food you eat, the visual representations of what your future could look like — all are distorted by structural racism,” said Jessica Isom, a community psychiatrist in Boston who studies health disparities in the Black community. “Other kids have internalized ideas of white supremacy — and that will have deep effects on a Black child’s psyche and body.”
And Black individuals often face baked-in barriers to accessing the resources that could help offset, even in part, the impacts of those effects, such as high-quality health care.
“The fact that the Black body experiences so much more harm, in so many ways, compared to other bodies — it really explains how racism continues to hurt people,” said Roberto Montenegro, a psychiatrist at Seattle Children’s Hospital who studies how perceived discrimination affects mental health.
Studies have shown that long-term discrimination can lead to a disruption in the stress hormone cortisol, leaving people with less biological energy and more fatigue, said Elizabeth Brondolo, a psychologist at St. John’s University who researches the issue. That type of chronic, sustained stress contributes to health conditions like diabetes, obesity, and depression. It can also take a significant toll on mental health.
“Everyone feels stress, but we forget how many more resources some people have to mitigate stress when they’re not a member of a discriminated group,” Brondolo said.
And structural social and economic disadvantages don’t account completely for health disparities, Montenegro said. One study compared childbirth outcomes of wealthy, educated Black women against white women with less income and education and found Black women have worse outcomes than white women with fewer resources.
“This is clear evidence that racism, and its biological and social impact, transcend a lot of the things we say we should work on — like education and income and poverty,” Montenegro said. “Black women experience racism; white women do not.”
The American Academy of Pediatrics last year published a policy statement on how racism is a core cause of health problems in children and adolescents. What wasn’t? Race itself. The paper drove home a crucial point: Racism, not race, affects health, and race shouldn’t be used to explain away disparities caused by racism.
“People think of race as a biological factor in health outcomes, when it is not,” said Jacqueline Dougé, medical director of the Howard County Health Department in Maryland and a co-author of that statement.
But that fact is not always carried over to medical education. In her coursework for medical school, Isom, the psychiatrist and health disparities researcher in Boston, said she was taught about disease risk factors grouped by age, sex, and race. Students weren’t, however, taught about racism itself. It’s a gap in the curriculum that other researchers and students have pointed out before.
“There’s an explicit lack of mentioning that it’s racism, as opposed to race, that is the root cause of vulnerability to disease,” Isom said.
“We were taught that to be Black was a risk factor for these diseases, without any context — because they think the Black body is flawed,” she added.
McMullen, the UCSF internal medicine professor, said her medical education focused on the most well-known examples of racism and mistreatment in medicine — such as the Tuskegee syphilis experiments on Black men or the story of Henrietta Lacks’ cell line — but did not involve a deeper exploration of why such stark health disparities persist today.
The remnants of racist ideology, too, can be found in certain medical devices. Take the spirometer, a tool that measures lung capacity. There’s often a button on it that “corrects” for race. Black people are measured on a different rubric than white people, based on rationale that dates back to when physicians on plantations used the tool to unjustly rationalize why slaves were fit only for field labor. The same settings are still in use today.
“That button came from medical racism,” Isom said. It’s one of a number of medical tools — from algorithms used in hospital care to tests for kidney function — that have been inaccurately shaped by racism against Black people and that can harm their health.
“Racist practices of medicine lead to worse outcomes.”
Roberto Montenegro, psychiatrist and researcher, Seattle Children's Hospital
“Racist practices of medicine lead to worse outcomes,” Montenegro said.
For that to change, the entire health care field — from medical schools and professional societies to hospitals and medical device manufacturers — needs to work to unravel and address racism within the system.
“I think health care is protected from this broader discourse because the narrative is that we’re all heroes,” said McMullen, who is working on an audio documentary about the issue. “We don’t actually address that the structure being perpetuated in health care is the same dynamic that’s playing out in the criminal justice system.”
While the effect of racism on health is well-established, progress will take time — and has to occur on a societal level, Dougé said. That has to involve a wide range of actions, including improving wages and closing pay gaps, improving access to health insurance, and ensuring more diversity in the health care system so that practitioners can provide culturally competent care.
“There has to be a systemic change,” Dougé said, “because racism — not race — has a profound impact on our health outcomes.”