Systemic racism and U.S. health care
Introduction
Decades of research indicate that a serious U.S. public health problem involves systemic white racism and its negative effects on minds and bodies in all racial groups, most especially Americans of color. Dealing justly with racial inequalities in health requires a conceptual analysis realistically assessing society's white-racist roots and contemporary structural-racist realities. We draw on the black counter-framed tradition and social science research in that tradition by Feagin, 2006, Feagin, 2010 and other analysts (Bonilla-Silva, 1997, Feagin and Feagin, 1978, Feagin and Vera, 1995). Systemic racism theory is firmly grounded in the race-critical literature created since the 1960s black civil rights movement and first articulated for the health care system by Kwame Ture and Charles Hamilton (1967: 3–4). They argued that “racism” involves “predication of decisions and policies on considerations of race for the purpose of subordinating a racial group.” While recognizing individual racism, they accented institutional (what we term systemic) racism that is “less overt” and “less identifiable in terms of specific individuals committing the acts. But it is no less destructive of human life.”
We use important concepts from this analytical tradition--which has more fully illuminated key aspects of systemic racism than previous work on U.S. racial matters--and use that lens to assess the extensive impact of systemic racism in the medical and public health world. Absent an adoption of systemic racism concepts, which go beyond the “structural stigma” paradigm, that world is unlikely to seriously address racist realities and, thus, is likely to perpetuate them.
Systemic racism theory (Feagin, 2006, Feagin, 2010) details these major dimensions of U.S. racism: the (1) dominant racial hierarchy, (2) comprehensive white racial framing, (3) individual and collective discrimination, (4) social reproduction of racial-material inequalities, and (5) racist institutions integral to white domination of Americans of color. The U.S. is a country with systemic oppression—centuries of genocide, 336 years of slavery and legal segregation, about 85 percent of U.S. history. Since the 17th century a white elite has played the central role in maintaining racialized institutions and a rationalizing white framing, while ordinary whites have usually supported oppression because of white privilege. Over about 20 generations, whites have inherited socioeconomic resources from ancestors who benefitted unjustly from slavery, segregation, and other racial oppression. Unjust enrichment of whites from this oppression brought unjust impoverishment for people of color. To the present, Americans of color have been economically impoverished and unhealthy because white Americans have long used extensive discrimination and resistance to change to insure they as a group are economically much better off and generally healthier.
Today, unjustly inherited white resources and continuing discrimination restrict access of many Americans of color to better jobs, quality education, healthy neighborhoods, quality health care, and political power. From the beginning a white racial framing with its major elements—not only racial bias, but also racial ideologies, images, narratives, emotions, and inclinations to discriminate—has aggressively defended this unequal and unjust society.
Section snippets
Powerful white actors and racial framing
The conceptual language of most contemporary health researchers regarding racial matters is euphemistic or white-concealing—for example, vague white-framed language such as “racial disparities.” Research on disparities typically focuses on health problems faced by people of color and neglects the white perpetuators of racist practices and institutions creating these problems. As researchers concerned with accuracy, we focus here on the roles, framing, and institutionalized actions of
The structural approach: an important research shift
An increasing number of articles in the research literature have begun to locate racism in the health care context and health disparities (Gee and Ford, 2011, Paradies, 2006, Walters, 2011). We offer our theoretical insights to assist in substantially expanding their conceptual implications in the direction of a much more institutional and systemic racism direction. Generally, these articles fail to situate analysis of racism in pivotal research by those working in the tradition of the
Important historical background: persisting systemic racism
Generally, the medical and public health communities, including their mostly white leadership and leading medical schools, seem unwilling to examine the current impacts of past racial oppression on U.S. medical and public health institutions. Systemic racism and medical/biological science, including the latter's medical and public health practices, evolved together in society. Medical treatments and public health practices were frequently matters involving a white-racist framing. For example,
Differential racial treatments today: health care providers
Much research demonstrates the systemically racist character of contemporary health patterns, medical framing and practices, and health care institutions. Numerous disparities reports demonstrate that Americans of color “continue to suffer from greater health problems than their white counterparts …. 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
Implicit bias: only one aspect of the white racial frame
Mainstream researchers have attempted to explain health care differentials. Some focus on patients of color as having problems communicating with or distrusting physicians, yet do not systematically examine why. Others reference the medical system as less responsive to patients of color, but such commentaries are usually underdeveloped or written in the passive voice with hidden causal agents. Researchers speak of "unknown” or “complex” causes. In no article that we have seen are the systemic
Beyond implicit bias: more extensive racial framing
Understanding systemic racism and how it shapes health and health care requires going beyond a conceptualization of individual racial biases disconnected from a broad white racial framing and associated structural power inequalities. Systemic discrimination has long been reproduced by a well-institutionalized white framing—through recurring racial stereotypes and prejudices (“biases”), but also through racist ideologies, images, narratives, emotions, and inclinations to discriminate in
Linking racial framing to treatment
White-oriented health practitioners typically bring to interactions with patients of color the broad racial framing that whites have long used. Only a few studies show more explicitly that physicians' racial framing includes views of how suitable black patients are for important procedures or how likely black patients are to follow a physician's directions (Anonymous, 2001, Feagin and McKinney, 2003). One study found that physicians were less trusting of nonwhite HIV patients. Researchers
The importance of listening to patients and physicians of color
Another issue is the lack of detailed attention paid by white health decisionmakers to views of black patients, physicians, and community representatives about health issues. A growing number of studies (Burgess et al., 2008, Hausmann et al., 2008, Krieger, 1990, Ryan et al., 2008) have reported on the important, often revealing views of patients of color. One Seattle survey (Seattle and King County Department of Public Health, 2001) found that African Americans and Native Americans were 3–4
Conclusion: seeking systemic solutions
Racism in health care and public health institutions is multi-dimensional and systemic. We recognize that generations of white-imposed racism in other institutions—including employment, housing, and education--have contributed greatly to racial inequalities in health. We accent here the racial character and impact of health care institutions and their practitioners on these significant health inequalities. Importantly, we emphasize that even much race-critical literature does not call out
Acknowledgment
We are indebted to Jessie Daniels and Verna Keith for comments on earlier drafts.
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