Elsevier

Social Science & Medicine

Volume 103, February 2014, Pages 7-14
Social Science & Medicine

Systemic racism and U.S. health care

https://doi.org/10.1016/j.socscimed.2013.09.006Get rights and content

Highlights

  • A full-fledged theory of structural (systemic) racism for interpreting health care data.

  • A full-fledged developed theory of structural (systemic) racism for interpreting public health data.

  • Focus on powerful white decisionmakers central to health-related institutions.

  • Importance of listening to patients and physicians of color on health issues.

  • Implications of systemic racism theory and data for public policies regarding medical care and public health.

Abstract

This article draws upon a major social science theoretical approach–systemic racism theory–to assess decades of empirical research on racial dimensions of U.S. health care and public health institutions. From the 1600s, the oppression of Americans of color has been systemic and rationalized using a white racial framing–with its constituent racist stereotypes, ideologies, images, narratives, and emotions. We review historical literature on racially exploitative medical and public health practices that helped generate and sustain this racial framing and related structural discrimination targeting Americans of color. We examine contemporary research on racial differentials in medical practices, white clinicians' racial framing, and views of patients and physicians of color to demonstrate the continuing reality of systemic racism throughout health care and public health institutions. We conclude from research that institutionalized white socioeconomic resources, discrimination, and racialized framing from centuries of slavery, segregation, and contemporary white oppression severely limit and restrict access of many Americans of color to adequate socioeconomic resources–and to adequate health care and health outcomes. Dealing justly with continuing racial “disparities” in health and health care requires a conceptual paradigm that realistically assesses U.S. society's white-racist roots and contemporary racist realities. We conclude briefly with examples of successful public policies that have brought structural changes in racial and class differentials in health care and public health in the U.S. and other countries.

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.

References (91)

  • P.B. Bach

    Racial differences in the treatment of early-stage lung cancer

    New England Journal of Medicine

    (1999)
  • I.V. Blair et al.

    Unconscious (implicit) bias and health disparities: where do we go from here?

    Permanente Journal

    (2011)
  • E. Bonilla-Silva

    Rethinking racism: toward a structural interpretation

    American Sociological Review

    (1997)
  • D.J. Burgess et al.

    The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample

    Journal of Health Care for the Poor and Underserved

    (2008)
  • D.J. Burgess et al.

    Why do providers contribute to disparities and what can be done about it?

    Journal of General Internal Medicine

    (2004)
  • M.H. Chin et al.

    Interventions to reduce racial and ethnic disparities in health care

    Medical Care Research and Review

    (2007)
  • A. Cintron et al.

    Pain and ethnicity in the United States: a systematic review

    Journal of Palliative Medicine

    (2006)
  • R. Clark-Hitt

    Doctors' and nurses' explanations for racial disparities in medical treatment

    Journal of Health Care for the Poor and Underserved

    (2010)
  • L. Cooper-Patrick et al.

    Race, gender, and partnership in the patient-physician relationship

    The Journal of the American Medical Association

    (2009)
  • L.A. Cooper et al.

    The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care

    American Journal of Public Health

    (2012)
  • J. Daniels et al.

    Whiteness and the construction of health disparities

  • W.A. Darity et al.

    Family planning, race consciousness and the fear of race genocide

    American Journal of Public Health

    (1972)
  • W.A. Darity et al.

    Fears of genocide among black Americans as related to age, sex, and region

    American Journal of Public Health

    (1973)
  • J. DeMuth

    Sick and tired of being sick and tired

    The Nation

    (1964)
  • W.W. Dressler

    Health in the African American community: accounting for health inequalities

    Medical Anthropology Quarterly

    (1993)
  • C.A. Fauci

    Racism and health care in America: legal responses to racial disparities in the allocation of kidneys

    Boston College Third World Law Journal

    (2001)
  • J.R. Feagin

    Systemic racism: A theory of oppression

    (2006)
  • J.R. Feagin

    Racist America

    (2010)
  • J.R. Feagin et al.

    Discrimination American style: Institutional racism and sexism

    (1978)
  • J.R. Feagin et al.

    The many costs of racism

    (2003)
  • J.R. Feagin et al.

    White racism: The basics

    (1995)
  • C. Fincher

    Racial disparities in coronary heart disease: sociological view of the medical literature on physician bias

    Ethnicity & Disease

    (2004)
  • G. Gee et al.

    Structural racism and health Inequities: old issues, new directions

    Du Bois Review

    (2011)
  • D.H. Gemson et al.

    Differences in physician prevention practice patterns for white and minority patients

    Journal of Community Health

    (1988)
  • D.K. Ginther et al.

    Race, ethnicity, and NIH research awards

    Science

    (2011)
  • M.M. Ginty

    Black women at higher risk for major diseases

    We News

    (2005)
  • M. Golub

    Community mobilizes to end medical apartheid

    Progress in Community Health Partnerships: Research, Education, and Action

    (2011)
  • M. Gottesman

    Valuing diversity at NIH

    NIH Catalyst

    (2011)
  • A.R. Green

    Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients

    Journal of General and Internal Medicine

    (2007)
  • A.G. Greenwald et al.

    Understanding and using the implicit association test: III. meta-analysis of predictive validity

    Journal of Personality and Social Psychology

    (2009)
  • A.H. Haider

    Association of unconscious race and social class bias with vignette-based clinical assessments by medical students

    The Journal of the American Medical Association

    (2011)
  • B. Hartmann

    Reproductive rights and wrongs: The global politics of population control

    (1995)
  • L.R.M. Hausmann et al.

    Perceived discrimination in health care and health status in a racially diverse sample medical care

    Medical Care

    (2008)
  • J. Hoberman

    Black and blue: The origins and consequences of medical racism

    (2012)
  • C. Jones

    Levels of racism: a theoretic framework and a Gardener's tale

    American Journal of Public Health

    (2000)
  • Cited by (0)

    View full text