Major NEJM Article Addresses Structural Racism in the U.S. Healthcare System

A group of healthcare policy leaders has authored an article in The New England Journal of Medicine urging their colleagues in U.S. healthcare not only to examine how structural racism has been embedded into healthcare delivery in this country, but also ways in which readers can help lead the system into greater health equity and awareness of racial issues.

Alexandre White, Ph.D., Rachel L.J. Thornton, M.D., Ph.D., and Jeremy A. Greene, M.D., Ph.D., on August 26 published “Remembering Past Lessons about Structural Racism—Recentering Black Theorists of Health and Society.” All three authors are affiliated with the Johns Hopkins University School of Medicine, Department of Sociology, Krieger School of Arts and Sciences, and/or Bloomberg School of Public Health, all in Baltimore. Drs. White and Greene are members of the Department of History of Medicine; Dr. Greene is in the Department of Medicine; Dr. Thornton is in the Department of Pediatrics at the School of Medicine; Dr. White is in the Department of Sociology; and Dr. Thornton is in the Department of Health, Society, and Behavior in the Bloomberg School of Public Health.

“Imagine your city is being ravaged by an infectious disease epidemic whose morbidity and mortality are disproportionately borne by Black Americans,” the article’s authors write, in the introduction to their article. “A prominent scholar of health disparities reports that this “strikingly excessive rate,” often misattributed to putative biologic or genetic differences between Black and White bodies, must be understood as a spotlight illuminating the fundamental racial inequities in American society. This structural impact of race and racism as social determinants of health, rather than any biology of racial difference, confers on Black Americans a higher risk of getting sick and lower chances of having access to or adequate service from the health care system. This argument sounds familiar in 2021.”

But, the authors note, it is extremely important to note that “[T]his study, commissioned by the University of Pennsylvania, was a report on health and welfare entitled The Philadelphia Negro, published in 1899 by W.E.B. Du Bois and supported by a team of researchers. It provided an empirical foundation to demonstrate that racial disparities in mortality from tuberculosis, “the most fatal disease for Negroes,” were a product of social forces.1 In meticulously mapped details accompanied by charts, survey data, and careful statistical analysis, it chronicled the processes by which the lives and lifestyles of middle-class, working-class, and unemployed Black Philadelphians alike were affected by racial segregation in regard to housing, economic opportunity, and access to healthy food and environments. These socially structured differences and enforced inequities, visible to anyone looking at a city map from across the room, worked their way into bodily differences in health and illness, life and death.”

Bringing their framing into the present moment, the authors write that, “Since the first data on racial disparities in Covid-19 mortality were published in April 2020, and in the wake of widespread mobilization and attention to bodily effects of structural racism after the police killing of George Floyd last May, more health care experts have acknowledged the centrality of structural racism as a driver of racial and ethnic disparities in clinical medicine and public health. The American Academy of Pediatrics published a policy statement on “The Impact of Racism on Child and Adolescent Health” that explicitly identifies racism as a threat to children’s health and describes the scientific evidence supporting this position.2 This report and others like it are the result of decades of theoretical and empirical scholarship by public health scholars and health equity researchers.3-7 Their work contradicts a prevailing myth that physicians are always impartial and that medical and public health institutions are somehow unaffected by the inequities and biases that saturate all aspects of American life.”

Indeed, they state, “We have reached an inflection point where understanding structural racism may become a central focus and core requirement of medical education, with social theory incorporated into health policy and medical practice. Though the mounting resolve to address structural racism as a fundamental problem in American medicine and public health is welcome and overdue, the existence and effects of that racism are not revelatory.”

The solution to these conundrums? “Today’s physicians and physicians-in-training must grapple with our openness to more than reeducation about the way Black people are seen,” the authors write. “If we embraced the scholarship of past Black theorists of health and society, we might avoid presenting Black–White health disparities as either inevitable results of individual behaviors, predetermined outcomes of biologic differences, or by-products of immutable social circumstances beyond the purview of medicine and public health. To create a health system that recognizes the full personhood of Black patients and practitioners, we need to acknowledge the active process by which Black scholars have been marginalized and discounted.”

Finally, they conclude, “Recentering the work of Du Bois, the Atlanta school, and other Black theorists of health and society could help medical professionals, medical and public health scientists, and medical sociologists reckon with our skewed assessment of culpability for racial health disparities. It could prod medical educators, doctors, medical schools, and health care systems to question their assumptions and priorities in the interest of recognizing and rectifying medicine’s complicity in propagating inequities. Revisiting their work today helps us engage with race as a phenomenon continuously written and rewritten in the lived health disparities of millions of Americans. Only with awareness and knowledge can we change behavior, motivate action, redesign systems, and monitor progress toward equity and justice.”