COVID-19 the ‘Great Equaliser’: Structural Racism in Medicine

‘Race is not a biological catgory that naturally produces health disparities because of genetic difference. Race is a political category that has staggering biological consequences because of implicit social inequality on people’s health.

Dorothy Roberts

Whilst deemed by Madonna as the ‘great equaliser, COVID-19 is far from a disease which holds the same risk of infection and mortality for different social groups. In Britain and the USA, racial minority groups are being disproportionately affected: a UK national critical care audit recorded 32% of critical care patients were BAME, a social group which contribute to 18% of the population. For more drastic figures, in the US state of Michigan African Americans make up only 14% of the population but 40% of deaths. The overt racism spouted by media outlets and political figures on this ‘chinese virus’, works in tandem with structural implicit racism which is costing lives. Racism is a public health issue, which I plan to unpick in this article.


To understand this arguement we must get our idea around the notion that Race is a social phenomena not a biological one. For evidence of this see below excerpts from a paper exploring the genetic basis of race:

Although on average populations that are geographically closer to one another show stronger correlation and higher genetic similarity than geographically seperated populations… substantial differences in allele frequencies are observed within geographical regions. Several studies including ours show that genetic diversity in humans is higher between individuals of the same race (~85%) than between races (~15%)… These observations reveal characterisation of races simply as ‘White’, ‘Caucasian’, ‘Asian’, ‘African’ or ‘Latino’ are poor predictors of human biological diversity or similarity’

(Mersha and Abebe, 2015)

Race is a social categorisation of people ( whereby an individual identifies with those who they feel they share a similar social experience due to factors such as skin colour, social environment ect) which differs from one’s genetic ancestry. An example of this distinction is the difference between saying Native American children require an additional round of chemotherapy to respond to treatment and children with more than 10% of Native American ancestry need an additional round of chemotherapy to respond to treatment. Genetic Ancestry is determined by locating Ancestry Informative Markers (AIM) often found in non coding DNA, hence an individual’s appearance is not usually an accurate depiction of their genetic ancestry. The colour of one’s skin, and other phenotypic considerations contribute to the social grouping of a Race – which is a combination of genetic, and socioenvironmental factors- instead of depending on genetic ancestry which is purely biological and can be used in a objective manner to determine an individual’s probabilistic predisposition for contracting a disease.

Therefore despite their subjective nature of categorisation, the use of ethnicity forms in medical contexts continue to to feed into the use of Race as a crude proxy for genetic ancestry which counters the approach of evidence based medicine. However, collecting data about Race could be beneficial if done in a transparent way to use both genetic and ethnic identification data to shed light on health disparities and the physiological effects of the phenomena on individuals- the results of such investigations could be used as catalysts for change in health outcomes and wider social contexts.


Health inequities arise from ‘the systemic and unjust distribution of social, economic, political and environmental resources needed for health’ . Racism is a cause of health inequities: from the implicit human bias of doctors, to the lower average socioeconomic living conditions of BAME populations this is a problem which permeates all levels of society before manifesting in the doctors waiting room. These health inequities are being highlighted by COVID-19 in the following ways:

BAME populations are more likely to be exposed to the virus.

BAME populations are more likely to live in deprived, densely populated urban areas, with occupations where they are less likely to be able to work from home, meaning individuals are more likely to be exposed to the virus

BAME populations are more likely to have poorer outcomes when exposed

Chronic health conditions, such as cardiovascular disease, type 2 diabetes and hypertension, are more common in BAME communities than their White counterparts. This can also be traced back to living conditions, and the effect that physical and mental stress ( especially that induced by racial aggravation) has on the body according to the John Henryism Hypothesis. This leaves individuals more vulnerable to developing complications that can land them in ICUs. But more worryingly during the current pandemic is what is happening in the critical care units, where resources are limited and doctors must make rapid decisions about who would be most likely to survive in order to distribute resources. To do this they must consider underlying health conditions, in which case BAME individuals, victims of social disadvantage, are disproportionately affected.

Furthermore healthcare providers, as human beings, harbour unconscious racial stereotypes and bias. The most dangerous aspect of this is not realising that Race is playing a role in ones desicion making by assuming racial bias is intrinsically tied with prejudice, when in reality ‘ the most profound aspects of racism operate without bias or stigma’. There are innumerable studies highlighting the impact of the doctor’s own subjective bias on their patient’s outcomes, examples abound in pain management: in a meta analysis the greatest racial disparity in pain treatment was for conditions such as back ache, migraine and abdominal pain. This ‘outgrouping’ effect, alienates the healthcare provider from their patient as they see them through a filter of group membership rather than in high definition by focusing on individual attributes, which can have devastating effects – such as disparities in fetal mortality rates.


So where do we go from here, how do we challenge these health inequities? Here are some proposals I’ve picked up from my research:

Diversify Clinical Trials

‘for minority populations few genetic data have been systematically analysed and the interplay between genetic and various socioeconomical factors remain to be investigated’

(Mersha and Abebe, 2015)

The history of medical research and trials has been tied to enslavement, subjugation and genocides of ethnic groups (for example look into the Tuskegee Syphyllis Study, and the Rwandan genocide). As a result ethnic minorities to this day are tentative to put themselves forward, as there is a deep seated distrust with the medical institution. More needs to be done to actively collect diverse data and there is a need to ‘target’ disease in specific ethnic groups and communities with the holistic lens of determining how the social interacts with the biological, with the aim to improve health outcomes of members of those populations.

The collection of data with minimal racial bias is especially important with the introduction of AI in healthcare. To break this cycle of injustice, their algorithms need to be fed with as much data as possible on all members of our society, whilst minimising the impact of human bias on diagnosing individuals who belong to different social groups.

Doctors and Healthcare Providers Must Improve Their Abilities to Successfully Interact with Socially Dissimilar Patients

1. Institutionally there needs to be an enhanced motivation to reduce bias without the artificiality of wanting to seem politically correct

2. Healthcare providers must understand their own psychological basis of bias

3. Healthcare providers must be more confident in their ability to successfully interact with patients with whom they don’t share the same background

4. Healthcare providers must enhance their emotional regulation skills

All of these ideas combine to form an improved ability to form a strong therapeutic alliance with their patients.

Doctors and Healthcare Providers Must Advocate for the Reduction of Health Inequities

Health inequities are rooted deeply in the cultural context of the society we live in. Doctors must actively pursue the best interests of their patients by being vocal in the medical circles of the issue, by acknowledging the potent power of latent racial bias, and in their wider societies to engender trust from the communities they serve.

Whilst the impact of health inequities in the current context of the COVID-19 crisis can’t be reversed, and unjustly many lives will be lost as a result of social conditions which could have been improved, the crisis is bringing potently latent ideas of implicit racial bias to the surface. The advocacy of a new generation of healthcare professionals ( https://bit.ly/2RO4dZq ) are already getting the wheels turning for institutional change with the aim of minimising- even eliminating if we want to be overly utopic- the negative effects of Structural Racism in Medicine .

Bibliography

https://threader.app/thread/1120301179957915660

http://archive.boston.com/news/globe/ideas/articles/2007/07/15/how_racism_hurts____literally/

https://www.sciencedaily.com/releases/2019/05/190531100558.htm

https://www.health.harvard.edu/blog/how-racism-harms-children-2019091417788

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447724/#!po=65.7895

https://www.youtube.com/watch?v=KxLMjn4WPBY&app=desktop

https://en.wikipedia.org/wiki/Haplogroup

https://discoversociety.org/2020/04/15/covid-19-racism-and-health-outcomes/

https://humgenomics.biomedcentral.com/articles/10.1186/s40246-014-0023-x

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30792-3/fulltext#coronavirus-linkback-header

https://www.motherjones.com/coronavirus-updates/2020/04/black-people-are-dying-from-covid-19-at-higher-rates-because-racism-is-a-pre-existing-condition/

https://www.newscientist.com/article/2236760-we-dont-know-why-so-few-covid-19-cases-have-been-reported-in-africa/

https://qz.com/india/1839018/why-does-india-have-so-few-coronavirus-covid-19-cases-and-deaths/

https://www.nytimes.com/2020/04/17/us/coronavirus-death-rate.html

https://tcf.org/content/report/racism-inequality-health-care-african-americans/?agreed=1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219858/

https://www.aamc.org/news-insights/how-we-fail-black-patients-pain

2 thoughts on “COVID-19 the ‘Great Equaliser’: Structural Racism in Medicine

  1. This was really interesting! as are all of your other posts. Something that I’ve noticed in my immediate somali community is the level of distrust people have, often to the point that they advise eachother not to seek medical attention when they have severe symptoms, which undoubtly contributes to how likely they are to recover. It’s seriously alarming how this distrust breeds misinformation and results in people being placed in danger, I feel like the contribution of this sense of distrust (which is most probably a result of racial discrimination in the past) is often underestimated. Anyways this is my little input in this really broad topic.

    Liked by 1 person

    1. Thank you for your comment and insight! Yes I totally agree, and I think the stigmatisation goes both ways as doctors also need to be able to develop ‘ingroup’ relationships instead of ,often unintentionally, othering those whose cultural practices don’t match their own. It is an issue often overlooked perhaps because of how hard it is to judge one’s own behaviour objectively.

      Like

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