Structural Racism: Medicine Forges a Path Forward

Patricia Jamieson, RN, has experienced racism from both sides of the patient-provider interaction.

Jamieson, age 67, is a former oncology nurse and cancer researcher who now works as a health coach in Birmingham, Alabama. In her years in oncology, she witnessed countless Black patients receive treatment she describes as “heartbreaking.”

When it came to treating pain, for instance, she saw white patients sent home with the opioid Percocet while Black patients got Tylenol.

As a patient, Jamieson said it took 8 years to be diagnosed with myopathy, a condition she suspected she had back in 2011. It took that long to be heard, she said.

“If you and I go to the hospital and we present with the same symptoms, I want to be treated just like you,” said Jamieson, a Black woman. “When I come in with severe pain, I should not be labeled as a drug seeker.”

Jamieson’s perspective is a window into the way structural racism pervades medicine today. While increased attention has been paid to the concept recently — sparked by a controversial JAMA Clinical Reviews podcast in February — misconceptions and misunderstandings abound, according to experts in health disparities. They shared important clarifications and paths forward with MedPage Today.

Structural Racism: What It Is

Back in March 1966, at the Medical Committee for Human Rights meeting in Chicago, Martin Luther King, Jr., said: “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”

That statement remains “resoundingly true today,” said Dayna Bowen Matthew, PhD, JD, dean of George Washington University School of Law in Washington D.C. She refers to the Harvard philosopher and ethicist Norman Daniels, PhD, who said, “If I have health, I have the ability to compete for all other civic opportunities as society has to offer. Without it, all else is meaningless.”

The first step in countering structural racism in medicine is acknowledging that “our most significant public-health crisis” hasn’t been recognized as such, said Selwyn Vickers, MD, a senior vice president and dean at the University of Alabama at Birmingham. Rather, it’s been viewed as “not taking advantage of all the opportunities that America provides.”

Similar misconceptions exist, Vickers said. For instance, in the controversial JAMA Clinical Reviews podcast, host Edward Livingston, MD, described racism as “illegal.”

Matthew, who is also the author of “Just Medicine: A Cure for Racial Inequality in American Health Care,” says that’s wrong.

“The only thing that’s constitutionally prohibited is for a state actor, the government, to discriminate against somebody based on race, color, or national origin,” Matthew said. “It is perfectly legal for you to discriminate against me in your individual capacity.”

“So to say racism is illegal is a patently false misunderstanding of the law,” she added.

It’s also a misunderstanding of what racism actually is: “Racism is a system; it’s not an individual attitude. You can be prejudiced as an individual, and you can be biased as an individual. You can be bigoted as an individual. But to be a racist is to be part of a system that organizes people, falsely asserting their inferiority or superiority. It gives them a value hierarchically,” Matthew said.

Racism comes from a historic ordering of people, “putting whites at the superior position and Blacks, Native Americans, Asian Americans, and others at an inferior position that is reinforced by all the institutions that are legalized in society,” she noted.

In the podcast, Livingston called “structural racism” an “unfortunate term,” and suggested that taking racism out of the conversation would help.

“Because it makes him feel uncomfortable,” Matthew said. “He may be fragile or offended, and I’m sorry for that. But a better way to face racism is to shed sunlight. It’s the best disinfectant.”

Medicine Forges a Path Forward

This week, JAMA‘s editor-in-chief Howard Bauchner, MD, stepped down as a result of the firestorm of criticism set off by the podcast, and 2 weeks ago, the American Medical Association released an 83-page report presenting a 3-year strategic plan to “dismantle structural racism starting from within the organization.”

The urgency of the plan, the AMA wrote, “is underscored by ongoing circumstances including inequities exacerbated by the COVID-19 pandemic, ongoing police brutality, and hate crimes targeting Asian, Black, and Brown communities.”

The plan outlined initiatives that include expanding capacity for understanding and implementing anti-racist equity strategies, building alliances with marginalized physicians and other stakeholders, and “strengthening, empowering, and equipping physicians with the knowledge of and tools for dismantling structural and social drivers of health inequities.”

The pandemic exposed “longstanding inequities in this country,” Aletha Maybank, MD, MPH, the AMA’s chief health equity officer, said in an interview with MedPage Today. “And then the public murder of George Floyd really sparked in this nation a renewed conversation around racism and its impacts on people’s health.”

“Our board issued a pledge in the summer, right after George Floyd [was murdered], saying the AMA is going to do all that it could do to dismantle racism in the healthcare system, and then formally passed policies around racism as a public health threat in the fall,” Maybank said.

The report emphasized that achieving “optimally equitable solutions requires disruption and dismantling of existing norms, collective advocacy, and action across sectors and disciplines.” It asserted that the AMA must “prioritize and integrate the voices and ideas of people and communities experiencing great injustice,” including people of color, women, those with disabilities, and the LGBTQ+ community.

It also noted that equity “is not a zero-sum reality that continues to create a set of winners and losers in health.” Instead, the healthcare community “must develop a critical consciousness that seeks truth and acknowledges the historical realities that powerful organizations and structures, rooted in white patriarchy and affluent supremacy such as the AMA, have both intentionally and unintentionally made invisible,” the report said.

The plan also introduced structural violence and racial capitalism as root causes of inequities in the healthcare system.

Maybank praised the plan’s boldness: “I think what excites me most about this plan as a physician and an equity leader – and also as a Black woman – is that we cut through it,” she told MedPage Today. “We were really intentional about pushing concepts and language forward that aren’t typically heard in healthcare and that healthcare really isn’t exposed to.”

David Williams, PhD, MPH, chair of social and behavioral sciences at Harvard’s T.H. Chan School of Public Health in Boston, believes that COVID-19 and a “pandemic of injustice” have mobilized many Americans to say, “We can do better than this. This doesn’t reflect who we are. This doesn’t reflect our values.”

Matthew agreed. The volume of the conversation around implicit racism in medicine has been raised, presenting an opportunity “to stop trying to dance around what we’re seeing clearly demonstrated in this pandemic,” she said.

“It’s an opportunity, and we should seize it. Good people have paused and said, ‘I see it now.'”

Last Updated June 02, 2021