Awareness Edition: Recognizing Racism in Medicine

In the vast landscape of healthcare, where the pursuit of well-being should have no prejudice, a disconcerting reality persists—a reality woven with the insidious threads of racism that have, for far too long, shaped the trajectory of medical practices. As we stand at the crossroads of compassion and bias, it becomes imperative to cast a discerning light on the shadows of systemic discrimination within medicine, a realm where patients' health outcomes are undeniably entangled with the webs of racial injustice. Amid the complex convergence of healthcare and social justice, racism has pervaded patient health outcomes relentlessly but insolently demanding immediate action focused on change. The public must become more aware of the impact of racism in medicine on patients' health outcomes so we can advocate for equitable and just healthcare practices, specifically regarding involuntary testing, racial education bias, and misuse of research variables of race. 

1. Racism has been historically present in medicine through the lens of consent forms and involuntary testing; a prominent example is the Tuskegee syphilis study. From 1932 to 1972, a government-sanctioned experiment in Tuskegee, Alabama, involved 600 mostly illiterate Black men. Unaware they were part of a medical study, these men were attracted by promises of high-quality healthcare. Instead of receiving treatment for syphilis, which became available in 1947, they were falsely informed that they had "bad blood." Physicians used many racial ideals to justify this unconsented study, such as those mentioned by Allan Brandt in the official report of the study submitted to the United States Public Health Services: “According to these physicians, lust and immorality, unstable families, and reversion to barbaric tendencies made blacks especially prone to venereal disease” (Brandt, 1978). Another example occurred in June 1991, when Crystal Ferguson faced an unauthorized drug test during a routine prenatal checkup at the Medical University of South Carolina (MUSC). Without her consent, she was tested for drugs, resulting in a positive finding for cocaine. Coerced into substance abuse counseling, Ferguson, on August 4, 1991, delivered her child at MUSC, where she was again tested without consent, revealing continued traces of cocaine. Given an ultimatum, she was arrested on August 7, 1991, for not complying with the order to undergo drug treatment.“Ferguson was one of forty-two women arrested [by] law enforcement officials in Charleston and MUSC [Medical University of South Carolina]. All but one of the women were black. Her arrest for "fetal abuse" sparked national media attention” (Gagan, 2000). Further, there is more evidence for immoral and non-consensual testing, namely the Cincinnati Radiation Experiments.  Between 1960 and 1971, Dr. Eugene Sanger, a radiologist from the University of Cincinnati, conducted exploitative experiments on 88 terminal cancer patients by subjecting them to excessive radiation. The patients, predominantly from poor backgrounds, were 60 percent Black and aged 9 to 84. They were falsely informed that the treatment would help fight their illnesses, without being given consent forms or knowledge of the Pentagon's involvement in funding the project. As Professor Martha Stephens noted in her analysis,  “Other basic assertions of the Junior Faculty report: that no consent form [...] had been attained for the first five years of the project[...]; there had been no publications by the team on cancer during the eleven years of the project” (Stephens, 2002). Patients were thus exposed to up to 300 rads in an hour, equivalent to 20,000 chest X-rays and well above safe radiation levels. Approximately a quarter of the patients are believed to have died from radiation exposure during this 11-year study; it can be safely stated that, upon analysis of the Tuskegee Syphilis Study, the Cincinnati Radiation Experiments, and unauthorized drug tests, the horrors of racism have been present in medicine for a long time and it is quite necessary to educate the public and advocate against this looked over the atrocity. 

2. The education of medical students has racial bias, thereby instilling racial bias in medical practitioners. In a 2016 study, it was revealed that a significant number of white medical students held inaccurate beliefs about racial differences in pain tolerance. Specifically, 73% of participants harbored at least one false belief regarding biological distinctions between races. One example includes a misconception about Black people having a thicker skin, Hoffman et al. write “Black Americans are systematically undertreated for pain relative to white Americans. We examine whether this racial bias is related to false beliefs about biological differences between blacks and whites (e.g., black people’s skin is thicker than white people’s skin)” (Hoffman et al., 2016). Other misconceptions include less sensitive nerve endings or stronger immune systems. The researchers highlighted the historical roots of these beliefs, dating back centuries, and noted that some 19th-century doctors used such notions to justify the inhumane treatment of slaves. Not just in the 19th century, recent research using Implicit Association Tests (IATs) has shown repeatedly that medical professionals and students have unconscious racial prejudices that affect their clinical judgment. An investigation was carried out wherein medical students completed IATs both during and after their academic careers. The study demonstrated a clear correlation: individuals acknowledging implicit bias tended to identify more racial disparities in healthcare, while those denying its existence perceived fairness in treatment  (Drew, 2021).  A follow-up study involving 56 medical students explored the existing bias curriculum, revealing significant themes. These included resistance and shame among students recognizing their implicit bias and negative emotions arising when witnessing implicit bias in faculty or attendings (Drew, 2021). These insights have implications for the development and expansion of bias-related curricula in medical education.

3. Race is still misused and incorrectly used as a variable in research and treatment. Genomic medicine bias is problematic because it limits the applicability of research findings, perpetuates health disparities, reinforces stereotypes, and hinders the identification of unique genetic variations, thereby impeding the development of effective, equitable, and patient-centered healthcare solutions. In the realm of genomic medicine, a concerning bias emerges from research that predominantly involves participants of European descent (Popejoy & Fullerton, 2016). Here, race is incorrectly used in genomics, as with only one ethnic group being represented, medicines that would work for those of European descent would not work for those of other descent. The underrepresentation of diverse ethnic and racial groups in genomic research perpetuates a skewed understanding of genetic variations, potentially overlooking critical factors that may significantly impact health outcomes in non-European populations. Not only is there a skewed understanding, but there is a skewed health algorithm with a strong racial bias that exists as well. The U.S. healthcare system relies on commercial algorithms to guide health decisions, but a study by Obermeyer, et al. reveals racial bias in one widely used algorithm. This bias results in Black patients, with the same level of risk as White patients, being sicker. The algorithm, using health costs as a proxy for needs, erroneously concludes that Black patients are healthier than equally sick White patients, leading to a significant underestimation of the need for extra care among Black individuals. “These results suggest that the driving force behind the bias we detect is that Black patients generate lesser medical expenses [..]. As a result, accurate prediction of costs necessarily means being racially biased on health” (Obermeyer et al., 2019). Further studies were performed in which it was concluded that due to predicted costs and assumed resistance to certain diseases, Black individuals need lesser care compared to a similar White patient, health-wise. 

Confronting the undisputed influence of racism in medicine on patients’ health outcomes requires an active response in our society. The main objectives should involve comprehensive education reform towards removing racial prejudices in medical curricula, fostering faculty diversity, as well as incorporating anti-racism elements in the core of medical training. At the same time, advocacy should also involve the support of fair research practices, endorsement of studies that represent the diversity of our population, and the challenge of research that promotes biased perceptions. Accountability of medical institutions has to be stressed; transparency, accountability, and affirmative action are important milestones on the road to atoning for past errs. Enhancing diversity in all aspects of health care enables a more refined interpretation of health care requirements and a dedication to eradicating systemic injustices. In addition, it is important to take part in advocacy and awareness-raising initiatives so that people become aware of the consequences of the healthcare discrimination inherent to the U.S. system and the required policy solutions that can change the situation. Now is the time for change, and if we act upon these steps, there will be a more equal and fairer health system to cater to all.

References

Brandt, A. M. (1978). Racism and Research: The Case of the Tuskegee Syphilis Study. The Hastings Center Report, 8(6), 21–29. https://doi.org/10.2307/3561468

Cogan-Drew, T. (2021). Implicit Racial Bias Education and Healthcare Students: A Review of Current Practices. Diversity and Equality in Health and Care, 18(6). https://doi.org/10.36648/2049-5471.21.18.246

Gagan, B. J. (2000). Ferguson v. City of Charleston, South Carolina: “Fetal Abuse,” Drug Testing, and the Fourth Amendment. Stanford Law Review, 53(2), 491. https://doi.org/10.2307/1229489

Hamed, S., Bradby, H., Ahlberg, B. M., & Thapar-Björkert, S. (2022). Racism in healthcare: a scoping review. BMC Public Health, 22(1). https://doi.org/10.1186/s12889-022-13122-y

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial Bias in Pain Assessment and Treatment recommendations, and False Beliefs about Biological Differences between Blacks and Whites. Proceedings of the National Academy of Sciences, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113

Ioannidis, J. P. A., Powe, N. R., & Yancy, C. (2021). Recalibrating the Use of Race in Medical Research. JAMA, 325(7), 623. https://doi.org/10.1001/jama.2021.0003

Kamran, S. C., Winkfield, K. M., Reede, J. Y., & Vapiwala, N. (2022). Intersectional Analysis of U.S. Medical Faculty Diversity over Four Decades. New England Journal of Medicine, 386(14), 1363–1371. https://doi.org/10.1056/nejmsr2114909

Nicholson, H. L., & Ford, J. A. (2018). Correlates of prescription opioid misuse among Black adults: Findings from the 2015 National Survey on Drug Use and Health. Drug and Alcohol Dependence, 186, 264–267. https://doi.org/10.1016/j.drugalcdep.2017.12.006

Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447–453. https://doi.org/10.1126/science.aax2342

Stephens, M. (2002). The treatment: the story of those who died in the Cincinnati radiation tests. Duke University Press.

Tello, M. (2017, January 12). Racism and Discrimination in Health Care: Providers and Patients . Harvard Health Blog. https://www.health.harvard.edu/blog/racism-discrimination-health-care-providers-patients-2017011611015

Williams, D. R., Lawrence, J. A., & Davis, B. A. (2019). Racism and Health: Evidence and Needed Research. Annual Review of Public Health, 40(1), 105–125. https://doi.org/10.1146/annurev-publhealth-040218-043750