Racism is the belief that one group of people is superior or inferior to another based on perceived physical and cultural characteristics. Although race has no biological basis, it has very real repercussions for its victims. Genetic variance within a given geographic population is greater than that between populations, and there are no genetic variables that can be identified and labeled as markers of race, yet race is used to justify unequal treatment around the world.

While racism has existed for as long as there have been societies, the racism against Black, Indigenous, and People of Color (BIPOC) in the United States was intentionally woven into its founding. This began with the forced removal of Native nations, the establishment of slavery, and the denial of representation for anyone other than white male landowners. While enslaved people were part of colonial society from the time Europeans first landed on the U.S. east coast, the U.S. Constitution’s Thirteenth Amendment, which abolished slavery, was not ratified until 1865, almost 100 years after the country’s founding. Racism against Asian immigrants was institutionalized through laws such as the Page Act of 1875 and the Chinese Exclusion Act of 1882, which explicitly restricted immigration from certain Asian countries. Additionally, mob violence and forced deportations of Latinx individuals have been persistent features of U.S. history since its inception.

Today, legal racism is less overt but still prevalent in laws that disproportionately affect people from different backgrounds. While individual acts of racism can have profound effects on their targets, the societal impact of racism is embedded in institutions such as the justice system, healthcare, education, and all levels of government. It is this systemic and institutional racism that primarily influences the social determinants of health discussed in this chapter.

Structural and Institutional Racism in Healthcare

Racism within the healthcare system can be both overt, through practitioner prejudices in patient interactions, or hidden and well-intentioned, such as when treatment protocols for BIPOC patients differ from those of white patients. In healthcare education, there is, unfortunately, still much much work to be done to address disparities in diagnosis and treatment that are taught at our institutions. Racism contributes to both mortality and morbidity rates in BIPOC populations.

A recent study (Hoffman et al., 2016) indicates that over half of the 418 students sampled from the UVA medical school system believed in myths about biological differences between Black and white patients. Specifically, they believed that Black people had thicker skin and a higher pain threshold than their white counterparts, although this is demonstrably untrue (Hoffman et al., 2016). While this is just a sample of students at one institution, it is not hard to imagine what harm these beliefs could cause if not addressed in early medical education. Indeed, unexamined biases can lead to unintentional outcomes that negatively affect patient care.

Tackling bias in medicine is an ongoing process. Studies that compare current treatment protocols, which vary depending on the race of the patient, to those without racial coefficients, show that when patients receive the same treatment, regardless of racial identity, outcomes for BIPOC individuals improve dramatically. For example, removing racial coefficients from kidney function tests resulted in 35% more African-American patients being diagnosed as eligible for a kidney transplant (Zelnick et al., 2021). Further studies have shown how racial bias in medical tests, such as pulse oximetry (which can be affected by skin color), has affected COVID-19 treatments (Valbuena et al., 2022) and how pulmonary function tests with racial coefficients underdiagnose severe lung disease (American Thoracic Society, 2021). These examples illustrate the serious consequences of racial bias in medical practice.

Statistically, disparities in health outcomes are not solely the result of racialized treatment algorithms. We must also factor in social determinants of health, which vary because of historical inequities that continue to this day. For example, while men have a 40% higher mortality rate than women, Black men have the highest mortality rates of any group, followed closely by Native American men, and both groups surpass the mortality rate of white men (CDC, 2014). Outcomes are similar in breast cancer diagnosis. Mortality rates are 40% higher for Black women than for non-Hispanic white women (Jatoi et al., 2022), indicating that factors such as access to healthcare and preventive screenings contribute to these disparities.

In addition to medical care, social determinants of health such as environmental pollutants, poor workplace safety and career opportunities, food deserts, and limited access to safe outdoor recreation and green spaces negatively affect BIPOC individuals at higher rates then white individuals. Systemic racism, which affects housing and incarceration rates, has been repeatedly shown to disproportionately impact Black and Brown individuals and their families.

One example of housing disparities is redlining, an illegal practice of discrimination in real estate and home buying that began in the 1930s. It affected mortgage, student loan, and car loan interest rates and approval, with lasting consequences for Black and Latinx families (Hayes, 2019). These disparities limited their ability to buy homes, and taxes on these homes would have funded education, infrastructure repair, and other social supports that dramatically affect social determinants of health today.

Institutional racism is evident in the laws that are enforced, sentencing guidelines, and mass incarceration, all of which disproportionately affect Black and Brown individuals. For example, differing sentencing guidelines for the possession of crack cocaine (more often used in poorer, predominantly Black neighborhoods) and powdered cocaine (more often used by upper-middle class white people) have had a dramatic effect on the number of young people imprisoned from different populations. The Fair Sentencing Act of 2010 attempted to minimize disparities in sentencing, although it only applies to federal laws and does not address the state laws under which most drug offenses are prosecuted. Also, it does not address the fact that approximately 80% of the people prosecuted for crack possession were Black, although two-thirds of the users were white or LatinX (Bigler, 2010).

During the COVID-19 pandemic, BIPOC individuals were more likely to hold essential positions that required continued contact with patients, customers, and clients as the virus spread. According to data published by the CDC in September of 2022, Native American/Alaska Native people had 1.6 times the rate  of COVID cases, 2.7 times the rate of hospitalizations, and 2.1 times the rate of deaths than non-Hispanic whites. Latino people had 1.5 times the rate of COVID cases, 2.0 times the rate of hospitalizations, and 1.8 times the rate of deaths than non-Hispanic whites. Black/African-American rates were 1.1 times higher, 2.3 times higher and 1.7 times higher, respectively. Only Asian-American/Pacific Islander rates were lower than white rates, with 0.8 times the rate for all three categories (CDC, 2022).

Developing Measures to Overcome Health Disparities Due to Racism

If racism is systemic, what can we, as healthcare professionals, do to combat it? How can we ensure that the next generation of providers views their patients through an anti-racist lens? And how can we make these changes both sustainable and institutionalized?

In 2020, students at the University of Washington School of Medicine challenged their instructors in Nephrology to examine racialized differences in diagnosis after a study revealed significant disparities in kidney care along racial lines. As a result, the UW School of Medicine eliminated the racial coefficient for the glomerular filtration rate test, which measures kidney function. This change has increased the number of African-American patients who qualify for severe kidney disease treatment and placement on a transplant list by over 30% (Cerdeña, 2020). Other schools and medical organizations are following suit, including major centers in Maryland, Mississippi, and Cedars-Sinai hospital in Los Angeles. By some estimates, using the race-blind kidney function test improves care and interventions for over 720,000 African American patients (Washington, 2021).

However, in other areas, such as medication dosing, cardiovascular and diabetic health guidelines, and even bone health and fracture risk assessments, race is still factored into calculations (Cerdeña, 2020). Proponents of re-examining these racialized tests and treatment algorithms suggest that although race-based coefficients were intended to improve outcomes, they may be doing the opposite. A push to re-evaluate clinical and diagnostic practices that divide patients into racial categories is well underway, and we can expect to see changes as more information is collected.

Laws that affect public health have been changing as well. For example, the Supreme Court’s decision to overturn Roe v. Wade has profound public health consequences for people who can become pregnant and their families. On a more positive note, the recent creation of the Environmental Justice Index, which integrates data from the EPA, CDC, U.S. Census Bureau, and MSHA, helps evaluate the health impacts of environmental concerns on different communities (ATSDR, 2023).

In addition to student-led reforms in medicine and new laws, social changes spurred by the pandemic, including a reimagined work-life balance, strengthened local community engagement, and renewed interest in climate change technology are influencing public health. Support for environmental measures and universal healthcare, along with these other changes, will have profound effects on the social determinants of health, especially for the BIPOC families and individuals who are disproportionately affected by health inequities.