July 22, 2020
For years, I’ve written about health disparities, with many posts on the importance of healthy foods and exercise, and how self-care reduces risks attributed to non-communicable illnesses such as diabetes and heart disease. I’ve commented on how the medical system treats symptoms with a multitude of medicines that raise healthcare costs but leave people suffering because the system fails to treat causes. But in these pieces, I have failed to call-out the underlying malignancy at the root of these diseases.
Racism creates illness. It’s the catalyst for poverty, homelessness, malnutrition, addiction disorders, violence, lack of access to preventive care, and high-level interventional misdiagnosis. Continued silence in the face of stark evidence encourages a status quo of neglect and inadequate care – a constant that kills. Throughout the generations, we have seen populations underrepresented in the care conversation. In public health, when we close our eyes to what is around us, death is invited into our communities. We must push for change.
In 1992, a DuPont Radiopharmaceuticals agency account team I was part of launched the “Difference in a Women’s Heart” campaign with the American College of Cardiology and the American Medical Women’s Association. What we now know to be an essential public-health truth was, at first, a fight to get into the public eye. Though the data demonstrated that women were at equal risk for heart attack as men, many – including healthcare professionals and frontline ER staff – thought heart disease was a “men’s illness.” Shifting that mindset was essential to saving lives. Now, cardiovascular disease is accepted as a killer of both men and women. The American Heart Association, National Institutes of Health, and society at large recognize that women and heart disease must be a top-of-mind public health priority in order to diagnose early and save women’s lives.
That was nearly 30 years ago. Today, when it comes to Black and Latinx people, we are behind. We are still drawing on language and mindset from many decades past. When I was an American Heart Association regional and affiliate volunteer, I too often heard the sentence “Blacks and Latinos are ‘predisposed’ to hypertension and diabetes.” As recently as 2011, authors wrote an article in the American Heart Association Journal Hypertension:
“Studies have consistently reported a higher prevalence of hypertension in blacks than in whites, a main reason for the higher incidence of cardiovascular disease in blacks. The long list of putative causes for this higher prevalence suggests that the real reasons are still unknown. Biological differences in the mechanisms of blood pressure control or in the environment and habits of whites and blacks are among the potential causes. The higher prevalence of hypertension in blacks living in the United States instead of Africa demonstrates that environmental and behavioral characteristics are the more likely reasons for the higher prevalence in blacks living in the United States. They could act directly or by triggering mechanisms of blood pressure increase that are dormant in blacks living in Africa.”
Suggesting that the “real reasons” Black Americans experience higher prevalence of hypertension, especially in comparison to Black Africans, are “still unknown” is tantamount to blaming the victim. Perhaps the wording reflects an effort to be apolitical – to be indifferent in assessing the data. But this is a disservice to science, and a conclusion that enables injustice to persist. Too many Black people in this country face poorer economic prospects than whites, poorer diet, and poorer access to care. No money, no healthy food, and no decent care net out quickly to poor health outcomes. And even the causes of these health disparities are only symptoms of the real, underlying condition: racism – no more and no less.
Even if we find it hard to speak the truth about the health impacts of racism, the numbers don’t lie. According to the CDC, Black women are 3.2 times more likely to die of pregnancy-related mortality (PRMR) than white women, a situation that has persisted for decades. It’s also a risk that increases with age; Black women older than 30 were four to five times more likely to die from PRMR than white women. These disparities are found in the statistics for nearly every non-communicable disease. For example, risk of being diagnosed with diabetes is 77% higher for African Americans and 66% higher for Hispanic Americans than it is for whites. This is not biology at work. It is systemic racism.
C. Virginia Fields, president and CEO, National Black Leadership Commission on Health, asks “Are we prepared as a nation to put in place systems that will address poverty, unemployment, racism? How do we address this through policies and budgets?”
The prevalence of these conditions and economic disadvantages – the cumulative effects of decades of racism – have placed people of color more directly in harm’s way from COVID-19 than any other community. Blacks are dying at a rate of 50.3 per 100,000 people, compared with 20.7 for whites. In New York City, the most densely populated place in America, 19% of residents, most of them people of color, live in poverty, while 17% live in overcrowded conditions. Is it any wonder then that the highest numbers of deaths from COVID-19 are among people of color who live in overcrowded conditions? And yet, when the American Medical Association issued a powerful report to its physician members – “Protecting public health & vulnerable populations in a pandemic” – its pages discuss at-risk populations including the homeless, incarcerated and impoverished, but fail to even mention people of color.
We seem unable to come to grips with the fact that racism impacts health, even though it’s clearly the cause of multiple public health disasters. The time to tackle injustice head-on is now.
Going forward, I hope that our health system – filled with dedicated people who want to help sustain and save lives – will begin to use language that expresses the challenge we must overcome and abandon “corporate-“ or “academic-speak” that mutes the truth. We need to recognize that structural and institutionalized racism are so entrenched that we have not seen them for what they are. It’s time to speak to and face reality: look closely enough and we see that health disparities come from racism; predisposition to disease comes from racism; poor access to care comes from racism.
We must also recognize that the fight against racism is constant. It isn’t something that will ever be fixed when we reach a threshold; it is a process that those of us who are privileged and white must constantly work toward, but will never be through with. Quiana Agbai, the sister of a colleague, writes:
“Racism is in the air we breathe and dominates our culture. A culture that is also obsessed with checked-off to-do lists, certificates of accomplishment and trophies. None of that exists for anti-racism. When you finish an e-course or read a list of books, you will not be “done” with anti-racism. Now that you’ve committed to actively pursuing a life of anti-racism it is until death do you part. As (author and professor) Brené Brown reminds us, it’s a vulnerable journey, you will make mistakes, it will be awkward and most importantly, uncomfortable. Be ready to sit in the discomfort.
Only when we work to meet the needs of those whose need is greatest can we make progress. On my part, I commit to actively fighting the epidemic of racism. I hope that my colleagues who are the beneficiaries of white privilege will also make that commitment. Together, we must work to address the underlying cause of many of our public health crises with truthful words and actions that get to the heart of the problem.
[Appreciation to Helen Shelton, Kristie Kuhl, Ariane Lovell, John Bianchi and Arielle Bernstein Pinsof for their counsel in developing this post.]
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