Post #3: Learning – Race is Real
See the prior posts introducing this topic and exploring the scientific myth of race. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“Although the concept of race invokes seemingly biological based human characteristics (so-called phenotypes), selection of these particular human features for purposes of racial signification is always and necessarily a social and historical process. Indeed, the categories employed to differentiate among human beings along racial lines reveal themselves, upon serious examination, to be at best imprecise, and at worst completely arbitrary. They may be arbitrary, but they are not meaningless. Race is strategic; race does ideological and political work.” Michael Omi and Howard Winant, Racial Formation in the United States
We need to go no further than the current crisis to see this in action. As is now widely acknowledged, current SARS COVID-19 mortality data in the US suggests a disparity based on race and ethnicity, with Black, and to a slightly lesser extent, Latinx patients suffering at much higher rates than whites.
As I limitedly argued in the last post, race is not scientific, so the reason for these disparate outcomes are not – at least not primarily – biologic. Prominent leaders in our country still hold this belief, however, including a physician senator when questioned on the data in his own state. But the truth of the matter is far more complex and damning. As explained recently in JAMA, there are two likely explanations for these data: racial and ethnic minorities have a disproportionate number of underlying comorbidities and risk factors, and minorities, especially in urban areas, live in more crowded neighborhoods and households and more likely to be employed in public-facing jobs; social distancing, safe at home, and other public safety efforts are privileges not extended or available to many in these communities. “As more data emerge, there will likely be evidence of racial/ethnic health disparities due to differential loss of health insurance, poorer quality of care, inequitable distribution of scarce testing and hospital resources, the digital divide, food insecurity, housing insecurity, and work-related exposures.”
These factors are called the social determinants of health, which broadly include all conditions in life that shape health. These are more specifically summarized in six categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (including transportation, housing, security, community self-efficiency), and fairness (in general, sufficient redistribution of wealth and income to ensure social and economic security and equity).
These social conditions help explain why, for example Black individuals at birth have a life expectancy of 3.5 years less than white individuals, 70-80% of which can be explained by socioeconomic factors, and a Black infant born in the US is more than twice as likely to die before their first birthday than a white infant.
Many of these determinants are “far upstream of health care and are deeply rooted in the distribution of money and power, at local and national levels”. These roots are foundational to our country, and a very limited and topical review of some of the branches include:
- Over the past 30 years, the U.S penal population exploded from around 300,000 to more than 2 million, with drug convictions accounting for the majority of the increase. The United States imprisons a larger percentage of its Black population than South Africa did at the height of apartheid.
- These stark racial disparities cannot be explained by rates of drug crime. Studies show that people of all colors use and sell illegal drugs at remarkably similar rates, yet in some states, Black men have been admitted to prison on drug charges at rates twenty to fifty times greater than those of white men.
- More African American adults are under correctional control today – in prison or jail, on probation or parole – than were enslaved in 1850, a decade before the Civil War began. The mass incarceration of people of color is a big part of the reason that a Black child born today is less likely to be raised by both parents than a Black child born during slavery.
- The total population of Black males in Chicago with a felony record (including both current an ex-felons) is equivalent to 55 percent of the Black adult male population and an astonishing 80 percent of the adult Black male workforce in the Chicago area. More than 70 percent of all criminal cases in the Chicago area involves a class D felony drug possession charge, the lowest-level felony charge.
- Black individuals are 3.23 times more likely than white individuals to be killed by a police officer in the United States.
- Black people fatally shot by police are twice as likely as white people to be unarmed.
- Bias in administrative records results in many studies underestimating or discriminately masking racial bias in policing.
- In 1910, Black Americans owned over 14 million acres of land, but today our population of 40 million Black Americans own only 8 million acres.
- Black Americans own less than 1% of rural land in the country. The five largest white landowners own more rural land than all of Black America combined.
- “The Color of Law: A Forgotten History of how our Government Segregated America” provides a detailed history of racial housing policy. Here is a map of redlining in Lexington, KY in 1940.
- The Black poverty rate in 2018 was 22%. It was 9% in whites.
- The Black unemployment rate has been at least twice as high as whites for the past fifty years.
- The median net worth of white households is roughly ten times that of Black households.
- More recently, by April of 2020, among the estimated 36 million jobs lost due to COVID-19, roughly 40% were by persons with an annual household income of less than $40,000. Unemployment rates at that time were 14.2%, 16.7%, and 18.9% among white, Black, and Latinx individuals, respectively.
This is (one reason) why acknowledging race is important, and it is absolutely imperative we do so in medicine. Circling back to COVID-19, the racial disparities were not widely or immediately recognized in the early months of the pandemic because municipalities were not reporting data broken down by race and ethnicity. This color-blind approach clearly can be harmful: “To insist on color blindness is to deny the experience of people of color in a highly racialized society and to absolve oneself of any role in the process.” A recent report of leading ophthalmology journals found that in 2019, 88% of studies reported background information including patient age and sex, but only 43% reported race and/or ethnicity.
To summarize up to this point, race is a sociopolitical construct that serves to create systematic inequity. It harms individuals and communities and directly impacts health. For those reasons and others, it is essential that we report race in the literature and continually raise awareness of these inequities. Simultaneously, it is important that we recognize these are not inherent or biologic traits, but the result of social injustices. The next post will try and make this more personal, including a discussion on the role of implicit bias in healthcare. The final post will focus on ways we can respond, including plans within our program.