As a woman practicing medicine, raised by a first-generation immigrant father and Hispanic mother, I fit the image of an underrepresented minority. Yet my education and position belie that stereotype.
As a young girl, I remember walking in our small town in Maryland watching my Indian father’s expression harden and eyes dim as he held back from reacting to racially directed comments—shouted as we walked by—urging him to return to his “home country.”
I didn’t understand at the time what racism meant or the traumatic impact that repeated experiences could have on health. Lately I have understood it all too well.
The recent shootings at a California synagogue and a New Zealand mosque, as well as acts of hatred at the university where I teach and work, demonstrate the ongoing prevalence of racism in places of religious worship and institutions of higher education—places where tolerance is generally promoted.
These events remind us of the collective responsibility we have to acknowledge and address racism.
Recognition of widespread health inequities in minority populations is growing, as is awareness that disparities in the adult population are mirrored in the pediatric population. As a pediatrician, I see firsthand that poverty is a key driver of poor health.
I have seen families struggle to keep children with chronic medical illness living at home because of their socioeconomic state. Often these children need home nursing support, but their family’s only housing options are limited to areas where agencies cannot get nurses to travel. These children come into the hospital sicker because they cannot get the support they need at home and can get stuck in the hospital when we are not able to find sufficient nursing support for them to be able to be at home with their families.
Emerging research addresses how socioeconomic status can impact individuals at the level of their genes and thereby influence their health. Although it is often assumed minority race and ethnicity are associated with lower socioeconomic status, in reality, minority race and ethnicity are independently linked to worse health.
Some researchers have reported that race makes one susceptible to worse health outcomes, but others have cautioned against the risk of treating race as being biologically related to poor health. Instead many of us have advocated for evaluating practices and policies that may change how certain minority racial or ethnic groups gain access to the highest quality care. This is an important difference because while we can’t change a person’s race, we can change practices and policies that make certain racial groups less likely to get the best health outcomes.
Indeed, for many reasons including economics, geography, insurance and more, some patients do not have access to the highest performing health care institutions. That lack of access can influence health outcomes for racial and ethnic minorities.
Even within institutions, racial and ethnic disparities may exist, related both to health outcomes and to patient experience. For instance, at several different hospitals, I have seen how the lack of doctors and nurses from racial and ethnic minorities can lead to racial and cultural barriers between health care providers and families. These barriers often place a strain on communication, which can impact how families make decisions for their child.
Medical schools have increasingly recognized the need to educate students on social determinants of health—a broad term used to encapsulate key socioeconomic factors impacting health such as economic stability, access to education and health care, housing and food security.
I am currently working with a Health Resources and Services Administration–supported national collaborative on efforts to identify and promote best practices for educating future health providers about social determinants of health and potential avenues to address them. This is an important first step towards a needed change in mindset from thinking about individual patient symptoms to including the broader social context in which our patients live.
Acknowledging that implicit racial bias and overt racism contribute to poor health, experts who were part of a study to determine the most important topics to teach about social determinants of health called for curricula to include racism, discrimination and stigma as core elements. Education about racism and bias is important because unconscious bias may lead us to treat individuals of certain racial groups differently. Although unconscious biases often cannot be changed, awareness of our biases can lead us to exercise more care in how we act towards groups that are especially vulnerable to them.
The education of future medical providers is surely an important step in creating a future health care workforce that is sensitive to the impact of racism on health. Health institutions are moving this education into communities of practice to ensure that providers at all levels—including those who are training the future generation of health professionals—have knowledge of the impact of racism on health outcomes, can recognize the role of implicit bias as a subtle form of racism, and appreciate the importance of a diverse workforce.
Training at multiple levels through medical schools and hospitals has the potential to reach large numbers of health providers. However, training only in medical schools and hospitals is not enough. For meaningful change in health outcomes related to racism at the community level, efforts must extend beyond health care institutions.
Implicit biases are present in young children as early as preschool. Yet, recent research also suggests that diversity in the school environment can have a positive influence on students’ health. Using health education as a model, schools across the educational continuum can be important partners in addressing bias and promoting tolerance to create the needed cultural shift over time.
Corporate codes of conduct and professionalism need to include bias training for employees and leadership.
Promoting recognition of the ill effects of bias and racism as adverse experiences—like recent efforts to implement a statewide trauma-informed awareness day—is an important step towards the development of a policy mindset that is sensitive to the health impacts of such experiences, particularly in young children.
Even if we are not the direct recipients of overt racism, everyone must contribute to the discussion to change the social context in order to raise a healthier next generation.
I understand now what I didn’t as a child: that racism is bad for everyone’s health.