Medicine, structural racism, and systems

Abstract

Medicine is having a reckoning with systemic racism. While some continue to believe medicine is apolitical and grounded purely in science, history and research reveal that medicine is inseparable from underlying systems, laws, and policies. Obesity is a useful case study. Weight loss trials have shown the immense difficulty in achieving and sustaining weight loss without addressing overlying systems. Barriers are double for Black, Indigenous, and People of Color (BIPOC) with obesity, who must contend with multiple layers of oppressive systems. Increasingly, illness is not a matter of bad luck, but is a function of oppressive structures. COVID-19 likely originates in a deteriorating environment, we have an increasing global burden of disease from oppressive sales of food, sugar, alcohol, guns, nicotine, and other harmful products, and social inequality and resource hoarding are at a peak. Medicine can and must participate in redefining these systems. In doing so, it must center the experiences of BIPOC and push change that alleviates power disparities.

Medicine is having a reckoning with systemic racism. Several medical journals recently issued apologies after being accused of downplaying or contributing to structural racism (Srikanth, 2021). Many physicians and other health providers, particularly those within racial and ethnic minority groups, have pushed for years to have recognition of structural racism’s broad impact on health. A recent raft of articles in prominent medical journals has pressed physicians and biomedical researchers to examine the ways racism can shape their work and to ask more appropriate research questions that respect the history and current reality of racial and ethnic minorities in the United States and abroad (Merchant et al., 2021; Boyd et al., 2020; Ogedegbe, 2020). We are at a pivotal moment where the medical establishment must make sincere efforts to introspect, learn to see in new ways, and make amends.

Many physicians continue to believe that medicine can be apolitical, fully science-based, and focused on the individual patient. Most prominently, Dr. Stanley Goldfarb, prior dean of the University of Pennsylvania Perelman School of Medicine, wrote that teaching health inequities comes at the expense of medical science training (Goldfarb, 2019). He added that this new “politicized” medical education should “worry all Americans.” (Goldfarb, 2019) While Goldfarb’s article was widely criticized, his view is shared by many physicians with power today. Goldfarb’s view suggests that physicians should prescribe appropriate treatments to patients, accepting the social environment, including racial inequities, as a given.

Unfortunately, medicine is not a bystander to racial inequities, but actively participated in them. Historically, medicine made “strides” off harming and using the bodies of people of color (Bajaj and Stanford, 2021; Skloot, 2011). The American Medical Association (AMA) and other medical organizations have a history of discrimination against physicians from underrepresented groups (Baker, 2014). Black, Indigenous, and People of Color (BIPOC) continue to suffer mistreatment by the medical establishment and diminishment of their claims of discrimination and other harms (Feagin and Bennefield, 2014). At pivotal moments in history, medical organizations such as the AMA opposed expanding health care in ways that would benefit BIPOC (Michels et al., 2018).

Medicine cannot separate itself from the systems that shape it. Rather than shy away from new perspectives, in a country with such ethnic and racial diversity as ours, we must recognize, see, and respect those with whom we live. That includes on the interpersonal level—doctor-to-patient—and on the systemic level.

1. The role of law

Law, in a way, has achieved much faster progress at examining racism in medicine than medicine has in evaluating itself. The critical legal studies movement has revealed how seemingly race-neutral systems entrench privilege and distribute resources from disempowered to those with power (Bridges et al., 2017). Law has taken on this role partly because of its historic ties to racial inequality, from Plessy v. Ferguson to Brown v. Board of Education, but also because law is concerned with systems. The legal writers who brought attention to racial power disparities often did so at great personal cost (Tushnet, 1991). Many of their ideas have been adopted by members of the Black Lives Matter movement, who have stirred broad criticism of racialized power dynamics embedded in law and its enforcers (Akbar et al., 2021).

Though medicine appears to be centered on individual patients, it is situated in a larger system shaped by law. Law determines who has insurance, what treatments are covered, whether there is protection against discrimination and harms, and whether BIPOC have equal access. Every dollar of government money spent must be spent through passage of a law, according to our Constitution. Every agency that regulates medicine and public health is established by law. Law has tremendous power over the social environment and over medicine. Sadly, many legal regimes contribute to oppression of BIPOC (Staggers-Hakim, 2018), and this is especially true in medical law, where comprehensive, equitable, and culturally appropriate health care remains elusive.

Some defensive physicians have argued that medicine should not concern itself with social policy, which could distract from the individual patient (Goldfarb, 2019). However, law, systems, and medicine are interconnected.

2. The case study of obesity in BIPOC

Obesity is a challenging disease for many physicians. The reasons are many, but it is known physicians generally have little training or confidence in counseling patients about obesity and nutrition (Devries et al., 2019; Butsch et al., 2020). Further, obesity treatments are often not covered by insurance (Jannah et al., 2018), despite public support for obesity care (Woolford et al., 2013). As a result, fewer than 2% of patients receive the standard of care in obesity treatment (English et al., 2020.

Physicians who work with minoritized patients with obesity are hindered by existing systems infused with structural racism. Although 81% of the public supports private insurers covering obesity treatments, only 55% of the public supports coverage by Medicaid (Woolford et al., 2013), which is disproportionately used by BIPOC. A 2010 study found that patients on Medicaid are 80% less likely to receive bariatric surgery than patients on private insurance, all else being equal (Wallace et al., 2010). Medicaid and Medicare have limited coverage of bariatric surgery to high-volume urban “centers of excellence.” (Wallace et al., 2010) Twelve states still have not expanded Medicaid, leaving more than 2 million Americans in a health care coverage gap, more than half of whom are BIPOC (Lukens and Sharer, 2021). Research has observed that states with more BIPOC are less likely to expand Medicaid, and that this difference is largely explained by lower levels of white support in states with more diversity (Grogan and Park, 2017). Beyond Medicaid, BIPOC generally are less likely to be diagnosed with obesity (despite higher rates) (Davis et al., 2009), have less access to health care, and frequently experience racism when they do access care (Feagin and Bennefield, 2014). As a result, BIPOC have less access to important evidence-based treatments for obesity, such as bariatric surgery (Byrd et al., 2018), a treatment that is effective with Grade A evidence according to the American Association of Clinical Endocrinologists (Garvey et al., 2016). Likely, these access limits intersect with physician biases in harmful ways. For example, within Medicaid, Black and Hispanic adolescents with severe obesity are far less likely to receive bariatric surgery than similar white adolescents (Perez et al., 2020), suggesting bias in referral patterns of providers.

Even more, obesity is significantly rooted in oppressive social structures. Many trials of obesity treatments have demonstrated the immense challenge to achieve and maintain weight loss (Purcell et al., 2014; Turk et al., 2009). Barriers are double for BIPOC; trials show Black patients consistently lose less weight during behavioral therapy than white patients (Byrd et al., 2018). These trials occur while embedded in racist systems and obesogenic environments, which highlight the futility of treating obesity in a siloed manner. Indeed, racism has been implicated as a cause of obesity as demonstrated in the Black Women’s Health Study (Cozier et al., 2014). And the obesogenic role of Western corporate food systems is well recognized (Swinburn et al., 2011). Courts have increasingly protected marketing and advertising as “commercial speech” under the Constitution’s First Amendment, leaving processed food companies largely unregulated (Kapczynski, 2018; Pomeranz, 2010) as they market unhealthy, sugary products disproportionately in BIPOC communities (Aaron and Stanford, 2021). Yet physicians, frustrated by lack of weight loss among their patients, often settle their frustration by blaming the patient. The lack of recognition of how racism and food systems lead to worsened clinical disease of obesity demonstrates that clinicians are inadequately equipped to factor racism and social determinants of health into the care plan of patients with obesity (Aaron and Stanford, 2021). BIPOC with obesity suffer from two levels of oppressive systems, each with many layers, that physicians should learn to recognize.

Obesity among BIPOC is an issue that shows promise in public health and racial equity policies. These policies operate at the systemic level to increase accountability of institutions and corporations that detract from, or fail to support, public health and fail to center equity of BIPOC. There are many options for change that can be fleshed out by strengthening connections with social movements and building more participatory structures in which people of all racial and ethnic groups can partake in research, policy and lawmaking, and systems redesign.

3. Intersecting systems

Increasingly, modern illness is not haphazard or due to bad luck, but it is a function of harmful systems. Given COVID-19 is likely a zoonosis, it would be a mistake not to examine its likely root cause in a deteriorating environment (Morens and Fauci, 2020), as well as the effects of climate change on health more generally. Health is heavily shaped by products that are sold on the market in oppressive ways. These include ultra-processed food, sugar, alcohol, guns, opioids, stimulants, and nicotine. And we suffer from inadequate responses of people, politicians, and structures to social inequality, deprivation, and resource hoarding. These responses range from apathy to ignorance to profiting from the status quo. It is even more striking that these responses continue in the face of clearly visible dire need, overt daily racism, and commodification of basic necessities such as health care and housing.

Medicine is having a reckoning with structural racism, and systemic problems more generally. Physicians carry a powerful voice in modern discourse. Rather than shy away from social problems, physicians can and must participate in defining the structures that shape our health.

As part of this reckoning, physicians can play several roles, which include the following: First, they can amplify the voices for change of patients and providers and protect these people from punishment or retaliation. Second, physicians can bring social causes of disease into the exam room, name them, discuss them with the patient, and cite them in the medical record where pertinent. To the extent possible, physicians should be creative in integrating social factors into the care plan. At minimum, these discussions can alleviate the stigma caused by racism and stigmatized diseases such as obesity and addiction, but it can also foster efforts to change the patient’s social conditions where possible (Stanford, 2021). One doctor in western Canada recently cited climate change as a diagnosis in a patient’s medical record after the patient was admitted during a climate change-induced “heat dome” (Hammond, 2021). Third, physicians can form alliances across fields and across identity groups, while emphasizing those at the center of intersecting systems. We can learn from the example of BIPOC with obesity suffering the most harm to engage stronger collaborative efforts and build a larger collective voice to better address the social factors and laws contributing to modern disease.