The COVID-19 pandemic affects us all, but it has taken an especially severe toll on Black and Hispanic state residents, magnifying inequities that have long produced worse health outcomes for people of color.
This reality has led to many policy proposals to address health inequities, as well as conversations that center on the role of racism in producing disparate health outcomes. In response, some have asked why focus on race or racism, rather than other factors, such as income, education, or geography.
As the leader of a foundation focused on health equity, I hear these questions often, and I would like to offer some answers.
First, why focus on race?
It’s important to understand that even controlling for income, education, and other factors, people of color face worse health outcomes than their white counterparts. For example, a Black woman with a college degree or higher is 1.6 times more likely to die from pregnancy-related causes than a white woman without a high school diploma. While other factors, such as income, play a role in health, we will not achieve equitable outcomes if we do not address race.
People often assume there could be genetic differences behind these disparities. While genetics contribute to some conditions, such as sickle cell anemia, there is no genetic explanation for the racial and ethnic disparities we see in conditions such as diabetes, heart disease, infant mortality, and adverse maternal outcomes.
So what causes worse health outcomes for people of color?
There are several explanations, both within the health care system and outside of it.
Research shows that Black and Hispanic patients receive less aggressive treatment than white patients. One study found that Hispanic patients were half as likely to be given pain medication in the emergency room when they had a broken bone. Another study of pediatric patients with appendicitis found that Black children and teens were significantly less likely to be given opioids to treat pain.
Among patients with heart issues, Black patients were significantly less likely than white patients to receive therapeutic interventions that could prolong long-term survival. While most health care providers aim to treat their patients equally, studies show that health care providers carry implicit biases that include negative attitudes toward people of color. Regardless of the cause, entering the health care system as a person of color can put you at a disadvantage.
There are physiological consequences of experiencing racism and discrimination. The stress of experiencing racism and discrimination can take a toll. Experiencing discrimination has been linked to negative health consequences including depression, anxiety, hypertension, breast cancer, and giving birth preterm or having a low-birthweight baby. One mechanism is the repeated activation of the body’s stress response system, which can have harmful effects on health.
Racism influences health in broader ways, too.
Racism is often conceived of as hateful acts or attitudes of individuals. Yet that only addresses part of the picture. Instead, we must also recognize the impact of structural racism – that is, the way policies, practices, and norms reinforce racial inequity. Policies from years ago that were designed to treat racial groups differently created an uneven playing field that still affects our society. Simply doing away with overtly racist policies did not dismantle the unequal playing field they created. We must create new policies that overtly undo the policies of the past.
One example is redlining, which began in the 1930s when a federal agency developed color-coded maps of neighborhoods and deemed those with more residents of color to be “high risk.” These classifications were used to deny home loans in “high risk” neighborhoods. As a result, Black and Hispanic families were significantly less able to build wealth through homeownership, contributing to a wealth gap that persists today. It also meant that certain areas had less funding for education and other critical services. Redlining is no longer legal, but its legacy continues today. A recent study found that among neighborhoods deemed “high-risk” by redlining, 74% struggle economically and in nearly two-thirds, the majority of residents are people of color.
Given this, it might not be surprising that people of color face many economic challenges that make it difficult to access resources that can help to stay healthy. For example, Black and Hispanic Connecticut residents are significantly more likely to experience food insecurity and unstable housing, lack access to a car, and to lack health care coverage.
The health care system is challenging for just about everyone. Focusing on equity doesn’t mean that people of color will be the only ones benefiting from improvements; it means ensuring that interventions designed to improve the system work for everyone, with a particular focus on interventions for those who are most often left behind. A system that works better for those who face the biggest barriers will be a system that works better for everyone.
None of this is to say that race is the only factor in inequitable health outcomes. There are many ways in which people can be at a disadvantage in trying to be as healthy as possible. At the same time, we must recognize the role that race and racism play. Using proxies such as income, education, or geography are not sufficient to eliminate the disparities that exist.
We cannot properly address a problem if we don’t understand its causes. Understanding the role of race and racism in inequitable health outcomes is a critical piece of the puzzle and must inform our actions and policy solutions.
Tiffany Donelson is President and CEO of the Connecticut Health Foundation.