The Forum

Racism is a public health crisis. Here's why health care leaders beyond the US also need to address it.

by Asya Igmen and Rachel Zuckerman

This is the first instalment in our 'Global perspectives on racism in health care' series.

In recent weeks, protests for racial justice have broken out around the world, sparked by outrage over police killings of unarmed Black Americans, such as George Floyd in Minneapolis.

10 takeaways: How to build true health equity amid a global pandemic

Countries with their own histories of racial and ethnic prejudice, including Australia, Canada, and several countries in Europe, have experienced large-scale demonstrations of solidarity with the Black Lives Matter movement and political mobilisation against police violence and racial inequities. 

Why global health care leaders can't look away

Though most Western democracies promote social and economic equity more aggressively than the United States, for example, through stronger welfare states, universal health coverage, or multiculturalist government policies, none are immune to the pernicious effects of structural racism. 

Even if we look only at racial disparities in Covid-19 outcomes, we'll find that the new coronavirus has not affected every race equally:

  • In the United Kingdom, when compared with white people, Black people are more than four times more likely to die from Covid-19, and people of Bangladeshi decent are twice as likely to die;

  • In Canada, a one percentage point increase in the share of Black residents in a health region is associated with the doubling of coronavirus infection rates;

  • In the United States, counties with Black majorities have almost six times the rate of deaths compared with white-majority counties, and the death rate for Indigenous people in Arizona is almost six times higher than it is for white people;

  • In Brazil, deaths among Indigenous populations are double those of the general population; and

  • In Norway, people of Somali origin have Covid-19 infection rates more than 10 times above the national average.

Take a moment to digest these numbers. In virtually every country where the data is available, being a person of colour—and Black or Indigenous specifically—is associated with a higher likelihood of dying from Covid-19. That is the very definition of inequality.

While Covid-19 provides the most recent evidence, race-based health care disparities are not new. Data shows that Black women in Canada are 43% more likely to die of breast cancer than white women. In the United States, Black men are 19% more likely to die of cancer than white men. Pre-existing diabetes is 3.6 times more prevalent in Indigenous compared with non-Indigenous pregnant women in Australia. In New Zealand, life expectancy at birth is seven years lower for Māori people than non-Māori people.

Many providers want to believe that these inequities do not exist in their own communities—and if you're not collecting organisation- and community-specific data, these disparities may not be obvious or recognised. But the truth is that they persist in most systems and jurisdictions around the world.

So why is race still so strongly influencing health and longevity? Health care providers need to know the answer to this question.

The three ways race influences health outcomes

There is undoubtedly intentional interpersonal racism in health care interactions around the world. But much of the reason why Black, Indigenous, and people of color (BIPOC) individuals face worse health outcomes is less explicit: unconscious biases that shape care decisions and societal systems that perpetuate disadvantages.

Within the four walls of any health care facility, two key sets of race-related factors can affect care outcomes:

  • Relational factors, which are differences in health care providers' decisions and care for BIPOC individuals, driven by conscious or unconscious biases; and

  • Systemic factors, which are related to the complexity of the health care system and how it is poorly adapted to the specific needs of BIPOC patients.

Beyond the health care system, there's an additional factor: structural racism, also called systemic racism. The non-profit think tank The Aspen Institute defines this as 'a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity'—with or without intentional bias on the part of individual participants.

Structural racism shows up in many forms, including in the fact that Black and Indigenous people are more likely to live in low-income communities, lack access to health care and key social goods (such as healthy food), and have higher rates of chronic conditions. These are among the root causes why BIPOC patients have been dying from Covid-19 at a higher rate than white people, and the root causes of why BIPOC individuals face worse health outcomes.

Just because many of these health disparities aren't driven by intentional bias doesn't mean health care providers and leaders can abdicate the responsibility to address them. Rather, this should provide an even greater impetus to address the factors harming our patients. As our colleague Micha'le Simmons recently said: 'If your mission as a health care organisation is to deliver patient-centred, high-quality care, we cannot deliver on this mission unless we address racism.'

What can you do?

In our next post, we'll explore concrete actions you, as a health care provider or leader, can take to stem racism in health care.

Until then, join us in educating ourselves on the impact of race and ethnicity on our communities' health and wellbeing. We recommend starting here:

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