October 20, 2020, 1:20 pm News Staff -- Family physicians are already well acquainted with the ways health equity affects their patients, but those who joined the virtual 2020 Family Medicine Experience on Oct. 13 learned about the roots of racial health inequities and what they can do about them.
Uché Blackstock, M.D., founder and CEO of Advancing Health Equity, LLC, a New York-based organization that partners with health care organizations and related agencies to address racial health inequities, touched on topics ranging from the historical aspects of racism in the American medical system to the effects of the COVID-19 pandemic on racial health disparities.
The following are highlights from her discussion.
Blackstock said research shows that Black people and other people of color fare worse than white individuals at every age and income level with regard to societal outcomes such as health, education, economic stability and incarceration rates.
As an example, Blackstock pointed to CDC data indicating that in the 1850s, the infant mortality rate was approximately 1.5 times higher for Black infants. While a century of improvements in hygiene, nutrition, living conditions and health care improved the overall infant mortality rate in the United States by 90%, by 2018 the difference in Black and white infant mortality rates had actually widened.
“If you notice the Black/white disparity, Black babies are more than twice as likely as white babies to die within their first year of life, which actually is a wider disparity than in 1850, 15 years before the end of slavery,” Blackstock said.
Blackstock noted that the United States is one of only 13 countries where maternal mortality rates have worsened over the last 25 years. She added that Black women in the United States are up to four times as likely as white women to die from pregnancy-related complications, and the maternal mortality rate persists regardless of socioeconomic status.
Blackstock related how preexisting racial health inequities impacted her own experiences with COVID-19. As the pandemic progressed, Blackstock saw changes in the racial and socioeconomic demographics of her patient population. “It became increasingly Black and brown, (with) more essential and service workers,” she said.
Blackstock then displayed a map of New York City that showed large variations in the concentration of COVID-19 cases by ZIP code, and a map of St. Louis that suggested a person’s ZIP code was a better predictor of health than genetic makeup. She used them to stress the point that no one factor or action is responsible for a person’s health.
“In our training and our education, we often are taught that individual choices are what dictate health outcomes, but that’s only a small fraction of what influences it. It’s really our larger social structures,” she said.
Several factors have contributed to the health inequities experienced by people of color during the pandemic, said Blackstock. These have ranged from questionable testing criteria to the presence of underlying medical conditions such as obesity and asthma, implicit bias and under-resourced health care institutions. “But what ties all of these factors together is systemic racism,” Blackstock said.
Blackstock said socioeconomic factors such as poverty and inequality have a bigger influence on patient health – and thus the greatest impact on health outcomes – than clinical interventions and counseling. “We need to figure out what is it that we can do besides what we do in the four walls of a clinic or a hospital that can really help our patients to improve health outcomes,” she said.
Blackstock pointed to differences in three main areas as causes of health inequality:
“All of these factors influence underlying health status,” Blackstock said.
So does systemic racism that adversely affects the health and education levels of communities of colors, she added, such as negative media portrayal, mass incarceration and lack of political representation.
“Often we hear about race being a risk factor for diabetes (or) high blood pressure, and what I want to emphasize to you all is that it’s not race. It’s racism,” said Blackstock.
Race, she said, is a social construct used to categorize human beings defined by physical characteristics and geographical ancestry. Racism, on the other hand, is a state-sanctioned system of social structures designed to produce race-based inequalities. It’s a system that reserves access, resources and structural power for those with racial privilege, she added.
Throughout the presentation, Blackstock linked historical occurrences with present-day health inequities, including a timeline of events she said every physician should know.
“In order for us to understand what communities of color have gone through in terms of the relationship between the institution of medicine and trust, and what’s led us to this moment where we actually see a high level of mistrust and distrust between communities of color and medicine, we need to understand and reconcile the history,” Blackstock said.
Blackstock told attendees of the experimental surgical procedures performed on enslaved women, without their consent – or anesthesia – by J. Marion Sims, M.D., in the 1840s. While Sims developed a technique for repairing vesicovaginal fistulas that allowed women to have normal lives after childbirth, Blackstock pointed out the economic incentive to Sims’ experiments. At the time, Black women were considered property, and Sims’ procedures allowed enslaved women to have more children, which increased their value to slaveowners since they were able to generate more “property.”
Non-consensual medical experiments continued into the 20th century, Blackstock said, along with compulsory sterilization, state-supported eugenics that targeted women of color and laws that prevented many Black people from accessing health care.
Mistrust was furthered, Blackstock said, by the stories of Henrietta Lacks, whose cervical cancer cells were obtained without consent in 1951 and are the source of the HeLa cell line still used in medical research today; the Tuskegee Syphilis Study, in which hundreds of Black men were infected with syphilis and never informed; and the early trials of oral contraceptive pills conducted in Puerto Rico in the 1950s.
Even today, people of color have unequal access to health care, and Blackstock cited the recent reports of medical neglect and unnecessary hysterectomies performed at Immigration and Customs Enforcement detention facilities as a further barrier to trust.
Blackstock also singled out federal programs that had effectively meant Black people could live only in certain areas.
“What we know is that many of the redlined neighborhoods across this country, when you look at the same maps that show where the highest rates of infant mortality are, where the highest rates of chronic diseases like asthma and diabetes are, and when you’re looking at life expectancy, these are the redlined neighborhoods,” explained Blackstock. “So (this is) just showing how federal policies from decades ago actually impact communities in the current day.”
Blackstock asked her audience to consider the challenges patients face, framed by the “Four I’s” of oppression – ideological oppression that says one group is better, institutional oppression, interpersonal oppression that might even be unconscious, and the internalized oppression that people have about themselves and others – and to envision change for their patients and their communities.
“Any effort to address health inequities has to really start upstream, even further upstream than the social determinants of health, and we have to, as clinicians, think more broadly about the determinants of the social determinants of health,” Blackstock said, such as economic systems and social hierarchies. These upstream factors influence other factors, such as physical environments and personal behaviors, which in turn affect disease levels, mortality rates and other health outcomes.
Blackstock asked her audience to envision structurally competent health care that addresses inequality. Structurally competent health centers, she said, should
Blackstock encouraged her audience to take action against the processes behind health inequities and to look for ways to make a difference beyond the individual or interpersonal levels.
“That’s definitely the lowest hanging fruit, but we have seen that in order to impact as many people as possible, we need to think more broadly,” she said.
Blackstock also asked participants to think about potential barriers to taking action and to look for resources to help them navigate and address these barriers. (The AAFP’s Neighborhood Navigator is one tool that helps physicians connect their patients with local resources.)
“We as physicians need to have a better understanding of what systemic racism has done,” Blackstock continued. “It’s not just at the interpersonal level, but there is a historical context for this (and) there is a current-day context for this,” she said, citing research showing that communities exposed to discriminatory policing may also be less trusting of medical institutions.
Finally, Blackstock encouraged her audience to be intentional in their actions. By doing so, she said, family physicians can intervene and advocate for their patients, address the impacts of racism on health and mobilize for health equity on multiple levels.