By Nithya Gurumurthy

Introduction

Racism in America affects people of color in multiple aspects of their daily lives, however, healthcare discrimination is especially impactful, as these inequities can have impacts that can be carried past health detriments. Racism in healthcare has become widely accepted, and therefore, it is not often addressed. Many people do not recognize this bias since it is often unconscious or “aversive” racism (Dovidio et al., 2008). This discrimination can affect different racial groups in different ways. African Americans are the victims of both implicit and outward racism. Generally, when the public thinks of healthcare discrimination, they imagine the Black experience; however, other racial groups, such as Asians, also face healthcare inequities. This discrimination is especially targeted toward those who have immigrated to the United States, victimizing those who are not fluent in English. These maltreatments have become a new norm for minority groups, almost so much that they fail to recognize the racial bias projected toward them, similar to the way white patients do not understand their own privilege. Many believe that since they have “normal” medical experiences, they are the same way for everyone, even though this is not the case.

African American Experience

According to a nationwide poll done by The Undefeated and the Kaiser Family Foundation, 55% of African Americans distrust the American healthcare system (Fletcher, 2020). This distrust has been prevalent for years, beginning over a century ago, but the most alarming case of maltreatment was the Tuskegee study in 1932 (CDC, 2020) The consequences of this study have endured for decades. The study involved 600 black men, almost ⅔ of whom had syphilis. Researchers told participants that they would be tested for various blood disorders, however, those with syphilis were not told that they had contracted the disease. While these White physicians knew about their diagnosis, they prolonged the study for 40 years instead of treating them with antibiotics. This negative treatment created a broken relationship between the American healthcare system and African American patients. This distrust often discourages Black Americans from seeking medical care, even when they need it (Dovidio, 2005). Since they do not feel comfortable enough to seek medical care, Black Americans have poor health compared to White Americans, which further contributes to the negative societal perception of the Black patient.

Negative perceptions of the Black Americans result in physicians forming preconceived notions about their patients of color. This bias results in Black patients receiving a lower quality of medical care than White patients. Bill Kearney, a Black American who grew up in Warren County, NC, recalls on the medical treatment he received during his interview for the Southern Oral History Project:

The staff in one part were white, the staff in the other part were black, so I believe that that impacted the quality of service we got or the availability of services. But we did go to doctors or hospitals, but usually it was during a crisis or emergency. Otherwise, information would be sought through the health department or the school nurse, you know, and then the treatment was done at home if it was for a cold or mumps or the measles or strep throat or something of that sort. (Kearney 12:10)

Kearney expresses his frustration with the healthcare system and the clear partiality it shows toward White people. Kearney lived during the Jim Crow era when Black students received a lower quality of education. Since they were unable to provide the same care as White physicians, many Black physicians felt imposter syndrome. Both Black providers and patients face constant negative consequences of systematic racism, showing that there must be a fundamental change in healthcare programs across the country.

Asian American and Immigrant Experience

While healthcare discrimination towards African Americans can be incredibly devastating, they are not the only racial group that faces these problems. Asian Americans are also victims of inequalities in healthcare, receiving a lower quality of care than White Americans.

People of color are often generalized into one category of “non-White” when viewed by those who are white. First, these people should be viewed as Americans before they are categorized by their skin color, especially when it comes to healthcare. Lata Chatterjee shares her experiences as an immigrant from India in her Southern Oral History Project interview. She tells the story of her physicians’ first prognosis of her mononucleosis:

Of course, the health clinic was convinced I had a tropical disease and they kept on, kept on trying this, trying that, trying that, and eventually I realized, “They’re going to kill me,” because they couldn’t find any tropical disease. African disease, Indian disease, every kind of disease they were testing me for, when nobody did a simple test to find out if I had mononucleosis. It didn’t even occur to them. (Chatterjee 31:17)

Chatterjee explains that physicians believed that since she was foreign-born, she must have a “tropical disease” and that she was tested for “African diseases,” even though she is Indian. This also highlights the experience that many immigrants of color face. Physicians immediately assumed that her illness was a foreign disease, and they did not consider mononucleosis for her diagnosis.

While Chatterjee was able to speak English well when she emigrated from India, this is not always the case for immigrants. A study done by the Medical Care journal in 2002 outlines the impact of lack of English fluency on healthcare treatment. The journal found that immigrant parents cite language fluency as the largest barrier to healthcare access for their children (Fiscilla et al., 2002). In addition, these non-English-speaking patients were significantly less likely to have had a physician visit, a mental health visit, or a vaccination, even compared to immigrant patients who were fluent in English. This indicates that medical professionals have a predetermined opinion about those who cannot communicate in English, as if they are subordinate to those who can, resulting in a lower quality of medical care.

White American Experience

White Americans often do not recognize racial biases when they occur in front of them. They choose to deem these behaviors as “normal,” rather than seeing them for their racist undertones. Jeffrey Balfrey, a White man who grew up in Albemarle, N.C., talks on his childhood ignorance toward racial issues:

And he also had a room in there for black people. Black people were not allowed to sit out in the white—in the room with the other—I didn’t understand. I remember one time seeing that. Sometime I was sitting there, and they opened the door, and the black— there was a whole roomful of black people. I’m like, that’s strange, but that’s about it. (Balfrey 19:08).

Balfrey explains that he always felt like something was off and that the segregation he saw was wrong, but he thought that was the way it was supposed to be, so he did not question it. This anecdote supports Fiscella’s claim in the Medical Care journal that suggests that White people may notice these behaviors but do not take action against them. Since they do not see these problems as racial bias, they do not feel responsibility to do anything about it (Fiscella et al., 2002). When this happens, they begin to make excuses for themselves and other White people, instead of holding each other accountable. When people are not held accountable, the problem persists instead of encouraging people to take action to make a change.

Effect on Identity

These negative experiences that people of color face in healthcare are often translated into other aspects of life, including mental health, social health, etc. The imposter syndrome that Black physicians face can be detrimental to their own mental health, which can lead to physician burnout or compromised quality of care (Fiscella et al., 2002). For immigrant patients, the negative care that they receive may cause them to begin feeling like even more of an outsider in their own country. If racism in healthcare is widely accepted, society will begin projecting these beliefs into other aspects of life (Kawachi et al., 2005). When people of color receive a lower quality of medical care, they also will have poorer health, which leads to negative perceptions of these groups by American society. While White people do not have to think about these negative perceptions, people of color are forced to carry this discrimination with them, as perspectives “impact the way you navigate a system” (Kearney 14:42).

Conclusion

While the unequal treatment of racial minorities in the American healthcare system has prolonged for years, it must be identified and treated at its core. African Americans feel uncomfortable seeking medical care, while immigrant families feel as if they are subordinate, all while White Americans refuse to acknowledge the problem at all. There must be a systematic change, which can include programs that promote implicit bias training for residents, similar to the ones that Sammy Zakaria has begun to implement in his internal medicine program in Baltimore (Zakaria et al., 2015). These programs strive for the future of physicians to become aware of these inequities so that they can slowly be eliminated. Once these biases can be eliminated, it will bring America one step closer to equality in all aspects of life.

Resources

Balfrey, Jeffrey. Interview with Caroline Efird, 24 June 2018, Y-0004 in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Chatterjee, Lata. Interview with Nick Allen, 11 December 2018, Y-0084 in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Dovidio, John F, et al. “Disparities and Distrust: The Implications of Psychological Processes for Understanding Racial Disparities in Health and Health Care.” Social Science & Medicine, vol. 67, no. 3, Aug. 2008, pp. 478–486., doi:10.1016/j.socscimed.2008.03.019.

Fiscella, Kevin, et al. “Disparities in Health Care by Race, Ethnicity, and Language among the Insured: Findings from a National Sample.” Medical Care, vol. 40, no. 1, Jan. 2002, pp. 52-59., https://www.jstor.org/stable/3767958.

Fletcher, Michael A. “Poll: Black Americans See a Health-Care System Infected by Racism.” History, National Geographic, 16 Oct. 2020, www.nationalgeographic.com/history/article/black-americans-see-health-care-system-infected-racism-new-poll-shows.

Kawachi, Ichiro, et al. “Health Disparities By Race And Class: Why Both Matter.” Health Affairs, vol. 24, no. 2, 2005, pp. 343–352., doi:10.1377/hlthaff.24.2.343.

Kearney, Bill. Interview with Anna Freeman, 28 June 2018, Y-0034, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Tuskegee study – timeline – CDC – nchhstp. (2020, March 02). Retrieved April 08, 2021, from https://www.cdc.gov/tuskegee/timeline.htm.

Zakaria, Sammy, et al. “Graduate Medical Education in the Freddy Gray Era.” N Engl J Med, vol 373, no. 21, Nov. 2015, pp. 1998-2000. doi: 10.1056/NEJMp1509216.