“It’s been a rough 2020 Doc,” said the middle-aged African-American female patient in response to my inquiry about stress during her visit for a “missed period.” She proceeded to share how she had lost three family members to COVID-19 within the last week, how her job as an “essential worker” was requiring her to report to work the following week, and how she has to try to hold it all together for her remaining living family members. We cried together and I thought to myself, “We failed her and her family… the system is failing…something has got to change.” As providers who have suffered personal losses of family and friends from this pandemic, we find ourselves with an uncomfortable commonality—the effects of systemic racism. The time is now to tackle systemic racism—here is why and how.
In recent decades, the intersection of racism and health in America has gained more attention; however, our experience of racism and health in America stretches for much longer. From the transatlantic slave trade, hundreds of years brutal violence, dehumanization, forced labor of millions of Africans to Jim Crow laws, involuntary and nontherapeutic experimentation of African Americans, the systematic removal of indigenous people from their native lands, and redlining, our country and its institutions are deeply rooted in racism and oppression. Systemic racism (also referred to as institutional and/or structural racism) includes the rules, policies, practices, and customs ingrained in systems and society that disadvantage and/or lead to the discrimination against or exclusion of designated racial groups, and further reinforce inequities.1 Manifestations of systemic racism can be found at every level of society from housing, employment, education, criminal justice, levels of wealth, and health care today. Hundreds of articles and books have shed light on the systemic racial inequities within medicine. More recently, data showing the excess morbidity and mortality among African Americans and Indigenous Americans with COVID-19 as well as higher COVID-19 incidence rates in Latinx populations has highlighted the health effects of systemic racism.
In addition, we witness a rise in harassment and hate crimes towards Asian Americans and wake up to repetitive images of Black men and women losing their lives at the hands of law enforcement officials, adding insult to injury. Systemic racism in the United States significantly limits persons from marginalized groups’ ability to participate fully and optimally in society. In addition to racism’s physiological and psychological impacts on individuals from marginalized groups, systemic racism impacts patient-provider relationships, access to high-quality care, evidence-based screenings and interventions, and diagnostic and treatment decisions. All contribute to poorer health and well-being, especially perpetuating health inequities of Black, Indigenous, and Latino populations. Systemic racism in medicine and society must be named and dismantled to truly achieve our goals of optimal and equitable care for all.
In May 2019, Dr. Camara Jones charged the Society of General Internal Medicine membership to identify and address the mechanisms by which our healthcare systems perpetuate racism. We are proud to call SGIM our professional home as SGIM and its members have long been at the forefront of addressing racism in the fight for social justice and health equity locally, regionally, and nationally through position statements, workshops, symposia, health equity research, articles, interviews, webinars, and advocacy for policy reform. SGIM’s Health Equity Commission’s 2016 symposium, “The Population Health Impact of Racial Bias and Social Injustice,” and recent webinar, “Lessons Learned From the Past: Addressing COVID-19 Disparities for a More Equitable Future,” along with SGIM’s separate statements on addressing social determinants of health and ensuring equity amid the COVID-19 pandemic are a few examples.2, 3 Yet, there is still so much work to do and progress to be made.
In keeping with SGIM’s long history in seeking to educate, lead, and advocate for policy change in America, many of SGIM’s members have either led the charge for or participated in our healthcare centers’ condemnation of racism through drafted statements, moments of remembrance, town halls, signage, and social media posts. While heartwarming and necessary first steps, the validation that racism exists and solidarity through hashtags, public statements, observances, and task forces are not enough to truly end racism and achieve health equity.
Healthcare institutions must prioritize anti-racism efforts and invest time and resources in the form of funding, personnel, and training specifically for these efforts. In addition, we must commit to addressing systemic racism in medicine through a restorative justice lens, one through which we help black, indigenous, and people of color (BIPOC) communities heal from years of injustice. We can create space for our BIPOC patients, learners, and colleagues to express anger, hurt, and frustration. Furthermore, dismantling racism must be intentionally weaved into every aspect of what we do from clinical care; curricular development; assessment of learners, faculty, and clinical and administrative staff; research and scholarship; development/revision of institutional policies and practices; and advocacy for local and national policy reform. Healthcare professionals, administrators, and other health center staff who fail to incorporate the work of dismantling of systemic racism into their work, must realize that one’s inaction does in fact perpetuate health inequities. Racism is a public health emergency and calls for “all hands-on deck.”
Boyd and colleagues have highlighted how scholars, medical journals, and healthcare institutions have failed to “interrogate racism as a critical driver of racial health inequities.”4 These scholars go on to suggest the necessary rigorous standards for publishing on racial health inequities for researchers, journals, and reviewers including naming racism, soliciting patient input, and citing experts, particularly BIPOC scholars in research and scholarship efforts.4 Furthermore, Hardeman and colleagues have outlined five principles to aide medicine in tackling systemic or structural racism in order to effectively promote health equity:5
- Divest from racial health inequities by restructuring the intentionally tiered health insurance market (e.g., consider universal health care models).
- Desegregate the health care workforce by extending opportunities specifically to BIPOC communities (e.g., invest in pipeline and training programs, and intentional recruitment, hiring, retention, and promotion practices).
- Make “mastering the health effects of structural racism” a professional medical competency so that every clinician is empowered and equipped to address racism.
- Mandate and measure equitable outcomes specifically for addressing structural racism just as healthcare systems and providers are required to meet safety and quality standards.
- Protect and serve. Ensure patients’ best interests are served and advocate for an end to causes of preventable death such as police brutality (and other social injustices).
Many BIPOC health professionals and allies who have been working on antiracism, social justice, and health equity efforts are exhausted. Many BIPOC have courageously shared their personal disheartening past and present experiences with racism in medicine in #BlackintheIvory twitter stories yet so many stories remain untold. Hearing these present-day reminders, it may appear that the medical system is failing us. Yet, we remain hopeful that the heightened awareness and current focus on systemic racism will create more collaborations, empower more educators, researchers, leaders, and advocates. We are energized by our learners who are leading efforts such as “White Coats for Black Lives” and encouraged by all who are already doing this necessary work.
When we tell future generations about 2020, how will we remember it? Will we remember it as a “rough year,” a year of death and injustice? Or as the year that prompted the renewal of a revolution to move our ideals of health equity for all forward? We, as healthcare providers and institutions, have the power and privilege to dismantle systemic racism in medicine and society and to have a meaningful impact on the well-being of the communities we serve, if we all commit to continuously work towards this goal. We end this article with a quote from James Baldwin’s The Fire Next Time that reminds us of the alternative:
“…We are living in an age of revolution….and that America is the only Western nation with both the power and, as I hope to suggest, the experience that may help to make these revolutions real and minimize the human damage. Any attempt we make to oppose these outbursts of energy is tantamount to signing our death warrant.”6