1

Racism in the Healthcare Setting

Anna Robson

California State University, Channel Islands

HLTH 499

Dr. Winans

5 March 2021
 2

Racism in the Healthcare Setting

Racism is an extremely pressing global topic in the modern world, specifically the racism

that occurs in America. It has been a structural, institutional issue since the founding of this

country, where the ideals and values are supposedly opportunity, freedom, and prosperity, yet

they are seemingly reserved for white people. The historical and contemporary policies,

practices, and norms maintain the structure that still oppresses people to this day. Many

improvements have been and are being made as the awareness and demand for equality grows

worldwide, but there are still miles we must go as a country to reach true equality, including

secure quality education, jobs, housing, healthcare, and equal treatment in the criminal justice

system. Healthcare in the United States is a major topic because a large portion of the population

remains uninsured. There is a major health disparity that is seen based on race in relation to

health outcomes. Many studies have shown that there is clear institutionalized racism, personally

mediated racism, and internalized racism happening in the healthcare field, and that it creates

lesser health outcomes for people of color.

The Relationship Between Racism and Health Outcomes

Many factors contribute to the racism that is seen in healthcare; sometimes it is bias or

prejudice, while other times it is simply communication issues occurring between the doctor and

patient. In the American healthcare system, a system referred to as shared decision making

(SDM) is commonly used, where clinicians collaborate with patients to reach evidence informed

and value-congruent medical decisions. It creates a more direct role for patients in their own

outcomes since they can express their personal preferences in how to proceed with the treatment

process, working together with the doctor and clearly communicating what they intend their

outcome to be. This system is extremely effective in improving health outcomes. According to
 3

Peek, M.E. et al (2010), in a general survey performed asking patients their preferences about

shared decision making in the healthcare field, there was no difference in responses interracially.

This leads to the questions: why is there racial inequities in terms of health outcomes? And, how

can we fight for health equality?

Racism and Physician/Patient Miscommunication

Miscommunication between a physician and patient is a complex concept, and based on

many studies, the reason for continual miscommunications is specific forms of racism. It is

important to be aware of such miscommunications because those alone lead to lesser health

outcomes for certain races compared with other races, especially because with a shared decision-

making healthcare system, there is a need for clear communication. A study was done using the

Camara Jones framework which directly links racism and discrimination to healthcare outcomes

(Peek, M.E. et al, 2010). This framework is focused on the three levels of racism:

institutionalized racism, personally mediated racism, and internalized racism.

Types of Racism Seen in the Health Field

Institutionalized racism is seen in differential access to goods and services based on race.

Institutional racism contributes to the health disparities in the U.S. and is reflected in the

disproportionate percentages of those who have health insurance when it is broken down by race.

In the United States, in 2019 only 9.8% of the white population was uninsured, while 27.2% of

the Hispanic population was uninsured and 13.6% of the Black population was uninsured

(Elflein, 2020). An institutional problem is presented in these statistics alone because the system

is set up so that specific races have a much harder time attaining a higher ranked job where they

would get quality health insurance. Instead, they are uninsured and unable to break the structural

glass ceilings. Personally mediated racism happens in direct communication with the patient.
 4

This is seen when one has prejudice, assumptions about the abilities, motives, or intentions of

those of other races. It can also occur in a form of direct discrimination, where a physician acts

differently towards others due to their race, manifesting in the forms of disrespect, poor service,

or failure to communicate all the options to those of specific races (Peek, M.E. et al, 2010). It is

quite common for this to occur subconsciously, meaning that one is mentally exaggerating the

interracial group differences and overgeneralizing a specific race in general without being fully

aware of what they are doing. Whether or not it is done consciously, it is extremely powerful

because bias in one’s mind leads to distrust in what the patient is talking about or whether they

will follow through on all the treatments that have been discussed. The final form of racism that

contributes to lesser health outcomes is internalized racism, which is seen when those of races

that are often stigmatized begin with distrust, hesitance, and helplessness because they are used

to being brushed off by anyone who is in a position like a doctor.

Analysis of Racism, Miscommunication, and Health Outcomes

The three forms of racism that are part of the Camara Jones framework all contribute to the

lesser health outcomes seen in the U.S. healthcare system. Miscommunication is important

because it is a factor in each form of racism, and it leads to the failure of the current healthcare

model, proving that much work must be done to improve upon structural racism and racial bias.

Doing so would improve the overall health of entire racial groups in the U.S. population.

Statistical Proof of Racism in the Healthcare Field

Coupling with the depths of discussion about types of racism, and how and why the occur

are many studies and statistics that show that racism has existed from healthcare providers in

America and continues to this day. A systematic review done by Paradies, Y. et al (2012)

examined evidence from 1995 onward looking for specifically interpersonal racism found
 5

significant proof of racist beliefs, emotions, or practices among healthcare providers about

minority groups. The review pulled from thirty-seven studies which were done solely in the U.S.

and twenty-six of them proved that racism exists in the health field. Little is known of the full

extent of it because that is much more difficult to quantify, but the existence of it alone is enough

to see the need for change in the healthcare system. The first major step that must be made in

order to start towards true equality in the health setting is by accepting and naming the fact that

institutionalized racism is happening in the healthcare field. This relates to another study focused

on public health literature from 2002-2015 which was done to see if racism was named or

viewed as a core concept of health disparities (Hardeman, R. R., 2018). They reviewed from the

top fifty high impact journals representing the public health field as a whole. Hundreds and

hundreds of articles were read, yet only twenty-five of them names racism in the title or abstract

of the article, and it was only a core concept in sixteen of those twenty-five. The conclusion from

this study is that explicitly naming racism in articles is extremely important, because it would

lead to racism becoming a central concept in research, which would help to overcome the

longstanding effects of racism on wellbeing and health of minorities (Hardeman, R. R., 2018).

Qualitative Proof of Racism in the Health Field

Prior research shows that healthcare providers hold negative implicit attitudes toward

patients of color, which is expressed by the methods of communication used in situations. Rhee,

G.T. et al (2019) performed a study focused on the impact of this perceived racism among older

adults in minority groups, proving that there is a mental toll when one experiences racism, and it

contributes to health outcomes. The study focused on those aged 65 and older in minority

groupings, using many logistic regression analyses with covariates including insurance coverage,

years in the United States, and languages spoken by the patient. The conclusion of the study was
 6

that if a patient perceived racism in the health setting, it would increase their likelihood of

delaying or forgoing necessary medical care. One factor that was specifically mentioned in the

article reviewing the study was poor doctor communication and its link to the heightened risk of

unmet or undermet health needs among minorities (Rhee, G.T. et al, 2019). The reason that this

occurs is either a language barrier or the fact that patients are often unaware that the doctor is

making assumptions about them and basing their treatment on those assumptions. Another factor

to consider is the distrust of healthcare providers commonly seen amongst minorities due to the

structural issues and life experiences that they have had. In order to improve upon these flaws,

healthcare providers would benefit from training in cultural competency, reduction of racial bias,

and efforts to increase trust with their patients.

Steps to Reduce Racial Bias in the Health Setting

With all the evidence collected about how institutional, personal, and internalized racism

give rise to lesser health outcomes in racial minorities, a plan of action is called for. In moving

forward, what can be done? Williams, D. R. & Cooper, L. A. (2019) suggested a plan of action

to reduce racial inequalities in health. It begins by attacking institutional racism and creating

communities of opportunity, leading to equal opportunities societally. This plan would include

early childhood development resources, policies to reduce childhood poverty, work and income

support opportunities for adults, and healthy housing and neighborhood conditions (Williams, D.

R. & Cooper, L. A., 2019). The second portion of the plan focuses on new emphases in the

healthcare system, creating access to high quality care for all, strengthening preventative

healthcare approaches, addressing patient’s social needs within delivery of care, and diversifying

the healthcare workforce to reflect demographics of patient populations. This plan focuses on the
 7

problem of health inequities from many angles, with the goal of seeing more equality in terms of

insurance, quality care, and overall health outcomes.

Conclusion

Racism is seen in a multilevel manner within the healthcare setting. It contributes to

lower health outcomes of minorities and creates an overall distrust in health providers. Statistical

and qualitative studies have proven that miscommunications are continually occurring, along

with internalized personal bias and institutional racism; all of these contributing to the issue of

inequality in the healthcare field. To begin the fight towards equality, first, it would be helpful

for public health journals to begin naming the issue of structural racism as a root cause of the

inequities, raising the national and global awareness of this shortcoming. Then, it is necessary to

develop a plan to reduce the structural, societal issues and to educate and train doctors to reduce

the problem of personally mediated racism.

References
 8

Hardeman, R. R., Murphy, K. A., Karbeah, J., & Kozhimannil, K. B. (2018). Naming

Institutionalized Racism in the Public Health Literature: A Systematic Literature

Review. Public health reports (Washington, D.C. : 1974), 133(3), 240–249.

https://doi.org/10.1177/0033354918760574

Peek, M. E., Odoms-Young, A., Quinn, M. T., Gorawara-Bhat, R., Wilson, S. C., & Chin, M. H.

(2010). Racism in healthcare: Its relationship to shared decision-making and health

disparities: a response to Bradby. Social science & medicine (1982), 71(1), 13–17.

https://doi.org/10.1016/j.socscimed.2010.03.018

Paradies, Y., Truong, M. & Priest, N. A Systematic Review of the Extent and Measurement of

Healthcare Provider Racism. J GEN INTERN MED 29, 364–387 (2014).

https://doi.org/10.1007/s11606-013-2583-1

Rhee, G.T., Marottoli, R.A., Van Ness, P. H., & Levy, B. R. (2019). Impact of Perceived Racism

on Healthcare Access Among Older Minority Adults, American Journal of Preventive

Medicine, 56 (4), 580-585, https://doi.org/10.1016/j.amepre.2018.10.010

Williams, D. R., & Cooper, L. A. (2019). Reducing Racial Inequities in Health: Using What We

Already Know to Take Action. International journal of environmental research and

public health, 16(4), 606. https://doi.org/10.3390/ijerph16040606