Race and wellness – Part I

Examining health disparities

“The COVID-19 pandemic has certainly laid bare the health inequities that we have in our society. There has never been a time that the social determinants of health have been exposed so clearly, so rawly. People in vulnerable communities are dying from a disease because of their race and because they’re poor. That should not be acceptable in the richest country on earth.”¹

–  Robert Harrington, MD, Chief of Medicine, Stanford Medicine

The following report is the first in a three-part series: Race and wellness. We begin here, in Part I, with an introduction to the what, where, and why of these disparities, which have been horrifically magnified by the lens that COVID-19 has placed upon them. In Race and wellness – Part II: Going beyond the data, we delve into the problems and pitfalls inherent in available racial health data, and how such faulty data fuels racist structures and substandard medical outcomes. In Race and wellness – Part III: Mending the inequities, we begin the discussion of how to address and mitigate racial disparities, in the hope of one day reducing the great pain, suffering and death occurring — disproportionately ­— in select sectors of our U.S. population.

While we have culled information and data from many sources, both at Stanford and from other organizations and individuals, BeWell is honored to have had the chance to speak with N. Kenji Taylor, MD, MSc, AAHIVS — an instructor of medicine at Stanford Medicine, a physician with Stanford Health Care and Roots Community Health Center (Oakland, CA) and a member of the Stanford-Intermountain Delivery Science Fellowship — about his work and perspective on this important topic of race and wellness.

Two crises, intertwined

In America today, racial disparities and inequalities exist on many levels and across multiple arenas. The police brutality that resulted in the deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery (just to name three) — and re-ignited the Black Lives Matter Movement — is what we will all remember the most about racism in America in the year 2020. However, those episodes of unequal treatment by the police mark but one form of racial injustice in our nation. Other disparities exist in such areas as our criminal justice system, the workplace (jobs procurement and advancement), housing and education (“segregation poverty” and inconsistent school disciplinary action).

In another vital arena, health care, racial and socioeconomic disparities are also disturbingly large — and they have been brought into sharper focus by the other unforgettable crisis of 2020: the COVID-19 pandemic.

A serious and shocking event, the COVID-19 pandemic has been made all the more cruel by the highly disparate experiences of varied groups of people (races, ages and socioeconomic groups). In the U.S., while Blacks account for only 13% of the total population, they represent a staggering 24% of COVID-19 deaths.² Therefore, if you’re Black, you’re twice as likely to die from COVID-19. The Hispanic/Latinx population, while not suffering as high a death rate as Blacks, are much more likely to get COVID-19 than are whites and Asians. California state data reveals that Hispanics comprise 39% of the population yet 58% of the COVID-19 cases.³ Native Americans also suffer disproportionately; while CA data is scant, in New Mexico, 60% of cases are Native Americans, even though they make up only 9% of the population. Those proportions are similar in Arizona, which reports a much higher death rate for Native Americans than for whites.

As Dr. Anthony Fauci stated in his recent Fireside Chat at Stanford Medicine, “For Blacks, Latinxs and Native Americans, it’s striking how disproportionately they are disadvantaged.”⁴

Sadly, it should not have taken a pandemic to shed light on these health disparities — which are far from new.

Racial health disparities: What are they?

When we ponder the health of our society, and at the same time discuss race and racism, it is important to first define: What is race? What is a health disparity?

As explained aptly in a 2017 National Academy of Sciences committee report:

“Race and ethnicity are socially constructed categories that have tangible effects on the lives of individuals who are defined by how one perceives one’s self and how one is perceived by others.”⁵

What one should notice about this definition are the words “socially constructed”; had the authors instead defined race as a condition determined by “biology” or “genes,” their definition in and of itself would have been a racist one. (We will explore this confounding connection between biological data and racism later in this report.)

And what are “health disparities”? Dr. Taylor lauds this definition published by The Centers for Disease Control and Prevention (CDC), with Dr. Taylor’s emphasis added:

“Health disparities are preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups, and communities.”⁶

While the term “disparities” is often used or interpreted to reflect differences between racial or ethnic groups, disparities can exist across many other dimensions as well — such as gender, sexual orientation, age, disability status, socioeconomic status, and geographic location. (Our report will primarily focus upon racial and socioeconomic disparities.)

For racial and ethnic minorities in the United States, health disparities take on many forms, including higher rates of chronic disease and premature death compared to the rates among whites. Examples include: the magnitude of the African-American/white disparity in acquired immunodeficiency syndrome (AIDS) diagnoses and mortality, which has grown substantially over time. A second example: African Americans are 30% more likely than whites to die prematurely from heart disease, and African American men are twice as likely as whites to die prematurely from stroke. Dr. Taylor cites data indicating that Blacks have higher rates of mortality in eight of the top 10 causes of death in the U.S., persistent disparities that result in at least 60,000 excess deaths per year.⁷

Racism: A major driver of health disparities

As British sociologist Hilary Graham CBE, FBA explained in her article on social determinants, health disparities stem from health inequities brought on by the “unequal positions in society”⁸ that differing groups hold.

Stanford’s Dr. Taylor extends this thinking further, stating that racism (in its many forms) underpins all  of the determinants that produce our nation’s racial health inequities. These determinants, states Taylor, include:

• Socioeconomics
• Access to care
• Disproportionate burden of comorbidities
• Discrimination
• Unemployment
• Biological mechanisms
• Cultural

Taylor backs up his assertion that racism underlies each of these determinants with data from a May 2020 retrospective cohort analysis of over 1,050 Sutter Health patients showing that Blacks are 2.7 times more likely to be hospitalized with COVID-19 even after adjusting for age, sex, comorbidities and income.⁹ In other words, biology and socioeconomic factors do not fully explain racial health disparities.

Taylor’s declaration that racism is a principal driver of health inequities is a view shared by a growing number of public health and bioethics experts. David Magnus, PhD, a professor of medicine and biomedical ethics and professor of pediatrics and medicine at Stanford, spoke recently on Ethics and COVID-19 and also indicated that we must look deeper than social determinants to get at the root causes of health disparities:

“There is a lot of discussion about the social determinants of health and inequality, but these are also moral determinants of health — as systemic racism built into our society and the tattering of any kind of social safety net has produced tremendously unjust and unequal outcomes for different populations, particularly for people of color and people who are poor.”¹⁰

Likewise, in a recent American Journal of Bioethics panel, Ruquaiijah Yearby, JD, MPH, a professor of law at St. Louis University, relates how it is “structural racism” that we must identify and examine when trying to understand the root causes of health inequities:

“Public health speaks of social determinants of health, but rarely brings it back to the structures underlying those determinants. … The structures are set up to disadvantage people. … Here you have public health officials beginning to blame African Americans and Latinxs for actually suffering. … We often blame the victims.”¹¹

Georges Benjamin, MD, the executive director of The American Public Health Association (APHA), summed it up on May 29, 2020 by saying, quite simply:

“Racism is an ongoing public health crisis.”¹²

To continue the discussion, see Race and wellness – Part II: Going beyond the data and Race and wellness – Part III: Mending the inequities.

Lane McKenna
August 2020

Sources:

1. Harrington, R. Stanford Department of Medicine Grand Rounds: June 3, 2020.

2. The COVID Tracking Project. The Atlantic Monthly Group. 2020.

3. COVID-19 Race and Ethnicity Data. California Department of Public Health. August 3, 2020.

4. Fauci, A. Stanford Medicine Fireside Chat: July 13, 2020.

5. National Academies of Sciences, Engineering, and Medicine. The State of Health Disparities in the United States. Communities in Action: Pathways to Health Equity. 2017.

6. Health Disparities. The Centers for Disease Control and Prevention.

7. Kelly, R. 2015 Kelly Report: Health Disparities in America.

8. Graham, H. Social Determinants and Their Unequal Distribution: Clarifying Policy Understandings. The Millbank Quarterly. 2004 Mar; 82(1): 101-124.

9. Azar K et. al. Disparities In Outcomes Among COVID-19 Patients In A Large Health Care System In California. Health Affairs. May 21, 2020.

10. Magnus, D. Stanford Department of Medicine Grand Rounds: July 1, 2020.

11. Yearby, R. Black Bioethics: Racism, Police Brutality, and What it Means for Black Health. American Journal of Bioethics. July 18, 2020.

12. Benjamin, G. Racism is an ongoing public health crisis that needs our attention now. American Public Health Association. May 29, 2020.