Discrimination in Health Care

By Linda Rath | March 24. 2022

Medicine has a history of neglecting or diminishing marginalized groups of people. Most if not all Western doctors historically have been men — generally white men. And for centuries, medical conditions specific to women were diagnosed as “hysteria,” an actual and common medical diagnosis. (The name, not coincidentally, derives from the Greek term for “womb” or “uterus.”) Even today, some physicians don’t consider fibromyalgia and chronic fatigue — disorders that affect mostly women — true medical conditions.

But while women have struggled to gain medical equity with men, Black Americans have faced even greater obstacles to equal and quality medical attention and treatment.

Ashira Blazer, MD, a rheumatologist at Hospital for Special Surgery and assistant professor of medicine at Weill Cornell Medical College in New York City, has researched this topic extensively. As a Black rheumatologist, scientist and expert in lupus, she treats people who have rheumatic diseases like lupus and inflammatory arthritis, especially people of African descent. Her research focuses on the genetic and environmental factors that help explain disease and comorbidity outcomes in people with African ancestry — which are worse than for white counterparts. (She also led the way to establishing African ancestry databases of patient information, in collaboration with rheumatologists in Accra, Ghana and Lagos Nigeria.)

The discrepancies in medical care and outcomes, Dr. Blazer says, come largely as a result of medical racism and “gaslighting” — denying someone’s reality in order to invalidate or dismiss them. Medical gaslighting exploits differentials in power between doctor and patient and in interest or intent — preserving the status quo vs. achieving health and socioeconomic equity. It is, she says, the ultimate tool of oppression. When people are confused, fearful and doubt their own reality, they feel powerless.  

Medical Racism

The notion that Black Americans are mentally and physically inferior to whites, concocted to “justify slavery, subjugation, and genocide,” was legitimized in medical journals for centuries, Dr. Blazer says.

In the mid-1800s, the respected Southern physician Samuel Cartwright wrote a widely read article claiming that Black people had smaller brains, thicker skin and weaker lungs than whites and were impervious to pain. The belief that Black patients don’t feel pain in the same way that white people do has persisted into modern medical education and treatment, according to a 2016 survey of white medical students and residents.  This myth is so entrenched in American medicine that research has shown that Black patients are less likely to receive opiate pain medication than their white counterparts--even for similar injuries or diseases.

Dr. Blazer says such beliefs bolster the argument that systemic racism doesn’t exist and that poor health outcomes in neglected communities are the result of biology rather than centuries of misinformation, discrimination, and structural racism. She also suggests that doctors of all races “are steeped in a culture that willfully ignores racial dynamics.”

Black Medical Schools Matter

At the turn of the 20th century, the American Medical Association hired an educator named Abraham Flexner to study and improve the nation’s medical education. The resulting Flexner Report recommended closing schools that didn’t meet rigorous standards, and it disparaged Black physicians as “undisciplined” and “lacking real training.” The report led to the closing of many academic institutions, including five of seven historically Black medical schools.

In the past 100 years, the percentage of Black U.S. doctors has barely risen, from 1.3% in 1900 to 5.4% in 2018, according to the Association of American Medical Colleges, though Black Americans make up 13% of the population. (The percentage might be slightly higher, however; 13.7% of those surveyed are of unknown race.) Historically Black medical schools Howard University, Meharry Medical College and Morehouse School of Medicine trained about 25% of Black physicians in the past two decades. Dr. Blazer, who graduated from Baylor College of Medicine, points out that none of these schools has a rheumatology program, even though Black Americans and Hispanics are disproportionately affected by lupus, and tend to have more aggressive disease. Black Americans also have higher rates of chronic conditions like diabetes, high blood pressure, and asthma than white Americans do and are less likely to receive preventive care.

Studies show that Black patients often avoid the medical system because they have been ignored, disbelieved or received poor care from white doctors. They’re more likely to seek medical care, agree to treatment and have better outcomes when they’re seen by a Black physician. Studies have also shown that deaths in Black newborns are halved when Black doctors care for them.  

Dismantling Racism

“When we measure racial differences in medicine, we are largely measuring the effects of racism,” Dr. Blazer says. “And we we must acknowledge that structural racism will not go away with time.” Instead, she says, “We have to be active in this process [of dismantling racism] if we want to promote the health of minorities and other marginalized people.” She suggests several key steps:

• Research to understand the scope of the problem
• Listening to the unique challenges Black patients face
• Educating doctors and medical students on cultural competence and implicit bias
• Ensuring that patients have the ability to advocate for themselves and be true medical partners
• Focusing on recruiting a diverse and inclusive medical workforce, especially in rheumatology and specialties like orthopedic surgery, which remains 85% white and overwhelmingly male

Jill Tyrer contributed to this report.