The COVID-19 pandemic has demonstrated how race and ethnicity influence the health outcomes of people of color, particularly Native Americans, Blacks, and LatinX. Wade (2020) states that past pandemics have demonstrated that such events have consistently played out along the preexisting fault lines of each society. The people at greatest risk, in the past and now, are often those already marginalized-the poor and minorities who already face discrimination (p. 700).

Racial/ethnic health inequities in the United States are well documented; however, there continues to be debate over how and why these inequities persist. Medical care is estimated to account for only 10%-20% of the modifiable contributors to healthy outcomes, whereas the remaining 80%-90% are thought to be related to social determinants of health (Hood et al., 2016). However, there is another piece of the puzzle in those outcomes. Racism is thought to be a major driver of the health inequities that are seen today (Bailey et al., 2017; Boyd et al., 2020).

What is racism? It is an organized social system in which the dominant racial group, based on an ideology of inferiority, categorizes and ranks people into social groups called "races" and uses its power to devalue, disempower, and differentially allocate valued societal resources and opportunities to groups defined as inferior (Williams et al., 2019, p. 106). The primary domains of racism include structural racism, cultural racism, and individual-level discrimination. One characteristic of racism is that its structure and ideology can persist in governmental and institutional policies in the absence of individuals who are explicitly racially prejudiced (p. 106).

Structural racism is the totality of ways in which societies foster (racial) discrimination via mutually reinforcing (inequitable) systems (e.g., housing, education, employment, earnings, benefits, credit, media, health care, criminal justice) and on how those systems, in turn, reinforce discriminatory beliefs, values, and distribution of resources and increase the risk of adverse health outcomes (Bailey et al., 2017; Williams et al., 2019). One example of structural racism is the ongoing residential segregation of Black Americans, which is associated with adverse birth outcomes, increased exposure to air pollutants, decreased longevity, increased risk of chronic disease, and increased rates of crime (Bailey et al., 2017, p. 1454). This residential segregation, in turn, systematically shapes healthcare access and utilization.

Cultural racism shows itself through media and stereotyping. Cultural racism can affect health in multiple ways, and it can lead to the creation and maintenance of structures that provide differential access to opportunities. In the classic work by Smedley et al. (2003), they note that, across virtually every type of diagnostic and treatment intervention, Blacks and other minorities received fewer procedures and poorer quality of medical care than Whites. Implicit bias occurs between a group, such as being Black, and a negative evaluation (implicit prejudice), or another category attribute such as being violent (implicit stereotype; FitzGerald & Hurst, 2017, p. 2). Research from van Ryn et al. (2011) reveals that higher implicit bias scores among physicians are associated with biased treatment recommendations in the care of Black patients. Providers' implicit bias is also associated with poorer quality of patient-provider communication. In addition to affecting judgments, implicit biases manifest in nonverbal behavior to others, such as frequency of eye contact and physical proximity. A research review by FitzGerald and Hurst (2017) reviewed 42 studies about healthcare professionals' implicit bias toward patients. The review indicated that healthcare professionals exhibit the same levels of implicit bias as the wider population. Correlational evidence indicates that biases are likely to influence diagnosis, treatment decisions and levels of care in some areas.

Discrimination is the most frequently studied domain of racism in the health literature. According to Williams et al. (2019), it exists in two forms: (1) where individuals or institutions deliberately or without intent treat racial groups differently, resulting in inequitable access to opportunities and resources, and (2) self-reported discrimination, a subset of those experiences that individuals are aware of (p. 111). In a 2015 meta-analysis, Paradies and colleagues assessed evidence for the association between self-reported racial discrimination and health (Paradies et al., 2015). The researchers were looking at racism as a determinant of health. Three hundred articles from 1983 to 2013, with 81% of the studies coming from the United States, were examined. Racism was associated with poorer mental health, including depression, anxiety, and psychological stress, and poorer general health, although not specifically poorer physical health.

Bleich et al. (2019) examined the experiences of racial discrimination in health care among Black adults. In a sample of 802 non-Hispanic Blacks, approximately one third reported experiencing discrimination in clinical encounters, whereas 22% avoided seeking health care for themselves or family members because of anticipated discrimination.

So what can we do? From the Association of Rehabilitation Nurses statement on racism and public health (Lutz & Irvin, 2020):

* Listen to those who are suffering.

* Recognize our own inherent biases and engage in sometimes painful but necessary conversations to address those biases.

* Educate ourselves about the systemic issues that have served to institutionalize racial biases.

* Learn how to be a positive influence for change.

* Denounce racism whenever we see it.

* Support efforts to reduce inequities and ensure basic human rights.

* Identify appropriate ways to respond personally, locally, regionally, and nationally.

I close with a quote from Dr. Martin Luther King, which was pertinent in 1966 and continues in 2021, in a speech to the Second National Convention of the Medical Committee for Human Rights in 1966 (King, 1966), "Of all forms of inequity, injustice in health care is the most shocking and inhumane."

Pamala D. Larsen

Editor-in-Chief

Loveland, Colorado

Conflict of Interest

There are no conflicts of interest.

Pamala D. Larsen, PhD, MS, RN

Editor-in-Chief

Rehabilitation Nursing

Loveland, Colorado

References