Racist History

Since its founding, the U.S. has actively worked over centuries to marginalize and oppress Black, Indigenous and people of color. While not an exhaustive accounting of the harms perpetuated, both the U.S. Senate resolution declaring racism a public health threat and the American Medical Association offer perspective. 

In nearly every aspect of the health system—from payment systems to research to treatment—white, male, cisgender health and wellbeing are consistently prioritized over the well-being of people of color, women and transgender people. 

“The underlying belief that some groups of people are superior to others is baked into medicine and healthcare and nursing,” one leader said. “The entire field needs to reorient itself to one of justice and equity. There is no quick fix through implicit bias training, new tools, or measures.  When people devalue others, they find ways to turn these tools and measures into racist tools and measures.”

The U.S. has not accounted for or reconciled the long and deep history of racism that is pervasive in society and remains embedded in today’s health system, a source of deep and ongoing distrust among many communities of color. Regaining the trust of communities of color will require the health system to be trustworthy, making real structural changes, while also attending to a shared process of healing. As one person shared, “Harm has to be acknowledged first and some kind of work like truth and reconciliation is needed.”

While some institutions have taken steps to account for this history of racism, several interviewees noted that there is a tendency to measure what’s happening now and plan toward the future, without recognizing the past is still present for many people most negatively impacted by the health system. 

“It upsets me that people land on Henrietta Lacks and Tuskegee, as if that’s the only thing,” one leader said. “It started in 1619 with the atrocities that happened to our ancestors. People need to understand that we’re not just upset because you let some people have syphilis for a long period of time. But also the fact that you think that we people of color don’t feel pain, so you operate on us. Without anesthesia. When you want to understand fertility, you remove our uterus and ovaries. The pain that you all have inflicted–that’s ancestral.” 

Despite more public awareness about structural racism, many health system leaders still avoid the subject and their responsibility to address it.  “People are tiptoeing around the issues and are often hesitant to call racism out,” one leader said.  “There’s a need to state that racism exists and acknowledge that it has been embedded into the system.”

Another leader put it this way: “People will admit to murder before they’ll confess to being racist.”

Stakeholders highlighted the need to go beyond education and awareness to “get to how deep racist ideology is embedded in the human psyche,” as one leader said.  

 “Racism is fed to you in the model, it’s taught to you while you’re a baby sitting in a high chair and your grandmother is using that language. It is so much a part of your human construct that you can’t see what you don’t see. To this day, 39% of medical students believe Black and Brown skin is thicker. It’s the reason 42% of them still believe that Black and Brown people have higher thresholds of pain.”

Health leaders highlighted how the health system mirrors an inequitable society in which people of color are systematically denied access to equitable housing, education, safe neighborhoods and employment, are criminalized through over-policing, and are more likely to struggle with the effects of intergenerational and collective trauma. 

“Patients of color experience racism and oppression embedded within the fabric of the world and yet the care they receive, for instance, in mental health is usually designed to help them, as individuals, solve their maladaptive thoughts, process their family history, or [receive] medication. This can neglect important sources of the patient’s distress and limit the possibilities of healing,” said scholar Dr. Miraj U. Desai, an adviser to this project and an expert in how organizational bias affects patient care. “Other possibilities exist for the field itself, including helping to advance structural change and participating in social movements.”¹

These are the views of health leaders who participated in an 8-month project to analyze structural racism across the U.S. health system and provide recommendations for the collective leadership required to dismantle it.