Our Kentucky governor, Andy Beshear, has announced that he wants to make sure that all people of color in the state are covered by health insurance. I’m already hearing the backlash. “That’s not fair. What about white people? You can’t just cover blacks.”
Frankly, I think we whine a lot.
First of all, if we didn’t believe it before, the COVID 19 pandemic has clearly shown us that people of color have a disproportionately high death rate. Probably that’s because their health is not as good to start with. Why is that? The higher rate of poverty is one reason. They are more likely to live in food deserts where healthy food is not as available and if it is available, it’s more expensive. Also, believe it or not, there are still many people who don’t have transportation which makes it difficult to get to the doctor. The bus system is not always an answer. Bus routes have been cut significantly, taxis are expensive, and some places don’t have either. Also, if you go to the doctor, you may have to take off work. Some people can’t afford to lose that pay.
But this isn’t just about poverty. If it was, we could at least focus on that one issue. It has more to do with lack of trust in the medical system. If you don’t trust that you will be treated well and taken care of, why go to the doctor? If you rarely saw doctors who look like you, if you felt that your parents and grandparents had not been taken seriously by the medical establishment, would you really want to go to the doctor? I wouldn’t.
It’s hard for whites to really understand the toll that living in our racist society has on people of color, both psychologically and physically. Yes, I did use the word racist. Whites immediately take offense to that. I’m not talking about deliberate racist acts perpetuated by individuals (though you don’t have to look far to see examples of that). I’m talking about white privilege, which most of us don’t even see because we take it for granted. I’m white. We don’t generally have to worry each time our sons or daughters walk out the door. Blacks do. That kind of stress takes a toll on health and makes it hard to focus on day to day things like taking care of yourself. Years of being seen as “less than” influences attitudes people of color have towards themselves and the institutions that seem to be dominated by those who see them as “less than.”
Do some research of your own. If you go to the National Library of Medicine and search for African Americans and the healthcare system, you will see a number of articles on how the experience of people of color in our health care system is different than that of whites. There is an interesting discussion from October 2019 titled How Our Health Care SystemTreats Black Mothers Differently. It’s a transcript of an interview with Kennetha Gaines, clinical nurse manager for UCSF Health in San Francisco. You can find it by searching TheCommonwealthFund.How Our Health Care System Treats Black Women Differently. By the way, black women die of pregnancy related complications at a rate 3 times greater than that of white women.
The book Communities in Action: Pathways to Health Equity (2017) has this quote in chapter 2:
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. It is important to acknowledge the social construction (i.e., created from prevailing social perceptions, historical policies, and practices) of the concepts of race and ethnicity because it has implications for how measures of race have been used and changed over time. Furthermore, the concept of race is complex, with a rich history of scientific and philosophical debate as to the nature of race (James, 2016). Racial and ethnic disparities are arguably the most obstinate inequities in health over time, despite the many strides that have been made to improve health in the United States.
Having been a physician for almost 40 years, I have seen close up how some patients get better treatment than others. It may not be obvious. It shows up in how much time is spent with the patient, how seriously their complaints are taken (or dismissed), whether tests are ordered to investigate the complaint, whether a return appointment is scheduled and just plain bedside manner. As a white physician, I hope I have not participated in that type of discrimination, but I’ve come to understand that most of us who are white have participated in some form of discrimination without realizing it. It’s because we are part of the dominant culture. We are so used to the way things are, that we don’t realize how many privileges we have that are not automatically available to people of color.
So, to answer my original question, is there systemic racism in medicine, I would say definitely yes. Making sure that people of color have insurance is a first step, but there is still much to overcome. They must be able to trust that they will be treated equally, they must buy in to the need for preventive care because they deserve it, they must have the time, flexibility, and means to get to the doctor. Most of all, we must convince them that we care about them, and they will be treated with respect and taken seriously. It would help if they saw more physicians and nurse practitioners who look like them. It’s up to us to make this happen. People of color didn’t create this problem. We did.
In my opinion, it’s OK to talk about making sure that all people of color have insurance. In my book, we owe them.