"Institutional Racism" in health care - buzzword or useful concept?

Stemming out of this thread in which Jackmannii (a poster for whom I generally have great respect) bemoans changes to the entrance exam for medical schools (the MCAT) for now testing concepts from intro psychology and sociology classes as well as organic chem and physics, in particular describing the fact that racial and ethnic disparities in health care outcomes based on structural and institutional factors rather than any individual intent (“institutional racism”) is one of the included concepts. To him that concept is ideologic and political and rightfully dismissed as a “buzzword”.

It seems to me that the importance or buzzwordiness of “institutional racism” in regards to healthcare is a reasonable separate thread for GD beyond the IMHO of changes to the MCAT …

I don’t know why we would expect the health care field to be exempt from the effects of institutional racism.

Like anything else (legal matters, law enforcement, etc.) I think more money = better service.

So I guess what I’m saying is that poor people get shitty doctors and that is probably more valuable a concept than the ever-ambiguous “institutional racism.”

But I’m willing to accept that healthcare outcome disparities are correlated with race, corrected for income disparities, if someone can provide cites.


One of the most studied is kidney transplants, both access and outcomes. A review identifies the mediators as including insurance status, yes income level, education level, and geography.

Non-Hispanic Blacks have more high blood pressure but Hispanics are the group most likely neither screened adequately nor treated.

OTOH Black children are less likely to have antibiotics inappropriately prescribed.

Depression care also.

That last bit brings up a major potential mediator of racial and ethnic disparities … doctors are not always great at the communication thing and potentially the process does worse in both directions the less they are “like” each other. Thus ethnic and racial minority groups tend to use health services less even when they are available.

Disparities begin in childhood even after correction

One success story of recognizing the structural barriers leading to disparities and addressing them has been in vaccinations.

Now the under and unimmunized are more often White and relatively affluent refusers … for whom a different set of cultural factors is at work.

Something can be both a buzzword and a useful concept!

I think talking about the social determinants of health is vital for the healthcare system as a whole, and the social determinants include race.

As I write this post, I’m sitting in a major university medical center preparing for a (business) meeting with the C Suite…as with most such facilities, this one’s service area includes a substantial black and hispanic population.

Is the idea that, where healthcare delivery and outcomes are disproportionate within (self-identified) race groups, the root cause is “institutional racism”?

If so, what does that mean, exactly? That these and other healthcare institutions are racists? That the limited outcomes of the populations involved are due to insitutional-level policies and behaviors?

Race may influence pain treatment.

The results of the UWash study desribed in that article are interesting. Note that the patients were hypothetical. If it were just a matter of income disaparities, you wouldn’t expect a hypothetical black patient to get different treatment from a hypothetical white patient.

If black patients receive inferior pain treatment, this could cause black patients to be less trustful of the medical establishment, thus exacerbating their health conditions and making it more likely that they will suffer unnecessary pain. A horrible positive feedback loop if there ever was one.

I’ve experienced a number of WTF moments in doctor’s offices over the years, usually in the context of psychiatry. I had one doctor who seemed okay…until apropos of nothing he started asking me why President Obama identifies as black. Then I noticed that he had a minstral black face on the wall. This wasn’t institutional racism. It could be argued it wasn’t even racism racism. But he was certainly racially insensitive. Fortunately, I had the means and the assertiveness to fire him and go to another doctor. Perhaps another patient would have given up altogether.

(This psychiatrist offered psychotherapy as well as pharmocology. I’m worried for the black person who ever deigns to talk about their negative experiences with racism and racial discrimination with him. I just don’t think he’d be the best person to disclose something like that to.)

One Disease Hits Mostly People of Color. One Mostly Whites. Which One Gets Billions In Funding? A Tale of Two Genetic Illnesses

Yes. Sometimes.

I say “sometimes” because sure, if you are going to talk about outcomes, some poor outcomes are due to behaviors that may be more or less prevalent in one group or another. But that doesn’t explain why people presenting with the same symptoms in an emergency room would receive more or less aggressive interventions.

I don’t see it in this particular article, but I have read in others that the disparities in treatment persist even when controlling for socioeconomic factors such as income, education, or insurance status.

What it means is that structures end up having impacts that are racist in effect, even if there is no explicit racist intent.

Let’s take the plight of many of those major university medical centers …

  1. Primary care to the main service area does not pay well and is rarely a high priority. The high priority is finding ways to align with physicians in higher SES (and of course often Whiter) areas and get those primary care docs to refer to your specialists and to get patients from there to self-refer. Having the best specialist for Sickle Cell disease is not as incentivized as have the best specialists for Crohns or Ulcerative Colitis or various cancers. The support, be it salary or research support, will go to where the money is. The people deciding to do that which attracts high dollar medicine in well insured patients are not racist in intent; they are just trying to have the hospital system make enough to pay the bills; the impact however is racially disparate.

  2. To the degree they do care for those in their service area they are not only punished with a lower rate of private coverage and a higher rate of uninsured, they are also punished by a pay for performance model that does not adequately normalize for the additional costs and challenges of that care to a poor populations incurs. That harm to institutions caring for those who are disproportionately minority status and poor is also not racist in intent but is of racist impact.

Now all disparate outcomes are not caused by racism (all inclusive of structural factors of no racial intent to implicit and to explicit racism) … there are genetic and cultural factors that run in subpopulations that are best identified by racial identification that contribute to outcomes as well. Clearly however some are and the recognition that such happens, inclusive of as a result of structural aspects of society that exist and persist in spite of the best intentions of the members of the society and even beyond the implicit (i.e. not consciously aware of) racist judgements many of us make every day is an important concept to not be ignorant of. It is not the only cause of disparate outcomes but it is an important one.

The three articles linked to in the last three posts are, btw, very good.

I was going to post this issue. and in googling for a cite I found the interesting fact it even applies to children who are black.

Does anyone have a clue what the source of this bias is? Are doctors less likely to sympathize with black patients?

Well, since DSeid (a poster for whom I usually have enormous, fulminating respect) just couldn’t let this die, I still have questions he left largely unaddressed from the last thread.

If trumpeting about “institutionalized racism” and the “power elite” is the way to ensure equal outcomes in healthcare, why isn’t demanding “holistic”, “patient-centered” care the way to ensure that allopathic practitioners like DSeid start listening to their patients instead of clinging to the old patriarchal model of practicing medicine?

The Mother Jones article on genetic disorders seems to think that racism is proven by the fact that there is a well-endowed, effective charity for researching cures/treatments for cystic fibrosis, but not a corresponding effort on behalf of sickle cell anemia.

This is sort of like saying that more and better-funded lobbying groups on behalf of Israel proves that there is racism against Palestinians/Muslims.

Maybe the Bill and Melinda Gates Foundation is racist for spending billions on behalf of disease prevention and agricultural innovation in non-African Third World countries and not pouring most of that into a cure for sickle cell anemia.*

Or perhaps name-calling obscures real issues and helps prevent working together to find solutions for problems.

*to be fair, the Gates Foundation has donated some money to help sickle cell patients.

Possibly socio-economic status. The study seemed to compare all black children with all children of other races. It would be interesting to compare by SES, and see if poor white children are under-medicated (or middle-class children are over-medicated) in comparison to black children of the same SES.

It may also have to do with the GOMER effect (Get Out of My Emergency Room). If one race is perceived as over-using ER facilities, doctors are going to be more likely to dismiss their complaints as trivial.

The part about longer waits in ER may be related. I would need to see figures on how long Hispanic or black children had to wait in the same ERs as other races, with the same presenting symptoms.


Jackmanni, I have answered before. Every item is judged on its own merits. I am happy to discuss the merits and definitions and misuses of the terms “holistic” and “patient centered” and what motivates how those terms are sometimes used. Open a thread specifically to discuss that if you so wish. It has however Jackmanni jack-shit to to with the subject of this or the other thread that you brought them up in. You think both the concepts of structural/institutional racism and of holistic/patient-centered care are both complete bullshit. Well and good. No, I am not being hypocritical or inconsistent to appreciate the importance of consideration regarding institutional structures on racial disparities, while being highly skeptical of what gets lumped sometimes into “holistic” and “patient-centered.”

The rest of your post evinces a persistent ignorance regarding what racism means in a structural or institutional context. Which only proves why we need to discuss these subjects as part of medical training early on.

Jackmanni, aren’t you a pathologist? That’s not an area in which I’d expect a lot of racial bias. (Ordering testing, sure, but once it’s in your hands, I’m sure you follow the same procedures for every sample, and sometimes may not even know the race of the patient.) So assuming I’m remembering correctly, I’m thinking you just don’t see much of it in your branch of medicine. That doesn’t mean it’s not happening in face to face patient care.

The actual study.

Controlling for income and insurance status and for pain level (also for age, gender, triage level, type of hospital ownership and geographic region) Black children were less likely to get analgesics for pain, for severe pain, and even more so less likely to receive narcotic analgesics than were White children. Also longer length of stay in the Emergency Room.

I’m thinking it may have something to do with reduced empathy for people who don’t look like you.

Neuroimaging shows that white people may experience less empathy for brown people.

I wonder if the same phenomona that explains why people of one race “all look the same” could account for lack of empathy.

Thanks. I should know better than to rely on press reports of a study. Is the “Multivariate logistic regression models adjusting for confounders” where they controlled for SES and insurance and so forth?

That could well be. Is there information on how different black doctors prescribe for other black people, or Asian doctors for Asians?

I know there was a study testing the association of black faces with crime, and the study found that people tended more to associate blacks with crime than whites. IIRC black people were just as subject to this as whites were. So it is possible that everybody undertreats black kids with stomach ache.


Institution racism is not predicated on the belief that “this race is inferior to another race”.

Institution racism is when policies result in disparate outcomes for different races.

Earmarking disproportionately more US funding to Israeli causes and concerns does not mean that the US is “anti-Muslim”.

But it would be an example of pro-Israel bias in institutional policy. It would be extremely disingenuous for the US to argue its policies are government-neutral when its bank statements indicate otherwise.

Research indicates that race, independent of socioeconomics, is a significant predictor in the quality of healthcare a person receives. Given the history of the US and our understanding of sociology and human behavior, it should be no great shock that there’s a racial bias in medine. Indeed, it requires a greater suspension of disbelief to assume there’s no bias at all, since this would be a break from status quo.

I’m on a mobile device so I can’t copy and paste easily, but according to the study described here, the answer is “No”. People feel more empathy for people who have their skin color, less empathy for people who don’t.