Behavior, not Racism, Explains Differences in Medical Outcomes Between White and Black Americans
May 29, 2021
By Kenny Xu
The American Medical Association came out with a statement on May 11th acknowledging that “racism is a public health threat.” A recent Boston Review article entitled “An Antiracist Agenda for Medicine,” concurred, making the case that racial health outcome discrepancies are evidence of systemic racism. To support this claim, they analyzed ten years of data from Brigham and Young Hospital in Boston, Masschusetts. Looking specifically at patients with heart failure, they found that Black and Hispanic patients were more likely to be admitted to the general medicine service, while White patients were more likely to be admitted to the cardiology service. Patients admitted to the cardiology service are given private rooms, better amenities, and more access to cardiologists. Their study found that the discrepancy was still not accounted for when controlling for insurance status or socioeconomic status, so therefore it must be the result of systemic racism.
The authors’ prescribed solution is medical reparations. Diversity trainings are not enough; fighting systemic racism requires “a proactively antiracist agenda for medicine.” They lay out two elements for providing reparations. The first is providing financial support to all BIPOC individuals and race-centric health institutions. The second is following a “Healing ARC” that entails Acknowledging that their hospital is racist, Redressing their wrongs by offering preferential admission to cardiology services to Black and Hispanic patients, and creating Closure by continuing to pursue these discriminatory policies until the local BIPOC community agrees that equity has been achieved.
Actually analyzing the authors’ study, however, leads to doubt on both Boston Review’s understanding of the problem as well as their proposed solutions. Within the article itself, the authors share a followup study they performed at the same hospital that found White patients were significantly more likely to advocate for themselves, i.e. asking to be placed in the cardiology service. And, they found no evidence Black patients that advocated for themselves were denied service or treated differently from White patients. The authors then use this study to claim that systemic racism causes White people to feel more comfortable asking for better care. But that is not systemic racism; rather, asking for better care is a personal choice.
Secondly, contravening data has revealed that White cardiac arrest patients are actually more likely to die than Black or Hispanic patients. Within 30 days of discharge from the hospital, 4% of White patients die, as opposed to 2% of Black and 3% of Hispanic patients. The medical inequity argued by the medical activists lies in readmission rates: 29% of Black and Hispanic patients were readmitted to the hospital within thirty days, as opposed to 26% of White patients. Yet, the paradox between readmission rate and death is a well-established phenomenon in medical research, referred to in other places as the mortality-readmissions paradox. So, even while Black cardiac patients are readmitted more to hospitals, they are actually less likely to die – suggesting that readmission has positive consequences for health outcomes, not negative. Making a “systemic racism” argument from this finding is simply counterproductive.
An article attempting to resolve the mortality-readmissions paradox claims that Black and Hispanic patients are also more likely to be obese or suffer from diabetes, which could explain why they are more likely to be readmitted after discharge. They go on to argue that these factors are also elements of systemic racism: historic oppression leads to poverty, which then leads to poor food decisions, which then leads to obesity. The purpose of our essay is not to deconstruct the racism/obesity argument. But even if that premise is accepted, that has no bearing upon purported systemic racism in a hospital scenario.
Furthermore, another study analyzed data from 1200 U.S. hospitals and found that there was no meaningful difference in quality of care based upon either race or socioeconomic status. They could not identify any specific hospital-controlled variable that explained health disparities, leading them to conclude that any differences in mortality or readmissions rates must be the result of external variables. Looking at both the original study performed by the authors of the Boston Review article, as well as multiple other studies addressing similar questions, it becomes clear that racism at the hospital level simply cannot explain why health outcome disparities exist. Additionally, the decision to declare readmission rates as evidence of racism when White patients suffer from drastically higher mortality rates is a value judgement unsupported by either medical practice or common sense. The flimsiness of evidence for white supremacy at Brigham and Young Hospital makes the very existence of the problem dubious. Additionally, it reveals that the authors’ suggested solutions are dangerous and not based on a sound interpretation of the evidence.
First and foremost, medical decision-making authority ought to lie in the hands of the doctors that are working in the clinical setting. Offering preferential treatment based upon race is not only blatantly racist policy; it also violates the autonomy of medical professionals to make decisions that will most benefit their patients. The authors of the Boston Review article themselves admit that there is no evidence of personal/individual racism being committed by any Brigham and Young doctors, which is why they must lay the blame at the feet of systemic racism. So long as doctors are continuing to treat their patients fairly on an individual basis, race-based health equity policy will only serve to harm patients. Offering cardiology services based on race will only widen the mortality gap that already harms White patients more than any other demographic.
A true solution to equalizing health outcomes would require an honest consideration of all relevant variables. While “systemic racism” is an appealing bogeyman due to its ability to explain away all existing inequities, it is not helpful in actually addressing the root causes of differential racial outcomes. As alluded to earlier, minority patients are indeed more likely to suffer from obesity and diabetes, which of course has detrimental impacts upon their health. Blaming that on a vague idea of white supremacy is not sufficient for actually addressing that problem; rather, an honest inquiry, made in good faith, as to the causes of poor individual health decisions would be required. Past racism may indeed be a contributing factor. But refusing to consider the possibility that individual decisions at a society-wide scale explain many disparate health outcomes serves only to perpetuate the very behaviors that lead to the discrepancies in the first place. A truly just health policy does not pursue input-blind equity by discriminating against individuals based on race, but analyzes all possible variables in order to discover what is driving undesirable health outcomes.