ARESTY RUTGERS UNDERGRADUATE RESEARCH JOURNAL, VOLUME I, ISSUE IV This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. IS IT ALL IN OUR HEADS? AN INVESTIGATION INTO AMERICAN AND HISTORICAL LEGACIES OF RACISM AND SOCIAL FRAMEWORKS THAT PERPETUATE RACIAL INEQUALITIES IN TWENTY-FIRST CENTURY HEALTHCARE SYSTEMS MEGHANA NAMPALLY ✵ ABSTRACT Racial bias in the healthcare system, origi- nating from the eminent founders of science and medicine, has numerous adverse effects on black populations and continues to have harmful conse- quences today (Byrd and Clayton, 2001). From poor clinical decision-making to preventing people of color from entering prominent fields in medicine, racism is ubiquitous in medicine and healthcare (Byrd and Clayton, 2001). The impact of racial bias on patient care is of great interest with many studies illustrating the detrimental impacts of bias on minor- ity groups, specifically in black communities. How- ever, there is additional research that concludes ra- cial bias does not play a role in patient care or in medicine (Dehon et al., 2017). The lack of acknowl- edgment within academia concerning racial dispar- ities in healthcare and science further oppresses black voices. With my research, I investigate the ex- tent to which various biased social frameworks in healthcare, medicine, and science negatively im- pact black individuals. I also address major historical events during the creation of the modern-day healthcare system and how these events perpetuate racism today. Focusing on the twenty-first century, I demonstrate that systemic historical and social events during this period eternalize racism in the modern-day American healthcare system. KEY TERMS: paternalistic racism, competitive racism, race-conscious professionalism, psychologizing racism 1 INTRODUCTION Confronting racial inequalities in healthcare requires examining the historical legacies of aca- demia and of federal policies. Neil Lewis Jr., an as- sistant professor of communications research in medicine at Weill Cornell Medicine, describes “that you can’t understand, much less change, people’s health behaviors without reckoning with larger so- cial structures and systemic forces” (Blackwood, 2021). Beginning in the nineteenth century, resi- dential segregation excluded people of color from obtaining adequate healthcare. This enabled and sustained “structural racism in other forms, includ- ing… the unjust distribution of high-quality health care” (Bailey et al., 2021). Exacerbating the effects of residential segregation, academic discrimination against colored communities preserves outdated racist attitudes and ideologies (Bailey et al., 2021) while also perpetuating distrust between marginal- ized communities and healthcare services (Dula, 1994). Another facet of this bias in academia can be seen in the underrepresentation of minorities in sci- ence and healthcare. In Dr. Michael Byrd and Dr. Linda Clayton’s paper “Race, Medicine, And Healthcare In The United States: A Historical Survey,” they delineate two different forms of racism: Paternalistic Racism and Competitive Racism (Byrd and Clayton, 2001). The former is the view that black people are imma- ture, child-like, and inferior — dispositions that are tolerated unless they deviate from socially accepta- ble roles (Byrd and Clayton, 2001). In the latter, ARESTY RUTGERS UNDERGRADUATE RESEARCH JOURNAL, VOLUME I, ISSUE IV emancipated slaves were seen as competition for scarce resources (Byrd and Clayton, 2001). These act as the foundations for the modern-day concept of race-conscious professionalism, wherein black in- dividuals in prestigious medical and academic fields feel a dual obligation to succeed (Powers et al., 2016). The idea of psychologizing racism, as de- scribed in “A socioecological psychology of racism: making structures and history more visible,” is the concept where one overly focuses on individual bias while neglecting the systemic and historical racism behind various institutions (Trawalter et al., 2020). This recognition of excessively analyzing the role of individual accountability rather than moving to un- derstand global structural forces at work is signifi- cant as it elucidates the true depth of racism in per- petuating racial disparities. In this paper, I consider three different his- torical and social domains that perpetuate racial in- equalities in the twenty-first century. The first is the role of academic discrimination in fueling fear and distrust in the healthcare system. Here, I also exam- ine the consequences of this bias through the un- der-treatment of black patients, and through the disproportionate number of physicians treating people of color. I then examine the significance of redlining in racial segregation. Redlining is the use of racial demographics to assess which communi- ties would receive investment (Bailey et al., 2021). The ramifications of this practice manifest as areas with increased pollutants, which worsen healthcare outcomes in colored communities (Li and Yuan, 2021) and demonstrate pollution inequity (Abra- ham et al., 2021). Finally, the lack of representation in academic and healthcare settings is analyzed us- ing the framework of race-conscious professional- ism. Academic discrimination, redlining, and un- derrepresentation in healthcare and academic insti- tutions are interrelated realms that perpetuate and eternalize racial inequalities in the modern-day healthcare system because of their historical and so- cial contexts in the United States. 2 ACADEMIC DISCRIMINATION Racial inequalities exacerbate distrust be- tween scholars and people of color. A prominent example of this is the Tuskegee Syphilis Study. Dur- ing this study, black men were infected with Syphilis without their consent (Trawalter et al., 2020). After this information was disclosed to study participants, decreased healthcare usage was seen among black men, which led to increased mortality rates (Trawal- ter et al., 2020). Trawalter et al. illustrate that “the disclosure of the study in 1972 is associated with a decrease in healthcare utilization, presumably due to decreased trust in the medical community, and a commensurate increase in mortality among [black] men” (Trawalter et al., 2020). This event is of histori- cal significance when discussing the perpetuation of racial discrepancies in healthcare as there is a his- tory of treating black people as inferior in the aca- demic community. It is important to note that the distrust demonstrated by the Tuskegee Syphilis Study is not an isolated event in academic history. James Marion Sims, the “father of modern gynecology,” rose to prominence for creating a surgical remedy for the obstetric fistula based on his experimentation on black, enslaved women (Cronin, 2020). During his experiments, he failed to use anesthetic ether on the individuals he experimented on, despite having ac- cess to such resources (Cronin, 2020). However, Sims did use anesthesia on his wealthy, white pa- tients (Khabele et al., 2021). The use of Sims’ work in modern medicine represents the exploitation of slaves and suggests a potential cause for the mis- trust black individuals have toward academia (Conteh et al., 2022). The results of this distrust between medical professionals and marginalized communities can be seen in the racial proportion of physicians to under- privileged, colored communities. Dr. Miriam Ko- maromy and her colleagues found that in areas with five times as many black residents, the number of black physicians was commensurate with the num- ber of residents (Komaromy et al., 1996). This dis- proportion in race illustrates that colored communi- ties mainly trust physicians of their own race and ethnicity, as well as black physicians feeling the need to practice in communities with large popula- tions of their own race and ethnicities. This is rein- forced by “the fact that the physician's race or ethnic ARESTY RUTGERS UNDERGRADUATE RESEARCH JOURNAL, VOLUME I, ISSUE IV group predicted whether he or she would care for greater-than-average numbers of black or Hispanic patients” (Komaromy et al., 1996). This further sup- ports the idea that racial disparities are perpetuated by mistrust in healthcare settings. Race was a con- tributing factor to where individuals would practice; therefore, individuals of the same race as their pri- mary care provider feel more comfortable receiving aid from members of their own race. Academic discrimination against black indi- viduals additionally stems from promoting biased teachings in medical schools, specifically in the per- ception of pain. In a 2016 study to determine racial attitudes, medical students held beliefs that black patients feel less severe pain than that of white pa- tients (Bailey et al., 2021). This bias leads to overt disparities in treatment regimens as “[black pa- tients] are less likely than white [patients] to receive pain medication and, when they do, they receive less” (Trawalter et al., 2012). The disparity in treat- ment between white and black patients by physi- cians and students contributes to the distrust that black patients feel as these false beliefs perpetuate the care of “greater-than-average numbers of black or Hispanic patients'' by physicians of the same race (Komaromy et al., 1996). This undertreatment of black patients because of academic bias intensifies the skepticism and suspicion of medical practices, ultimately leading to disparities in healthcare as seen through the disproportionate number of black physicians practicing in communities with large populations of similar ethnicities. 3 REDLINING IN RESIDENTIAL SEGRE- GATION Redlining makes use of racial compositions to assess investment opportunities for communities (Bailey et al., 2021). It involves the conscious dis- crimination against black people from obtaining fi- nancial resources that would aid them in acquiring adequate housing as well as other necessities (Bai- ley et al., 2021). Redlining impacts the proximity to which individuals receive adequate education, nu- trition, recreation, and medical care services as “neighborhoods influence the collective resources” these individuals receive (Li and Yuan, 2021). Seg- regated neighborhoods face greater barriers to re- cruiting and retaining physicians, which limits indi- vidual access to healthcare services (White et al., 2012). These neighborhoods have limited re- sources (e.g. diagnostic imaging services) which also contribute to healthcare disparities (White et al., 2012). Due to disparities in resources, “women whose residential neighborhood[s are] character- ized by a lower quality-built environment are also at increased risk of adverse perinatal outcomes such as preterm birth” (Anthopolos et al., 2014). Further augmenting the impact of redlining, historically dis- advantaged neighborhoods have “a higher risk for COVID-19 infection in ZCTAs with present-day eco- nomic and racial privilege” (Li and Yuan, 2021). Here, Li and Yuan (2021) illustrate a greater risk for COVID-19 infection in present-day redlined areas. This mirrors the impact of poor-quality environ- ments due to previous residential segregation, as this leads to an increased risk of “adverse perinatal outcomes” (Anthopolos et al., 2014). Therefore, modern-day redlined zones illustrate the perpetua- tion of racial inequalities in healthcare outcomes through limiting the number of resources marginal- ized communities can gain access to due to the pro- gression of “racially segregated communities [be- coming] economically segregated, resulting in the large-scale disinvestment often characterizing ma- jority non-white neighborhoods” (Anthopolos et al., 2014). This ultimately leads to overt consequences such as “preterm birth through poor-quality built en- vironment [and] poor-quality housing stock” (An- thopolos et al., 2014). Clearly, Anthopolos, Li, and Yuan illustrate that standard of care is impacted by geographic factors. Redlining has influenced racial inequalities in healthcare outcomes through increased expo- sure to pollutants and other toxins, which further il- lustrates the lack of investment in black communi- ties. This disparity is demonstrated as “better HOLC neighborhood grades are associated with lower lev- els of airborne carcinogens and higher levels of tree-canopy coverage (which mitigates air pollu- ARESTY RUTGERS UNDERGRADUATE RESEARCH JOURNAL, VOLUME I, ISSUE IV tants and heat)” (Bailey et al., 2021), whereas pre- dominantly black communities face “pollutant expo- sure through proximity to neighboring industrial plants or landfills, water leakage, mold, lead paint, pest infestation, and poor ventilation” (Abraham et al., 2021). This demonstrates pollution inequity as white individuals create most of the fine-particulate pollution due to their overconsumption of goods; however, black and Latinx minorities face the conse- quences and inhale this pollution (Abraham et al., 2021). Li and Yuan further illustrate pollution ineq- uity as the government and society’s “devoid of in- vestment” in black communities leading to “the in- stitutionalized segregation of capital (e.g., loans and investments) from black people [which] shaped the socio-spatial arrangement of goods and services [e.g. medical care] in the USA” (Li and Yuan, 2021). The fact that white individuals do not face the same consequences as their black counterparts demon- strates the disadvantage and inequality that these marginalized communities endure, ultimately lead- ing to more adverse health outcomes such as asthma and low birth rates (Li and Yuan, 2021). Li, Yuan, and Bailey et al. illustrate that the racial ine- qualities between black and white individuals be- cause of racial segregation keep people of color in disadvantaged and disinvested neighborhoods. These past policies continue to perpetuate racial disparities in healthcare since white individuals do not experience this increased risk of illness. Clearly, redlining and racial segregation promote racial dis- crepancies in healthcare. 4 UNDERREPRESENTATION IN HEALTHCARE AND ACADEMIA The absence of minority groups in healthcare positions and academic settings illus- trates the depth of racial inequalities in society. This lack of representation can be seen in the recruit- ment and retention of black faculty, as a study con- ducted in 2010 demonstrated that “among faculty members who had been hired in 2000, blacks were less likely to have been retained than any other de- mographic group” (Ansell and McDonald, 2015). This exclusion of black professors and faculty from academia is also perpetuated through “poor educa- tion and school quality; lack of role models; financial cost of education and training; and persistent bias, stereotyping, and racism” (Powers et al., 2016). The paucity of black representation in academic and healthcare settings leads to the existence of racial inequalities in healthcare in the form of extrinsic fac- tors such as “persistent bias, stereotyping and rac- ism” (Powers et al., 2016). These factors lead to “only 2.9% of all faculty members at U.S. medical schools [being] black” (Ansell and McDonald, 2015). This contributes to the disproportionate ratio of black to white physicians by creating environments in which black medical students lack black role models, re- sulting in fewer people of color in these fields. The effects of underrepresentation in aca- demia and healthcare can be illustrated through the idea of “race-conscious professionalism” where Af- rican Americans understand the implications of their professional success in race politics and marginal- ized communities (Powers et al., 2016). This leads to black physicians experiencing a dual obligation to reach professional excellence in order to protect their communities. The two-fold responsibilities that black physicians experience are not limited to the present day; many of the first formally trained physi- cians used their scientific credibility and community leadership to build hospitals to care for black com- munities, while also bolstering the African-American professional class (Powers et al., 2016). Race-con- scious professionalism gives insight into the intrinsic obstacles that black physicians face as “most have experienced or witnessed, firsthand, inequalities in the access to, and quality of, health care” (Powers et al., 2016). Since many black physicians have experi- enced the disparities that their communities are fac- ing, they feel an obligation to aid their communities, which leads to a disproportionate number of “black and Hispanic physicians locat[ing] their practices [to] areas with higher proportions of residents from underserved minority groups (Komaromy et al., 1996). The lack of black representation in academia and healthcare perpetuates racial inequality as it leads to increased pressures placed on minority physicians to practice in marginalized communities ARESTY RUTGERS UNDERGRADUATE RESEARCH JOURNAL, VOLUME I, ISSUE IV who have also “witnessed inequalities in the access to, and quality of, health care” (Powers et al., 2016), resulting in “black and Hispanic physicians consist- ently car[ing] for disproportionately high numbers of [black and Hispanic] patients” (Komaromy et al., 1996). This burden is a direct result of the lack of in- clusivity in science and medicine for black individu- als, which leads to incommensurate physician de- mographics. Confining colored physicians to prac- tice in underprivileged areas to protect and advo- cate for their own racial and ethnic groups pre- serves racial inequality as this responsibility is placed solely on colored minorities while their white counterparts are liberated from this accountability. 5 DIFFERENTIATING SYSTEMIC BIAS FROM INDIVIDUALISTIC BIAS While I have argued that racial inequalities in healthcare must be viewed from a systemic lens through observing past historical and social abuses, there are also those who argue that an individualis- tic lens is more suitable. Sabin et al. illustrate priori- tizing the individualistic perspective as “physicians [holding] strong implicit associations for black pa- tients as being ‘less cooperative’ and demonstrating that this implicit bias was related to quality of care” (Sabin et al., 2009). They support viewing racial ine- qualities as an individual’s responsibility because this has direct consequences in clinical decision- making. This can include treatment plans for pa- tients, as with the use of thrombolysis for coronary symptoms. For example, in Green et al’s study to measure implicit bias in physicians about race, phy- sicians that favored white patients more than black patients were more likely to treat their white patients with thrombolysis for coronary symptoms (Green et al., 2007, as cited in Sabin et al., 2009). Therefore, physicians who maintain strong implicit biases con- tribute to inappropriate, adverse courses of treat- ment toward black patients, resulting in disparities that can explicitly be seen in the fact that “relative to [white] Americans, [black] Americans experience higher rates of diseases, disability, and premature death” (Trawalter., et al 2012). Although examining the impact of physician implicit bias on clinical decisions is important in evaluating racial disparities, solely relying on indi- vidual accountability negates the impact of greater systemic and structural forces. The significance of evaluating systemic elements when discussing ra- cial inequalities can be seen in “the systematic dis- investment… within segregated black neighbor- hoods [which] has resulted in under-resourced facil- ities with fewer clinicians, which makes it more diffi- cult to recruit experienced and well-credentialed primary care providers and specialists and thereby affects access and utilization” (Bailey et al., 2021). Therefore, when examining the influence of sys- temic factors such as the disinvestment in black neighborhoods, it transcends the quality of care. Because access to resources is limited in black com- munities, this leads to fewer physicians and difficulty in obtaining a higher standard of healthcare. This showcases the greater depth and effect behind the nature of care that black neighborhoods receive. Viewing racial disparities in terms of barriers such as redlining and race-conscious professional- ism is more effective in understanding racial ine- qualities because it provides reasoning for the per- vasive disadvantages that black people face, inde- pendent of individual actions. Regardless of physi- cian bias, black patients “consistently have much higher rates of premature, preventable death and poorer health throughout their lives” (Bassett, 2015). This can be attributed to greater forces that are deeply entrenched in institutions and policies rather than interpersonal interactions, as this ena- bles a holistic framework for addressing the obsta- cles and adverse outcomes that are ubiquitous in black communities. In addition, global factors are significant because the “ongoing exclusion of and discrimination against people of African descent throughout their life course, along with the legacy of bad past policies, [continues] to shape patterns of disease distribution and mortality” (Bassett, 2015). This further reinforces that the “higher rates of dis- eases, disability and premature death” (Trawalter et al., 2012) in black demographics are not limited to implicit bias. This only provides a partial picture of the factors that perpetuate racial inequalities as ARESTY RUTGERS UNDERGRADUATE RESEARCH JOURNAL, VOLUME I, ISSUE IV these consequences continue to exist past individ- ual interactions. 6 CONCLUSION Perpetuating racial inequalities are the re- sult of direct and indirect social and historical factors pervasive in academia and healthcare systems. The academic prejudice against black communities pro- motes distrust in medical services, leading to the un- dertreatment of black patients and the inordinate number of black physicians practicing in these ra- cialized neighborhoods. This academic prejudice is further supported by the underrepresentation of mi- norities in academia and the responsibility placed upon black scholars to excel in their fields. Moreo- ver, structural mechanisms that continue to preserve racial disparities surpass academia and science and can be observed in residential segregation, which leads to unequal access to healthcare services and negative health outcomes in black patients. These systemic forces depict the extensive nature of racial bias in medicine and society in the United States as these are not limited to individual interactions. The decisions made by individuals are based on histori- cal and cultural bias. The ubiquity of the impact of structural racism is supported through the act of psychologizing racism, where the excessive analysis of one’s own prejudice, discrimination, and stereo- types towards people of color invalidates the expe- riences of black minorities (Trawalter et al., 2020). This results in minimizing the true effect of institu- tional bias and injustice. It is important to validate the role of various systemic elements when examin- ing the barriers placed upon black communities ra- ther than focusing on individual biases. Recognizing the social and historical con- texts behind modern-day healthcare practices gives us insight into racial inequalities and disparities in academia and medicine. Moving forward, reform requires the recognition and reconciliation with the past abuses against black individuals while also con- tinuing to educate on historical and social policies. This entails medical schools educating on past his- torical injustices against black communities and the consequences of these abuses in modern-day med- icine. Additional initiatives to combat underrepre- sentation in academia should be proposed and en- forced to dismantle systemic and structural racism most effectively in healthcare and beyond. This re- quires implementing programs that consider the so- cial and historical contexts unique to the black ex- perience. Understanding the frameworks that perpet- uate racial disparities today allows for a greater ap- preciation of black experiences as it elucidates long-standing obstacles that validate distrust in ac- ademia and medicine, prevent access to healthcare, and demonstrate underrepresentation in academia. 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