Behavior, Not Racism, Explains Racial Differences in Medical Outcomes

The American Medical Association released a statement on May 11 acknowledging that “racism is a public health threat.” A recent Boston Review article, “An Antiracist Agenda for Medicine,” concurred, making the case that racial health outcome discrepancies are evidence of systemic racism. 

To support their claim, physicians Bram Wispelwey and Michelle Morse analyzed 10 years of data from Brigham and Women’s Hospital in Boston, Massachusetts. Looking specifically at patients with heart failure, Wispelwey and Morse 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 greater access to cardiologists. Their study found 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.

Wispelwey and Morse’s 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 black, indigenous, and people of color (BIPOC) and race-centric health institutions. The second is following a “healing” program 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.

Closer scrutiny of the authors’ study, however, raises doubts both about Boston Review’s understanding of the problem as well as the proposed solutions. 

Within the article itself, the authors share a follow-up study they performed at the same hospital that found white patients were significantly more likely to advocate on their own behalf, for example, by asking to be placed specifically in the cardiology service. What’s more, Wispelwey and Morse say they found no evidence black patients who spoke up for themselves were denied service or treated differently from white patients. The authors conclude that “systemic racism” causes white people to feel more comfortable asking for better care. But that is not systemic racism; rather, demanding better care is a personal choice . . . and a smart one.  

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, four percent of white patients die, compared with two percent of black and three percent of Hispanic patients. 

Wispelwey and Morse contend the medical inequity may be found in readmission rates: 29 percent of black and Hispanic patients were readmitted to the hospital within 30 days, compared to 26 percent 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 ones. Making a “systemic racism” argument from this finding is confused, at best.  

An article in the Journal of the American College of Cardiology: Heart Failure attempts to resolve the mortality-readmissions paradox by noting 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. Yet authors Karen E. Joynt and Jessica M. Peña argue that those factors are also elements of systemic racism: historic oppression leads to poverty, which then leads to poor food decisions, which then leads to obesity. My purpose 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.

Yet another study analyzed data from 1,200 U.S. hospitals and found no meaningful difference in the quality of care based upon either race or socioeconomic status. Authors Nicholas S. Downing, Changqin Wang, and Aakriti Gupta 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 highlighted in 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. 

The decision to seize upon readmission rates as evidence of racism when white patients suffer from drastically higher mortality rates is a value judgment unsupported by either medical practice or common sense. The flimsiness of evidence for white supremacy at Brigham and Women’s Hospital makes the very existence of the problem dubious. If anything, it reveals that the authors’ recommended prescriptions are dangerous and not based on a sound interpretation of the evidence.

Medical decision-making authority should reside with the doctors who are working in the clinical setting. Offering preferential treatment based upon race is not only blatantly racist policy but it also violates the autonomy of medical professionals to make decisions that will most benefit their patients. Even Wispelwey and Morse admit they could find no evidence of personal racism among Brigham and Women’s doctors, which is why they must lay the blame at the feet of “systemic racism.” 

So long as doctors are continuing to treat their charges fairly on an individual basis, race-based health equity policy will only serve to harm patients. Offering cardiology services based on race would 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 addressing the root causes of differential racial outcomes. 

Minority patients are indeed more likely to suffer from obesity and diabetes, which of course have 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 every possible variable to discover what is driving undesirable health outcomes.

 

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