ABSTRACT

The American health care system is, in its own right, abysmal. Administrative inefficiencies, high costs, barriers to insurance, and lack of public health education are all large factors that contribute to the explanation for America’s low ranking on the World Health Organization’s health care-by-country ranking list. However, one of the more overlooked factors is becoming increasingly more apparent and disastrous for the industry: racism and xenophobia against minority communities. Generally combined with either social or economic inequalities, discrimination on the basis of ethnic and racial identiy is now more blatant and destabilizing to the infrastructure supporting adequate standards of health. This paper seeks to analyze the historical and contemporary scopes of racism and discrimination against two of the largest minority communities and groups in the United States, the Black and Asian populations, and contextualize the changes in outdated perceptions of racialized and discriminatory interactive medicine. 

Both populations have had deep and unfortunate histories in the US; beginning with the historical arrival and beginnings of discrimination against Asian in the United States and the horrific torture and abuse done under the name of research to African-Americans in the 19th century, history sets up an uneven social playing field and encourages the continuation of incorrectly preconceived notions of what it means to be a POC indivdiual seeking health care in the United States. These racist ideals that have carried over and persisted in the consciousness of American health care workers can be analyzed in both blatant and subconscious prejudices against Black and Asian communities in the US, and ultimately decrease access to health care, creating a cycle of medical abuse and negligence. From historical primary and secondary sources, medical data sets, exam protocols, and personal accounts, it is ultimately revealed just how false the notion is that American health care truly is inclusive for all.

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RACISM FOR ALL, HEALTH CARE FOR FEW

It is no secret that there exists racism in contemporary American culture and society.  Discrimination, xenophobia, microaggressions, and preconcieved notions or stereogtypes are all harmful components of racism that persist in all public spheres in the United States. Two of the largest, most marginalized and discriminated against groups in the United States are the Black American population and the Asian-American population. From issues as obvious as slavery and lack of civil rights to discriminiatory legislation prohibiting the admission of peoples into the country, both are well known to have an incredibly tumultuous and difficult history in the America. The effect of the ‘beginning’ of racism towards these two groups were not singular in instance, and their aftershocks can still be felt today in all aspects of American society and culture. 

One of the most notorious instances of this long standing negative effect of racism towards either of the two peoples is in health care; as one of the largest and most important parts of the existing American infrastructure, health care is one of the single most important systems that people require to even physically maintain an adequate standard of health. Health care in the United States, both as an experience for individuals seeking medical treatment and as the system in which medical care is dispensed is in its own right abysmal. Lack of access, the privatization of healthcare, and administrative inefficiency are all fairly large factors that contribute to the dismal state of health care in America, but perhaps one of the more overlooked aspects of destabilization is the existing racism and xenophobia that plague the industry. ¹ Of course, the factors are seldom ever isolated, and for the most part, work together to create a barrier of inaccess and inefficiency that ultimately leaves citizens worse off than they started in the scope of health care — but each individual factor of this destabilization is so large and so negatively impactful to a multitude of populations within the US that its effect can be analyzed individually. This paper seeks to analyze the effects of racism in the Black and Asian-American populations through the lenses of history and the subsequent effect on contemporary attitudes and attempts to seek or receive health care. 

HISTORY

As stated earlier, the context of this paper involves two different frames for analysis of each individual subject within the idea of racism in health care: the history, in which some of the first recorded instances are explored, and the current state of events, which recalls how people living in the United States today are affected by mistreatment anywhere in the scope of health care. 

Nevertheless, it would be incorrect and misleading to imply that the racism and xenophobia existing in health care today are a product of individual instances in history specifically within health care that have influenced generations of the continued mistreatment of non-white POC indivdiuals; discimination on the basis of race or culture is not a new concept, and should not be attributed to singular instances like the ones discussed in this paper. They are systemic, and the discrimination reported in this paper are a result of those preconceived racist and xenophobic notions of the time — not vice versa. The most facile way in which to understand how treatment has changed by group lies not only in analyzing how racism and xenophobia has changed over time, but also in what the status quo of health care was for these individual groups. By using these two different snapshots of time, ideals, values, and notions of what racialized medicine in America looks like today can be seen.  

Black Americans

The history of Black Americans in the United States is one of the most well known and unfortunate blemishes in American history; in the context of health care, however, the history becomes even darker and more disturbing. Arguably, the most well known records of African-Americans in American health care feature unethical experimentation and abuse in the name of research for medical and teaching practices. However, even far before more recent horrors like the Tuskegee experiment were conducted does this history of abuse date. Slaves were utilized as the subjects of experimentation to further biomedical sciences; this was most apparent in women, so much so that the father of modern gynecology, Dr. James Marion Sims, was in fact discovered to have conducted much of his research on enslaved Black women, without consent and without anaesthesia. ² These experiments were conducted and justified under the false notion that Black individuals felt less pain than white ones, and continue to be one of the largest ethical issues in the field of gynecology. ³ This so-called research has had lasting and unfortunate consequences in the consideration of Black individuals in health care today, especially within the reproductive scope of medicine. The morbid nature of both the forced gynecoligcal experiments and Tuskegee trials are equatable to torture, and make it difficult for Black indivdiuals in today’s social setting of health care to feel comfortable in a sphere with such a dark history and receive treatment based on the incorrectly preconcieved notions about Black individuals differing from Whites on a physiological level.

Asian Americans

Since their arrival to the United States, Asian-Americans have been a marginalized group. It is important to note that the term “Asian-American” is very general, and includes a multitude of different ethnicities, races, cultures, and people. Each different group has had a different, individual experience in the United States, and generalizing these groups into a conglomerate of one identity as “Asian-American” has the potential to exclude different perspectives and experiences, so specific instances and naming of different ethic or individual groups in examples will be specified, unless otherwise indicated by primary sources. 

In the context of health care, racism and xenophobia towards Asian-Americans has been less explicit, although still dangerous and harmful. Dating from the implementation of the Chinese exclusion act all the way through the implementation of Executive Order 9066, harmful stereotypes and perceptions of Asian-Americacns have since. persisted. Many of these perceptions are simply racist in nature, like the so-called belief that Asians are less educated and less clean than their White, non-POC counterparts. Other beliefs come from unfair and incorrect conclusions and generalizations about specific groups. One specific example of this was apparent in the justification that the US used in their colonization of the Philippines, where the government claimed that the persistence and prevalence of tropical diseases in some Phillipino citizens warranted complete and absolute imperialism on the American end ⁴— these ideals were carried back to the United States, and to some extent, have unfairly and incorrectly persisted as prejudices and barriers to equitable treatment in the common perception of Asian Americans in the scope of health care. With both of these histories in mind, it is easier to understand the unfortunate and dark context for the status quo of discrimination against these two groups in the US and pinpoint and connect specific instances of blatant racism and racialized medicie — however conscious or unconscious.  

RACIALIZED MEDICINE

One of the most fundamental concepts in health care is the notation of the patient’s history. This umbrella term ‘history’ refers to many different aspects of personal life: past pertinent medical procedures, known allergies, immunization and exam record, and perhaps most importantly, family medical history. Family history is the most important factor involved in determining ailments in sudden and unexpected medical cases. This narrow subsection of patient history primarily focuses on known diseases and problems existing within nuclear families, but also largely factors in personal background — generally assumed to be the patient’s ‘race’. However, the inclusion of and heavy dependence on an individual’s race in diagnostic and preventative medicine is inherently discriminatory and racist, and has the potential to be disastrous for patients. 

Until recently, race-based medicine was a widely accepted and unchallenged method of taking patient history. However, after intense sociological and biological research, it is now becoming more and more rejected by major medical associations. ⁵ This shift away from socialized medicine is based on the now well-known fact that race is a social construct. This, however, does not mean that history does not include some deep insight into a patient’s genetic and phenotypic history — instead, physicians are actively practicing personalized medicine in place of racialized medicine. ⁶ It is important to note that there does indeed exist a difference between the two. The major difference between personalized and racial medicine (specifically in the context of ensuring that patients belonging to different socially-constructed races receive equitable health care) is the understanding that the environment in which a person lives is far more important than their far-back ancestral phenotypic history. Essentially, the superficial identification of a person as “African-American” or “Asian-American” is an inaccurate representation of their personal history and should instead be more reflective of their individual genetic and environmental situations. 

Within this idea that racialized medicine is counterproductive to health care, there still exists a need for more blatant and active attention to the environmental and genetic factors and a shift to correct the common misconceptions about the place that “race” has in medicine. Both of these ideas can be found within the Asian and Black populations in America, largely within access to medical research and paramedicine and the still pertinent beliefs about wildly incorrect biological myths. 

Access and Research

Access to health care is one of the most important parameters to measure success in racial equity. Access has many forms — the physical capabilities of people to seek out and receive assistance, the diffusion of education across communities, and the continual research that is inclusive of different populations are all forms of access to health care that are becoming increasingly more important.  Representation is incredibly important in both research and education in the medical field — they are the cornerstone to advances in health care; without them, public health would remain in a sort of limbo, never having the potential to improve. However, the distribution of topics of research is not equal across the board — many different populations (specifically communities and ethnicities) are consistently ignored and excluded from research, causing these groups to be disproportionately disadvantaged and disenfranchised in health care. These disparities persist in the continued existence of racism in health care in the US — the lack of care to seek a more representative data set is a form of “systemic racism,” and inadvertently upholds the ideals of racist “institutional policies and unconscious bias.” ⁷ The rejection of different populations (which largely include so-called ‘races’) in major scientific and medical research is inherently racist and ultimately ends up discriminating against this group of people by decreasing access to equitable health care that non-POC White populations dominate.

Perhaps the most prominent example of this is in cardiovascular diseases in Indian-Americans. The term cardiovascular disease itself is very loose, and generally describes a multitude of possible defects relative to the heart, including coronary heart disease, hypertension, coronary heart failure, and arrhythmias. ⁸ All are incredibly dangerous and require immediate and focused treatment, and in ideal scenarios, prophylactic care even precedes worst case scenarios where issues become dramatically apparent. Thus, it makes sense that cardiovascular diseases are the subject of much research and education in the health care field — however, it seems that Indian Americans are a subject that are very often overlooked in research in cardiovascular disease. Indian Americans, in general, have different nutritional epigenetics and microbiomes in the US, meaning that their personalized response to disease is slightly different than that of a different ethnicity or perceived race. ⁹ This is not in support of the idea of race-based medicine; in fact, it is the opposite. The immediate cultural environment that Indian Americans live in in the US increases their risk factor — their so-called race has no impact on their propensity to acquire a cardiovascular disease, whereas individual/personal genetic history and socially relevant factors unique to non-White POC populatinos are more important in determining likelihood of inheriting disease. While in the large scale of research, inclusion of different populations and groups of individuals does not particularly affect treatment patterns, it does effect prophylactic care and intervention steps. In the context of dramatic and dangerous ailments like cardiovascular diseases, prophylactic care precedes all else in importance, meaning that exclusion of Indian Americans in medical research and public health and service is inherently racist and biased, and decreases an entire peoples’ access to fair and equitable health.  

Myths and Misconceptions

As discussed previously, African-Americans have a long and difficult history in health care in the US. The instances outlined above are only a fragment of the different horrors that Black individuals have been subjected to in the scope of American health care, but are some of the most negatively influential in today’s understanding of the Black experience in medicine in America.  The notions conceived in these two eras enforced the incorrect assumption that on a physiological level, Black individuals are different from White individuals, but are perhaps more understood in the context of where the idea of race and racialized medicine began. These myths stem from the racist and xenophobic research of Dr. Samuel Moron, a well known physician and researcher in the mid to late 1800s. Morton argued that upon analysis of skulls belonging to individuals from different continents and populations, people could be categorized into races — furthermore, he wrongly declared that non-White races were inherently disadvantaged with smaller brain sizes and thus “suffered intellectually [and physically.]” ¹⁰ Of course, it is well known now that his research on skull measurements was largely skewed by his “unconscious racial bias,” but the aftereffects of his claims that African/Black individuals were of “the lowest grade of humanity” on a physical and mental scale can still be seen as prejudices today. ¹¹

This wildly inaccurate conclusion about Black populations is unfortunately very prevalent in the pharmaceutical department; many health care workers (either unconsciously or consciously) believe Black individuals to be less sensitive to pain or illness — even today, up to 40% of medical students believe that African-American individuals are less likely to feel pain, due to “black people’s skin [being] thicker than white people’s,” and that “[their blood] coagulates more quickly.” ¹² These incorrect assumptions are harmful and detrimental to patients’ health — this is evident in the “implicit bias” that physicians have, favoring White individuals over Black ones in distribution of pain medications, so much so that Black individuals are over 20% less likely to receive pain medications over white individuals. ¹³ This is a far cry from the recent attempts to convert to personalized medicine in favor of race-based medicine, and ultimately does more harm to patients than good. 

INTERACTION BASED MEDICINE

Medicine is inherently social. The very basis of the patient-health care relationship is rooted in a solid and consistent flow of communication between all parties involved. These parties are numerous, and refer to all pertinent health care workers (including physicians, nurses, CNAs, EMTs, etc), volunteers, and the infrastructures in place to assist in the delivery of health care to the patient. Given the sheer quantity of relationships webs a patient forms in a health care scenario, it is easy to see how discriminatory problems that are not rooted solely in race-based medicine can arise. Racism and xenophobia can be much more blatant and equally as harmful to patients as social misconceptions of  how race affects treatment. Perhaps the most obvious form of discrimination in medicine is in the microagressions and weaponization of language against POC invidiuals like those belonging to the Black American or Asian American communities. 

In general, studies have shown that non-white, POC individuals are far more likely to be treated poorly in a health care setting than whtie individuals. ¹⁴ Of course, to the extent to which they are treated poorly differs greatly, and can include language barriers, disrespect, and racial and ethnic discrimination. ¹⁵ Interaction-based racism is less easily characterized by a simple claim that discrimination exists, but the general consensus that can be understood is that non-white, POC indivduals are greatly mistreated in the health care industry to the point where health care access is diminished. Inaccess to health care is the hallmark of  a weak, racist, and xenophobic overall health care system. 

Examples of this are apparent everywhere — a study conducted in 2004 sought to determine how Asian Americans compared with their white counterparts in experience and satisfaction in visits to their physicians. ¹⁶ Asian Americans reported lower rates of satistication, lower instances of counselling, and less positive interactions with their physicians than their white counterparts. While it is difficult to objectively measure rates of satisfaction and quality of language and atmosphere, it is absolutely essential that physicians are able to understand the goals and expectations of their patients. If patients leave feeling unsatisfied and misunderstood, then the health care system has failed them in being able to take autonomy and control over their own body. This instance of racism in health care by means of impersonal and distancing language works in tandem with the aforementioned idea of inaccess to research and medicine. The cold atmosphere that a patient reads from their physican is tantamount to patient discrimination, and in light of the studies showing that Asian-Americans are more likely to receive it, can be boiled down to racism.

Personal testimony regarding racism in health care is even more disturbing than statistics can reveal. One physician in a hospital revealed an instance in which a young Black woman who was a patient in her hospital was essentially being held hostage. ¹⁷ The patient repeated multiple times that she did not wish to be admitted or treated, and despite not showing valid reasons to be deemed at a medical loss of consciousness to have inability to legally give or withdraw consent, she was locked in the ward. Distressed, the patient called the police for assistance and refused to allow treatment, but she was ignored and assaulted against her will. The author of this testimonial then went on to describe how just a week prior, a White man had physically assaulted three staff members at different instances before being forcibly restrained and secured. The dichotomy between the two situations highlights how different so-called racial groups in the United States are treated based on skin color. The continuous ignorance of the medical staff to take action on the man who had assaulted health care workers clarifies their interpretation of the Black woman being uninformed about her condition enough to the point where her consent to treatment was not considered, and is disgusting and a blatant violation of her human rights. Moreover, the fact that a physician was the one to publish this piece shows just how difficult it is for patients to be taken seriously and for their voice to be heard in such a discriminatory setting. This recollection is one of many that have been published that show just how deep racism and discrimination is rooted in the social aspect of health care, and shows how badly prejudice affects patients’ access to medicine.

CONCLUSIONS

Health care is perhaps one of the most controversial industries in the world. However, the consistent comparison of different forms of health care systems against that of the US and different subjective rankings by organizations like the World Health Organization and United Nations have made it easier to understand the flaws and weaknesses of the American healthcare system. One of the most obvious of the lot is racism and xenophobia in health care against non-White, POC individuals. Two of the largest of those groups, Black and Asian Americans have long and distinct histories in America that facilitate the contextualization of their respective experiences in the health care system as patients.

This paper described how the deep and dark history that the two groups have in the United States has unfortunately had long-lasting effects on incorrectly educated people in the health care system that have lead to prejudices and discrimination, whetehr concscious or unconcsious. Furthermore, it was described how the incorrect conclusion of race as a form of biological categorization has made racialized medicine one of the largest inhibitors of equitable medicine for all. The myths and misconceptions that have since arisen from the conceptualization of race still plague the industry, despite attempts to shift towards personalized medicine. Finally, the other major form of racism that was described was interaction-based, in which minority individuals described their respective negative experiences in health care, both on a persona and community level.

Discrimination in the health care field is far more common and dangerous than many expect. The damage done by centuries of institutionalized and systemic racism will take years to remedy. Ultimately, meaningful growth and change is not quick, and takes time and research to be properly understood and enacted. From shifts in understanding of how relevant medical information should be taken to whistleblowing abusive and racist behavior in health care, however, it seems that the status quo seems to be improving to be more inclusive of minority groups. Continuous efforts to provide equitable and satisfactory access to care will need to be enacted to end discriminatory practices and truly make health care for all.