#57390: Structural Racism and Bias: Impact on Patients and Care

Today, it is acknowledged that race is not a biological category but is a social and political construct. In fact, there is more genetic variation within so-called racial groups than between them [4]. Race was invented as a hierarchy to justify the economic exploitation of enslaved people and the colonization of indigenous communities. Yet while race is not biologically meaningful, racism (and its health consequences) are very real [5]. The health differences we observe between racial groups are the product of racialized systems, not of race itself.

Racism is a system of structuring opportunity and assigning value based on the social interpretation of how a person looks (what we call "race") that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources [6]. This definition, developed by Dr. Camara Phyllis Jones, emphasizes that racism is a system, not merely an attitude.

Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, media, healthcare, and criminal justice [7]. It describes cumulative and compounding effects of an array of factors that systematically privilege White people and disadvantage people of color. Structural racism does not require individual racist actors. It functions through the policies, laws, and institutional practices that have become normalized over time (Table 1) [8].

Bailey and colleagues define structural racism as the macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups [1].

Institutional racism refers to the policies and practices within institutions (e.g., hospitals, schools, banks, government agencies) that result in differential outcomes by race, whether or not those differential outcomes were intended [6]. Examples in health care include hospital siting decisions that locate full-service facilities away from communities of color, credentialing processes that create barriers for minority applicants, and clinical algorithms that embed race-based corrections that alter treatment recommendations [9].

Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner [10]. Unlike explicit bias, which is conscious and deliberate, implicit bias operates outside of awareness and can influence clinical decision-making even among well-intentioned providers. Importantly, implicit bias alone does not explain health disparities; it functions within a broader structural context.

Jones describes these as the "gardener's tale," or the soil in which seeds are planted that matters as much as the seeds themselves [6]. Two patients with identical clinical presentations may have vastly different outcomes based on the conditions of their social environments.

The history of American medicine includes documented cases of nonconsensual medical experimentation on Black Americans, including the infamous Tuskegee Syphilis Study (1932–1972), in which Black men with syphilis were deliberately denied treatment so researchers could observe disease progression [11]. In another, more recent example, members of the Havasupai Tribe in Arizona provided blood samples to Arizona State University researchers for research into type 2 diabetes in the 1990s and 2000s. Tribe members understood the research to concern diabetes, but the samples were subsequently used for studies involving schizophrenia, population migration, and inbreeding, without obtaining consent for those uses [36]. This history, and its contemporary echoes, shapes the distrust that many patients of color bring to healthcare encounters today.

Until the passage of the Civil Rights Act of 1964 and the implementation of Medicare and Medicaid in 1965 (which required participating hospitals to desegregate), most hospitals in the South (and many in the North) were explicitly racially segregated. Black physicians were excluded from medical school training programs, hospital staff privileges, and professional associations for much of the 20th century [12].

The American Medical Association (AMA) formally excluded Black physicians from membership for decades and opposed the inclusion of Black hospitals in accreditation systems. In 2021, the AMA acknowledged this history and committed to embedding racial justice across its strategic priorities [13].

Beginning in the 1930s, the federal Home Owners' Loan Corporation (HOLC) systematically graded neighborhoods by perceived investment risk, with Black and immigrant communities almost universally marked in red ("hazardous") for mortgage lending. This practice, known as redlining, denied generations of Black and immigrant families the opportunity to build wealth through homeownership [14].

Neighborhoods redlined in the 1930s and 1940s continue to show significantly higher rates of poverty, lower life expectancy, higher rates of chronic disease, and reduced access to health care compared to previously "green-graded" neighborhoods [15]. In a very real sense, a map from 1940 can predict health outcomes today. A patient's zip code remains one of the strongest predictors of health outcomes, stronger, in many cases, than genetics or individual behavior. This is not a coincidence; it is the direct consequence of decades of policy decisions that concentrated disadvantage in specific communities [8]. Healthcare professionals who understand this history are better equipped to recognize when a patient's challenges are systemic rather than personal and to respond with appropriate advocacy and support rather than judgment.

School funding systems tied to local property tax bases mean that communities with lower property values (often communities that were redlined) receive less funding per pupil. This creates compounding educational disadvantages that affect health literacy, employment prospects, and lifetime earning potential [16].

The racial wealth gap in the United States is dramatic and persistent. In 2019, the median White family held approximately eight times the wealth of the median Black family and five times the wealth of the median Hispanic family [17]. Wealth determines health in many direct ways: access to health insurance, ability to afford medications, capacity to take time off work for medical appointments, and the ability to live in resource-rich neighborhoods.

Discriminatory credentialing, hospital segregation, and exclusion from medical training programs meant that communities of color were left with fewer providers who shared their cultural backgrounds or linguistic identities, and with healthcare facilities that were structurally under-resourced. These conditions were not corrected overnight with civil rights legislation, and they set in motion resource gaps that persist today.

Black Americans have significantly higher age-adjusted death rates from heart disease, stroke, diabetes, and cancer than White Americans [2]. Non-Hispanic Black adults are 60% more likely to be diagnosed with diabetes and twice as likely to die from the disease compared to non-Hispanic White adults [20]. Asian and Pacific Islander men are twice as likely as their non-Hispanic White counterparts to have stomach cancer and are 1.7 times more likely than White men to die from liver cancer [37]. These differences are not explained by genetic differences; they are explained by the differential exposure to social risk factors that structural racism produces.

The Black maternal mortality crisis is one of the most striking examples of structural racism's health impact. Black women in the United States are approximately two to three times more likely to die from pregnancy-related complications than White women, regardless of income or education level [21]. Dr. Shalon Irving, a CDC epidemiologist with expertise in social determinants of health, died in 2017, six weeks after giving birth, from complications of hypertensive crisis. Her death illustrated that even professional status and advanced education do not fully protect Black women from the effects of cumulative racial stress and inadequate postpartum care [38].

Contributing structural factors include inadequate access to prenatal care, higher rates of uninsurance, lower rates of continuity of care, and the biological effects of chronic racial stress (known as weathering), which accelerates physiological aging in Black women [22].

Communities of color face unique barriers to mental health care, including provider shortages, lack of culturally competent services, stigma within communities where mental health services have been historically unavailable, and the psychological burden of experiencing racism itself [23]. Chronic exposure to discrimination is associated with elevated rates of depression, anxiety, post-traumatic stress, and cardiovascular disease [24].

The life expectancy gap between American Indian/Alaska Native and Black Americans compared with White Americans, driven by higher rates of preventable death, has been documented for decades. LaVeist and colleagues estimated that racial health inequalities cost the United States $229 billion in direct medical care expenditures and economic losses over a three-year period [25]. This is not only a moral problem; it is an economic one.

Structural barriers, including lack of insurance, provider shortages in underserved areas, transportation challenges, and lack of time off work, all contribute to lower rates of preventive service utilization in minority communities. These are not preferences; they are consequences of systems that allocate resources inequitably.

Who gets screened and when is shaped by both guidelines and access. When guidelines are based on data that under-represents minority populations, they may fail to identify risk appropriately. Additionally, lack of access to primary care means that screening occurs less frequently in communities of color, resulting in later-stage disease diagnoses [27.

Diagnostic tools and reference ranges developed primarily in White populations may perform differently across racial groups. More critically, research demonstrates that patients of color are more likely to have their symptoms attributed to non-organic causes, to be undertested, and to receive delayed diagnoses across multiple conditions [2,3].

Multiple studies document that race influences treatment decisions. Black patients are less likely to be referred for cardiac catheterization after heart attacks, less likely to receive adequate pain management, less likely to be offered clinical trial participation, and less likely to receive guideline-concordant care for a range of conditions [3]. These patterns persist even after controlling for clinical severity.

Fragmented care disproportionately affects patients with limited resources. When specialty referrals require transportation, time off work, and the navigation of complex insurance requirements, patients who lack these resources fall through the gaps. For example, Patient J's four-month pending nephrology referral reflects this systemic failure.

How health systems deploy their resources, including where they locate facilities, which services they fund, how they staff clinics, and which language access programs they invest in, directly reflects and reproduces structural inequities. Health systems that serve predominantly minority populations are consistently underfunded relative to those serving predominantly White populations [25].

Standard quality improvement approaches measure outcomes at the population level but may not stratify data by race, ethnicity, language, or other equity-relevant characteristics. Equity-focused quality improvement (EFQI) builds on established quality improvement methods by explicitly examining whether improvements are distributed equitably [31]. The Institute for Healthcare Improvement's framework for achieving health equity recommends that organizations [31]:

It is not possible to address what is not measured. Health systems should routinely collect, analyze, and act on data stratified by race, ethnicity, language, gender identity, and socioeconomic status [31]. This includes not only outcome data (e.g., mortality, readmissions, complications) but also process data (e.g., wait times, referral completion rates, prescription fill rates) and experience data (e.g., patient satisfaction, communication ratings).

Trauma-informed care recognizes that many patients, particularly those who have experienced racism, poverty, violence, or historical institutional betrayal, carry trauma that affects their health behaviors, their healthcare interactions, and their physiologic stress responses [32]. A trauma-informed approach:

For patients like Patient J, whose prior negative healthcare experiences contribute to avoidance of care, a trauma-informed framework is not optional—it is clinically essential.

Culturally responsive practice involves recognizing and incorporating patients' cultural values, health beliefs, and community contexts into care planning [33]. This is distinct from stereotyping, as it requires asking and listening rather than assuming. Key elements include:

Health systems that partner with community organizations, including faith institutions, community health workers, neighborhood associations, food access programs, are better positioned to address the SDoH that drive outcomes between clinical encounters [34]. Community health workers in particular have demonstrated effectiveness in reducing disparities in chronic disease management, prenatal care, and cancer screening.

Building a diverse, equity-competent workforce requires intentional investment across the educational pipeline. Health systems can support this through: