Feature Article
The Health Care Institution, Population Health and Black Lives

https://doi.org/10.1016/j.jnma.2016.04.002Get rights and content

The ongoing existence of institutionalized racism and discriminatory practices in various systems (education, criminal justice, housing, employment) serve as root causes of poor health in Blacks Lives. Furthermore, these unjust social structures and their complex interplay result in inefficient utilization of health services and reactive or futile interactions with medical providers. Collectively, these factors contribute to racial disparities in health and treatment represents a significant portion of the nation's health care expenditures. In order for health care systems to optimize population health goals, racism must be recognized as a determinant of health. As anchor institutions in their respective communities, we offer hospitals and health systems a conceptual framework to address the issue within internal and external constructs.

Introduction

While some may assert we live in a post-racial era, a body of scholarship corroborates the presence of structural racism in contemporary settings.1, 2, 3, 4, 5 Most recently, a series of events have elevated social consciousness about the Black experience in America.6 Consequently, the Black Lives Matter movement gained momentum in 2012, serving as a “call to action and a response to the virulent anti-Black racism that permeates our society.7” The mission specifically focuses on addressing “ongoing and widespread devaluation of Black Lives and the social, political, and economical structures that result in unequal opportunity.7” Such forms of injustice have a profound effect on communities of color and are manifested through inequities in common correlates of health, including access to quality education, healthy foods, livable wages, and affordable housing.

Moreover, a substantial body of evidence highlights the relationship between race, racism and health status.8, 9, 10, 11, 12 Blacks are disproportionately burdened by poorer access and lower quality of care even when controlling for factors, such as income, education, and insurance.8, 13 They also represent higher rates of morbidity and premature mortality when compared with white counterparts. Some of the starkest differences can be found in hypertension, diabetes, and asthma rates, resulting in higher frequencies of treatment for comorbidities and ambulatory care sensitive conditions.14, 15, 16, 17, 18, 19 Such racial disparities have a significant financial impact and are estimated to cost $35 billion in excess health care expenditures and $10 billion in illness-related lost productivity.20

In response to these disparities, many health care institutions have demographically stratified and analyzed health outcome data and incorporated best practices to create interventions to reduce or eliminate disparities in care. However, due to broader structural contexts, significant disparities persist. We assert that these trends will remain intractable until structural racism and its effects (bias, discrimination) are recognized as root causes of poor health. This approach is especially relevant as health reform is incentivizing health care leaders to find new and more creative ways to promote wellness, reduce readmissions, and manage the health of populations. By applying a racial equity lens in how they are governed and operated, hospitals, as anchor institutions, can advance their population health goals.21

Using health reform as a springboard, we articulate why this approach is important and close with a conceptual framework to stimulate thought and organizational practices that (1) promote racial equity within health care settings; and (2) contribute to the advancement of historically marginalized communities of color.

Section snippets

Health Equity and Black Lives

In light of the magnitude and long-term psychological impact of racism, coupled with a history of implicit and explicit injustices imposed on those of African descent, two definitions in the literature inform our interpretation of health equity within the context of Black Lives. In 2003, Braveman and Gruskin defined health equity as a goal of eliminating systemic disparities in health or in the major social determinants of health (i.e., education, housing, employment) between social groups who

Institutionalized Racism and Its Effects

In order to be effective in improving health through a racial equity lens, it is important to recognize how the health care institution is a subset of a larger ecosystem with vestiges of institutionalized racism, stemming as far back as the 1600s.9 The legacy continues to influence how low income communities of color are structured and resourced.23, 24 Institutionalized racism is defined as “the structures, policies, practices, and norms resulting in differential access to the goods, services,

Population Health

The gravity of these dynamics must be recognized within the context of population health – a term that has progressively increased in the literature since 2010.45 While the interpretation and its utility tend to vary depending on discipline or profession, health care institutions are likely to perceive population health as clinically managing the patients under the auspices of their care. However, health outcomes for these patients are heavily influenced by structural conditions and the quality

Conceptual Framework

Hospitals are components of a larger ecosystem; they cannot take sole responsibility for addressing complex and intersectional inequities that perpetuate poor health in communities of color. However, as health care providers, they can be instrumental in eliminating racial disparities within clinical settings, and as anchor institutions, they can be socially impactful – using their business models to create opportunity and stimulate investments in historically marginalized communities. To incite

References (56)

  • B. Smedley et al.

    Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare

    (2004)
  • K.A. Schulman et al.

    The effect of race and sex on physicians’ recommendations for cardiac catheterization

    N Engl J Med

    (1999)
  • L.M. Crawley et al.

    Perceived medical discrimination and cancer screening behaviors of racial and ethnic minority adults

    Cancer Epidemiol Biomarkers Prev

    (2008)
  • D.R. Williams et al.

    Racial bias in health care and health: challenges and opportunities

    JAMA

    (2015)
  • K. Fiscella et al.

    Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample

    Med Care

    (2002)
  • D.J. Gaskin et al.

    Racial and ethnic differences in preventable hospitalizations across 10 states

    Med Care Res Rev

    (2000)
  • S.K. Davis et al.

    Disparities in trends of hospitalization for potentially preventable chronic conditions among African Americans during the 1990s: implications and benchmarks

    Am J Public Health

    (2003)
  • J.N. Laditka et al.

    Race, ethnicity and hospitalization for six chronic ambulatory care sensitive conditions in the USA

    Ethn Health

    (2006)
  • J.N. Laditka

    Hazards of hospitalization for ambulatory care sensitive conditions among older women: evidence of greater risks for African Americans and Hispanics

    Med Care Res Rev

    (2003)
  • T.A. LaVeist et al.

    Estimating the economic burden of racial health inequalities in the United States

    Int J Health Serv Plan Adm Eval

    (2011)
  • Hospitals As Anchor Institutions: Linking Community Health and Wealth | Community-Wealth.org....
  • P. Braveman et al.

    Defining equity in health

    J Epidemiol Community Health

    (2003)
  • C.P. Jones

    Confronting institutionalized racism

    Phylon 1960

    (2002)
  • D.R. Williams

    Race, socioeconomic status, and health the added effects of racism and discrimination

    Ann N Y Acad Sci

    (1999)
  • V.L. Shavers et al.

    Racism and health inequity among Americans

    J Natl Med Assoc

    (2006)
  • R. Clark et al.

    Racism as a stressor for African Americans: a biopsychosocial model

    Am Psychol

    (1999)
  • A.T. Geronimus et al.

    “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States

    Am J Public Health

    (2006)
  • J.M. Hall et al.

    “It’s Killing Us!” Narratives of black adults about microaggression experiences and related health stress

    Glob Qual Nurs Res

    (2015)
  • Cited by (23)

    • Racial disparities in provider-patient communication of incidental medical findings

      2021, Social Science and Medicine
      Citation Excerpt :

      For example, evidence indicating “differential diagnosis and treatment for a wide range of diseases and disorders” across racial groups serves as striking evidence that healthcare providers routinely, “… employ racially-motivated thinking” when treating patients of color (Hoberman, 2007, 507). Discriminatory treatment of patients of color within healthcare contexts has been documented in multiple studies, demonstrating that patients of color receive lower-quality and less rigorous care across a variety of conditions (King and Redwood, 2016; Laditka et al., 2003; Phelan and Link, 2015; Schpero et al., 2017; Van Ryn and Burke, 2000). Patients of color are more likely to receive inadequate treatment recommendations for breast cancer and cardiovascular diseases (Beyer et al., 2019; Williams and Wyatt, 2015), and Ashton et al. (2003) and Mayberry et al. (2000) have shown that Black patients often receive less clinical attention and fewer diagnostic tests than White patients, net of other health factors.

    View all citing articles on Scopus
    View full text