The Historical Roots of Racial Disparities in American Health Care
A new documentary from the Smithsonian Channel, ‘The Color of Care,’ produced by Oprah Winfrey, shines a light on medicine’s biases
“Racial inequity shows up in every dimension of health care,” says Neel Shah, an assistant professor in obstetrics and gynecology at Harvard Medical School and chief medical officer of Maven Clinic, a pioneering virtual clinic for women and families. “The thing about maternal health that has made it the galvanizing focus of my whole career is that the wellbeing of mothers is a bellwether for the wellbeing of society as a whole.”
The physician lent his expertise to Color of Care, a new documentary from the Smithsonian Channel about racial disparities in health—and how to address them. The program, executive produced by Oprah Winfrey and set to premiere on May 1, will delve into these issues and how the covid-19 pandemic laid bare the issues facing the nation. We asked Shah about the historical roots of the connections between race and wellness.
Are racial health inequities mainly a legacy of medical pedagogy? Are they also cultural?
Well, you can't separate the two. Racism shows up in a number of ways. There's interpersonal racism, which can be explicit but almost always is tacit. These are the biases that we carry around with us in our daily interactions. And then there is institutional racism. One of my really close friends lost his wife after having a C-section; he had been raising alarm bells because she didn't look quite right. But in hindsight, one of the things he worries about is that he could have advocated more strongly for her, but also, as a Black man, he didn't want to be perceived as a threat at the front desk. This is such a clear example of how implicit racism can operate. Racism operates in really any environment, and shows up in the hospital. Health care is not immune from the injustices that pervade society more broadly, including racism.
You’ve pointed to longstanding deficiencies in medical education, including a lack of representation.
Yes. This has been true throughout the history of medical training, but even in 2022 it remains uncommon when you’re learning about rashes in dermatology to see representation of melanated skin. Similarly, a common way to know that certain patients are unwell—perhaps they’re bleeding internally, causing anemia—is if they’re pale. But if you’re brown or Black, that may present differently.
How else has medical education historically contributed to racial inequities in health?
There’s the persistent, tacit idea that Black patients are somehow biologically different. Medicine as an institution grew up alongside slavery. In order to commodify another human being, you have to dehumanize them. So there’s this idea that people with Black skin are somehow biologically different from people with white skin, which is simply not true scientifically. For example, there has been a deeply held belief from the time of slavery through the present day that Black people have higher pain tolerance. There’s even a recent study that showed that many medical students still believe that Black people literally have thicker skin. They don’t.
And of course there are material and geographic barriers to health care for many people of color.
The pervasive and infuriating history of redlining has had its effects on access to hospitals. In almost every major urban center in America, there’s an area with the inner-city hospital that is vastly under-resourced relative to hospitals elsewhere in the city. This is a direct consequence of century-old policies that caused divestment from certain majority-Black neighborhoods. So if you’re a Black person in America today, you’re three to four times more likely to die in childbirth than if you’re white, irrespective of education or income; in New York City, you’re 8 to 12 times more likely to die. In part, that’s because of the difference between access to resources for someone living in the Bronx vs. the Upper East Side.
You note that maternal health hasn’t improved overall in the past generation. Why is that?
A woman in America today is 50 percent more likely to die in childbirth than her own mother. When you look into the reasons, it’s the same story that we see in every corner of America: Widening inequality is actually what’s driving an overall increase in maternal mortality in America.
What current efforts to improve health care for people of color seem most promising?
A really important thing that I’ve seen happen in the last two years is changes in leadership. Like other institutions, medicine requires representation at the highest levels of people who share the lived experiences of those who we’re trying to serve. And historically we haven’t had that, but everything from editorial boards at leading journals to the leaders of top health care institutions, we’re starting to empower the right leaders. And second—this is where I’m putting all of my professional energy right now—we want to use technology to get to a place where, for the first time in the world, your ZIP code doesn’t have to be your destiny. It’s not as though an app is going to fix health care, but there is an opportunity to use digital devices as portals into health care services. And that is really exciting to me.