Health inequalities are 'direct result of institutional racism'

Large inequalities in health are the result of systemic institutional racism that has produced a 'truly rigged system', a world-leading public health expert has said.

Dr David Williams

Dr David Williams, chair of the Harvard Chan School of Public Health, and a professor of African and African American studies at Harvard University, said that even after taking account of socio-economic factors, which show that black and other ethnic groups in both the US and UK have lower incomes and lower wealth status than their white counterparts, 'there is an added burden of race'.

Speaking at the RCGP's online conference 'A Fresh Approach to General Practice' last week Dr Williams said: 'There's something about social class or socio economic status that predicts your health regardless of your race. But there's something else about race, even after you've taken those economic factors into account. And so researchers have been asking for the last 25 years or so could racism be a critical, missing piece of the puzzle to understand the pattern of racial inequities in health.'

Dr Williams presented data showing there was a significant over representation of Pakistani, black, Bangladeshi and other ethnic groups in the most deprived 10% of neighbourhoods in England and similar data for the US. He argued that this 'segregation' was the result of 'a carefully crafted system, functioning as planned, successfully implementing social policies, many of which have historically been rooted in racism'.

'These large inequities we see are not accidents or acts of God,' Dr Williams said. 'They show how upstream systemic, institutional mechanism of racism can nonetheless produce a truly rigged system.'

COVID-19 death rates

He highlighted that COVID-19 death rates in the UK showed that, even after adjusting for age, urbanicity, education, wealth and other socio-economic and demographic factors, black men were 1.9 times more likely to die than white men, Bangladeshi and Pakistani men were 1.8 times more like to die and Indian men 1.3 times more likely to die. The figures for females followed the same pattern.

'So even after taken into account a broad range of economic and demographic factors, we see the persistence of an effect of race - the same is true in the US,' Dr Williams said.

'Every day' discrimination has a direct impact on health outcomes, he explained.

Dr Williams developed the Everyday Discrimination Scale in the 1990s, which is globally the most widely used scale to measure discrimination.

He told the conference that over 300 peer-reviewed papers from around the world had shown that people who had high scores for every day discrimination have poorer health across a range of areas, even when adjusted for other factors.

Clinical impact of racism

These included higher rates of incident metabolic disease, cardiovascular disease, breast cancer and type 2 diabetes. Discrimination also led to 'a range of indicators of sub clinical development of disease', Dr Williams said, including coronary artery calcification, visceral fat, early onset of asthma, poorer sleep quality and sleep duration, as well as higher levels of a number of biomarkers like inflammation cortisol.

In addition, higher levels of obesity, lower involvement with screening services and increased mental health problems have also been observed.

Dr Williams said that data showed that higher numbers of black people suffered from ill health earlier in their lives than white people across a broad range of clinical areas.

He said that US researchers were starting to use terms such as 'accelerated ageing' and 'biological weathering' 'to capture the fact that disadvantaged populations like blacks and Hispanics are literally physiologically ageing more rapidly than the white population'.

Unconcious bias

Dr Williams also highlighted studies from the US that showed black and Hispanic patients received poorer care than white patients, adding that researchers had concluded that the 'driving force' behind these differences was implicit bias or unconscious discrimination.

'The good news is that there are a number of prejudice reducing strategies that can be implemented and that have been shown to be effective,' Dr Williams said. 'So every institution needs to think about ways in which they can raise awareness of implicit bias and implement strategies that can be effective in reducing them.'

He outlined results from a study conducted in California which had shown that 'there was no racial disparity' in the treatment of patients by clinicians and providers who were 'high on cultural competence'.

Doctors were recognised as having a high cultural competence if they agreed that friends and family were as important to health as doctors, they asked their patients about their religion, were familiar with the beliefs that their patients had and that they felt competent with patients from different background and they involved patients in decisions about their healthcare.

Connecting patients to non-medical services that would help improve their health or encouraging them to engage with screening programmes was also vital in tackling both socio-economic and racial health inequalities, he added.

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