Why do Black Americans have worse COVID outcomes?

Check out our article originally published on KevinMD, which outlines how implicit bias in medical education and race-based medicine can lead to poor outcomes for Black patients:

Our country is currently battling two urgent and severe healthcare crises: COVID and Systemic Racism. Project R.I.B.M.E.A.T lies at the intersection between these two phenomena. Our research shines light on the embarrassing-but-changeable roots of unjust medical biases, which are intensifying the COVID pandemic's growing toll on Black Americans.  We believe that addressing systemic racism now is as urgent and as dangerous to the health of our nation and its people as the COVID19 pandemic. Our study looks at one part of systemic racism: how we are imbedding implicit bias in our medical education system at a national level through reinforcement of negative racial stereotypes in required, high stakes national tests. We believe systemic racism is intersecting with the COVID19 pandemic as seen through disproportionate access, morbidity and mortality among people of color and therefore our research is of immediate interest. New medical students start in 6 -8 weeks across the country and immediately start worrying about and preparing for the USMLE Step exams. Our goal is that students and medical educators start medical school on the right footing, with a "lens of equity" and a chance to make incremental changes in the system in which we participate.

At the explicit/conscious level, non-Black physicians are more likely to perceive Black patients as “less trustworthy, more contentious, and less likely to adhere to their recommendations than White patients”30.  At the implicit/unconscious level, it has been observed that non-Black physicians display a preference for White over Black patients and are more likely to associate White patients with being compliant and cooperative30,31.  In 2002, The Unequal Treatment by the Institute of Medicine concluded that “for almost every disease studied, black Americans received less effective care than white Americans”16.  Further, “race and ethnicity remain significant predictors of the quality of health care received,”6 and minority patients receive a generally lower quality of care, even with equal access to care and insurance coverage18.  Currently, black men have the lowest life expectancy of any major demographic group in the United States17.  During pregnancy complications, Black women are more likely to die from them than White women18.  Surveys reviewing 25 years of data (1993 – 2017) from the CDC and Prevention’s Behavioral Risk Factor Surveillance System revealed that “there has been a clear lack of progress on health equity during the past 25 years in the United States”19. 

Crudely stated, in medicine, race is used as a shortcut.  It is a “convenient proxy for more important factors, like muscle mass, enzyme level, [and] genetic traits,” that physicians do not have time to investigate in a clinical setting21.  However, race is a bad proxy since it does not add relevant information and usually overwhelms clinical measures blinding doctors to patients’ symptoms, history, and presenting illness21.  A study showed that clinicians were more likely to diagnose a young black woman with lower right quadrant pain as having pelvic inflammatory disease rather than appendicitis when compared with a young white woman with the same symptoms and history28.  Race medicine is perpetuated through clinical measures as well.  Glomerular filtration rate, an indicator of kidney function, produces a different GFR estimate for the same creatinine level depending on whether a patient is African-American21, which has implications for whether patients are placed on transplant lists29.  Our research in no way is advocating to ignore race, however, race medicine is flawed.  For example, based on current understandings of race in medicine, how would you treat siblings with one white parent and one black parent but who appear phenotypically different – one appears externally to be white and one black?  Which GFR calculation or ASCVD risk score would you use?  Which first-line blood pressure medication would you start?32.  

 In David Ansell’s “Bias, Black Lives, and Academic Medicine,” he notes that there is evidence that physicians hold stereotypes based on patients’ race that has the ability to influence their clinical decisions20.  In addition, there is research to suggest that “there’s a direct relationship among physicians’ implicit bias…and clinical outcomes”16.  Dorothy Roberts, J.D. has stated that race medicine leaves patients of color vulnerable21.  For example, the stereotype that black and brown people feel less pain, exaggerate their pain, and are predisposed to drug addiction correlates with studies that reveal “relative to white patients, black patients are less likely to be given pain medications and, if given…they receive lower quantities”22.  In addition, the medical literature on hypertension uses genetic explanations of the disease’s higher prevalence among US blacks than whites to support the categorization of treatment strategies by race23.  However, hypertension prevalence is higher in Spaniards, Finns, and Germans than in US blacks23, and a systematic review of genomic studies focused on race and cardiovascular research indicates that the contribution of genetic difference among races is minimal at best24.  The problem with race medicine is that it re-directs focus away from structural determinants that cause racial gaps in health outcomes and places attention on racial differences in disease. 

 Populations who experience the most negative cultural stereotypes also have the greatest healthcare inequalities10.  While our research cannot provide direct evidence of what students learn from study materials, it is known that race shapes public beliefs.  Therefore, at best, the mention of race reinforces existing biases, and at worst, introduces new biases to student-doctors.  These biases have the potential to become part of larger systemic racism, which ultimately increases health disparities experienced by minority patients.  Despite the multitude of breakthroughs in medicine, there still exists a “failure of imagination” when it comes to race in medicine21.  Many physicians and medical educators are confused about the meanings of race and feel ill-equipped to engage debates about race in the classroom7, yet educators must improve academic capacities for teaching about race in medicine.