Health Care Is Racist. Here’s What Needs to Change

As scholar Harriet Washington explains, it’s time to consider financial penalties for doctors who discriminate

As the data continues to show, Covid is wreaking disproportionately more havoc on Black, Latinx, and Native American communities in the U.S. A range of factors conspire to make this so — factors well understood by Harriet Washington, a medical ethics scholar and award-winning author of books such as A Terrible Thing to Waste, on the effects of environmental racism, and Medical Apartheid, on the history of medical experimentation on Black Americans.

GEN caught up with Washington to discuss the structural reasons for the virus’s unequal lethality, and what changes can be put into place to make health outcomes in the U.S. more equitable.

GEN: CDC data is now showing that Black Americans are three times as likely to contract Covid as whites, and twice as likely to die from it. How does your research on environmental racism help explain this?

Washington: I’m happy to address that because there’s a profound synergy here. First, there are the usual suspects. We know that African Americans are less likely to have a personal physician. We know that too often, they have to rely upon local emergency departments. We also know that there have been a lot of hospital closures in the areas where we live, which removes even that safety net. When African Americans do get medical care, that medical care is substandard compared to that given to white Americans. We also know that they’re less likely to have health insurance, and even should they be insured, they’re less likely to have jobs which will allow them to take time off to see the doctor.

But the thing that I think people maybe don’t realize is that environmental racism causes diseases and vulnerabilities, every single one of which is a risk factor for coronavirus. We know that air pollution causes lung ailments, and it exacerbates and causes asthma, which is a risk factor for coronavirus, but it also causes kidney disease and heart disease, both of which are risk factors for coronavirus. Lead poisoning is related to increased vulnerability to a lot of viral assaults.

There’s also vitamin deficiencies — and ones that have been tied directly to coronavirus, like vitamin D deficiency — in African Americans who live in food deserts. Well, actually, I call them food swamps. These are areas where there’s a very low or no access to affordable sources of good nutrition, but a plethora of fast-food establishments. For people living in these areas — African Americans and Hispanics, unfortunately — they’re much more likely to be vitamin D deficient.

I could go on and on, frankly, but the fact is that every single risk factor that we know of for coronavirus is caused or exacerbated by environmental racism. Let’s not forget, though, I’m talking about African Americans, but other ethnic groups suffer from a lot of these as well, and Native Americans have often been left out of the discussion, even though it’s Native Americans who often suffer the worst brunt of these exposures.

What can be done to fix the problem of people receiving different care based on their race?

The way to treat everyone the same is like everything else: You institute meaningful penalties if [doctors] don’t treat everyone the same. You peg people’s advancement to treating everyone the same. You make that a criterion for successfully finishing your residency. You make that a criterion for gaining advancement, for taking home a complete paycheck, for your ability to do surgeries.

When we wanted health care providers to do more hand-washing, there were individuals who resisted that. Part of the problem was, they were appointing nurses to tell surgeons to wash their hands more. You can imagine how well that went over. Then, one hospital decided that they were going to address it differently. They still had nurses reminding surgeons to do appropriate hand-washing, but they tied the surgeons’ pay to meeting the standard. The improvements they wanted came about really quickly.

We also have to change medical training. There is no reason why, as of 2016, half of medical students should think that Black people don’t feel pain as whites do. This belief in biological dimorphism is certainly not supported by science, but they are learning that from seeing how patients are treated. There need to be penalties put in place to discourage that, so that new doctors are not being taught that it’s acceptable to think that Black people are biologically different from whites.

What are the changes that could be put in place right now to make the rest of this pandemic look different for African Americans and Native Americans?

I don’t think there are many. I don’t want this to sound too dire — I don’t want to say it’s too late for this particular pandemic because it’s never too late to change — but I think that it’s really important for us to think about the next infectious disease outbreak, and to apply the failures that we’ve seen now to the next one to make sure they don’t happen again.

You wrote in Medical Apartheid, which explored the history of unethical experimentation on African Americans, that an administrator of a medical school told you she didn’t want you to write this book because she said it would make Black people not want to go to the doctor. You thought, “Well, maybe they don’t want to go to the doctor because they already know this.”

Exactly.

How does that factor into Covid? Do you think that Black people are expecting to be treated differently? How do you think that fear is playing out?

I’ve read many articles on the subject, and very often they talk about African Americans’ wariness of the health care system. First of all, the way the question is posed. “What makes African Americans wary of the system? Why are they afraid? Why do they distrust?” That’s the wrong question. You might better ask, “Why is our health care system so untrustworthy that a large swath of the population doesn’t trust it, even when they’re sick?”

Another way of putting it is that, if someone harms you, then denies they have ever harmed you, would you trust that person under any circumstances? But if the person has harmed you, and then admits it and apologizes for it, and says, “Yes, I know we did these horrible things. We’re very sorry. We’re trying to do better now.” Then, you might have a chance. That step is a step that, unfortunately, American medicine has been very loath to take.

This makes me think of the vaccines being tested. How are we going to make sure that a vaccine is safe for everyone, and how are we going to convince people to get vaccinated?

The problem with the new vaccines, with this coronavirus, is that these are being expedited. I totally understand why they’re being expedited. We don’t want to sit around for five, six, seven years. But going more quickly also means you’re cutting corners when it comes to safety and efficacy. I’m sorry, you can’t tell me differently. Maybe that trade-off is necessary. I think it might be necessary. But it also mitigates against convincing people it’s going to be safe.

What concerns you about the pandemic that people may not be paying attention to?

Blanket DNR orders have been discussed, where they would apply it to everybody without consent. I don’t think it’s actually happened, but the fact that discussions are taking place concerns me. These are dire breaches of medical ethical behavior. Invoking emergency situations is typically the way that these things get instituted, and if we start losing informed consent now, I worry about how it will expand to other situations. You don’t want to be in a situation where eventually, people with the flu can have their right to say yes or no violated because it’s an infectious virus.

A recent Pew study showed that 42% of Black Americans worry that the combination of their race and their mask-wearing will make people suspicious of them in public. But at the same time, they’re more likely than white Americans to wear the mask most of the time. How does it affect people who now have to worry about their safety in these two opposing ways?

Again, this is the wrong question. Let’s look at the data. What is happening to African Americans who wear the mask? Clearly, newspaper accounts have showed, in New York City alone, police officers were dragging to the ground, abusing, harassing, and arresting [Black] people for not wearing masks. At the same time, police officers in other parts of the city were smilingly handing out masks to white people who weren’t wearing one. So frankly, it’s yet another excuse for abuse.

In that scenario, I don’t want to talk about how people feel about it. That’s the reality. Even in the face of that, you’ve got African Americans wearing masks, taking the precaution that we want everyone to take. You know what I worry about, I worry about these Karens acting out in Trader Joe’s, tearing up the store when someone politely asks them to put a mask on. I think to myself, “You must have had very little friction in your life if being asked to wear a mask politely is going to set you off like this.”

Right, and just the lack of regard for other people’s health — because it’s to protect other people that we wear masks, in large part.

For most of us, yes, exactly. This invocation of freedom is kind of ridiculous. It shows that they have no regard for other people’s well-being, that their only concern is some kind of ludicrous comfort. The fact that they feel entitled to tear up the store, to throw things around — I thought, “Oh, let me do that once. You’d be going to my funeral tomorrow.” I mean, can you imagine? Forget it. You’d never see me again.

And the male Karens, I have to say, are right there with them. We’ll have to call them Kennys, right?

I like that.

Karen and Kenny, they’re taking over social media. But there’s also the more passive-aggressive stance. I live in Yonkers, on the waterfront. I look out my window every day and I see families at the waterfront, kids are playing. Almost no one is wearing a mask. I want to shout, “Just because it’s nice out doesn’t mean it’s safe out.” I’ve got three aunts who are nonagenarians, and when I see people running around without a mask, I can only hope they don’t work at a nursing home.

I’m not usually an advocate for the state mandating health behavior, but this is certainly a case where I would not be averse to the state instituting more penalties for people not wearing a mask. The carrot is not working. Perhaps it’s time for a stick.

This interview has been edited and condensed for clarity.

Deputy editor for books at Medium. Formerly a staff writer and editor at Time.

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