It is unlikely that those of us who work in American medicine spent any time over the past year dwelling on our points of similarity with the police officers who killed unarmed black Americans, or with the Charleston shooter. In the wake of the murders, attention has been focused on the corrosive culture of militarism in our police forces, on the fringe nature of ignorant racism, or on the many dangers of daily life for a black woman or man in this country. Many of us, incensed, nodded our assent to these analyses, while experiencing a simultaneous relief at our perceived personal and collective progress. And yet it could be argued that the American health care establishment is more threatening to black lives than a lone gunman, with or without a badge, ever will be.
Today, blacks continue to die more often and younger than whites from every measurable health cause aside from drug-induced deaths and suicide. A few years ago, a report from the Black AIDS Institute noted that a freestanding Black America would rank 16th in the world in number of people living with HIV, behind half of PEPFAR recipient countries. The same report placed Black America 88th in infant mortality and 105th in life expectancy, the latter positioned in the bottom half of the world. Many of the disparities between black and white disease-specific mortality actually widened between 1990 and 2005.
Limited access to care and poor socioeconomic status (including issues of environment and housing) are two of the great drivers of racial differences in health outcomes. It should be no surprise then that many health disparities between blacks and whites are worsening concomitant with economic disparities as the country inequitably climbs out of the Great Recession. Even after the enactment of the Affordable Care Act, the US remains the only wealthy country to eschew universal coverage, a political decision that disproportionately affects marginalized and minority communities and is responsible for tens of thousands of unnecessary deaths per year.
A just political solution to our current health system would seek to remediate health outcome inequities by aiming not simply for civil equality, but by aggressively enacting preferential policies. Only such active and accountable mechanisms can hope to narrow racial health disparities, a stated ambition of the Healthy People 2020 initiative. Regrettably, American medicine falls short of even basic racial equality in treatment and research, from a systems-level down to individual doctor-patient interactions.
Doctors who practice far from the corridors of power, and without access to the purse strings, may be tempted to shrug off responsibility for racist health outcomes. But there is a growing body of evidence that we treat blacks differently, and worse, than whites. Black Americans wait longer to be seen in both emergency departments and office waiting rooms. They are more likely than whites to either not receive care when appropriate or to receive lower quality care even when they are being seen at the same facility, by the same doctors and nurses, for the same disease, and with the same health insurance.
In addition to racism in direct clinical care, the US has a shameful history of violating black rights in pursuit of medical knowledge. While today's manifestations of institutional discrimination within health care may be more subtle than the notorious 40-year Tuskegee syphilis experiment, they are no less damning. In 2011, national foundation funding of cystic fibrosis (CF), a predominantly white disease, was over $176 million compared with less than $1.2 million for sickle cell disease (SCD), which affects mostly blacks--an incredible 440-fold difference per person affected. Perhaps more disturbing, if less extreme, is the discrepancy in public funding: the National Institutes of Health financially favors CF research 3.5 fold per person affected over that of SCD.
In an abundant society with the means to address racial disparities, the implication of our abject failure to do so is revealing. The senseless murders of black Americans at the hands of both police officers and individual racists have appropriately gripped the nation's attention. But if we are going to honestly contend that Black Lives Matter, we -- the American public in general, and the practicing physician in particular -- must acknowledge, claim, and work to fix the dangerous implicit biases as well as the rigged social structures that preferentially kill people of color. As it stands now, we are all complicit.