Our Healthcare System: Built to Discriminate

“Black Americans are dying at three times the rate of White Americans due to COVID-19” [1]. The news anchor neglects the weight of this statement as he quickly moves onto the weather and the upcoming election.

Systemic bias is deeply ingrained into every aspect of our society, from our policing system to education to healthcare. Poor racial representation and healthcare research bias, along with a myriad of other discriminatory factors, compound to perpetuate racial health disparities like we see today amidst the COVID-19 pandemic.

I first realized the pervasiveness of systemic bias in medical research at Memorial Sloan Kettering Cancer Center, a high ranking research center and hospital according to U.S. News [2]. An eager pancreatic cancer research intern ready to analyze genetic data and discover life-saving treatments, I soon noticed health disparities cropping up regularly in my work.

First, my research samples were sourced from MSKCC’s patient database, a demographic essentially limited to those who can afford to live in or travel to the expensive Upper East Side of Manhattan. Gentrification by White property-seekers combined with generational wealth means that wealthy locations are often dominated by Caucasian individuals. On the other hand, the living situations of POC, especially Black Americans, are undeniably intertwined with poverty, especially due to historical housing segregation and redlining by the Federal Housing Administration (FHA). The FHA even explicitly dictated in their Underwriting Manual that "incompatible racial groups should not be permitted to live in the same communities,” heavily restricting Black housing mobility [3].

Today, the Upper East Side is a direct reflection of historic housing discrimination, with its demographic breakdown of 72.5% white, 13.1% Asian, 9.1% Hispanic, and only 2.3% Black residents [4]. Similar trends created by historical housing discrimination can be seen across America [5]. In other words, well-funded hospitals in wealthy neighborhoods offer their services to a majority of White patients, leaving low-income and patients of color to use understaffed and underfunded community hospitals.

Realizing the inaccurate representation in MSKCC’s samples, I decided to go global, collecting pancreatic sequencing data from all publicly available studies. I found hundreds of European studies and a fair amount of Asian studies, but there was not one comprehensive genetic sequencing study that included Black patients. Not one.

This global-scale bias can be attributed to a plethora of factors, starting with European colonialism in continents like Africa. After they had extracted resources and enslaved natives, European colonial countries retreated with a strong economy and powerful national system built on the backs of African people, setting Europeans up to perform comprehensive research today. African countries, meanwhile, were left to rebuild their societies with a fraction of the resources they first had and a fractured political system [6].

This global imbalance in resources and stability has spiraled into

a lack of representation of many POC in research leadership positions. As a result, medical research has long lived in the shadow of racial discrimination - race was even considered a legitimate hierarchical structure by early physicians and medical researchers. Famously, craniologist Samuel Morton’s skull collection embodies racial discrimination in its suggestion that White humans are inherently more intelligent than Black

humans due to (inaccurately measured) skull size [7]. This is just one of thousands of such experiments that wraps its discriminatory fingers around our medical system today.

Half of White medical trainees surveyed as recently as 2016 in a study published in the Proceedings of National Academies of Science believe that Black patients have “thicker skin” than White patients, contributing to systemic disbelief of Black patients’ reporting of pain complaints [8]. This misinformation leads to overlooked health complications and under-prescribed pain medication; unfortunately this is not an isolated phenomenon. Black mothers are up to four times as likely to die from pregnancy related complications than White mothers [9]. Black COVID-19 patients are 2.6 times as likely to be hospitalized and 1.9 times as likely to die when compared to than White patients [1]. And when White healthcare workers and researchers are vastly overrepresented, particularly in leadership positions, this bias can be fatal.

So, how do we tackle this fatal discrimination? How do we make sure people do not die solely because of the color of their skin? In a world where discrimination is so connected to every aspect of life, we can really start anywhere.

We can start by pushing for an end to discriminative housing legislation.

We can start by including comprehensive bias screenings in research patient samples, so my fruitless pursuit of representative data does not remain the standard.

And we have to start now, because today's headline carries the weight of the statement, “Black Americans are dying at three times the rate of their white counterparts from COVID-19” [1].

References:

1. Centers for Disease Control and Prevention. (2021, November 22). Risk for COVID-19 infection, hospitalization, and death by Race/Ethnicity. Centers for Disease Control and Prevention. Retrieved 2021, from https://www.cdc.gov/coronavirus/2019-ncov/covi d-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html.

2. MSK earns U.S. News "Best Hospital" ranking for more than 30 years. Memorial Sloan Kettering Cancer Center. (2021). Retrieved from https://www.mskcc.org/u-s-news- world-report-names-msk-top-hospital-cancer-care.

3. Gross, T. (2017, May 3). A 'forgotten history' of how the U.S. government segregated America. NPR. Retrieved November 30, 2021, from https://www.npr.org/2017/05 /03/526655831/a-forgotten-history-of-how-the-u-s-government-segregated-america.

4. Upper East Side Neighborhood Profile. NYU Furman Center. (2019). Retrieved 2021, from https://furmancenter.org/neighborhoods/view/upper-east-side.

5. Illing, S. (2020, May 5). The sordid history of Housing Discrimination in America | Department of African American Studies. Princeton University. Retrieved 2021, from https://aas.princeton.edu/news/sordid-history-housing-discrimination-america.

6. Ocheni, S., & Nwankwo, B. C. (2012). Analysis of Colonialism and Its Impact in Africa. Cross-Cultural Communication, 8(3), 46–54. https://doi.org/10.3968/j.ccc.1923670020 120803.1189

7. Kelleher, S. R. (2021, April 18). How a museum's Human Skull Collection sparked a racial reckoning. Forbes. Retrieved 2021, from https://www.forbes.com/sites/suzan nerowankelleher/2021/04/16/penn-museum-samuel-morton-human-skull-collection-black-slaves-repatriation/?sh=f7e708a7d4c9.

8. Sabin, J. A. (2020, January 6). How we fail black patients in pain. AAMC. Retrieved 2021, from https://www.aamc.org/news-insights/how-we-fail-black-patients-pain.

9. Flanders-Stepans M. B. (2000). Alarming racial differences in maternal mortality. The Journal of perinatal education, 9(2), 50–51. https://doi.org/10.1624/105812400X87653.