Medical racism in the United States refers to racial and ethnic disparities in healthcare, including discriminatory medical practices and misrepresentations in medical education. Medical racism is usually driven by biases based on characteristics of patients' race and ethnicity and especially affects vulnerable subgroups such as women, children and the poor. Since the 18th century, examples of medical racism include various unethical studies, forced procedures, and differential treatments administered by health care providers, researchers, and government entities.

Medical racism can stem from explicit prejudice, unconscious bias, or structural racism. Government policies allowed for segregated medical facilities, and federal programs have often failed to equitably serve racial and ethnic minorities, contributing to disparities in access to and quality of care. Underfunded safety-net hospitals, low Medicaid reimbursement rates, and inequitable coverage policies—further perpetuate these disparities.

Despite legislative efforts like the Affordable Care Act aimed at reducing disparities, gaps in access to care persist, disproportionately affecting racial and ethnic minorities. The enduring influence of structural discrimination in healthcare contributes to these inequities.

History

Medical racism has deep historical roots, including unethical studies, the foundations of medical education, Enlightenment-era racial science and medieval European ideologies which justified racial hierarchies in medicine and influenced how physicians understood disease, pain, and treatment in non-white populations. These ideas were further reinforced by medical institutions that actively participated in slavery and colonization, often conducting experiments on enslaved individuals.

The history of medical racism has also contributed to the distrust of health professionals by many people in marginalized racial and ethnic groups. Studies within the last couple decades have elucidated ongoing disparate treatment from health professionals, revealing racial biases. These racial biases have impacted the way in which treatments such as painkillers are prescribed and the rate at which diagnostic tests are given. Black patients have a long history of receiving contrasting medical treatment based on different perceptions of the pain thresholds of Black people. The eugenics movement is an example of how racial bias affected the treatment of women of color, specifically African American women.

While studies like the Tuskegee Study of Untreated Syphilis in the Negro Male are widely known, the U.S. Public Health Service Sexually Transmitted Disease (STD) Inoculation Study of 1946-1948 harmed Guatemalan prisoners, sex workers, soldiers, and mental health patients by purposely infecting victims with STDs such as syphilis and gonorrhea. Forcible sterilization of Indigenous women as young as 15 years old occurred from 1970 to 1976 by the Indian Health Service Many other examples exist in American history of the unethical actions of health care providers, researchers, and government entities.

Racial minorities have faced constant and significant barriers to entering and advancing in the medical profession. African American medical professionals, in particular, encountered systemic exclusion, discrimination, and limited access to training opportunities. Until 1940, the American Medical Directory—compiled by the American Medical Association—marked Black physicians with a "col." notation, reinforcing professional marginalization and restricting their inclusion in medical institutions, professional organizations, and fair insurance practices. These historical inequities have shaped patient distrust in the healthcare system and limited the diversity of the medical workforce.

Contributing factors

Cultural competence Physicians who are not culturally competent can harm patients due to poor relationship dynamics, contributing to medical racism. While physicians may consciously condemn racism and negative stereotypes, evidence shows that doctors exhibit the same levels of implicit bias as the greater population. Racialized minority groups report experiencing both overt and covert racism in healthcare interactions.Racism in Healthcare: A Scoping Review.(2020, December 1). Sarah Hamed, Hannah Bradby, Beth Maina Ahlberg, Suruchi Thapar-Bjorkert. Implicit bias is also seen in mental health services, Healthcare providers may not consciously have biases on racial stereotypes. These tend to occur automatically. Psychological studies have demonstrated that "...persons who do not see themselves as prejudiced will make health care allocation decisions…". Based on this research, several authors argue that there is an intense need for cultural competence education in healthcare for explicit racism and implicit biases. Cultural incompetence exists for a number of reasons, such as lack of diversity in medical education and lack of diverse members of medical school student and faculty populations. This leads to marginalization of both minority healthcare providers and minority patients.Hoberman, John M. Black and Blue: The Origins and Consequences of Medical Racism / John Hoberman. Berkeley: University of California Press, 2012.

Medical education There is a lack of medical education about minority groups. In a 2016 study, White medical students incorrectly believed that Black patients had a higher pain tolerance than White patients. These beliefs were rooted in unfounded notions, such as thicker skin or less sensitive nerve endings in Black individuals, echoing racist ideologies. Minority patients report feeling unjustly reprimanded and scolded by healthcare staff, as noted by African American women. Furthermore, research reveals disparities in pain medication prescriptions, with White male physicians prescribing less to Black patients, fueled by perceptions of biological differences in pain reactions between races. African Americans are disproportionately subjected to less desirable healthcare services, like limb amputations, highlighting systemic inequalities. In medical schools in the US, within assigned textbook readings, there exists a disparity between the representation of race and skin color in textbook case studies relative to the US population. This is true for both visual and textual lecture materials.

A group of studies done on the representation of race and gender in course slides for the University of Washington School of Medicine, preclinical lecture slides at the Warren Alpert Medical School of Brown University and case studies used at the University of Minnesota Medical School simultaneously showed associations of race as a "risk factor" and a lack of racial diversity.

The study done on the University of Minnesota Medical School employed the use of the concept of hidden curriculum to describe the ways in which lack of representation and informal teachings can greatly influence the minds of aspiring physicians. The interactions had between students and faculty or the transmission of unintentional messages can be just as, if not more, influential than formal lectures. These can include the associations of diseases such as sickle cell anemia as a "black disease" and cystic fibrosis as a "white disease" which leads to poor health outcomes. In this study, the 1996-1998 year one and year two curriculums of the school were analyzed. It revealed that only 4.5% of the case studies mentioned a racial or ethnic background of the patient and when the patient was black or had "potentially unfavorable characteristics" race or ethnicity was more likely to be identified. There was also a greater prevalence of health-related themes discussed when race or ethnicity was identified. Researchers determined that the inclusion of specific racial or ethnic identities in those cases was intended to indicate something about that disease or health condition. The authors state that practices such as these contribute to the racialization of diseases.

A study of medical textbooks has also yielded information on minority representation in medical teachings. Based on the required texts of the top 20 ranked medical schools in North America, US editions of Atlas of Human Anatomy (2014), Bates' Guide to Physical Examination and History Taking (2013), Clinically Oriented Anatomy (2014), and Gray's Anatomy for Students (2015) were chosen for the study. Using the total 4146 images from the four textbooks that depicted visible faces, arms, heads, and skin, researchers discovered two of three books were close in diversity to the US population, one book displayed "diversity on basis of equal representation" and one matched neither definition of diversity. On a topic level there were also issues of diversity. When discussing health issues such as skin cancers three of four books included no imagery at all and the one book that did had only imagery of white and light-skinned patients. According to researchers, symptoms might manifest differently depending on skin tone. Missed indicators may go unreported if there is a lack of education on how to recognize these discrepancies.

Some medical students have also done their own research and added to the discourse on underrepresentation in medical school education. They've noted specific examples such as skin infections like erythema migrans being depicted on almost exclusively white skin. As an indicative first symptom of lyme disease, a lack of knowledge on how to detect this rash on patients with darker skin colors means failed diagnoses of the disease. Studies have shown that there is in fact a delay in lyme disease diagnoses for black patients. The lack of representation in medical school lectures risks creating adverse impacts on the health outcomes of minority populations in the US.

Representation in the profession of medicine According to US Census data, Black and Hispanic people account for 13% and 18% of the overall population, respectively. However, they only make up 6% and 5% of medical school graduates, respectively. Black physicians make up only about 3% of American doctors. Black physicians have historically faced numerous obstacles to obtaining membership in the larger medical community. During the 20th century in the United States, groups such as the American Medical Association neglected Black physicians. This has led to continued marginalization of Black physicians in the US due to their small numbers among other factors and this contributes to the marginalization of Black patients. Minorities often perceive medical facilities as "white spaces" because of a lack of diversity at the institutional level.

Racial depictions

Disparities can also be due to perceptions, by physicians, of pain tolerance and cooperation – aspects of medical racism. Social Darwinism has been utilized to justify Slavery in the United States among other historical practices and the racist ideas about Black people that it created persisted into the 20th century. The Three-Fifths Compromise also reinforced the notion that Black people were less than human.

However, this has not just been relegated to the past. As recently as the 1990s, California state police came under fire for referring to cases involving young Black men as "N.H.I" or "no humans involved." One police officer involved in the Rodney King beating in 1991 was cited as saying that a domestic quarrel between a Black couple was "something right out of Gorillas in the Mist." This comparison mirrors early theories about the evolution of primates. Proponents of this social Darwinistic theory believe that White people are the most advanced humans, descended from primates, and that Black people must fall somewhere in the middle of the two.