This article originally appeared in The Huffington Post on June 11, 2014.
By Paloma Toledo, M.D.
A well-respected physician colleague told me recently that he did not understand why my research focused on racial and ethnic disparities in health care. He claimed racism no longer exists in the United States.
As a white, male physician, his perspective is that of someone who had seen the roll-out of Medicare in 1966, and the subsequent desegregation of hospitals. He had seen neighborhoods in New York and other urban areas that were once 100 percent minority, morph into diverse mixing pots of ethnicities.
Yet, while there have been improvements in the past several decades on many counts (the recent Donald Sterling and Justin Bieber recorded comments aside), everyday racism continues to directly affect the daily health and well-being of millions of Americans.
I know that because in addition to my professional acknowledgment of disparities in health care, I was confronted recently with racism even much closer to home.
At Ogden International School in Chicago, where my daughter attends, three students this week were banned from attending eighth-grade graduation ceremonies for their apparent racist attacks on a fellow student. Leading up to that decision, parents and community members addressed what Chicago Public Schools initially called a "sensitive issue."
Several eighth-graders were bullying a Jewish classmate, both in person, and through an online game called Clash of the Clans. Their clan's motto on the site was, "We are a friendly group of racists with one goal -- put all Jews into an army camp until disposed of. Sieg! Heil!" The students involved had a one-day suspension. At that time, no one from Chicago Public Schools was officially calling it racism or a hate crime.
But it was.
I am a Latina, and though I am not Jewish, I identify with the outrage of every person who finds bigotry indefensible, whether it is from children or adults, and whether it affects my family or profession. That is because, as a physician, I understand that perceived discrimination has a multitude of health repercussions, both mental and physical.
The list of psychological consequences is long. A meta-analysis of the literature has found that there is an association between perceived discrimination and anxiety, depression, post-traumatic stress disorder, and even psychosis.
Discrimination functions as a stressor that activates the body's sympathetic nervous system, which is known for the "fight or flight" response. The release of stress hormones, such as epinephrine and cortisol, results in elevations in both heart rate and blood pressure.
Over time, these increases result in the development of chronic hypertension can lead to the development of other cardiovascular disorders. This chronic stress can weaken the immune system, affect sleep, and even sexual function.
Several parties are actively debating in the literature whether overt discrimination occurs in the medical setting. Several known health care disparities occur by both race/ethnicity; but other disparities exist, including disparities by social class and sexual preference.
Specifically, my research evaluates disparities in the management of labor pain. Minority women are less likely than non-minority white women to use epidurals for the management of labor pain.
While many believe that this is a patient choice issue, my work has revealed that patients are fearful of labor epidurals, and many women don't understand the risks and benefits of the procedure. It is possible that this may be the result of health care providers either not explaining epidurals to their patients, or discussing epidurals in a way in which minority patients choose not to use labor epidurals.
Evidence for provider bias exists. In a study where cardiologists were asked to manage the chest pain for hypothetical patients (whose clinical presentation was identical, except for the patient's age, gender or race), the authors found that women and blacks were less likely to be referred to cardiac catheterization, the gold standard treatment, than men and whites, respectively.
The implicit association test (IAT) is a tool, which measures unconscious preference for race and social class. In a study published in the Journal of the American Medical Association in 2011, the majority of medical students who took the IAT had an implicit bias towards whites and those from the upper class.
The students completed a series of vignettes, and there was no difference in the management of the cases by either race or social class. However, the bias exists.
While I personally doubt that physicians deliberately use race or class in their medical decision-making, the possibility for covert, insidious racism exists. This unconscious bias, coupled with a patient's experiences of discrimination, could result in worse health for stigmatized groups.
In my family life, the events at my daughter's school involved eighth-graders. To be sure, it is possible that these children were playing a game and really do not hold racist thoughts. Peer pressure may have played a role in the decision to bully a classmate.
While all of these things are possible, the children consented to such cruelty. None of them stood up to oppose the group, the practice or the implications. None of them reported it to the school. In their passive acceptance, they were promoting racist behavior. It is a reminder of racism in the 21st century.
As physicians devoted to equity in health care, it is important that overt as well as covert examples of racism are acknowledged and addressed because such disparities are life-threatening.
As parents and community members, we need to understand the elimination of racism from an early age will only serve to improve the health of our community, in school and far beyond, both now and in the future.
Paloma Toledo, M.D., is an assistant professor of medicine at Northwestern University.