Fighting Bias in Healthcare: Racism & Xenophobia

Discriminatory practices have shaped many structural elements undergirding modern society, and healthcare is no exception. Racism and xenophobia can and do cause avoidable disease and premature death among groups often already disadvantaged (The Lancet 2022). These forms of discrimination are hardly relics from the past: some of today’s most cutting-edge technology has racist and xenophobic biases built into it.

Healthcare is a basic human right, and the US healthcare system needs to work for all Americans instead of just some. Tomorrow’s healthcare leaders can play a critical role in shaping healthcare delivery in such a way that it does. Forget the political discourse: this is a science-backed issue of public health. Healthcare is an area where cultural competency, diverse workforces, and community-minded approaches have real, measurable, life-saving effects.

To learn more about how racism and xenophobia impact healthcare and what can be done to address it, read on.

Dr. Faina Linkov is the department chair and associate professor for the John G. Rangos Sr. School of Health Sciences at Duquesne University. She earned her MPH in behavioral and community health science and her PhD in epidemiology from the University of Pittsburgh Graduate School of Public Health.

Dr. Linkov is a multidisciplinary researcher interested in molecular epidemiology, cancer, prevention, health systems research, global health, scientific communications, and research productivity. She has over 100 original research publications and reviews. She has received grants and awards from the American Cancer Society, Phi Beta Psi Sorority Foundation, the Department of Defense, Scaife Foundation, CDC, Hillman Foundation, USAID, the Government of Kazakhstan, and NATO.

“Racism and xenophobia in the US healthcare system today is a great public health threat, undermining decades of achievements in both medical and public health preventive practices,” Dr. Linkov says.

Racism and xenophobia do not need to be overt or intentional to have measurable negative effects (though, unfortunately, many overt and intentional cases exist). Many elements of US policy, including those directly related to healthcare and those only indirectly related, allocate resources so that minority groups are left disempowered and disenfranchised. Certain hierarchies embedded into the nation’s social structure implicitly reinforce themselves.

“Data from multiple research studies reported that minority groups in the US experience higher rates of morbidity and mortality compared to their white counterparts, with life expectancy of non-Hispanic/Black Americans being four years lower than that of white Americans,” Dr. Linkov says. “Published data also suggests that members of racial and ethnic minority groups are less likely to receive preventive health services and are likely to receive lower-quality care in comparison to their non-minority counterparts.”

Structural racism and xenophobia need to be addressed at the policy level. The Affordable Care Act in 2010 was a large step forward: it pushed against existing imbalances by increasing access to healthcare for an unprecedented number of Americans. But each new crisis tends to underscore the persistence of the problem and push latent inequalities to the surface.

“The Covid-19 pandemic disproportionately impacted racial and ethnic minority groups, giving us yet another example of health disparities our country is experiencing,” Dr. Linkov says. “Another example is the very high rates of maternal mortality in the US in comparison to other developed nations. Maternal mortality is very high among non-Hispanic/Black Americans, and the situation has been getting worse over the past decade.”

Racism and xenophobia have diminished the trust of the medical community in certain demographics, particularly demographics who have been systemically and overtly mistreated by the healthcare system in the past. This type of medical mistrust makes people less likely to follow medical advice or keep follow-up appointments; it also makes HIV-positive patients less likely to adhere to their prescription medication regimens. A 2021 poll by the African American Research Collaborative and the Commonwealth Fund found that discrimination from medical professionals deterred Black, American Indian, and Alaska Native respondents from getting a Covid-19 vaccine (Commonwealth Fund 2021).

“To build a healthier America for all, we must confront the systems and policies that have resulted in the generational injustice that has given rise to racial and ethnic health inequities,” Dr. Linkov says. “From the standpoint of healthcare professions, schools, and healthcare systems, it is important to build community education campaigns focusing on building trust in public health and research, especially primary prevention measures such as vaccinations.”

Trust is repairable. It can start with care systems remodeling themselves to better understand and communicate with all segments of the population. That means cultural competency training, bilingual and multilingual staff, and a diverse set of providers. Representation within the provider workforce is particularly important: individuals tend to trust their providers more than they trust the healthcare system (Journal of General Internal Medicine 2006). Some health systems are piloting programs designed to build trust, carving time and space outside of the exam room to hear patients about their experiences and frustrations.

“Tailoring care models towards the cultural and linguistic needs of the local community is vital to improving health on both local and global scales,” Dr. Linkov says. “Published evidence demonstrates that patients typically prefer healthcare providers who share their race/ethnicity. Limited diversity among clinicians can potentially lead to mistrust in doctor-patient relationships among minority groups, even while obtaining routine healthcare interventions such as vaccinations for flu. To improve patient-centered care for minority populations, health systems need to diversify the workforce.”

Racism and xenophobia isn’t just embedded in policies; it’s present in technology, too. Pulse oximeters used to triage patients during the peak of the Covid-19 pandemic were less effective on patients with darker skin tones than patients with lighter ones, potentially leading to sick patients being denied critical treatment (The Economist 2021). Early generations of wearable tech similarly favored the lighter skinned, and some studies have found machine learning and computer vision algorithms have higher error rates when attempting to process certain demographics (Georgia Tech 2019).

Unless they’re acknowledged, biases recreate themselves; they can even be spread contagiously. Healthcare administrators have a responsibility to seek out and eliminate policies and attitudes that reinforce racist and xenophobic elements within the healthcare system. This is an area where cultural competency has real and human stakes, and education is its own form of vaccination.

“Leadership and staff need to be trained in diversity, equity, inclusion, and antiracism principles,” Dr. Linkov says. “Education on all levels is a key to eliminating racism and xenophobia in healthcare settings.”