Unequal Health: A sweeping and timely synthesis on how anti-Black racism threatens America’s health

Unequal Health(ANN ARBOR) – Anti-Black racism is a direct danger to the health of Black Americans and a threat to the health of all Americans. 

This is the key takeaway of a timely new book, Unequal Health: Anti-Black Racism and the Threat to America’s Health, and a point that researchers and healthcare professionals must recognize to understand or address persistent racial disparities in health and healthcare. 

The book assembles insights from a veteran team of researchers and healthcare policy experts, including Louis Penner, a social psychologist and emeritus affiliate of the Research Center for Group Dynamics (RCGD) at the University of Michigan Institute for Social Research. Penner, also an Emeritus Professor of Oncology at Wayne State University, spent much of his half-century career studying the roots of racial bias and identifying the various kinds of harm it causes. His research with John F. Dovidio of Yale University and Diversity Science was among the first to show that implicit bias in physicians affects the outcomes of medical interactions.

When the COVID-19 pandemic began shortly after he retired, Penner was struck by the fact that many people were surprised at the much higher COVID-19 mortality rate among Black Americans. He recognized that this kind of racial health disparity was neither new nor transitory. He then contacted Dovidio and two other professional colleagues– Nao Hagiwara of the University of Virginia, and Brian D. Smedley of the Urban Institute– with the idea of co-authoring a book on the causes and consequences of racial health disparities. The resulting book, just out from Cambridge University Press, is one of the most comprehensive publications to date gathering research on the various pathways by which racism impacts health.

“Americans may be aware that, overall, the health of Black Americans is substantially worse than the health of White Americans,” said Penner. “What people typically don’t know is that various aspects of anti-Black racism play a significant role in the health problems of Black Americans, threaten the health of all Americans, and are a root cause of racial health disparities.”

Unequal Health documents large disparities in the health of American citizens and in the quality of healthcare they receive. Black Americans have shorter life expectancies, greater disease-related mortality, and are much more likely to contract serious diseases, but less likely to receive adequate treatment for these diseases than are White Americans. These disparities have important consequences for all Americans because they create enormous costs to the American economy. “According to the National Institute on Minority Health and Health Disparities, it costs about $450  billion per year, and places a tremendous burden on an already inadequate healthcare system,” Penner said.

These disparities have persisted over time. Even as the health of Americans has improved overall in the past hundred years, Penner said, the gaps in the health of Black and White Americans has remained fairly consistent. For example, while many fewer Black infants die today than they did in the past, the racial disparity in infant mortality is almost exactly the same as it was 100 years ago, Penner said.

The book provides important historical context to the linked problems of anti-Black racism and health disparities in America, telling a story that begins with the enslavement of Black people in North America some 400 years ago, with chapters on the effects of racist theory and practices in American medicine, racial segregation in medical care, government policies that have imperiled the health of Black Americans, and the contemporary impact of race-related thoughts and feelings on healthcare disparities.

“To understand where we are currently, we need to understand the historical context,” said Hagiwara, whose public health work is grounded in experimental social psychology. “Learning that history can make us feel real anger, sadness and frustration, and those negative feelings can motivate people to act.”

Unequal Health identifies three separate paths from anti-Black racism to the health challenges of Black Americans. The first is the direct physiological effects of being constantly being exposed to racial bias and racial discrimination. Greater exposure to discrimination is associated with a higher incidence of a host of health conditions, including hypertension, obesity, heart disease, stroke, diabetes, genetic and immune disorders. The authors give special attention to the research of Arline Geronimus, an affiliate of the Institute for Social Research’s Population Studies Center, who coined the term “weathering” to describe the corrosive effects of systemic oppression on marginalized people’s bodies. Her book “WEATHERING: The Extraordinary Stress of Ordinary Life in an  Unjust Society,” also out this year, chronicles this dimension, making a strong case for how pervasive racial discrimination threatens the health of Black Americans.   

Second, racially biased public and private policies have made America a racially segregated country and created many predominately Black, under-resourced neighborhoods that present dangers to their residents’ health. These neighborhoods have more environmental toxins, poorer air quality, more dangerous housing, less access to healthy food and health care, and greater access to unhealthy food. This results in a greater incidence of many different diseases among the residents of these communities.

“These neighborhood attributes are not the fault of their Black residents,” said Penner. “They are the result of racially biased government policies that result in Black people having to live in less desirable locations, which lack the infrastructure and economic resources that exist in predominantly White neighborhoods.”

Finally, Black Americans have less access to healthcare, and when they receive healthcare, it is consistently of a lower quality than the  healthcare received by White Americans. Systemic racism plays a role in creating a de facto segregated healthcare system, with the facilities that predominantly serve Black patients have significantly fewer resources and as a result are often less safe than those that predominantly serve White patients.  Racial bias among individual healthcare professionals also results in poorer health care for Black patients.

“There is nothing natural about the substantial racial health and healthcare disparities that exist,” said Penner. “They are the direct result of the racism that has existed in the US since it became a nation.”

Despite the enormity of this public health problem, the book suggests it is not insoluble. The authors devote the final chapter to proposing new ways to reduce racial health and healthcare disparities, and identifying existing public and private interventions that have already been shown to be effective in addressing some of the causes of these disparities. 

“We are not naïve about the challenge of  achieving racial equity in health and healthcare,” said Penner. “It will require widespread commitment in the public and private sectors and will not come quickly or easily.”

But the authors argue that if this public health problem is not addressed, it will grow at an exponential rate. “Taking action is a personal necessity as well as an ethical imperative,” they conclude. “It is in everyone’s best interest to find ways to make health and healthcare fairer and more equitable for all.” 

Louis Penner presented this research in the Institute for Social Research Insights speaker series: