I take respectful care of my patients regardless of skin color, but in the past few years, I’ve realized that is not enough. There are many sources of information that have influenced me. Conversations, particularly a recent interview with integrative physician Andrea Pennington MD. Books, mentioned in this article, including How to Be an Antiracist by Boston University Professor Ibram X. Kendi and founder of the Antiracism Center for Research,1 and rigorous articles, such as a provocative editorial by my colleague Deborah Cohan MD in the New England Journal of Medicine titled “Racist Like Me: A Call to Self Refection and Action for White Physicians.”2
The book’s central message is that the opposite of “racist” isn’t “not racist.” Professor Kendi brilliantly argues that the true opposite of “racist” is antiracist. “The good news,” Kendi writes, “is that racist and antiracist are not fixed identities. We can be racist one minute and an antiracist the next.”
As a recent guest on Dr. Andrea Pennington’s podcast, we discussed what issues are behind the racial disparities and what physicians need to know in order to deliver antiracist healthcare.
There are hundreds of studies that point out racial disparities in healthcare but none are more staggering than the recent data from COVID-19. There are multiple sources including a preprint from Yale,3 but one that I am following closely is the Covid Tracking Project established by Ibram X Kendi in collaboration with several journalists from The Atlantic. Their data show that Black people are dying from COVID19 at a rate 2.5 times higher than White people.4
Image from Covid Tracking Project
Many attempt to explain the data by referencing comorbidities and underlying conditions such as higher rates of hypertension and diabetes in the Black population. But that in itself leads to the question, why does the Black population have higher rates of these underlying conditions?
Here is where we need to get crystal clear: the increased risk factors and underlying conditions underlying the higher rate of COVID mortality are not about biology or genetics, as addressed in a recent New England Journal of Medicine Perspective.5 Race is a social construct. There are no biological differences to explain the disparity. There are no genetic differences to explain the disparity. What’s the root cause?
Social Determinants of Health
Social determinants of health provide one explanation. These social determinants drive the underlying health conditions that make the health of Black people more vulnerable.
Dr. Pennington describes the five factors, the social determinants of health, as:
- Economic stability
- The neighborhood or environment around you
- The community context or the social contex
Lack of access to fresh food, to education about healthy food choices, access to medical care, and many other factors disproportionately affect the Black population—these provide some explanation for why Blacks are more at risk of dying from COVID-19 than Whites, as well as most other chronic health conditions. We know that people experiencing food insecurity are more likely to struggle with obesity, diabetes, and other conditions that increase their risk of COVID-19—nutrition plays a fundamental role in immune health.6
What evidence-based interventions improve population health and reduce racial disparity? They are targeted disparity-reducing policies that address early childhood, nutritional support, education, urban planning and community development, housing, care support, income, and employment. Cost-effectiveness analysis demonstrates long-term societal savings.7
Another important factor behind these disparities is racial weathering and the effect of stress on a person’s general health. Arline Geronimus of the University of Michigan coined the term “weathering” to evoke a sense of erosion by constant stress. She defines it as the difference between chronological and biological age. In other words, chronic, multiple stressors cause accelerated aging. One of her landmark studies is “Do US Black Women Experience Stress-Related Accelerated Biological Aging?” Using telomere length as a biomarker of aging, the study showed that Black women are aging faster than their White counterparts due to chronic, multiple stressors, some of which include the racism that Black women face on a daily basis. Furthermore, while socioeconomic hardship played a role in the accelerated aging, surprisingly it played less of a role than expected. Poor Black women are aging fastest but middle class Black women are aging faster than their poorer White counterparts.
How Does Stress Impact Us on a Physiological Basis?
I like to talk about good and bad stress, or eustress versus toxic stress. Eustress or hormetic stress is a good stress for your body, like exercise or the stress the night before an exam—it helps you rise to the occasion and be productive. Toxic stress, on the other hand, takes a toll on your physical body and wears on your health. Toxic stress can take on numerous forms. Having to face racism on a regular basis would be considered a toxic stress, as are Adverse Childhood Experiences (ACEs, described below).8
Trauma such as ACEs can cause epigenetic changes that lead to transgenerational transmission of stress. Rachel Yehuda, Ph.D., knows about soul wounds because she’s studied epigenetic changes in the survivors of the Holocaust and the 9/11 terrorist bombings.9 She is a Professor of Psychiatry and Neurosciences at Mount Sinai Hospital. But where are the studies of trauma across generations and paths to adaptation and resilience in Black and Indiginous People of Color (BIPOC)?
What Are Adverse Childhood Experiences?
Adverse childhood experiences (ACEs) are traumatic events occurring before age 18. ACEs include all types of abuse and neglect as well as parental mental illness, substance use, divorce, incarceration, and domestic violence. The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood adversity and middle-aged health and beyond, and in the past 20 years, more than 96 articles have been published linking ACEs to outcomes in mid-life and beyond.10
The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection.11 Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors. Importantly, these were mostly white middle class and upper middle class patients. Still it was shown that 2/3 of patients experienced ACEs, and the rate was higher in women and minorities.
Adverse Childhood Experiences (ACE) predict toxic stress, alcoholism, cancer, suicide, psycho-immuno-neuro-endocrine (PINE) dysfunction. The original research was done by the CDC and Kaiser Permanente in a mostly white, mostly upscale population of 17,000 people to find out how many had experienced any of 10 types of ACE. The association between childhood trauma and adult outcomes was remarkably strong. People with an ACE of 4 were 7X more likely to develop alcohol use disorder compared to people with an ACE of 0.12 They were 2X more likely to be diagnosed with cancer, and people with an ACE score above 6 were 30X more likely to attempt suicide. ACEs shorten telomeres as a marker of accelerated biological age.13
Dr. Andrea Pennington has a quiz on her website to help you determine your ACE score. The rougher your childhood, the more at risk you are for disease in the future. Black children are disproportionately positive for ACEs. 20 years of data show that 4 or more ACEs make disease happen in middle age in a way that many physicians are not yet aware. I believe that all clinicians must start screening their patients for ACEs. (To learn more about Andrea Pennington MD, watch her TEDx talk.)
Nadine Burke-Harris, the Surgeon General of California, shares a story in the first chapter of her outstanding book on childhood adversity that cogently illustrates this point.14 She describes a 43-year-old man who wakes up in the middle of the night, tries to get out of bed but finds he can’t move. Later at the hospital, his wife overhears the doctor describing his case to others as a “43-year-old male, stroke, no risk factors,” yet he had an often overlooked risk factor that doubled his risk of stroke. Her book also contains an outstanding ACE quiz.
We need to reform healthcare and make it antiracist. When clinicians say they treat patients equally regardless of their skin color, it may seem non-racist but as Ibram X. Kendi argues, it’s not enough.15 In fact, it is ignoring the social determinants of health, racial weathering, and the disproportionate number of ACEs that impact our BIPOC patients. Acknowledging this is one of the first steps in providing antiracist healthcare.
As clinicians, we need to constantly take inventory and reaffirm identity as an antiracist, and to examine our attitudes, behaviors, and actions. This starts as an inside job.
We need to realize the imbalance of power that exists and work to mitigate it. We need to recognize the lack of cultural humility that exists in medicine, and change it. We need to provide the proper context for racial disparity. We must change our policy and policy makers, and make sure that we hold our institutions accountable. Most of all, I hope we can all recognize that our acquired education and credentials are insufficient to address social determinants and health inequities.
- Ibram X. Kendi, How to Be an Antiracist (London: Bodley Head, 2019)
- Cohan D. Racist Like Me – A Call to Self-Reflection and Action for White Physicians. N Engl J Med. 2019;380(9):805-807.
- Gross C, et al. Racial and Ethnic Disparities in Population Level Covid-19 Mortality. Preprint 2020 https://www.medrxiv.org/content/10.1101/2020.05.07.20094250v1.full.pdf
- https://covidtracking.com/race Accessed July 9, 2020. Note: These calculations are based on data from The Covid Racial Data Tracker and the U.S. Census Bureau. Race categories may overlap with Hispanic/Latinx ethnicity. Rates are not age-adjusted and some rates are underestimated due to lack of reporting of race and ethnicity categories for COVID-19 deaths.
- Chowkwanyun M, Reed A, Racial Health Disparities and Covid-19 — Caution and Context NEJM May 6, 2020 DOI: 10.1056/NEJMp2012910 https://www.nejm.org/doi/full/10.1056/NEJMp2012910?query=featured_home
- Wolfson JA, Leung CW. Food Insecurity and COVID-19: Disparities in Early Effects for US Adults. Nutrients. 2020;12(6):E1648; The Lancet Global Health. Food insecurity will be the sting in the tail of COVID-19. Lancet Glob Health. 2020;8(6):e737; Zabetakis I, Lordan R, Norton C, Tsoupras A. COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation. Nutrients. 2020;12(5):1466. Published 2020 May 19.
- Thornton RL, Glover CM, Cené CW, Glik DC, Henderson JA, Williams DR. Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health. Health Aff (Millwood). 2016;35(8):1416-1423; Taylor LA, Tan AX, Coyle CE, et al. Leveraging the Social Determinants of Health: What Works?. PLoS One. 2016;11(8):e0160217. Published 2016 Aug 17; Chung EK, Siegel BS, Garg A, et al. Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians. Curr Probl Pediatr Adolesc Health Care. 2016;46(5):135-153.
- Bethell, CD, Gombojav, N, Issue Brief: A National and State Profile on Child Flourishing and Adverse Childhood Experiences in the United States, Child and Adolescent Health Measurement Initiative, Johns Hopkins Bloomberg School of Public Health, March 2019 (www.cahmi.org), accessed July 9, 2020.
- Lehrner A, Yehuda R. Trauma across generations and paths to adaptation and resilience. Psychol Trauma. 2018;10(1):22-29.
- Petruccelli K, Davis J, Berman T. Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis. Child Abuse Negl. 2019;97:104127. doi:10.1016/j.chiabu.2019.104127
- Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258; Republished: Felitti VJ, Anda RF, Nordenberg D, et al. REPRINT OF: Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 2019;56(6):774-786.
- Merrick MT, Ports KA, Ford DC, Afifi TO, Gershoff ET, Grogan-Kaylor A. Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse Negl. 2017;69:10-19.
- Ridout KK, Khan M, Ridout SJ. Adverse Childhood Experiences Run Deep: Toxic Early Life Stress, Telomeres, and Mitochondrial DNA Copy Number, the Biological Markers of Cumulative Stress. Bioessays. 2018;40(9):e1800077.
- Nadine Burke Harris, The Deepest Well (Boston, Houghton Mifflin Harcourt, 2019).
- Ibram X. Kendi, How to Be an Antiracist (London: Bodley Head, 2019)