Dr. Hamid Shaaban (center) with members of the Saint Michael’s Medical Center at a public community outreach event.
Read this opinion essay as it originally appeared February 27, 2022 in TAPintoNewark.
As National Black History Month comes to an end, I’ve been ruminating about this year’s theme “Black Health and Wellness,” the goal of which was to take a look at how American healthcare has often underserved the African American community.
The theme is supposed to acknowledge the legacy of not only Black scholars and medical practitioners in Western medicine, but also birth workers, doulas, midwives, naturopaths, herbalists, etc., throughout the African Diaspora.
The theme is supposed to highlight, denounce, and agitate against the interconnected, intersecting inequalities which were historically and intentionally baked into systems and structures in the USA.
But then I asked myself why? Why do these healthcare disparities exist? How does healthcare racism work?
Being a physician, I recognize that in order to deliver the best care to my patients, I must first understand the cause and pathophysiology of what’s ailing my patient. To fix healthcare racism, we must look to the lessons from the past to provide the light for our future.
So during my education this Black History Month, I realized that racism affects both population and individual health in two interconnected realms: redlining and racialized residential segregation and unequal medical care. The predominant features of these examples are that the harms are historically grounded, involve innumerable institutions, and hinge on racist cultural tropes.
In the 1930s, the Federal Housing Administration (FHA) was established to offer government-backed mortgages and encourage homeownership. However, these benefits were not offered to everyone. Only neighborhoods that the federal Home Owners’ Loan Corporation designated as desirable were eligible for these loans.
They devised color-coded maps, on which green stood for “best,” blue for “still desirable,” yellow for “definitely declining” and red for “hazardous.” Much of the designation relied on the neighborhood demographics; neighborhoods with predominantly African Americans, immigrants, and religious minorities were labeled as undesirable, making it more difficult for residents to buy homes and reinforcing residential segregation.
From 1934 to 1962, 98% of loans insured by the FHA went to white Americans. The maps became self-fulfilling prophesies, as “hazardous” neighborhoods — “redlined” ones — were deprived of investment and deteriorated further in ways that most likely also contributed to white flight and increasing racial segregation.
Although housing discrimination was prohibited in 1968, discriminatory housing policies keep formerly redlined areas segregated and make it harder for residents in these neighborhoods to buy homes and build wealth.
Homes in formerly redlined neighborhoods are chronically undervalued, decreasing the wealth that homeowners in these neighborhoods can accumulate. And residents of formerly redlined areas are more likely to be victims of extreme heat waves, air pollution, and other environmental hazards.
Similar trends are seen when it comes to health disparities and redlining. Residents of formerly redlined neighborhoods are at increased risk of health issues like preterm birth, cancer, tuberculosis, and maternal depression.
The Annals of Surgery recently published a paper in which clinician researchers and architects at the University of Michigan studied whether patients who lived in formerly redlined neighborhoods had worse outcomes after one of five common surgeries.
They found that the color-coding of HOLC maps corresponded almost exactly to patients’ risk of 30-day post-operative mortality, complications, and readmissions.
For example, the rate of post-surgery mortality for patients in the “best” neighborhoods defined by the HOLC was 5.4%, 5.8% in “still desirable,” 6.1% in “definitely declining,” and 6.4% in “hazardous.” The color-coding of HOLC maps corresponded almost exactly to patients’ risk of 30-day post-operative mortality, complications, and readmissions.
Even when researchers controlled for a modern measure of neighborhood disadvantage including education, employment, housing quality, and poverty, patients in neighborhoods formerly labeled “hazardous” had significantly higher rates of post-operative mortality and complications.
This study augments the evidence of how structural racism negatively impacts health. Despite the fact that redlining was prohibited decades ago, one must take into serious consideration the impact of this policy when dissecting the complex issue of health disparities.
This research suggests that factors not scrutinized in current measures of neighborhood disadvantage, such as segregation and racism, can have a significant effect on recovery from surgeries.
For policymakers seeking to abate racial health disparities, in addition to pushing for improvements in education and environment, we need to urge them to also address police violence, which has a strong impact on mental health, and prejudice in the real estate industries that safeguard the institution of residential segregation.
Hospital quality too plays an integral role. There is enough data to show that hospitals in communities of color are more likely to have poorer outcomes. Hospitals are certainly not created equal. Health care system sets up safety net hospitals for failure, because they are paid less to care for patients with public insurance like Medicaid, and not paid at all to care for uninsured and undocumented patients. This leaves safety net hospitals with a deficiency of resources to ameliorate their quality of care.
Despite all this, Saint Michael’s Medical Center in Newark, where I am an oncologist, provides quality patient care even though it is one of New Jersey’s safety net hospitals. The Lown Hospitals Index for Social Responsibility ranked Saint Michael’s second in the nation for social equity. The Index includes 54 metrics across the equity, value, and outcomes categories. The index is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.
Saint Michael’s has been awarded the Patient Safety Excellence Award from Healthgrades for the last three years in a row and has received an A grade from Leapfrog for four straight periods beginning in the fall of 2018.
Still, there is much more work to be done to dismantle the legacy of redlining and its ongoing impact health outcomes. We need to embrace and encourage the intellectual research projects of documenting the health impact of structural racism. We have to use the results of that research to improve the delivery and equality of health care. We need to educate the future healthcare providers of America about American history and of the ways in which medicine and public health have perpetuated and continue to perpetuate racist practices.
This education of self-reflection should include recognition of harms arising from implicit racial assumptions and bias. We have to end our unequal reimbursement system, so that all hospitals are compensated equally for the patients they serve and treat. At the same time, hospitals caring for communities of color need more support to provide quality of care on par with wealthier hospitals.
Confronting healthcare inequalities and racism requires not only confronting our uncomfortable past with difficult conversations and spirited debates but also changing individual attitudes, which will in turn result in a systematic transformation and dismantling of the policies and institutions that buttress the American racial hierarchy.
In doing so, we will effectuate policies that will not only right the wrongs of history that continue to shape our everyday life but it will moreover bolster the chances for a healthy life for people of color.
Dr. Hamid Shaaban is an oncologist at Saint Michael’s Medical Center.