# Medical racism in the United States

Medical racism in the United States refers to racial and ethnic disparities in healthcare, including discriminatory medical practices and misrepresentations in medical education. Medical racism is usually driven by biases based on characteristics of patients' race and ethnicity and especially affects vulnerable subgroups such as women, children and the poor. As an ongoing phenomenon since at least the 18th century, examples of medical racism include various unethical studies, forced procedures, and differential treatments administered by health care providers, researchers, and government entities.
While medical racism can stem from social factors like explicit prejudice or implicit bias, structural elements also play a significant role. Government policies allowed for segregated medical facilities, and federal programs have often failed to equitably serve racial and ethnic minorities, contributing to disparities in access to and quality of care. Underfunded safety-net hospitals, low Medicaid reimbursement rates, and inequitable coverage policies—further perpetuate these disparities.
Despite legislative efforts like the Affordable Care Act aimed at reducing disparities, gaps in access to care persist, disproportionately affecting racial and ethnic minorities. The enduring influence of structural factors in healthcare contributes to these inequities, suggesting a need for continued examination and consideration of reforms to improve healthcare access and outcomes.

## History

The history of medical racism has created distrust of health professionals and their practices among many people in marginalized racial and ethnic groups. Studies within the last couple decades have elucidated ongoing disparate treatment from health professionals, revealing racial biases. These racial biases have impacted the way in which treatments such as painkillers are prescribed and the rate at which diagnostic tests are given. Black patients in particular have a long history of receiving contrasting medical treatment based on different perceptions of the pain thresholds of Black people. The eugenics movement is an example of how racial bias affected the treatment of women of color, specifically African American women. However, medical racism has not been limited to Black people in the United States. While studies like the Tuskegee Study of Untreated Syphilis in the Negro Male are infamous, the U.S. Public Health Service Sexually Transmitted Disease (STD) Inoculation Study of 1946-1948 harmed Guatemalan prisoners, sex workers, soldiers, and mental health patients by purposely infecting victims with STDs such as syphilis and gonorrhea. Forcible sterilization of Indigenous women as young as 15 years old occurred from 1970 to 1976 by the Indian Health Service as revealed in researcher Jane Lawrence's paper "The Indian Health Service and the Sterilization of Native American Women." Many other examples exist in American history of the unethical actions of health care providers, researchers, and government entities pertaining to the health services of minority groups.
Racial minorities have faced constant and significant barriers to entering and advancing in the medical profession. African American medical professionals, in particular, encountered systemic exclusion, discrimination, and limited access to training opportunities. Until 1940, the American Medical Directory—compiled by the American Medical Association—marked Black physicians with a "col." notation, reinforcing professional marginalization and restricting their inclusion in medical institutions, professional organizations, and fair insurance practices. These historical inequities continue to shape both patient trust in the healthcare system and the diversity of the medical workforce today.

## Contributing factors
### Cultural competence

Physicians who are not culturally competent can harm patients due to poor relationship dynamics, contributing to medical racism. Racism is defined as “a form of social formation embedded within a network of social, economic, and political entities in which groups of people are categorized...” As a result, there are groups of people that are racialized as inferior. Most times, individuals tend to categorize these groups with negative stereotypes with connotations that have a high level of acceptance and endorsement. While physicians may consciously condemn racism and negative stereotypes, evidence shows that doctors exhibit the same levels of implicit bias as the greater population. Racialized minority groups report experiencing both overt and covert racism in healthcare interactions. Implicit bias is also seen in mental health services, which are plagued by disparities viewed through lenses of racial and cultural diversity. Much of the discrimination that occurs is not intentional. Healthcare providers may not consciously have biases on racial stereotypes. These tend to occur automatically. Psychological studies have demonstrated that “...persons who do not see themselves as prejudiced will make health care allocation decisions…”. Based on this research, several authors argue that there is an intense need for cultural competence education in healthcare for explicit racism and implicit biases. Cultural incompetence exists for a number of reasons such as lack of diversity in medical education and lack of diverse members of medical school student and faculty populations. This leads to marginalization of both minority healthcare providers and minority patients.

### Medical education

The lack of medical education about minority groups is evident in various studies and experiences. In a 2016 study, white medical students incorrectly believed that Black patients had a higher pain tolerance than white patients, perpetuating harmful stereotypes. These beliefs were rooted in unfounded notions, such as thicker skin or less sensitive nerve endings in Black individuals, echoing racist ideologies of the past. This bias extends beyond education, as racialized minority healthcare users report feeling unjustly reprimanded and scolded by healthcare staff, as noted by African American women in the USA. Furthermore, research reveals disparities in pain medication prescriptions, with white male physicians prescribing less to Black patients, fueled by perceptions of biological differences in pain reactions between races. These findings underscore the urgent need for reforms in medical education to address racial biases and promote sensitivity. Additionally, statistics show that African Americans are disproportionately subjected to less desirable healthcare services, like limb amputations, highlighting systemic inequalities that several authors state must be confronted and rectified. Studies done on the curriculums of medical schools in the US have found that within the assigned textbook readings, there exists a disparity between the representation of race and skin color in textbook case studies relative to the US population. This is true for both visual and textual lecture materials.
A group of studies done on the representation of race and gender in course slides for the University of Washington School of Medicine, preclinical lecture slides at the Warren Alpert Medical School of Brown University and case studies used at the University of Minnesota Medical School simultaneously showed associations of race as a "risk factor" and a lack of racial diversity.
The study done on the University of Minnesota Medical School employed the use of the concept of hidden curriculum to describe the ways in which lack of representation and informal teachings can greatly influence the minds of aspiring physicians. The interactions had between students and faculty or the transmission of unintentional messages can be just as, if not more, influential than formal lectures. These can include the associations of diseases such as sickle cell anemia as a "black disease" and cystic fibrosis as a "white disease" which leads to poor health outcomes. In this study, the 1996-1998 year one and year two curriculums of the school were analyzed. It revealed that only 4.5% of the case studies mentioned a racial or ethnic background of the patient and when the patient was black or had "potentially unfavorable characteristics" race or ethnicity was more likely to be identified. There was also a greater prevalence of health-related themes discussed when race or ethnicity was identified. Researchers determined that the inclusion of specific racial or ethnic identities in those cases was intended to indicate something about that disease or health condition. The authors state that practices such as these contribute to the racialization of diseases.
A study of medical textbooks has also yielded information on minority representation in medical teachings. Based on the required texts of the top 20 ranked medical schools in North America, US editions of Atlas of Human Anatomy (2014), Bates' Guide to Physical Examination and History Taking (2013), Clinically Oriented Anatomy (2014), and Gray's Anatomy for Students (2015) were chosen for the study. Using the total 4146 images from the four textbooks that depicted visible faces, arms, heads, and skin, researchers discovered two of three books were close in diversity to the US population, one book displayed "diversity on basis of equal representation" and one matched neither definition of diversity. On a topic level there were also issues of diversity. When discussing health issues such as skin cancers three of four books included no imagery at all and the one book that did had only imagery of white and light-skinned patients. According to researchers, symptoms might manifest differently depending on skin tone. Missed indicators may go unreported if there is a lack of education on how to recognize these discrepancies.
Some medical students have also done their own research and added to the discourse on underrepresentation in medical school education. They've noted specific examples such as skin infections like erythema migrans being depicted on almost exclusively white skin. As an indicative first symptom of lyme disease, a lack of knowledge on how to detect this rash on patients with darker skin colors means failed diagnoses of the disease. Studies have shown that there is in fact a delay in lyme disease diagnoses for black patients. The lack of representation in medical school lectures risks creating adverse impacts on the health outcomes of minority populations in the US.

### Representation in the profession of medicine

According to US Census data, black and Hispanic people account for 13% and 18% of the overall population, respectively. However, they only make up 6% and 5% of medical school graduates, respectively. Black physicians make up only about 3% of American doctors. Black physicians in particular have historically faced numerous obstacles to obtaining membership in the larger medical community. During the 20th century in the United States, groups such as the American Medical Association neglected black physicians and their pursuit of success in the field of medicine. This has led to continued marginalization of black physicians in the US due to their small numbers among other factors and this contributes to the marginalization of black patients. Minorities often perceive medical facilities as "white spaces" because of a lack of diversity at the institutional level.

### Racial depictions

The dehumanization of certain racial groups such as black people can also contribute to disparities in healthcare due to varied perceptions, by physicians, of concepts such as pain tolerance and cooperation – one aspect of medical racism. In American history, social Darwinism has been utilized to justify American chattel slavery among other historical practices and the racist ideas about black people it created persisted into the 20th century. The Three-Fifths Compromise worked also to reinforce the notion that black people were less than human.
However, this has not just been relegated to the past. As recently as the 1990s, California state police came under fire for referring to cases involving young black men as "N.H.I" or no humans involved. One police officer involved in the Rodney King beating in 1991 was cited as saying that a domestic quarrel between a black couple was "something right out of Gorillas in the Mist." This comparison has historical prevalence in that it stems from early theorizations about the evolution of primates. Proponents of this social Darwinistic theory believe that white people are the most advanced humans, descended from primates, and that black people must fall somewhere in the middle of the two.
Research published in 2008 studied undergraduate students from two universities in the United States. The researchers attempted to determine whether or not the association of black people with apes influenced the perceptions and behaviors of 242 white and non-white students, using a format in which images were presented to the subjects subliminally and their responses were recorded. The study found that even without explicit knowledge of the historical association, the students implicitly related one with the other. This study was done in the context of criminal justice and aimed to reveal whether associations with animals impacted the likelihood of jurors to give the death sentence. Researchers were able to conclude that, "The present research foregrounds dehumanization as a factor in producing implicit racial bias, and we associate it with deadly outcomes."

### Socioeconomic status

Studies also show that social class is critical to the effects of racial disparities in health care, due to the correlation and relationship between health status and health insurance or the absence of. There was an interview study of 60 African Americans whom of which had one or multiple illnesses and the results showed that those of whom fell under the low-income category expressed more dissatisfaction with their health care than their fellow middle-income respondents. Socioeconomic status is very entangled and highly associated with racism, which thus restricts many members of minority groups in various ways. Low SES (socioeconomic status) is an important determinant to quality and access of health care because people with lower incomes are more likely to be uninsured, have poorer quality of health care, and or seek health care less often, resulting in unconscious biases throughout the medical field.
A recent study at the Institute of Medicine reported that Whites are more likely than African Americans to receive a broader range of medical specific procedures while African Americans are more likely to receive undesirable procedures such as amputations and not as many options. Of the study, respondents reflected their socioeconomic status, their professions, if they were homeowners, if they had medical insurance, versus those who lived in public housing, had no medical insurance, etc. The study showed that SES directly correlated with health insurance status due to the fact that people that considered themselves as low-income, had a history of either being a Medicaid recipient or had no health insurance overall.
Discrimination based on race is among those of who fall into a minority category, especially being of low-income due to the fact that medical practitioners tend to have more racial biases towards people of color.

### Implicit bias

Implicit bias refers to unconscious attitudes or stereotypes that influence an individual's decisions and actions without their awareness, and thought to contribute to disparities. In healthcare, implicit racial and ethnic biases can contribute to disparities in access to care, quality of care, and health outcomes for people of color.
A systematic review conducted by Hall et al. (2015) examined implicit racial and ethnic biases among healthcare professionals and their impact on healthcare outcomes. The review analyzed 15 studies, most of which used the Implicit Association Test (IAT) to assess implicit bias. The IAT measures implicit biases by assessing the strength of automatic associations between concepts (e.g., racial groups, genders) and attributes (e.g., good, bad). Participants quickly categorize words or images by pressing keys, with the test assuming that stronger associations result in faster, more accurate responses when related concepts share the same key. The results indicated that healthcare professionals generally exhibited low to moderate levels of implicit bias, with attitudes similar to those in the general population. Notably, levels of bias against Black, Hispanic/Latino/Latina, and dark-skinned individuals were relatively similar.
While some associations between implicit bias and healthcare outcomes were nonsignificant, the review found that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. These findings highlight the potential influence of implicit bias on the quality of care received by patients of color.
The review calls for further research to employ more rigorous methods to explore the relationships between implicit bias and healthcare outcomes. It also stresses the need for interventions to address implicit bias among healthcare professionals as a means of reducing health disparities.

## Patient experiences

Racial discrimination in healthcare is a systemic issue that has persisted across generations, shaping patient outcomes, provider interactions, and institutional policies. Studies show that marginalized racial and ethnic groups frequently experience disparities in treatment due to implicit bias, stereotyping, and structural inequities within the healthcare system. Factors such as income, education, and geographic location further influence the severity of these disparities, contributing to unequal access to quality care.
Patients from historically marginalized communities have reported that healthcare providers often make assumptions about their background, leading to dismissive attitudes and differences in treatment. Research indicates that racial and ethnic minorities are more likely to receive inadequate pain management, face longer wait times, and have their concerns downplayed or ignored compared to white patients. The assumption that patients of certain racial backgrounds are less educated or financially unstable has been cited as a factor in healthcare providers offering lower-quality care or reduced options for treatment. One participant in a study described how assumptions about their cultural background influenced their provider’s approach:
   “I've had both positive and negative experiences. I know the negative one was based on race. It was [with] a previous primary care physician when I discovered I had diabetes. He said, ‘I need to write this prescription for these pills, but you'll never take them and you'll come back and tell me you're still eating pig's feet and everything… Then why do I still need to write this prescription?’ And I'm like, ‘I don't eat pig's feet.’” (African American participant)
These persistent disparities continue to affect patient trust in the healthcare system but also reinforce tbroader inequities in health outcomes, reinforcing cycles of medical racism for marginalized communities.

## Black Americans

Black Americans have faced numerous obstacles to equal access to healthcare due to medical racism and the consequence of this has been poor health outcomes. Within this paradigm, American doctors and institutions have historically played a large role in perpetuating scientific racism, denying equal care to black patients, and perpetuating structural violence as well as committing acts of physical assault and violence against black people in the context of medical experimentation, withholding of treatment, medical procedures performed without consent, and surgical procedures performed without anesthesia
Ideas about black people's relationship to primates and their biological and intellectual inferiority to white people, in the US, were just a few ways in which chattel slavery was justified. Following this was the introduction of the belief that black people have much higher pain thresholds or the introduction of the belief that they do not feel pain at all. Proponents of ideas such as this also proposed that black people had thicker skulls and less sensitive nervous systems, and they also proposed that black people contracted diseases which were linked to their darker skin color. Some proponents of these racist ideas even believed that black people could go through surgery without any pain medicine and they also believed that when black people were punished, during their enslavement, they felt no pain. White American physicians also operated on the assumption that poor health was the status quo for black people which meant that they would naturally die off due to syphilis and tuberculosis, a situation which was detrimental to the quality of the healthcare which they then provided to black people. The high rate of syphilis among black people was used to reinforce this notion. However, racial myths also have negative impacts on the health outcomes of black Americans, starting from infancy. Beliefs in the "supernormal health" of black babies and children fosters ignorance and leads to the avoidance of the health issues which black children face in their early lives. With a large role in the perpetuation of such widely believed ideas, oral traditions can be highly influential, even when they are not explicitly included within medical curriculum.
When false ideas of pain tolerance based on race are present within people's minds, they lead to detrimental consequences even if those who believe in them have no explicitly prejudiced beliefs, as was discovered by researchers in a study on racial bias in pain assessments. In this study, a correlation between racial bias in pain assessment and subsequent pain treatment suggestions was found. It was also found that in both a significant number of laypersons and those with medical training, incorrect beliefs about differences between black and white people on a biological level were held. Beliefs such as these can lead to the differential treatment of patients on the basis of their race. Staton et al., showed that physicians had a higher probability of underestimating the pain intensity that black patients were feeling. In the early 2000s, multiple studies demonstrated discrepancies in the pain treatment of black patients as compared to white patients. From children to adults, differences were as much as black patients only taking half of the amount of pain medications as white patients were taking.
Freedom from slavery did not stop the impacts that slavery had on black people: the denial of access to healthcare recreated the experiences of slavery by exposing black people to many infectious diseases. A notable difference between the services which were offered and rendered to black patients and the services which were offered and rendered to white patients has been observed in the American healthcare system even with the presentation of the same severity of symptoms and the same health insurance.
Along with unequal access to medical care, medical racism has contributed to violence perpetrated against black Americans throughout history. Including the use of "resurrectionists" to retrieve newly buried bodies of deceased black people for medical study use, the bodies of black people were abused for forced medical experimentation for many years. As noted in writings on the American medical field's history of medical racism, "American medical education relied on the theft, dissection, and display of bodies, many of whom were black." This is especially true for women, such as was the case for Henrietta Lacks. The nonconsensual experimentation on enslaved black women was used to help further the field of gynecology. Following this, due to the history of eugenics in the United States, this same population once again fell victim to forced procedures, in this case sterilization. This went on in the US as late as the 1970s and 1980s as is documented in Killing the Black Body. For black Americans, the involuntary sterilization of black women was so well known it began being referred to as the "Mississippi Appendectomy".
The violence which was perpetrated by American physicians and institutions has a long, documented history. Besides the Tuskegee syphilis study, there are many other instances of experimentation on black populations without their knowledge or consent. In 1951, the US Army intentionally exposed large numbers of black citizens to Aspergillus fumigatus to ascertain whether they were more susceptible to this fungus. In the same year, black workers at a Norfolk supply center in Virginia were exposed to crates contaminated with the same fungus. Journalist Richard Sanders reported that from 1956 to 1958 the US Army intentionally released mosquitoes in poor black communities of Savannah, Georgia and Avon Park, Florida. Many people subsequently developed fevers for unknown reasons and some of them died, it is theorized that the mosquitoes were infected with a strain of yellow fever. Pulitzer-prize winning author of The Plutonium Files, Eileen Welsome wrote on how the US secretly injected thousands of Americans with plutonium while it was developing the atomic bomb. A number of these victims were black and they were completely unaware of the injections.

## Indigenous Americans

Starting in the 18th century, the United States has committed many acts of medical injustice against Indigenous Americans. In the 18th century, smallpox was used as a biological weapon to wipe out indigenous populations. In particular, in 1763 Sir Jeffery Amherst ordered soldiers to take the blankets and handkerchiefs of smallpox patients and gift them to indigenous people of Delaware at a peacemaking parley. There is also the prevalence of involuntary sterilization of young indigenous girls and women. From the data yielded by multiple studies, it was suggested that the Indian Health Service sterilized between 25 and 50% of indigenous women from 1970 to 1976.
Contemporarily, the health outcomes of indigenous populations in the US are still vastly worse than the greater population. In the state of Montana, the life expectancy for indigenous women is 62, while for men it is 56. These numbers are significantly lower than the national averages by around 20 years. This is due to a number of factors such as the fact that unequal funding plagues the Indian Health Service that is in charge of ensuring the access the federal government must provide and that around 25% of indigenous people in the US report facing discrimination in medical settings. An executive director at South Dakota Urban Indian Health, Donna Keeler, explains that while her clinic receives federal funding for indigenous people living in urban areas, federal prison inmates would have more federal funding allocated to their healthcare.

## Hispanic Americans

In the United States, 20% of Hispanic Americans report encountering discrimination in healthcare settings and 17% report avoiding seeking medical care due to expected discrimination. Studies of Hispanic people living in the U.S. reveal that after experiencing an instance of discrimination in a healthcare setting they, afterward, delayed seeking medical treatment again. The discrimination faced by Hispanic Americans can further contribute to the negative health outcomes that stem from the experience of racism and discrimination by minorities. Cultural incompetency can hinder productive relationships between healthcare providers and patients because different cultural norms of communication can give the impression that a physician is not properly attending to the concerns of their patient as was found in studies on Latina experiences with the healthcare system. It was found in one study that in the role that communication plays in the dynamic between Latina patients and healthcare providers, the way women perceived their communication with their provider was greatly impactful to their perception of discrimination.
The aforementioned U.S. Public Health Service Sexually Transmitted Disease (STD) Inoculation Study of 1946-1948 is just one historical example of the way in which Latin American populations have been victim to medical racism and medical injustices.

## Contemporary issues

Racial and ethnic disparities in healthcare persist due to systemic factors that influence access to quality care. Structural inequities in healthcare funding, policy, and delivery disproportionately impact minority communities, leading to disparities in treatment quality and health outcomes. These systemic barriers, including discriminatory policies and unequal resource allocation, contribute to persistent gaps in healthcare access and outcomes.
From 2006 to 2013, California prisons performed illegal sterilizations on inmates and more than half of the women were black or Latina. In 2020, a nurse whistleblower alleged the practice of forced hysterectomies at a US Immigration and Customs Enforcement facility. Additionally, studies have shown that Black and Hispanic patients continue to be under-treated for pain compared to their white counterparts.
Structural racism in healthcare policy remains a critical barrier to equitable access. Safety-net hospitals and clinics, which primarily serve racial and ethnic minority populations, are often underfunded and financially constrained, resulting in lower patient satisfaction, underperformance on evidence-based care metrics, and higher rates of adverse safety events. The Affordable Care Act significantly expanded healthcare coverage, but failed to eliminate racial gaps in access. Its continued reliance on private insurance disproportionately leaves minorities uninsured or underinsured, limiting their access to quality care.
Low Medicaid reimbursement rates can discourage provider participation, as many lawsuits argue it contributes to disparities in healthcare access. Additionally, government pay-for-performance programs can inadvertently penalize safety-net providers, further exacerbating healthcare disparities rather than addressing them.[ The closure of nonprofit and public hospitals in minority communities has also contributed to physician shortages, forcing many patients to rely on emergency departments for primary care, adding to existing challenges.
Without targeted reforms aimed at eliminating structural racism in healthcare policy, racial and ethnic minorities continue to experience inequitable access to high-quality care.

## Mitigation

In addressing medical racism in the United States, there are several strategies to mitigate unconscious bias that contributes to health disparities. Practices like better diversity training, introspection of biases, "cultural humility and curiosity", and a full commitment to changing the culture of healthcare and the impact of stereotypes can work to lessen the effects that unconscious bias can have on patients. Medical schools also play a role in helping students recognize and address race-based inequities and microaggressions. Curricula that specifically address racial bias can improve patient interactions by preparing incoming healthcare professionals to better navigate these challenges. A 2020 study of resident-led programs dedicated to racism training showed positive results in promoting awareness of racism in the workplace, with the goal of generating early awareness of institutional racism and reducing its negative effects.
One approach that has proven effective is Health Equity Rounds (HER), a longitudinal, case-based conference series designed to address bias, structural racism, and other forms of systemic oppression in healthcare. HER aims to explore root causes of adverse events, with a particular focus on inequities in care delivery, outcomes, and experiences. It also works to normalize conversations about medical racism and catalyze institutional changes. At Boston Medical Center (BMC), the HER model has been implemented successfully since 2016, involving over 68 residents and 9 faculty mentors in 36 grand rounds conferences. HER has helped foster dialogue on medical racism, resulting in both policy changes at the institutional level and broader engagement in state and national advocacy efforts.
In addition, community-based health promotion plays a crucial role in addressing racial disparities in healthcare. Localized, data-driven community health planning allows interventions to be tailored to the specific needs of different populations. Sustainable funding for community infrastructure and preventive care is essential in reducing long-term health inequities, particularly in underserved areas. Furthermore, addressing home-based healthcare challenges is critical, as many marginalized groups face systemic barriers to accessing traditional healthcare settings.
Another structural change involves value-based reimbursement and social determinants of health (SDOH). Shifting from a fee-for-service model to value-based reimbursement can incentivize equity-focused care by rewarding providers for improved health outcomes rather than the volume of services provided. This transition creates economic opportunities for upstream interventions that address SDOH, such as housing, education, and food security, which significantly impact health disparities.
Finally, workforce diversity and education are critical in reducing disparities in healthcare. Increased funding for STEM education in under-resourced communities can help create a more diverse pipeline of future healthcare professionals. Additionally, federal support for diversity initiatives in medical schools and hospital systems can improve representation within the medical workforce, ultimately leading to better cultural competency and more equitable healthcare delivery.