Abstract

Racism and its manifestations in health care is not a new topic. However, structural racism revealed during Covid-19 pandemic has drawn more attention within health care sector. This paper aims at providing an overview of structural racism in global health care systems focusing on its impacts in the pandemic. The presence of structural racism needs to be addressed to call for measures and ensure equity in health care.

Understanding structural racism and its conceptualized framework clarifies multi-dimensional aspects of racism in health services. The reality of structural racism in Covid-19 pandemic is detected in many facets, from infection testing, development of medical treatments, to the distribution of vaccine. Despite its unfavorable impacts, the pandemic provides opportunities for all health care systems to inspect their functions, learn from the past mistakes and move forward.

Further research is needed to raise awareness of structural racism in health delivery and promote cultural diversity practices as a measure to decrease negative attitudes towards racial and ethnic minorities. Equality in health care should be an objective for global health.

1        Introduction

Racism is not a newly emerged issue. It, in fact, has lingered for centuries in human’s history; from the slave trade era, throughout colonization period, to existing migration flows as a response to globalization. Racism is not solely associated with races, but has close connection to underdevelopment, poverty, and social marginalization, also known as social disadvantage or social exclusion, interchangeably. It also involves growing economic disparities between different regions in the world (United Nations, 2002).

Year 2019 remarked significant changes in every facet in the whole world. SARS-Cov-2 virus appeared and impacted vastly on everyone’s daily life. Besides, it also revealed the hidden side of structural racism within health service sectors. While the pandemic affected every individual, statistics show that certain groups of people suffered more seriously than others. During the first six months of 2020, the rates of age-adjusted hospitalization in America are highest among non-Hispanic American Indian, Alaska Natives, non-Hispanic black persons, and Hispanic or Latino persons. Meanwhile, the rate for non-Hispanic white persons is 4-5 times lower. This issue is stated to be the consequence of systematic health and social inequities that linger (CDC, 2020).

This research article aims at presenting an insight into structural racism and its connection to health care services, especially during the Covid-19 pandemic. Furthermore, the paper also aims at raising awareness to the existence of structural racism in health care systems and addressing the need for further research in health services field regarding health disparities.

2        What is structural racism?

According to Cambridge Dictionary, racism in social studies is defined as ’’the belief that some races are better than others’’. The attitude, therefore, leads to discrimination and unfair treatment of someone based on race (Cambridge Dictionary, n.d.). Racism is not always noticeable and detectable, but often so well rooted into societies that it is believed to be a part of social structures. However, while there is no clear evidence to use biological features to divide races and ethnicities, it is proven that race is socially and politically constructed (Braveman et al., 2022).

The concept of structural racism is used interchangebly with systematic racism and institutional racism, while each term implies a distinctive meaning. Structural racism refers to components of structure; for example, laws, policies, institutional regulations that construct the frame of a system. On the other hand, systematic racism indicates the involvement of the overall system with all of its structural components. By definition, structural racism is included in systematic racism. Institutional racism is often used as synonym for systematic racism or structural racism, or used to refer to racism occurred in a specific institution  (Braveman et al., 2022).

In the field of health studies, racism is conceptualized as a theoretical framework on three levels: institutionalized, personally mediated, and internalized. Institutionalized racism involves disparate access to goods, services, and societal opportunities. Moreover, institutionalized racism is usually structural and associated with law, custom, and practices.  Personally mediated racism is the next level, which is defined as prejudice and discrimination, which is commonly understood whenever racism is referred. Prejudice concerns divergent presumptions on people’s capacities, intension, and actions based on their race. Discrimination is when prejudice is brought into unfair maneuvers. The last level in the framework is internalized racism. It associates with the affirmation of the denigrated groups that their abilities and values are truly limited according to assumptions. Internalized racism is characterized with helplessness, self-devaluation, and limitations in self-expression and self-determination   (Jones, 2000). Understanding the basis of this theoretical framework enables us to recognize the connection between structural racism, health delivery and outcomes. It is also helpful to explain how racism can result in negative health outcomes and health disparities (Peek, 2021).

3        Structural racism in health care

Structural racism is present in numerous areas in our societies, from policymaking, housing, to education. Therefore, the existence of racism in health care is not an exception. Compared to racism in other settings, addressing racism and its manifestations in health care is particularly crucial as it involves people’s life as well as their morbidity and mortality, especially among racial minorities (Peek, 2021). In addition, understanding of structural racism may provide an explanation on underlying causes of health inequities identified worldwide (Gee & Ford, 2011).

Gee and Ford (2011) claimed that structural racism is multi-dimensional and considered a hidden root of health disparities. The connection between racism and health inequities is discussed emphasizing on three main aspects: social segregation, immigration policy, and intergenerational effects. Social segregation indicates the segmentation of society into smaller social units. As a result, health care access and health outcomes may differ. For example, immigrants often work in a more hazardous and stressful environment, which may cause health problems, such as heart disease. Immigration policy is also a type of structural racism that affects health inequities. One illustration is that, if a foreigner wants to enter the United States, he or her is expected to be qualified for health screening for certain infectious and mental diseases, as well as substance use. In other words, only healthy individuals are more certain for entry into the United States. Furthermore, the relationship between racism and health care services is stated to possess intergenerational effects. It means that historical events may influence existing disparities as experiences of racism and unfair treatment can be carried down to the next generation. In short, racism in health care should be examined in multiple dimensions and their interactions to discover the root cause of the issue (Gee & Ford, 2011).

4        COVID-19 – the reality of structural racism

Health disparities has lingered within health care systems worldwide, but Covid-19 has further revealed underlying profound issues in the limelight. The United States has long endured unfairness and injustice in health care delivery. Statistics show that the rate of infection, hospitalization, and mortality is higher among racial and ethnics groups in the pandemic. This fact is rooted from privatization of health care services in the U.S., which allows health disparities to establish and exacerbate. Racial and ethnic minorities often face limitations in high quality care and experience unsound health results. For example, covid testing is mainly located in areas with high income inhabitants. In addition, once seriously infected by corona virus, citizens in less wealthy neighborhoods hardly afford the cost of hospitalization and medical invoices  (Sabatello, et al., 2021).

Diseases do not discriminate, so does Covid-19 infection. Anyone can be the host for SARS-CoV-2 virus, regardless age, gender, race, or national borders. However, poverty and poor living conditions might impact on the level of severity that the infection has on each and everyone. For instance, certain individuals are at higher risk of infection due to involuntary exposure. Meanwhile, access to health care is disproportionate. As in early 2020, when the world was struggling to contain the virus and efforts was made in searching for effective treatments to the infection, a tremendous clinical trial was undergone to test several antiviral medications. Yet the effectiveness of cure was confirmed, the trial led to a shortage of hydroxychloroquine and chloroquine when wealthy countries intended to stockpile these treatments. The situation raised an ethical concern on global health as hydroxychloroquine and chloroquine are crucial for lupus patients, whose symptom management relies on those drugs (Ho & Dascalu, 2020).

Another issue with the above-mentioned medication shortfall was the burden for those countries who had higher demand for these medicines to control the spread of malaria in the country. Unfortunately, malaria is more common in low- and middle-income countries whose health care systems are relatively fragile. This form of structural racism needs to be addressed. Since Covid-19 is a global issue, no single nation is segregated and self-determined. One from a wealthy nation can still be at risk of infection when travelling to areas with unprotected communities. Therefore, the circumstance calls for an international solidarity instead of worldwide disparity in the combat of Covid-19 pandemic (Ho & Dascalu, 2020).

During the pandemic, racism does not only exist in medication supply, but also appears in the distribution of corona vaccine. A successful development of a new medication is often believed to worsen health inequities. Generally, the demands of treatment significantly surpass the supply resources. Therefore, the target to implement equitable allocation of vaccine is challenging. It requires a thorough leadership and a collaboration between the government and local communities. The whole process needs to be transparent, fair, and ideally evidence based (Gaylea & Childress, 2021).

Even though Covid-19 pandemic has affirmed the existence of disparities and inequities in global health care systems, it is also believed to be an opportunity to learn from past mistakes and continue ’’moving forward’’. Sabatello et al. (2021) discussed the future anticipations of Covid-19 pandemic in three major aspects: study to identify treatments; Covid-19 testing, contact tracing, and surveillance; and post-covid health demands and long-term disability. With the expectation to encounter Covid-19 as a seasonal infectious disease, it requires enormous biological data for the development of remedies and vaccine in the future. Samples and clinical information from Covid-19 patients are essential data for analysis and discover possible treatments for severe infections. The sufficient collection and use of diverse Covid-19 biomedical data is determined by the support of research participants. However, the interest in participation may vary since racial and ethnic groups often encounter health disparities during the pandemic. Their willingness is low because they have lost their trust in the health care system that has failed them. Moreover, the outlook of Covid-19 pandemic also perceives infection testing, tracing, and surveillance as resources for detecting new outbreaks and inhibiting the infection from spreading. Furthermore, in the post-covid era, the demand of health care and disability prevalence is likely to expand. While full impacts of Covid-19 have yet to be discovered, current data of respiratory diseases suggest that Covid-19 patients might encounter both short-term and long-term disabilities. These involve impaired pulmonary functions, cardiac diseases, and physical and cognitive impairments. Moving forward requires institutional measures to ensure equal access to high quality care, promote quick recovery, and decrease the overall strain of the disease (Sabatello, et al., 2021).

Establishing Truth and Reconciliation Commission (TRC) has been mentioned as an appropriate approach to guide strategic planning for addressing health inequities through engagement of diverse parties in communities. Sabatello et al. (2021) addressed two key subject matters in TRC, namely common morality and sociobiological solidarity. Common morality involves people’s contribution to the development of biomedical research. The participation in biomedical research may not benefit individuals but it implies a collective benefit to communities in the future. As an illustration, pharmaceutical companies collect and use patient data to develop new medications, they then in turn should offer these medications at an affordable cost. Sociobiological solidarity considers all humans as a species regardless genetics and socially constructed notions such as race and ethnicity. Research in health care, therefore, should promote human beings to be equal in risk taking and benefit sharing (Popejoy, 2021; Sabatello, et al., 2021).

5        Conclusion

Structural racism does exist and impacts on different stakeholders in every society. Structural racism in health care is not an exception. Covid-19 pandemic appeared and carried along influences on numerous facets. Even though the pandemic caused enormous damages to human health, it opens chances for reconciliation of long existed health disparities in global health care systems. Better awareness of racism and discrimination in health services allows health care providers and policy makers to investigate the deep root of a conflict. Thorough understanding of structural racism also suggests remedies for historical mistakes to move forward.  A practice of cultural diversity introduced into health care sector can be an effective tool to minimize racist attitudes towards vulnerable and disadvantaged groups. In short, all human beings belong to the same species. There should not be segregation, racism, and discrimination regardless any social determinants.

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