Impacts of racial discrimination on

people's health and public health

systems in multicultural societies
Dino Galinović1

Abstract

Systemic racism represents a major threat in multicultural societies in which

racial biases and framing still play a significant role in the creation of public
policies and organizing public systems such as health care. This paper
argues that racism and racial framing directly influence negative effects on
people's health, especially among minority groups such as African
Americans in the United States and Aboriginal people in Canada. These
groups of people are more likely to get unsatisfactory or inadequate medical
service and suffer from chronic illnesses, such as cardiovascular problems,
diabetes, mental health issues, drug abuse and overdose, or HIV infection
more/in a higher degree than the white population. Furthermore, racism
has a direct impact on inequalities in health care systems due to a lack of
diverse health care providers in more urban areas and inaccessible
treatment because of geographical reasons or cultural differences. In this
paper, we have taken into consideration the concept of race and ethnicity,
decades of racial framing in the United States and Canada, and shown the
negative impacts on health within different ethnical groups. The paper
concludes by emphasizing the need for structural change within health care
systems.

Key words
racism, racial framing, health care systems, United States, Canada

1Dino Galinović is a graduate student at the Faculty of Political Science, University of

Zagreb. Contact: [email protected].

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Introduction

Health care systems around the world have experienced exceptional

change, restructuring, and downsizing in the last two decades. In the media,
we can often hear health policy experts describe health care infrastructure
as being in a state of crisis. Health care providers are faced with caring for
patients with increasingly complex health challenges. Patients are getting
sicker because of the impacts of climate change, hospital stays are shorter
due to low income, and medical treatment is becoming more inaccessible
because of social, economic, political or geographic determinants. At the
same time, communities like those in the United States of America and
Canada are becoming increasingly diverse every year. The heterogeneity of
one population is also reflected in the health care system.

The health care system, complex as it already is, is even more complicated
for people of color, minorities, and "others", as they face different obstacles
in getting fair and good treatment because of various forms of
discrimination that go way back to the times of racial framing and racism
in general. This paper aims to examine the influence of race and ethnicity
on health care systems and services, and what kinds of outcomes racism in
all its forms has on the health of people of color and ethnic groups, as well
as their treatment within the health care system. The main hypothesis of
this paper is that people of color (e.g. African Americans) and ethnic
minorities (e.g. Indigenous people) are more likely to get worse health
service and to suffer from chronic diseases in a higher percentage than the
white population.

Decades of systemic racism have left significant consequences on

contemporary health systems and on the ways in which these systems fail
to provide the same quality of health care to all who need it. In this paper,
we will introduce and analyze concepts of race, ethnicity, and racism, and
show how racism can be “measured” in health care. Furthermore, along
with a descriptive revision of literature, we will give an overview of the
different impacts of discrimination (racism) on people's health, and why
groups such as black people and Aboriginal people are more likely to suffer
from high blood pressure, mental illness, HIV and AIDS or higher infant
mortality.

Understanding race and ethnicity

Race and ethnicity are issues of high importance not only in social sciences
but also in public health. Public health is the organized effort of society to
protect, promote and restore the public's health (Weeramantrhi, 2000:2).

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Race is a word frequently used in general conversation and the media. It is
enshrined in constitutions and legislations, such as the “racial
discrimination acts” (Weeramantrhi, 2000:2). The concept of race is taken
to be a result of its extensive use in assembling boundaries that
simultaneously include and exclude people and lead to imagined
communities (Pettman, 1992). Several features are associated with the use
of the term race in scientific literature, especially in the last couple of years
(Weeramantrhi, 2000:2). The first feature is the notion that a specific moral
character can be imputed to a person based on their physical type; the
second feature is the creation of associated hierarchies where the people
constructing the hierarchy generally find themselves in the highest stratum
with the right to dominate others (Weeramantrhi, 2000:2-3).

However, we cannot talk about race or ethnicity without mentioning

culture. Culture is perceived as the process of cumulative adaptation of a
social group to a particular environment (Shannon, 1994:33-34). On the
other hand, an ethnic or racial group refers to a culturally defined group
that may include common geographic origin, language, and faith, as well
as shared traditions and values (Polednak, 1989:4-5). Like race, the concept
of ethnicity can be mobilized for political purposes, and the expansion of
shared political values and traditions can shape ethnic identity.

Before conceptualizing racism, in this case as a determinant of health, it

should be acknowledged that racism is only one of several causes of ethno-
racial differences in health. Sociocultural and socioeconomic differences
between ethno-racial groups also contribute to such disparities (Paradies,
2016:1). So, racism impacts health and wellbeing, and it does so in
interaction with other oppressions such as sexism, homophobia, and
classism (Bauer, 2014:12). The study of racism as a determinant of health
has predominately focused on understanding how discrimination impacts
health through several recognized pathways:

„First, reduced access to social outcomes such as employment, housing,

education, and increased exposure to risk factors such as racial violence;
second, negative cognitive or emotional and related pathopsychological
processes such as hypervigilance and anxiety; third, allostatic load and
concomitant pathopsychological processes; fourth, diminished
participation in healthy behaviors – sleep and exercise and increased
engagement in unhealthy behaviors such as drugs, smoking or alcoholism;
and fifth, physical injury as a result of racially motivated violence“
(Paradies, 2016:2).

To sum up, various socio-economic aspects directly influence racial

discrimination towards individuals, which is, ultimately, reflected not only
in their health but also in their way of life, education or employment. This

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is one of the numerous reasons why we are witnessing an increasing
number of progressive policies being put on the political agenda to tackle
unjust systems and systemic discrimination in different forms.

“White supremacy” and racial framing through history

Research on inequality typically focuses on health problems faced by

people of color, while neglecting to mention white perpetrators with racist
practices and institutions which create the problems. However, Feagin and
Bennefield focus throughout their research on the roles, framing, and
institutionalized actions of influential white people and problematize them
as responsible for many health-related problems (2013). They claim that
“[t]he majority-white decisionmakers include public health researchers and
policymakers, medical educators and officials, hospital administrators, and
insurance and pharmaceutical executives, as well as important medical
personnel” (Feagin and Bennefield, 2013:8).

Many researchers who have dealt with the topic of social inequality in every
aspect of society have managed to develop concepts such as bias, prejudice,
cultural competence or racial hate. The gathered data suggests that the
conduct of the majority of white health care and public health personnel is
based on white framing, with its pro-white and racist orientation; moreover,
this framing includes notions of biologically and culturally distinct racial
groups, and links them to discriminatory practices which account for
institutionalized inequalities in health care and health (Feagin and
Bennefield, 2013:8). Public health communities, with their dominant white
leaderships, seem reluctant to examine the current impacts of past racial
oppression in U.S. medical and public health institutions. Systemic racism
and medical and biological science, including the latter’s medical and
public health practices, evolved together in society (Feagin and Bennefield,
2013:9). Medical treatments and public health practices were often matters
involving white racial framing. For example, in the 18th and19th centuries
prominent white physicians, medical professors, and biological scientists
played a central role in creating the concept of “race” at the heart of the still-
dominant white racial framing (Feagin, 2010).

„In the 19th century, profit-driven growth of the scientific medical system
pressed white physicians and scientists to discover technologies and
treatments to serve whites. In the South medical experiments were carried
out on black women that no white physician would try on whites. This
resulted in death for many enslaved women and set the model for
continued use of African Americans as guinea pigs for medical progress, as
well as for white physicians’ provision of inadequate care for them. Black
women were often denied treatment for real ailments, resulting in

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excruciatingly painful deaths for many. The racialized abuse endured today
by black patients frequently replicates the racialized abuse their ancestors
suffered.“ (Feagin and Bennefield, 2013:9)

Furthermore, Washington highlights one important aspect of history, an act

of injustice towards black women. Black women were subjected in a higher
percentage to “eugenics” in the early 20th century by doctors and scientists.
According to Washington, „eugenics was appropriated to label Black
women as sexually indiscriminate and as bad mothers whose biology
caused them to give birth to defective children. The demonization of Black
parents, especially mothers, as medically and behaviourally unfit has a long
history, but twentieth-century eugenicists provided the necessary
biological foundations to scientifically validate these beliefs” (2006: 191).
Feagin and Bennefield also mention Margaret Sanger, birth control pioneer,
who helped devise a 1939 “Negro Project,” which sought to reduce the
black population through negative eugenics (2013: 9-10). Due to her
lobbying, numerous forms of birth control were tested in black
communities. Because of high levels of hormones in early pills, black
women were exposed to high health risks such as hypertension and stroke.

How to measure racism in health care?

Paradies states that one of the most persistent challenges in operationalizing
health effects is the complexity involved in attributing a particular event to
racism (2016:2). If we think about it, racism can be subtle, unintentional, and
even unconscious. Subjective experiences of racism may be caused by
different forms of oppression, while objectively racist experiences may be
attributed to other forms of oppression. Moreover, some forms of systemic
or internalized racism are frequently not perceived as such and may not be
perceivable by those affected. With regard to approaches to
operationalizing racism in health research, one can distinguish between
indirect inference and direct perception. Concerning indirect inference,
Habtegiorgis and Paradies have stated that the relationship between racism
and health is inferred by eliminating other possible explanations such as
randomization or matching, and by using decomposition or causal
inference approaches; any residual or unexplained differences by ethno-
race are considered to be due to racism (2013). An indirect approach to
studying racism is, generally, the only available option when racism is not
perceivable or expressible by individuals or when racism cannot be readily
or comprehensively measured – as is the case for some forms of systemic
and internalized racisms (Paradies, 2016:3). Direct approaches that involve
the self-reporting of internalized, interpersonal, or systemic racism as an
endangerment are the ones most regularly utilized in evaluating health
impacts. Although the self-reporting of racism is influenced by a range of

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psychological and sociodemographic factors, in no sense is this kind of
racism experienced or perceived; on the other hand, however, it is neither
imagined, fabricated, nor illusionary (Paradies, 2016:3).

There are several factors to consider in the understanding, attribution, and

reporting of racism, and Paradies highlights three of them: “overestimation
due to system blame, external attribution, or aspects of identity or social
context that may lead to hypervigilance or hypersensitivity;
underestimation due to internalized racism, internal attribution, or aspects
of identity or social position, including social norms and pressures, that
may preclude recognition or conscious awareness of racism; and cognitive
or affective and methodological factors such as domain priming or social
desirability bias that can either increase or decrease the perception,
attribution, and reporting of racism” (2016:3).

Differences between indirect and direct studies of

racism in health care systems

We can agree that most of the effects racism has on health are exercised
through institutional mechanisms, which makes them difficult to measure
in epidemiological studies. Berard says there is a noteworthy conceptual
debate about the nature of systemic racism, including the role of
individuals, and whether nonhuman actors such as organizations can
perpetrate anything in and of themselves (2008:741-742). For example,
residential racial segregation, well known in American history, the physical
separation of ethno-races in different residential areas, is an obvious
example of such institutional mechanisms at work.

Kramer and Hogue believe that residential segregation adversely affects

health in multiple ways, resulting in higher rates of mortality, as well as
disparities in certain chronic and infectious diseases (2009:184-188). But if
we think about it in a broader context, it can also serve to limit access to
education, employment, and participation in socio-political processes.
Segregation results in unhealthy physical and social environments for
minority ethno-racial groups either through poor quality or high cost of
nutritious foods, a lack of appropriate recreational facilities, exposure to
toxic environmental substances, increased levels of crime and more retail
outlets for alcohol and tobacco (Paradies, 2016:6). Health care service is also
of poorer quality in segregated areas, with segregation contributing to racial
disparities in preventive, screening, diagnostic, treatment, and
rehabilitation services.

Regarding indirect racism, and research of it, in the last couple of years
there has been a growing concern about the impact of racial discrimination
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and it has resulted in many reviews and findings. For example, mental
health or chronic illnesses like HIV diagnoses have been the focus of many
reviews, as well as, in some cases, specific population groups such as Asian
Americans, Latino Americans and Black Americans, Aboriginal and
Indigenous people. Many reviews have found that racism is significantly
related to poorer health, most significantly mental health, but also, to a
lesser extent, physical ill-health (Paradies, 2016:7). Poor mental health is
about twice as strongly related to racism as physical ill-health (Paradies,
2016:7). With regard to mental health, racism most often leads to depression
and anxiety. As for physical health, current evidence indicates that racism
is not associated with blood pressure or hypertension, but rather with
weight gain and obesity (Paradies, 2016).

Measurement of healthcare provider racism

Although considered a key factor in perpetuating racial inequalities in
healthcare, comparatively little is known about the degree of interpersonal
racism perpetrated by healthcare providers; moreover, there is no
consensus on how best to measure such racism. Paradies, Troung and Priest
(2013) have, in their research paper “A Systematic Review of the Extant and
Measurement of Healthcare Provider Racism,” reviewed evidence from all
around the world, spanning from 1995 to 2012, concerning racism among
healthcare providers. They have compared existing measurement
approaches to the emerging risk practice, while focusing on interpersonal
racism. What we might find interesting is that they were only able to find
research which relates almost exclusively to the United States of America,
and some European countries like Denmark and the United Kingdom,
while they were unsuccessful in finding research papers regarding
healthcare provider racism in Canada or Australia. However, later in the
paper, we will present findings for Canada and Australia from other
authors.

The existence of racial variations in medical treatment, health service

utilization, and patient-provider intercommunication is supported by a
wide group of researchers from around the world. Although a study on
healthcare provider racism was first conducted over 30 years ago, it was not
until the publication of the report “Unequal Treatment” that racism was
recognized as a key driver of racial disparities in healthcare (Paradies and
others, 2014: 364). Focusing on interpersonal racism rather than internalized
or institutional racism, Paradies, Troung, and Priest (2013) have reviewed
worldwide evidence concerning racism among health care providers,
comparing existing approaches of analysis to the best new practices. Their
database consists of studies published between 1995 and 2012, and as the
subject of their research, they focus on health care providers such as

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physicians, nurses, social workers, health assistants, etc. The authors have
managed to find a total of 37 studies published between 1995 and 2012 that
meet the inclusion criteria.

It is necessary to emphasize that direct measurements of racism happened

when the subject in question was asked about it specifically, while indirect
measures require inference from congregated data. In their research, self-
completed surveys were the most commonly utilized direct measurement
approach. Some authors have assessed beliefs about patient abilities and
personality characteristics by way of physicians rating a series of semantic
differentials: intelligent – unintelligent; self-controlled – lacking self-
control; pleasant – unpleasant; educated – uneducated; responsible –
irresponsible (Paradies and others, 2013:366). Providers rated patients in
terms of how likely they were to lack social support; exaggerate discomfort;
fail to comply with medical advice; abuse drugs, including alcohol; desire a
physically active lifestyle; participate in cardiac rehabilitation; try to
manipulate physicians; initiate a malpractice suit; have major responsibility
for the care of a family members; and have significant career demands or
responsibilities (Paradies and others, 2013:366).

Vignettes are indirect measures that infer bias in diagnosis, recommended

treatment or patient characteristics, practices or behaviors, from differential
response to hypothetical situations that are identical except for the race or
ethnicity of the patients involved (Paradies and others, 2013:381). Vignettes
are primarily based on brief written scenarios but can also include more
detailed approaches, such as medical chart abstraction and audio-visual
material. For example, some authors have used audio-visual clips of
virtually generated characters along with vignettes to examine the influence
of contextual information such as sex and race on pain-related decisions
among nurses (Paradies and others, 2013:381).

Health care providers’ perception of race

The influence of nonclinical features on the provider’s perception of racial
or ethnic minority patients, might also have consequences on the health care
received by patients. Physician recommendations and referrals have been
shown to contribute to racial inequalities in referrals for kidney
transplantation and subjects of some cardiovascular procedures (Shavers
and Shavers, 2006:392). An example of how health care providers can
intentionally or unintentionally contribute to racism is their potential bias
against racial minorities and scepticism in interactions with minority
patients (Shavers and Shavers, 2006:392-393). Almost 20% of Asians, 19% of
Hispanics and 14% of African American respondents to the Commonwealth
Fund 2001 Healthcare Quality Survey reported being treated with

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disrespect or being looked down upon during a patient-provider encounter
(Shavers and Shavers, 2006: 393). In another report, 63% of the 76
participants in a cross-sectional survey indicated that they had experienced
discrimination in their interactions with their healthcare provider because
of their race or skin-color; 29% of African Americans and more than 10% of
Latino/Hispanic, Filipino and Korean people reported that they had
experienced discrimination when seeking or obtaining healthcare due to
their race and/or ethnicity (Shavers and Shavers, 2006:393).

Systemic racism in the American public health system

The United States of America are a multi-ethnic society that is becoming
more diverse every year. The 2000 U.S. Census already indicated that 34.6
million Americans identified as Black or African American, 10.2 million
people as Asian or Asian-American, and 35.3 million people as Hispanic or
Latino (Brondolo, Gallo and Myers, 2009:1). By 2050, demographers
estimate that 14.6% of Americans are going to be Black, 8% Asian, and
almost one in four (24.4%) Latino or Latina (Brondolo, Gallo and Myers,
2009:1). Looking at the present situation, immigrants and their descendants
across all ethnic groups will likely become the most numerous populations
in the United States of America, increasing the heterogeneity of the U.S.
population both across and within ethnic groups.

Decades of witnessing police brutality towards African Americans,

segregation in public schools, discrimination in the workplace and much
more, indicate the presence of racism in American society even nowadays.
Moreover, many researchers have found that (the) public health (system)
involves systemic racism and has negative effects and outcomes on the
physical and mental health of all racial or ethnic groups, especially
Americans of color. The systemic racism theory is firmly grounded in race-
critical literature which first appeared during the 1960s black civil rights
movement and which argued that racism involves a proclamation of
decisions and policies by which a dominant race subordinates a racial group
(Feagin and Bennefield, 2013:7). Feagin has pointed out that racism theory
within the American society has five dimensions: 1. dominant racial
hierarchy; 2. comprehensive white racial framing; 3. individual and
collective discrimination; 4. social reproduction of racial-material
inequalities; and 5. racist institutions integral to white domination of
Americans of color (2010).

A lot of research claims negative health outcomes are not equally common
among various ethnic groups. For example, rates of hypertension and
related complications are significantly higher in African Americans than in
non-Hispanic Whites or Asians; and even within broad groupings, there is

~ 36 ~
substantial heterogeneity in health outcomes (Brondolo, Gallo and Myers,
2009:2). Among Latino(a)s, Puerto Ricans demonstrate particularly poor
health – for example, relatively high rates of premature mortality, whereas
Cubans show better health when compared to other Latino(a) subgroups
(Brondolo, Gallo and Myers, 2009).

Racial treatments today

Feagin and Bennfield have pointed out that numerous reports demonstrate
that Americans of color continue to suffer from greater health problems
than their white counterparts – African-American women are more likely
to die of breast cancer than women of any other racial or ethnic group;
American Indians are nearly three times as likely to be diagnosed with
diabetes as White Americans; 82% of pediatric AIDS cases consisted of
African-American and Latino children (2014:12). These kinds of social
inequalities are nothing less than health outcomes of systemic racism's
pathways of negative impact. Many public health experts have found
obstacles for black people and low-income people in getting kidney
transplants, and that black patients are less likely to receive transplants than
whites; the reasons suggested by one group of experts include a physician’s
subconscious bias and financial disincentives (Feagin and Bennfield,
2014:10).

Moreover, a lot of analyses have found that for decades, African Americans
have regularly been misdiagnosed by mostly white mental health
professionals. Back in the 1960s, black men were seen by white doctors as
anti-establishment protestors, and then commonly diagnosed as
“schizophrenic” or otherwise mentally ill; moreover, African Americans in
some areas are even today at a greater risk of being recruited into health
care research without giving their consent than white people, because black
people are more likely to receive their health care from emergency rooms
(Feagin and Bennefield, 2014:10).

Distribution of primary care physicians in the United

States
Racism within the health system is not only evident in the form of
producing poor medical service to members of a racial or ethnic minority
group, but it's also evident in the availability of life-saving medicines and
in the workforce, where, for example, doctors who are African-American
have lower representation in certain medical specialties, as well as the fact
that they have a much lower chance of getting a job in urban hospitals or
clinics where white people are a majority. Primary care physicians are the

~ 37 ~
first stop for every patient in case of illness or health problems. However,
in recent years, there has been a growing number of African American
physicians who are staying in primary care without getting specialization
in other fields of public health service, and mostly, their place of
employment is often in more rural areas – smaller cities or villages.

Some authors have researched this subject and compared representations

of different ethnic and racial groups within individual medical (public
health) specialization or geographical areas. The geographic distribution of
the health care workforce is a long-term problem in many countries. The
long-time existence of U.S. communities without satisfactory physician
services is an ongoing challenge to medical and public health systems in the
United States. Racial and ethnic minority physicians are more likely to
practice primary care and serve in underserved communities. Some
research implies that medically underrepresented minority physicians are
important for the delivery of primary care, provide care to indigent and
minority populations, and improve access to health care services in
underserved communities (Xierali and Nivet, 2018: 1-2). The racial and
ethnic diversity of the U.S. population is increasing constantly, but the
physician workforce is expanding at a much slower rate. Reports of a
general lack of diversity in several medical and surgical specialties, such as
radiology, oncology, emergency medicine, orthopedic surgery, obstetrics
and gynecology, and ophthalmology document the continuing lack of
diversity in certain specialties (Xierali and Nivet, 2018:2).

Xierali and Nivet conducted the cohort study. The study cohort are primary
care physicians who graduated from medical school in or after 1980. They
excluded international medical graduates in this study, as U.S. medical
schools’ diversity efforts are mostly relevant for U.S. medical graduates;
moreover, there is a lack of race or ethnicity data for a solid proportion of
international medical graduates in their data sources. The term primary
care physician refers to physicians whose self-declared primary care
specialties are in family medicine, general practice, general internal
medicine, and general pediatrics (Xierali and Nivet, 2018:3). In their study,
they examined the differences in the racial and ethnic diversity of primary
care physicians from a national perspective and studied the correlation
between a physician’s race or ethnicity and their geographic distribution.
The other goal of their research was to portray the regional distribution of
areas most affected by the presence of primary care physicians who were
from backgrounds underrepresented in medicine.

Figure 1. Racial-ethnic composition of primary care physicians in the

study cohort. Source: Author according to Xierali and Nivet (2018) The
Racial and Ethnic Composition and Distribution of Primary Care
Physicians

~ 38 ~
 Asian % Black % Hispanic % White %
75.9
72.6 72.5
68.4

15.6
11.3 11.2
7.5 5.8 5.7 7.8 5.6 7.3 6.8 6.8 5.9

Family Physicians and General Internists Pediatricians (31,056) Primary Care Physicians
General Practitioners (51,974) (147,815)
(64, 785)

Figure 2. Variations in practice location by primary care physician race

ethnicity and specialty: rural areas.
Source: Author according to Xierali and Nivet (2018) The Racial and
Ethnic Composition and Distribution of Primary Care Physicians

40 35.1
35
30 27.5
24.4
25 20
20 16.5
15 11.9
9.9 9.3 10.4
8.7 7.7
10 6.5 6.3 6.5 6.6
4.9 4.3 3.8
2.7 2.5
5
0
Family Physicians General Internists Pediatricians % Primary Care
and General % Physicians %
Practitioners %

Asian Black Native Hispanic White

Figure 3. Variations in practice location by a primary care physician’s

race, ethnicity and specialty: Percent in Primary Care Health
Professional Shortage Areas.
Source: Author according to Xierali and Nivet (2018) The Racial and
Ethnic Composition and Distribution of Primary Care Physicians

~ 39 ~
 50
44.3
45
40 38
34.5
35 32.8 32.4
30.228.9 29.4 29.4
30 27.3
24.7 25.8 24.4
25 20.9 19.8
20 17 16 16.1
15.6
15
10
5
0
Family Physicians and General Internists % Pediatricians % Primary Care Physicians
General Practitioners % %

Asian Black Native Hispanic White

There were 147,815 primary care physicians in the study cohort. In the
cohort, 6.8% (or 10,064) were Black, 5.9% (or 8,697) Hispanic, 0.7% (or (1,014)
Asian, 72.5% (107,222) White, 2.9% (or 4,314) with other or unknown
race/ethnicity (see Figure 1). Race and ethnicity data of 97.2% of the
physicians were based on self-reported data sources and 0.5% were based
on secondary, not self-reported data sources (Xierali and Nivet, 2018).

Additionally, there is a significant distinction in geographic distribution

across primary care specialties with family physicians and general
practitioners overall having higher proportion practicing in primary care
health professional shortage areas (HPSA), medically underserved areas
(MUA), and rural areas in the study cohort (see Figures 2. and 3.). Among
primary care physicians, visible racial and ethnic differences exist in how
they spread geographically. In this regard, Black, Native American, and
Hispanic groups have a higher number of practices in areas where there is
not a sufficient number of primary health care professionals. Within each
primary care specialty, significant differences by race and ethnicity also
exist in the spatial context (Xierali and Nivet, 2018:3). Black people, Native
Americans, and Hispanic groups have higher proportions practicing in
HPSA and MUA than their white peers in all three primary care specialties;
Native American primary care physicians have the highest proportion
practicing in rural areas, whereas white primary care physicians have
higher proportions practicing in rural areas compared to Black or Hispanic
primary care physicians (Xierali and Nivet, 2018:3). Furthermore, there is a
high percentage of Native American primary care physicians in all three
underserved areas. The Asian primary care physicians also have a solid

~ 40 ~
number practicing in these areas, but their percentage in these areas is much
smaller compared to any other racial or ethnic group.

Impact of racism on indigenous people’s health

Indigenous people face systemic racism and prejudice in the Canadian
health care system. The health care system is set up to ignore Canada’s
colonial history, during which its Indigenous people. especially women,
greatly suffered. Systemic racism in health care is not unique to Canada. It
is also present in other countries. In New Zealand and Australia, for
example, Indigenous nationalities are unlikely to get timely access to
coronary angiography or revascularization following acute myocardial
infarction in spite of high rates of cardiovascular disease (Boyer, 2017:1408).
Boyer says that in Canada, Indigenous people carry the intergenerational
trauma of the residential school system and its myriad tentacles of physical
and sexual abuse; and that such policies are rooted in racism and colonial
perspectives of superiority and wardship beliefs (2017:1409). Even today, a
firm power asymmetry still exists between non-Indigenous health care
providers and Indigenous communities, which underpins many of their
unacceptable experiences in the health care system.

However, it is important to emphasize that Aboriginal women in Canada

suffer the most and succumb to illnesses more often than other social
groups. For example, they have a lower life expectancy, elevated morbidity
rates, and elevated suicide rates in comparison to non-Aboriginal women,
mostly white women. Bourassa and others have said that epidemiologists
suggest that many of these chronic health conditions are a result of the
forced acculturation imposed on Aboriginal peoples; and yet, for
Aboriginal women, low income, low social status, and exposure to violence
also contribute to poor health (2004:23). Also, conceptual distinctions
between definitions of ethnicity and race in population health research
suggest that race is used to describe natural units or populations that share
distinct biological characteristics; whereas ethnic groups are seen as being
culturally distinct (Bourassa and others, 2004:23). In fact, racism is a stressor
that has real and serious negative health effects on individuals, in this case,
on Aboriginal women. Sexism, racism, and colonialism are dynamic
processes, measurable determinants of health; they began historically and
continue to cumulatively and negatively impact the health status of
Aboriginal women (Bourassa and others, 2004).

Furthermore, significant gaps exist between material, social, and health

outcomes for Aboriginal men and women. Racist underpinnings of
colonialism have also produced gaps between Aboriginal women. For
example, Métis women in Saskatchewan are more likely to be employed

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than status Indian women but less likely to be employed than non-
Aboriginal women (Bourassa and others, 2004:24). Therefore, it is evident
that even cultural identity has implications for the status that women have
in the world and this has also an impact on their health. Additionally,
Aboriginal women acknowledged that many factors shaped their health
and well-being including poverty, housing, violence, and addictive
behaviors. However, cultural identity served as a potential anchor to help
them deal with these issues and promote health (Bourassa and others,
2004:25). It is good to stress that they have made recommendations for
health practices to introduce more holistic solutions that include more
traditional cultural practices and take into account their health and
wellbeing more respectfully.

Detailed research among experts of the post-contact history of indigenous

peoples in Canada demonstrates that direct practices of genocide have
transformed into legislated control of Aboriginal identity and colonization-
based economic, social and political disadvantage that disproportionately
affects Aboriginal women (Bourassa and others, 2004). The government's
definition of who can be called Indian, who cannot and who must exist in
liminal spaces where they are outsiders both on and off reserve lands has
implications for citizenship, but it also has implications for access to health
services and ability to maintain health and well-being (Bourassa and others,
2004:27). With this knowledge, data must be re-examined in light of how
colonization and postcolonial processes have conferred risks to the health
of Aboriginal women, and barriers to accessing quality health care, with
special focus on the fact that Aboriginal women are excessively vulnerable
to cerebrovascular disease, coronary heart disease, diabetes, suicide cancer,
depression, substance use, HIV or AIDS, and violence abuse (Bourassa and
others, 2004:27).

Health and (in)equity among Canadian Aboriginal

people
In the Canadian context, the consistent growth of Aboriginal health and
social inequity signals that the Canadian (political) society is in a public
health policy crisis; and current policy reflects a historic relationship
between Aboriginal people and Canada that neglects the up-to-date health
needs of Canada’s Aboriginal peoples (Richmond and Cook, 2016). Even
though Canada is perceived as a country with a universal health care
system where every person has affordable health care insurance,
unfortunately, there is a distinct absence of Canadian public policy
supporting the health of Aboriginal peoples and well-being at the national
and provincial levels. Even today, the only active national-level legislation
specific to the First Nations people in Canada remains the Indian Act of

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1876, which gave the responsibility of health and health care for First
Nations to the federal government, while for the general population, health
was primarily a provincial responsibility (Richmond and Cook, 2016:2).

At the very beginning, the Indian Act was generated and implemented
under the presumption that the Aboriginal population was inferior,
unequal, and uncivilized. Canada’s Aboriginal population is growing faster
than the general population, having increased by 20.1% from 2006 to 2011.
At the same time, the non-Aboriginal population growth has been 5.2%
(Richmond and Cook, 2016: 4). Why is that happening? Richmond and
Cook found out in their research that the fertility rate is higher is higher
among Aboriginal women than other Canadian women, mostly white ones.
The First Nations women are having babies at a significantly younger age;
over half of the First Nations women who gave birth in 1999 were less than
25 years old; and secondly, while life expectancy is increasing across all
Aboriginal groups, it is still lower than the non-Aboriginal population (68.9
for Aboriginal males and 76.6 for Aboriginal women versus 78 among non-
Aboriginal males and 81 for non-Aboriginal women) (2016:4).

The overall leading causes of Aboriginal mortality are injury and poisoning,
circulatory disease, cancer, and respiratory disease; chronic diseases also
disproportionately affect Aboriginal populations in Canada, the most
significant one of which is diabetes (Richmond and Cook, 2016:5) In terms
of morbidity, Aboriginal people also experience an excessive burden of
infectious disease, including pertussis, chlamydia, hepatitis A, and
tuberculosis; HIV/AIDS diagnoses in the Aboriginal population are also on
the rise, and in 2011, Aboriginal peoples accounted for 12.2% of new HIV
infections and 18.8% of reported AIDS cases (Richmond and Cook, 2016:5).

According to the Aboriginal Peoples Survey (APS), only 13% of the overall
Aboriginal population described their health status to be either “fair” or
“poor” whereas 26% indicated that they considered their health status to be
“excellent” (Adelson, 2005: 53). These figures are significant, and even more
so in contrast to the overall percentage of people with disability (30%) or
people who saw either a general practitioner (67%) or health-care
professional (73%) (Adelson, 2005:53). What is perhaps even more shocking
is that 23.1% of those living off-reserve rated their health as either fair or
poor and in the same population 60% reported at least one chronic
condition such as arthritis, high blood pressure or diabetes, while 16.2%
reported a long-term activity restriction, which is more than 1.6 times
higher than non-Aboriginal population; moreover, 13.2% of those living off-
reserve had experienced a major depressive episode in the year before the
survey (Adelson, 2005:52-53).

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The health and social inequities suffered by Aboriginal Canada are rooted
radically in their historical position within the Canadian social system. In
spite of treaty and other Aboriginal rights preserved in the Canadian
Constitution, including access to health care, the present Aboriginal policy
endures, characterized by jurisdictional uncertainty, inasmuch as it lacks
clarity about both the federal and provincial government’s level of health
service delivery and financial responsibilities to the First Nations and Inuit
communities (Richmond and Cook, 2016:6). Furthermore, Richmond and
Cook have pointed one very crucial fact about the current situation, saying:

„Aboriginal health policy also demonstrates widespread neglect, and a

distinctly lacking political will to improve access to health and health care.
For example, the Auditor Generals’ Report on Access to Health Services in
Remote Communities identified substantial concerns about the quality of
care in remote First Nation communities, citing a number of critical issues
that compromise both provision and management of health care including:
the inability or unwillingness of government to ensure the competency of
service providers; low perceived safety of health care facilities, untimely
record keeping with respect to non-insured health benefits, and poor
community consultation“ (2016:6).

Therefore, it can be concurred that the combination of non-effective

coordination of health care services, difficult access to quality health care,
and significant geographic variation of communities have reduced the
ability of the First Nations, as well as Inuit people, to access the basic human
right that is health care.

Suicide and chronic illness among Aboriginal

population
Suicide is the most distinct indicator of the cruelty of social disruption in
Aboriginal Canada and the rates are tellingly high by any standard.
Suicides are the result of a toxic mix of poverty, powerlessness, depression,
bad living conditions, and so on. The strongest risk factors for suicide
attempts are male gender, having a friend who had attempted suicide, the
experience of physical abuse, a history of solvent abuse, and having a parent
with an alcohol or drug problem (Adelson, 2005: 56). And one of the reasons
why this is happening in such a high percentage among Aboriginal people
in Canada is the lack of effective and proactive public health care
administration. Adelson mentions the limitations on an individual’s
mobility either from or to a remote community, inadequate family and child
services that are replete with jurisdictional disputes between prevention
and protection services, and the absence of appropriate counseling
(2005:56).

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In the last decade, the proportion of Canada’s total HIV and AIDS cases
contracted by Aboriginal people has risen sharply from 1.0% in 1990 to 7.2%
in 2001 (Adelson, 2005: 57). Like many other health issues among
Aboriginal people in Canada, HIV and AIDS are also a result of poverty,
sexual and domestic abuse, drug abuse, unstable access to health care
services, and so on. Furthermore, many studies have found that when
Aboriginal people test positive for HIV infection, they often do not access
the available services; as a consequence of multiple stigmas associated with
HIV and AIDS, both within the Aboriginal and non-Aboriginal
communities, most Aboriginal people living with HIV or AIDS prefer to
remain invisible, silent and anonymous (Adelson, 2005:57). What is even
more concerning is that the majority of Aboriginal people, both men, and
women, in most cases, will not seek out care, treatment or support from
their families or friends upon HIV diagnosis.

Conclusion
The study of racism and health has gained traction significantly in the last
couple of years, what with the rise of socially aware young politicians and
activists across the world, and it is becoming one of the key areas of study
in public health. Even though many studies have proved that racism acts as
a negative determinant of health and well-being, and is a contributor to
racial disparities in healthcare, the public health infrastructure with long-
term racial framing has not changed yet. This paper has provided a
comprehensive literature and data overview, emphasizing the importance
of condemning racism within current health care systems that are being
disproportionality equitable to different populations. Racism in health care
and public health institutions is systemic, and it has been present for
decades. Generations of white privileged systems and white-imposed
racism has completely reconstructed the way health care institutions
function and provide health services to people. Of course, white-imposed
racism contributes not only to racial inequalities in health but also in
employment, education, political representation, and other aspects of
everyday life.

This paper has put the focus on systemic racism in health systems and
highlighted both the racial character of and the impact of health care
institutions and health practitioners on health inequalities. Inequalities in
health care are produced by the direct and indirect discriminatory
behaviours of dominantly white men, and women in a much lesser
percentage, who operate out of racial framing, which has produced
institutionalized health care inequalities for racial and ethnic minorities
such as African Americans in the United States and Indigenous people in

~ 45 ~
Canada. The initial hypothesis of this paper was that people of color (e.g.
African Americans) and ethnic minorities (e.g. Indigenous people) are more
likely to get unsatisfactory or inadequate health service and to suffer in a
higher percentage of chronic illnesses than the white population.
Descriptive research and data analysis have shown that racism has negative
impacts and outcomes on people's health, even though it is not something
that is often recognized in public discourse when it comes to the topic of
the quality of health care system and services.

~ 46 ~
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Utjecaji rasne diskriminacije na
zdravlje ljudi i sustave javnog zdravlja
u multikulturnim društvima
Dino Galinović

Sažetak

Sustavni rasizam predstavlja veliku prijetnju u multikulturalnim društvima

u kojima rasna pristranost i dalje igra značajnu ulogu u kreiranju
javnih politika i organiziranju javnih sustava poput zdravstvene
zaštite. Ovaj rad tvrdi da rasizam i rasni framing izravno utječu na
negativne ishode zdravlja ljudi, osobito među manjinskim
skupinama poput Afroamerikanaca u Sjedinjenim Američkim
Državama i Aboridžina u Kanadi. Navedene će skupine ljudi vrlo
vjerovatno dobiti nezadovoljavajuće ili neadekvatne zdravstvene
usluge i u većem će postotku bolovati od kroničnih bolesti, poput
kardiovaskularnih problema, dijabetesa, problema mentalnog
zdravlja, zlouporabe lijekova i predoziranja ili HIV infekcije u
odnosu na bijelu populaciju. Nadalje, rasizam ima izravan utjecaj na
nejednakosti u zdravstvenim sustavima u vidu nedostatka različitih
pružatelja zdravstvenih usluga u urbaniziranijim sredinama ili
nepristupačnog liječenja zbog geografskih udaljenosti ili kulturnih
razlika. Kroz ovaj rad uzeli smo u obzir koncept rase i etničke
pripadnosti, desetljeća rasnog framinga u društvu Sjedinjenih
Država i Kanade, pokazali negativne utjecaje na zdravlje unutar
različitih etničkih grupa te uspješno naglasili potrebu strukturnih
promjena zdravstvenih sustava.

Ključne riječi
rasizam, rasni framing, zdravstveni sustavi, Sjedinjene Države, Kanada

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