Driving Racial Equity as a Psychiatrist

Nora Dennis, M.D., M.S.P.H.

December 2021

As psychiatrists, we are not only physicians caring for individual patients, but also healthcare leaders tasked with setting the tone and agenda for critical thinking about the ways in which the health system functions. There is rising awareness of significant, pervasive, and persistent disparities between sociodemographic groups in both the processes of receiving treatment for psychiatric disorders, as well as the outcomes for individuals in these groups. Among the groups for whom disparities constitute a critical issue, racial groups are a central point of focus. Our investigations into the origins of racial health disparities and action to alleviate them must be underpinned by a valid understanding of race itself.

Race is a social construct without biological taxonomic validity. There is far more genetic variation within continental racial groups than between them.[i] This is particularly true for individuals of sub-Saharan African descent- within this group there is as much genetic diversity as that found in the rest of humanity.[ii] For example, if race were genetic, then the Basque people of Spain, who are genetically distinct from other Europeans, should be a separate racial group.[iii] While certain alleles may track with continental racial groups, these are less consequential to and explanatory for health outcomes than social factors such as racism and poverty. One example in psychiatry that I have used in teaching residents this topic was a study on weight gain with antipsychotics – self-identified race was a much stronger predictor of weight gain than race determined by allelic markers of African descent.[iv] The logical conclusion is that race is not a genetic reality so much as a social determinant of health. As such, as physicians we are obligated to be specific and focused on our language choices to avoid reinforcing the myth of biological race.[v]

Race as a construct originated concomitantly with colonialism – its purpose was to justify enslavement and genocide. The “science” of race sought to provide biological explanation for observed differences in phenotype, and then to extrapolate those observed differences into a justification for exploitative economic relationships.[vi]

The relationship between the persistence of this categorization schema and our own practice of medicine might be unclear. Ultimately, clinical practices that are not accessible to all groups and do not have functional awareness of the context of racism and its impacts upon them may unintentionally reinforce segregation and inequity.[vii]

What then are we to make of race, which seems to be so tightly correlated with a large array of outcomes but has no clear biological underpinning? Race functions as a proxy measure for exposure to racism. While this definition may seem tautological, ultimately it is more accurate to view racism as the progenitor of race rather than vice versa. Our interpretation of data on race then requires constant evaluation and clarification of the meaning of the category itself. Quantitative exploration of racial disparities is more accurately viewed as an exploration of the impacts of racism – both systemic and interpersonal.

Our own nation, far from being well past its racist origins, is only in the early stages of reckoning. Residential and social segregation were more extreme and prolonged in the United States than anywhere else in the world and occurred in the context of simultaneous genocide of Native Americans.

The extent and duration of this intergenerational trauma continue to impact the health of minoritized populations and to undermine confidence in the healthcare system. And indeed, it is not unreasonable to have limited confidence in a healthcare system that produces such disparate outcomes. We can see clearly that Intersectionality is key to understanding all that we see in the data. The theory of intersectionality holds that there is an additive burden that stems from an individual’s inclusion in multiple marginalized groups, and that the whole in terms of disparate impact may well be greater than the sum of its parts.  Sociodemographic factors compound to create adverse health outcomes, such that race cannot be separated from all that it connotes in this society in terms of poverty, language barriers, or educational barriers.[viii]

Ultimately, most healthcare systems and practices have not been designed with minoritized communities in mind.  As we collectively approach the work of eliminating racial health disparities, the perspective that all patients have the same right to consideration of their needs and preferences is foundational. Systemic racism and the attendant segregation silence the perspectives of members in minoritized groups. However, our responsibility is to use our clinical skills to understand their experiences in seeking and receiving healthcare and to create systems that protect their right to access safe, responsive, high-quality care. Each psychiatrist has different resources at their disposal – some might start with simply observing the contrast between the demographics of their community versus that of their clinical population. Others might be in a position that allows quality improvement at a health system level to quantify and intervene on health disparities. Wherever we find ourselves, part of our duty as physicians is to consciously undo the harms of systemic racism on health outcomes through actions large and small.