Recognizing the Role of Systemic Racism in Diabetes Disparities

A broad acceptance of the role systemic racism plays in social determinants of health (SDOH) needs to take hold in order to improve metabolic outcomes among minority populations in the United States, authors writing in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism argued.

The paper, which focused on Black Americans who suffer from diabetes, highlights historical events that have shaped the health care landscape today, where the risk of receiving a diabetes diagnosis is 77% higher for African Americans and 66% higher for Hispanics compared with White Americans.

As SDOH perpetuate increased rates of chronic disease incurred by minority populations, it is imperative to mitigate these disparities by addressing the root causes, the researchers argued.

“We [endocrinologists] acknowledge…that minority populations are less likely to have adequate health insurance or access to high quality health care, resulting in poorer health outcomes and health inequity. But why does this disparity exist?” the authors wrote.

Because diabetes is an exemplar health disparity disease, endocrinologists in particular are positioned “to view the contributing factors and solutions more broadly and contribute to health system, public health, and policy-level interventions to address the historical root causes embedded in our medical and social systems.”

Numerous historical events wherein Black Americans were subjected to medical experimentation against their will has led to biased beliefs among health care providers, including “that Black patients have higher pain tolerance than White patients.” Closures of medical schools devoted to Black physician education in the early 1900s resulted in “a dearth of Black medical professionals to care for African-American communities across the US and to protect the population from unethical practices,” in addition to an underrepresentation of Black medical professionals in the workforce.

Lasting imprints from these events and the eugenics movement have contributed to ongoing health care provider bias toward African American patients. Studies have found “Black patients are viewed as less intelligent, less able to adhere to treatment recommendations, and more likely to engage in risky health behaviors compared to White patients.”

These biases can lead to a host of disparities in treatment recommendations, expectations of therapy adherence, and pain management, while contributing to reduced patient-centered clinical interactions and less effective care overall, the researchers explained.

Discriminatory housing policies implemented throughout the country’s history—including those that prohibited African Americans from living in suburban neighborhoods and imposing zoning restrictions—have all contributed to resource inequities.

“The consequences of these actions resulted in racial residential segregation and inadequate investment in these neighborhoods, which were now all Black, to maintain public works, school systems, and economic development.”

The residual effects of structural and institutional racism are apparent in current-day racial residential segregations, which manifest as neighborhoods with inadequate affordable housing, open spaces, healthy food access, and increased exposure to environmental pollutants.

“These important SDOH contribute to poor health for the African Americans and other minoritized populations who live in these neighborhoods, promoting decreased physical activity and access to healthy food, consequently leading to increased rates of obesity and diabetes," the authors wrote.

Compounding these disparities, studies have shown both obesity and diabetes are risk factors for more severe cases of COVID-19—marking one reason racial/ethnic minorities are falling ill and dying from COVID-19 at disproportionate rates in the United States. Higher rates of employment in essential jobs in the service sector that require in-person work, reliance on public transportation, and other factors also contribute to higher exposure rates among these populations.

In an effort to combat these SDOH fueled by systemic racism, the researchers urged widespread implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards). The standards include:

• Collecting and maintaining accurate and reliable demographic data to monitor and evaluate disease outcomes based on race, ethnicity, sex, English proficiency, ability status, sexual orientation, and gender identity
• Training health care staff in the proper interview techniques to ascertain patients’ self-identified race, ethnicity, and preferred language for health care and their sexual orientation and gender identity, which also includes pronouns
• Prioritizing language-concordant care, which has been shown to result in significant improvement in glycemic and low-density lipoprotein cholesterol control
• Recruitment and promotion of a diverse and inclusive workforce to achieve health equity, specifically diversifying the endocrine workforce with culturally competent and bilingual physicians

Data from 2018 show that only 10.5% of endocrinologists and 12.6% of internists in the United States identify as Black/African American, American Indian/Alaska Native, Hispanic, or Native Hawaiian/Other Pacific Islander. The researchers argued increased diversity of medical and graduate school applicants, in addition to training on awareness of unconscious bias and the value of diversity within healthy systems, will “repair historical harm, increase trust, provide tools to address structural racism in health care, and ultimately advance health equity.”

To have a lasting impact on broader SDOH like economic stability and food access, the authors encouraged academic medical centers to advocate for policies directly redressing the SDOH conditions in their communities. Policy interventions should focus on compensating for the social determinant conditions under which people continue to live and on the root cause of interventions to dispel SDOH altogether.

“On behalf of people living with diabetes and other endocrine disorders, members of our specialty must become advocates for social policies that support environmental justice as necessary for the attainment of health equity,” the researchers concluded. “Through partnerships with the Government Affairs Offices at our local academic institutions and Endocrine Society Advocacy, we can support the development of legislation to address housing and food insecurity, lack of access to physical activity options, and job insecurity so that everyone can attain their highest level of health.”

Reference

Golden SH, Joseph JJ, Hill-Briggs F. Casting a health equity lens on endocrinology and diabetes. J Clin Endocrinol Metab. Published online January 18, 2021. doi:10.1210/clinem/dgaa938