Improving Health Outcomes through Disruption of the Individual, Cultural and Structural Cycle of Racism

Background: Over the past two decades, racism and its influence on health outcomes has gained interest as a preventable cause of health inequities. Persistent inequities in health outcomes for members of marginalized racial/ethnic groups coupled with empirical evidence that socioeconomic status alone does not account for health differences, supports naming racism as a driver of disparate health outcomes. Systemic racism is born from a vicious cycle of individual level prejudices, cultural racism, and structural racism. Further work is needed to identify points along this continuum to disrupt the cycle and move towards health justice. The purpose of this dissertation is to explore the cycle of systemic racism in healthcare at the individual, cultural, and structural levels. Aim 1 of the study sought to explore the current state of the evidence for individual level racism in the form of implicit bias at the provider level. Aim 2 explored the cultural influences of eugenics and public health on nursing. Aim 3 sought to measure the impact of an overt act of racism on the health of the community and its relationship to the cycle of systemic racism.
Methods: A systematic review of reviews on implicit bias in healthcare was conducted to explore what is known about individual level implicit bias at the provider level. An intersectionality framework was used to identify gaps in the evidence and to provide considerations for future research. This was followed by a historical inquiry of eugenics, nursing, and public health in the early twentieth century. Textual analysis and archival research was used to explore the cultural influences of eugenics on public health nurses in the areas of disease prevention, child and family health, and mental illness. In addition, the inquiry explored avenues in which eugenic concepts were normalized and socialized to and by nurses both at the macro level of the United States and at the micro level of Charlottesville and nursing students at the University of Virginia. Findings from this inquiry provided the social and historical context for a quasi-experimental study of the health effects of the August 11th and 12th, 2017 Unite the Right Rally on the community in which it took place. An existing dataset was used to conduct an analysis of ICD-10 codes for Emergency Department admissions for the years 2016, 2017, and 2018. A regression discontinuity model was used to compare the probabilities of visits among Black and White patients for anxiety and depression, medically unexplained symptoms, and acute alcohol related issues after a shared community violence event. A community advisory board was engaged to provide guidance and perspective from voices in Charlottesville/Albemarle County most affected by the shared community violence.
Results: Implicit biases are prevalent among healthcare providers at a rate consistent with the population in general. Research has shown that these biases affect patient /provider communication and to a lesser extent, treatment decisions. Interventions aimed at reducing implicit bias at the individual level have not demonstrated effectiveness. Historical evidence points to a conclusion that healthcare providers are greatly influenced by cultural norms. The socialization and normalization of eugenic concepts to and by public health nurses in the early twentieth century provides some insight into how this occurs. For the two week pre and two week post August 12, 2017, periods, there were significant differences in indicators for stress responses among Black, but not White, people with Charlottesville/Albemarle County zip codes for alcohol related visits and MUPS. We found no significant increase in anxiety/depression related visits in the post period for either group.
Conclusion: An awareness of the purposeful embedding of eugenic ideology in nursing education and practice provides a stimulus for active removal of its legacy. The history of Charlottesville and the University of Virginia were important factors leading up to the Unite the Right Rally. The social and historical context of Charlottesville, Virginia likely contributed to its selection as the rally site. Understanding the role of culture and structures in the cycle of systemic racism is a key element in disrupting it. Individuals both influence and are influenced by the cultural norms and structures established across time. Future research and activism aimed at disrupting the cycle of racism and its negative influence on health outcomes will require the identification and dismantling of racist structures at the institutional and policy level along with tactics to reduce prejudice at the community and individual levels.