Nurses are often revered as the cornerstone of healthcare and work with compassion and ethical principles under the oath of “doing no harm.” One of the famous pioneers of this field and an instrumental powerhouse in the care of soldiers during the Crimean War was the illustrious Florence Nightingale. Florence Nightingale’s contribution to the nursing profession became the foundation upon which our current healthcare system is built (Morris, 2022). Her initiatives and interventions for soldiers during World War I were revered, but what is rarely discussed is Nightingale's racism and her political role in the genocide of Indigenous People under British rule (Morris, 2022). Some may say that Florence Nightingale was a “product of her time.” However, she was also the product of xenophobic conservative ideology which was demonstrated in her beliefs that “disease was the responsibility of Indigenous People” and that it was necessary to impose British culture, even if it may cost lives (Morris, 2022). Florence also tightened the patriarchal chains rampant in the 1900’s, as she saw the nursing profession as “an extension of the female role in society” (Morris, 2022). Furthermore, she advocated for the foundation of nursing to be built using a system of “patient care founded on traditional women's virtues of endurance, obedience, and cleanliness” (Morris, 2022). Consequently, she facilitated creation of a system that became a breeding ground for oppressive healthcare towards patients and those residing within it.
Recognizing that racism unfairly penalizes minorities, policy statements and funding have been increasingly directed towards addressing institutional racism in medical care (Sim et al., 2021). Unfortunately, despite these measures, significant progress in combating healthcare racism has been stalled. Despite stalling, much needed attention has been brought to racial discrimination in our healthcare system and at the interpersonal level stemming from healthcare providers’ racial biases (Sim et al., 2021).
Racism is embedded into the foundation of human creation; where there are people, there will be differences. Unfortunately, even the highly regarded moral career of healthcare can’t free itself from the roots of hatred. For one to understand how a vicious and morally depraved ideology infiltrated one of the most trusted professions in the world, one must understand the ideology that precipitated this. Eugenics was founded on the belief that social problems could be solved by isolating, sterilizing, and even eliminating the physically, mentally, and morally disabled (Lagerway, 2020). Additionally, the pseudo-science of eugenics was rooted in the belief that “degeneracy” was an organic defectiveness that was hereditary (Appleman, 2021 & Lagerway, 2020). For example, higher rates of tuberculosis among immigrants and African Americans were attributed to their perceived inherent genetic inferiority, rather than considering environmental and socio-economic factors (Appleman, 2021 & Lagerway, 2020). As a result, eugenics provided scientific legitimacy to racism, and led to disability, mental illness, criminality, homosexuality, alcoholism, and syphilis all being considered signs of “degeneracy” (Appleman, 2021 & Lagerway, 2020). As absurd and ill-suited as this ideology was, it was implemented in multiple countries across time spans, resulting in habitual violence against certain groups in the healthcare system. In 1907, both Japan and Indiana legalized forced sterilization. In 1921, Canada followed with recommendations for sterilization of mentally ill persons. By the beginning of World War II forced sterilization was legal and actively being utilized in all of the Nordic countries, Switzerland, Austria, Estonia, Mexico, Canada, Japan, and 33 states in the U.S. (Lagerway, 2020). People of color were disproportionately affected by this tactic and were more likely to be sterilized than their white counterparts (Lagerway, 2020). The disproportionate targeting of minoritized groups for sterilization demonstrated the medical establishment’s beliefs about who represents the deserving and undeserving poor (Shepherd, 2021). Beliefs that have become popular amongst healthcare professionals, and highlights the danger of believing in superiority with a misguided moral compass (Shepherd, 2021). As a result, the ideas and fears that fueled the eugenics movement still remain forces within our society and healthcare system and have created structural-based harms (Klann, 2021; Simmonds, 2006).
Racism Embedded in Healthcare
Medical racism against people of color occurs within the healthcare system largely due to the massive effects of structural racism (Bronson, 2020 & Yearby et al., 2022). These negative systems are perpetuated from racial and ethnic minority populations’ inequitable access to health care systems, which persists because of structural racism in health care policy (Yearby et al., 2022). Structural racism is intertwined with healthcare policy, creating policies that promote inequitable access to insurance, specialized care, medications, and healthcare educational programs, thus resulting in unequal access to high quality healthcare (Bronson, 2020 & Yearby et al., 2022).
The severity of racial health inequities is further reflected in the COVID-19 pandemic where racism in healthcare has been a significant driving force of the disproportionately high mortality rates in minorities (Sim et al., 2021). Since November 2021, in the United States American Indian and Alaska Native, Black, and Latino people have all suffered from higher rates of hospitalizations and deaths related to COVID-19 compared with White people (Yearby et al., 2022). A horrifying statistic that demonstrates how members of racial and ethnic minority groups have long suffered from health inequities, which the COVID-19 pandemic mercilessly worsened (Centers for Disease Control & Prevention, 2021). Racial health disparities have been long standing, as evidenced by the landmark report from the Institute of Medicine (IOM) in 2003, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, that examined racism in medicine (Sim et al., 2021). The report concluded that bias, prejudice, and stereotyping contributed to inequitable care and disparate outcomes in our healthcare system. Furthermore, it included a call to action for healthcare systems to combat the racism and bias in healthcare that had previously gone unchecked; yet twenty years later we continue to see racial disparities in healthcare access and outcomes (Smedley et al., 2003).
Health disparities are created and exacerbated by systemic racism, which research has demonstrated is increasingly affected by social determinants of health such as education, employment, transportation, among other factors (Alder et al., 2016). There are a multitude of health disparities that have individually and cumulatively ravaged minority populations. Hypertension (which is higher among African Americans than Whites) was linked to discrimination, as the experience of discrimination could also cause emotional distress (Sims et al., 2012; Williams & Leavell, 2012). Furthermore, a larger study found that everyday discrimination was associated with higher diastolic blood pressure in older African Americans when compared to older Whites (Sims et al., 2012; Williams & Leavell, 2012). These findings indicate that race-based medical practices have limited benefit for Black and African American patients and cause irreparable harm (Sims et al., 2012; Williams & Leavell, 2012).
Diabetes is the seventh leading cause of death in the United States and is common amongst members of some racial and ethnic minority groups and groups with lower socioeconomic status (Hill-Briggs et al., 2020). Pain has also been associated with less favorable outcomes in minority populations despite guidelines, educational interventions, and standards aimed at optimizing pain management (Daumeyer et al., 2019). As it currently stands, the literature continues to report the undertreatment of pain, particularly among patients of color (Daumeyer et al., 2019). These negative healthcare outcomes have the potential to erode overall confidence in the healthcare system and lead to avoidance which will have devastating costs (Dovidio & Friske, 2012). These outcomes in a rich Western society with a healthcare system considered among the world’s best represent an issue of significant ethical challenge, juxtaposed against the ethical and moral behavior required to serve the public (Elias & Paradises, 2021).
The poor outcomes of medical racism will only be rectified when the healthcare community and broader society begin taking a reparative approach to damages caused. This begins with addressing explicit and implicit biases in ourselves, our coworkers, and our systems. We must take a reparative approach, acknowledging all harm, even unintentional harm, and redress the harm by taking actions that compensate and rectify the situation (Wispelwey et al., 2022). Race is entirely a socio-political construct; therefore, racism, rather than race, is more likely to be the cause of outcome inequality (Vyas et al., 2020). As a result, dismantling systemic racism must be given high priority to addressing inequities in the determinants of health (Braveman et al., 2022). This will require a multi-layered approach as no single approach will be sufficient to dismantle a system that permeates all sectors of society (Braveman et al., 2022). Addressing systemic racism will require changing systems, laws, policies, and practices in ways that will be effective, endure long-term, and affect many people, and dismantle the oppressive barricades in place (Braveman et al., 2022). The time has come to eradicate the structural racism in health care policy that perpetuates inequitable access to high-quality health care, and prevent further devastation against minority communities and the entire country (Yearby et al., 2022)
- Adler, N. E., D. M. Cutler, J. E. Fielding, S. Galea, M. M. Glymour, H. K. Koh, and D. Satcher. 2016. Addressing Social Determinants of Health and Health Disparities: A Vital Direction for Health and Health Care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC.
- Appleman, L. (2021). Hiding in plain sight: Public health, eugenics, and COVID-19. Harvard Public Health Review, 30.
- Braveman, P. A., Arkin, E., Proctor, D., Kauh, T., & Holm, N. (2022). Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling. Health affairs (Project Hope), 41(2), 171–178.
- Bronson, E. (2020, July 21). What is medical racism? YWCA Seattle | King | Snohomish.
- Centers for Disease Control and Prevention. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity [Internet]. Atlanta (GA): CDC 2021 Jul 16.
- Daumeyer, N.M., Onyeador, I., Brown, X. & Richeson, J.A. (2019). Consequences of attributing discrimination to implicit vs. explicit bias. Journal of Experimental Social Psychology, 84(103812).
- Dovidio, J.F. & Fiske, S.T. (2012). Under the radar: How unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. American Journal of Public Health, 102(5), 945-952.
- Elias, A., Paradies, Y. (2021). The Costs of Institutional Racism and its Ethical Implications for Healthcare. Journal of bioethical inquiry, 18(1), 45–58.
- Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2020). Social Determinants of Health and diabetes: A scientific review. Diabetes Care, 44(1), 258–279.
- Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US).
- Klann, M.C. (2021, April 9). Week 10: Reproductive rights. Mary C. Klann, PhD: Historian and lecturer.
- Lagerwey, M.D. (2020). Eugenics and healthy families: Interdependence and legitimation. European Journal for Nursing History and Ethics, 2.
- Morris, Gayle. “Florence Nightingale: Uncovering Her Impacts on Nursing and Colonialism.” NurseJournal, 28 Feb. 2022.
- Shepherd, S. (2021). The enemy is the knife: Native Americans, medical genocide, and the prohibition of nonconsensual sterilizations. Michigan Journal of Race and Law, 89(27). doi:10.36643/mjrl.27.1.enemy (source of quotation)
- Simmonds, J. (2006). Coercion in California: Eugenics reconstituted in welfare reform, the contracting of reproductive capacity, and terms of probation. Hastings Women’s Law Journal, 17(2), 269-294.(8), 1300–1309.
- Sims, M., Diez-Roux, A. V., Dudley, A., Gebreab, S., Wyatt, S. B., Bruce, M. A., James, S. A., Robinson, J. C., Williams, D. R., & Taylor, H. A. (2012). Perceived discrimination and hypertension among African Americans in the Jackson Heart Study. American journal of public health, 102 Suppl 2(Suppl 2), S258–S265.
- Vyas, D.A., Eisenstein, L.G. & Jones, D.S. (2020). Hidden in plain sight: reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine, 383(9), 874-882.
- Williams, D. R., & Leavell, J. (2012). The social context of cardiovascular disease: challenges and opportunities for the Jackson Heart Study. Ethnicity & disease, 22(3 Suppl 1), S1–21.
- Wispelwey, B.P., Marsh, R.H., Wilson, M., Mazimba, S., Heysell, S.K., Aisiku, I.P., Desai, A.S., Georges, C. & Morse, M.E. (2022). Leveraging clinical decision support for racial equity: A sociotechnical innovation. New England Journal of Medicine: Catalyst.
- Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US health care policy. Health Affairs, 41(2), 187–194.(8), 1300–1309.