Abstract
Despite growing attention to racism in health care, most interventions fail to address the underlying structural policies and practices that perpetuate or exacerbate harm for communities of color. Like canaries in a coal mine, the experience of these communities often presages the experience of other communities who experience relative social disadvantage — communities who are poor, in rural areas, etc. — and eventually, can affect the majority. By fixing the system for those who are marginalized, we can create a better system for everyone. This article outlines an alternative systemic approach to transforming health care through a series of shifts that can help us create a more level playing field for everyone, a strategy that can yield deep, more powerful change even in the current legal and political context. By understanding and owning our system’s policies, practices, and systems that may be causing delay or harm to marginalized communities, by protecting space for meaningful change created in partnership with communities that are affected, and by taking an asset-based approach to building the collective leadership we need to change the system, we can build a health care system that removes barrier to participation for everyone. We offer a “Better Ancestors for System Change” framework, which integrates a seven generational Indigenous view, historical reclamation (Sankofa), and systems theory (Two Loop Model) to guide this transformation. By acting with courage, integrity, and humility, we have the opportunity to use this time to advance a fair, trustworthy, and healing health care system for generations to come.
Over the last 5 years, there has been a deepening movement to address racism in healthcare, without a clear field-level analysis and agreement about why the problems exist and what we are talking about. As a result, many have sought to address these issues in a way that try to either solve structural problems with individual or interpersonal training and solutions (common to many DEI curricula, which focus largely on educating people, an important piece of the puzzle but an incomplete one) without a clear analysis or set of solutions that address the underlying structural inequities that creates an unfair playing field and generates unconscious bias.1,2Â Others have sought to address social barriers to health (work to address social needs like food and housing) at the individual level without an analysis or strategy to address why people need food and housing in the first place.
In today’s environment, words like “health equity” and “racism” are hard to talk about for fear of reprisal or controversy. Yet the problem doesn’t go away when we don’t talk about it, any more than a cancer does — and threatens our mission, the economy, and trust with the people who need to trust healthcare the most — patients, communities, and our workforce. While race may be a social construct, racism has real impacts on our racial health. David Williams, in his work on the impact of everyday discrimination on health outcomes, found that individuals who experienced discrimination four or more times per year lost up to 5 years of life expectancy.3,4 Fifteen years after the IOM Report, To Err is Human was published by the National Academies of Science, Engineering, and Medicine,5 naming equity as an aim in addressing harm, Sivashanker and Gandhi wrote that over one-third of safety events that persist today are attributable to disparities.6
In addition, communities of color might best be described as canaries in a coal mine — their experiences of harm within the healthcare system are increasingly emblematic of the experiences many other populations face. Medical bankruptcy, for example, is the leading cause of bankruptcy for all Americans. While communities of color have experienced disproportionate harm from debt collection practices and have often sought to avoid care as a result, the cost of care is now a cross-cutting threat to communities everywhere. Safety events are on the rise and the US currently remains the costliest healthcare system in the world per capita and was ranked the poorest performing among ten high-income countries ranked by the Commonwealth Fund on access, care process, administrative efficiency, equity, and health outcomes in 2024.7 Similarly, the provision of access and care works everywhere. Policies such as Medicaid, which support access for low-income, predominantly working families, reduce mortality by 21%.8
We have reached a tipping point in the public’s willingness to let the trust they feel in their doctors and nurses offset the harm they experience from the system.
A Few Definitions
Structural racism in healthcare — John A. Powell describes structural racism as: “the normalized and legitimized range of policies, practices, and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color.”9
In healthcare, this refers to normalized clinical and operational policies, practices, and algorithms that result in poorer outcomes.
Health equity: just and fair inclusion into a society in which all can participate, prosper, and reach their full potential for health and well-being, freed from unfair structural and systemic barriers in society and the healthcare system.10
Collective leadership: “A group of people working together toward a shared goal with leadership that is decentralized, distributed, inclusive, participatory, and/or shared (even across organizational hierarchy), characterized by shared responsibility, accountability, and decision-making grounded in co-design and co-implementation.”11
Shift: a significant change from one system to a different way of being and doing.
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