The protests unfolding around the world against racial injustice were sparked by the death of George Floyd at the hands of Minneapolis police officers in the United States. But the injustices the crowds are fighting go far beyond the US and police brutality alone.
Marginalized communities globally are forced to confront deeply ingrained societal issues that often place them in second place, a process rooted in systemic racism and discrimination that affects every aspect of their lives.
And as the COVID-19 crisis plays out around the world, the ways in which that marginalization impacts access to good health has become all the more evident.
Black communities, Indigenous peoples, and other communities of color in many countries are being hit the hardest by the virus. And poor communities — often disproportionately made up of people of color, as a result of systemic racism and marginalization — are forced to wonder if they will have access to the same treatments and vaccines, once they are developed, as people with higher incomes or different skin color.
Intersectional marginalization impacts access to health globally in many ways, from racism in health care to financial barriers to stigma, and much more.
These inequalities, while significantly highlighted in health care through the lens of wealth and race, cut across many marginalized and underserved communities — including women and girls, LGBTQ+ communities, people with disabilities, and more — for a variety of reasons.
Marginalization and Social Determinants of Health
Foster Baah, MS-PhD dual-degree student at the University of Pennsylvania School of Nursing, is currently examining the relationship between social determinants of health and marginalization as part of his doctorate research.
Marginalization is the process of pushing something or someone into a position of lesser importance, essentially pushing them to the sidelines. The World Health Organization (WHO) outlines social determinants of health as the conditions in which people are born, grow, live, work, and age. But Baah adds that it's about more than that — it's about truly looking at an individual’s everyday life.
"I see marginalization and social determinants of health as very interlinked," Baah told Global Citizen, explaining that marginalization can be connected to someone's social position — defined by education, income, gender, sexual orientation, ethnicity, race.
The very things that categorize people as "second class" through the process of marginalization impact their access to health in a very big way.
For instance, education access is not only a social determinant of health, but it also impacts an individual’s social class. People with less education are less likely to have good employment and income — and are more likely to live in poverty.
Higher levels of education generally lead to less dangerous jobs and secure employment can provide health insurance or retirement plans.
This connection between marginalization and health manifests itself in many different ways: People living in poverty cannot afford health care; people with health conditions that are stigmatized become marginalized; when women are not seen as equal to men, their health becomes less important; when racism marginalizes people of color, their needs go unmet.
From financial barriers to stigma to gender to race — marginalization makes fully accessing good health impossible for marginalized groups.
The Physical Impact of Racism on Health
Racism in health care is certainly not a new issue, but it has made headlines more often in recent years, especially surrounding Black maternal mortality rates in the US and the UK, Indigenous health care discrimination in Canada, and — most recently — through the lens of COVID-19’s impact on Black people and communities of color worldwide.
Joe Feagin is a distinguished professor in sociology at Texas A&M University. He has done extensive research on race and gender issues in the US, including on systemic racism and US health care, and is the author of many books, such as Racist America: Roots, Current Realities, and Future Reparations.
In the context of the impact of racism on health, Feagin told a story of how he once asked the father of one of his Black students how many incidents of racism he experienced every year, to which the man responded, "Probably 250 times a year," and those were just the ones he remembered.
The man was in his 80s. Feagin points to this example to explain the impacts of racism on the health of Black people in the US.
"These 20,000 incidents over a lifetime — that’s going to do damage," Feagin told Global Citizen. "Stress alone is a killer."
Racist experiences can therefore generate illness from stress to high blood pressure to mental health issues, among many others.
A study published in the journal Psychoneuroendocrinology in 2019 actually revealed that racism has a toxic effect on the human body.
The team of scientists reported that racist experiences seemed to increase inflammation in Black individuals who were part of the study — increasing their risk of disease.
Inflammation is a reaction in the immune system — generally it’s a way in which the human body protects against a threat.
But if a person feels under threat for a long time, they can end up with chronic inflammation.
"If those genes remain active for an extended period of time, that can promote heart attacks, neurodegenerative diseases, and metastatic cancer," the study's co-author Steve Cole said.
Cole’s past research also noted increased inflammatory responses in people who were marginalized.
On top of it all, Feagin highlights that the health care system has an inherently racist design. In short: It is designed to fail people who are not white.
The System Designed to Fail
Dr. Ala Stanford speaks with volunteers ahead of the opening of a COVID-19 test location in Philadelphia, Pa. Stanford and other doctors formed the Black Doctors COVID-19 Consortium to help address heath disparities in the African American community.
Health care systems, as they stand in countries like the US, were set up for white people and the kinds of diseases that mostly impact middle-income white people, according to Feagin.
For example, responding to heart attacks — something that greatly affects white men — has been at the forefront of medical research for years, whereas research for sickle cell anemia — a disease that is particularily common among the Black community worldwide — has only come on the radar of medical research in the last 15 or 20 years, Feagin said.
There is a lack of representation in health care from a clinical research perspective, too. Not only does the industry prioritize research for white health conditions, but they often leave Black people out when testing for them.
The Black Women’s Health Imperative (BWHI) is a non-profit organization dedicated to improving the health and wellness of Black women and girls in the US. The organization advocates for better policy and works to address the most pressing health issues that affect Black women and girls through evidence-based strategies.
Some of the initiatives spurred by the BWHI involve working to get a larger participation of Black women into clinical trials for cancer therapies, where they are sorely underrepresented.
"If [you] don’t have minorities in the clinical trials, then you can’t even see how those drugs would actually [affect different people]," Tammy Boyd, chief policy officer of BWHI, told Global Citizen.
There are also some key health issues that impact Black women specifically.
Breast cancer, for instance, impacts Black women differently than it does white women. A Black woman’s breast tissue tends to be denser and therefore requires 3D imaging to detect cancer, rather than 2D imaging, which commonly works when detecting cancer in white women, Boyd explained.
In the US, there’s a copay (a sort of deductible that Americans can pay for medical services, with the rest being covered by insurance) available for 2D imaging — but there isn’t one for 3D imaging, Boyd said.
So not only are Black women not accurately reflected in clinical trials, but even when the option for testing is there, it comes with a potentially higher financial cost.
Boyd said it would take a multifaceted approach to address racism in US health care.
"It’s coalition, it’s also really having a seat at the table in terms of policy and changing what the policy is," she told Global Citizen.
It’s looking at the assumptions being made when health care solutions are being developed, too. Boyd gave the examples of telehealth and drive-through COVID-19 testing options — these interventions assume that everyone has access to a phone or a car.
"And so it’s really also addressing social determinants of health," Boyd said, which again means looking at the surrounding circumstances — money, power, resources.
If you are living in poverty, you’re more likely to experience inequity; if you’re experiencing inequity, you’re likely lacking in power; without money or power, your access to resources is then limited.
"The social determinants of health are mostly responsible for health inequities — the unfair and avoidable differences in health status seen within and between countries," the WHO notes.
It also comes down to shedding light on the issues through research and data.
Data on Racism in Health Care
"Everything is driven by data," Boyd said, citing BWHI’s CEO Linda Goler Blount, when discussing the need for more research regarding racism in health care.
And the data that exists is stark.
Take maternal mortality rates, for example. Black, Native American, and Alaska Native women are two to three times more likely to die from pregnancy-related causes than white women in the US, according to data from the Centers for Disease Control and Prevention.
Black people are more than four times more likely to die from COVID-19 than white people in the UK, according to the Office of National Statistics (ONS) — in large part due to systemic differences in wealth, health, education, and living arrangements.
Even after taking pre-existing circumstances into account, the ONS report found that Black people were still almost twice as likely to die from COVID-19.
Black Americans are dying at almost three times the rate of white Americans, according to figures from APM Research Lab.
In Canada, there is a lack of reporting on race when it comes to COVID-19, which experts say is detrimental to the Black community.
History Repeats Itself
Some health care systems were founded through blatantly racist processes, which means that not only is there distrust, but that behaviors need to be unlearned.
The man considered to be the "father of modern gynecology" experimented on enslaved Black people without anesthesia; Black men were told they were being treated for "bad blood" during the Tuskegee syphilis experiment. Henrietta Lacks’ cells, unbeknownst to her and her family for many years, led to great medical achievements: They were used in testing the polio vaccine, to develop in-vitro fertilization (IVF), helped create chemotherapy drugs, and more.
Because of this precedent, Feagin said he’s seen in his research that Black people are reluctant to go to white doctors, which presents yet another health issue — because it means Black people are less likely to go to a doctor when they have a condition that needs treatment.
And then there is the actual racism that people face when they do seek medical care, through unconscious bias or explicit discrimination.
"Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system," according to the authors of a 2016 report published in the New England Journal of Medicine entitled "Structural Racism and Supporting Black Lives — The Role of Health Professionals."
In 2018, tennis player Serena Williams made headlines when she described her health care experience when giving birth to her daughter, highlighting how quick Black women are to be dismissed in the context of health care — her story led to many other Black women coming forward with stories of their own, showing neglect or dismissal.
"I think there’s a lot of pre-judging, absolutely, that definitely goes on," Williams told the BBC. "And it needs to be spoken about, it needs to be addressed."
Systemic Reform Is Needed
When something so important to the well-being of people is systematically flawed, much needs to be done to overhaul the system.
Kevin Kimble, founding member of the Health Equity Collaborative, has worked with non-profit organizations and groups on inclusion and parity issues, and has worked with the US Congress for many years.
"What you’ll find is that no matter how many systems you put in place, the individuals who are racist, who end up running these organizations, can thwart it at every measure," Kimble told Global Citizen. "And so one of the things you really have to do in legislation is put criminal teeth into all of these things."
This concept doesn't just relate to health care.
Kimble referenced some work he’s currently doing with members of Congress, calling on police chiefs to be held accountable for the actions of their officers.
"There’s no way really to ease someone’s prejudices," he said. "You really have to get very aggressive about the criminal side of this stuff."
For example, Kimble said it’s not enough to convict the officers involved in Floyd’s death; it needs to go beyond that.
"The police chief that put [the officers] on the street should be held accountable criminally as well for reckless endangerment ... because at the end of the day, you or I have a dog that bites our neighbor — we’re held responsible for that," he explained.
"The rules are not set up in a way that punishes correctly those who are using their position to enforce racist policies," Kimble added.
The same theory can be applied to health care. When health outcomes are worse for Black people or other people of color because they did not receive the same treatment as a white person, legislation needs to hold the health practitioners accountable, he said.
Financial Barriers to Health
On top of everything, there's the undeniable fact that people living in poverty are less likely to have access to proper health care around the world.
In countries with privatized health care, accessing good health becomes a question of insurance and financial security. When health care is profit-oriented and pharmaceutical companies can charge whatever they want to deliver their services, poor communities are immediately denied easy access.
Global health care company GSK reports that some of the most neglected communities when it comes to accessing health services live in the poorest countries in sub-Saharan Africa and in rural, hard-to-reach areas. In Nigeria, for instance, more than 70% of the population lives in semi-urban and rural areas, making affordability and access to medication difficult.
In 2015, about 1.6 million Africans died of malaria, tuberculosis, and HIV-related illnesses — illnesses that can be prevented or treated with access to proper care.
But according to the United Nations, less than 2% of drugs taken in Africa are produced within the continent, which means that access to locally produced drugs is minimal and many cannot afford imported ones.
Meanwhile, more than 20 million children globally missed out on measles vaccines over eight years, according to a report from UNICEF in 2019. Those immunizations prevent death and illness and should be accessible to everyone, everywhere — but communities living in hard-to-reach areas or without financial access do not receive the same routine immunizations.
As of 2017, 800 million people spent at least 10% of their household income on health expenses — for almost 100 million people, the costs are high enough to push them into extreme poverty, according to a report from the WHO and World Bank.
In some cases, access to health services can be improved through global health funds like Gavi, the Vaccine Alliance, which aims to deliver vital vaccines to some of the poorest communities worldwide. But when it comes down to addressing the barriers put into place by systemic issues around the world, it is about so much more than access to health care — it's about combating racial injustice, marginalization, and inequality on many significant levels.
Article correction: An earlier version of this article misstated that Black women's breast tissue commonly requires 2D imaging rather than 3D imaging to detect cancer; and that there is a copay for 3D imaging rather than 2D imaging.