Shortly after I wrote my first perspective piece on discussing patients’ social and cultural vulnerabilities, I received a question from a clinic staffer regarding their1 struggle discussing institutionalized racism with patients. They shared that their training as a social worker equipped them to ask about the “social determinants of health,” but the current process of providing care does not touch upon patients’ experiences of institutionalized racism.
Immediately, I began to think about how loaded the concept of “institutionalized racism” is. Institutionalized, or structural, racism, as discussed by Dr. Camara Jones, is one of three levels of racism, in which certain groups of people are afforded differential access to opportunities such as housing, education, employment, and positions of power because of society’s structures, policies, and practices.
In health care, our focus has been on how we can increase access to and improve such opportunities, also characterized as the social determinants of health. Institutionalized racism seems to be a topic that is more widely understood and thought about within academic settings than within clinic walls. For these reasons, I wonder: Is the phrase “institutional racism” itself inaccessible to our safety net patients? If so, how can we begin having conversations about institutionalized racism?
In an effort to move even more upstream, I would urge us to reframe the way we think of health inequities and reexamine the ways in which our health care system intentionally and unintentionally perpetuates institutionalized racism.
First, clinic staff must reevaluate the ways they are engaging with patients. Are we talking to patients in a manner that is respectful of their social, cultural, and political backgrounds? During visits, how can we provide patients a safe space to share their challenges outside of the clinic?
At the same time, it’s important to recognize and affirm the work that is already being done to uncover patient vulnerabilities during clinical visits. Inquiring about and documenting patients’ social determinants is a good start to building out a larger picture of how our systems can better meet the needs of our patients. For a long time, clinic staff have been trained to provide advice about what patients can do outside the clinic to improve their health. A practicing physician at a New York Federally Qualified Health Center (FQHC) recently blogged that she had to “unlearn” the ways she was practicing medicine because she did not realize that her patients lacked access to basic needs such as food, housing, and transportation. “When was the last time you ate?” is a question she used to ask when ordering labs that required fasting. Today, she asks “When was the last time you ate?” as an indicator of whether patients needed to be connected to food resources.
Secondly, we — as health equity advocates — need to understand the ways in which institutionalized racism occurs inside and outside our organizations. Institutionalized racism can be perpetuated through who gets hired as clinic staff, how much certain people get paid, who receives access to particular treatments, and who is involved in the planning and development of programs.
For instance, at our first Roles Outside Of Traditional Systems (ROOTS) session, Dr. Noha Aboelata, chief executive of the Roots Community Health Center, shared that “the people closest to the problem are also closest to the solution.” Her clinic hires community health workers who have been formerly incarcerated to support a patient population that bears the devastating costs of mass incarceration. By intentionally diversifying the clinic staff, as well as placing traditionally underserved and oppressed people into positions of power, this health center is addressing one piece of institutionalized racism.
But that’s not the only approach. Clinics can center vulnerable populations in the development and execution of their programs and policies.
I believe that these steps are necessary for building a culture where institutionalized racism can be discussed with all stakeholders of health care, including our patients. The discussion of social determinants has traditionally helped health care leaders to look at what services, programs, and resources are needed to improve opportunities for vulnerable communities. Calling out institutionalized racism, when discussing the social determinants of health, pushes all partners — clinicians, frontline staff, patients, policymakers — to recognize that the lack of access to opportunities comes from the social, political, and economic systems that currently exist in our society.
1. The pronoun “they/them/their” was to remain gender neutral, since the person’s gender was not explicitly shared with me. >