Implicit Bias and Racial Disparities in Health Care

Why are black people sicker, and why do they die earlier, than other racial groups? Many factors likely contribute to the increased morbidity and mortality among black people. It is undeniable, though, that one of those factors is the care that they receive from their providers. Black people simply are not receiving the same quality of health care that their white counterparts receive, and this second-rate health care is shortening their lives.

In 2005, the Institute of Medicine—a not-for-profit, non-governmental organization that now calls itself the National Academy of Medicine (NAM)—released a report documenting that the poverty in which black people disproportionately live cannot account for the fact that black people are sicker and have shorter life spans than their white complements. NAM found that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.” By “lower-quality health care,” NAM meant the concrete, inferior care that physicians give their black patients. NAM reported that minority persons are less likely than white persons to be given appropriate cardiac care, to receive kidney dialysis or transplants, and to receive the best treatments for stroke, cancer, or AIDS. It concluded by describing an “uncomfortable reality”: “some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care.” 

Scores of studies buttress NAM’s findings by documenting that providers are less likely to deliver effective treatments to people of color when compared to their white counterparts—even after controlling for characteristics like class, health behaviors, comorbidities, and access to health insurance and health care services. For example, one study of 400 hospitals in the United States showed that black patients with heart disease received older, cheaper, and more conservative treatments than their white counterparts. Black patients were less likely to receive coronary bypass operations and angiography. After surgery, they are discharged earlier from the hospital than white patients—at a stage when discharge is inappropriate. The same goes for other illnesses. Black women are less likely than white women to receive radiation therapy in conjunction with a mastectomy. In fact, they are less likely to receive mastectomies. Perhaps more disturbing is that black patients are more likely to receive less desirable treatments. The rates at which black patients have their limbs amputated is higher than those for white patients. Additionally, black patients suffering from bipolar disorder are more likely to be treated with antipsychotics despite evidence that these medications have long-term negative effects and are not effective. 

In light of these studies, some scholars have concluded that racial disparities in health can be explained by looking to the individuals who are choosing not to prescribe the most effective, health- and life-conserving treatments to racial minorities. The argument is that if people of color are sicker and are dying at younger ages than white people, this may be because physicians have racial biases. Their biases cause them to give their patients of color inferior health care and, in so doing, contribute to higher rates of morbidity and mortality.

If physicians harbor racial biases, these biases can either be consciously held or unconsciously held. Dayna Bowen Matthew's book, Just Medicine: A Cure for Racial Inequality in American Healthcare (2015), explores the idea that unconscious biases held by health care providers might explain racial disparities in health. She notes that precious few physicians, like the general public, admit to harboring negative attitudes about any particular racial group. And we probably do not gain much by disbelieving their accounts. Thus, physicians’ explicit racial biases likely cannot account for racial disparities in health. That is, if physicians’ choices around which treatments to prescribe and which care to offer are harming their patients of color, it is unlikely that physicians are intentionally doing so; nor is it likely that physicians are aware that they have beliefs about people of color that negatively impact the way they practice medicine.

However, Matthew notes that there is little reason to believe that physicians have not been exposed to the negative narratives about racial minorities that circulate in society—discourses that become the stuff of unconscious negative attitudes about racial groups. Matthew proposes that physicians, like the rest of the American public, have implicit biases. They have views about racial minorities of which they are not consciously aware—views that lead them to make unintentional, and ultimately harmful, judgments about people of color. Indeed, when physicians were given the Implicit Association Test (IAT)—a test that purports to measure test takers’ implicit biases by asking them to link images of black and white faces with pleasant and unpleasant words under intense time constraints—they tend to associate white faces and pleasant words (and vice versa) more easily than black faces and pleasant words (and vice versa). Indeed, research appears to show that these anti-black/pro-white implicit biases are as prevalent among providers as they are among the general population. Matthew concludes that physicians’ implicit racial biases can account for the inferior health care that the studies discussed above document; thus, physicians’ implicit racial biases can account for racial disparities in health.

A number of experiments support her claim. One study showed that physicians whose IAT tests revealed them to harbor pro-white implicit biases were more likely to prescribe pain medications to white patients than to black patients. Another study administered an IAT test to physicians and then asked them whether they would prescribe thrombolysis—an aggressive, yet effective treatment for coronary artery disease—to patients presenting symptoms for coronary artery disease. The experiment revealed that physicians whom the IAT tests revealed harbor anti-black implicit biases were less likely to prescribe thrombolysis to black patients and more likely to prescribe the treatment to white patients. 

Proposing that implicit biases are responsible for racial disparities in health might seem dangerous if one believes that individual and structural factors can never operate simultaneously. But this is not the case. United States’ policies make public health insurance unavailable to undocumented immigrants as well as documented immigrants who have been in the country for less than five years. Our residential neighborhoods remain dramatically segregated. We have a two-tiered health care system that provides wonderful care to those with private insurance and mediocre care to those without. The list of structural factors that make people of color sicker than their white counterparts is long. If providers’ implicit racial biases contribute to excess morbidity and mortality among people of color, we must recognize that individuals with implicit biases practice medicine within and alongside structures that compromise the health of people of color. 

Khiara M. Bridges is a professor of law and professor of anthropology at Boston University. She is the author of Reproducing Race: An Ethnography of Pregnancy as a Site of Racialization (2011) and The Poverty of Privacy Rights (2017). This piece is an excerpt from her forthcoming book, Critical Race Theory: A Primer, under contract with Foundation Press.