More Cities and Counties Declare Racism a Public Health Crisis

The number of cities and counties that have issued declarations about racism has skyrocketed since George Floyd was killed in 2020 and Black Lives Matter protests erupted across the United States. As of spring 2021, 109 cities, 76 counties, and 8 states have formally declared racism a public health crisis, according to Rita Soler Ossolinski, program director for the National League of Cities' program Race, Equity, and Leadership.

“I think there's real intentionality behind them,” Soler Ossolinski said. “The first step is acknowledgment.” These declarations can begin to “normalize” the conversation around racism. The next step is accountability, she said, by developing plans and programs to address racial inequalities. “Racism is a system; it's not necessarily a pejorative remark.”

In Ohio, both the Franklin County Board of Health (1) and the City of Columbus City Council (2) declared racism a public health crisis. Columbus is the state capital and largest city in the state. The Board of Health committed to creating an equity and justice-oriented organization, identifying areas where it can embrace diversity and incorporate anti-racism principles. It stated that the plan must “understand, address and dismantle racism, in order to undo how racism affects individual and population health and provide tools to engage actively and authentically with communities of color.”

The Board of Health also plans to advocate for relevant policies that improve health in communities of color and build partnerships with other organizations confronting racism. Alejandro Diez, MD, associate professor and transplant nephrologist at The Ohio State University Wexner Medical Center, said the Columbus declarations “really opened up a lot of eyes and were a catalyst for looking inward.”

The National League of Cities has been asked by at least 38 cities—compared to 20 in 2019—to help them develop racial equity plans, Soler Ossolinski said. While many of these programs are still in the planning stage, some of the declarations have mentioned various health conditions that disproportionately affect Black and/or Hispanic populations, including diabetes and hypertension, primary drivers of kidney diseases.

The declarations “matter because it now means someone is listening; someone is paying attention,” said Maya Clark-Cutaia, PhD, RN, assistant professor at New York University Rory Meyers College of Nursing and an acute care nurse practitioner at Pennsylvania Hospital in Philadelphia.

“The problem with that is the lip service isn't enough,” said Clark-Cutaia, who studies kidney disease and dialysis patients. “The reason these disparities have been perpetuated is because there's no action. It's going to take a lot more than declarations. We need investment in these communities. That's what's missing.”

During the COVID-19 pandemic, kidney diseases have been in some cases a “perfect storm” of racial and ethnic health disparities; racism; disproportionate rates of diabetes, hypertension, and other comorbidities; and increased vulnerability to the coronavirus, Clark-Cutaia said.

“I feel like kidney disease patients are the embodiment of the many things that cause health disparities,” she said.

Racial and ethnic minorities have higher rates of diabetes and hypertension than White Americans. In fact, Black Americans are 60% more likely than non-Hispanic White adults to have been diagnosed with diabetes, and non-Hispanic Black adults are 3.5 times more likely to be diagnosed with end-stage kidney disease compared to non-Hispanic White adults, according to the US Department of Health and Human Services (3). Black Americans are also more likely to get diagnosed later, be referred to a nephrologist later, and have longer kidney transplant waits, Clark-Cutaia said. A complex mixture of a person's social determinants of health—the conditions in which people are born, live, learn, work, play, worship, and age—affects disease risk and access to healthcare (4). Over the past year more cities and counties have recognized and acknowledged that structural racism affects a person's social determinants of health.

Clark-Cutaia says her Philadelphia kidney disease patients have unique vulnerabilities that are often out of their control. For example, they are instructed to cut down on their salt intake, but they tend to live in lower socioeconomic neighborhoods that are “food deserts,” without supermarkets and affordable, nutritious food sources. These neighborhoods often have only convenience stores, with higher priced, high-sodium processed foods, an example of the structural problems that cities and counties have declared racism a public health crisis must address, Clark-Cutaia said.

Furthermore, adults in these communities often have lower education levels, which could make it difficult to understand or access complex nutrition guidelines. And those without cars often rely on the city bus system to go to a supermarket or to their doctor's and dialysis appointments. Diez pointed out that it can take some of his Columbus patients an hour and a half to get to an appointment by bus, including at least one bus transfer—a distance that takes only 30 minutes by car.

Then came COVID-19, adding to their risks and health disparities. Black Americans, American Indians, and Alaska Native and Hispanic Americans have disproportionately higher rates of COVID-19 cases, hospitalizations, and deaths (5). This does not surprise Clark-Cutaia because, she said, the communities in which they live have not addressed the social determinants of health that put them at greater risk. These adults are also more likely to be essential workers, such as grocery store employees and bus drivers, who cannot work from home and are more exposed to the virus. They may also live in multi-generational homes, which puts more people in their family at risk, Diez said.

“These are often the ones who prepare our food, clean our offices, stock our food at the supermarket,” he said. “These are jobs that they depend on, and a lot of times you have one individual who the entire family depends on for income.” While clinicians and researchers may point to racial and ethnic health disparities—and more and more, structural racism—individual racism also harms the health of racial and ethnic minorities. There are longstanding falsehoods that plague the care of these vulnerable populations, such as that Black people have a higher pain tolerance, Clark-Cutaia said. This belief does not recognize that race is a social construct with no biological basis. In addition, Black women, in particular, may be viewed as histrionic or as having a history of abuse of pain medicine.

In a 2016 study of 222 White medical students and residents, one-half reported that they believed at least one false statement about Black adults having higher pain tolerance. Participants who endorsed such false beliefs were more likely to show racial bias and inaccuracy in their pain treatment recommendations, according to the study, published in the Proceedings of the National Academy of Sciences (6).

In December 2020, a Black physician, Susan Moore, MD, died from COVID-19 after documenting her struggle to get proper medical care on social media. From her Indianapolis hospital bed, she explained in a Facebook video how a White male doctor said he was uncomfortable giving her more narcotics and suggested she be discharged. She also said she had to beg for remdesivir and for tests to be done. After complaining, she received more pain medication and was sent home. However, her case worsened, and she was taken to a new hospital only 12 hours after being discharged. She died about 2 weeks later (7).

Awareness of these stereotypes and unconscious biases can help nephrologists and other clinicians not fall prey to them—and step in when spotting other healthcare professionals acting on these falsehoods. In addition, “It's always good to approach a patient with empathy and humility,” said Romita Mukerjee, MD, MHS, a nephrologist at a large private practice in the Raleigh, North Carolina, area.

Being more aware of the social determinants of health that affect patients is also important. “I think if there is a greater awareness of social determinants of health, that would improve empathy for the patient experience,” Mukerjee said. “Instead of blaming patients, for example, for not following a healthy lifestyle or not showing up to their appointments the way they're supposed to or not taking their medications correctly, we would have a general understanding that there might be other life factors that play into some people's ability to take care of their health.”

In Mukerjee's state, five counties, three health boards, and the North Carolina Healthcare Association (8) have declared racism a public health crisis, according to the National Association of Counties. (See what your county has done at www.naco.org/county-resources-race-equity-and-inclusion.) These declarations give validity to the problem, Mukerjee said. “Instead of it being an issue that just certain sections of the population have concerns about, it becomes more of a universal concern for the community, as well as for the larger healthcare system infrastructure in which we practice,” she said.

“I think also, in a pragmatic way, declarations of this kind can have implications from a monetary standpoint, in terms of funding appropriate community resources and other public health interventions and more concrete structures that would allow for addressing racial disparities and health,” she added. “So, I think, from a social and public health standpoint, these types of statements do have a lot of impact.”