Millions of people experience overt or covert racism that affects their day-to-day lives. But sometimes, the impact of such discrimination spills into healthcare, bringing life threatening consequences. So, when it comes to racial health disparities, can so-called biological differences explain these statistics, or is the misuse of science preventing us from getting to the root of the problem?

Have you ever been asked a seemingly innocuous question that later left you feeling uncomfortable? Perhaps it made you think, would any other person, especially someone of a different ethnic or racial background, be asked that same question?

For some of us, this can be the classic question of “Where are you really from?” or perhaps comments such as “You are so articulate” or “I’m not racist, I have several [insert race/ethnicity here] friends.”

These questions and behaviors are what are now coined as ‘microaggressions,’ which, by definition, are negative racial slights, biases, prejudices, and insults—whether intentional or unintentional—toward people of different races and ethnicities.

We can encounter such behaviors wherever we go and in a multitude of environments. One such instance is within healthcare settings. I, for example, was recently asked by a healthcare professional if I had experienced “female genital mutilation,” which at the time did not seem pertinent to the issue I was facing but left me feeling rather uncomfortable after I sat with it. Being of British-Turkish mix descent, I wondered if any of my other white friends would be asked the same question.

Although, in my case, it did not have any adverse effects on my treatments or care, that may not always be the case. And I know I receive rather ‘privileged’ treatment because of the way I present, compared to other minoritized groups.

Within healthcare contexts, the gravity of this discrimination becomes more apparent when patients and healthcare workers experience negative consequences, which often lead to lower standards of care and a higher risk of illness.

This month, we sat down with Dr. Monique Rainford, obstetrician and gynecologist at the Yale School of Medicine, and author of the book “Pregnant While Black,” and Angela Saini, science journalist and author whose most recent work includes the book “Superior: The Return of Race Science,” to discuss what impact racism has on health and whether biological ‘race’ science can actually explain all the health disparities experienced by different racial groups.

You can listen to this month’s episode below, or on your preferred streaming platform:

Microaggressions and the COVID-19 pandemic

After I shared my own experience, Dr. Rainford explained what a microaggression is and how it may feel to the person experiencing it:

“[The] example that you shared is a microaggression, in the sense that when you were asked a certain history, and you wondered if you would have been asked otherwise [if you were from a different background]. You don’t necessarily realize it at the time [that] something is off [or] different. You don’t realize it at the time because it’s almost a shock. [A]nd then at some point, you realize and say ‘Oh, it is because I’m a person of this race or this ethnicity. And it is happening to me again, and again,’” she said.

Chiming into the conversation to share her own experience was Angela Saini.

“I can feel the frustration because I feel the same a lot. I’ll just give you an example. So, at the beginning of the pandemic, in 2020, there was so much speculation on the part of medical doctors as well and medical professionals, researchers about racial differences in who was catching the virus.”

Did COVID-19 affect races differently?

Describing it as “bizarre,” Saini pointed out how “bizarre” it was for the medical community to have thought that SARS-CoV-2, the virus that causes COVID-19, was affecting people of different races and ethnicities in varying severities.

“This would be first time in history that a virus affected races differently if that had been the case with COVID-19,” she said.

“And yet there was this widespread assumption that this was possible with this particular one. And I couldn’t believe some of the things that I was reading, [t]hat was being published in the medical literature,” she continued.

During the early days of the pandemic, news outlets and the UK government were reporting that British Asians were dying at a higher rate than other ethnic and racial groups due to COVID-19. These concerns were reflected in the correspondence Saini received from medical professionals in the field.

“I remember one dentist, Asian dentists, emailing me and saying, ‘Is it safe for me to go to work because I’ve heard that Asian people are more susceptible to this virus naturally, genetically more susceptible than other people.’ And I just said ‘The reason that British Asians are dying in larger numbers, especially that year was because we tended to work in frontline professions more than anybody else,’” she said.

Saini also pointed out that the first SARS-CoV-2 outbreaks hit London, which is “a minority white British city with a huge British Asian population.”

She said comparatively, “the statistics are not going to look the same” as the rest of the U.K. This not only propagated misinformation at the time but also affected vaccine uptake.

Racism: A maternal health problem

Dr. Rainford also shared Shalon Irving’s story, a 36-year-old Black mother, who was an epidemiologist at the Centers for Disease Control and Prevention (CDC) at the time, but died three weeks after giving birth due to complications of high blood pressure.

“Dr. Shalon Irving was a double Ph.D., and she worked at the CDC. So she was a woman, an educated woman with means who had a successful delivery by cesarean section for other reasons. But after delivery, she had some issues, and she kept returning to seek medical care for those issues related to high blood pressure, which was existing,” she said.

“She kept returning, however, it seems—based on everything I’ve read and know—that the system failed her. They kept telling her everything was okay. They kept telling her; she was alright, they kept sending her home. And the last time they sent her home, they gave her a prescription for an antihypertensive pill. And she went home collapsed, and was immediately rushed to the hospital life support. Shortly after that, she died, that was within weeks of delivery of her very first child,” she continued.

Dr. Rainford said Dr. Irving’s story was one that influenced her to discover more about the disparities that Black women face in America and write her book, in which she aimed to uncover, expose, and explain this problem.

How the stress of racism affects aging and health

When one talks of the impact of racism on health, epigenetics is an important area of study to include in the discussion. In essence, epigenetics is rooted in the idea that people’s behaviors and their environment can cause changes in the way genes are expressed.

Such changes—or the transgenerational effects of adversity—have been observed in the immune system, on mental health, and even the gut microbiome.

A recent study, for example, found that hardships experienced by mothers during their childhood or pregnancy were reflected in the composition of their children’s gut microbiomes.

Dr. Rainford said that the works of Dr. David Barker originally from the U.K. and Dr. Kent Thornburg in the U.S. are of particular importance when discussing epigenetics.

“They found that epigenetic changes [d]on’t change the genes, but they change how genes are expressed that can be passed from generation to generation. And they’ve noted that stress, including the chronic stresses of racism, can cause those epigenetic effects that affect the children of people suffering those stressors, and the grandchildren of people suffering those stressors. And those stressors could be both economic and racial discrimination,” she said.

Racial weathering

Dr. Rainford introduced the terms “weathering” and “allostatic load” to our conversation when discussing the long-term health impacts of racism. The latter can be described as “the wear and tear on the body” from the chronic stress and cumulative burden an individual faces.

“Another effect that is ‘biological’ but due to the stress of racism is something called weathering, quantifying this allostatic load,” she said, referring to Dr. Arline T. Geronimus‘ work.

“She found that Black women have a biological age of 10 years in excess of their chronological age because of the stresses of racism,” she said.

Multiple studies have since found evidence of this type of accelerated aging. One, for example, found that Black people are approximately three years older biologically than white people.

Dr. Rainford also touched on the work of Dr. Elizabeth Blackburn on telomeres, the protective tips at the end of chromosomes, which have been hailed as the “secret to longevity.”

“[Dr. Blackburn] found that chronic caregivers had shorter telomeres because of the stress of giving chronic care to someone who’s ill. And she found that non-poor Black women also had shorter telomeres compared to white women and even men,” she said.

Dr. Rainford said this can explain why chronic stressors such as racism often lead to having diseases at an earlier age than one normally would.

Can science explain racial health disparities?

Often when discussing racial differences in health outcomes, the renin-aldosterone-angiotensin system is one of the first things to come to mind. Dr. Hilary Guite asked our guests what their take on it was.

“We know that hypertension is higher among Black Americans and Black Britons. Preventable heart disease and stroke resulting from high blood pressure are two to three times more likely to kill a Black American than a white American. So it’s very easy for physicians then to draw correlations between some kind of biological difference and race,” said Saini.

She quoted research by Canadian epidemiologist Jay Kaufman, and American hypertension expert Richard Cooper, who found little to no genetic evidence that can account for such differences.

“[G]enetics has hugely undermined our ideas about deep-seated racial difference. And sometimes to the surprise of some geneticists who are expecting to see, for example, some kind of exceptional genetic groups in faraway places among indigenous groups, [they see] they are not particularly genetically exceptional. So, the vast majority of genetic difference is at the individual level, not at the group level,” she said.

Making a distinction between biology and genetics, Dr. Rainford further explained that the environmental conditions people grow up in are more likely to have a larger effect on health outcomes.

“If you are in a low-income community, and you do not have access to fresh food, you will eat what you can get, and what you can get is unhealthy for you. Also, what they found in studies is that air pollution in areas where predominantly Black people and people of color live is worse than air pollution in areas where predominantly white people live. [I]t’s a multiple of factors that ultimately have a biological effect, but nothing to do with genetic[s],” she said.

Is race a biological variable?

Using color to understand human differences and “dividing up the world by color—black, white, yellow, red, brown” was “outlandish,” said Saini.

“[Racial categories were] largely informed by the politics of the time, the transatlantic slave trade, colonialism, the patterns of economic political power at that time, which were divided along continental lines. And so this became conflated in the public imagination and in the medical imagination as some kind of meaningful way of understanding human variation,” Saini explained.

She reiterated that the classification of race has varied between countries and over time, which is testament that it is not a biological variable.

“So, for example, I moved to the U.S. two years ago. If I had moved in 1971 instead of 2021, I would be officially categorized as white. I’m now categorized as Asian. But in the U.S., people of Indian heritage were categorized as white in 1971. So we have to understand that these categories are not fixed. They’re not static; they’re always moving. And the reason for that is because the social conception of what race is, the social meaning of it is always changing,” she explained.

“Because race, I cannot stress enough, is not a biological variable. It was invented a few 100 years ago because of society and politics. If you understand the history of it, there’s no way that you can start to treat it as a biological variable because it just doesn’t make sense. It’s like talking about class as a biological variable.”
— Angela Saini

What can we do to lessen the impact of racism on future health?

Dr. Guite recounted her own experience of being in medical school and how the teaching shaped her views and behaviors as an epidemiologist.

“[I was not] taught that different races were inferior [per se], but they were different. And as a doctor, you [might] need to know that so you’ve got a heightened awareness and a heightened trigger for action,” she said.

She went on to reference a study in the U.K. that found a disparity in the link between BMI and diabetes risk for specific populations.

“For example, Dr. Tom Barber was one of our guests on a recent podcast and said he’d conducted a study showing that South Asian populations had the same risk of diabetes at a BMI of 24 compared to a white population of 30. So as a doctor, you need to have that heightened awareness to say, ‘Okay, I think I should check your HbA1c. So, in a sense, that, to me, doesn’t sound inferior. That sounds like something [like] a call to action. What am I missing here?” she asked.

Dr. Rainford said it was implicit racism.

“So, for example, you didn’t think you were taught any racist policies, but it was implicit. It’s implicit in everything that you learn,” she said.

“When you said we weren’t taught the races were inferior, we were taught that they were different — to be taught that races are different is the problem here. That is not true,” added Saini.

Is diversity the solution?

Representation for minoritized groups, although helpful, isn’t enough on its own. Looking at racism within the National Health System (NHS) in the U.K. gives a wider perspective.

“The BMJ and other journals have done some really good work lately, surveys that have looked at the experience of racism of not just patients, but staff within the NHS. The NHS in the U.K. has a disproportionately high number of ethnic minorities working within it. So we know that representation itself hasn’t made a difference there,” Saini said.

“[T]hat’s because of the way that you are taught, the world in which you live in; you will take what is there, whatever prejudices are there become your prejudices, whether they benefit you or not, whether you, deep down, believe them or not, whether your politics align with them or not, makes no difference. If that’s all that you know, then that is going to be reflected in your work,” she said.

“[The way we are taught] that’s part of the problem with the medical profession. We have diversity in medicine, pretty good [in terms of] gender and ethnic diversity. And yet we still have problems with racism because of the way that we are trained, the way that we understand race, as a society hasn’t moved on.”
— Angela Saini

More support, better education

Dr. Rainford, meanwhile, drew attention to the lack of social, financial, and educational support for disadvantaged people due to structural racist policies.

“[I]t’s important that we even list the categories of race, not because of the genetic difference, but we do need to [recognize] that people who self-identify as Black are treated differently, disadvantaged, and may need more social and health support, because what racism has done to get them where they are now,” she said.

To enact greater change and see these attitudes shift, it all comes down to re-learning and re-teaching.

“[I] believe that the social sciences and humanities need to be integrated into the way that we teach race. So every year I’ve been part of a panel at Harvard Medical School for incoming undergraduates, in which myself and historians come together and explain the genesis of the idea of race to students, break down what it means to use race in medicine, and how to think about it more accurately, to remember that when you’re using it, you are talking about something that is heavily socially and politically defined,” said Saini.

Dr. Rainford was cautiously optimistic about the new generation.

“I am very hopeful for the medical students coming up because they know way more than we did; they are exposed, they are taught. However, training only works if people are concerned about learning. [I]f someone is motivated and open and recognizes that they may have limitations in their beliefs, then I believe there’s a great deal of hope,” she said.

Apart from changing the education system, on an individual level, we can also check our own biases. Dr. Rainford suggested Harvard’s Implicit Association Test to help people see their blind spots or uncover implicit racial biases.

Keeping the conversation going and engaging in such discussions, no matter how uncomfortable it may seem at first, is also crucial.

“[H]aving conversations like this is important because even a few people will listen and hopefully their eyes will be opened. And hopefully, they will think differently, even about things that were taught their whole lives. And to be clear, as a Black person, you are not exempt from holding racist attitudes against other Black people.”
— Dr. Monique Rainford

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