Why racism is a public health crisis

Racial biases in science and medicine harm people's health, writes Layal Liverpool in her new book Systemic: How Racism Is Making Us Ill. She tells David Robson about the litany of healthcare disparities she uncovered.

When Layal Liverpool was a teenager in the Netherlands, she started noticing small patches of pigment loss on her face and arms. She was prescribed antibiotics and antifungal medications, but to no avail. She assumed it was a very rare and untreatable condition.

It was only once she met a dermatologist in the UK who also happened to have darker skin that she found out that the real cause was eczema. He suggested that the other doctors she had seen – who were mainly white – simply hadn't known how the condition might appear on brown skin, leading to a misdiagnosis.

After working as a biomedical researcher, Liverpool is now a science journalist, and her debut book Systemic: How Racism Is Making Us Ill examines the health gap between people in marginalised ethnic groups and their white counterparts, and the ways it might be fixed. She spoke to fellow science writer David Robson about what she discovered.

What inspired you to write this book?

I recently became a mum, and in the UK, black women like me are four times more likely to die during pregnancy and childbirth compared to white women. There are similar statistics in many other places, and as a science journalist with a background in medical research, I felt compelled to look into it.

I thought I knew a lot about this topic, but I was even quite shocked by what I discovered. I found that marginalised racial and ethnic groups in many countries around the world are experiencing far worse health outcomes in many areas besides maternity – including infectious diseases, cardiovascular disease, cancer, mental health conditions. I would characterise racism as a public health crisis. It makes our healthcare systems unfair, but also inefficient: it wastes, time, money, and resources.

You cite research showing that medical students often have these totally false beliefs about biological differences between people of different ethnicities. What are some examples of those misconceptions?

At the beginning of the book, I look at this belief that black people's skin is thicker than white people's or their nerve endings are less sensitive – so that black people experience pain differently. Around half of medical students in this US believed some of these false ideas.

That's just one example, and in other areas the myths have even been translated into medical guidance. For example, there used to be guidelines to adjust kidney test results based on a patient's race, based on the idea that black people's kidneys work differently from white people's. This seems to have come from one small study, which was then cited by other studies, and it eventually became embedded into guidelines, and there's been research showing that this has negative health consequences.

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I first reported on this for [the science magazine] New Scientist, and after I contacted Nice – the UK's National Institute for Health and Care Excellence – and shared a study showing these consequences, they eventually updated their guidance to remove use of race. We're now seeing changes to the international recommendations too.

We can also see race-based medicine in lung function tests. It can be traced back to a physician and slaveholder in the US named Samuel Cartwright, who had this idea that black people's lungs were weaker, and so they benefited from being enslaved. This somehow became embedded in practice, and when I reported on this in 2021, it was still present in international guidelines which suggest that we need to adjust for race when measuring lung capacity. But then last year, when I was editing the final version of the book, I learned that the American Thoracic Society and the European Respiratory Society have removed race adjustment from their joint recommendations. They explicitly stated that race is a social construct and doesn't have a basis in biology. It would have been great if this had happened before, but I'm just happy that it's happening at all, and that there are these discussions.

How does racism influence mental healthcare?

There are a lot of inequalities that should be taken more seriously. We see, for example, that black people are more likely to be detained against their will for psychiatric care. In the US, black men are more likely to end up being killed by police when they're having a mental health episode compared to white men. The research suggests that this may be due to perceptions of black people being more threatening or dangerous.

Racism can also influence diagnoses. There's evidence that depression is under-diagnosed and undertreated among marginalised groups, while schizophrenia in some cases, is over-diagnosed among black people in the UK and US. So there may be some stereotypes and perceptions that affect the way that practitioners are interpreting people of colour and the conditions that might be affecting them, which is a problem.

Finally, in many countries people of colour find that their experiences of racism, and its effects on their wellbeing, aren't taken seriously by mental health practitioners. That may reduce people's willingness to seek care to talk about the problems they are facing, when they're vulnerable and need support.

Our mental state can also influence our physical health. What is the link between racism and illnesses like cardiovascular disease and Alzheimer's?

Cardiovascular disease is the world's biggest killer and it's a huge problem for public health – and the evidence shows that racism also plays a role there. There are day-to-day stresses that you experience, such going into a shop and being followed, because of the stereotypes that black people are more likely to steal – you might feel that your heart rate is elevated and you're stressed. And experiencing racism day-in and day-out over a lifetime can have a kind of chronic effect on your nervous and cardiovascular systems. Black people in the US, for example, are more likely to have hypertension – high blood pressure – which is a major risk factor for cardiovascular disease. Chronic stress and trauma may also be linked to age-related cognitive decline and dementia.

Is there any room for optimism?

While writing the book, I met a lot of people who care about these issues and are working to tackle them. For example, there's a grassroots organisation called Five X More that is campaigning for black maternal health in the UK. They conducted a study showing that 43% of black and black mixed women reported experiencing discrimination in their maternity care. And they have come up with recommendations for black people who are pregnant on how to advocate for themselves in the healthcare setting. They have also offered training for healthcare workers who want to engage with this issue and make sure that patients from all backgrounds can feel comfortable when they're accessing maternity care.

Lots of scientists are working hard to remove bias from their medical research. And doctors have started tackling the systemic forms of racism and the race-based medical practices that we discussed at the beginning of our conversation. I would love to see a more widespread reckoning across medicine, but it is already happening within individual fields, which is amazing.

Layal Liverpool's book Systemic: How Racism Is Making Us Ill is published by Bloomsbury Publishing (UK) and Astra Publishing House (USA)

David Robson is an award-winning science writer and author. His latest book is The Laws of Connection: 13 Social Strategies That Will Transform Your Life, published by Canongate (UK) and Pegasus Books (USA & Canada). He is @d_a_robson on Twitter and @davidarobson on Instagram and Threads.

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