Just Medicine: A Cure for Racial Inequality in American Health Care

A key theme of Matthew’s work in Just Medicine and her broader academic and advocacy work, is the systemic challenge that makes it difficult to effectively address and reduce implicit bias in healthcare settings. Matthew argues that implicit bias is deeply rooted in the broader social, legal, and institutional frameworks of the US. Consequently, overcoming it requires not only individual-level interventions, such as bias training for healthcare providers, but also large-scale reforms that address the structural conditions perpetuating these biases.

While Matthew emphasizes that implicit bias in healthcare is not simply the product of individual prejudices held by doctors or nurses but a structural issue, she also notes that the social system that sustains implicit bias remains a challenge in and of itself. Systemic bias is shaped by a long history of discrimination against BIPOC and immigrant communities in the US. Moreover, bias is learned through socialization and reinforced by media and public policies. As a result, Matthew argues, implicit bias is embedded within the healthcare system as a whole, making it extremely difficult to address.

One of the primary systemic challenges identified by Matthew is the fact that healthcare institutions often operate within a larger framework of structural racism, informed by a long history of segregation and discrimination. In Chapters 1 and 2 Matthew discusses American institutions as the descendants of a social, economic, and political system rooted in racial inequality. She describes this lineage of racial discrimination as no longer overtly displayed but still active. In healthcare, this lineage manifests in multiple ways, from the underfunding of hospitals that serve predominantly BIPOC populations to the lack of access to quality healthcare services in marginalized communities. These structural conditions contribute to the persistence of healthcare disparities, and create environments where implicit biases are more likely to influence decision-making.

For example, Matthew points out that the racial segregation of neighborhoods in the United States, driven by historical and contemporary policies, leads to unequal access to healthcare. BIPOC communities are often served by under-resourced healthcare facilities that lack the necessary staff, technology, and funding to provide high-quality care. In these environments, healthcare providers may be more likely to rely on implicit biases when making treatment decisions, as they may be working under conditions of stress, time pressure, and resource constraints. These topics have also been explored by Lauren Ralph in Renegade Dreams: Living Through Injury in Gangland Chicago (2014), in which Ralph demonstrates specifically, through anthropologic and ethnographic research, how a marginalized Black community in the Eastwood neighborhood of Chicago has gradually, over decades, lost access to high-quality healthcare facilities. Another study tracing the devastating effects of systemic discrimination in healthcare is The Death Gap: How Inequality Kills (2017) by David A. Ansell.

In Chapter 6 of Just Medicine, Matthew expands the discussion of implicit bias to include broader institutional and societal factors that perpetuate health disparities. She argues that while individual biases affect care, these biases are supported and exacerbated by institutional structures. Matthew provides particular emphasis on this theme in her discussion of the ways implicit biases influence diagnostic and treatment decisions: doctors often unconsciously make assumptions about a patient’s socioeconomic status or likelihood of adherence to treatment based on race. These assumptions, rooted in societal stereotypes, lead to unequal treatment decisions, contributing to worse health outcomes for BIPOC patients.

For example, Matthew highlights research demonstrating that physicians are less likely to recommend preventive measures for Black patients compared to white patients. Even the manner by which the recommendation and follow-up is done, significantly differs: “Studies show physicians are less aggressive about urging Black patients to modify risk factors for heart disease such as smoking cessation, diet modification, and increased exercise” (57-8). These disparities are not just a matter of individual prejudice but are tied to historical and systemic racism that shapes both the medical profession and patient outcomes.

Matthew discusses the resistance to change often encountered within healthcare institutions who remain hesitant to acknowledge the role that implicit bias plays in healthcare disparities. She explains that the way healthcare institutions function is directly related to racial bias: “The systemic divisions by race and ethnicity in health care preserve power and protect the institutional health care delivery system from economic and social destabilization” (177). Thus, Matthew argues, the reluctance to address implicit bias reflects the structures that maintain the status quo. By preserving these divisions, healthcare institutions shield themselves from the economic and political pressures that might arise from implementing more equitable practices.

Ultimately, Matthew advocates for the development of new legal standards that recognize the harm caused by systemic implicit bias. For example, she suggests that healthcare providers could be required to undergo regular assessments of their clinical decisions to identify patterns of bias, with consequences for those who consistently demonstrate biased decision-making. In addition, Matthew argues that healthcare institutions should be legally bound to collect and report data on healthcare disparities, so that disparities can be tracked and addressed at the institutional level.