Racism Is the Ultimate Pre-Existing Condition

Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

Recently, leaders across states and municipalities have declared racism a public health crisis after years of tireless advocacy and evidence demonstrating this fact.¹ The COVID-19 pandemic, having captivated the world, has demonstrated our nation’s unwillingness to protect communities of Black, indigenous, and people of color (BIPOC). There is ample evidence on other racial disparities prevalent throughout health care. It is no surprise that COVID-19 disproportionately affects communities of color so starkly. Racism, not race, is the ultimate pre-existing condition.

A recent article yet again noted racial disparities found in analgesic use in patients presenting to the emergency department for kidney stones.² This study used data from the Premier Hospital Database, an all-payer hospital discharge database that captures about 20 percent of all discharges from nearly 700 private and academic hospitals. The study’s primary focus was on the quantity of analgesia, specifically opioid and IV nonopioid (ketorolac) pain medication.

The study found that Black and Hispanic patients with acute renal colic received less opioid pain medication than white patients. White patients received a median of 20 morphine milligram equivalents (MME), while Black patients received 3 MME less and Hispanic patients received 5.4 MME fewer (P<0.0001). Additionally, there was a difference in the administration of ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), in combination or as monotherapy despite ample evidence suggesting that NSAIDs are as, if not more, effective than opioids for acute renal colic. These differences were not explained by geographic or practice setting differences, suggesting that unrecognized health care worker biases were the culprit. These data suggest we need to vigilantly evaluate the etiology of these biases on an individual and systemic scale.

Despite the dedication of emergency departments to serve “anyone, anywhere, anytime,” evidence exists that unacceptable disparities in the emergency care for BIPOC persist. As the COVID-19 pandemic continues, it underscores the inextricable link between health care and racism. Woven into the fabric of emergency medicine are the principles of egalitarianism, social justice, and compassion for the poor and underserved. As such, we have a unique position to be at the forefront of addressing racism by cultivating equitable environments and implementing anti-racist policies in the delivery of high-quality health care.

Ms. Turgeon is a student the Robert Larner, M.D. College of Medicine at the University of Vermont.