Advancing racial and ethnic equity in health

“Racism is a public health emergency of global concern.” Since we wrote these words in June, 2020, a monumental worldwide reckoning with racism, xenophobia, and discrimination in society—its roots, its consequences, and its redress—has gathered pace. Marches have taken place and statues have been toppled, activists galvanised and institutions investigated, reforms proposed and elections contested. Progress has been uneven, but interrogation of the power structures that prejudice and mistreat specific groups of people while privileging others has heightened an acknowledgment of racism and its harms—hatred, intolerance, and discrimination kill. These issues are as pervasive in medicine, medical science, and global health as in society. Today, The Lancet publishes a special issue bringing together the strongest evidence and analysis on advancing racial and ethnic equity in science, medicine, and health. Our issue does not offer easy solutions, but does set out important principles to guide thinking and actions in the future.

First, racism, xenophobia, and discrimination are fundamental determinants of health globally. The misclassification of race as a biological (rather than social) construct continues to compound health disparities. Four research papers show how discrimination leads to poorer health outcomes and quality of care. In a study of over 2 million pregnancies across 20 high-income and middle-income countries, neonatal death, stillbirth, and preterm delivery were more likely among babies born to Black, Hispanic, and south Asian women. Another shows how theft of land and destruction of traditional practices of Indigenous Brazilians are associated with adverse cardiometabolic outcomes. Among people diagnosed with brain tumours in the USA, Black patients were more likely to have recommendations against surgical resection, regardless of clinical, demographic, and socioeconomic factors, suggesting bias in clinical decision making. In Australia, everyday discrimination contributes to half the burden of psychological distress experienced by Aboriginal and Torres Strait Islander peoples. The logical conclusion is that racism and discrimination must be central concerns—for practitioners, researchers, and institutions—to advance health equity.

This issue also shows how systems intersect to perpetuate inequities. Racism converges with systems of oppression, including those based on age, gender, and socioeconomic status, to exacerbate or mitigate experiences of discrimination. The core problem is an inequality in power, historically rooted but still operating today. It shapes environments and opportunities. Specific recommendations for health include increasing cultural safety and diversity in the health-care workforce; co-designing with affected communities health-care systems that are more flexible, accessible, and welcoming; and strengthening Indigenous self-determination and land rights. A four-paper Series shows that social equity can be promoted best through interventions that target structures and systems, particularly through radical rights-based legal and political measures, led by affected communities. These are important lessons for health care, education, research, funding bodies, and government.

And for journals. The Lancet operates within structures of scholarly publishing that have perpetuated discrimination and inequities. From its beginning, the journal had a role in supporting colonial medicine and discriminatory health-care practices. We today publish a statement on offensive historical content, acknowledging its harms. We aim to be accountable to communities affected by racism and discrimination by living up to our commitments on diversity, as well as a joint commitment for action on inclusion and diversity in publishing. We continue to encourage submissions on the effects of racism on health. We seek fair representation of geography, gender, race, and ethnicity in authors and reviewers. We expect that papers concerning minority ethnic and discriminated populations include authors who represent those populations and for data to be disaggregated appropriately. To stop perpetuating racist stereotypes and misperceptions of race as a fixed biological construct, we ask authors to avoid use of race-based reference ranges and algorithms, and to qualify race-based associations drawn from observational data by discussing potential limitations and the possible role of unmeasured confounders.

Racism is not only about the health of particular persecuted or excluded groups—it inflicts a collective trauma on us all. The positive corollary of this fact is that lessening inequities and restoring justice can bring healing to society as a whole. This special issue outlines a path towards doing so for health and medicine. It is a beginning, not an end.

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