The force of segregation in American life is both obvious and overlooked. Though de jure segregation ended in 1964—and the Fair Housing Act of 1968 was crafted to fight redlining—the structures and practices that separate people of different races continue today, and have a profound effect on public health. Black people who live in redlined neighborhoods have shorter lifespans and are more at risk for cancer, preterm birth, and emergency room visits due to asthma, diabetes, hypertension, and kidney disease. They are also more likely to receive care at lower-quality hospitals. And if a nearby hospital does have a good reputation, Black folks may avoid it because of the feeling that it’s unwelcoming to them.
But even when a Black person seeking care has navigated these obstacles and lands at a well-resourced and apparently integrated hospital, the risk of receiving separate care persists.
The phenomenon, known as “care team segregation,” occurs when some teams of providers within the same hospital see mostly white patients while other teams see more Black ones. A new study focusing on this form of segregation has found that Black patients in a hospital are more likely than white patients to die following a cardiac bypass if they are treated by a group of clinicians—surgeons, anesthesia team, cardiologists—who tend to treat more Black patients than white ones.
The extent of the segregation seen by researchers was higher than is seen in nonclinical situations known for racial separation or disparities, such as within school systems where Black kids are punished more harshly than their white counterparts are, or within lunchroom settings.
When a care team treats patients of all races, the morbidity rates between white and Black patients who are equally sick are comparable. (The study found that Black patients were more likely to be women as well as poorer, younger, sicker, and less likely to have scheduled the procedure in advance. This is likely attributable to the ways in which systemic racism generally has a negative impact on the health of Black folks.)
“What’s killing people is the segregation,” said Ekow Yankah, a law professor at the Cardozo School of Law and one of the study’s co-authors. “It’s not their preconditions—the study controls for all the comorbidities—it’s not what shape you’re in when you come in.”
“In the most extreme examples, one team is seeing essentially all the Black or brown patients and all the other teams are seeing only white patients,” Yankah said. “It’s hard to know whether or not the team that’s seeing the minority patients is just worse, or if they expect worse outcomes.”
How care teams get assigned is a subtle, opaque process, but the study provides an understanding of how networks within hospitals affect patient care. Typically when people analyze why Black patients have worse outcomes, they attribute it to structural factors, such as hospitals that sit within Black neighborhoods tending to be more poorly resourced.
Preventing care team segregation wouldn’t require sweeping institutional mandates like relocating hospitals. It could be alleviated by research into how teams are assigned and taking measures to stop sorting patients the way they’re being sorted.
“There is a potential for some actionability, that we can actually make things better—and that’s really, I think, a gap that exists in this literature,” said Brahmajee Nallamothu, a cardiologist and internal medicine professor at the University of Michigan who co-authored the study. “So many of the challenges are hard to imagine overcoming, but this is one that seems both directly impactful and potentially modifiable.”