Abstract and Introduction
The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.
In June 2020, Americans bore witness to the murder of George Floyd at the hands of the police. This pivotal event, amid a surge of racially motivated hate crimes in the US, galvanized many organizations and institutions to commit additional resources toward diversity, equity, inclusion, and antiracism initiatives. In healthcare, the outcry protesting race-related violence, including police brutality, occurred against the backdrop of the COVID-19 pandemic, in which data had already emerged showing a greater impact of the pandemic on historically marginalized communities. These communities were experiencing much higher rates of infection and hospitalization from COVID-19 than White communities. Older Black Americans, in particular, experienced disproportionately high morbidity and mortality from COVID-19. The pandemic has laid bare the disparities that exist in the workforce and training of healthcare professionals, educators, and investigators. Across the US, individuals, organizations, and institutions have recognized that lasting and meaningful change to advance equity will require collaboration and commitment.
The American Geriatrics Society (AGS), a nationwide not-for-profit society of geriatrics health professionals, was among the organizations that expressed opposition to violence rooted in racism, bias, and discrimination. In a statement after the death of Mr. Floyd, the AGS committed to doing more to actively oppose all forms of discrimination in healthcare. As a first step, the AGS modified its vision for the future to include the AGS commitment to creating a future in which we are all supported by and contributing to communities where bias and discrimination no longer impact healthcare access, quality, and outcomes for older adults and their caregivers. Subsequently, the AGS outlined a multiyear, multicomponent plan to address the intersection of structural racism and ageism in the Journal of the American Geriatrics Society (JAGS). The AGS has long championed efforts to oppose ageism, defined as discrimination against a person based solely on their age, across its portfolio of programs and products, but had not focused on the long-standing but under-addressed intersection of structural racism and ageism. Given how little has been written about this intersection, the AGS reached out to us, a diverse group of concerned and committed AGS leaders, and asked us to author this paper on behalf of the Society.
This paper provides an overview of important frameworks that should inform future efforts both to identify and eliminate bias within healthcare delivery systems and train health professionals with a particular focus on the intersection of structural racism and ageism. The language we use in this paper moves between current recommendations from the American Medical Association and the language used in the articles we cite (e.g., we use African American when citing research that used that term, and Black American in all other instances). We use minoritized throughout this paper to convey that structural racism is inherently an action taken by a dominant group that subordinates another group. Our approach to addressing the intersection of structural racism and ageism is grounded in the concept of a just healthcare system. A just healthcare system recognizes that membership in groups, whether classified by age, race, gender, socioeconomic status, or other descriptors, should not affect the quality of the healthcare that is delivered or who is trained to deliver that care. A just healthcare system also ensures that all of us receive timely, high-quality care that is responsive to our individual needs and offered with cultural humility.
In the US, healthcare injustices have direct adverse impacts, especially on Black Americans and other racially minoritized groups. These injustices are deeply embedded in the policies, practices, and systems that undergird American institutions, including the healthcare system. The lack of access to high-quality healthcare in historically and intentionally excluded urban and rural communities in the US is well-documented, and Black or African American individuals are under-represented as healthcare professionals.[8,9] Equally problematic is the practice of using race, a social construct, as a proxy to inform clinical protocols that drive healthcare decision-making. Race-adjusted algorithms that use race as a proxy for biological, genetic, or behavioral risk of disease reinforce racial biases and perpetuate health inequities. For example, the equation for estimated glomerular filtration rate (eGFR) overestimates kidney function in Black Americans. This leads to transplant delays and increases the risk of progression to kidney failure. A second example is in the assessment of lung function using spirometry; the equation inappropriately uses race and could lead to delays in lung transplant as well as decreased likelihood of receiving compensation for occupational lung disease in Black Americans compared with White Americans. Many of these clinical protocols and algorithms are currently undergoing critical reevaluation or have already been revised to remove race as a variable. A third example involves inaccurate pulse oximetry readings among Asian, Black, and non-Black Hispanic patients that led to delays in diagnosis and treatment of COVID-19 infection. The pandemic demonstrated how the intersection of age, race, and socioeconomic status contributes to poorer health outcomes for those of all ages in historically marginalized communities, as exemplified by the finding that the location of one's neighborhood predicts survival from COVID-19.
The discipline of geriatrics is grounded in a comprehensive, interprofessional, and biopsychosocial approach to patient care. Good geriatrics care promotes well-being and quality of life by customizing care to what matters most to patients with a focus on function and maintaining independence. As such, injustice in any form is an affront to the core values of geriatrics practice. When people from historically marginalized groups who have experienced a lifetime of racism then become older, they experience the added injustice of ageism as well. As such, the intersection of structural racism and ageism amplifies the harm resulting from either of these injustices alone. This intersection of structural racism and ageism has received little attention in healthcare but demands further exploration and action.[17,18]
"Good geriatrics care promotes well-being and quality of life by customizing care to what matters most to patients with a focus on function and maintaining independence. As such, injustice in any form is an affront to the core values of geriatrics practice. When people from historically marginalized groups who have experienced a lifetime of racism then become older, they experience the added injustice of ageism as well."
This paper is divided into sections on (1) structural racism, (2) ageism, (3) the intersection of racism and ageism, and (4) disadvantages related to social determinants of health. The goal is to inform our understanding of these pervasive types of bias in healthcare. In addition, we recommend three initial positive steps that we, together with colleagues in other specialties and disciplines, can take to move us further along the path to a future in which healthcare is free of discrimination and bias that continue to perpetuate disparities.
J Am Geriatr Soc. 2022;70(12):3366-3377. © 2022 Blackwell Publishing