Interpreting and Addressing Racialized Inequities in Rheumatic Disease Care and Outcomes

Abstract

Health inequities, according to the World Health Organization (WHO), are "differences in health status or in the distribution of health resources among different population groups, arising from the social conditions in which people are born, grow, live, work, and age." 1 Numerous published studies to date among individuals with rheumatic and musculoskeletal conditions demonstrate profound and persistent inequities in care and outcomes by race and ethnicity. Among individuals with systemic lupus erythematosus (SLE), studies consistently show that individuals of African descent receive poorer quality care-from inadequate treatment regimens to inconsistent access to care, to fragmented care use patterns-and have more damage accrual, adverse outcomes, and higher mortality. [2][3][4][5][6] In individuals with osteoarthritis, studies demonstrate racial disparities in the receipt of joint arthroplasty and of recommended treatments like physical therapy, more severe disease at the time of presentation, and poorer outcomes. 7,8 Although there are fewer published studies examining these factors in rheumatoid arthritis, racialized inequities have been observed in receipt of disease-modifying antirheumatic drugs, in disease activity, and in access to rheumatologists. 9-11 A recent study by Sowa et al 12 has similarly demonstrated significant racialized inequities in receipt of knee arthroplasty among individuals cared for in the US Military Health System. Key challenges in rheumatology, and across all fields of medicine, include defining what race does and does not represent, understanding the mechanisms that drive these persistent racialized inequities, and developing sustainable, measurable interventions that close these gaps. Defining race and ethnicityRace and ethnicity are social constructs that the categories of which have changed over time based on geographic, cultural, and sociopolitical shifts. 13 In general, race arbitrarily divides people based on ancestral origin and physical characteristics (eg, skin color), whereas ethnicity captures shared values, language, and cultural norms among a group of people. 13 Ethnicity is distinct from race; the two should not be conflated because it risks minimizing other forms of discrimination such as xenophobia, colorism, and religious oppression. 14 According to Bailey et al, 15 "the modern concept of race emerged" in the United States as "early European settlers sought to preserve an economy" founded on exploiting the land and labor of Indigenous people and sustained by enslaving African people. 16,17 In the making of the United States, the colonists created a racial hierarchy, based on the unfounded premise that Black and Native American individuals were inferior, to justify the subordination and oppression of these groups. [16][17][18] After slavery, state and federal governments continued to perpetuate racial domination through Jim Crow laws, racial residential segregation, and mass incarceration, among others, to maintain political, social, economic, and ideological power ...