Majoritarian Stories and Racial Bias in the Medical Field

In this essay, I look at how majoritarian stories affect the medical/healthcare system, and how it then impacts a person of colour’s experience in accessing healthcare, treatment and diagnosis. I argue that majoritarian stories result in racial bias in the medical/healthcare system in the form of ignorance of medical issues and concerns of non white patients. Racialised patients are often put into the position of “other” under current biomedical models and thus their health concerns are not adequately addressed, diagnosed, and treated. This is a result of insufficient medical research on people of colour, specifically, as well as medical professionals’ unaddressed biases within the healthcare system.

I also look at how Critical Race Theory could be used to analyse these areas, arguing that Critical Race Theory does, in fact, reveal these biases and where they may come from, as well as suggest alternative ways of dealing with these problems and improving the healthcare system. Critical Race Theory can be used here to disprove these beliefs regarding biological differences between races by helping to understand race as a social rather than biological construct, as well as how majoritarian stories regarding racial differences play a role in the difference in treatment between patients. It could also be used in tandem with social determinants of health framework to analyse racial differences in health as consequences of race being a social construct, as these determinants can and do impact one’s health.

Solórzano and Yosso’s Critical Race Methodology: Counter-Storytelling as an Analytical Framework for Education Research (2002) discusses the concept of majoritarian/master stories, which are stories that are told about racial or gender minorities as a way to justify privilege for the dominant group. These stories appear as though they are objectively true facts and it is through these stories that racism is continually perpetuated as members of both the dominant and minority groups come to believe and continually share these stories. They give the examples of ideas that Latino Americans are more likely to dropout of school because they inherently hold less value for education, and stories that violent crimes do not happen in White neighbourhoods and thus giving the implication that they more “naturally” occur in racialized communities; stories such as these are so widespread and believed by both members and non members of these communities, that they are viewed as seemingly “natural” parts of everyday life and thus they are not questioned (Solórzano & Yosso 2002). It is through majoritarian stories that racism is continually perpetuated in various aspects of life, including the medical field. False beliefs regarding biological racial differences in experiencing pain, one’s protection from the sun based on skin colour, as well as simply lack of information can and do cause direct harm to people of colour. These false beliefs and lack of information are driven by majoritarian stories and the fact that they appear to be objective truths. Because of this false objectivity, these beliefs/stories are not questioned and continue on, which works well with the biomedical world’s premise of operating objectively, as it does not consider racial differences and personal bias (as will be explained further).

Malika Sharma’s Applying Feminist Theory to Medical Education (2019) identifies and analyses issues within medical education that result in discriminatory practices, most notably the idea that medical research and practice is objective and neutral. However, this neutrality results in the white, male body as the basis of study for symptoms of various illnesses and diseases. This then places racialised and female bodies as ‘other’ and thus their health concerns are not taken as seriously by healthcare professionals. Humans are not neutral beings and therefore it is impossible for the work they do to be neutral and objective. This then impacts their patients, as healthcare professionals’ own unaddressed racial bias would affect the care they give, especially since the curriculum for medical workers does not touch on issues of bias and racial difference, under the guise of being neutral (Sharma 2019). This is heavily influenced by the historical priority placed on male knowledge within medical education, as well as the field being heavily male dominated, as these factors “create barriers for critical, and specifically feminist, research and practice” (Sharma 2019, pp. 570).

Because the white male body is placed at the centre of research and education for biomedicine and the medical field, racialized individuals are placed at a disadvantage when trying to receive healthcare, as their specific needs and racial identities are not taken into consideration within medical research and education. This results in a lack of knowledge and understanding of how non white people may experience various illnesses or how some diseases may present in their bodies. This “neutral” viewpoint in the medical field prioritises white bodies and this then influences the broad understanding of how illness or disease appears in someone, as well as the diagnostic criteria for many disorders or illnesses. This means that if a non white person were to have a certain condition or illness, but it presented in them differently than it does in white people, they would not fit the diagnostic criteria and thus would be misdiagnosed which could have fatal effects.

Not only this, but this “universal objectivity” teaches medical professionals to treat all patients the same and does not teach them how to address their own biases and beliefs (which often stem from majoritarian stories) that would inevitably influence any work they do and have harmful implications for their patients. Majoritarian stories and biomedicine’s false objectivity work in tandem to create barriers for people of colour accessing medical care, as they do not take into consideration the role that racial difference may play in one’s health, and do not address the medical worker’s own bias and role in the patient’s experience.

One way in which these issues can be seen is in rates of skin cancer fatalities between whites and people of colour. Gupta et al.’s Skin Cancer Concerns in People of Colour: Risk Factors and Prevention (2016) looks at rates and severity of skin cancer in white people versus people of colour, finding that people of colour are more likely to die from skin cancer. There is very little research on skin cancer and how it appears in people of colour which results in doctors having limited knowledge regarding the subject both for their own practice and to pass on to their patients. Additionally, there is widespread false belief that darker skin is better protected from the sun in comparison to fair skin and thus those with darker skin are less likely to take the proper measures to protect themselves from the sun. This results in people of colour, particularly those with darker skin, being more vulnerable to skin cancer caused by sun exposure and then being misdiagnosed or receiving delayed diagnoses of skin cancer, which then increases the risk and rates of fatality (Gupta et al. 2016). Evidently, the current research on skin cancer under biomedicine’s “universal neutrality” is not universally applicable, as it does not consider differences such as skin colour. As a result, doctors are not given the education and knowledge to properly diagnose and treat their non white patients. Doctors are also not taught to address racial differences in their patients and how it may impact their health, meaning in addition to a lack of research on skin cancer in darker skin, doctors are also not given the tools to be critical and consider how differences in complexion may influence their diagnoses, illustrating how racialized individuals are harmed by the lack of nuance in the medical field.

Additionally, the lack of research and knowledge on this subject contribute to false beliefs regarding sun protection and risk of skin cancer for darker skinned individuals, demonstrating how even members of a minority group can come to believe majoritarian stories about themselves and how these stories cause serious harm. Because doctors also have limited knowledge on the subject, they may also fall victim to this belief and thus give false information to their clients regarding sun protection, thereby causing further harm to their patients and further perpetuating majoritarian stories. Critical Race Theory could be applied to this field in order to incorporate proper consideration for racial differences and how the presentation of diseases, such as skin cancer, may present differently on different complexions. Critical Race Theory could also be applied to research and medical education in order to conduct thorough research on skin cancer that contains more nuance in order to account for racial differences that are not considered under the current “objective” biomedical model.

Differences in health can also be understood in terms of social factors under the social determinants of health model. Javed et al.’s Race, Racism, and Cardiovascular Health: Applying a Social Determinants of Health Framework to Racial/Ethnic Disparities in Cardiovascular Disease (2022) looks at how social factors, specifically race and ethnicity, impact cardiovascular health. The authors argue that racism, as well as other social factors such as economic class and education, increases racialized individuals’ risk of cardiovascular disease. People of colour are subject to more barriers in accessing medical care, receiving equal employment opportunities, and quality education, all of which make them increasingly vulnerable to cardiovascular disease. Racism impacts not only these aspects, but it has also been proven to impact one’s physical health. Socioeconomic status is one of the largest factors in determining one’s health, and this is inherently linked to race as people of colour are subject to more discriminatory hiring practices, thus influencing their income. Income, subsequently, is the basis for their quality of living, their access to a safe living environment, and access to healthcare (Javed et al. 2022). One’s stress is also impacted and this then affects physical health, illustrating how all of these socially determined factors influence one’s health and how people of colour are increasingly vulnerable to poorer health (Javed et al. 2022).

Similarly, Coughlin’s Social determinants of breast cancer risk, stage, and survival (2019) looks at how race and socioeconomic status influence one’s health and risk of breast cancer and survival. The article’s findings show that for racial groups, socioeconomic status is closely linked to health and risk of breast cancer, with lower status being associated with increased risk of more severe breast cancers, delayed diagnosis, and poorer survival rates (Coughlin 2019). Institutional, personal, and internalised racism impacts various aspects of life including housing, employment, and access to healthcare, all of which can increase the risk of breast cancer. Lower socioeconomic status impacts one’s access to healthcare and thus affects the stage at which one is diagnosed, typically being linked to diagnosis at later, more severe stages of cancer and thus decreasing the chance of survival. Chronic stress caused by racism is also linked to other behaviours such as smoking and other harmful coping mechanisms, which put individuals at an increased risk for cancer (Coughlin 2019).

Armour-Burton and Etland’s Black Feminist Thought (2020) examines breast cancer disparities in African American women in comparison to their white counterparts, finding that although white women have a higher incidence rate of breast cancer, African American women have a higher rate of being diagnosed with more aggressive forms of breast cancer. They also found that African American Women are more likely to die from their breast cancer before the age of 45 and in 2012, African American women’s mortality rate from cancer was 42% higher than white women (Armour-Burton & Etland 2020). Similarly to Coughlin and Javed et al., this article attributed this discrepancy to psychological stress caused by these women’s experience of the intersectionality of gender, race, and class, as well as due to “active marginalisation” such as

being overlooked and devalued by others, including medical workers (Armour-Burton & Etland 2020).

These articles demonstrate a social determinants of health framework for looking at the health of racialized individuals. By using this framework of analysis, areas in which the current, “objective” biomedical fall short are addressed, such as race. As evidenced by these articles, one’s race and the way their race impacts their experience of the world directly impacts their health and their risk of cardiovascular disease and breast cancer, illustrating how the current biomedical model lacks in addressing these concerns. The current biomedical model and its ignorance of social factors like race and socioeconomic could also be understood as a form of a majoritarian story that harms patients; because it behaves “objectively”, it essentially makes social factors of identity irrelevant to healthcare and pushes a narrative that race is not a factor in one’s health. In reality, while race may not biologically influence health, its social implications do, thus making the idea that race (and its subsequent factors such as socioeconomic status) is irrelevant to one’s health a harmful majoritarian story. By not addressing how social factors influence one’s health, in addition to the lack of research and education on non white patients and medical bias, patients’ concerns are not properly addressed and could potentially be harmed as a result of misdiagnosis, delayed diagnosis, and other health concerns.

Armour-Burton and Etland’s article also addressed the implications of active marginalisation in the medical field and being overlooked by medical workers, and the additional psychological stress this causes. As previously discussed, ignorance from medical workers due to biomedicine’s “objectivity” causes harm in the sense that it does not adequately consider racial differences and thus often leads to mis/delayed diagnosis. As illustrated here, there are also psychological implications of this issue which cause further harm to non white patients, thus further demonstrating the harms of the current “objective” biomedical model which does not consider race or bias within the field. Should Critical Race Theory be implemented into the medical field, the social implications of race as outlined here could be more properly addressed and used to help treat non white patients who do not fit under the current biomedical mould for research and diagnosis by actually considering the role that difference plays both in the patient’s life and health, as well as in the medical worker and their own personal biases which inevitably impact the work they do.

Hoffman et al.’s Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences between Blacks and Whites (2016) looks at how white medical students’ and residents’ racial bias and false beliefs regarding biological racial differences impacts how seriously black patients’ pain is considered. Their research shows that those who held more belief that black people biologically have a higher threshold for pain (due to false beliefs that black people have thicker skin than whites, and others of the like) not only rated these patients’ pain as being lower/less severe than white patients, they also prescribed less amounts of and less accurate pain relievers, arguing that “individuals with at least some medical training hold and may use false beliefs about biological differences between blacks and whites to inform medical judgements” (Hoffman et al. 2016, pp. 4296).

Majoritarian stories and their impact on people is clearly demonstrated in this article’s research and findings, as false beliefs regarding biological differences in race directly influenced one’s medical assessment and judgement. This article also illustrates how majoritarian stories are able to disguise themselves as truthful facts, without the need for questioning; despite the fact that the individuals in the study had medical education and experience, they still held false beliefs regarding racial differences at the biological level, and did not consider whether or not they were actually true nor their implications in their own medical work. This then led to sub par medical care for their black patients, as their pain was not perceived as severe and they were not given the proper prescriptions and treatment, thereby proving how majoritarian stories impact the healthcare system and result in the ignorance of non white patients’ concerns.

This study also indicates the medical education system’s inefficiency in addressing racial biases in its students due to the “objective” view/goal of the biomedical model. It is inevitable for students to have bias somewhere in their work because, as stated by Sharma, humans are subjective beings and thus it is impossible for their work to be completely objective (2019). Rather, the medical curriculum should teach students to address their own biases and to think critically about how their biases may, inevitably, affect their work and their medical judgements in an attempt to, at least, decrease the extent to which their biases influence their work and subsequently their patients. This study proves Sharma’s points regarding the harms and surrealism of the “objective, universally applicable” biomedical model.

By implementing Critical Race Theory into healthcare and medical education curriculum, students could have better awareness of their own biases that affect their work, as well as about the power their position as a doctor holds, and be better equipped to handle said power and biases in order to deliver more equitable, beneficial care to their patients. Additionally, Critical Race Theory could be used to teach students about understanding race as a social construct, rather than a biological one, in order to hopefully deflect false beliefs regarding biological differences (as seen in this article), as well as to encourage more understanding for how social factors of one’s life influences their health, as was previously discussed.

In addition to Critical Race Theory, the Social Determinants of Health Model (SDOH) is another, more common, suggestion to improve medical education, as has been seen through various articles mentioned throughout this essay. However, SDOH can still be problematic in addressing inequalities within the medical system. Tsai et al.’s Seeing the Window Finding the Spider: Applying Critical Race Theory to Medical Education to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short (2021) discusses how SDOH models can also lack in comparison to Critical Race Theory and advocates for the implementation of Medical Critical Race Theory into medical education. They argue that while SDOH does address social factors and inequalities, it does not address the historical conditions of where they originate and are caused. As a result, it makes factors such as race and class, and their subsequent vulnerabilities and inequalities, appear to be natural differences rather than socially constructed inequities caused by historical, unjust systems of power. This then teaches medical students to view these issues as personal choices and frames poor health as simply the responsibility of oneself. Additionally, while SDOH may teach students about the fact that health inequalities exist due to these social factors, it does not teach them how to properly address them in order to work towards health equality (Tsai et al. 2021).

Implementing Critical Race Theory into medical education and practice would alternatively address race as a social construct made historically through institutions of power rather than a biological (biomedical) or natural social condition (SDOH). Additionally, it would work to address how institutional power continues to perpetuate racism to the point that it is not always noticeable (Tsai et al. 2021), and this could also be applied to racist majoritarian stories that continue to circulate due to their appearance as facts, as Critical Race Theory could teach students about how they work, as well as how students may address and handle their own false beliefs and their power in their role in the medical system.

In summary, majoritarian stories result in racial bias in the medical/healthcare system in the form of ignorance of medical issues and concerns of non white patients. This is largely due to the fact that the current biomedical model operates as though it is objective and can be universally applied. However, this universality does not take into consideration how race plays a role both in a patients’ life and subsequent health, as well as how this “objectivity” places a white male body as the focus of study and inevitably excludes and causes harm to patients who do not fit this mould. This view also does not give medical workers the tools to appropriately address their biases and thus it allows said biases to influence their work. Critical Race Theory helps to reveal these areas and the shortcomings of the biomedical model, and the common improvement suggestion of the Social Determinants of Health Model. Critical Race Theory, should it be implemented into medical education and practice, would teach students about the racist implications of the biomedical model and teach them to question their own racial bias and majoritarian stories that often go unquestioned due to their appearance as truthful facts. In addition to the implementation of Critical Race Theory, what other changes may be needed in order to address these concerns within the medical and healthcare fields, particularly in regards to institutional power and historical inequalities?