8.8.2: Discrimination

Discrimination is any difference in the way a person is treated that is unfair, unjust, and causes harm. Discrimination can be structural or systemic (see Systemic Racism, above) or individual and interpersonal. Laws, regulations, policies, practices, and even unspoken rules in how individuals are treated can create structural and systemic discrimination. Interpersonal discrimination refers to poor treatment of one individual by another based on personal characteristics, whether or not there was an intent to cause harm. It might be a difference in the way a doctor talks to a specific patient, or the way a group of people is served at a restaurant. It could mean getting repeatedly passed up for promotions at work, or a difference in the appraised value of a house depending on who is living there. Discrimination is based on personal, inherent characteristics like race, ethnicity, sex, gender, sexuality, age, religion, or disability. The term intersectionality recognizes that a person may face discrimination based on multiple facets of their identity. For example, a Black woman may experience discrimination differently than a Black man, and a transgender person who has a disability may experience discrimination differently than a cisgender person with a disability.

Structural discrimination influences health outcomes through other social determinants of health. For example, when a location for a landfill is chosen near a town with a majority Black and Hispanic population, or when sidewalks are not maintained and people using wheelchairs are forced into the street, or when fewer trees are planted in lower-income neighborhoods, depriving them of shade and natural air purification - all of these structures and policies create unjust environments and contribute to health inequities. Systemic discrimination can also include attitudes and beliefs that have been so ingrained in a practice or culture that it might not be obvious that they are there. For instance, some algorithms used in medicine make assumptions about racial differences in biology and genetics, or ascribe higher risk factors for specific surgeries and treatments to patients of color. These algorithms may put Black and Hispanic people at risk for getting denied treatment for no valid medical reason (Vyas et al., 2020). Alternatively, some medical devices have been found to be inaccurate for people of color because they have only been validated on white patients. As a case in point: pulse oximeters were found to be overestimating blood oxygen in Non-Hispanic Black COVID-19 patients, which delayed their care (Sudat et al., 2022).

Interpersonal discrimination can also become a systemic problem when people are repeatedly treated differently due to inherent characteristics, especially by those working in positions of power or authority. Prime examples of systemic, interpersonal discrimination can also be found in healthcare. Healthcare providers may have explicit bias (when they are aware of their biases), or implicit biases (unconscious beliefs and attitudes). Particularly when healthcare providers are rushed or stressed, these biases come out in interactions with patients, resulting in poorer communication and even differing treatment recommendations (Hall et al., 2015). For example, Black patients are less likely to be referred for cardiovascular treatments, receive less pain medication, and have poorer maternal health outcomes. LGBTQ+ individuals may defer or avoid seeking treatment due to fears of discrimination. Negative interactions with healthcare providers decrease trust in medical care and increase the stress response in patients, which in turn affects overall mental and physical health (Apodaca et al., 2022).

All types of discrimination cause higher stress and worse health for those affected by it. And the stress experienced from discrimination, unfair treatment, and unjust systems can have a cumulative effect over time. This long term effect of discriminatory stress to health is part of the “weathering hypothesis” first proposed by Dr. Arlene T. Geronimous to describe disparities in fertility and maternal health of African American women. Subsequent research has linked the cumulative “allostatic load” of stress over the lifetime - including social stressors like discrimination - to brain aging and mental health (Contributors to Wikimedia projects, 2024).