Racism, not race, impacts surgical outcomes

We read with interest the paper by Li et al. (May 2023), which analyzed patient outcomes following abdominal aortic aneurysm (AAA) rupture.1Li B. Ayoo K. Eisenberg N. Lindsay T.F. Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair.J Vasc Surg. 2023 May; 77: 1413-1423https://doi.org/10.1016/j.jvs.2023.01.181Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In the authors’ description of racial inequities, they document that Black patients were more likely to be uninsured or Medicaid insured, suffer from a larger burden of cardiovascular risk factors while not being more likely to be on appropriate risk reduction medications, and have longer "door-to-intervention” times.1Li B. Ayoo K. Eisenberg N. Lindsay T.F. Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair.J Vasc Surg. 2023 May; 77: 1413-1423https://doi.org/10.1016/j.jvs.2023.01.181Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We agree with some of the strategies suggested by the authors to reduce health inequities such as “redesigning health care infrastructure to improve transportation times for disadvantaged populations” and “implicit bias training for health care professionals to decrease racial bias and discrimination”.1Li B. Ayoo K. Eisenberg N. Lindsay T.F. Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair.J Vasc Surg. 2023 May; 77: 1413-1423https://doi.org/10.1016/j.jvs.2023.01.181Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar However, we are concerned that the authors do not identify the driving force behind these racial inequities—structural racism.2Bailey Z.D. Feldman J.M. Bassett M.T. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities.N Engl J Med. 2021 Feb 25; 384: 768-773Crossref PubMed Scopus (628) Google Scholar This paper does not state explicitly that race, which is a sociopolitical and legal construct with no biological basis, is not itself a risk factor, it is in fact the exposure to racism that is the risk factor.2Bailey Z.D. Feldman J.M. Bassett M.T. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities.N Engl J Med. 2021 Feb 25; 384: 768-773Crossref PubMed Scopus (628) Google Scholar, 3Kaufman J.S. Cooper R.S. McGee D.L. Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race.Epidemiology. 1997 Nov; 8: 621-628PubMed Google Scholar, 4Breathett K. Spatz E.S. Kramer D.B. et al.The Groundwater of Racial and Ethnic Disparities Research.Circulation: Cardiovascular Quality and Outcomes. 2021; 14Crossref Scopus (55) Google Scholar Notably, the authors use the terms ‘race’ or ‘racial’ 29 times in the manuscript text but do not use the word ‘racism’ a single time.1Li B. Ayoo K. Eisenberg N. Lindsay T.F. Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair.J Vasc Surg. 2023 May; 77: 1413-1423https://doi.org/10.1016/j.jvs.2023.01.181Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We are also concerned that the authors may have inadvertently perpetuated the myth of inherent biological difference between racial categories by stating that some of their findings “suggest a potentially more aggressive natural history for aortic and iliac aneurysms in Black patients owing to racial differences in biological factors and/or screening inequities.”1Li B. Ayoo K. Eisenberg N. Lindsay T.F. Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair.J Vasc Surg. 2023 May; 77: 1413-1423https://doi.org/10.1016/j.jvs.2023.01.181Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Biomedical research must be clear that racial inequities do not stem from inherent “racial differences in biological factors.” Race is a social—not a biological—construct. There are no categorical biological differences between the races.2Bailey Z.D. Feldman J.M. Bassett M.T. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities.N Engl J Med. 2021 Feb 25; 384: 768-773Crossref PubMed Scopus (628) Google Scholar, 3Kaufman J.S. Cooper R.S. McGee D.L. Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race.Epidemiology. 1997 Nov; 8: 621-628PubMed Google Scholar, 4Breathett K. Spatz E.S. Kramer D.B. et al.The Groundwater of Racial and Ethnic Disparities Research.Circulation: Cardiovascular Quality and Outcomes. 2021; 14Crossref Scopus (55) Google Scholar, 5Kuzawa C.W. Sweet E. Epigenetics and the embodiment of race: developmental origins of US racial disparities in cardiovascular health.Am J Hum Biol. 2009 Jan-Feb; 21: 2-15Crossref PubMed Scopus (462) Google Scholar Invoking racial difference in “natural history,” even if unintended, distracts the reader (researchers, providers, patients, learners, etc) and obscures the role that racism holds in creating these described health inequities. As previously published, health disparities in AAA outcomes start with screening gaps.6Sachdev-Ost U. Gaps in aneurysm screening.J Vasc Surg. 2022; 76: 1227-1228https://doi.org/10.1016/j.jvs.2022.07.173Abstract Full Text Full Text PDF Scopus (0) Google Scholar And as O’Donnell and colleagues reported in this journal in February 2023, the structural causes of racial inequities in surgical outcomes for AAA include differences in the turndown rates, transfer rates, and underinsurance. In this manuscript, they conclude that “the weight of our data strongly suggests that systemic racism and/or implicit bias could play an outsized role in the triage and management of patients with ruptured AAA (rAAA)”.7O'Donnell T.F.X. Dansey K.D. Marcaccio C.L. Patel P.B. Hughes K. Soden P. Zettervall S.L. Schermerhorn M.L. Racial disparities in treatment of ruptured abdominal aortic aneurysms.J Vasc Surg. 2023 Feb; 77: 406-414https://doi.org/10.1016/j.jvs.2022.08.009Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar This is compounded by the fact that Black patients, due to structural racism, have a higher burden of cardiovascular disease risk factors4Breathett K. Spatz E.S. Kramer D.B. et al.The Groundwater of Racial and Ethnic Disparities Research.Circulation: Cardiovascular Quality and Outcomes. 2021; 14Crossref Scopus (55) Google Scholar and, too often, Black patients obtain surgery at hospitals with fewer resources and lower quality care.4Breathett K. Spatz E.S. Kramer D.B. et al.The Groundwater of Racial and Ethnic Disparities Research.Circulation: Cardiovascular Quality and Outcomes. 2021; 14Crossref Scopus (55) Google Scholar,8Dimick J. Ruhter J. Sarrazin M.V. Birkmeyer J.D. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions.Health Aff (Millwood). 2013; 32: 1046-1053https://doi.org/10.1377/hlthaff.2011.1365Crossref PubMed Scopus (188) Google Scholar,9Lasater K.B. Rosenbaum P.R. Aiken L.H. et al.Explaining racial disparities in surgical survival: a tapered match analysis of patient and hospital factors.BMJ Open. 2023; 13 (Published 2023 May 11)e066813https://doi.org/10.1136/bmjopen-2022-066813Crossref Scopus (0) Google Scholar In line with explicitly naming racism as the root cause of the described racial inequities and avoiding the notion of inherent race-based differences in the natural history of illness, some minor modifications would go a long way in focusing on the root causes of inequity so that they can be addressed. It is racism, not race that leads to inequities in surgical outcomes.2Bailey Z.D. Feldman J.M. Bassett M.T. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities.N Engl J Med. 2021 Feb 25; 384: 768-773Crossref PubMed Scopus (628) Google Scholar, 3Kaufman J.S. Cooper R.S. McGee D.L. Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race.Epidemiology. 1997 Nov; 8: 621-628PubMed Google Scholar, 4Breathett K. Spatz E.S. Kramer D.B. et al.The Groundwater of Racial and Ethnic Disparities Research.Circulation: Cardiovascular Quality and Outcomes. 2021; 14Crossref Scopus (55) Google Scholar, 5Kuzawa C.W. Sweet E. Epigenetics and the embodiment of race: developmental origins of US racial disparities in cardiovascular health.Am J Hum Biol. 2009 Jan-Feb; 21: 2-15Crossref PubMed Scopus (462) Google Scholar, 6Sachdev-Ost U. Gaps in aneurysm screening.J Vasc Surg. 2022; 76: 1227-1228https://doi.org/10.1016/j.jvs.2022.07.173Abstract Full Text Full Text PDF Scopus (0) Google Scholar, 7O'Donnell T.F.X. Dansey K.D. Marcaccio C.L. Patel P.B. Hughes K. Soden P. Zettervall S.L. Schermerhorn M.L. Racial disparities in treatment of ruptured abdominal aortic aneurysms.J Vasc Surg. 2023 Feb; 77: 406-414https://doi.org/10.1016/j.jvs.2022.08.009Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 8Dimick J. Ruhter J. Sarrazin M.V. Birkmeyer J.D. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions.Health Aff (Millwood). 2013; 32: 1046-1053https://doi.org/10.1377/hlthaff.2011.1365Crossref PubMed Scopus (188) Google Scholar, 9Lasater K.B. Rosenbaum P.R. Aiken L.H. et al.Explaining racial disparities in surgical survival: a tapered match analysis of patient and hospital factors.BMJ Open. 2023; 13 (Published 2023 May 11)e066813https://doi.org/10.1136/bmjopen-2022-066813Crossref Scopus (0) Google Scholar Therefore, the title of the paper would have been more accurate if it was “The impact of racism on outcomes following ruptured abdominal aortic aneurysm repair.” Similarly, the conclusion would have been more accurate if it stated, “The structural racism that leads to these differences should be further investigated and there are opportunities to improve rAAA care for Black patients.” We implore authors, journals, and those interested and engaged in racial disparities research to choose language carefully and intentionally to be more scientifically accurate when investigating and describing racial health inequities. Response to “Racism, not race, impacts surgical outcomes”Journal of Vascular SurgeryPreviewWe would like to take the opportunity to respond to the letter from Rollin and colleagues (2023) and we would like to thank them for their insights and comments regarding our article entitled “The impact of race on outcomes following ruptured abdominal aortic aneurysm repair1.” The authors propose highlighting racism as a driving force for the inequities identified in our paper, including longer door-to-intervention times for ruptured abdominal aortic aneurysm (rAAA) repair in Black patients compared to White patients. Full-Text PDF