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Until the 1980s, the practice of turning away patients on the basis of their ability to pay, without evaluating or treating them, was legal and frequent in US hospitals. A 1986 study at Cook County Hospital, a public hospital in Chicago, noted that 89% of patients transferred from private hospitals to their facility were Black and Hispanic, and 87% of them were transferred because they did not have adequate insurance. Mortality was disproportionately high among those transferred, likely due to delays in stabilisation and definitive care. This practice was ultimately disrupted—although it continues today—not by institutions recognising its unethical nature and voluntarily halting it, but by the passage of the federal Emergency Medical Treatment and Active Labor Act, which requires hospitals to stabilise and treat patients before transfer, irrespective of insurance status. It took an act of Congress to change this fundamentally racist, inequitable practice. I thought of this history recently because of a conversation with a colleague about hospital equipment that retains components labelled “master” and “slave”. “Why not remove those names?”, I asked. “It's written into the manuals and the systems and the technology”, he told me. “Removing those terms everywhere would take an act of Congress.”

ory recently because of a conversation with a colleague about hospital equipment that retains components labelled “master” and “slave”. “Why not remove those names?”, I asked. “It's written into the manuals and the systems and the technology”, he told me. “Removing those terms everywhere would take an act of Congress.” Elements within medicine that reinforce racism—eg, racist clinical calculators, patient transfer practices, equipment design, poor representativeness of clinical trials—are put into everyday practice easily, frequently, with surprisingly little challenge, barriers, or argument. The dismantling of racism in medicine, by contrast, is laborious, gradual, and painstaking, often done against great resistance. This easy-in, tough-out system of inequity is like a dam: it is, by nature, designed for accumulation, for retention of racism. When health-care organisations establish new policies, programmes, and decision-making processes with an equity lens, these gradual inflow improvements cannot change what is happening in total when there has not been any corresponding removal of already accumulated policies, programmes, and processes that reinforce racism. © 2021 ErichFend/Shutterstock2021

This easy-in, tough-out system of inequity is like a dam: it is, by nature, designed for accumulation, for retention of racism. When health-care organisations establish new policies, programmes, and decision-making processes with an equity lens, these gradual inflow improvements cannot change what is happening in total when there has not been any corresponding removal of already accumulated policies, programmes, and processes that reinforce racism. © 2021 ErichFend/Shutterstock2021 This phenomenon also applies to the care individual patients receive. Physician–scientist Tamorah Lewis has described “cumulative deprioritization” in health-care settings: as health professionals make constant decisions about allocating limited resources of supply, time, and attention, “implicit bias and deep subconscious beliefs about who matters and who is more valuable/dispensable creep in”. The many small delays or relative disadvantages in the delivery of care compound and lead to inequitable outcomes by race. And yet this gradual accumulation can go unseen by health-care providers at a macro level. Thus, in patient care, I would argue, the easy-in harms Lewis describes are matched with a tough-out system of corrections. If we recognise the disparities in patients' outcomes on the basis of race and ethnicity, and as we begin to understand the mechanistic, logistical, and structural underpinnings, what actions are needed to prevent or course correct in real time at the bedside? What are the release valves for racism?

tem of corrections. If we recognise the disparities in patients' outcomes on the basis of race and ethnicity, and as we begin to understand the mechanistic, logistical, and structural underpinnings, what actions are needed to prevent or course correct in real time at the bedside? What are the release valves for racism? Medicine recently lost a physician in a scenario that prompts reflection on such questions. Susan Moore was a Black woman and a physician who contracted COVID-19 in November, 2020. During her initial hospitalisation, she posted online, voicing her concerns about facing racial discrimination. She described how pain medication was withheld and how her symptoms were dismissed, leaving her feeling that she had to beg for appropriate treatment. “I put forth and I maintain if I was white”, Moore said in a video, “I wouldn't have to go through that.” Shortly after her discharge, she presented to another hospital, febrile and hypotensive. She was intubated within days and died on Dec 20, 2021. When inequities in care begin to accumulate before our very eyes, what effective countermeasures are needed to dismantle them in the moment? In the aftermath of Moore's tragic death, will medicine begin to identify and use such measures? There is no question that in both health systems and the daily actions of clinicians, we remain far less facile and assured in removing racism than we are in incorporating it. And until that imbalance changes, our statements and aspirations about being anti-racist cannot connect meaningfully to progress.