2020 Rise to the challenge

Abstract

This is not how I planned this Address to go. I had hoped for a large get-together to celebrate the annual meeting, perhaps with a breakout session of the Society for Vascular Surfing, with some Italian wine and local craft beers. I would talk about aortic aneurysms, either screening or physician-modified endografts. However, coronavirus disease 2019 (COVID-19) changed everything. It presented challenges for all of us. It brought fear and vulnerability. We were unable to care for our patients in the manner in which we had been trained, which was very frustrating. We put our practices on hold. This had affected our pay for many of us. But vascular surgeons rose to the challenge. Many of us formed line services, jumping into the fray and performing procedures on those acutely ill. Others became ICU (intensive care unit) doctors managing ventilators for COVID-19 patients. Others took care of COVID-19 patients on the floor. One of us went to New York City to help at the Jacob Javits Center. Several of our members were practicing at busy referral centers in Manhattan that were overwhelmed with COVID-19, and I suspect that they have been forever changed by the experience. We got new uniforms. We learned new terminology. Most of us had never heard of “social distancing” before, or PPE (personal protective equipment), or telehealth, or Zoom (except for those of us old enough to remember the children's television show filmed here in Boston many years ago). We have learned how to use the new technology, perhaps a bit slowly. We have all seen various troubles with the mute button and struggled with when to talk and when to listen. However, the technology is actually quite good and has helped many patients receive care. I plan to continue to use it extensively even after mass vaccination to help those patients who must travel a long distance and do not like driving and parking in Boston. The vascular surgery community should be congratulated for their management of COVID-19. But then came another issue, one that is much harder. It can be difficult to recognize, especially when we do not look for it or if we look away. For this, no vaccine will be forthcoming. The murder of George Floyd at the hands of police was caught on film and seen around the world. It is painful to look at; however, imagine his pain, and the pain of his family, and the pain of every person of color who must worry that this could happen to them. There is Breonna Taylor, Ahmaud Arbery, Daniel Prude, and countless others that, if I took the time to name them all, I would have room for little else. This has sparked outrage and protest. The protest has been multicultural, multiracial, and multigenerational. Perhaps an opportunity is here, finally, for meaningful change. You might be asking why I chose to discuss this topic and why now for the New England Society for Vascular Surgery (NESVS) Presidential Address. I believe it is crucial to understand the impact on our patients, our trainees, and our society—both broadly and in our NESVS. I really did not believe it was appropriate for me to discuss anything else. I was recently asked to author a chapter for the upcoming textbook Vascular Disease in Women, edited by Caitlin Hicks and Linda Harris. The chapter was titled “Race and Cultural Issues in Vascular Disease.” My co-author was Christy Marcaccio, and the work was based in part on previous studies completed by former research fellows Pete Soden, Tom O'Donnell, Sarah Deery, and Axel Pothof. Christy found this definition of health disparities that we liked: “A particular type of health difference that is closely linked with economic, social, or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”1Secretary’s Advisory CommitteeSecretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020: Phase I Report Recommendations for the Framework and Format of Healthy People.https://www.healthypeople.gov/2020/About-Healthy-People/History-Development-Healthy-People-2020/Advisory-CommitteeDate accessed: January 22, 2021Google Scholar I recently read a series on structural racism and health inequities in the United States in the Lancet.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar According to Bailey et al,2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar “structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, median, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distributions of resources.” Health care disparities result from a complex interplay of numerous factors, many of which are challenging to study. Adil Haider's conceptual model lists five major themes, which include patient factors, provider factors, system and access issues, clinical care and quality, and postoperative care and rehabilitation, all of which contribute to disparities in surgical patient populations.3Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. Hisam B. Kodadek L.M. Lilley E.J. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Census data have shown that across the United States, black Americans constitute 13% of the population compared with 76% white and 6% Asian. However, in New England, the black population is lower at 7% and, in northern New England, decreases to less than 2%. The Hispanic population is also lower in New England at 11% compared with 19% across the United States. Data from the Centers from Disease Control and Prevention and elsewhere have predicted that the non-Hispanic white population will no longer be the majority in ∼20 to 30 years, with the largest growth expected in the Hispanic population. The life expectancy in the United States is greater for women than for men (81 vs 76 years). However, it is 4 years less for black people compared with white people (75 vs 79 years) and greater for Hispanic people (82 years). Considering atherosclerotic risk factors, the epidemic of obesity is worst for black women (57%), followed by Hispanic women (47%), Hispanic and black men and white women (38%), and white men (35%) and is lowest for Asian women (12%) and men (13%).4Flegal K.M. Kruszon-Moran D. Carroll M.D. Fryar C.D. Ogden C.L. Trends in obesity among adults in the United States, 2005 to 2014.JAMA. 2016; 315: 2284-2291Crossref PubMed Scopus (2015) Google Scholar Black women and men are most often affected by hypertension (41% and 39%), with the proportion for white and Hispanic men and women ranging from 26% to 28% for all.5Cutler J.A. Sorlie P.D. Wolz M. Thom T. Fields L.E. Roccella E.J. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988-1994 and 1999-2004.Hypertension. 2008; 52: 818-827Crossref PubMed Scopus (737) Google Scholar Smoking rates are highest among Native American men and women at roughly 25%, followed by black and white men (23% and 18%), white and black women (16% and 15%), and Hispanic and Asian men (15% and 13%), with the lowest rates seen in Asian and Hispanic women (8% and 4%).6Drope J. Liber A.C. Cahn Z. Stoklosa M. Kennedy R. Douglas C.E. et al.Who’s still smoking? Disparities in adult cigarette smoking prevalence in the United States.CA Cancer J Clin. 2018; 68: 106-115Crossref PubMed Scopus (197) Google Scholar We have previously evaluated the presentation and treatment of vascular disease by race7Soden P.A. Zettervall S.L. Deery S.E. Hughes K. Stoner M.C. Goodney P.P. et al.Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention.J Vasc Surg. 2018; 67: 549-556.e3Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar (Fig 1). Analysis of the data from the Vascular Quality Initiative showed that black patients undergo vascular surgery at more advanced stages of disease compared with white patients. They are more likely to undergo carotid endarterectomy for symptomatic disease. When symptomatic, they are more likely to have stroke as the presenting symptom. They are also more likely to require abdominal aortic aneurysm (AAA) repair for a symptomatic or ruptured aneurysm. They are more likely to require lower extremity intervention for limb threat and not claudication compared with white patients. Black patients are also less likely to be treated with aspirin or a statin, even at discharge, representing a missed opportunity provide an intervention. Among patients who underwent endovascular aneurysm repair (EVAR) in the National Surgical Quality Improvement Program, Hispanic and black patients were more likely to have received nonelective EVAR than were white patients (26% vs 35% vs 18%, respectively).8Yang Y. Lehman E.B. Aziz F. African Americans are less likely to have elective endovascular repair of abdominal aortic aneurysms.J Vasc Surg. 2019; 70: 462-470Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Not only are black and Hispanic patients less likely to undergo elective AAA repair, but, also, when they do undergo repair, they are more likely to receive treatment at low-volume facilities compared with white patients.9Williams T.K. Schneider E.B. Black J.H. Lum Y.W. Freischlag J.A. Perler B.A. et al.Disparities in outcomes for Hispanic patients undergoing endovascular and open abdominal aortic aneurysm repair.Ann Vasc Surg. 2013; 27: 29-37Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 10Vogel T.R. Cantor J.C. Dombrovskiy V.Y. Haser P.B. Graham A.M. AAA repair: sociodemographic disparities in management and outcomes.Vasc Endovascular Surg. 2009; 42: 555-560Crossref Scopus (53) Google Scholar, 11Lemaire A. Cook C. Tackett S. Mendes D.M. Shortell C.K. The impact of race and insurance type on the outcome of endovascular abdominal aortic aneurysm (AAA) repair.J Vasc Surg. 2008; 47: 1172-1180Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 12Deery S.E. O’Donnell T.F.X. Shean K.E. Darling J.D. Soden P.A. Hughes K. et al.Racial disparities in outcomes after intact abdominal aortic aneurysm repair.J Vasc Surg. 2018; 67: 1059-1067Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Unequal access to high-quality centers is an important contributing factor to racial disparities. Black patients are known to have increased perioperative morbidity after AAA repair compared with White patients, with longer operations, higher blood loss, longer hospital stays, more returns to the operating room, and more likely to require dialysis postoperatively. Using the Nationwide Inpatient Sample, Rowe et al13Rowe V.L. Weaver F.A. Lane J.S. Etzioni D.A. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006.J Vasc Surg. 2010; 51: 21S-26SAbstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar reported that black and Hispanic patients are far more likely to undergo amputation during ad admission for peripheral artery disease than were white patients13Rowe V.L. Weaver F.A. Lane J.S. Etzioni D.A. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006.J Vasc Surg. 2010; 51: 21S-26SAbstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar (Fig 2). Morrissey et al14Morrissey N.J. Giacovelli J. Egorova N. Gelijns A. Moskowitz A. McKinsey J. et al.Disparities in the treatment and outcomes of vascular disease in Hispanic patients.J Vasc Surg. 2007; 46: 971-978Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar used statewide discharge data from New York and Florida and found that compared with non-Hispanic white patients, Hispanic patients were less likely to undergo lower extremity and carotid revascularization or AAA repair but were more likely to present with symptomatic carotid disease, ruptured AAAs, and limb-threatening ischemia and were more likely to undergo amputation. John Birkmeyer's group found that among Medicare beneficiaries, black patients were less likely to undergo an attempt at revascularization before amputation compared with white patients (24% vs 32%).15Holman K.H. Henke P.K. Dimick J.B. Birkmeyer J.D. Racial disparities in the use of revascularization before leg amputation in Medicare patients.J Vasc Surg. 2011; 54: 420-426.e1Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Perez et al16Perez N.P. Stapleton S.M. Tabrizi M.B. Watkins M.T. Lillemoe K.D. Kelleher C.M. et al.The impact of race on choice of location for elective surgical care in New York City.Am J Surg. 2020; 219: 557-562Abstract Full Text Full Text PDF Scopus (3) Google Scholar showed that among people living in the Bronx, white patients were more likely than either Hispanic or black patients to travel to Manhattan for major surgery.Fig 2Black and Hispanic patients are more likely to undergo amputation during an admission for peripheral arterial disease (PAD) than are white patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Black and Hispanic Americans have been disproportionately affected by COVID-19 with a death rate 2.8-fold greater than that for non-Hispanic whites according to the Centers for Disease Control and Prevention.17Centers for Disease Control and PreventionRisk for COVID-19 Infection, Hospitalization, and Death by Race/Ethnicity.https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.htmlDate accessed: August 2, 2020Google Scholar Martin Luther King said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” So how did we get here? This is a tough one but is crucial for real understanding. We must be honest with ourselves and acknowledge that it traces back to the origins of our country and slavery.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar,19Wildeman C. Wang E.A. Mass incarceration, public health, and widening inequality in the USA.Lancet. 2017; 389: 1464-1474Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar I found out last week that one of my more famous ancestors was a slave owner from a web excerpt describing how Symon Schermerhorn, an early settler of Schenectady where I grew up, was attacked during what was called the French and Indian war.20Schenectady Digital History ArchiveSchermerhorn Genealogy and Family Chronicles: Chapter III: Descendants of Simon Jacobse Schermerhorn (Part 1 of 2).http://www.schenectadyhistory.org/families/schermerhorn/chronicles/3a.htmlDate accessed: August 2, 2020Google Scholar I had known that his family members were killed, and he was shot in the leg and rode his horse the 20 miles to Albany, successfully warning them so they could fend off the attack. However, I recently found out that he had had three slaves who were also killed—11 of the 60 people killed in the Schenectady massacre were slaves. We often think of slavery as being a southern issue and that the northerners were all against slavery. However, 40% of the households in New York owned slaves in the 1700s.21Harris L.M. In the Shadow of Slavery: African Americans in New York City, 1626-1863. University of Chicago Press Books, Chicago2007Google Scholar Slavery was common in every New England state. The earliest slaves were primarily Native Americans until the 18th century, when they were violently forced onto reservations and were replaced with Africans. New Englanders were active participants in the slave trade and profited from it greatly. Slavery was not abolished in New York until 1827; Rhode Island banned slavery in 1843 and New Hampshire in 1865 with ratification of the 13th Amendment. Certainly, a greater number of slaves were in the south because that was where the large plantations were located; however, Northerners were guilty as well. All freed slave families were promised 40 acres of land and a mule. However, that same year in 1865, President Andrew Johnson ordered all land under federal control returned to previous owners and only 30,000 freed slaves in the south had owned land and 4 million had not.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar After slavery was abolished, conditions were still very slow to improve, with Jim Crow laws and segregation laws enacted that kept black Americans as second-class citizens. Selective imprisonment for unemployment and vagrancy led to a population of black men who could continue to provide free labor during their imprisonment or cheap labor as sharecroppers, often not earning enough to pay their rent and with extremely limited ability to buy land. Although these laws were slowly removed over many years, we still have segregation. After World War II, the Federal Housing Administration (FHA) and Veterans Affairs provided federally subsidized housing grants that allowed primarily white people to purchase homes in the suburbs, with low-income housing built in cities.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar Only 2% of the $120 billion in FHA loans from 1934 to 1962 was awarded to nonwhite families. The federal government under Franklin D. Roosevelt believed that if black families were allowed to move in to these suburbs, it would adversely affect the value of the homes they had subsidized (without evidence). In fact, the evidence was to the contrary, because black families were willing to pay more owing to their more limited housing opportunities. The FHA manual stated that the best financial “bets” were those in which safeguards such as highways separating communities could prevent the infiltration of lower class occupancy and inharmonious racial groups. The 1944 GI bill guaranteed mortgages to veterans but were designed to accommodate Jim Crow laws. Thus, banks could refuse to lend to black veterans despite the federal backing. In Mississippi, only 2 of 3000 mortgages on the GI bill went to black men, although one half of the state's veterans were black. “Red-lining” is the term that many have heard; it describes the practice of the Home-Owners Loan Corporation, established as a part of the New Deal, which created maps to assess the risk of mortgage refinancing and federal underwriting and was based in part on racial composition. Areas considered high risk or “hazardous” were colored in red; thus, the term “red-lining.” Subsidized loans were not provided to the red areas. The long-term effects are evident in that 74% of these “hazardous” areas remain low to moderate income today and >60% are predominantly nonwhite. Local politics usually pushed the low-income housing units into nonwhite neighborhoods with zoning restrictions.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar City planners zoned areas adjacent to multifamily homes for commercial and industrial use with subsequent exposure to environmental hazards, further slowing the appreciation of the home values in these areas. In 1910, zoning laws were race based in that black families could not purchase homes in predominantly white neighborhoods and vice versa. This was stricken down by the Supreme Court in 1917. However, the reason the Supreme Court gave was that this limited the ability of white homeowners to sell houses. Real estate brokers who lived in a predominantly white suburb would often refuse to show houses in white neighborhoods to black people.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar When black people did attempt to move into the suburbs, they were often met with violence and other forms of intimidation. Other real estate brokers would do something quite different, known as “block-busting,” where they would tell white homeowners that a black family that moved in had lowered their property value and that they should sell to the broker immediately, telling them “don't be the last one out.” They would then resell the property to another black family at a large markup. A declining inner-city tax base and the lack of state funding led to urban decay.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar Also, busing in its attempt to equalize education led to further outmigration of white people to the suburbs or to private schools, such that predominantly white inner-city schools quickly became predominately black within many cities. In addition, the suburban tax base and federal support led to business development and greater appreciation of home values in white suburbs. Rather than explicitly ban black people from neighborhoods, they were subsequently zoned for single family dwellings because white people were far more likely to be able to afford these. This prevented the building of apartment buildings and multifamily homes. At the turn of the 21st century, lenders had sold a disproportionate amount of higher interest “subprime” loans to black families, although many were qualified for better lower interest loans. At the financial crisis, black and Latino families lost 48% and 44% of their wealth, in part resulting from these practices. Another example of structural racism is the Social Security Act of 1935, which deliberately excluded agricultural workers and domestic servants, positions held largely by black men and women. In 1972, we declared war on drugs. This led to a continuation of the disproportionate imprisonment of black men.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,19Wildeman C. Wang E.A. Mass incarceration, public health, and widening inequality in the USA.Lancet. 2017; 389: 1464-1474Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar,22Alexander M. The New Jim Crow. The American Prospect, 2010https://prospect.org/special-report/new-jim-crow/Date accessed: August 2, 2020Google Scholar Given how common marijuana was, there could never be complete enforcement; thus, enforcement was selective. Mandatory sentencing laws were inherently racist; as an example, the punishment for possession of 1 oz of crack cocaine (affordable in poor communities) was the same as that for 100 oz of powder cocaine (preferred by the wealthy white). Possession of two “joints” has led to sentences as long as 13 years. Prisons became filled with nonviolent criminals. Labels such as “super-predators” were introduced, leading to intensified policing in black communities and harsher sentencing. At present, 1 in 3 black men will be imprisoned during their lifetime compared with 1 in 17 white men. Black men constitute 6% of the U.S. population but 40% of the U.S. incarcerated population. Even after release, they are labeled as felons and subject to legal discrimination in employment and housing. They are denied the right to vote, food stamps, and other public benefits. Prisons also became a cash crop for private companies, as well as for some state and local police departments, being paid more for each prisoner at the expense of taxpayers.19Wildeman C. Wang E.A. Mass incarceration, public health, and widening inequality in the USA.Lancet. 2017; 389: 1464-1474Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar,22Alexander M. The New Jim Crow. The American Prospect, 2010https://prospect.org/special-report/new-jim-crow/Date accessed: August 2, 2020Google Scholar This cash incentive to police departments created a vicious circle. The recent opioid crisis led to the incarceration of numerous white people and has forced a rethinking of incarceration vs rehabilitation. The trends of incarceration in 21 developed democracies from the 1980s through the early 2000s are shown in Fig 3. The United States is in the bottom right corner. It speaks for itself. Sadly, this is how we arrived here, but I am only scratching the surface. If we cannot understand and acknowledge it, we are unlikely to change it. The current disparity in accumulated wealth is striking at >100k for whites and ∼7k for Hispanics and blacks.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar Similar disparities are present in the percentage living below the poverty level at 10% for whites and ∼25% for Hispanics and blacks. Unemployment is also twice as high for blacks (11%) as for whites (5%). The incarceration rates are sixfold greater for blacks than for whites and are also higher for Native Americans and Latinos than for whites. Hispanics and Native Americans have the highest rates of those uninsured (26% and 28% vs 13% for whites). Infant mortality is also twice as high in the black population as in the white population. Two examples of employment discrimination have been highlighted by studies that showed that with fictional resumes identical other than in the name, white names such as Brad or Emily were 50% more likely to receive a call for an interview than were black names such as Jamal or Lakisha.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar Similarly, another study found that with otherwise identical fictional applications, white applicants with a criminal record were more likely to be called for an interview than were black applicants without a criminal record. Structural racism leads to health inequities.2Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (1837) Google Scholar,18Sugrue T.J. The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit. Princeton University Press, Princeton, NJ2014Crossref Google Scholar Most research has focused on interpersonal racism because it is easier to identify, especially when it is overt. However, microaggressions, which can be inadvertent, such as a judge asking a black defense attorney, “Can you wait outside until your attorney gets here?” also have an effect. These have been associated with primarily mental health issues such as depression, anxiety, loss of self-esteem and life satisfaction but also with sleep disturbances that can affect physical health. Residential segregation affects access to transportation, education, employment opportunities, home value appreciation, and health car