“Although it is popular to blame the poor for their poor health by pointing to risky health behaviors, careful studies of nationally representative populations conclude that the significantly higher prevalence of cigarette smoking, alcohol consumption, obesity, and physical inactivity are only one aspect of the relationship between lower socioeconomic status and poor health. Moreover, behavioral disparities must not be taken out of their societal context where unequal exposure to the stress of discrimination, inequitable access to healthy food and built environments, and inferior access to resources generally are integrally associated with many racial and ethnic differences in health behavior. In fact, racial and ethnic differences in health treatment and outcomes persist in multiple studies even after controlling for differences in insurance status, income, education, geography, and socioeconomic status.”

Matthew’s analysis rejects the simplistic association between individual behaviors and poor health outcomes when it comes to BIPOC populations. She argues that health outcomes are inseparable from broader societal factors such as discrimination, unequal access to resources, and structural inequities. She challenges the tendency to place blame solely on personal choices, arguing that the systemic stressors and environmental disadvantages faced by marginalized communities are much more accurate in terms of predicting health disparities.

“This book lays bare a disturbing contradiction. On one hand, injustice and inequality are anathema to our professed national identity. Yet on the other hand, unconscious bias has become an entrenched and acceptable social norm, empirically demonstrated to control decision-makers not only in health care, but in civil and criminal justice proceedings, law enforcement, employment, media, and education. Unconscious racism has become the new normal. Thus, to defeat inequality due to unconscious racism in health care, individuals as well as institutions must realign themselves away from this social norm that is incongruous with the core underlying values to which our nation’s doctors, patients, and health care professionals expressly aspire. The solutions this book proposes are comprehensive; they have their origin in law, and to some this may seem radical. But they are solutions grounded in a historical and empirical record.”

In her introduction, Matthew discusses the troubling paradox between America’s professed commitment to justice and the pervasive influence of unconscious bias, which subtly perpetuates racial inequality across multiple sectors. She argues that unconscious racism has become so normalized that it undermines the values of fairness and equality, particularly in healthcare, emphasizing The Systemic Challenge in Addressing Implicit Bias. Matthew asserts that addressing this systemic issue requires a fundamental shift in both individual and institutional practices, grounded in legal reforms that challenge entrenched biases.

“Tragically, the American legal system began during colonial times to sow the seeds of health inequality. The weak legal regime that currently regulates modern health care delivery continues to provide fertile ground for rampant health care discrimination today. Throughout most of our country’s history, the rule of law has been perversely instrumental in enabling the racism—both conscious and unconscious—that has produced, and continues to exacerbate, the unjust distribution of health care, as well as other resources that permit people to live healthy lives, such as property, wealth, income, housing, food, employment, and education.”

Matthew critiques the American legal system for being complicit in fostering health inequality. Throughout the book, Matthew makes a case for recognizing the historical roots of racism in America’s institutions. She emphasizes that the current legal framework remains inadequate in addressing these inequalities, perpetuating discrimination in healthcare delivery.