By Sheela Ivlev, MS, OTR/L
June 10, 2020
Racism touches every aspect of society, including healthcare. As health care providers, we have an ethical obligation to serve patients equally regardless of race. Yet, provider bias places patients’ health and lives at risk daily, whether or not we are aware of it.
We work with patients when they are at their most vulnerable. Most of us know the uncertainty, pain, and worry we face when we are physically or mentally unwell and seek help. Now imagine adding to this the weight of fear and stress associated with racial bias and the risk of receiving worse treatment because of skin color. This is the reality of millions of Americans navigating our healthcare system daily.
Health Care and Outcomes
Both race and socio-economic factors play a significant role in health risks. People of color (POC) and poor people receive worse health care and have less access to care than White and wealthy people.
These stark statistics are a sample of the bleak reality that POC face in healthcare. Latinx and Black Americans experience 30–40% poorer health outcomes than White Americans, leading to increased illness and shortened lives. Over 4.2 million Black people have died needlessly in the past 60 years due to racial disparities in health care. Though overall health outcomes have improved over the years, Black people have higher rates of health risks and deaths than White people. Black and Native American infants die at significantly higher rates, and Black children are twice as likely to die during their first year of life than White children. Black and Native American women are two to three times more likely to die from pregnancy-related conditions than White women, which increases to four to five times after the age of 30, read Shalon Irving’s story. In 2018, 26.7 out of 100,000 Black women died from breast cancer compared to 19.3 out of 100,000 White women; this isn’t a new trend. There are many stories of Black people dying after being denied testing and treatment for COVID-19, which is killing Black people at a rate 2.4 times higher than White people. Black people have more negative health outcomes than any other POC. Think of any disease or health condition, and there are racial disparities in health care and health outcomes for all of them.
Even clinical trials marginalize. Black people make up 12% of the U.S. population but only 5% in clinical trials. Latinx individuals make up 16% of the population but represent only 1% of clinical trial participants.
Racial Trauma and Health
It is essential to understand the role of racial trauma and its impact on health. Racial trauma is a form of race-based stress experienced by people of color in reaction to dangerous events and racial discrimination, including witnessing racial discrimination toward other POC. It involves both individual and collective injuries from exposure and reexposure to race-based stress. These injuries are ongoing, lifelong, and often intergenerational. Black, Asian, Hispanic, and Native American adults report that race is the main reason they have experienced prejudice. Black adults report experiencing the most discrimination. Race-related stress increases vigilance and contributes to chronically elevated stress hormone levels that can lead to changes in the brain, immune system, and DNA. This stress results in longterm negative consequences for physical and mental health outcomes. The toll of racism is associated with higher maternal and infant mortality rates and poor pre and perinatal outcomes.
Bias in Care
Bias leads to unequal treatment and outcomes. Explicit or intentional bias is apparent. Then there’s implicit or unconscious bias, which can be either negative or positive and happens unintentionally. Stereotypes inform unconscious biases. Being aware of a stereotype can influence decisions, even if we don’t believe the stereotype to be true. False beliefs about POC like “black people’s skin is thicker than white people’s skin,” results in inaccurate and sometimes harmful treatment. One in five patients reports experiencing discrimination, with Black patients noting racial prejudice as the reason for poor treatment. Take the time to read these personal accounts of discrimination in health care.
What Can Providers Do?
People of color are dying from discrimination. They are dying from a lack of access, funds, availability, and awareness of services and health information. Here are some ideas on where to begin to break down the barriers to care and make lasting changes to combat racism in healthcare:
To overcome unconscious bias, we must first acknowledge it. Start by taking Harvard’s Implicit Association Test and watch UCLA’s video series on implicit bias.
Look for tells of bias, such as less time touching a patient, more time looking at other providers or the computer, and subtle body language (e.g., arms crossed, hands in pockets, standing further away from a patient in bed, etc.).
Remember to check our colleagues’ bias too. It is our responsibility to call them out when they are discriminating, being biased, and doing harm. Things will change if we hold each other accountable. If we feel discomfort in confronting a colleague, let’s remind ourselves of the discomfort and violation of rights that a patient may be subjected to when seeking care from this individual if we do not speak up.
Now is not the time to stop seeing color. It doesn’t help and makes things worse. Acknowledge the difference and respect it. Taking the time to understand each individual’s unique experiences, strengths, and limitations will result in more effective treatment, higher compliance, and better health outcomes.
Consider alternate language options for information sheets. Hospitals are required to provide language translation services, but these services don’t always get used because it takes longer to see a patient. Can we provide appropriate care if we can’t understand our patients, and they can’t understand us?
Make considerations for POC and low-income individuals in treatment and interventions. Many recommendations are predetermined based on the diagnosis. How will our recommendations work if patients can’t afford or have no access to what we are recommending? Are there cultural considerations that impact compliance?
A patient’s lifestyle and choices are often associated with increased health risks. Take patients’ lives into account. Are we considering their opportunities, environment, supports, and daily and likely life-long exposure to racism?
Many POC face numerous barriers to accessing health care, including lack of insurance, low-quality coverage, provider availability, language barriers, and distrust in providers. If unable to take on a patient, find alternate providers instead of turning them away.
Ask employers what they are doing to increase diversity in the workplace. More people of color in healthcare will increase trust, reduce language barriers, and improve cultural competence. Ask for more cultural awareness training in addition to personal work on cultural humility.
Improving the overall quality of care reduces disparities for POC. When hospitals report race in their quality measures, care improves for POC. Improve quality and equity to serve everyone better.
Educate interns and students on the disparities, so they can be more conscientious in their careers and educate their peers and subordinates. Remind seasoned colleagues as well; this will only further their commitment to the cause.
Connect with community organizations that support POC and low-income individuals. Offer education and outreach. Let people know what their health risks are, where, and how they can access care. When possible, offer services pro bono or consult with community providers to increase access, availability, and affordability.
Reach out to local schools in underprivileged neighborhoods and schools with diverse student bodies and offer talk to students about our healthcare careers. Be sure to tell them why we love what we do, the steps to entering our profession, why our field needs representation from all backgrounds, and how they fit into this picture.
What Can Patients Do?
If you are a patient who has been discriminated against, you have the right to report any unethical behavior or mistreatment. You can file a complaint with your state health department about the facility. For grievances about specific providers, contact that professional’s state licensing board. The Joint Commission accredits 80% of hospitals, report concerns here. For discrimination in violation of your civil rights, file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights.
A Commitment to Anti-Racism
We chose a helping profession for a reason, and the majority of us do what’s in our power to provide the best care we can for all of our patients. Let’s commit to undoing centuries of hurt and harm and fight for what we believe in — appropriate health care for all. It’s simply not enough to not be racist; we must be anti-racist to transform the system.