Applying a Racial Equity Analysis: Medical Care Past and Present

August 11, 2020
By Yanique Redwood

In 2018, CHF began contributing short blogs that apply a racial equity analysis to different issues. These blogs are not intended to provide solutions. Rather, they apply a lens to issues to give our partners a sense of the kinds of questions that they can ask to sharpen their racial equity analysis. Read the previous blogs here. Read the Spanish translation of this blog here


Here at CHF, we rarely talk about medical care. As a health foundation, we recognize that only a small portion of our health—20% according to experts—is determined by what happens in medical care settings. The rest of our health is determined by the food available nearby, the quality of our neighborhoods, access to wealth to weather financial storms, sleeping at night in safe and affordable housing, learning in identity-affirming schools and the ability to enjoy the fruits of secure living wage jobs.

Yet, as we witness COVID-19 ravage communities of color, I can’t help but wonder how people are faring inside of medical care settings that have never been racially equitable or just.

I don’t have to go back in history to find examples of racism and medical care. It exists today. We wrote about it in this blog on maternal mortality in the District of Columbia. But, to apply a racial equity lens to any issue requires a historical analysis. The purpose of taking a historical approach is two-fold. First, it establishes how ingrained racism is and thus how powerful the solutions need to be in order to undo centuries of efforts to cement and perfect racial hierarchy. Second, it debunks the oft-repeated arguments that pin devastating outcomes on the very people who have suffered as a result of these intentional efforts to establish racial hierarchies.

Racism and Healthcare: The Pain Example

Last year I read Ibram Kendi’s Stamped from the Beginning: The Definitive History of Racist Ideas in America. While most of the book left me shaking my head, jotting exclamation points in the margins, and at times laughing at the absurdity of racial hierarchy, no section of the book shook me like the story of J. Marion Sims. Just one paragraph was devoted to him, but I had to set the book aside for a week or two after reading this paragraph. The pain of reading it was searing. I felt it in my body.

If you don’t know the name J. Marion Sims, you absolutely should. He is touted as the father of gynecology. Beginning in 1845, he experimented on the vaginas of eleven enslaved women for a procedure to heal a complication of childbirth called vesicovaginal fistula. He did this without anesthesia even though he noted in his memoir “Lucy’s agony was extreme.” Another woman, Anarcha, was experimented on thirty times to perfect the procedure for curing fistula.

Marion Sims then packed up his lessons and moved from Alabama to New York to build the first woman’s hospital to heal white women. While he noted that it was too much trouble to use anesthesia on the Black women at the center of his experiments, he was sure to use anesthesia on the white women at his hospital. A statue of him sat across from the Academy of Medicine in New York for decades and was removed in 2018 after immense pressure from activists and academics.

This story of J. Marion Sims, Lucy, Anarcha and the other women who experienced medical racism under his knife is a 175-year precursor to a recent pain study by Hoffman and others published in 2016 in the Proceedings of the National Academy of Sciences. The researchers in this study found that physicians who more strongly endorsed false beliefs about biological differences between Blacks and whites reported lower pain ratings and made less accurate treatment recommendations than physicians who did not hold these beliefs.

The chart below highlights some of these biases. Of note, there is a false belief that Blacks’ nerve endings are less sensitive than whites and that Blacks’ skin is thicker than whites, which is believed to be the biggest contributors to inaccurate treatment recommendations related to pain. As you can imagine, many have suffered and died as a result of this racial hierarchy cemented and perfected in our medical care system. Many patients have been blamed for not taking action, when in fact they are often not listened to when they do act.

 

 

 

 

 

 

 

 

 

Addressing Implicit Bias in Health Care Delivery

My friend Adaeze Enekwechi co-authored a Health Affairs blog earlier this year with her colleague Shantanu Agrawal. They outlined a reform agenda for the healthcare delivery system. While they, too, welcome the attention to the social determinants of health, they refuse to let the healthcare system off the hook. They eschew the supposition that social issues exist outside of healthcare. In the article, they tell stories of Latinx patients in pain being labeled with the term “hispanicus hystericus” and Black children not receiving topical anesthetics provided to white children.

Their reform agenda includes bias training in medical, nursing and other allied health schools as well as hospitals and delivery systems. They advocate for interpretation and translation services to ensure that every clinician and care team can, at a minimum, communicate with patients in real time. They recommend that chief equity officers become a mainstay of delivery systems to 1) address performance issues related to quality and access for all patients; 2) oversee staff training and accountability; and 3) engage with communities to focus on the social determinants of health. In addition, they call for a diversified pipeline and performance metrics and incentives that reflect a comprehensive approach to equity. Many of these recommendations are also in this article that I co-wrote with trustee Christopher King in 2017.

Beyond these reform ideas that I wholly support, I am also asking some new questions, versions of which, should be included in racial equity impact assessments: How do medical systems benefit from racial hierarchy? What narrative does racial hierarchy allow them to uphold? Where does racism show up, not just in institutional policies and practices, but also in the very knowledge that doctors and nurses possess? In what ways can communities heal themselves? What spaces, time and training do communities need to develop and implement their own systems of care? Without the answers to these questions, I fear that all the training, incentives and staff diversity in the world won’t change a single thing.

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