Diagnosis: Racial Bias

“This is the week, here we go!” I tell myself with a mixture of dread and excitement.

For the last two years I have co-led a weekly class where several hours of the course are dedicated to racism and bias in medicine. I walked into the week with a bit of dread because I know, given the demographic and geographic characteristics of my medical students, there is going to be resistance. I had to prep myself going in that at least some of my students were going to reject a reality that plagues our healthcare system: racial bias.

I knew this because I live and work in the State of Idaho, in a medical program that exclusively draws it’s students from the State, many from rural communities. However, I was also excited because I had the opportunity to teach such an important topic. These are future physicians many who are not aware of these facts. What’s great, is that now we are requiring these topics to be a part of their medical education.

Medicine and Racial Prejudice

Race and medicine is a topic in which everyone – patient and provider alike, regardless of racial or ethnic identification – needs to be made aware. The racial biases that exist in our world bleed into our healthcare system preventing many minorities from receiving equitable care. Healthy People 2020 defines health equity as medical persons addressing the avoidable, historical, and current injustices that create health disparities or differences in health outcomes across groups. These differences show up for example in rates of death and disease between groups based on their race, religion, gender, or other characteristics historically linked to discrimination or exclusion.

I’m sure many of you are saying to yourself, “well this doesn’t happen today.” “People are not dying from various illnesses or infections because medical personnel are refusing to care for them based on their race, religion, gender, or what have you.” “That goes against their oath to care for sick persons!” The truth is that yes, this is still a problem in 2019. African-Americans and other racial/ethnic minorities have historically been and remain affected by healthcare disparities. And it is important that we call it out so we can address it!

A History of Malpractice

The Institute of Medicine (IOM) found that various sources, including the bias, stereotyping, and prejudice of health systems and health care providers, are contributing to racial and ethnic disparities. In fact, they suggest they may be related to worse health outcomes among the racial/ethnic groups affected (Betancourt & Ananeh-Firempong, 2004).

For example, the framing of blacks as primitive and inferior has resulted in denied treatment for real ailments. This was seen in the 1932 Tuskegee, AL syphilis experiment on black men. These men were denied treatment for syphilis just so white physicians could identify how syphilis destroys the body. Or, in the case of Henrietta Lacks whose body was used for various scientific experiments for breakthroughs in medicine without her permission, or the permission of her family.

Even as far back as 1758, race has been factored into how patients are viewed and treated. A scientist named Carl Linneaus put humans into categories based on their race assigning them physical and psychological characteristics. Europeans he described as “fair…gentle, acute, inventive…governed by laws,” whereas Africans were described as “black…crafty, indolent, negligent…governed by caprice” (Witzig, 1996). In other words, this scientist used, or manipulated science, to describe Africans or those of African descent as sneaky, lazy, careless, and as people who act on a whim. Can you see how these stereotypes impacted, and still impact, how people of color are treated in society at large? But also, in medicine.

Enduring Effects

Black patients still suffer the same treatment and abuse their ancestors suffered. This history of racism in the U.S. has lingering effects that are evident in the medical care African Americans and other people of color receive. When I coordinated health programs in Tuskegee, AL I saw firsthand how the history of that tragedy still impact blacks in that community. Many, almost 80 years later, still have a poor relationship with healthcare professionals and struggle to trust medical providers. The sad truth is that they still have reason to distrust.

In 2015, the CDC published a report with a special feature on racial and ethnic health disparities. In this report, black mothers had the highest percentage of pre-term births; Hispanic and black children and teenagers had the highest prevalence of obesity (21.9% and 19.5 % respectively, compared to 8.6% in whites); black men (42.4%) and black women (44.4%) had the highest prevalence of high blood pressure, and Hispanic adults were the largest groups without health insurance, followed by blacks (National Center for Health Statistics, 2016).

More recently, the Harvard Public Health magazine has published its winter 2019 report entitled, “America is Failing its Black Mothers.” In this report Amy Roeder writes that “African American women are three to four times more likely to die during or after delivery than are white women. According to the World Health Organization, their odds of surviving childbirth are comparable to to those of women in countries such as Mexico and Uzbekistan, where significant proportions of the population live in poverty.” The study goes on to state this is directly linked to racism and racial bias in medical practices.

Assumptions and Responses

These realities produce several common racial biases in medical practice that include:

  • Lower rates of major surgical procedures for black Medicare patients
  • Lower rates of pain control medication given for broken bones for African American children seeking care in emergency rooms
  • Lower quality of basic hospital services for things like pneumonia and congestive heart failure in black patients (Tsai et al., 2016)
  • Fewer referrals for kidney transplants when a patient is on hemodialysis (Betancourt & Ananeh-Firempong, 2004)

 

But there are ways that people of color can navigate racial bias when seeking medical attention:

  1. Listen to your gut. If you know something isn’t right with your body or your provider pay attention, make a note, and make a complaint.
  2. Come prepared for your visit. Have questions related to the reason for your visit ready with notes about your symptoms along with any concerns you have.
  3. Bring someone with you. It is always good to have support and an extra pair of ears to listen to what your provider is saying. They may even ask questions that you haven’t thought of.
  4. Be firm and aggressive. If a provider dismisses your conerns, it’s ok to ask them to explain why you should not be concerned. Make them explain things to you until you fully understand. It’s ok to keep asking questions. Even if someone seems impatient or irritated, it’s your right.
  5. If possible, go to a doctor of your race/ethnicity. There is a chance that this person will be someone who will better understand your physical, mental, cultural, and social needs.
  6. Get recommendations on a healthcare provider from people of your race/ethnicity when possible, people you know have a similar experience as you.

Conclusion

“Even well intentioned physicians may be susceptible to stereotyping and may unknowingly contribute to racial/ethnic disparities in health care,” (Betancourt & Ananeh-Firempong, 2004). Fortunately, these topics are being taught and discussed more and more within healthcare education. Unfortunately, there is still a great deal of work to be done and one cannot rely on every provider to accept and “buy-in” to the reality of racial bias as experienced by their patients.

The fact is, it should not be the responsibility of the people oppressed by the injustices of the healthcare system to fix it. However, until it is fixed we have to protect ourselves. We have to do what we can to get what is needed from a broken system, including self-advocacy, researching providers before visits, identifying and using various support systems (e.g. friends and family), as well as being open to getting second opinions. Ultimately, when it comes to your health always be aware, and always come prepared.




The Starbucks Moment: Take a Second Look

May I offer you a puzzle that I would like you to experience?  Please take a moment and identify the confusion in the following story:

A father and his son, while driving cross country, end up in a terrible car accident. The father dies at the scene and the son, bloody and badly injured, is rushed to the hospital.  In the operating room, the surgeon looks at the boy and shouts, “I can’t operate on this boy. He is my son.”  Fifty to 75% of people have stumbled in finding the solution.   The solution, recounted in Blindspot: Hidden Biases of Good People (Delacorte, 2013), is this: the surgeon is the boy’s mother.

Snap Judgement

Blind spots, or implicit bias, or hidden bias is the tendency to make hair-trigger associations.  Our unconscious takes over, and from among those thousands of mental artifacts and images housed in our brain, we come to a snap judgment or evaluation of a different person. We are left wondering in a conscious moment, “Now why did I think that?” 

In the story above, the very word surgeon was associated with a male by the majority of readers.  This is because of the history of gender-association in the medical profession.  We could change just one word in the story. “The nurse looks at the boy and shouts, ‘I can’t operate on the boy, he’s my son!’” Then the dilemma would have been easily solved—but not for the right reason!

Embed from Getty Images

Real-Time Application

Now, I offer you a second, more recent story—except this time it is altogether true.  On Tuesday, May 29, Starbucks closed more than 8,000 stores to educate its employees in the science of implicit bias. They explored those unconscious attitudes, perspectives, and assumptions often triggered when encountering the “other.” 

Bias is caused by overriding the sub-surface differences in favor of superficial, stereotypical evaluations. African American boys and African American college students and job applicants suffer explicit consequences due to implicit bias.

This decision by the Starbucks’ CEO arose from the April 12, 2018 arrest of two African-American men, Rashon Nelson and Donte Robinson. The two men had been sitting in a Philadelphia Starbucks awaiting a visitor who was a part of a real-estate transaction.  The Starbucks’ employee assumed that two black men “hanging out” in the store, and not ordering a product, must be up to something nefarious.  Video of the arrest of the two gentlemen, filmed by another customer, and taking place over the protests of a white customer, triggered a worldwide conversation about race, prejudice, and of course, implicit bias.

How pervasive is implicit bias?  According to experts in research on implicit bias, implicit bias is resident in every person they tested but in varying degrees.  In-field testing shows that real-time bias continues, and is widespread. For instance, white job applicants get about 50 percent more call-backs than blacks holding the same qualifications. College professors are 26 percent more likely to respond to a student’s email when it is signed by Brad rather than Jaquan.  And, physicians recommend less pain medication for black patients than for white patients with the same injury was what we learned from the 2004 Institute of Medicine’s healthcare disparities research. 

How Martin Luther King, Jr. Addressed Bias

But implicit bias is not new.  One of the classic exposures of implicit bias came from the civil rights era.  Dr. Martin Luther King insightfully attacked implicit bias in his Letter from Birmingham Jail.   King was responding on April 16, 1963 to the “Christians-should-model-law-and-order” criticisms of southern white clergy against the Civil Rights Movement.  We did not have the language, then, but the indictment of bias is central to what he wrote:   

“You deplore the demonstrations taking place in Birmingham.  But your statement, I am sorry to say, fails to express a similar concern for the conditions that brought about the demonstrations.   I am sure that none of you want to rest content with the superficial kind of social analysis that deals merely with effects and does not grapple with underlying causes.  It is unfortunate that demonstrations are taking place in Birmingham, but it is even more unfortunate that the city’s white power structure left the Negro Community with no alternative.” [Emphasis supplied]

King skillfully called out the implicit bias of his colleagues by appealing to reason and justice.

Self-Check

How can we become aware of the implicit bias in each of us?  We can first begin the process by assessing personal attitudes and biases using the Harvard Implicit Associations Test at https://implicit.harvard.edu/.

Second, can we honestly acknowledge that all of us are prone to make snap decisions on surface appearances?  Please indulge my premise—each of us reflects implicit bias in varying degrees—whether gender bias, or racial bias, or class bias, or nationalistic bias, or cultural bias, or numerous others.  These biases are triggered by overriding the sub-surface differences among us, and losing individuality to a stereotypical association. Let me illustrate.

I shall never forget my first trip to Africa 30 years ago.  It was the trip of a lifetime.  I had desired to visit what we warm-heartedly called “the motherland.”  Accordingly, I was steeping myself in the art, culture, and writers of the continent.  I landed in Lagos, Nigeria but my clothes were mistakenly sent to Cairo, Egypt.  My host, seeing my challenging condition, arranged for me to receive some beautiful and colorful Nigerian garments to wear.  Then my host said to me, “Dr. Pollard, let’s go to town center in Lagos so that you can see the city.”  Dressed like the exquisite Nigerian, that’s exactly what we did.

Sub-Surface

While strolling downtown, a little Nigerian street child of no more than six or seven years-old, and his little brother (I assume) approached me. With his upturned palm he began speaking in Yoruba (a tribal language of western Nigeria).  I played along by nodding as if I understood his attempts to get me to give him a donation.  After about two minutes of entertaining his best and most animated appeals, I finally said to him, “I am so sorry, but I don’t understand a word you are saying.”  Then the strangest thing happened.  At the sound of my American accent, a smile crawled across his face as he turned to his little companion and began speaking in perfect English. Giggling, he said to his little companion, “Hurry, hurry!  Come over here and meet the black white man.”

I expected that I would be welcomed as a son of the soil, and of course, I was accepted during my three-week stay.  However, in that moment, the assumptions of my African-ness were restructured by the reality of a small boy’s insight. My little visitor’s quick and comical analysis revealed a profound insight. Surface appearances can trigger responses that confuse situations.  People may look alike, but subsurface differences make the difference. 

Can we honestly acknowledge that all of us are prone to make snap decisions on surface appearances?

See Me

And that’s the third point—let’s do the critical second look at our assumptions about others. Let us view them through critical lenses of their individual story and experiences.  That requires that we get to know them and to dialogue with them. And to “see” them.

So, let’s go back to Starbucks.  The tendency to associate a black male with “trouble,” “criminality,” and/or “social deviance” is unfortunate, but all too common in our society.  In fact, from their earliest years, black boys suffer from implicit bias. According to an April 5, 2018 article by Valerie Strauss published in The Washington Post, “Implicit racial bias causes black boys to be disciplined at school more than whites, federal report finds.”  As early as kindergarten, black boys suffer disproportionately from bias.  So it’s no surprise that Nelson and Robinson were singled out on that April day.  What is surprising is the comprehensiveness of Starbucks response. My prayer is for this Starbucks moment to be transforming for our society!

 

 




Race Talk

Prejudice, discrimination and stereotyping—whether overt or implicit—are alive and unfortunately well. Sue’s research and observations are included in his most recent publication Race Talk And The Conspiracy of Silence (Wiley, 2015, 2016) in which he challenges us to push through racial dialogue, especially in today’s climate of overt expressions of bias. Do this, he says, even though it can be upsetting.

How races come together

We know from social-psychological research the principles that lead to reduction of prejudice and discrimination. One of them is that we have to have intimate contact with people that we hope to understand. We have to have mutually shared goals. We have to have the ability of what I call equal status relationships between individuals in order to be able to begin to feel again that we’re one another.

What we are experiencing in the United States is a worldwide phenomenon that we’re witnessing in Europe as well. ‘I don’t care about other groups,’ that we have to ‘protect borders,’ and these borders are not just physical but psychological. We need to get people to realize that we are connected to one another and that the ultimate outcome of this splitting and segregation is that our society as a nation will deteriorate.

To Those Who Say, Give It Time, A Chance, And That It Will Be OK.

What we are witnessing now is scary. We aren’t moving in a positive direction.

The people who are quick to normalize it are those people who have power and privilege. They do not understand the social, cultural and psychological significance that people of color and other marginalized groups in our nation experience as [they] are saying that things will be OK.

Well, things aren’t OK with us now and there are whole groups that are suffering. We see this going on with indigenous people at Standing Rock, where Native American people are feeling that their spiritual and sacred lives are at risk. Their physical lives are at risk.

The Black brothers and sisters indicate—you know, with the Black Lives Matter movement—that our society is saying that Black lives don’t matter. It may not say it specifically, but it is operating under the impression that some lives are worth more than others, and it is White lives that are worth more.

You frequently hear this invalidation that goes on when people say “Black lives matter.” You hear our political leaders say, “Well, all lives matter.” What they don’t realize is that they are dismissing, diluting and negating the primary message that is coming out from Black brothers and sisters that the way that our society operates, and how people operate is that our lives are worth less than White brothers and sisters in this nation.

Even when we try to point out to them that Black men are being killed—I mean this deadlocked jury—one juror—[in the trial of North Charleston Police Officer Michael Slagle for killing Walter Scott] indicates that no matter what people of color do the judgment and the decision hurts them.

It’s a false assumption and false attempt to calm people by saying that things will be OK, because the truth is, things aren’t OK. They haven’t been OK for centuries.

Work To Unveil Implicit Bias

That’s why I did all this work on micro-aggressions because well-intentioned White brothers and sisters don’t realize that that are complicit in engaging in actions and behaviors that harm people of color through micro-aggressions. And, as long as it is invisible to them, they can go on with their lives in innocence and naivete’ as though they had nothing to do with it.

How The Struggle Births Strength

As people of color we have always struggled. Racism is a reality in our lives. It’s a constant, omnipresent. What we need to realize is to look at the history of our brothers and sisters of color in terms of how they have struggled and overcome and realize that we have assets, that we are not in the struggle by ourselves. Each and every one of us has to find the motivating factor.

I went through a period in my life when I felt hopeless, like what am I doing if it won’t change? My salvation was that fact that on an individual level I do affect some people. But the thing that makes me continue the struggle, despite my belief that racism will never end, is that I want to do the right thing.

Having ‘The Talk’ With Someone Of Another Race

All racial discussions are clumsy and awkward, and push powerful emotional buttons in people. When you’re having a good racial discussion with people, people are experiencing anger, anxiety, sadness, defensiveness and so forth. So, all of those indicate that you’re moving in the right direction. But you have to get beyond the feelings. Because the feelings, unless you understand them, block actual touching of minds.

Let me give an example of White students who originally did not understand and feel defensive because they feel blamed by students of color when they engage in a racial dialogue. It takes a long time for them to come to the realization that they are privileged; that they are putting up defenses. They don’t really want to see what racism is because ultimately they have to acknowledge to themselves that they have racial biases and behaved in ways that hurt and harmed others.

That is a major obstacle to overcome and it takes long discussions where you continue to provide challenges but support for others to come to the realization. But once they get to that level of realization they are likely to be overwhelmed with feelings of guilt.

What you try to do is tell them, ‘I acknowledge your guilt is legitimate, but guilt doesn’t help the situation.’ ‘But you can deal with that guilt if you become a valuable ally with us in terms of dealing with the disparities that are present in our everyday lives.’

I usually get to that point if I’m allowed to work with the class over an extended period of time. To think that you can have a dialogue for five minutes and achieve the goal is a falsehood. This is a long term soul-searching that many of my White brothers and sisters need to go through.

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Author, Columbia University Professor and Researcher Derald Wing Sue

CARMELA MONK-CRAWFORD, editor of Message Magazine, interviewed Derald Wing Sue for this article.