Calling Out Systemic Racism in Healthcare
It is time to speak out about entrenched racism in the American healthcare system, particularly after researchers have been targeted by white supremacists who claim better care for people of color will come at the expense of Caucasian patients, says David Ansell, MD, MPH, senior vice president for community health equity at Rush University Medical Center in Chicago.
Ansell recently published a commentary piece calling for individuals and institutions to speak out against racism and defend those trying to end decades of discrimination in medicine. He cited a quote from Martin Luther King, Jr.: “In the end, we will remember not the words of our enemies but the silence of our friends.”1
“It’s not the hatred of people that is disturbing,” Ansell says. “It is the silence of people who would be our friends or allies in this.”
An incident occurred Jan. 22, when 20 white nationalists and neo-Nazis stood in front of Brigham and Women’s Hospital in Boston holding a long makeshift sign that said, “B and W Hospital Kills Whites.” Brigham hospital clinicians are conducting research to create more equity in healthcare delivery and treatment, which was exposed most recently when COVID-19 took a much greater toll on people of color.2
Ansell called for institutions and individuals to call out any attempts of racist intimidation of healthcare workers. A regularly updated petition of support for “racial conscious” approaches to healthcare had been signed by some 800 healthcare workers and others as this report was filed.3 As opposed to the seemingly objective “colorblind” approach — which measures averages and medians of healthcare outcomes — a race-conscious approach breaks down patient outcomes by color and other measures to identify specific populations.
“Importantly, we’re seeing movement at the national level for the first time by regulatory agencies,” Ansell says. “The Centers for Medicare & Medicaid Services [CMS] is coming out with a new set of rules that are going to require hospitals to look at their outcomes by race, ethnicity, and language to see who is not thriving and do something about it.”
Reporting patient outcomes by race is one of the early priorities in a sweeping 10-year plan by CMS to “leverage quality improvement and other tools to ensure all individuals have access to equitable care and coverage.”4
Both a medical doctor and a social epidemiologist, Ansell has conducted a wealth of research on racial health inequities. He took on his current leadership role in community health when the hospital decided to revamp its mission in 2016 to address the chronic health problems in nearby neighborhoods.
“We’re one of the highest-quality hospitals in the country, and yet people were literally dying in neighborhoods just outside our door of chronic diseases,” Ansell laments. “I stepped down from chief medical officer roles and began to think more strategically about the social and structural determinants of health in these neighborhoods. We began to build an organizational strategy, which by the way, has at its heart ‘our first community’: our employees, particularly our non-professional employees, who were suffering as well.”
Why Was Tuskegee Possible?
Hospital Employee Health asked Ansell to comment further on this critical subject in the following interview, which has been edited for length and clarity.
HEH: Do you have any thoughts on what individual healthcare workers can do to reduce healthcare racial inequities?
Ansell: It’s somewhat straightforward. One is, approach every patient with humility. Understand that patients have mistrust in our system — and that could be very well-earned mistrust. Approach every patient as an individual with humility and ask them what their experiences have been in the past with the healthcare system, because only then can we begin to build bridges. We can all ask the questions, “What does our leadership look like in our organization? What does our board look like? How representative is our board, our leadership, of the community? Is the hospital “segregated,” with largely white doctors on top, with the cleaning staff, entry-level dietary [workers] largely people of color? What do we do to address that? How are we creating pathways for entry-level workers to gain skills that lead to wealth-creating jobs?”
HEH: Did you find signs of racially based outcomes when looking into your communities?
Ansell: Yes. In the Chicago area, Black women were having — and still do — higher mortality for breast cancer than white women. A lot of people just said it was biological; the cancers were worse and more undifferentiated. But we said there was a quality and access to care issue. Sure enough, when we got everyone to share quality data, it was a quality issue. Black women predominately went to get their breast cancer care in lower-quality institutions. We did the work to improve the quality, but also navigated the women to higher-quality places, and we saw the racial mortality gap reduced. It had nothing to do with biology. It had to do with where women got their care. There are studies that show when white people get care at a low-quality hospital that serves predominately people of color, their care is worse as well.
HEH: What about this argument that if you help one group it will hurt another?
Ansell: The point is that the race-conscious approach can improve care for everybody. The reason to name racism as among the root causes of poor health outcomes in the United States is so we can create solutions and mitigate that, just like we would when something goes wrong in a hospital. It’s not to blame. It’s not to judge. It’s just to point out that something is going on. In every state in the United States, Black people are more likely than white people to die from a condition a hospital can treat. For every state. To get to understanding of why Black people have higher mortality than whites, we’ve got to consider racism. This is poorly understood by the public, by even CEOs and medical leaders. When you design systems to address the outcomes in those who are historically or systemically most vulnerable, those systems are good for everybody.
HEH: The pandemic has exposed inequities in care of patients of color, but it also has given momentum to white supremacy movements. What tactics can you use to address these critical issues in such a divisive time?
Ansell: When haven’t we been divided, right? There was a lot of eye-opening and racial reckoning in the moment of COVID and the murder of George Floyd and other things. But for those of us who have been in the field, this is nothing new. The fact that you can suddenly see it doesn’t mean it’s time for me to get glasses. The fact that people are now seeing it doesn’t mean it didn’t exist before. It just became more visible to everyone. Listen, of course we have to stand up against white supremacism. We have to stand up against extremism of any sort. That’s our social obligation as citizens, as residents of a complex, diverse country. But at the end of the day for hospitals and healthcare, we need to look at our outcomes, identify who is not thriving, and implement strategies that improve the health of those people. If we do that, the health of everyone will get better.
HEH: As someone with a depth of knowledge in this field, how do you process something like the Tuskegee Experiment, where Black men were not treated for syphilis so U.S. researchers could study the progression of the disease over decades? How was that even possible?
Ansell: One reason it was possible is that we needed to make Black people and other people of color in this country sub-human as part of an ideology of white supremacism. This devalued their very being through time. The Tuskegee Experiment was based on common ideas that still prevail today, that somehow Black people are biologically different than white people. We segregated the blood supply in this country up until World War II because it was thought that Black blood and white blood were not compatible. That’s how deeply embedded white supremacism is into all of our thought. Many white supremacists and others believe that they’re good people and wouldn’t be racist toward anyone. That’s why we must be actively anti-racist. It’s not OK just to say, I’m not a racist. It’s important to point out how these systems of dehumanization have perpetuated themselves over time and end up causing worse health outcomes.
The Tuskegee Experiment is only a surprise in a world that doesn’t have white supremacism in it, but it’s a logical consequence of white supremacism. There were actually beliefs that in order to make someone a slave, and subjugate people through other forms of economic deprivation, you had to come up with theories of biological inferiority. Some of this was then taught in medical schools, and then people went out to prove it by doing things like Tuskegee: “I want to see what the natural history of syphilis is in Black people, because it must be different than what it is in white people.” We should be shocked that we were shocked, because most of us — 53% — don’t believe that racism is a problem.5
REFERENCES
- Ansell DA, James B, De Maio FG. A call for antiracist action. N Engl J Med 2022;387:e1.
- Evans G. Violence against HCWs increased during pandemic. Hospital Employee Health. April 2022.
- Massachusetts Coalition for Health Equity. Open letter of support for race-conscious approaches to promote health equity. Feb. 5, 2022.
- Centers for Medicare & Medicaid Services. CMS Framework for Health Equity 2022-2032. 2022.
- Harvard T.H. Chan School of Public Health. Confronting racism in health care delivery: An imperative to improve the public’s health. Sept. 28, 2021.
It is time to speak out about entrenched racism in the American healthcare system, particularly after researchers have been targeted by white supremacists who claim better care for people of color will come at the expense of Caucasian patients.
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