Racism and Healthcare
Many years ago, when working as a medical social worker for a home healthcare agency in a small southern town, I was asked to evaluate an elderly African American woman in her home regarding her ability to make medical decisions. Her visiting nurse was concerned that the woman’s refusal to seek hospital care for a serious and painful foot infection could be related to mental status changes resulting from infection. After introducing myself to “Mrs. Adams” I shared her nurse’s concerns about the condition of her foot and asked about her refusing to go to the hospital for treatment. Mrs. Adams told me, “I’m not going over there. No one ever talks to me and then they do things to me that hurt.” At that moment, without her having to explain things any further, I realized in a very powerful way that Mrs. Adams description of her poor treatment experiences at the town hospital in the past was likely related to her being Black, elderly, female, and poor. Mrs. Adams taught me a great lesson that day; one that has continued to open my eyes for the past 25 years or so.
While we’d like to think that everyone who needs healthcare will be treated equally and equitably, this is oftentimes not what people of color or from other minorities experience when they encounter the healthcare system in the U.S. Recent events capturing national attention have underscored race-based and other inequalities that have become embedded in virtually every facet of American culture. Like other American institutions that include government/politics, education, and the military; healthcare is far from free of racism. Sadly, Mrs. Adams’ experience was not an isolated event. Of course, racism is only one of many isms that exist in our culture. We’ve also heard of sexism, ageism, anti-Semitism, heterosexism, ableism, elitism, and a host of others. Each of these isms have, whether we want them to or not, become embedded in our personal ways of thinking and our social institutions; leading to differential and sometimes very disparate treatment experiences for people in different minority groups.
What Is Racism?
So, when discussing isms, what are we really talking about? Well, we’re essentially describing the subtle and not-so-subtle ways in which people from minority groups are systematically denied equal and equitable access to the types of resources and experiences that lead to the achievement of personal and professional life goals. Access to these types of resources and experiences is also known as privilege. Privilege is something experienced by people in majority groups. It can be something as small as receiving the benefit of the doubt from others about the content of your character or something quite large, like being selected for a timely promotion because you are a member of a majority group. Life goals are related to various dimensions of our lived experiences that include health or biological functioning, as well as psychological, socioeconomic, and spiritual functioning. Racism and the other isms have an adverse effect on life dimensions and can be expressed at both the personal and institutional levels. This means that isms can be expressed in interpersonal encounters between members of minority and majority groups and also between members of minority groups and majority institutions, like healthcare.
At the personal level, the isms often emerge in members of the majority group in the form of what is often referred to as implicit biases or unconscious prejudices about the value of others that inform the way we think, believe, and ultimately behave toward others who are different. For people in the majority, these biases can be unconscious or pre-conscious and otherwise out of awareness. However, when a person from a minority group encounters these biases in a person from a majority group, whether they are expressed intentionally or unintentionally; the experiences are at best exhausting or confusing and at worst, can be painful or in some instances traumatizing. Whether unconscious, pre-conscious, or intentional, the biases often lead to the subtle and overt behaviors that are an expression of racism, or sexism, or ageism, or…you get the point. The bad news is that virtually no one escapes the influence of the isms. If you are thinking: “This guy doesn’t know ME, I’m a good person. I’d never hurt someone because they’re black or female or elderly or transgender,” please consider taking one of the Harvard University’s Project Implicit surveys. You might be surprised to discover where your biases lie.
At the institutional level, and healthcare is no exception, racism and the other isms are ever-present. Sometimes referred to as structural racism, isms at this level mean unequal access to institutional resources is essentially built-in to organizational structures. It wasn’t until the 1980s that race-based disparities in access to and quality of healthcare were formally recognized and attempts to understand them began. Still, differential treatment of people from minority groups, especially people who are African American and other minority groups, continues. Unlike racism at the interpersonal level, institutional racism emerges via accepted policies and procedures that lead to differential treatment of minority patients. For example, people from minority groups may have their physical complaints regarded less seriously by health professionals, leading to delays in treatment or longer waiting times. More to the point, some studies have shown that people from minority groups don’t receive as much time with their healthcare professionals as people from majority groups. While these types of experiences don’t necessarily happen every time a person from a minority group encounters the healthcare system, they’ve happened regularly and for many generations to people from minority groups; leading to a deep mistrust of healthcare systems and providers.
Addressing Racism in Healthcare
“I did then what I knew how to do. Now that I know better, I do better.” – Maya Angelou
Just as racism and the other isms appear at the personal and institutional levels, so too do the strategies for confronting it. First, following Maya Angelou’s quote, it is important to understand that, for most of us, our isms are something that have become a part of us in ways that we’re often unaware of. Confronting racism first depends on us recognizing how it appears in our own thoughts, attitudes, and beliefs about people who are different and to accept, whether intentional or not, our isms at some point become actions, large and small, that can be experienced as harmful to other people. Making this effort requires a willingness to walk into uncomfortable places within ourselves and taking responsibility for our biases and acknowledging privileges that have come to us by virtue of having one or more majority group characteristics related to race, sex, age, sexual nature, physical ability, etc. Next, it is important to recognize the very same biases as they are expressed by the institutions we are a part of and how these perpetuate large-scale unequal or disparate treatment of others. The goal is to reduce institutional bias and work toward gaining the trust of people who have, for generations, not been treated equitably. This can happen, but only after holding those who create institutional policies responsible for creating procedures that ensure the equitable delivery of resources and services to all their constituents; not just those from majority groups.
A Footnote. Mrs. Adams and I were able to create a plan for getting her foot treated right in her home without the need for a trip to the hospital. Although the severity of her health challenges restricted her range of activity to her home, she continued to benefit from the home-based care of our nurses and other health professionals. I hope her story will remain with you as it has with me.