Combatting Structural Racism in Health Care

October 20, 2021

The COVID-19 pandemic disproportionately impacts communities of color. Coupled with George Floyd’s murder, an uncomfortable truth was laid bare in 2020: institutional racism remains deeply embedded in American society, including in health care.

A 2021 AABB Annual Meeting session, “Crucial Conversations about Structural Racism, Equitable Access to Healthcare and Social Justice: Creation of a Multidisciplinary Task Force for Action,” opened a powerful dialogue about white privilege, power-sharing dynamics and inequitable access to medical education for communities of color. Solutions regarding the social determinants of health were discussed. 

Yvette M. Miller, MD, ABIHM, from the American Red Cross, began with an overview of structural racism. While no official definition exists, at its core it is racism produced and reproduced by laws, rules and practices—not private prejudice held by individuals. It is sanctioned and implemented by various levels of government and is woven into the fabric of the United States—its economic systems, its cultural and societal norms, its health care system. 

Examples of the racism baked into the U.S. health care system include:
• Hospitals were segregated until Medicare was implemented in 1965. Private hospitals that did not receive Medicare dollars did not have to desegregate.
• Black doctors had no or limited privileges at white hospitals.
• Black doctors could only treat Black patients, and there was—and still is—a profound lack of Black doctors (only 5%).
• For more than a century, the American Medical Association (AMA) actively reinforced and accepted racial inequalities, such as the exclusion of Black physicians and the barring of them from some state and local medical societies. AMA only formally apologized in 2008.

One of the reasons behind the disproportionately low number of Black physicians today is the Flexner Report, a 1910 publication that aimed to standardize and improve medical schools in the US, but actually codified racism in health care. It forced the closure of institutions lacking the resources to implement more rigorous instruction, including five of the seven historically Black medical schools. Flexner wrote that Black physicians should be trained in "hygiene rather than surgery" and should primarily serve as "sanitarians" whose purpose was "protecting whites" from tuberculosis and other diseases.

Social Determinants of Health Disparities
If a health outcome is seen to a greater or lesser extent between populations, there is said to be disparity. Some of the social determinants of this health disparity include:
• Economic stability: lower incomes, barriers to wealth accumulation and greater debt.
• Social and community context: disproportionately represented in areas with few to no grocery stores, limited transportation and exposure to personal and environmental stressors or violence.
• Neighborhood and environment: disproportionally affected by difficulties with finding affordable, quality housing in neighborhoods that are environmentally safe and offer safe recreational areas.
• Health and health care: disproportionally affected by lack of access to quality health care, insurance and health care that is linguistically and culturally responsive.
• Education: disproportionally affected by inequities in access to high-quality education, thereby causing lower literacy and numeracy levels, lower graduation rates and stronger barriers to higher education.

Miller explained the difference between equality and equity. Equal access means everyone has the same access to health care. Equitable access means that individuals who need more get more. “Equitable access to a health care system that is fundamentally racist and structurally broken means that there is not true access,” she said.

A 2020 report in Morbidity and Mortality Weekly Report was centered on the noticeable disparities in COVID-19 mortalities among underrepresented racial/ethnic groups in virus hotspots. The report emphasized what experts already knew: long-standing health and social inequities fueled increased risk for infection, illness severity and death from COVID-19. Fortunately, identifying health disparities in COVID-19 hotspot counties can not only fuel testing and prevention efforts, but also improve community-wide outcomes related to COVID-19 and improve health disparities as a whole. 

Call to Action
“Personal actions can make a difference,” Miller said. Floyd’s murder proved to be a catalyst for social change and, coupled with AABB’s “Dear Colleagues” letter that was sent to the entire Association soon after, Miller found her call to action. She shared her thoughts with AABB leadership and provided specific examples of what could be done to promote diversity, inclusion and equity among the membership. She was invited to an AABB Board meeting to provide more details to her earlier comments and respond to questions. From this the DEIA (Diversity, Inclusion, Equity, Access) Task Force was born.

Miller also partnered with medical, nursing and allied health schools at historic black colleges and universities to promote educational and training opportunities, discuss equitable access to health care and address shortage of health care providers from communities of color.

Attendees seeking their own call to action were advised to:
• Acknowledge that racism is a major public health threat that directly affects the health of communities of color and marginalized communities.
• Acknowledge, both as an individual and a member of an institution, that they have participated and continue to participate in racist practices which must be alleviated.
• Take personal, collective, societal, legal and institutional deliberate actions to combat racism and bias.

“Unity is in our diversity,” Miller added.

Integrative Medicine
I. Jean Davis, PhD, PA, DC, from the Charles R. Drew University of Medicine and Science talked about her experiences with the Academy of Integrative Health and Medicine (AIHM) Black, Indigenous and People of Color (BIPOC) Task Force, which was created in 2020 to lead dialogue and build a coalition of diverse individuals, organizations and institutions to address the needs of health care inequity. 

AIHM, a global interprofessional integrative health association, has been a leading professional organization for the holistic and integrative community since 1978. It works to transform all aspects of health care and wellness globally through education and collaboration.

Integrative medicine (IM), Davis explained, is a way to bring conventional and complementary medical approaches together. The emphasis is on treating the whole patient rather than one organ system. Included are lifestyle changes, traditional tribal medicine, herbal medicine, naturopathy, acupuncture and more. The American Board of Physician Specialties recognizes IM as a medical specialty.

In 2018 the AIHM held a minority health forum to discuss health issues impacting historically medically underserved and unserved communities. In 2019 a global health panel was held, focusing on public health and historically excluded communities. It provided tools, training and education to enhance the health and wellness in those communities. In 2020, the AIHM was spurred to further action by COVID-19 exposing health care inequities among communities of color. 

The newly formed BIPOC Task Force was organized to oversee program and policy development around diversity, equity and inclusion. Miller and Davis serve as its co-chairs. Two virtual workshops were held on the topics of racism in integrative medicine and ethics related to race, ethnicity, gender, sexual orientation and age. The Task Force then identified key partnerships with complementary organizations and held a conference that focused on historical and current institutionalized racism, discrimination and bias in health care. 

Davis detailed her experiences as an AIHM Board member and talked some of the BIPOC Task Force’s next steps, including drafting a declaration against racism and inviting the global integrative health community to sign, launching a monthly book club and developing taskforce workgroups to harness interest across various sectors involved with integrative health and health care in general.

AABB’s DEIA Task Force
Celina Montemayor, MD, PhD, from the Canadian Blood Services, spoke about AABB’s DEIA Task Force, its structure and its goals. In 2020, AABB’s Board of Directors, recognizing that actively embracing our differences will make us stronger, unanimously endorsed the establishment of the Task Force. 

The Task Force, Montemayor explained, is not meant to be a static group or a one-time conversation. She envisions it as a plane sitting on the runway, preparing for takeoff, knowing a long flight is ahead. Task Force members are charged with setting the initial roadmap that will ensure AABB actively embraces the DEIA principles. It will recommend resources and develop guiding principles and recommendations, both internally and externally.

Montemayor was invited to facilitate as chair of the DEIA Task Force. “I thought that this was the most meaningful task that I would ever be called to do in my professional life,” she said. Connecting with the community and starting these conversations proved to be a rewarding experience. 

The Task Force partnered with Avenue M Group and meets monthly. It is committed to a dialogue and decisions driven by data, as well as setting goals that will be high-impact, but still achievable, and capable of driving meaningful change. 

One of its first steps was collecting information through a baseline survey. Session attendees were brought into the fray by being asked: What is the change that you would like to see? What can we do better? Are there any barriers you perceive see that you would like to see removed? What are the DEIA efforts and challenges in your organization?

Montemayor ended her talk with a heartfelt message. “I’d like to close today by inviting you again to have an open dialogue and help us unleash the power of DEIA,” she said. “The dream is that we will move beyond just basic compositional diversity and truly embrace and encompass the whole spectrum of human multidimensionality. Not just race, ethnicity, age and gender but also ideas, perspectives and values and to ensure there is equal treatment and opportunity for all the groups. Let’s work together so that this goal is not lost but that it remains a priority in order to achieve meaningful and long-lasting change.” 

A Message That Resonates
This powerful session resonated with attendees. Feedback in the session’s chat box was overwhelmingly positive, with attendees describing the session as timely, thoughtful, fantastic, informative, important, necessary and stirring. In fact, the accolades continued after the session ended and the speakers left.
Two attendees called it their favorite session of the entire Annual Meeting.

The Q&A session, described by one attendee as engaging and collaborative, brought many issues to light. Questions raised involved racism embedded in hidden curricula in workplaces, the disparity in delay of activation of massive transfusion protocol in cases of obstetric hemorrhage, whether we are doing enough as a community to advocate for equity/structural changes, how laboratories can get involved to help promote health equity and many more. “We have to create the space to have these conversations,” Miller said.

When one white male attendee asked how privileged people like himself can be active partners in meaningful discussions to drive change, Montemayor responded, “Set the stage for everyone to speak, have a voice, and tell us their story.”

As one attendee said, “We need to build new structures. Just tearing down the old will not foster positive change.”