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June 06, 2020 01:00 AM

To battle racism, experts say make health equity a central principle

Steven Ross Johnson
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    Stop talking, do something.

    The civil unrest that has erupted across the country following the May 25 death of George Floyd while in police custody has sparked calls from healthcare leaders to address structural racism as a public health crisis.

    For Dr. Gary LeRoy, a dramatic shift is long overdue in how the nation not only discusses but addresses the issue. LeRoy, president of the American Academy of Family Physicians, said he hasn’t seen much change in how healthcare providers tackle racial health disparities since he entered medical school in 1984.

    “There’s this implicit bias that we have had to fight consciously and unconsciously with the way the system is structured because of a lack of opportunities,” LeRoy said.

    Much of healthcare has yet to fully acknowledge how racial discrimination and bias have shaped the structures and policies that helped create the systemic socio-economic disadvantages present in many predominantly-minority communities, he argued.

    “In the healthcare profession, we’re not making widgets; we’re saving lives. Prejudice and inequities and racism can kill people—and it does kill people.”

    American Academy of Family Physicians

    “There’s this implicit bias that we have had to fight consciously and unconsciously with the way the system is structured because of a lack of opportunities.”

    Dr. Gary LeRoy
    President of the American Academy of Family Physicians

    Floyd’s death comes amid the COVID-19 pandemic, which has disproportionately hit communities of color. Data compiled by the Atlantic’s COVID Tracking Project found that African Americans accounted for nearly a quarter of all COVID-19 deaths since the outbreak began; a death rate that’s two times higher than expected based on their share of the population. The larger context, highlighted by many public officials over the past week, is the role that institutional racism plays in perpetuating health inequities.

    But the connection between race and health has been well-documented for at least 30 years. HHS in 1990 issued its Healthy People 2000 report that listed eliminating “health disparities among different segments of the population” by 2010 as one of its three broad goals. Among the population segments noted were racial and ethnic minorities.

    Progress toward many of the goals laid out in the Healthy People reports for 2000, 2010 and 2020 has been incremental at best. Despite gains in expanding insurance coverage, a number of health disparities have either not improved or gotten wider over the past three decades. Notable is the HIV incidence rate, with black teens and adults diagnosed at more than eight times the rate of whites in 2017, according to the Kaiser Family Foundation.

    Gaps in health outcomes could widen as African Americans continue to be among the hardest hit by layoffs due to stay-at-home orders during the pandemic. Unemployment for African Americans hit 16.8% in May, the highest rate since March 2010, according to the Bureau of Labor Statistics.

    Efforts to improve health inequity have providers studying how to address socio-economic factors like poverty, food insecurity and housing instability.

    But experts say many health organizations have yet to really address the role structural racism and racial bias play as health determinants within their own institutions, as well as throughout their communities.

    Health status for groups of color post-ACA

    Though minority groups combined made up approximately 37% of the U.S. population in 2015, they accounted for just 14% of hospital board members that year and 11% of executive leadership posts, according to a 2015 benchmark diversity survey from the American Hospital Association’s Institute for Diversity in Health Management, the group’s most recent available data.

    “Health systems and hospitals themselves can commit to advancing diversity and including persons from historically marginalized populations in their leadership and governing bodies,” AHA CEO Rick Pollack said in an emailed statement. The study found that the percentage of executive leadership positions filled by minorities had remained flat since 2011, and that chief diversity officers represented 77% of those positions.

    “People in my generation who have had the blessing of leadership positions, we just have not gotten the job done,” said Dr. David Skorton, CEO of the Association of American Medical Colleges. “We have not done enough to relieve the burden of structural racism—first, perhaps in our own hearts, in the organizations that we lead, and in our communities in general.”

    Healthcare providers need the courage and will to assess if they’re actually improving diversity and inclusion in their organizations—in recruiting, professional development, procurement, community investment and beyond, Skorton said.

    Such actions are part of what hospitals should be doing to forge stronger ties with their communities, he added. In light of current events, Skorton said one step hospitals could take is speaking out against the kind of policing tactics that led to Floyd’s death. Several organizations have issued such statements and posted on social media.

    “Why can’t we as leaders in our communities get involved in discussions about policing tactics—it’s all part of being part of a community,” Skorton said.

    In Minneapolis, Allina Health has taken a top-down approach to assessing policies regarding race, said Jackie Thomas-Hall, the system’s diversity director.

    One of the health system’s main hospitals, Abbott Northwestern, is in the neighborhood where much of the unrest after Floyd’s death has occurred. Allina Health CEO Dr. Penny Wheeler said the health system decided in 2005 to move its headquarters to help revitalize one of the city’s most economically disadvantaged areas and better address its health needs.

    Becoming more embedded within the community provided insights on forming effective partnerships with stakeholders, Wheeler said. The system works with a community wellness center that has developed action teams tasked with addressing specific health concerns of residents. “We have learned significant lessons,” Wheeler said. “The community told us, ‘Don’t tell (us) what (we) need,’ but rather they articulated (their) needs and had us support them.”

    Thomas-Hall said Allina’s diversity and inclusion initiatives must pinpoint what needs improvement and determine what it means to deliver equitable care. “One of the first things that we’re focusing on is our whole understanding around bias and how bias really is the impetus behind how we make decisions and the impact of those decisions.”  

    Still, a lot of organizations don’t regularly update their policies, LeRoy said. AAFP reviews its policies to weed out potential bias every five years. Such assessments were necessary to ensure policies were keeping up with societal and cultural changes.

    “You can’t just let your policies become stagnant,” LeRoy said. Organizations “just keep adding more policies, but they don’t go back and look at the old policies and refresh them.”

    Clear policies and strong enforcement are crucial for creating a culture of zero tolerance for racial bias and discrimination against patients or staff, said Dr. Aisha Terry, associate professor of emergency medicine at George Washington University School of Medicine in Washington, D.C., and an American College of Emergency Physicians board member.

    “It’s vital to create official policies that speak to the selective opinions of an organization,” she said. “But a policy or statement without subsequent action is a disservice to the topic and the organization’s capacity to ignite change.”

    Organizations should factor health equity into all their decisions, much like the “health-in-all-policies” approach that public health advocates have lobbied governments to use in developing public policy, Terry and LeRoy said.

    “For organizations, there must be a theme threaded throughout every aspect of its mission that addresses health equity,” Terry said. “Whether it be related to leadership, membership, quality initiatives, health information technology or even education … there should be some representation of health equity.”

    Ensuring health equity is included in every policy discussion should be the chief diversity officer’s role. But organizations should expand the position’s scope so diversity officers participate in policy decisions that may not seem directly connected to diversity, Terry added.

    Organizations often see diversity officers as devoted to recruiting and retaining a diverse workforce or addressing workers’ racial discrimination concerns.

    “You cannot just hire someone brown to take care of brown problems,” LeRoy said. “You have to make certain that they have a voice and they have a choice of detailing racist policies and weighing in on the conversation—we need to be included in the conversation and not just talked about.”

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