COVID-19 Reveals an Unsurprising Harsh Reality: Health Care is Not Immune to Racial Injustice

By Vineet Kumar Sharma, MD, MS and Devjani Das, MD

The United States has been severely hit not new and have been highlighted by COVID-19, more so than any other further during the COVID-19 pandemic. nation, accounting for approximately Health disparities, as defined by Health one-third of all global confirmed cases. People 2020, adversely affect groups In the initial stages, New York City who have systematically experienced became the global epicenter of the greater obstacles to health based on pandemic. Amidst the devastation that their racial or ethnic group, religion, wrecked New York City’s health system gender identity, sexual orientation or is a harsh reality: racial minorities are other characteristics historically linked being disproportionately impacted. to discrimination or exclusion. Social As of June 12, 2020, age-adjusted determinants of health (SDoH), which hospitalization rates for non-Hispanic include racial inequalities, account American Indian or Alaska Native and for anywhere from 40-80 percent of non-Hispanic Black persons were nearly all health outcomes, compared to five times that of non-Hispanic white traditional clinical care, which comprises persons. Hispanic or Latin persons have approximately 20 percent. Despite this, a rate approximately four times that the United States is the only developed of non-Hispanic white persons. Agecountry that spends more on health adjusted mortality rates per 100,000 care than on social services. Given this, people are just as appalling: as of June it should be of no surprise that Black 10, 2020 African American had 92 and Hispanic Americans, along with deaths and Hispanic/Latin individuals American Indians, have higher infant had 74 deaths compared to 45 deaths mortality rates and that premature reported for Caucasian Americans. deaths from stroke and heart disease While these statistics are damning, are highest among Black Americans. health disparities seen in minorities are Additionally, chronic diseases, such as asthma, diabetes, hypertension, obesity and preterm births are more prominent in minorities. (Amer Jour of Pub Health, CDC Health Disparities and Inequalities Report U.S. 2013, 2013 National Healthcare Disparities Report)

There is no singular cause for racial inequalities seen in health care, but a contributing factor is implicit racial biases amongst health care providers towards people of color and/or specific ethnic backgrounds. Implicit biases may be universal amongst all individuals and subtle, but they do hinder any chance in developing a trusting patient-provider relationship, which is vital, particularly in the emergency setting. As the safety net of society, emergency departments (ED) serve as an interface between medicine and society. Our patients come to us when they have nowhere else to go, and as emergency providers we are often defined more by our ability to be their advocates than by the procedures we perform. However, the high volume and fast-paced nature of emergency

medicine usually affords us only one chance to make a positive impression on our patients, and this interaction is paramount for us to address their needs and provide the best care. When we unknowingly fail and let our prejudices enter the equation, it is the patient who suffers. If a provider believes that their Black and/or Hispanic patients are less intelligent, more likely to engage in risky health behaviors, or unlikely to accept responsibility for their own health, and thus less able to adhere to treatment recommendations, it impacts the providers’ decision in doing a more or less thorough diagnostic workup. For example, they may potentially spend less time explaining diagnoses and treatment with certain minority patients. Furthermore, a dominant or condescending tone decreases the likelihood a patient will feel heard and valued. Likewise, failing to provide an interpreter when needed, or offering limited empathy and positive emotions, causes people of color to become less trusting of the health care system, compounding the disparity.

The impact of racial/ethnic biases extends well beyond simply patient outcomes. Since implicit biases often exist outside of conscious, they are difficult to acknowledge and control — a fact that likely has allowed health disparities to persist in various sectors of health care (e.g. diversity and promotion of underrepresented minorities and lack of emphasis in medical education and training).

A study by Fang et al. demonstrated that minority faculty in academic medicine are less likely to be on tenure track or to received NIH awards, and thus less likely to be promoted compared to their white counterparts, despite the fact that their representation has steadily increased over time. Additionally, the concept of racial inequalities in medical school curricula has been dominated by biological perspective rather than focusing on alternative approaches such as the sociopolitical aspect. The combination of these issues perpetuates the vicious cycle of racial disparities within health care and has a domino effect on medical education and training, as attending physicians, nurses, and senior colleagues play the largest role in the learning process, more so than textbooks or simulations. Take for example an attending physician who has the power to impact a student's or resident’s grade/evaluation and, more importantly, oversees all his or her decisions, thus shaping his or her understanding of “appropriate” medicine. If there continues to be a lack of minorities represented and/ or promoted to leadership positions within academic medicine, it will worsen the growing concern of being able to adequately provide culturally competent care and training to our medical students and residents in an increasingly diverse patient population. Furthermore, without increased minority faculty, it will be nearly impossible to provide unbiased bedside teaching and uncover specific implicit biases that may already exist within students or residents. A systematic review done in 2015 highlighted this fact when it demonstrated that although health profession students may have similar levels of racial/ethnic bias to those of practicing providers, it has less of an impact on health outcomes. This suggests that implicit bias becomes more pronounced as professionals progress through their training and career, likely from following in the footsteps of their peers and colleagues.

The United States is currently in the midst of two pressing issues: the COVID-19 pandemic, and social injustice highlighted by the recent murders of George Floyd, Breonna Taylor, and Ahmaud Arbery. Although these issues are being addressed individually, they both are an endemic that highlights racial inequalities that are a daily reality plaguing the patients and communities that we have served for decades. At its root, emergency medicine is a specialty born of the societal need to provide

equal care for all patients, regardless of their socioeconomic or racial status; therefore, we must unify as a specialty to address these racial inequalities within the medical profession. At Columbia University Medical Center Department of Emergency Medicine, members of the Social EM group are actively working on initiatives to reduce health disparities and advance anti-racism efforts. Through a multi-faceted approach, we hope to promote health equity by creating pipeline programs that increase diversity within health professions, collaborate with public health colleagues on initiatives that lead to policy change and research opportunities, and formalize a social medicine curriculum that places greater emphasis on better recognizing and understanding SDoH, including racial inequalities which can be incorporated into medical education and training. We hope that such an approach may be adapted by other institutions in the near future to help address these pressing issues.

ABOUT THE AUTHORS

Dr. Vineet Kumar Sharma is an emergency medicine resident (PGY-4) at New York-Presbyterian, University Hospital of Columbia and Cornell.

Dr. Das is director, Undergraduate Point-of-Care Ultrasound Medical Education and assistant professor of emergency medicine, Columbia University Vagelos College of Physicians & Surgeons.