Black doctors push for anti-bias training in medicine to combat health inequality

• Black doctors are calling for the nation's health system to take action to reduce racial inequity in medical care for African Americans.
• Advocates want training on systemic racial bias in health care to be part of physician education.  
• The twin crises of Covid-19 and the George Floyd anti-police protests have raised the stakes for the nation's health-care system to address racial disparities in treatment.     

George Floyd's last words, "I can't breathe," have become a rallying cry during the weeks of protests against police violence.

Doctors writing in the New England Journal of Medicine use those words as a refrain to lay out how systemic racism has negatively impacted the health of African Americans and how this is the moment to change it.

"We are still speaking very much in the canon and I guess tradition that journals like that value — and yet we're saying it in a way they're not used to us saying these types of things," said Dr. Rhea Boyd, a pediatrician at the Palo Alto Medical Foundation clinic and co-author of "Stolen Breaths," published in the journal.

She and her colleagues are calling on health-care systems to take the lead advocating against police brutality, to diversify their work forces to better reflect their patient population, and to incorporate addressing racial health disparities as part of clinicians' training.

"I think the moment and the unrest allowed us to do that," said Boyd, who has written and lectured about the impact of police violence and racial inequity on the health of African Americans. "We can use words like that, and we can be very direct,"

Police violence and Covid

Major medical organizations, including the American Medical Association, the American Academy of Pediatrics and the American College of Physicians, have backed some of the same prescriptions Boyd and her colleagues outlined in the journal. They all condemned police violence following the death of George Floyd when a Minneapolis police officer applied his knee the African American man's neck for about eight minutes. 

"We really wanted to take the stand at this moment in time, but we already had a policy regarding these issues," said Dr. Patrice Harris, the first Black woman to serve as president of the AMA, who focused on addressing social disparities in health care during her tenure. "Covid has laid bare a lot of that again." 

Dr. Patrice Harris

Shannon Stapleton | REUTERS

The coronavirus pandemic has caused disproportionate illness and death in the African American community. Blacks account for 22% of U.S. deaths from Covid-19, while making up 12.5% of the population, according to the Centers for Disease Control and Prevention. Those national numbers are based on incomplete data, because only 45% of cases reported to the CDC through May 30 included racial identification of coronavirus victims.

"It's absolutely devastating," said Boyd, adding that she has come to think of it in the words of a Princeton University professor who calls it, "The Black Plague. We allowed this to be a Black plague in this country. That weighs heavily on my conscience."

The CDC says underlying health conditions make patients 12 times more likely to die from coronavirus, yet even after accounting for a higher prevalence for poverty, diabetes and insurance coverage, coronavirus death rates for African Americans are higher according to a study this month from MIT.

"We have many good hard-working health-care providers go to work every day intending to do their best for all of their patients, but yet they're producing a pattern of care that appears to be discriminatory. We need to fix that, and it can be fixed," said professor David Williams, of the Harvard T.H. Chan School of Public Health, whose research has focused on systemic racial bias in health care.

"Addressing the implicit biases begins by recognizing that it could be me — that I could be prejudiced'," Williams said. "I like to tell my students that I think of myself as a prejudiced person because I think of myself as normal human being. … It's about how human beings process all of the cognitive information that we face every day."    

Addressing physician biases  

African American health-care leaders say the medical system has to begin by confronting ingrained biases within the medical profession and changing the way clinicians are trained.

"We need to start in the medical school. There need to be lectures on social determinants of health, lectures and training and study on implicit bias," said Harris, recalling her own course material when she trained to be a doctor. "When you learn about burns and rashes and skin diseases, they are described in white patients."

Part of the reason may be the continuing lack of diversity among U.S. clinicians when it comes to African Americans and Latinos. More than half of U.S. practicing physicians are White, 17% are Asian, nearly 6% Hispanic and just 5% are Black, according to 2018 data from the Association of American Medical Colleges.

A doctor holds up a mask that reads "Black Lives Matter" during a rally against the killing of George Floyd, Foley Square on May 29, 2020 in New York.

Kevin Mazur | Getty Images

Research has shown that for patients of color this lack of diversity can translate into less-responsive care.  Black patients are generally undertreated for pain than are White patients, according to a 2016 study that found White medical students and residents believed the Black body was "biologically different — and in many cases, stronger — than the White body," and in some cases believe that Blacks have a higher tolerance for pain.

When it comes to cancer treatment, systemic racial issues can lead to higher mortality. More than 15 academic papers examining residential segregation found that living in segregated Black communities is associated with later-stage diagnosis of breast and lung cancers, and lower survival rates. 

"I like to believe that people in health-care have made a choice to dedicate their lives to make a difference. So are we really making a difference, if there is a great injustice that is impacting millions of people?" asked Tosan Boyo, chief operating officer of Zuckerberg San Francisco General Hospital.  

Boyo says the combination of the heavy toll the coronavirus crisis has had on people of color and the social unrest over police violence have raised the stakes for health-care leaders to address the issues that lead to racial disparities in health. 

"If we approached health equity the way we do other major diseases, with a unified standard as to what we are prioritizing, how we are understanding the problem … and how we resolve it, I think we'll make a lot of progress," said Boyo.

Registering patients to vote 

The National Medical Association, the largest organization of African American doctors, has decried police use of excessive force as a public-health issue and has called for anti-bias training for all U.S. law enforcement agencies.

Now, the organization is going a step further with its activism, pushing its members to register patients to vote in this year's election. They're rolling out the effort with the nonpartisan VotER project, which was launched by health-care and social-work professionals to push for greater funding for public health.

"Black doctors have always been politically active, but there's never been more of a need," said Dr. Oliver Brooks, NMA president. "We have to have a leadership that represents our interests, and it's just became painfully obvious based on everything that has happened."

A turning point 

The care industry has been focused on addressing social determinants of health like affordable housing and racial disparities over the last several years, but advocates say the social unrest in the streets has galvanized the discussion.  

Individual doctors have protested along with demonstrators, often taking a knee outside the same facilities where they care for patients with coronavirus.

"That gives me hope that you have a diversity of voices, saying this is not OK, the status quo is not OK," said Harris.

Health-care corporations have responded with pledges of financial support to address racial inequity.  Health insurer Anthem committed $50 million to social justice groups over the next five years, UnitedHealth Group and Johnson & Johnson each pledged $10 million, while Humana committed $11.5 million.  

"It'll be documented, who was doing what at this period of time, and they have enough sense to know which side to speak for. This is a turning point," Brooks said.

Boyd is trying not to let her hopes get ahead of her.

"If past is prologue, people are going to say a lot of things, but they're going to do a lot less," she said. At the same time, she feels "energized and encouraged, and honestly loved … by the civil unrest that has happened."

She says hearing people speak so passionately about racial health inequities beyond health-care circles has been inspiring. She's hopeful the momentum won't let up.