Health Equity

Time to tackle hard questions on root causes of health inequities

Marc Zarefsky , Contributing News Writer

The renewed focus on racial inequities in the American justice system—sparked by the deaths of George Floyd, Breonna Taylor and many others—also should spur reexamination of how racism is manifested in the disparities that bedevil U.S. health care, according to a panel of physicians and other experts who took part in a virtual panel discussion hosted by the AMA.

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At the 2020 AMA Special meeting, the AMA Board of Trustees pledged action to confront systemic racism and police brutality. The AMA recognizes that racism in its systemic, structural, institutional, and interpersonal forms is an urgent threat to public health, the advancement of health equity, and a barrier to excellence in the delivery of medical care.

The AMA Board of Trustees also said it will actively work to dismantle racist and discriminatory policies and practices across all of health care. One place to start this process is in medical school, said panelists in the “Prioritizing Equity: The Root Cause & Considerations for Health Care Professionals” discussion. The conversation, a part of the AMA’s YouTube health equity series, was moderated by Aletha Maybank, MD, MPH, chief health equity officer and group vice president of the AMA.

LaShyra “Lash” Nolen, a second-year medical student and the first African American woman student council president at Harvard Medical School, said that based on her own experiences and those of students she’s talked with, it is clear that anti-racism training needs to be integrated into overall medical training.

For example, when Nolen learned how to recognize Lyme disease, she was only shown examples of the condition in white skin. When she and her classmates learned how to perform cardiopulmonary resuscitation (CPR), all the manikins they practiced on had white skin. When she learned about anatomy and the human body, all of the images shown to her were of white people.



Implicitly and explicitly, students are given the message that white people are the standard.

“What ends up happening is that when we go out to serve patients with black skin,” Nolen said, “we already don’t see them as human because that’s not the way that we’ve been presented the human body throughout our entire medical education.”

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Nolen also acknowledged the biases that physicians develop after reading statistics about a certain disease, be it type 2 diabetes or COVID-19. Often, a slide is presented or a section of an article is added that highlights how black, Latinx and indigenous people are disproportionately affected by the disease. And that’s it.

“We’re only presenting the data without recognizing the structural oppression that contributed to those outcomes,” Nolen said. “I think a lot of my classmates end up leaving the classroom thinking black bodies are inherently damaged or we were just born this way, and that’s not true.”

Throughout the COVID-19  pandemic, the AMA is carefully compiling  critical health equity resources from across the web  to shine a light on the structural issues that contribute to and could exacerbate already existing inequities.  

Ways to implement change

Dr. Maybank highlighted a perspective piece recently published in The New England Journal of Medicine called “Stolen Breaths” that highlights steps that health care systems can take to “dismantle structural racism and improve the health and well-being of the black community and the country.” Steps could include making a professional medical competency for physicians to “master learning the ways in which structural racism affects health.”

Such changes will take time, and they will involve difficult reflections and conversations, said Emily Cleveland Manchanda, MD, MPH, an assistant professor of emergency medicine at Boston University School of Medicine. Dr. Manchanda works as an emergency physician at Boston Medical Center, and she recommended that white clinicians approach racism just like they approach any other new or emerging health problem.

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“You can treat this like educating yourself for any other thing you have to treat in your clinical practice,” she said. “To educate yourself on how to understand racism in America and your role in it—that's a really challenging process for a lot of white people, because there is an immense amount of shame that comes out of realizing for the first time that this exists and that you didn't know about it and that you're part of the problem.”

David A. Ansell, MD, MPH, agreed.

“This has created an opportunity, a break-the-glass moment to have the conversations around racism,” said Dr. Ansell, senior vice president for community health equity at Rush University Medical Center and associate provost for community affairs at Rush University. “This is a moment for white people in general, white faculty specifically—and white men extra specifically—to step up and take responsibility.”

Dr. Manchanda reiterated Dr. Ansell’s point.

“Racism is not a black person's problem,” she said. “It effects them, but it is a problem created by white people in America and it's perpetuated by our actions. ... We can all do our part to make sure we're on the right side of history as this moves forward.”