Equity in Medicine

By John Gallagher

Members only; sign-in required.

An estimated 10,000 health care professionals and students, wearing white coats and scrubs, walked from Harborview Medical Center to Seattle City Hall on June 6 in a Doctors for Justice event to protest racial violence. They had responded to a call to action from Estell Williams, MD, an acute care surgeon at the University of Washington Medical Center and an assistant professor of surgery at the UW School of Medicine, who asked her colleagues to “show the full strength of Medicine that seeks justice for the most marginalized of our community.”

Motivated in part by the experiences of her own family, Dr. Williams organized the march with her husband, Edwin Lindo, JD, a lecturer at the UW School of Medicine. “I have experienced police violence, racism, and mortality as a result of disparate outcomes experienced by the Black community within my family,” Dr. Williams says.

In a letter announcing the march, she recalled a childhood event seared in her memory. Her father was pulled over by police while they drove home through a predominantly white neighborhood. As the officers searched their car, “I cried in fear and terror in the backseat, thinking of what they had done to others who looked like my dad,” she wrote. “They handcuffed him, took him to the police station and forced him to stay there, while I had to wait in the street for my mother to pick me up. They released him two days later without a charge or valid reason for arresting him. To be clear, my father never committed a crime in his life, and the pain and fear I felt for the days he sat in the jail never leaves my mind. I knew there was a possibility that I would never see him again.”

Just as importantly, she believes doctors should use their position of privilege to call out all the issues that harm the health of their patients, from overrepresentation in the justice system to poverty, housing, and employment.

“All of these things interconnect,” Dr. Williams says, “and we as health care workers have to recognize it and speak out because the true health of our communities exists outside the walls of the hospitals and clinics.”

The renewed awareness about racism has led to a fresh look at health equity issues. For decades, physicians have known that the race or ethnicity of patients or the language that they speak can have an effect—often negative—on their health. According to the Kaiser Family Foundation, Blacks, Hispanics, and Native Americans/Alaska Natives had higher infant mortality rates, die from diabetes at a higher rate than whites, and are in general more likely than whites to report fair or poor health status. Asian Americans/Pacific Islanders overall often fare better than whites, but with wide variation among subgroups.

Health equity has always been a complex issue.

“Defining ‘equity’ depends on who you are,” says Michael Schaffrinna, MD, chief medical officer at Community Health of Central Washington, which operates federally qualified health centers (FQHCs) in underserved areas. “For some, it’s access to care. But there’s much more to health care than just getting an appointment or, for that matter, having good clinical care.”

The COVID-19 pandemic has thrown into sharp relief the issue of health disparities, with much higher rates of infection and death among Blacks and Hispanics. But another event this spring has also affected the discussion about health equity: the killing of George Floyd by police officers in Minneapolis and the subsequent demonstrations about racial injustice.

The extent to which racism has affected medicine’s ability to eliminate health disparities is now part of the conversation in a way that it never has been in the past. “Racism is a public health emergency of global concern,” a recent editorial in The Lancet said. “It is the root cause of continued disparities in death and disease between Black and white people in the USA.”

“It feels that the normalization of the conversation is much more universal,” says Benjamin Danielson, MD, chair of the Governor’s Interagency Council on Health Disparities and clinic chief at Seattle Children’s Odessa Brown Children’s Clinic. “I spent a lot more time preaching to the choir before. Now perhaps the sense of importance and maybe the less compromising nature of the situation does put some emphasis behind real conversations about health equity.”

Certainly, medical systems have been working hard for years to reduce health disparities. Dale Reisner, MD, medical director (OB-GYN Quality & Safety) at Swedish Health Services and a past president of WSMA, notes that her health system started working to address the issues well before the latest focus on racism.

“Even before George Floyd, we have really been trying to enhance our abilities to address health disparities with trainings, information sessions, and respectful treatment of all patients,” she says. Reisner has had a particular focus on reducing Black maternal mortality, which in Washington state is twice the rate than for white women, even with the state’s mandate for access during pregnancy. (The mortality rate for Black mothers nationally is threefold higher than for white women.)

Suicide and postpartum overdoses are major contributors to Black maternal mortality. “Women with mental health and substance use disorders often are not respected, so we’ve had a very innovative addiction recovery program at Swedish with compassionate care basically as the core of the model,” Dr. Reisner says. She adds that the fact that such an approach is even necessary is “sad, when you think about it.”

Swedish has a program that includes doulas, trained professionals who serve as support for women during pregnancy, birth, and the postpartum period. “Many of them have come from disenfranchised communities, so [they] can relate to the patients,” Dr. Reisner notes. “As an advocate with white skin, I can do my best, but someone with brown skin is not going to trust me as much because I don’t share their same experience.”

But as Dr. Reisner and other physicians point out, the progress to date still leaves a lot to be desired, Dr. Williams says.

“Even though medicine is getting better, we’re still seeing the same disparities,” she says. “You can make the argument that people are not only not getting the same level of care but are getting a worse level care.”

The real challenge with addressing health disparities is that many of the factors that drive it happen outside the clinic. “We give this prescription in the clinic, but we don’t then try in a meaningful way to address the ways patients experience the world when they leave the clinic,” Dr. Williams says. “We need to recognize that there are certain diseases that need to be treated in a hospital setting, but a lot of problems are directly related to systemic racism.”

Researchers have long documented the impact that social determinants of health—the conditions in which people are born, live, and work—have on outcomes. Now, the urgency of that work is gaining more recognition and acceptance. “There is greater regard for social determinants of health in embracing health equity in a systematic way,” says Dr. Danielson. “Health care systems getting involved in social determinants is a health equity act.”

Dr. Schaffrinna says that for those kinds of discussions to be successful, “we have to approach it not with blame, but ‘How do we change?’ ” That means acknowledging up front that racism is a problem.

“Is there discrimination? Absolutely,” he says. “We must confront it.”

But he believes that medicine should also focus on how poverty is a driver of disparities.

“When you look at Americans suffering from the effects of poverty, it appears that all of them suffer,” he says.

Even within the confines of the system, barriers exist, notably the chronic challenge of financing. Addressing health disparities costs money, such as Swedish’s investment in doulas. Investing in such efforts is especially difficult when practices and medical systems are facing huge drops in revenue as a result of the pandemic.

“Everybody is recognizing that it’s an issue, but no one is willing do anything,” says Dr. Schaffrinna. “Most of the FQHCs are trying to begin the process of addressing social determinants, but there’s no revenue coming in for that expense.”

Moreover, some solutions have the potential to shift money away from the medical system altogether. “As a nation we spend an enormous amount of money on health care, and it’s not giving us the biggest bang for buck,” adds Dr. Schaffrinna. “We should put some of that money into addressing social determinant factors. Our country can’t afford to do it all, and the only way to do it is to reallocate resources to other areas, similar to what people are saying about police departments.” (Activists have been pushing for cities to invest in mental health workers as front-line respondents to individuals in crisis, instead of the police.)

The respect that society places on physicians offers them a special opportunity to play a role in tackling the problem of health equity. “Because we have by nature and profession a caring tendency and because we’re interacting with patients who manifest all the effects of this social injustice, it positions us in a unique way to be the ones who also can bring awareness and advocacy for the need to make change,” says Okechukwu Ojogho, MD, a transplant surgeon at Providence Medical Group in Spokane.

The really thorny question is the extent to which medicine is willing to broaden the conversation about health equity to racism, including institutional racism in medicine. The profession is starting to recognize, as the New England Journal of Medicine said in a recent editorial, that “slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to present, and that legacy infects medicine as it does all social institutions.”

Dr. Williams says that the current conversation about racism reveals some long-standing assumptions about medicine. “We’ve done a disservice to medicine as an entity by attempting to exist as an apolitical, neutral entity,” she says. “We have for a long time felt that we’re altruistic human beings who are neutral and somehow colorblind, and in doing so, we have blinded ourselves to the root causes that perpetuate the health outcomes we see.”

Ultimately, the profession has to have a painful conversation about racism if it is going to conquer health disparities, Dr. Danielson says.

“I’m hoping a health equity conver- sation is not a substitute for a conversation about racism,” he says. “You can do a whole lot toward health equity without changing any power paradigm. You can still hold all the strings and be in a position of power and do more things to promote health equity. An anti-racism perspective has built into it a pretty strong power shift.”

How much change happens depends on doctors themselves, says Dr. Danielson.

“I would imagine a lot of us are on the edge of our seats right now,” he says. “Will this really be a transformational time? It would be too bad if people sit on their seats and wait for something external to show them it’s time to move forward. Moving forward is the thing we need to do, not the thing we wait for someone else to do.”

Dr. Williams says that just a year ago, something like the march would have been impossible to imagine. But one conversation with another doctor that she had at the event stood out. In her speech at the march, Dr. Williams noted that “we scrutinize all our actions in the hospital to minimize harm to patients, but we don’t consider actions in our greater community with the same scrutiny.” The physician that Dr. Williams spoke to had never considered this.

“Hearing that physician declare that their eyes were opened showed me that we did something good that day,” Dr. Williams says. “And if we opened just a few more eyes, we can do something good for many more lifetimes to come.”

John Gallagher is a freelance journalist who specializes in health care issues. He is a regular contributor to WSMA Reports.

This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA’s print newsletter.