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CMA Today | JulAug 2022 13

By Mark Harris

n many ways, 2020 was a watershed year

for public health concerns. In the United

States, the impact of the COVID-19

pandemic created unprecedented pressures

on health system resources.

The public health crisis also exacts a

disproportionate cost on racial and ethnic

minority populations. In fact, Hispanic,

Black, American Indian, and Alaska Native

people have been approximately twice as

likely to die from COVID-19 as White

Americans and one and a half times more

likely to be infected.

Simultaneously, the year 2020 was also

witness to a strong public focus on racism,

as the murder of George Floyd and other

highly publicized incidents of police violence

against Black people led to historic antira-

cism protests in cities across the nation.

These events have led to “heightened aware-

ness of racism as a public health crisis,”

according to an American Family Physician

editorial.

A Social Determinant of Health

With a renewed interest in racism’s impact

on health and society, many leading health

care organizations are developing programs

and initiatives to promote racial justice and

health equity.

A starting point for antiracist education

and activity in health care is the understand-

ing that racism is a significant social deter-

minant of health. In other words, structural

or systemic racism is a contributing factor in

poorer health outcomes for many medical

conditions, including cardiovascular disease,

diabetes, hypertension, infant mortality,

obesity, and psychological conditions such

as depression and anxiety.

The issue of racial health disparities

is also shaped by both current and historic

Address This Public Health Threat

with Awareness and Strategy

Racism

in Health Care

foster within the medical profession a new,

more nuanced level of awareness of racism

as a public health issue.

“As an emergency room physician

at Boston Medical Center, which is New

England’s largest safety net hospital, and in

my work with the AMA, I have the opportu-

nity to see the impact that racism has on the

health of individuals and communities,” says

Dr. Cleveland Manchanda. “The challenges

can differ at the individual, community,

and national levels, but there are also some

similarities in the challenges. One of those

is the historical silence on the topic of rac-

ism, certainly within health care but also

in society at large. Before 2020, there was

not a lot of conversation about the impact

of racism on health. We talked about racial

disparities, but we didn’t talk about race

as a proxy for the experience of racism.

That’s a nuance that’s important for people

to understand as they start to address racial

inequities in health care.”

Notably, AMA policy now recognizes

that race is a social, not a biological, con-

struct.

This means that traditional medical

practices that use race as a proxy for biology

in medical education, research, and clini-

cal practice should be ended. Additionally,

descriptions of risk factors for disease should

focus on genetics and biology, the experience

of racism, and social determinants of health.

Finally, physicians and clinical practitioners

should be educated on how racism and forms

of systemic oppression can contribute to

racial and health disparities.

The AMA strategic plan recommends

mandatory antiracism, structural com-

petency, and equity-explicit training and

competencies for all trainees and staff.

support its strategic objectives, the AMA

developed the Racial and Health Equity:

Concrete STEPS for Health Systems tool kit.

While the AMA is a physician-led orga-

nization, the group recognizes that every

member of the health care team, including

medical practice managers and staff, has a

role to play in facilitating transformative

change in support of racial and health equity,

notes Dr. Cleveland Manchanda.

“Any time you are looking to embed

racial justice within an organization [or]

experience higher rates of illness and death

… when compared to their White coun-

terparts. Additionally, the life expectancy

of non-Hispanic/Black Americans is four

years lower than that of White Americans.

The COVID-19 pandemic, and its dis-

proportionate impact among racial and

ethnic minority populations is another

stark example of these enduring health

disparities.

With this perspective in mind, the CDC

and other leading health care organizations

have declared systemic racism an urgent pub-

lic health threat, calling for expanded efforts

by health care leaders to promote racial

and health equity in medicine and society.

Toward this end, the American Medical

Association (AMA) adopted a new strategic

plan in 2021 to advance a broad, antiracist

health care initiative. The Organizational

Strategic Plan to Embed Racial Justice and

Advance Health Equity, 2021–2023 represents

a far-reaching initiative by the AMA to

promote equity-centered practices in every

aspect of patient care, medical education,

and health system operations.

Led by the AMA Center for Health

Equity, the strategic plan proposes estab-

lishing new national health care equity

and racial justice standards, benchmarks,

and other measures.

The plan is further

committed to eliminating all forms of dis-

crimination in medical school admissions,

medical education and training, and hiring

and promotion.

From Silence to New Dialogues

The AMA’s strategic plan is part of a national

conversation on racism in medicine and

society—one that seeks to stimulate educa-

tion, awareness, and action for meaningful

improvements in the health care system’s

ability to provide equitable care. It attempts

to not only effect change but also to deepen

understanding of the ways racism under-

mines health equity.

One physician who is involved in the

AMA’s antiracist work is Emily Cleveland

Manchanda, MD, MPH, director for social

justice education and implementation at the

AMA Center for Health Equity. She explains

that the AMA’s antiracism agenda hopes to

JulAug 2022 | CMA Today

 racism is a public health threat

concerns. For example, a 2003 Institute

of Medicine report found that African

Americans have higher mortality rates from

heart disease, cancer, cerebrovascular dis-

ease, and HIV than any other racial or ethnic

group.

Hispanic Americans are nearly twice

as likely as non-Hispanic White people to die

from diabetes.

Health disparities were also

found to disproportionately impact Native

American and Asian American populations.

Significantly, the Institute of Medicine

also found racial and ethnic minorities expe-

rience a lower quality of health services and

are less likely to receive routine medical

procedures.

“The Institute of Medicine report from

2003 showed the quality of health care

received is different for people of differ-

ent races and ethnicities,” remarks Bram P.

Wispelwey, MD, MPH, an associate physi-

cian in the division of global health equity at

Brigham and Women’s Hospital in Boston.

“That was a landmark assertion based on

really extensive evidence at the time of …

institutional racism. But what is striking

is that they did a follow-up ten years later

documenting that not much had changed.

And now when we look at a lot of the studies

currently being published, we still see that

not much has changed.”

Undoubtedly, the roots of enduring

racial and ethnic health disparities need

to be understood in a larger historical and

societal context, as acknowledged by a 2021

statement by the Centers for Disease Control

and Prevention (CDC):

A growing body of research shows that cen-

turies of racism in this country [have] had a

profound and negative impact on commu-

nities of color. The impact is pervasive and

deeply embedded in our society—affecting

where one lives, learns, works, worships,

and plays and creating inequities in access

to a range of social and economic ben-

efits—such as housing, education, wealth,

and employment. These conditions—often

referred to as social determinants of health

[italics added]—are key drivers of health

inequities within communities of color,

placing those within these populations at

greater risk for poor outcomes.

The data show that racial and ethnic minor-

ity groups, throughout the United States,

organizational practices, you really need

everyone to come along for the ride,” says

Dr. Cleveland Manchanda. “You need every-

body to be on board, in particular those who

are in leadership positions. The Racial and

Health Equity tool kit is meant to outline

practical steps that can be taken by manag-

ers, including office managers and people

managers, to begin to address racial justice

within clinical practices.”

As an implementation guide, the tool kit

is designed to help medical practices navi-

gate a series of steps toward improvement,

explains Dr. Cleveland Manchanda: “The

steps include committing as a group—as a

health system or a practice—to doing the

work, then looking into your organizational

norms and figuring out what you don’t know.

This involves getting a handle on your data

[and] understanding where racial inequities

are emerging in your setting. Once you

have an understanding of where you are, the

group can then develop a shared, compelling

vision and goals for that health care system or

practice. Of course, this is followed by actually

doing the work, which is launching your tar-

geted improvements. I’ll add that whether the

work is being led or championed by [practice]

managers or by physician leadership, as long

as there is buy-in from all decision-makers,

CMA Today | JulAug 2022 15

Resources

AMA Center for Health Equity

https://www.ama-assn.org/topics/ama-center-health-equity

The Centers for Disease Control and Prevention

https://www.cdc.gov/healthequity/racism-disparities/index.html

the work can be undertaken by anyone in a

practice leadership position.”

The AMA Center for Health Equity mod-

els its Racial and Health Equity tool kit on several

successful interventions that led to improve-

ments in care. One is the Accountability

for Cancer Care through Undoing Racism

and Equity (ACCURE) clinical trial, which

sought to improve racial equity at two cancer

treatment centers in the United States. The

ACCURE trial involved early-stage lung and

breast cancer patients. Prior to the inter-

vention, the study found only 80% of Black

patients completed treatment compared to

87% of White patients.

Researchers reported multiple reasons

for the disparity; one was implicit bias on the

part of some clinicians who were less inclined

to recommend the same treatment to minor-

ity patients. To address these dis-

parities, a real-time warning system

was derived from electronic health

records, race-specific feedback on

completion rates was provided to

clinical teams, and staff training ses-

sions on health equity were held.

Notably, specially trained nurse

navigators were also assigned to engage

with patients during treatment, building

16 JulAug 2022 | CMA Today

 racism is a public health threat

trust and communication. As a result, the

trial intervention led to near elimination

of inequities in treatment and outcomes.

“Essentially, they were working with

Black women who had worse outcomes than

White women with breast cancer and got

them involved in redesigning the cancer care

system,” explains Dr. Cleveland Manchanda.

“In so doing, they not only eliminated racial

inequities in cancer care but also improved

the outcomes for all groups—for White

women as well as Black women. It’s a really

nice example of how when you target your

interventions to address inequities, the care

for everyone gets better.”

The Healing ARC

A growing number of antiracist initiatives

and activities are currently underway in

U.S. health systems. One is a pilot project

championed by Dr. Wispelwey and col-

leagues at Brigham and Women’s Hospital

to address inequities in care for heart failure

patients. The project began after a review of

10 years of hospital records found evidence

that Black and Latinx patients with heart

failure were less likely to be admitted to the

hospital’s specialized cardiology unit than

White patients. This was a critical concern

to address, asserts Dr. Wispelwey, as patients

receiving specialized cardiology care services

have better recovery rates, including lower

readmission rates and mortality, than those

in the general medicine service.

Under the pilot program, changes to

facilitate more equitable care were made

in the hospital’s admissions and electronic

health record system. “We’ve designed our

medical records system now so that if a

Black or Latinx patient with heart failure

is selected to be admitted to the general

medicine service, the physician will get an

[electronic] pop-up stating that this patient

is from a racial and ethnic group with his-

torically inequitable access to cardiology

and [asking them] to consider admitting

them to cardiology,” explains Dr. Wispelwey.

“We’re studying this process now to see how

it is working.”

The heart failure project is part of a new

Brigham program called the Healing ARC, a

hospital initiative that seeks to identify and

root out racial inequities in their system.

The “ARC” of the program is based on three

components: acknowledgement, redress, and

closure. First, health care providers should

CMA Today | JulAug 2022 17

acknowledge the role of racism in contribut-

ing to health inequities. Then, they need to

redress the harms linked to unequal treat-

ment by creating new pathways to equity.

Finally, providers should seek closure by

reconciling with the communities that have

suffered inequities in care.

Dr. Wispelwey and other antiracist

advocates have expressed concerns that

“color-blind solutions” in health care have

failed to adequately address existing racial

health inequities. While diversity and inclu-

sion efforts, implicit bias training, objective

checklists for clinical criteria, and other

solutions are certainly helpful, he says, more

needs to be done to truly embed racial and

health equity in medicine. The Healing

ARC is thus built on the notion of building

a deeper, more robust awareness of race-

conscious solutions to health inequities.

“We like to say in medicine when you

have a problem, you have to go after the

underlying cause of the problem,” remarks

Dr. Wispelwey. “The key problem in a heart

attack, for example, is an obstructed artery.

So, you’ve got to break up that clot in the

artery. You go right after it. Now, if we’re

documenting examples of institutional rac-

ism, our view is we have to address the

racism directly, and that requires being race

conscious as opposed to being race blind.”

In this spirit, the Brigham initiative

also emphasizes the critical importance of

including input from the local community.

“The idea of the Healing ARC is to try to say,

How do we actually develop that institutional

accountability?” explains Dr. Wispelwey.

“How do we develop a mechanism to address

and redress these racial inequities that we

find in health care? This isn’t just a theoretical

problem. We know we’ve been treating our

heart failure patients differently. This is an

example of documented institutional racism.

Since we want to do right by our patients, we

also created a wisdom council of Black and

Latinx community members to discuss what

each of these components should look like—

acknowledgement, redress, and closure. I

believe it’s very important that we bring in

the voices of impacted communities.”

Equal to the Task

The Ohio State University Wexner Medical

Center and College of Medicine in Columbus

have taken the lead in supporting antiracist

initiatives. “As an institution, we denounce

18 JulAug 2022 | CMA Today

 racism is a public health threat

“We have adopted the idea that we have

to educate with intent. We believe medical

education of new physicians should include

learning about racism, health, and health

care delivery from an African American per-

spective, as well as [the perspectives of]

other marginalized groups. A failure to do

so … is a disservice to the education of all

medical students.”

—Demicha Rankin, MD

racism in all forms,” says Demicha Rankin,

MD, associate dean for admissions for the

College of Medicine. “We believe that rac-

ism, specifically … discriminating against a

person because of their race or ethnicity, is a

social determinant of health that is damaging

to our community. We believe it damages our

patients in how they’re treated, our faculty

in terms of promotion or opportunities,

and our faculty and trainees in terms of

encountering bias. It impacts all levels in

its damage to our community.”

In 2020, a university-wide task force

of faculty, staff, and students at Ohio State

University was created to provide recom-

mendations on ways to foster an equitable,

antiracist campus community. This included

establishing an initial $1 million seed fund

for interdisciplinary research on racism and

creative solutions for the campus and com-

munity. The result was the adoption of their

campus-wide Anti-Racism Action Plan.

As institutions that provide comprehen-

sive patient care services, medical education,

and research, academic medical centers can

play an especially important role in lead-

ing antiracist work. “I do think we have

a responsibility to be leaders in this area,”

says Dr. Rankin. “We have a long history of

existence and of solving problems creatively.

As an academic medical center, we have

to be cognizant of creating a culture that

fully embraces and respects inclusion in all

aspects of the learning, research, and clini-

cal environments. It starts with education

and training—creating a workplace culture

and environment where everyone can be

their full authentic selves and be valued

for their skills and perspectives. Whether

it’s in research, teaching, or interactions

with staff—all of the different spaces we

occupy—we want to foster a community that

prioritizes and celebrates diversity, equity,

and inclusion in every area.”

The Anti-Racism Action Plan rep-

resents a coordinated series of initiatives

designed to create a culture of equity, fair-

ness, and inclusion in every facet of Wexner

Medical Center and the College of Medicine,

explains Dr. Rankin. As such, a task force

of medical students, faculty, and staff set

out to identify key areas requiring action

CMA Today | JulAug 2022 19

tion and other family and health resources.

The Moms2B program addresses a

significant public health issue by working

to reduce adverse pregnancy outcomes.

Nationally, infant mortality for Black infants

is 11.4 per 1,000 live births, which is more

than double the 4.9-per-1,000 rate for White

infants. In Ohio, Black infants die at nearly

three times the rate of White infants.

The

state’s fetal mortality rates also show Black

women are more than twice as likely as

White women to experience fetal death

during pregnancy.

Since its inception in 2010, Moms2B has

helped thousands of women. From 2011 to

2017, Moms2B babies were 55% less likely

to die in their first year of life. Program

participants also had fewer premature or

low-birthweight babies.

Notably, the pro-

gram’s success has also led to the creation

of a Dads2B program to provide additional

support and education for new fathers.

Help Wanted in the Workplace

The issue of racial and health equity in medi-

cine is an issue not limited to patient care.

Those who work in health care settings also

have the right to be treated with respect and

dignity and not be subject to racial or ethnic

bias or other forms of discrimination or

abuse by employers, colleagues, or patients.

Civil rights laws have been in place

for some time to protect employees from

employer discrimination. Unfortunately,

encounters with racism or other forms of

bigotry from patients still occur, acknowl-

edges an American Association of Medical

Colleges report.

In such instances, institu-

tions have an obligation to provide guidance

and support for employees who are subject to

racial prejudice or abuse. This includes encour-

aging staff to report discriminatory incidents

and even at times informing patients they

may be asked to leave the provider’s care.

“Being Hispanic, racism is an issue [for

me],” says Liliana Nava, CMA (AAMA),

a staff member at UNC Primary Care at

Chatham and UNC Endocrinology in Siler

City, North Carolina. “I’ve been working in

family practice for four years and unfortu-

nately have witnessed racism toward me

and others.”

In one instance, Nava describes work-

ing with a White physician assistant whose

last name is commonly associated with a

Hispanic background: “We actually had a

patient contact our front desk and say they

didn’t want to see ‘them’ again, meaning me

and the other staff member. When the front

desk asked why—if they had been treated

wrongly—the person replied, no, they just

wanted to see someone ‘normal,’ which for

them meant a ‘White person who would

understand me.’ ”

Incidents of racial prejudice should be

reported to a clinical manager or provider,

stresses Nava: “You should bring it up with

your manager. I would also say it’s important

in these situations to stay professional at all

times. Stay calm. Even if at the end of the

day you don’t feel that much was done, at

least the incident is on record.”

Nava encourages providers to recog-

nize how critical it is for minority staff to

feel supported when racism appears. “We

need that support from our employers,” she

emphasizes. “We want to know our voices

will be heard. Some people might think

they’re superior to you, but they’re not. Of

course, there is going to be a mix of people

in our work, and we need to understand and

respect all of them. I believe everybody’s

equal. We all need to remember our value

and the fact that we all need each other.”

The goal of racial and health equity

is invariably rooted in a holistic vision of

fairness and justice, one that extends from

patient care to medical education and the

organizational cultures of health systems.

While the challenges are certainly daunting,

the goals of the antiracism movement in

medicine herald the possibility of improved

health and health care services for all com-

munities. ✦

References

1. Hill L, Artiga S. COVID-19 cases and deaths by

race/ethnicity: current data and changes over time.

Kaiser Family Foundation. February 22, 2022.

Accessed June 14, 2022. https://www.kff.org

/coronavirus-covid-19/issue-brief/covid-19-cases

-and-deaths-by-race-ethnicity-current-data-and

-changes-over-time/

2. Sexton SM, Richardson CR, Schrager SB, et al.

Systemic racism and health disparities: a statement

and attention.

“We came away with three pillars that

we wanted to focus on,” says Dr. Rankin.

“The first pillar was the curriculum—look-

ing at how we teach, who’s teaching, what’s

in the content, what’s in the materials? Is

there bias? Is the curriculum dynamic? Is

the curriculum antiracist? We also looked at

culture—ensuring that the culture allows for

representation of everyone’s full authentic

selves unapologetically. The third pillar was

commitment—affirming our commitment to

providing resources, access, and opportuni

ties to ensure student success.”

As a result, several new curriculum

offerings have been introduced into the

medical education program, reports Dr.

Rankin. “For instance, we now have a four-

week advanced elective in medical ethics for

our [fourth-year] students that addresses the

African American experience. In addition,

we also offer a new curriculum for [first-

and second-year] medical students where

we discuss racism, health, and health care

delivery, as well as a first-year module on

issues with race-based medical misinforma-

tion and history’s impact on today’s medical

practices.”

Other changes have been relatively

easy to make. For example, the College of

Medicine has introduced the use of Black

manikins in the simulated education center

where students learn responses to mock

emergency room codes.

“This is an example

of something we were able to identify—the

low-hanging fruit in our curriculum, so to

speak—where we realized we can do better,”

says Dr. Rankin.

Multiple components are involved in

antiracism activity at Ohio State University,

such as the 21-Day Anti-Racism Challenge,

an educational activity inviting individuals

and groups to learn more about systemic rac-

ism, privilege, and equity. Another, older Ohio

State University program that addresses racial

health disparities is the Moms2B program.

Led by a multidisciplinary team of health

professionals, Moms2B is a community-

based program to help people deliver healthy,

full-term babies. The program provides

access to a variety of pregnancy-related

health necessities, including prenatal educa

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 racism is a public health threat

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