Bridging the Gap: Confronting racism in health

Introduction from Vice Chancellor Steve Goldstein

Systematic racism, especially anti-black racism, is woven into the fabric of American life. Sometimes racism is overt and at other times it is insidious, practiced without self-recognition. In the world of health care, racism manifests as life-threatening inequity, a statement that can be made without qualifications given the travesty that the COVID-19 pandemic has wrought on people of color.

For this installment of the University of California, Irvine Health Affairs Bridging the Gap series, Heather Shannon interviewed Dr. Alison Holman of the UCI Sue & Bill Gross School of Nursing, to understand how her teaching and course work provides the next generation of nurses with tools to address institutional racism and what the school is doing now to address its own institutionalized racism.

We can achieve health equity if we confront explicit racism and unconscious biases as a priority, and with unrelenting dedication, in each aspect of our mission to discover, teach and heal. As health care investigators, teachers and providers doing anything less is a failure to meet the moral imperative and our professional obligations.

Dismantling internal biases for better care

Nurses are bound by a core mission to care for everyone, regardless of the color of their skin or socioeconomic status.

The death of George Floyd this May, however, led many institutions to look inward and examine how they have contributed to anti-Black racism.

Faculty and staff at the UCI Sue & Bill Gross School of Nursing are actively identifying ways they can do better. They have initiated a Diversity committee with several members of the school that their Equity Advisor, Dr. Jung-Ah Lee, leads with the support of the DECADE mentor, and other dedicated faculty (including Dean Adey Nyamathi) and staff. Several faculty have long been weaving topics of racism in healthcare into their curriculum.

Raising awareness of the Black experience

E. Alison Holman, PhD, teaches a compassionate care course that’s intended to raise awareness of the issues Black people have faced for centuries.

“I want to educate our students about the history of racism in this country and how it has played out so they understand how the system itself has created the health disparities we see today.”

She screens “The Power to Heal” each year. The powerful 2017 documentary tells the history of racism in the American Medical Association and its impact on the healthcare available to Black Americans over the past century.

For more than a century, the AMA actively promoted attitudes and beliefs that exacerbated racial inequalities in health care delivery and excluded Black physicians from membership. Though the association apologized in 2008, the damage has long been done.

“We’ve created a system that is inherently racist because it was built upon racist ideology. Black people in America have never had equal access to healthcare,” Holman said.

After the Civil War, Black people could only access lower-tier hospitals with fewer staff and supplies. Holman wants her students to understand the impact of these policies and how they contribute to gaping health disparities and higher mortality rates in the Black population.

Indeed, inequities and bias have worsened a health crisis for Black Americans and rendered them more vulnerable to the current pandemic with COVID-19 killing Black, Indigenous, Asian, and Latinx Americans at rates higher than those of white Americans. Several serious chronic diseases also strike the Black population harder and more frequently than they do white people, placing them at greater risk for serious illness if they are infected with COVID-19:

• Diabetes is 60% more common in the Black population
• Black people are 3 times more likely to die from asthma
• Black women are 3 to 4 times more likely to die from pregnancy-related causes than white women
• Black men are 50% more likely than white men to get lung cancer despite lower tobacco exposure
• Black people develop high blood pressure earlier in life
• Black men have a 40% higher cancer death rate than white men; Black women have a 20% higher rate than white women

Awakening to implicit biases

To change this grim picture, Holman says healthcare providers need to look inward.

“A lot of us don’t have a clue about our biases. We’re so used to operating in the current institutional system that we do not see the biases built into the system,” she says.

“It’s incumbent upon us to stop, think, and act for justice.”

Holman recognizes that true change comes from within, and implicit bias training helps uncover hidden biases. She wants her students to confront their own internal racial biases (we all have them) and beliefs.

One of the best ways to mitigate the impact of bias is to slow down and seek out colleagues for consultation about a patient’s care.

“When you consult with others on the team, that slows down your thought process. That slower thinking allows you to reflect and make more conscious decisions that are less likely to be biased,” she says. In the healthcare setting, this kind of team approach to care lessens the risk of a harmful decision being made.

Seeing the whole person

Holman’s work with her students will ultimately challenge them to look deeper when they see patients and see the whole person. Doing so removes the barriers to open and honest communication, she says.

“We have to understand where our patients are, what they think, what they feel, what their goals are. We have to make room, to make space for our patients’ lived experiences.”

Too often, she says, the approach in healthcare is to make assumptions about patients based on deeply engrained racial stereotypes and then tell them what they need to do. That often causes patients to feel like they are not being heard or seen as the person they are.

Citing her own doctor as an example of effective communication, “She listens to me, respects my wishes, makes recommendations, gives me options. How you communicate is critical to being an effective health professional who wants to function in an anti-racist way.”

Deep reflection and conversation

Many of Holman’s assignments are reflective, allowing her students to challenge themselves (and hopefully change) from within. And it doesn’t stop there: She encourages the whole family to get involved in these conversations.

“I have my students think about their family and their beliefs, attitudes and health behaviors. What were you taught about your relationship with doctors, nurses, and other health professionals? How did your family culture instill beliefs in you about what healthcare should look and be like.”

She finds that her students are often willing to openly share their thoughts and feelings during class discussions.

Holman remembers one day shortly after George Floyd was killed, a Nigerian-born undergraduate shared her experience of growing up in America.

“She never felt like she belonged anywhere in America — except at home with her family. Imagine walking through life feeling like you do not belong. What a terrible, inhumane experience for a person to go through.”

Hearing such stories helps students see how unique experiences and worldviews shape all of us, and we need to take the time to listen.

“We need to learn how to communicate with someone whose needs may be unfamiliar or different from our own, and to challenge the internal biases that color our decision-making. Active listening, interpersonal exposure to people from different cultural and racial backgrounds, and personal reflection are essential for gaining the insights necessary to preventing your biases from undermining patient care.”