Leonard Ezenagu, MD, FACOG
WMJ. 2021;120(Suppl 1):S84-85.
In many aspects of health care, White patients always seem to have a better outcome. As a medical student, I noticed that almost every time a disease condition was discussed, it would be stated that Black people have the worst outcome for virtually every condition, from prostate cancer to breast cancer, to diabetes, hypertension, and many more diseases. The current COVID-19 pandemic is killing more African Americans and other members of minority communities than White people as well.1,2
As a physician practicing obstetrics and gynecology in Wisconsin, I am well aware of the disparities in health care affecting women and children from minority groups, particularly African American women. Approximately 700 women die each year in the United States from pregnancy or pregnancy-related complications, and American Indian/Alaska Native and Black women are 2 to 3 times more likely to die from complications of pregnancy than White women.3 The Wisconsin pregnancy-related maternal mortality is markedly higher in non-Hispanic Black women compared to White women. Although many factors are cited as accounting for this disparity, the issue of race and racism is also a contributing factor.
Racism touches many areas of health care and minorities of all ages. African American babies born in Wisconsin die before age 1 at a higher rate than any other state in the nation, according to a report from the Centers for Disease Control and Prevention (CDC).4 Wisconsin also has the nation’s highest gap between White and Black babies with regard to racial disparities in infant mortality. According to the CDC’s National Center for Health Statistics, the death rate for Black babies in Wisconsin is nearly 3 times higher than White babies.5 Wisconsin had the highest mortality rate for infants born to non-Hispanic Black women in the US between 2013 and 2015 at 14.3 deaths per 1,000 babies compared to the national average of 11.1.4
Unfortunately, many studies have shown that racial disparities exist in health care,5,6 and they result from differences in geographical location, lack of access to adequate health coverage, communication barriers between patient and provider, cultural barriers, provider stereotyping, and lack of access to providers.5
To address this disparity without acknowledging that racism plays a major role is missing the point. It is of note that in May 2018, the Wisconsin Public Health Association passed a resolution declaring that racism is a public health crisis in Wisconsin.7 It was recommended that actionable measures be put in place to address this issue, including the following:
- Incorporate educational efforts to address, dismantle, and expand understanding of racism and how it affects individual and population health; provide tools to engage actively and authentically with communities of color.
- Advocate for relevant policies that improve health in communities of color and support local, state, and federal initiatives that advance social justice, while also encouraging individual advocacy to dismantle systemic racism.
- Work to build alliance and partnership with other appropriate organizations that are confronting racism and encourage partners and/or stakeholders to recognize as a public health crisis.
- Advocate adequate financial and human resources to accomplish all selected activities.
Conscious and unconscious biases harbored by health care providers, which are intertwined with racism, contribute immensely to the racial disparities in health care in Wisconsin, as well as other parts of our nation.
For example, physicians have been observed to disregard or ignore complaints of pain by Black patients more frequently than for White patients.8,9 A study conducted in 2016 by researchers from the University of Virginia showed that White patients are more likely than Black patients to be prescribed strong pain medications for similar health conditions.8 Some people have held beliefs that there are biological differences between Black and White people. According to the study, these beliefs result in some people thinking that Black people feel less pain than White people, which will invariably lead to inadequate treatment recommendations for Black patients’ pain. Glance et al conducted a study in 2007 on racial differences in the use of epidural analgesia for labor.10 They concluded that Black and Hispanic women in labor are less likely than non-Hispanic women to receive epidural analgesia. They also found that these differences remain after accounting for differences in insurance coverage, provider practice, and clinical characteristics.
It is important for those of us in health care to engage in periodic introspection to identify our own biases and work hard to resolve them. This will help us to provide more balanced and equitable care to our patients. In my current practice, as well as my previous practices in other states, I have observed that some Black patients don’t have trust in the health care system, something that can be traced to past research conducted on Black people without appropriate consent and honesty. It is also important that health care providers be trained in cultural competency. I have observed situations where a physician will be quick to suggest ordering a urine drug screen on a patient based on her persona. No patient should be judged based on how she looks or how she dresses.
Notably, elevated socioeconomic status, having a college education, good insurance coverage, and access to health care does not protect Black patients from experiencing inadequate care from their doctors. Serena Williams, a high profile athlete with access to quality health care, almost died of undiagnosed pulmonary embolism after giving birth to her daughter. Despite the fact that she has a history of thrombosis, she stated that no one at her hospital believed her when she was telling her nurse “between gasps” that she needed a CT scan and a blood thinner. Ms Williams was reported to have stated that her nurse thought the pain medication she received might have been confusing her. It is also possible that Ms Williams was not taken seriously, not only because she is Black, but also because she is a woman.
In Wisconsin, addressing social determinants of health with patients will help physicians provide more equitable care to all patients. The racial segregation patterns of many cities, including Milwaukee, seem to affect the type of care provided to patients from those communities.11 Eviction disproportionately affects neighborhoods where the majority of the residents are people of color. Health care organizations, payers, and other interest groups in Wisconsin must be honest with themselves in answering the fundamental question: to what extent are our approaches rooted in a framework that addresses structural racism and equity?
Wisconsin must do better. We must continue to have open discussion on ways to find solutions to racial disparities in health care. It will require a team effort and everyone working together to solve this problem. With the current social climate in the United States, generated by recent deaths of young Black men in the hands of members of law enforcement, people from all walks of life in Wisconsin must continue to speak up, even when it is uncomfortable, in order to confront and eliminate racism. Many organizations in Wisconsin have redoubled their efforts in addressing and promoting equity, diversity, and inclusion. This is a welcomed approach, since it is through open and candid dialogue that we can move forward, have a better understanding of one another, and solve problems.
- Williams DR, Cooper LA. COVID-19 and health equity-a new kind of “herd immunity.” JAMA. 2020; 323(24):2478-2480. doi:10.1001/jama.2020.8051
- Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891-1892. doi:10.1001/jama.2020.6548
- Racial/Ethnic Disparities in Pregnancy-Related Deaths-United States, 2007-2016. Centers for Disease Control and Prevention. Updated February 4, 2020. Accessed October 30, 2020. https://www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancy-related-deaths/Infographic-disparities-pregnancy-related-deaths-h.pdf
- Mathews TJ, Ely DM, Driscoll AK. State variations in infant mortality by race and Hispanic origin of mother, 2013-2015. Centers for Disease Control and Prevention. National Center for Health Statistics. NCHS Data Brief No. 295. January 2018. Accessed February 25, 2021. https://www.cdc.gov/nchs/products/databriefs/db295.htm
- American College of Physicians. Racial and Ethnic Disparities in Health Care, Updated 2010. Policy Paper. American College of Physicians; 2010. Accessed January 10, 2021. https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/racial_disparities.pdf
- Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev. 2000;21(4):75-90.
- Racism is a public health crisis. 2018 Resolution. Wisconsin Public Health Association Business Meeting. May 22, 2018. Accessed January 10, 2021. https://cdn.ymaws.com/www.wpha.org/resource/resmgr/2018_folder/WPHA_Racial_Equity_Resolutio.pdf
- Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113
- Sabin J.A. How we fail black patients in pain. Association of American Medical Colleges. January 6, 2020. Accessed January 10, 2021. https://www.aamc.org/news-insights/how-we-fail-black-patients-pain
- Glance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW. Racial differences in the use of epidural analgesia for labor. Anesthesiology. 2007;106(1):19-25. doi:10.1097/00000542-200701000-00008
- Foltman L, Jones M, Bourbeau C. How redlining continues to shape racial segregation in Milwaukee. University of Wisconsin Applied Population Laboratory. WisCONTEXT. February 28, 2019. Accessed January 10, 2021. https://www.wiscontext.org/how-redlining-continues-shape-racial-segregation-milwaukee