Confronting Implicit Bias: A Remedy for the Public Health Issue of Racism?
I could write a multi-volume book series about the negative effects of institutional racism on society in the United States. I could talk about how it disadvantages minority citizens in the realm of education, resulting in lower high-school graduation rates among minority communities. I could mention the “school-to-prison-pipeline,” which disproportionately funnels public school students of color into the juvenile justice system. I could delve into issues of food insecurity, environmental justice, and socioeconomic mobility — all of which are largely influenced by institutional racism.
The conversation around health disparities along racial lines in the United States is particularly pressing and relevant considering recent changes in the healthcare system. The bottom line is that minorities consistently receive worse healthcare than their white counterparts. Even when we get rid of factors like insurance, access, and income, ethnic and racial minorities still see worse health outcomes. Take, for example, the fact that white women and black women are diagnosed with breast cancer at a similar rate, yet black women are 42% more likely to die from the disease than white women.
Health and healthcare are multi-dimensional issues. It’s important to recognize that there are countless factors that contribute to a person’s health, including their environment, family, ethnicity, income, race, gender, social status, education, nationality, sexual orientation, and more. Of course, these factors all intertwine to create an even more complex and intersectional problem.
“Because the conversation about institutional racism and health disparities is multi-faceted, nobody can claim to have all the answers. But here’s a good starting point: let’s acknowledge that implicit bias plays a large role in the health disparities that exist in the U.S.”
Because the conversation about institutional racism and health disparities is multi-faceted, nobody can claim to have all the answers. But here’s a good starting point: let’s acknowledge that implicit bias plays a large role in the health disparities that exist in the U.S. If we want to break the various institutional chains placed on minority citizens, we must first challenge implicit bias in our healthcare systems.
We all have biases that affect our decision-making processes in one way or another; it’s human nature. An implicit bias can be described as a bias we hold unintentionally. These biases are influenced by all the social, political, and culture forces in our lives, from the environment we grew up in, to our family dynamics, to our favorite TV shows and books. Implicit biases can be harmless; for example, I implicitly associate springtime with positivity, color, and vibrancy. As a result, I may unconsciously be more positive and vibrant when springtime comes around every March or April. However, this is not the case with the implicit biases that have been harbored in the systems that support institutional racism in American society and that contribute to health disparities.
Our brains tend to store patterns because I realize that every new thing I encounter is absolute disorder. And every key we have is something that helps us sort patterns. Race is one of those things, ethnicity is one of those things….in some respects it’s functional, in terms of our being able to make sense of the world…the question is do you take it to a level of personal insight so you can check those things that are going to be destructive?
-Dayna Bowen Matthew, Just Medicine: A Cure for Racial Inequality in American Health Care
A 2012 study conducted at Johns Hopkins found that implicit biases among physicians led to poor communication with black patients, and negatively affected both the doctor-patient relationship and the way care was delivered individually. The physicians weren’t necessarily aware that they were treating their black patients any differently, but many of the black patients felt unwelcome in the hospital setting, or that they weren’t receiving good care. As a result, some even began to avoid the medical system.
In another study conducted in 2000 by researchers van Ryn and Burke, 193 physicians were asked to assess their perceptions of 842 patients (57 percent white and 43 percent black) following their hospital visits. The physicians rated each patient based on various personal characteristics such as intelligence, rationality, independence, and perceived educational level. They also rated their feelings toward each patient, and whether they felt like the patient would comply with medical advice, exaggerate pain, or use drugs or alcohol. The researchers found that black patients, in general, were rated and perceived as less intelligent, more likely to use drugs or alcohol, more likely to exaggerate pain, and less likely to comply with medical advice.
Of course, there’s no clear answer on how to solve implicit biases. We also know that there are myriad other reasons why healthcare disparities exist, ranging from lack of nutritious food, to unsafe housing, to unequal access to health insurance. However, acknowledging that these biases exist and confronting them is a necessary step in the direction of health equity.
Before writing this blog post, I found it important to confront my own implicit biases, so I took Harvard University’s Implicit Association Test (IAT). This test measures the strength of associations with and evaluations of certain groups. On the IAT, I was asked to sort words or images into categories and received a score based on how long it took me to do this. In this way, the IAT reveals that some categories are linked more closely in our minds than others. For example, some people find it easy and natural to link negative words or images with some racial groups, and positive words or images with other racial groups. (I encourage you to take any one of the Harvard IATs and become acquainted with your own implicit biases.)
In 2012, all members of the Ohio State University College of Medicine admissions committee took the IAT prior to the admissions cycle. The test found that a majority of the committee displayed significant levels of implicit white preference. After the IAT, 48 percent of the admissions committee became conscious of their results when interviewing candidates, which then led to the most diverse incoming class the medical school had ever seen the following year. Additionally, many medical schools are realizing that future patients will suffer if medical schools do not accommodate a more diverse cohort and if their curricula do not include confronting implicit bias.
“…physicians must be part of the process of dismantling the many oppressive systems that impede health equity.”
Many medical schools are also focusing on social progress to combat institutional racism. The Duke University Health System is instituting a population health improvement strategy which collaborates with the government, nonprofits, and the private sector to address social determinants of health. The Boston University School of Medicine is addressing the physician diversity gap by supporting promising undergraduates who may not otherwise have the means to attend medical school. Efforts like these reflect the steps many medical schools around the country are taking to educate more socially aware physicians. After all, these physicians must be part of the process of dismantling the many oppressive systems that impede health equity.
There is still much work to be done in the movement for health equity. Recognizing and confronting implicit bias is an important first step.