By Gauri K. Shevatekar, MBBS, MPH, CHES
With the ongoing Covid-19 pandemic, as we witness its disproportionate impact on minority populations, the spotlight is back on the inequities in health and health outcomes. Undoubtedly, health equity is at the center of discussions, especially among the health care providers and public health practitioners. As we look ahead, I wish to reflect and share my thoughts on our role in advancing the efforts to achieve health equity.
My deep dive into disparities occurred through the doctoral courses where three-hour long lectures, journal clubs, roundtable discussions, hot debates and multipage assignments provided a rich learning environment to learn about the driving forces, influencing factors that create and perpetuate disparities, and strategies to address them.
In my role as the population health faculty for the Office of Graduate Medical Education and by developing and teaching the health disparities curriculum to all residency programs here at the University of Illinois College of Medicine Peoria, I keep learning more every day about the exemplary work done by many health equity experts and a multitude of agencies and institutions across the nation and across the globe.
The works of experts such as Drs. David Satcher, David Williams, Camara Phyllis Jones, Lisa Cooper, Ana Diez Roux, Donald Barr, Thomas LaVeist, Sir Michael Marmot and many others have been instrumental in advancing our understanding about health disparities, health care disparities, social determinants of health, health equity and social justice.
Now, I am clear when it comes to the question, “Who does health equity begin with?” My answer is, “It begins with us” — and by “us” I mean not only as individuals, but ‘we’ as a part of a team, ‘we’ as a program, as an organization/institution, and ‘we’ as a community or society as a whole. For me, achieving health equity is a journey that begins with self-reflection and self-awareness, followed by education and then empowering ourselves and others to change.
In the limited space provided by this blog, I would like to address only a few key elements and provide resources, so that each one of us can play our role in reducing disparities/achieving health equity.
1) Understanding our own implicit and explicit biases
Research suggests that providers’ implicit biases are more likely to underlie treatment disparities than overt prejudice. Implicit biases are widely prevalent, so it is not surprising that physicians would harbor them. These biases arise from our sociocultural learning over time. Similarly, our implicit and explicit stereotypes and attitudes contribute to the biases. Stereotypes are the beliefs that most members of a group have certain characteristic(s), and attitude is a set of beliefs and behaviors toward particular group(s)/individual(s). Stereotypic expectations can bias interpretations and evaluations, especially about patients belonging to minority and lower socioeconomic status. Physicians’ implicit biases, stereotypic expectancies, beliefs, and attitudes can negatively affect clinical decision making, clinical interactions, communication, quality of care, patient satisfaction and health outcomes.
It is important to understand that implicit biases do not imply overt racism; but these, by their very nature, are hidden from the conscious awareness. Therefore, implicit biases need to receive our explicit attention. The Implicit Association Tests (IATs) have been used to study implicit preferences and stereotypes for a long time now. Project Implicit is a non-profit organization and international collaborative among researchers interested in social cognition. The goal of this organization is to educate the public about hidden biases and to provide a virtual lab for collecting data over the internet. It is an excellent resource allowing the users to assess their implicit biases through a plethora of available tests.
If you haven’t already, please consider participating in UIC’s Bias Reduction in Internal Medicine (BRIM) workshop. I am sure you will find it very valuable in combating implicit biases and stereotypes.
2) Understanding racial microaggressions
According to Dr. Derald Sue and colleagues, racial microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities. These may be intentional or unintentional, and communicate hostile, derogatory, or negative slights and insults towards people of color. When interacting with racial/ethnic minorities, the committers of microaggressions are often unaware that they are engaging in such communications. The three forms of microaggressions are microassaults, microinsults, and microinvalidations. Racial microaggressions negatively affect trust and serve as barriers for the clinical practice. For us to be truly inclusive and to truly embrace diversity, understanding microaggressions and their implications for learners, providers and patients is immensely important. Here is a short talk by Dr. Toya Webb on the topic of microaggressions that is very action-oriented and thought provoking. The resource Speak Up: Responding to Everyday Bigotry shares powerful stories and strategies.
Discussion on microaggressions is also an integral part of the UIC’s BRIM workshop, and in UICOMP’s Health Equity Grand Rounds that took place on Feb. 24, 2022, the presenters, Dr. Gonzaga and Dr. Mustapha discussed about the strategies to address microaggressions and discrimination.
3) Understanding own privileges
In the context of diversity, inclusion and social justice, privileges are societally granted, unearned, systemic, or structural advantages given to people who fit into specific identity factors such as race, gender, sexual orientation, nationality, religion, disability, education, socioeconomic status, and physical features such as body type. Privilege is inextricably linked to oppression, as systems and structures, social norms, and biases advantage some and disadvantage others. Privilege is often invisible to those who have it. Having privilege(s) doesn’t mean that one is immune to hardships or things are handed down to them. Privilege is not about who we are as individuals but more about the groups we belong to/identify with and how these groups are viewed and treated in the society.
Privilege is also intersectional. Intersectionality refers to the ways in which aspects of identity intersect to create specific experiences, needs and opportunities. Understanding and acknowledging our privileges enables us to be a better ally. An ally is an individual who uses their privilege to advocate on behalf of individuals who don’t have it — those who have been marginalized. Understanding privilege and being a better ally is a constant, ongoing journey. To help learn more about various forms of privileges and their impact, here’s a brief video of a privilege walk exercise that I use in my lectures.
4) Understanding racism
Dr. Camara Phyllis Jones defined racism as the system of structuring opportunities and assigning values on the social interpretation of how one looks. This system unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources. Racism can be divided into institutional/structural, interpersonal, and internalized racism. Biases, prejudice, microaggressions and discrimination fall under interpersonal racism.
Structural/institutional racism is one of the social determinants of equity or, in other words, one of the driving forces along with other “-isms” that create the contexts/environments, more commonly known as the social determinants of health, in which individual behaviors arise. These driving forces also define one’s access to social/economic/political power, privileges, and community-based as well as individual resources, thus creating and perpetuating disparities. To learn more about the social determinants of equity, social determinants of health, and strategies to address racism, watch this video by Dr. Jones or read the Cliff’s analogy paper by Dr. Jones and colleagues.
I believe that in our quest to achieve health equity, to become more inclusive and equitable society, self-reflection comes first. We need to introspect, reflect on the biases, privileges that we have, attitudes and behaviors that we exhibit and keep learning about how to be a better ally. This journey includes challenging our innate beliefs, challenging norms, paving a way for and accepting change. Our commitment to achieve health equity and social justice will only be strengthened by our ability to embrace diversity and dismantle all forms of oppression, discrimination and racism. This starts with our own self-awareness.
It is true that the journey of a thousand miles begins with one step.