Prejudiced Providers: Addressing Discrimination in Healthcare

[Note: A version of this article originally appeared on Medium.com on March 10, 2021.]

In high-income countries, such as the US and the UK, Black populations died of COVID-19 at a staggering rate as compared with white populations. In the US, African Americans died of COVID-19 at 1.9 to 2.8 times the rate of white people; in the UK, Black men and women were respectively 4.2 and 4.3 times more likely than their white counterparts to die from a COVID-19-related illness.

Much of the discussion regarding COVID-19 racial inequalities focused on two explanations. First, the media dabbled with the idea that the mortality inequities were genetic. This approach, arguably couched in race science, was the basis of research being carried out at the University of Nottingham, UK.

One key social factor that was largely ignored in relation to the COVID-19 pandemic, was the elephant in the room that no one wanted to consider — racial bias in healthcare.

Other commentators disputed race-based medical theories with the more enlightened "social determinants of health" explanation of health inequalities, namely, that COVID-19 inequalities were largely due to social factors such as low income, difficult employment situations, and poor housing conditions. However, one key social factor that was largely ignored in relation to the COVID-19 pandemic, was the elephant in the room that no one wanted to consider — racial bias in healthcare.

As Martin Luther King noted in 1966, “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” It is perhaps because the very idea of racial bias in healthcare is so uniquely horrific, and because we are socialized to put medical providers on a pedestal, the mere suggestion of discrimination in this setting is taboo. However, a growing body of research indicates that racial discrimination in medicine is a reality, and permeates the healthcare system in the same way it does in the general population. For example, a 2015 systematic review found that in 14 out of 15 published studies, healthcare providers displayed negative attitudes toward people of color while revealing positive attitudes toward white people.

A growing body of research indicates that racial discrimination in healthcare is a reality, and permeates the healthcare system in the same way it does in the general population.

Moreover, these negative attitudes translate into negative healthcare interactions, discriminatory decision-making, unequal treatment, and worse health outcomes across numerous healthcare specialties (in addition to the Covid-19 inequities discussed above). For the sake of brevity, they cannot all be covered here, however, the high maternal death rates among Black women in the US and UK is an additional example that has received media attention in recent years. Indeed, in the US, Black women are dying of pregnancy-related causes at two to three times the rate of white women, and in the UK, Black women are a staggering five times more likely to die from pregnancy-related complications than white women.

Legal reform as a way forward

Racial inequities in healthcare in the US and the UK are well documented, yet disparities stubbornly persist at disturbing levels in high-income countries such as these. While some healthcare institutions have been using anti-bias training to address the problem, it has had no impact on reducing inequities. While well-intentioned, it could be argued that mere training, without legally enforceable procedures to reduce racial bias, will maintain the status quo. Thus, in order to achieve meaningful equity in healthcare, there needs to be a focus on legislative reforms in medicine as opposed to the softer reforms (for example, anti-bias training) currently being used.

Body cam recordings would make providers more accountable and therefore more careful, in turn reducing medical errors and enhancing patient safety.

First, there is a need for legislation to reduce discretion in the decision-making of healthcare providers. A reduction in their discretion would require their strict adherence to clinical guidelines, which in turn would reduce the opportunities for racial bias in healthcare decisions. Second, there is a need for legislation to increase the accountability of healthcare providers. An increase in accountability would help to ensure that healthcare provider decisions are subject to scrutiny, and in turn serve as a deterrent to racial bias in healthcare decision-making.

One way of achieving accountability in the healthcare context may be to mandate that healthcare providers wear body cameras, as is increasingly being required in policing. It could be argued that body cam recordings would make providers more accountable and therefore more careful, in turn reducing medical errors and enhancing patient safety.

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The COVID-19 pandemic drew special attention to the staggering racial inequities in healthcare that had long existed, underlining the need for meaningful action. It is time to tackle this problem head-on, that is, focus on legislative reforms which reduce discretion and increase accountability among healthcare providers.