Archive for March, 2021

Inside Voices: A Look at Clinician-Experienced Racism

This is something new for us. We hear a lot of stories, many relating experiences outside our own that open doors to broader understanding of the many lives that make up the American experience. Today’s author, Fatima Adamu-Good, is an occupational therapist and writer with 15+ years of experience in research, diversity advocacy, urban design, quantitative analysis and cultural competency. As an advocate for diversity, equity and inclusion, she has collaborated with local and national leaders in the healthcare and non-profit communities to address systemic racism in clinical practice, delivered presentations on the detrimental effects of implicit bias in the academic sphere and published articles highlighting the experiences of people of color as they strive for success. She is currently an adjunct professor in occupational therapy at Thomas Jefferson University in Philadelphia, Pennsylvania.

Fatima told us this story in passing, and was kind enough to write it up. Thanks also to Stephanie MacKay for edits.

A Look at Clinician-Experienced Racism

One morning in early April of 2020, an occupational therapist walked toward the room of the newest rehabilitation patient at a skilled nursing facility in Southeastern Pennsylvania. She mentally reviewed information from the patient’s hospital chart*; race: White, gender: male, age: late 70s, weight: 185, height: 5’ 9”, past medical history: unremarkable, the reason for admission: fall with hip fracture and subsequent replacement. The therapist grabbed a rolling walker conveniently located next to the doorway, prepared for a standard intake process; this was the latest fall/hip fracture patient in a line of the many seen in a facility devoted to geriatrics. Upon entry, the patient seemed fatigued but well-oriented to his surroundings. He peered skeptically from smeared glasses and said, “Whoa! What’s going on with that hair?!”. The therapist, taken aback, reached up to touch her afro, styled the same way it was every day. The next morning, her supervisor informed her that the patient had requested non-African-American rehabilitative and nursing staff because he “had difficulty understanding the instructions” of African-American staff.

That therapist was me.

What are the economic consequences of the above anecdote? There is a financial cost to attitudes and policies colored by racism as the 2020 Peterson and Mann report on the economic impact of inequality makes clear. African-Americans currently make up 12.8% of the country’s population and the cost of their exclusion from higher education access equates to $90-$113 billion from 2000 to 2020. Such encounters as the one I experienced undermine remedial initiatives that increase the quality of care for African-American patients. The percentage of African-American physicians is currently 5%, less than half the overall population share. The avoidance of preventive care services accounts for 75 percent of national healthcare expenditure and reduces economic output by $260 billion a year. Efforts to increase national figures for African-American doctors, such as the $100 million contribution to historically black medical colleges by former New York Mayor Michael Bloomberg, could also reduce economic opportunity barriers while buoying GDP.

A 2020 cross-sectional survey in the Journal of Family Medicine found that twenty-three percent of the 71 physician participants reported a patient directly refusing their care due to race. It concluded that physicians of color experienced significant racism while providing health care in their workplace and were likely to feel unsupported by their institutions in which they practiced. Another study, in 2007, of minority medical students, showed a correlation of racial bias with burnout and depression symptoms in 48% of participants. Before its 2008 apology, the American Medical Association failed to address 100 years of the racial inequalities African-American physicians faced, and excluded them from vital organizational conversations. African-Americans are underrepresented amongst the management that determines patient-handling policy, the business people who fund these measures, and the professional staff that control who enters educational institutions and higher-wage occupations. The aforementioned structural imbalances need to be remedied to ensure that income gains fostered by the growing share of African-Americans physicians, and the companion better health outcomes for their patients, are not eclipsed by sidelining and burnout.

The CDC reports that deaths from the Sars Cov-2 virus in racial minority groups are more than 50% higher than in White or Asian persons residing in the United States. This surge in deaths has a resonance with another set of findings with economic roots and ramifications for an entire demographic category. The 2015 Case and Deaton paper chronicling a marked increase in mortality for middle-aged non-Hispanic White working-class people identified educational attainment, access to mental health services, and availability of stable work as life and death determinants. Louisiana, one of the ten U.S states with the highest African American population, demonstrates a microcosm of a larger pandemic pattern: African American Covid19-positive patients had a higher prevalence of conditions manageable via preventative healthcare services such as obesity, diabetes, hypertension, and chronic kidney disease. These patients were also three times more likely to have Medicaid insurance than white non-Hispanic patients. The Affordable Care Act (ACA) has made a dent in the country’s uninsured numbers and could be critical in addressing inequities in care-access; between 2013 and 2016, the ACA’s expansion of Medicaid lowered the uninsured rate for non-elderly African Americans from 18.9 percent to 11.7 percent.

In other, heartening, news, there has been a marked increase in African-American applicants to medical schools since the Covid-19 pandemic began. If the face of healthcare is more representative of the communities most in need, it equates to increased traffic through a clinic’s halls and consequently an increase in revenue along with quality care. Many potential African-American patients avoid utilizing preventative care services for fear of discriminatory treatment. A Stanford study reported higher communication levels between African-American male patients and doctors of similar ethnicity, extrapolating conclusions to indicate better cardiovascular health outcomes for such patients by 19%.
When an incident of overt or covert racial bias against a clinician does occur, current institutional methods of redress are lacking.

Any ameliorative strategies to address the racial inequalities created in our centuries-old simmer, fueled by bias and frustration and detailed in this research note are rendered toothless if framed as ethical issues or limited to philanthropic gestures. Much of the literature reviewed for this article framed the racially biased patient phenomenon as an ethical dilemma, left to be either addressed or more often ignored by White senior physicians, clinicians, or administrative staff. Targeted and purposeful investment is critical in order to achieve the best economic outcomes framed by years of research that repeatedly concludes that income inequality and race have wide macroeconomic consequences. The Covid19 pandemic has made it clear that all these factors are intimately intertwined. Now’s our chance to restructure a society-wide foundation offering broader economic opportunity while building resiliency and better health outcomes for those who have been excluded and underrepresented.

The scope of the pandemic-related public health crisis has brought many societal inequities into stark relief, none more glaring than the impact of racial disparities on physical and economic health. I have experienced the drain that racism has on institutional resources and the quality of healthcare first-hand. My supervisor chose to reassign the White male patient to the caseload of a less-credentialed therapist simply because they were White and not because they were more qualified to treat him. As a daughter of Nigerian-American parents, I was taught to excel at everything I do, for better or worse. Can you imagine the sense of betrayal at the realization that my good faith efforts to learn these valuable skills, years spent hunched over textbooks working six and seven days a week to pay for graduate school, were put in jeopardy by racism?

A 2016 survey of 400 White medical students and residents found that 50% believed that African Americans felt less pain due to thicker skin. I sometimes wonder if patients, colleagues, or superiors presume the same about me, that I am impervious to physical, psychological, and emotional pain. I do not have thicker skin, but I am angry and weary of institutional injustice that disproportionately hurts so many, which this pandemic can no longer let us deny. Feel my anger, know my anger, respect my anger. And join me, even in the smallest of gestures, to collectively channel that anger towards meaningful change. I am hopeful that more of the collective will begin to understand that to hinder one is to hinder us all.

Further reading/References:
https://www.msn.com/en-us/news/other/surge-in-african-american-medical-school-applicants-drive-to-action-by-covid/vi-BB1dslXB

Bloomberg Gives $100M to Historically Black Medical Schools

https://www.census.gov/library/stories/2018/03/graying-america.html
Hospitalization and Mortality among Black Patients and White Patients with Covid-19. https://www.nejm.org/doi/10.1056/NEJMsa2011686

https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018

Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America. http://pnas.org/content/113/16/4296.abstract
Does diversity matter for health? Experimental evidence from Oakland. https://siepr.stanford.edu/research/publications/does-diversity-matter-health-experimental-evidence-oakland
Williams, D. R., & Rucker, T. D. (2000). Understanding and addressing racial disparities in health care. Health care financing review, 21(4), 75–90.

www.cdc.gov/nchs/fastats/white-health.htm

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61

https://www.census.gov/popclock/

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/413324

https://www.bls.gov/cps/cpsaat11.htm

https://www.cdc.gov/404.html

https://journals.stfm.org/familymedicine/2020/april/serafini-2019-0305

Closing the Racial Inequality Gaps: Long-term Economic Effects of Racism – Dana Peterson and Catherine Mann, Ph.D.

https://www.cdc.gov/404.html

‘Deaths of despair’ are rising. It’s time to define despair

www.statista.com/statistics/200970/percentage-of-americans-without-health-insurance-by-race-ethnicity/

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A Multi-Century Elevator Ride

In the late 1800s, Native Americans told naturalists working in Alaska that the marbled murrelet, a small seabird that flies underwater when fishing, breeds in the ancient forest. Apparently they weren’t listening. The nesting habits of this small chunky alcid remained a mystery until the 1970s when a tree surgeon working on a damaged branch over a campground in a state redwood forest came across a nest, not a first, with a lone chick, unusual, but a chick that had webbed feet, a first.

One clue had been noticed prior to this discovery, murrelets flying up rivers miles from the ocean during breeding season, and more became apparent after. For example, the species ranges from Monterey Bay to the Aleutians, and its pelagic populations are closely correlated with proximity of old growth forests.

One of the most destructive of our many destructive economic narratives is the claim that economic and ecological outcomes are at odds. Among the most polarized, brutal, and misunderstood of battles engaged by this polarity were the Timber Wars concerning California and Oregon’s old growth forests.


Photo from San Francisco State University linked below. If anyone knows M. Hobson, the photographer, please send him or her our way.

They didn’t have to happen. The team of biologists and historians who put together Coast Redwood, A Natural and Cultural History, details how, in the 1930s, the Pacific Lumber Company, under the leadership of Stanwood Murphy, became a pioneer in sustainable timber harvesting, cutting only certain percentages of trees leaving others to hold the soil together and for future harvest. PL maintained these practices for half a century. Their timber holdings were their major asset, and their employees believed the “extensive holdings and sustained-yield logging would ensure their long-term employment.” The last Murphy to run the company said, “We were the good guys. It was fun, it was easy—it was a great life.”

In the 1980s, Pacific Lumber owned about 70% of the old growth forest held privately. Unfortunately for their employees, PL’s under-valued stock came to the attention of Houston-based Charles Hurwitz and his company, Maxxam, who financed a hostile take-over with junk bonds and, heavily levered, raided PL’s pension fund, and began selling off secondary operations, like a welding shop, and clear cutting to service the debt.

By this time the marbled murrelet’s population had been decimated by logging, declining fisheries, you name it, and its habitats were protected. When PL illegally entered those habitats to log valuable old-growth trees, the Environmental Protection and Information Center, among others, sued PL, eventually taking the suit to federal court, who sided with the environmental groups, noting PL had used “fraudulent wildlife assessing methods,” concerning murrelet populations. PLC’s licenses were revoked for “gross negligence & willful” violations of state forestry regulations, and eventually the land was purchased from PL and taken into public hands.

The marbled murrelet isn’t the only species up there. In the late 1990s researchers led by Humboldt State’s Steve Sillett began climbing into redwood crowns. (If you’ve read Richard Powers’s The Overstory you know something about this, but there’s more.) The crown of one mapped redwood contains 210 trunks and fills 32 cubic yards, the tree itself embodies over 37,000 cubic feet of wood. Within those crowns, in addition to ferns, lichens, mosses and epiphytes, huckleberries produce fruit, and some trees become natural bonsais, while others can grow to 8 feet. Wandering salamanders have been found breeding in water-logged humus mats above 200 feet. Salamanders are good climbers, but it is hard to imagine what would impel an individual to use the energy it would take to make that climb, and some biologists believe centuries ago salamanders climbed onto young trees and rode up as the tree grew, as did generations of offspring. There are also crustaceans and, so far, no one knows how they got there. How many STEM jobs, some entry level, could those aerial habitats also support?

Murrelets begin nesting in April, the chicks fledging at about 4 weeks. Until recently no one knew how the young birds reach the ocean. It has now been observed that they fly out of the nest and to sea alone in the evening dark, another mystery solved.

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