Vanessa Grubbs, MD, MPH Nephrologist. Writer. Speaker.
Dr. Grubbs was asked to discuss core ways in which all people, including health and human service professionals, can begin the process of creating an equitable society. Our interest was not to underestimate the enormity of the problems associated with inequities; rather, we candidly discussed our opinions regarding what we all can do to make a positive impact on America’s racial divide.
1. Acknowledge the problem.
Racial discrimination in this country is obvious in many areas and the health and human services care field is no exception. Any reasonably informed or educated individual, of any color, knows that black and brown people are systematically and disproportionately denied personal safety, economic security, fairness in the criminal justice system, higher education options…the list goes on. This is an old and disturbing reality. Bigotry and its resulting evils still exist, even though recent polls suggest that Americans are finally realizing that more time and money needs to be spent on leveling the black vs. white playing field. Despite this growing awareness, few real-life opportunities have arisen for our black fellow citizens.
In a time of national disaster related to COVID-19, it is especially important to acknowledge that this alarming disparity reflects business as usual in many aspects of the health care system, as well. Across the continuum of health and wellness care—from access to preventative resources, well-balanced nutrition and diet, affordable prescription medications, safe housing conditions, available health providers and adequate insurance coverage—black people significantly lag behind white. The result: black individuals consistently have higher death rates than whites for all-cause mortality in all age groups under 65 years.
“Communities of color tend to be disproportionately poor. They do not have the ability to shelter at home and still pay their basic bills. This means that people of color who already lack equity in medical treatment are essential workers and they are experiencing much greater exposure to COVID-19.”
Here are just a few of the resulting numbers: while making up 33 percent of the population, African-Americans accounted for 70 percent of the dead in Louisiana. In Michigan, black people made up 14 percent of the population but 40 percent of the deaths. In Wisconsin, black people are 7 percent of the population but 33 percent of the deaths. In Mississippi, black people are 38 percent of the population but 61 percent of the deaths. In Milwaukee, black people are 39 percent of the population but 71 percent of the deaths.
These shocking numbers should force Americans to sit up and take meaningful notice. The COVID-19 statistics regarding black deaths are beyond alarming; they reflect an unconscionable state of disparity in our country.
We must stop minimizing the lack of equity experienced by 13% of our fellow citizens.
“It is time to fully digest and acknowledge the truth and be willing to look at the bias, unconscious or not, that brought these devastating results. Until we all acknowledge the problem, we will not find the will to create and maintain the solutions.”
2. Question ourselves about the way we act, the decisions we make, what we believe
Most people—black and white—carry around unconscious, biased beliefs about people of color. I would assume you have seen many examples in your practice.
“As a physician, I’ve observed a “baked in” belief about race as a biological factor rather than something that we just made up to categorize people.
I'm currently working on a book about all the examples of race-based medical decisions made by clinicians that factor totally incorrect, but long-held, assumptions about the black race. I became particularly interested in this concept in my own nephrology practice. I was made aware within the first week of my fellowship training that a race adjustment was being applied when estimating kidney function, differentiating between black and white patients. I questioned these assumptions, and the response was, “well, yeah, black people in general have higher muscle mass than white people and that affects baseline kidney function.” That is not true, but very intelligent and educated people are making life-and-death decisions for their patients incorporating this type of incorrect information.
In my research I find that most of the healthcare field still holds on to old beliefs that assert a biological basis for proving that black people are different from white people. And as the country has become more diverse, it still is a “thing” about clinical assessment of black people versus everyone else.
Another example are some long-assumed beliefs about immunity. Early on, during a yellow fever plague in the Southeast, right around the time of slavery, it was assumed that black people were immune because they had lower levels of infection and related deaths. Now we know, in truth, that this population had probably already been exposed before to this tropical disease and survived, but the observations made at that time became conflated into something else.
And so I believe these kinds of myths carry on. I think the rationale behind these ideas finds its origins in times of slavery, when there was a need to justify the enslavement of a race of people. Black people were, and still are, depicted as less-than or other; in other words, they should be slaves, that is the way they're built, they are different from white people.
And I think (even though it is not said explicitly), that black people embrace some of that belief about their own uniqueness, but for different reasons. In the black community, I think it comes more from not really suggesting that we are inferior as a people to white people or anyone else, but not wanting to be lumped together with people who have been capable of such atrocities as slavery. That's why a lot of the black community will hang on to a sense of difference from white people because of their desire to place themselves outside of the realm of discrimination, cruelty and bias.
For instance, in some black communities, initially the same type of belief was true regarding COVID-19. I heard “black people don't get coronavirus, you know, we're immune to COVID-19. That’s a white disease.” And so I think maybe some black people may have been more careless than they ought to have been. It wasn't until Idris Elba reported that he had been diagnosed that minds were changed. Elba’s illness really caught the black community's attention. The idea of a white-only viral disease was far-fetched, yet some chose, once again, to believe that we are different from white people.
Conversely, conscious, intentional discriminatory behavior also is to some extent determining how we respond to those with coronavirus. I just read about Shalondra Rollins, the first person who died of COVID-19 in Hinds County, Mississippi. She was a black woman in her mid-thirties who had collapsed in the shower after experiencing some difficulty breathing. 911 was called. “The ambulance was driving like it was a normal day, like someone coming home from work,” the young woman’s mother, Cassandra, reported as she followed the ambulance. “There was no sense of urgency.” The ambulance proceeded without turning on the siren or the red and white lights. Less than an hour later, Shalondra’s heart stopped while she waited for the hospital to find her a room.”
Now that sounds like intentional neglect based upon the color of Shalondra’s skin. Maybe, or maybe not, but Shalondra’s family reports a lifetime of institutionalized medical neglect for all the members of the family. And they are not alone in making those reports.
So, for people of all colors, we need an honest self-appraisal of what we believe about race. We have to take responsibility for our part in this systemic bias and lack of compassion and take action. We have to become more practiced at questioning our attitudes and our beliefs and how we make decisions based upon misunderstanding, misinformation or just plain dislike born of ignorance about the facts. This will be a lifelong practice for most of us and the sooner we begin, the better health and wellness outcomes will be for both white and black communities.
3. Be willing to innovate and try new ways
Many in the healthcare field struggled for a long time to get tele-medicine in place. Often it seemed most sensible to touch base with a patient by telephone or Facetime. Forcing someone with an illness to take a bus and come into the clinic for a check-up that could have taken place remotely seems wasteful and potentially harmful to the patient. Nonetheless, we couldn’t get third-party payers to reimburse for remote visits.
With the advent of COVID-19, private and public insurers find that they can and will pay in full for remote or tele-visits.
It is amazing to me how the rules can change at a moment's notice, but why did it take a pandemic for us to do this?
I agree. Innovative utilization of tele-visits for certain types of appointments could revolutionize health and human service care access, especially for poor or other under-served populations.
While most people have a cellphone, many do not have broadband or a data plan that allows affordable Facetime or video conferencing. So, more often than not, people go to the emergency room because I can't see them; I can't verify what is going on.
And that's disproportionately true for black and brown people because they don’t have access to tablets. A colleague told me that Google was willing to donate tablets in the fight to provide care during COVID-19. It would be great if someone could start a program designed to get the right data plans and tablets in the hands of those who need better and easier access to routine health care—again disproportionately people of color.
Yes, it sounds as if that type of innovative program could save lives and dollars.
4. Stop letting ourselves be led by the money
Regarding shortages of testing of ventilators or whatever equipment is needed to protect healthcare workers and treat coronavirus, you immediately hear that public hospitals in poorer communities have a much harder time accessing supplies. Even basics such as testing are largely unavailable to any but the richest hospitals and communities. What is your reaction to this situation?
I worry about how decisions are being made, particularly when rationing is required. I already know that the public hospitals in which I have worked care for the poor and particularly black and brown communities. And I'm already hearing how they can't get the things they need because they're competing with for-profit hospitals.
I have read several studies that show public hospitals with limited funds often lose that competition and it stacks the deck against survival rates in poor communities.
There is a large body of research that shows distrust of the medical establishment by people of color—and for good reason. How people were treated in the Tuskegee experiment is a big one with which most people are familiar.
Indeed. You know a few of those men are still living? While the personnel involved defended their actions, the withholding of life-saving treatment to men with venereal disease because their findings would save others, their true motives are transparent. They were using black people’s bodies, without their consent, to learn and, ultimately, to make money for pharmaceutical companies that had access to the research.
The point is that we are the richest country on earth but we don't have facemasks for our health care workers. We were woefully unprepared for this pandemic and it was primarily because we didn’t want to spend the time or money required to be prepared for an event that might not happen.
I hope we learn from this disaster. And I hope we now understand that a health care system that works best for the wealthiest is going to hurt our communities of color.
Dr. Grubbs’ first book, HUNDREDS OF INTERLACED FINGERS: A Kidney Doctor's Search for the Perfect Match, was released from HarperCollins, Amistad on June 13, 2017. The book discusses issues in nephrology, from denial of impending kidney failure, to how the kidney transplant system works (and doesn’t), and our sometimes over- and irrational use of dialysis, through her story as a kidney donor and those of patients, families, and colleagues she has encountered since entering the specialty.