How health systems can build a culture of anti-racism

Amid the national uprisings over the summer after the murder of George Floyd, a host of health systems spoke out against racism and released unprecedented statements of solidary with the African-American community.

But talk is not enough, says a trio of Black academicians at the Perelman School of Medicine.

Now is the time for action.

“Statements are great but if they’re not backed up with actual action, then they’re meaningless,” says Eugenia C. South, an assistant professor in the Department of Emergency Medicine and faculty director of the Penn Urban Health Lab.

With the aim of guiding health systems that are genuinely interested in becoming anti-racist organizations, South, Raina Merchant, and Paris Butler have provided concrete actions organizations can take, specified in their commentary, “Toward an Equitable Society: Building a Culture of Antiracism in Health Care,” which was published in The Journal of Clinical Investigation.

“We really felt that this was incredibly important not only for our own institution, but nationally in terms of health care institutions,” says Merchant, an associate vice president at Penn Medicine and an associate professor of emergency medicine. “We wanted to frame this around an equitable society really thinking about how we can create equity for all individuals, but particularly with a focus on anti-Black racism.”

Butler, an assistant professor of surgery at Penn Medicine, says he was moved to join forces with Merchant and South in order to voice his concern and displeasure about how Black and Brown people have been treated in America “for hundreds of years, let alone what has gone on recently.”

“I had been publishing on this topic prior to Gina and Raina kindly suggesting that we should collaborate on a manuscript,” he says. “[This journal commentary] carried even more weight in my mind because it was coming from two emergency medicine physicians and a surgeon, with very different lenses from a clinical standpoint, but very cohesive in our vision for creating an anti-racist climate and culture in health care systems.”

South, Merchant, and Butler each have a longstanding commitment and interest in anti-racism and equality in health care. They say addressing racism in all its forms—interpersonal, institutional, and structural—from within health care is critically important to creating an equitable society.

Health disparities caused by racism

The most obvious way racism manifests in health care is through health disparities, says Butler, which exist across all specialties. A plastic and reconstructive surgeon, he says inequalities exist in the surgical realm along racial and ethnic lines.

There is a significant disparity in post-mastectomy breast reconstruction for women diagnosed with breast cancer. In some areas of the country, Black and Latino women receive breast reconstruction at about half the rate of white women.

View large image

Racism appears in who provides health care in the U.S., too. Butler says African Americans comprise 13 percent of the U.S. population, but only 3.5 percent of academic surgery faculty and 2 percent of plastic surgeons. A similar disparity exists for Latinos, who are 17 percent of the population but just shy of 4 percent of academic surgical faculty.

“Those that carry out health care in the United States are not reflective of the patient population for whom they are charged to treat,” he says.

South says there is a “segregated way of providing care, across all health systems,” borne from the insurance-driven nature of the health care industry. In primary care, she says resident clinics often serve people with Medicaid or those who are uninsured or under-insured, while faculty clinics serve individuals who can afford private insurance.

“Insurance status is patterned by race so it’s almost like within our own institutions we’re separating patients by race with this arbitrary thing that we all sort of grew up in medicine not questioning,” she says. “Residents provide excellent care, but there is a lack of continuity. There are problems with that model.”

Racial inequalities also exist in research funding. South says there is a large discrepancy in funding provided for the study of diseases like sickle cell anemia, which predominately affects Black people, and cystic fibrosis, which predominately affects white people. She says much more money goes toward funding cystic fibrosis research than sickle cell anemia research, even though the number of patients in this country who have cystic fibrosis is much lower than people with sickle cell.

“And that impacts the disease process and the treatments that are available,” says South. “The science behind sickle cell is behind where it should be because of funding dollars and decisions that have been made.”

The power and might of health systems

To confront the coronavirus pandemic, health systems, in a matter of weeks, transformed and revised their operations, shifted to remote work, utilized telehealth, reimagined researched protocols and productivity, and crowdsourced personal protection equipment.

Butler, Merchant, and South say health systems should keep that same energy in combating the centuries-long pandemic of systematic racism.

View large image

Large, complex institutions that employ thousands of people and spend millions or billions of dollars, health systems are often huge drivers of local economies and could use their power and influence to improve racial disparities. South says health systems could specifically target financial counseling, tax preparation, wealth building, and home buying assistance programs to lower wage staff, who are often predominately Black, and purchase supplies from Black-owned businesses to increase wealth in Black communities.

“There’s a big racial home ownership gap and a big wealth gap that flows in part from that as a result of government policies like redlining and difficulty getting loans,” she says. “Health systems could try to rectify some of that by focusing on their lower wage and their Black staff.”

Amongst health system employees—students, trainees, faculty, staff, and administrators—South says racism manifests in the lack of diversity among leadership, both leaders of health systems and leaders of departments, which can negatively impact employees of color.

“There are microaggressions that happen frequently,” she says. “For example, I’ve heard of many Black medical students and even faculty being stopped by security and questioned about if they belong there and asked to show their ID. That doesn’t happen to white students or faculty.”

View large image

Merchant says the current, equality- and anti-racism-focused environment presents an appealing opportunity for health systems to play an expanded role in the communities they serve, in terms of school, housing, education, and access to food, which all have a tremendous impact on health.

“More closely linking our attention and efforts on not just taking care of patients after they’ve had their heart attack, but really all the factors that influence what happens to them before they show up in the hospital, the more that we can improve creating more equitable environments for all, which will improve the health of Black patients, but also for all patients,” she says.

Holding ourselves accountable

The University of Pennsylvania Health System has 43,907 employees and an annual operating revenue of $8.6 billion.

Hundreds of Health System employees gathered on Franklin Field in June and knelt in silence for eight minutes and 46 seconds, in remembrance of George Floyd and countless other victims of racism.

View large image

It was a heartfelt presentation, one that Merchant, Butler, and South say has been followed by actual action. The week after the Franklin Field event, the Health System held the first in a series of online community dialogues on racism, racial justice, and social equity.

In subsequent weeks, Penn Medicine named a vice chair for inclusion, diversity, and equity in every clinical department; South serves in that role in Emergency Medicine. She praises Health System CEO Kevin B. Mahoney, Executive Vice President and Dean J. Larry Jameson, Vice Dean for Inclusion and Diversity Eve J. Higginbotham, and Vice Dean for Professional Services Deborah A. Driscoll for establishing the vice chairs.

“I’m really excited to step into the role and really try to hopefully dismantle generations of structural racism, chipping away at it slowly,” South says.

Merchant says Penn is well equipped to address enormous challenges in health care, such as structural racism, buoyed by a “big bench of researchers” who have the requisite expertise.

“All those usual tools that we use for addressing every other problem, we can do the same [for addressing structural racism],” she says. “We aren’t starting from scratch. Our view is that we can bring those same skills to bear here in addressing this incredibly challenging and important issue.”

Butler, South, and Merchant were among three of 127 Penn Medicine physicians of color who wrote a letter to senior leadership recommending that the Health System create the vice chairs for diversity, and also mandate unconscious bias training for all faculty, which has been decreed.

Most important of all, Butler says, is an accountability system.

“I think it’s important to put into place accountability metrics in order to ensure that it’s not just a conversation we’re having right now that goes away in six months, but it’s something that we will circle back to annually or even more regularly to determine if we’re actually making strides,” he says. “If there’s a time that we’re going to make a difference, this needs to be the time because there’s so much momentum.”