Remedies for an age-old problem: Race-related disparities in health care

Negative stereotypes and poor health outcomes related to race persist in America. DMU is tackling the issue with a three-pronged approach – working to increase the number of minorities in the health care workforce, preparing all students to provide culturally competent care and providing students with opportunities to work directly with underserved populations.

In 2002, the Institute of Medicine issued a report titled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” which found that a consistent body of data indicated that minority Americans were experiencing both poorer health outcomes and lower-quality health care than whites, even when insurance status, income, age and severity of conditions were comparable. 

#1: Increase the number of minorities in the health care workforce

Recent research reveals little progress has been made since, especially for black Americans. According to sources such as the Centers for Disease Control and Prevention, March of Dimes, American Heart Association, Urban League and the National Academies, the rate of preterm birth – birth at less than 37 weeks’ gestation – among black women is 48 percent higher than the rate of all other women. Pregnancy-related deaths among African American women are 3.3 times greater than those deaths among non-Hispanic white women. The burden of COVID-19, the infant mortality rate, death rates by heart disease, mortality by breast cancer and lung cancer, and the existence of diabetes all are higher among African Americans than white Americans.

Student National Medical Association Co-presidents Ruffin Tchakounte, M.S.A.’18, D.O.’22, and Tope Banwo, D.O.’22, back row, with immigrant youth at Genesis Youth Foundation

Myriad factors cause these disparities. The deep imprints of slavery and racial segregation have shaped aspects of American life, from housing and education to public policy and the justice system, which in turn affect health and quality of life. African Americans have lower rates of health insurance compared with whites. Personal experiences with racism and legacies of abuse and mistreatment, such as the infamous Tuskegee Syphilis Study, have created mistrust of the health care system among African Americans. “Implicit bias,” the unconscious assumptions humans make about others whom they perceive as different from themselves, affects decision-making, including in how providers treat patients. 

Adding to that problem is that while blacks make up 13.4 percent of the U.S. population, they comprise only about 5 percent of active physicians, according to the Association of American Medical Colleges (AAMC).

“Most of us aspire to be what we can see,” said Ruffin Tchakounte, M.S.A.’18, D.O.’22, during a recent panel discussion on race and health care at Des Moines’ Plymouth Congregational Church. “If you don’t see people who look like you working in health care, you’re left thinking you can’t do it.”

While issues of race and health care are dauntingly complex, that doesn’t get us off the hook in trying to resolve them. 

“It’s important for us to not just talk about these issues; it’s important for us to understand we have the responsibility to take action,” said Richard Salas, Ph.D., DMU’s chief diversity officer, speaking at the Plymouth Church event. “It’s going to require all of us working together to change this system.” 

To make medical and health sciences programs more accessible to minority students, in 2004 DMU established the Glanton Fund to provide scholarships for minority students under-represented in health care professions and also to support initiatives to enhance the cultural competency of all students. Named in honor of the late Des Moines civil rights leaders Willie Stevenson Glanton, J.D., and Luther Glanton Jr., J.D., the Glanton Fund has grown to nearly $3.2 million and has provided more than $2.2 million in scholarship dollars.

The impact of implicit bias 

Early in her medical career, Lisa Green, D.O.’91, M.P.H., typically experienced two reactions. 

“As I first came out to practice as a young, female African American, it was either ‘you don’t know what you’re doing; they had to let you in to medical school,’ or ‘I want to be seen by you, because I know how hard you worked to get here,’” says Green, chief executive officer of Family Christian Health Center, a Federally Qualified Health Center with locations in Harvey, Dolton and Lynwood, IL. “That’s a hard pill to swallow as a provider, because I did work hard.” 

Now, nearly three decades later, that “implicit bias” persists. Britney Williams, who will graduate from DMU’s physical therapy program in May, felt it during her clinical rotations. “When I walk into a room, I can immediately tell the patients who don’t think I should be there to treat them,” she told the audience at the panel discussion at Des Moines’ Plymouth Congregational Church. “I have to work 10 times as hard to get patients to trust me and 10 times as hard among the other clinicians and staff. It feels like it takes all my energy. But I love what I do, and it’s something I’m willing to fight for.” 

Implicit bias involves the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. Implicit bias allows our brains to absorb and organize information that constantly bombards us and then make decisions in a highly efficient manner. While it affects everyone, it can have especially significant consequences in medicine, where the majority of physicians are white and male and the pressure to make decisions quickly is often high. 

That does not necessarily mean white, male physicians are racist, however. 

“No one is calling you or anyone else a racist or sexist. Bias itself is the enemy,” says Thomas Newkirk, J.D., a civil rights and equal employment attorney with the Des Moines law firm of Newkirk Zwagerman. 

Research supports a link between disparate treatment decisions and implicit provider bias. For example, the pain of black Americans, including in children, is systematically underdiagnosed and undertreated compared to the pain of their white counterparts. A study published in 2015 in the Journal of the American Medical Association-Pediatrics of nearly one million children diagnosed with appendicitis revealed that, relative to white patients, black patients were less likely to receive any pain medication for moderate pain and were less likely to receive opioids – the appropriate treatment – for severe pain. 

Reducing the negative impact of implicit bias is not about assigning blame, Newkirk says; rather, it’s about accepting that it exists and then mindfully acting to counter it in the best interest of patients. Viewing patients as individuals rather than as members of a social-group stereotype can help; so can actively listening to patients’ perspectives. Equally important is the long-term goal of increasing the number of minorities in the health care workforce. 

Every semester, Newkirk talks with DMU students about implicit bias as part of the University’s Diversity Health Series. He compares the concept to bacteria. 

“We know it’s real; it can’t be seen by the human eye; it’s not all bad, but some can hurt us pretty badly,” he says. “We don’t want to eliminate it, because it allows us to process information quickly in order to survive. But we need to understand how it works and recognize when it is hurting others. Who doesn’t want to be on the right side of that?” 

First, do no harm 

DMU is working to tackle race-based health care disparities by increasing the diversity of the health care workforce. Since those efforts will take time, the University also seeks to foster the cultural competency of all students. 

That’s been the motivation driving Richard Salas, Ph.D., since he joined the University in 2012. DMU’s chief diversity officer has worked with leaders across campus to intentionally embed diversity, equity and inclusion in the curriculum and to offer additional learning opportunities for members of the DMU community. Salas is a member of the board of directors of the National Association of Diversity Officers in Higher Education (NADOHE), which supports efforts to identify and share best practices in diversity initiatives, offer professional development and influence policies relating to diversity and inclusion. 

Thanks in part to his work in the organization, in 2019 NADOHE approved the creation of a Health Professions Chapter to lead health professions education toward inclusive excellence and to spark efforts to advance diversity, equity and social justice in health care education. 

“The Health Professions Chapter serves as a catalyst and think tank for fostering that cultural competency and humility among our students, who are going to be future health care providers,” he says. “I tell our students that the ‘do no harm’ oath taken by anyone wanting to become a health care provider has no exception clause. Health care professionals must be able to treat every individual with respect, compassion and dignity regardless of their race, sexual or gender orientation and background, and to be aware of those aspects as assets, not deficits.”

#2: Work directly with underserved populations

LeAndre Kennedy, D.P.M.’23, M.S.A.’23, and Charles Gaccione, D.O.’22, check the blood pressure of Clippernomics customer Paulette Wade.

Meeting patients where they are 

Equipping DMU students to provide culturally sensitive care is especially important since they are by far mostly white. Fall 2019 enrollment data show that among the 866 students in the osteopathic medicine program, six identified as black; of the 199 students in the podiatric medicine and surgery program, four identified as black; in physical therapy, two of 155 students identified as black; and no students did so among the 101 physician assistant students.

In addition to embedding cultural knowledge and skills in clinical curricula, DMU gives students opportunities to work directly with underserved populations. They include an elective, the Community Health Immersion Project, in which students visit five African American and Latino barbershops and salons in Des Moines, over a six- to eight-week period, to provide weekly blood pressure screenings and information about local health care resources. The rationale: Hypertension is more prevalent among African Americans than among whites, and black and Latino people remain chronically underserved by the health care system. 

“We want students to know what it’s like to be the ‘different’ person in the room in surroundings that are unfamiliar to you,” says Muhammad Spocter, Ph.D., associate professor of anatomy and one of the elective’s instructors. “That can help them understand how it feels to walk into a clinic as a patient.” 

Marc “Tony Mac” Nalls, owner of Clippernomics, one of the elective’s partnership barbershops, says having the students screen his customers shows he cares about them. “Black men have a high severity rate for high blood pressure. It’s convenient and comfortable for my customers to be tested here,” he says. 

The elective emerged from a research project that Simon Geletta, Ph.D., professor of public health, began in 2012 with a grant first from the Polk County Community Action Coalition and then from the Polk County Health Department. The barbershop owners were taught to measure their customers’ blood pressure; Geletta collected the data. When the health department championed following up with customers who’d been screened, Geletta brainstormed with Spocter on getting students involved. 

As a student in DMU’s Community Health Immersion Project elective, Megan Elsenheimer, D.O.’19, helped coordinate the class, assisted with data collection and maintained connections with the barbershop owners. 

“They’re the reason the project succeeded all along. They were really excited when we showed up,” she says, now an emergency medicine resident at Regents Hospital in St. Paul, MN. “For students, you learn in pharmacology what medicine is prescribed for high blood pressure. But learning why or why not your patient is getting the treatment needed is so important. That’s something you can’t learn sitting in a classroom or even on rotations.”

Opening doors for more diverse health care professionals 

Increasing diversity among health care providers may improve the health of minorities: Having more health care providers of color, many believe, can help the African American community overcome a historical mistrust of the medical system, a factor in poorer health outcomes for black Americans. 

In a 2018 randomized controlled trial in Oakland, CA, researchers recruited more than 1,300 black men to complete a health questionnaire. The men also were given a coupon for a free health screening at a clinic set up for the experiment. As described in the National Bureau of Economic Research’s Bulletin on Aging and Health, participants were randomly assigned to a black or non-black (white or Asian) doctor. They were shown a photo of their doctor and asked whether they wanted to receive any of several health screening services. Participants then could talk with their doctor in person and revise their choice of health screenings. 

The researchers found no significant difference by doctor race in the initial acceptance of screening services before patients talked with their doctors. After patients and doctors had a conversation, however, black male patients assigned to black doctors had a much higher take-up of screening services than those assigned to non-black doctors. 

“Better communication between same-race patients and doctors appears to be a key driver of these results,” the Bulletin on Aging and Health reported. “Patients were more likely to bring up other health problems when assigned to a black doctor, and black doctors were more likely to write notes about their patients.” 

#3: prepare all students to provide culturally competent care

Planting seeds in young minds 

Members of DMU’s Student National Medical Association (SNMA) mentored youth during the spring semester. Twice a week, they interacted with immigrant school kids from Africa at Genesis Youth Foundation, a nonprofit organization founded by Tricia and Sam Gabriel, both refugees from the Ivory Coast. Located in a former junior high, the organization offers athletic activities, academic enrichment and tutoring and arts programs to foster the success of youth. 

SNMA is the medical student branch of the National Medical Association, the largest and oldest organization in the U.S. representing African American physicians and their patients. SNMA is committed to supporting current and future under-represented minority medical students, addressing the needs of underserved communities and increasing the number of clinically excellent, culturally competent and socially conscious physicians. That has to start early, says Ruffin Tchakounte, M.S.A.’18, D.O.’22, SNMA co-president. 

“Mentoring youth has always been one of our biggest desires, because we know that a lack of minorities in medicine is directly linked to the fact that younger kids at the grade-school level do not have access and information on the steps to take to pursue a career as a physician,” he says. 

“Almost all of the kids we have shared our time with have been excited to learn about medicine and have enjoyed the different topics we have spoken to them about,” Tchakounte says. “I believe what we are saying that resonates the most to them is that there are not a lot of minorities in medicine and that we need them. We need to continue to diversify medicine in the United States, and the kids are starting to buy into that fact. 

“A great moment for me has been when some of the kids remembered that we were studying to be doctors and acknowledged that they have never seen black or brown doctors before. They were happy to know that we were going to be doctors someday,” he adds. “Challenging moments have been tied to hearing some of the kids tell us that no one in their family has pursued a career in medicine, and that because no one in their immediate life is a doctor, medicine isn’t for them. We are hoping to change that narrative.”

Diverse efforts to foster cultural competency

Generally defined, “cultural competency” in health care describes the ability of providers and systems to care for patients with diverse values, beliefs and behaviors. DMU seeks to foster the cultural competency of all students while diversifying the health care workforce.

DMU is the first osteopathic institution to require first-year D.O. students to take “Foundations of Physicianship,” a course designed to extend awareness of their cultural identity and hone skills in caring for diverse patients.

The Diversity Health Series explores various forms of “difference.” It is part of the core curricula of the osteopathic, podiatric and physical therapy programs.

The Seeking Justice Series examines disparities, ethics and social issues that influence health and health care.

The annual Boys Reaching for Opportunities in Science, or BROS, and Girls Exploring Medicine and Science, or GEMS, offer elementary school kids hands-on science activities. Preference among applicants is given to students in Des Moines Public Schools, the most diverse school district in the state.

The annual Health Professions Advanced Summer Scholarship Program – Health P.A.S.S. – brings to campus undergraduates from backgrounds that are under-represented in health care for immersive experiences in DMU’s four clinical programs.

The Safe Zone program promotes education, awareness, acceptance and support of gender expression, sexual orientation and non-binary identities.

The Multicultural Affairs Student Advisory Committee provides input on programming to explore topics of diversity.

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