As we take stock of where we are and all that has come before – of all that was lost and all that was won on the arduous road toward equity in the realization of the American dream for all peoples, I am compelled to pay tribute to those who endured and were unshakable in their commitment to the realization of today. While the millennial within me often feels that equity in both health care personnel and delivery should be an unquestionable reality, my grandmother’s spirit reminds me of the hard battles already fought and won, with great sacrifice.
“After 350 years of enslavement, the struggle for the education of newly freed black people should give us pause as we reflect on the sheer determination and desire to improve their lot. Nowhere is this story more enlightening than in the history of medical education of African Americans.” Early “Black” medical schools were often church-based/funded and substandard in comparison with the institutions that accepted only Whites (J Natl Med Assoc 2006;98:1425-9). One of the earliest Black medical school graduates was Herbert Erwin Sr. His son, Howard Erwin, was quoted in the “Gastonia Observer” in 1990, recalling his father saying that he used candles to study because the schools required lights to be out by 9 p.m. to preserve power to the facility (J Natl Med Assoc 2006;98:1425-9).
As of 2022, 85% of Black physicians in this country still matriculate from historically Black colleges or universities. Today, there are four medical schools dedicated primarily to training African American physicians. Two of these schools were established in the last 40 years (i.e., during my lifetime). So, for a generation prior to that, only Howard University College of Medicine and Meharry Medical College existed (J Natl Med Assoc 2006;98:1425-9). Even in 2023, the sacrifices and suffering endured by our grandparents and great-grandparents to establish themselves and succeed at still severely underfunded historically Black colleges do not go unappreciated. Indeed, their pioneer efforts facilitated things for the ensuing generation of underrepresented minorities.
If we have yet to achieve equity in medical education, how can we lay claim to equity in health care delivery? The terms equity and equality, while related, are very different. A picture is worth a thousand words in this case (see image below).
The World Health Organization (WHO) defines health care inequity as “Systemic differences in the health status or distribution of health resources of different population groups” (J Natl Med Assoc 2006;98:1425-9). Equality is giving everyone the same pair of gloves, while equity is giving everyone a pair of gloves that fits their hands.
Equality exists when law and government treat everyone the same, irrespective of their status or identity. Equity means that, in some circumstances, people need to be treated differently in order to provide meaningful equality of opportunity. An alleged “opportunity” may simply represent a cruel joke for those to whom it is literally impossible to obtain.
Decades of policy choices made by our federal, state, and local leaders have led to systematic economic suppression, unequal educational access, and residential segregation, all of which have contributed in their own ways to worsen health outcomes for persons of color (J Natl Med Assoc 2006;98:1425-9). Equity in health care is cost-saving in both dollars and quality. Adam J. Milam, MD, PhD, and Abimbola O. Faloye, MD, will expand on that in this issue.
It begins in medical education, within and across national borders
As many of us are now aware, the COVID pandemic unveiled in the most public way longstanding structural racial disparities in health and health care access. This was not unique to our country. There was a study conducted with Canadian medical students that unearthed beliefs said students held of Canadian Aboriginal/Black populations. They carried perceptions that these patients were less interested in remaining healthy, were to blame for their poorer health, and most strikingly, many felt those patients were vastly different from themselves (J Natl Med Assoc 2006;98:1425-9).
In the United Kingdom, medical colleges have now acknowledged that Black and minority ethnic groups lack equal access to career opportunities within the National Health Service and have been disadvantaged in terms of career progression, salary, sanctions for misconduct, and the likelihood of experiencing bullying and harassment (J Natl Med Assoc 2006;98:1425-9). On page 21, Leona F. Wilson FANZCA, MPH, who lends insight from New Zealand, explores efforts to achieve equity outside the U.S.
With a lifetime of the shared experience of being Black in America, the above information has always been known and shared freely over generations of colored people. I challenge us to take a look within our respective “houses.” You may find that we do not, in fact, have a diversity problem. We may find that there are talented underrepresented minorities already within our workforce. However, without hiring, firing, and promoting based on merit, we end up hiring and advancing people that are often male and White. There is a longstanding understanding among underrepresented minorities in the medical community that you will have to work twice as hard to be seen as just as good, and whereas others will be given grace for bad behavior, you will not. You are not allowed to be angry or aggressive, while such behavior from your White counterparts may often be tolerated or excused as a one-off. We know that this is particularly true if you happen to be both a minority and a woman. Included in this month’s Monitor is an article by Odinakachukwu Ehie, MD, and colleagues that summarizes the current status of the anesthesia workforce in this context and suggests strategies to make it more diverse, inclusive, and equitable.
While many of our efforts in this country have been aimed at addressing diversity in medicine, little has been done to ensure equity. We find ourselves repeating the same statistics year after year. For example, the Centers for Disease Control and Prevention (CDC) reports that Black women remain 3%-4% more likely to die during childbirth than White women (asamonitor.pub/3RHNiYc). While Serena Williams’ near-death experience during childbirth brought this issue to public attention, it has long been known that “Even after controlling for age, gender, marital status, region of residence, employment status, and insurance coverage, African Americans have worse health outcomes than whites in nearly every illness category” (asamonitor.pub/3RHNiYc). This month, obstetrician-gynecologist LaRae C. Brown, MD, MHA, FACOG, contributes an important article on maternal morbidity and mortality in women of color.
Achieving equity will require that we acknowledge that the purposeful way we have both benefited from and reinforced inequity in our health care structure is not a political talking point, nor a partisan agenda aimed at elevating particular parties at the expense of others. Being mindful of where we have come from, in order to give direction and clear intent on where we want to go, has measurable benefits for our patients. You will read more on this subject from George W. Williams, MD, FASA, FCCM, FCCP.
Equity is effectively a leadership issue, much more so than a diversity problem. Unless we make equity a strategic priority and inseparable from cultural and institutional core values, I fear we will still be discussing the way forward into the next decade.