WITH THE COVID-19 PANDEMIC still in its early stages in the US, a series of Black Lives Matter protests broke out in May 2020 in response to the murder of George Floyd, as well as the killings of Ahmaud Arbery, Breonna Taylor, and others. This movement against police brutality and racism erupted in cities and localities across the US and in countries around the globe. Along with these uncertainties, Black people have died at a disproportionate rate from COVID-19, continuing to reveal the racial inequities that span the US healthcare system.1,2 Over a year later, it is important to acknowledge that the US healthcare system still has a long way to go before its racial inequities are adequately addressed. However, nurses can help address the gaps. This article discusses some of the key reasons behind historic and current health disparities, identifies key terms, and discusses strategies for nurses who are interested in allying with efforts to tackle inequity and racism in healthcare.
Disparities in healthcare
Health disparities persist in the Black community. Health indicators such as life expectancy and infant mortality have improved for most Americans, yet some people of color experience a disproportionate burden of preventable disease, disability, and death compared with White people.3 For example, the current prevalence of doctor-diagnosed childhood asthma is higher for Black children. Hospitalization with asthma complications is higher for Black children than White children.3,4 Black people are 25% more likely to die of cancer than White people.5 When factors such as income, insurance coverage, and preexisting health status are accounted for, race and ethnicity continue to remain notable predictors of health.6,7
Systemic racism has been identified as a cause for these healthcare disparities.8 (See Key terms to know.) It results in a poor allocation of key resources or opportunities, which in turn causes disadvantages and discrimination for marginalized groups.8 Access to healthier foods, insurance coverage, and other social determinants of health can lead to health concerns such as anxiety and depression.6,8,9
Implicit bias describes subconscious feelings, perceptions, attitudes, and stereotypes that have developed over time as a result of prior influences, but the individual may be unaware that their biases may be behind certain decisions or actions.10 Research shows that healthcare professionals hold just as much implicit bias as the general population.11 For example, in one study, White medical students and residents held false beliefs about biologic differences between Black people and White people in pain assessments. These findings acknowledge the ways in which such implicit biases can affect effective pain management for Black patients.12
Although some individuals may not directly experience the trauma of racism, the cumulative negative generational effects can impact health.2,7 For example, the impact of discrimination, bias, microaggressions, and denial of healthcare access takes a toll on health and well-being due to higher rates of shame and fear, disruption of familial structures, and mental illness.7 A history of systemic racism in healthcare, as well as lived experiences, has led to decreased healthcare access, a lack of trust in healthcare, lower health literacy, and overall quality of care for the Black community.13,14 This type of distrust has been identified for years among Native American communities as well.6,15 This results in a fear of the healthcare delivery system and a lack of confidence in seeking help or care.13,14 For example, from 1932 to 1947, a study was conducted in which men of color with syphilis did not receive treatment for a known infection. (See A timeline of racism in healthcare.) Medical mistrust is associated with negative health outcomes, such as underutilization of healthcare, lapses in recommended cancer screenings, and poor self-reported health status.13 Indeed, growing research suggests that Americans may avoid or delay seeking healthcare from providers in a system they do not trust.15,16 Race-based traumatic stress (RBTS), similar to posttraumatic stress disorder, stems from the experience of racial discrimination.17,18 Signs and symptoms of RBTS include depression, anger, low self-esteem, avoidance, and even physical symptoms.18 People of color who feel healthcare providers and their organizations are not acting in their patients' best interests are less likely to comply with their healthcare regimen.16
Nurses as allies
Nurses comprise the largest portion of the healthcare workforce, and they are the primary providers of hospital patient care. Therefore, nurses play a significant role in acknowledging the impact of racism on healthcare and advocating for positive change.14,19 As nurses, what can we do?
First, nurses can educate themselves and others about systemic racism in healthcare, and it is important for individuals to evaluate themselves in relation to the structural imbalances in healthcare and society.20
Second, nurses can participate in solutions to reduce stigmas.21 Stigma is another determinant to poor quality of care in certain marginalized populations. Antistigma training for healthcare professionals shows positive results. These interactive training methods can be effective in changing attitudes and combating stigma and discrimination in healthcare.22
||James Marion Sims was a praised American physician known as the father of modern gynecology. However, his advancements in reproductive health were a result of several medical experiments conducted on enslaved Black women without anesthesia. After the development of these operations, he proceeded to The Women's Hospital in New York, where he routinely used anesthesia on White women.28
||Indiana passes the world's first sterilization law, and 32 states would eventually have eugenics programs.29 Sterilization laws were centered toward people with mental illnesses in their beginning stages, but they expanded to a list of different medical conditions and extreme circumstances that gave doctors leeway in choosing who to sterilize. These laws drastically affected Black Americans. From 1950 to 1966, Black women were sterilized at more than 3 times the rate of White women and more than 12 times the rate of White men.29
||The Alabama Legislature passes a law forbidding a White female nurse to care for Black men. Many racial segregation laws were passed that divided aspects of the hospitals and care.30
||The Tuskegee Experiment, organized by the Tuskegee Institute and the US Public Health Service (USPHS), involves 600 black men—399 had been diagnosed with syphilis and 201 did not have the disease.1 In exchange for participation, the researchers granted the men free meals, medical exams, and burial services. The participants were not given full informed consent and were never made aware of their diagnosis. Although originally projected to last 6 months, the study went on for 40 years and was terminated in 1972 after the Associated Press published a story about the study.1
||USPHS establishes “rapid treatment centers” to treat syphilis. Men in study are not treated, but syphilis declines.28 The subjects in the Tuskegee Experiment were not given treatment even when penicillin became the drug of choice for syphilis.1
||Henrietta Lacks visits The Johns Hopkins Hospital for vaginal bleeding. Upon examination, Dr. Howard Jones discovered a large, malignant tumor on her cervix. At the time, The Johns Hopkins Hospital was one of the only hospitals to treat poor Black Americans.31 In The Immortal Life of Henrietta Lacks (2010), author Rebecca Skloot reveals that throughout US history, countless Black men, women, and children have been exploited in human research studies—Henrietta Lacks being the prime example as her cancer cells were biopsied and exploited without her consent. Although HeLa cells made large contributions to scientific and medical research, her family did not reap any of the benefits and her story went untold for years.
||With the passing of the Civil Rights Act, Medicare enforces the desegregation of hospitals in the US.1
||The American Medical Association (AMA) apologizes to the National Medical Association, a society of Black physicians. For more than a century, the AMA reinforced or passively accepted racial inequalities and excluded Black doctors from the AMA as well as state and local medical societies.32
||Publishing firm Pearson publishes a nursing textbook, Nursing: A Concept-Based Approach to Learning, which included a page that lays out differences in how people from different ethnic backgrounds respond to pain. The page reinforced stereotypical depictions of minorities, with statements such as “Blacks often report higher pain intensity than other cultures.”33 In 2017, Pearson apologized for the publication of the page and removed it from electronic and future print editions of the textbook.33
||A study is conducted to determine racial bias in pain assessment and found that about 50% of the medical students and residents who participated believed that Black people felt less pain than White people.12
||The National Center for Health Statistics releases 2018 data on pregnancy-related deaths showing Black women die 2½ times more often than White women. Hispanic women have the lowest rate of maternal mortality. Researchers do not have a clear reason for the high mortality in Black women, but suspect institutional racism and susceptibility to certain conditions such as obesity and hypertension as well as lack of access to quality prenatal care.34
Third, nurses can promote more diversity in the profession. Nurses from racial minority groups represent about 19% of the RN workforce.23 By increasing diversity in nursing, patients can interact with healthcare providers who reflect their community and organizations and can recruit an untapped population to address the nursing shortage.23 Nurses or leaders at the healthcare organization can do this simply by inviting young people of color who reflect the diversity of the surrounding community to enter the profession.
Fourth, nurses can build trust with patients to achieve better health outcomes by recognizing biases and how they may be limiting or negatively influencing nursing practice and patient care. Nurses should avoid becoming overly defensive or overgeneralizing. Instead of presuming that others feel similarly, they should leave room for dissenting points of view.11,24 Speak with patients and families kindly, caringly, and honestly, regardless of their race.25 Ask individuals about their experiences and listen respectfully. Last, nurses can remember that the learning process is never over in the nursing profession. We are on a lifelong journey, and we all have work to do. Continue to support patients by providing individualized patient-centered care that promotes the safety, control, comfort, and success of recovery for the patient. Increasing racial diversity, building trust, and ending systemic racism will take time, but it is important to begin laying the foundation for future nurses to continue this work.
Key terms to know
Explicit bias: individuals being aware of their prejudices, attitudes, or preferences toward certain groups.10
Health disparities: differences in health outcomes and their causes among groups of people.3
Health equity: every person has the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.1
Implicit bias: subconscious attitudes, stereotypes, prejudice, or beliefs that have developed over time and may affect decision-making, actions, and understanding without the individual being aware of it.10
Microaggression: an apparently minor and innocuous degradation or putdown of a member or members of an oppressed, systematically disadvantaged, or marginalized community.26
Racism: a combination of stereotypes and prejudice that leads to unfair treatment solely based on race and how it is embedded and normalized within structures of our society.8
Structural racism: The Aspen institute (2021) describes structural racism as a system in which public policies, institutional practices, and other norms reinforce ways to perpetuate racial group inequity.27
1. Centers for Disease Control and Prevention. Health equity considerations & racial & ethnic minority groups. 2021. www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
2. University of North Carolina School of Medicine. Recognizing mental health month for black, indigenous and people of color (BIPOC), an interview with Amy Weil, MD, on trauma informed care. 2020. www.med.unc.edu/medicine/recognizing-mental-health-month-for-black-indigenous-and-people-of-color-bipoc-an-interview-with-amy-weil-md-on-trauma-informed-care
3. Centers for Disease Control and Prevention. Strategies for reducing healthcare disparities. 2016. www.cdc.gov/minorityhealth/strategies2016/index.html
4. Rodríguez MA, Winkleby MA, Ahn D, Sundquist J, Kraemer HC. Identification of population subgroups of children and adolescents with high asthma prevalence: findings from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med
5. Kendi IX. How To Be An Antiracist
. 1st ed. New York, NY: One World; 2019.
6. Smedley B, Stitch A, Nelson A, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.
7. Mohatt NV, Thompson AB, Thai ND, Tebes JK. Historical trauma as public narrative: a conceptual review of how history impacts present-day health. Soc Sci Med
9. Pieterse AL, Todd NR, Neville HA, Carter RT. Perceived racism and mental health among Black American adults: a meta-analytic review. J Couns Psychol
11. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics
12. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA
13. Richmond J. What can we do about medical mistrust harming Americans' health? Interdisciplinary Association for Population Health Science. https://iaphs.org/can-medical-mistrust-harming-americans-health
14. Alegria M, Lin J, Chen C-N, Duan N, Cook B, Meng X-L. The impact of insurance coverage in diminishing racial and ethnic disparities in behavioral health services. Health Serv Res
. 2012;47(3 Pt 2):1322–1344.
15. Hunt KA, Gaba A, Lavizzo-Mourey R. Racial and ethnic disparities and perceptions of health care: does health plan type matter. Health Serv Res
16. Greer TM, Brondolo E, Brown P. Systemic racism
moderates effects of provider racial biases on adherence to hypertension treatment for African Americans. Health Psychol
17. Odafe MO, Salami TK, Walker RL. Race-related stress and hopelessness in community-based African American adults: moderating role of social support. Cultur Divers Ethnic Minor Psychol
18. Polanco-Roman L, Danies A, Anglin DM. Racial discrimination as race-based trauma, coping strategies, and dissociative symptoms among emerging adults. Psychol Trauma
19. American Association of Colleges of Nursing. Enhancing diversity in the workforce. 2019. www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity
20. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved
21. VanderWielen LM, Vanderbilt AA, Crossman SH, et al. Health disparities and underserved populations: a potential solution, medical school partnerships with free clinics to improve curriculum. Med Educ Online
22. Karadag Caman O, Basar K, Mihciokur S. Training of healthcare professionals to reduce stigma and discrimination towards minorities in Turkey. Eur J Public Health
. 2018;28(suppl 4):269–270.
23. American Association of Colleges of Nursing. Nursing Fact Sheet. 2019. www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Fact-Sheet
24. DiAngelo RJ. White Fragility
. Boston, MA: Beacon Press; 2018.
25. Kivel P. Uprooting Racism: How White People Can Work for Racial Justice
. Rev. ed. Gabriola Island, B.C.: New Society; 2002.
26. McTernan E. Microaggressions, equality, and social practices. J Political Philosophy
27. The Aspen Institute. Glossary for understanding the dismantling structural racism/promoting racial equity analysis. www.aspeninstitute.org/wp-content/uploads/files/content/docs/rcc/RCC-Structural-Racism-Glossary.pdf
28. Wall LL. The controversial Dr. J. Marion Sims (1813-1883). Int Urogynecol J
29. Institute for Healthcare Policy & Innovation. Forced sterilization policies in the US targeted minorities and those with disabilities – and lasted into the 21st century. 2020. https://ihpi.umich.edu/news/forced-sterilization-policies-us-targeted-minorities-and-those-disabilities-and-lasted-21st
30. Equal Justice Initiative. Alabama bars treatment of black patients from white nurses. https://calendar.eji.org/racial-injustice/sep/29
31. Johns Hopkins Medicine. Honoring Henrietta: The legacy of Henrietta Lacks. www.hopkinsmedicine.org/henriettalacks
32. American Medical Association. The history of African Americans and organized medicine. www.ama-assn.org/about/ama-history/history-african-americans-and-organized-medicine
33. Walker A. People are freaking out over ‘racist’ theories in nursing textbook. 2017. www.nurse.org/articles/racist-stereotypes-in-nursing-textbook
34. Chuck E. The U.S. finally has better maternal mortality data. Black mothers still fare the worst. 2020. www.nbcnews.com/health/womens-health/u-s-finally-has-better-maternal-mortality-data-black-mothers-n1125896