Injustice in Health Care

By Dr. Sharon Kelly-West –

The late, great Dr. Charles Blair, founder of ABIPA, introduced me to the term “health disparities” in the early 1990s.

Though a registered nurse for close to twenty years at that time, I had heard of the term but was not totally familiar with it.

I recently uncovered one of many reports Dr. Blair would make available to the Asheville community on mortality (death) statistics of the Black population of Asheville and Buncombe County. In 1992, the top five leading causes of death for the Black population were: 1) infant mortality; 2) heart disease; 3) diabetes; 4) kidney failure; and 5) cancer, with heart disease being the leading cause.

I wrestle with the outcomes from 30 years ago when compared to those of today and can only conclude that outcomes today continue to show huge chasms when compared to outcomes for white residents—in spite of policy regulations, improved technology, racial equity initiatives, and Racial and Ethnic Approaches to Community Health (REACH) initiatives over many years. Even REACH has edited its aim from “eliminate” health disparities to “reduce” health disparities.

I wrestle because we reside in a land where supposedly there is “liberty and justice for all,” yet the top diagnoses negatively impacting Black people in the Asheville/Buncombe community today are: 1) heart disease; 2) renal failure; 3) cancer; 4) infant mortality; and 5) diabetes. There is an addition to this list: significant increase in incidences of homicide and suicide, especially among Black youth.

Death from opioid addiction is no respecter of persons, therefore impacting all, regardless of racial, ethnic, and socioeconomic makeup.

Why are the poor outcomes still so glaring, almost 60 years after Dr. Martin Luther King, Jr made this statement in 1966: “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.”

Concerning injustice in health care, Dr. King further stated: “It is more degrading than slums, because slums are a psychological death while inequality in health means a physical death.”

I cannot help but hover over a word that seems to be the most common theme in the many readings, experiences, and conversations I have had over the years relative to health disparities; “justice,” or lack thereof.

For a clinical ethicist, the principle of justice has been defined as treating all individuals equitably and fairly—not based on the color of their skin, economics, religious preference, gender identity, or any other attribute. For certain populations who are considered in the US as the least, the least likely, and the unlikely, this principle has not been honored very well,  historically or currently.

What ought to be a universal action—that equity is achieved for all of humanity—has seemingly eluded certain populations of color. The executive summary of a two-year study done several years ago states: “Racial and ethnic minorities experience a lower quality of health services and are less likely to receive even routine medical procedures than are white Americans.” Based on current medical outcomes, this summary still applies today. The folks in this study were all insured. If these folks experienced less than equitable medical care, what happens to those who have no insurance or are underinsured?

Reasons Behind Inequity in Healthcare

Here are some of the reasons from various academic sources.

• Patient’s refusal of care based on trauma that occurred during a prior visit(s), leading to a lack of trust in the healthcare system.
• Provider bias—belief in stereotypes
• Lack of institutional accountability
• Extremely limited presence of healthcare professionals who share the same culture as those they serve—physicians, nurses, researchers, medical school faculty, administrators, etc.

Gaining trust is essential. Have you heard this statement before? “Trust is hard to gain yet easy to lose.” I firmly believe that our personal biases determine the level of care a patient receives. I recall a white registered nurse, who witnessed discrepancies in care, sharing her experience in a certain department approximately four years ago.

“Sharon, what you shared in your talk today is exactly right. I remember a Black gentleman in his mid-40s, meeting all of the criteria for a certain cardiac intervention procedure. He was a perfect fit for this. The two doctors spoke to each other and said, no, we will not offer this option, we will adjust the medication instead.” She added, “I felt so badly about what happened. But what could I have done?”

This is when institutional accountability comes into play. Based on this nurse’s experience and her awareness of the criteria and expertise in prepping these patients, she should have felt comfortable advocating for the patient by: 1) asking the doctor, “Help me to understand why this person was not a candidate;” 2) sharing her observation with her supervisor; 3) taking her concern to the Ethics Committee at the hospital for discussion and investigation.

The mere thought of her feeling helpless (moral injury/distress) to speak out informs me that the institution has created a culture where sharing these observations could be cause for a type of silent retaliation.

All medical institutions should re-examine their culture and offer an open door for staff to report observations anonymously. This would only improve the wellness and accountability of the institution.

Does your hospital, clinic, medical practice represent equity for all? Do you call people out when you witness bias or difference in care because of race, religion, economic status, etc.?

Every practice should adopt the statement, “If you see something, say something.”

For certain populations in the United States, there are harms that have been inflicted due to prejudice and prejudiced policy dating from hundreds of years ago. These policies promoted separation and inequity in the distribution of resources—faithfully reproduced generation after generation. There has been progress but, as the old saying goes, “the little foxes destroy the vine.” The nuisances of microaggressions and implicit bias made in a more politically correct, systematic approach, remain highly impactful. There are still glass ceilings for some.

Remember, health and healthcare disparities (unequal outcomes as compared to dominant populations) are the result of injustice in the delivery or lack of delivery of health care. Ethically speaking, health disparities are the result of inflicting harms based on bias—whether through personal bias, biased policy, or both.

It is time to put care back into healthcare. It is time to re-read and to put into practice our professional code of ethics and to hold each other accountable. Once we know better, we can do better!

Dr. Sharon Kelly-West serves as Nurse Manager of Women Veteran Services at the Charles George VA Medical Center; Bioethics and the Law adjunct faculty at Mars Hill University; and Applied Ethics adjunct faculty at Asheville-Buncombe Community College. She is a graduate of Winston Salem State University, earned her master’s degree at Western Carolina University, and received her doctorate from Albany Medical College.