The aftermath of the George Floyd killing has led to a burst of activism among medical professionals, with hospital staff leading demonstrations across the country calling for health care equity for Black patients. This solidarity was mirrored at the national level, with the American Medical Association (AMA) putting out a statement opposing racism, stating it “will actively work to dismantle racist and discriminatory policies and practices across all of health care.”
Such demonstrations and statements are well-timed and necessary; racial health disparities are well known and documented and persist across specialties and conditions. The COVID-19 crisis has deepened these disparities as it focuses its devastation on people of color, with Black Americans and their communities suffering an inordinate share of deaths. These disparities are worsened by the absence of representation in hospitals. A 2004 health care workforce report concluded that the poor health outcomes of minorities may be due more to the lack of diversity among health care providers rather than to the persistent lack of health insurance. Non-white physicians are also more likely to care for minority communities, and when paired with doctors of the same background, patients may have better medication adherence, shared decision-making, and shorter time to treatment. It is thus critical that hospitals build diverse workforces that can best serve these populations.
The medical establishment should first look within itself if it wants to dismantle systemic racism. Before the 1960s Civil Rights era, the AMA turned a blind eye to the discriminatory membership standards of state medical societies. Without local society membership, Black physicians could not join the AMA nor get specialty training that relied on admitting privileges endowed by local society membership. In 1956, the AMA did not weigh in when the Supreme Court heard the case of a Black physician who brought a lawsuit against a hospital for denying him staff privileges. The lawsuit challenged the 1946 Hill-Burton Act that had a monumental effect on American health care by funding the rapid build-up of hospitals and clinics. The Act also codified the “separate but equal” doctrine within health care, permitting federal funds to construct segregated hospitals.
The legacy of institutional exclusion has had a persistent impact into the present. Only 6% of all physicians are Black, hardly increased from a century before. Fewer Black men are applying or enrolling in medical school than in 1978. Of all medical students who started in 2019, only 8.8% of these were Black. Just 3.6% of full-time faculty are Black and their attrition has been attributed to lack of mentorship and opportunities for advancement.
As the corporate world has had to face up to its lack of Black leadership, so must the health care industry. Hospital C-suites and boards have failed to make headway on minority representation, with minorities representing 11% of executive leadership positions at hospitals and 14% of board members. The pay gap among health care executives is striking, with a 2014 survey finding that Black men earned 17% less than white men, even when controlling for education and experience.
What, then, can be done to counter this history of exclusion?
Representation must start at the top. Kaiser Permanente, for example, has demonstrated that diverse leadership can represent a diverse patient population; 43% of its board and about a quarter of its C-suite is composed of minorities. There are concrete steps that organizations can take to achieve such results. Job search committee members should prioritize diversity in fielding candidates for senior management positions, have recruiters use transparent criteria, and tap into pipeline programs so that they go beyond their insular networks. Within clinical staffing, hospitals can make clear diversity benchmarks for clinical staffing and disseminate clear standards for advancement. A designated faculty member for inclusion can regularly review compensation scales and support formal mentorship programs. Without addressing inequities in leadership, the medical community cannot meaningfully affect inequities among our patients.
As broader conversations lay bare the effects of federally-backed segregation in housing and education, the legacy of government and institutionally-backed racism within the health care community must not be forgotten. The exacerbation of racial disparities seen with COVID-19 are due in part to exclusionary practices of the medical establishment. While the public calls for companies to diversify their boards, the same must be expected of those health care organizations that have long sidelined Black physicians and patients. This current crisis has made clear that these historical failings have left minority groups vulnerable to the worst of COVID-19. If we are to address inequities amongst our patients, we must also create equality in our own ranks.
Raj Reddy, MD MPH is a resident physician in Harvard’s integrated residency in Obstetrics and Gynecology, practicing at Massachusetts General Hospital and Brigham and Women’s Hospital.