Blacks Face Unfair Fight Against COVID-19 and Racial Discrimination in Health Care

If medical professionals prefer white patients, where does that leave Black people who are trying to survive COVID-19?

KEY POINTS

  • Studies show the widespread bias in healthcare systems harms Black COVID-19 patients.

  • Doctors worry the most life-saving measures to fight COVID-19 may be denied to Black patients.


Before Blacks enter hospitals to treat their COVID-19 symptoms, the medical professionals inside already harbor implicit biases that can dramatically affect the care and treatments they receive — and ultimately affect whether Black patients will survive the pandemic currently gripping the nation.

"You think about racism in and of itself, it's ingrained in our society," said Dr. Nicole Del Castillo, director of the Office of Diversity, Equity and Inclusion at the University of Iowa Carver College of Medicine. "It's ingrained in our thoughts and our actions, how we behave and even how we react to people."

The report, "Are Clinicians Contributing to Excess African American COVID-19 Deaths? Unbeknownst to Them, They May Be," stated COVID-19 is a call for "radical intervention and policies" to screen providers for implicit bias and offer training.

"It stands to reason that implicit biases are impacting conversations that well-trained and well-meaning medical personnel are having with African American COVID-19 patients and their families about code status and disease management," wrote the authors of the 2020 report published recently in Health Equity. "This alone will likely result in a smaller number of critically ill African American patients with COVID-19 being placed on a ventilator — a virtual death sentence."

Nationally, more than 26,425 Blacks have died from COVID-19 in the US. Blacks make up 13 percent of the US population, but 23 percent of the COVID-19 deaths, where race is known, according to the COVID Racial Data Tracker, a rate more than 1.5 times higher than their population share.

  • In the District of Columbia, Blacks make up 47 percent of the population, 51 percent of the cases and 74 percent of the deaths

  • In Michigan, Blacks make up 14 percent of the population, 35 percent of the cases and 40 percent of the deaths

  • In Iowa, Blacks make up 4 percent of the population, 11 percent of the cases and 5 percent of deaths.

“This is what we are seeing right now with the COVID pandemic,” said Dr. Martha Carvour, assistant professor of internal medicine, infectious diseases at the University of Iowa Carver College of Medicine, in the training, Always A ‘Hot Spot’: African American Health in the Time of COVID-19. “We are seeing disparities that were expected in a number of racial and ethnic minority groups and unfortunately unless we intervene now, we are going to continue to see worsening disparities.”

The video is part of the medical college’s Grand Rounds lecture and is viewed by members of the internal medicine department.

The Killing of George Floyd

After the world watched the May 25 video of George Floyd — the handcuffed black man who died after a white police officer knelt on his neck for more than eight minutes — protests erupted and thrust Black concerns into the mainstream.

While a spotlight is shining on police brutality and healthcare, Blacks are also working to dismantle the systemic racism present in other systems like housing, education and prisons.

The American Medical Association, in a June 23 statement to the US House of Representatives Committee on the Budget, stated that America’s “legacy of racism disadvantages Blacks” who already have higher rates of high blood pressure, diabetes and asthma.

“Research shows that racially marginalized communities are disproportionally subject to police force, and there is a correlation between policing and adverse health outcomes,” the statement read.

Bias in Health Care

According to the definition used at the medical college, implicit bias consists of “attitudes, stereotypes and mental shortcuts that affect our understanding, actions and decisions in an unconscious manner.”

So where are biases occurring in the health care systems? Apparently, everywhere.

According to the training used at the medical college, implicit bias is pervasive in the medical community, including their:

  • Daily interactions

  • Patient and clinical encounters

  • Diagnosis and medication

  • Outcome and mortality rates


“I think that some of the time, people come in and they don’t realize they have these biases,” said Del Castillo. “And so they come into medical school, they come into their residency, they come into their profession with all of these biases that they’ve been harboring for years.”

Even an algorithm used nationally in health care discriminated against black patients, researchers found.

New cases of COVID-19 continue to skyrocket, with the US setting a record Thursday with more than 50,000 new cases and more than 10,000 of those cases were in Florida alone. As these cases threaten to once again overwhelm the nation's health systems, medical professionals are looking within to understand how their unconscious bias may play a role in the outcomes for Blacks.

In March, a steady stream of news stories chronicled seriously ill Black COVID-19 patients repeatedly being turned away from hospitals and repeatedly being denied COVID-19 tests. Some would ultimately die at home. In New York, even Blacks employed at a hospital couldn’t seem to get the care they needed to survive. And, those heartbreaking stories are plentiful.

Even in Iowa — nearly four months after the first confirmed COVID-19 case — not everyone who wants a COVID-19 test can get one. Test Iowa, the state’s testing site states, “We can’t test everyone.” Iowa has more than 30,357 positive cases of the virus, and the statewide death toll is 720, according to the state’s website.

The Fight for Black Lives

Black Lives Matter protesters have marched for five weeks in Iowa and across the country, while President Donald Trump tweeted, "When the looting starts, the shooting starts." He threatened military action against protesters. He retweeted then deleted a video containing a Trump supporter shouting, "white power." He labeled the words Black Lives Matter a "symbol of hate." He refused, until recently, to wear a face mask, which the Centers for Disease Control and Prevention has stated, along with social distancing and hand washing, can help prevent virus transmission.

As a possible explanation for higher COVID-19 rates in Blacks, Ohio lawmaker and Dr. Steve Huffman suggested in June that “colored people” might not wash their hands as well as others — showing a startling lack of awareness and racism, some critics alleged.

Blacks are fighting for their existence amid these conditions. Health officials have long known that structural racism is harmful to Blacks, who often lack access to quality health care, housing and education. A host of inequities permeate Black American life, health officials said.

"We have an opportunity right now in the setting of a pandemic where there are marked racial and ethnic health disparities particularly impacting the Black or African American community," said Carvour, a professor in the medical college training.

The very people tasked with helping Blacks manage COVID-19 prefer whites over Blacks, according to studies the Iowa medical college shared during the lecture and in its implicit bias training.

Most providers, across training levels and disciplines showed bias vs African American, Black, Hispanic, Native and dark-skinned individuals.

The Iowa medical college’s training and the 2020 report referenced other disturbing findings:

  • The majority of health care providers has implicit bias against Blacks.

  • Black health care providers tended to have lower biases than other races.

  • Stronger implicit biases were associated with worse patient provider communication.

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According to the medical college training, bias can have harmful consequences, including:

  • Blacks are systematically undertreated for pain compared with whites.

  • Nonwhite patients receive fewer cardiovascular interventions and fewer renal transplants.

  • Doctors assume Black men won't adhere to treatment.

  • Black women are more likely to die after breast cancer diagnoses.

  • Black men are less likely to receive chemotherapy and radiation for prostate cancer and more likely to have testicles removed.

“It's not surprising that the African American community do not trust white doctors," said Dr. Lama Noureddine, a clinical assistant professor of internal medicine, nephrology, at the University of Iowa Carver College of Medicine, in the training, "And this should not come as a shock to anyone.

‘Crisis Mode’

When US hospitals first began to experience shortages of PPE or masks, ventilators and beds in critical care units, medical professionals apparently considered “uncomfortable truths,” lectured Noureddine.

Most Black patients likely would be shocked to know about the deliberations.

  • “Are African Americans being steered toward "Do Not Resuscitate" (DNR) orders during critical illness in the COVID-19 pandemic?

  • Are African Americans less likely to be offered early intubation and ventilation?

  • Are physicians and medical staff less aggressive with treatment of African American patients?

"All valid questions to think about," lectured Noureddine.

Why is COVID-19 More Deadly for Blacks?

Professors lectured about the factors that can make COVID-19 more deadly for the nation’s Black population.

  • Preexisting conditions, like diabetes and hypertension

  • Employment as essential workers in meatpacking plants, food service, transportation and restaurants where high public contact can cause an inability to social distance

  • Implicit Bias

  • Mistrust of doctors

  • Lack of insurance

  • Lack of affordable insurance

"COVID-19 is not impacting all of us equally and yet we are all vulnerable," said Dr. Janette Taylor, associate professor at the University of Iowa College of Nursing, Gender, Women's and Sexuality Studies and African American Studies, in the medical college training.

If these health care inequities continue, medical professionals worry COVID-19 may one day be talked about in the same conversation as the infamous Tuskegee syphilis study, Henrietta Lacks and gynecological experiments conducted on Black women without anesthesia.

"We talk about these as great injustices in history and great injustices in medical history,” said Carvour, in the medical college training. "We are in an era where we can choose to do the right thing and not have COVID-19 fall into the same category in the future with that."

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By the Numbers: US COVID-19 Data for Blacks

  • 33 percent of hospitalized patients with COVID-19 were Black, even though Blacks made up 18 percent of the hospitalizations evaluated by the CDC in April, according to a report by the AMA, an association which represents physicians.

  • Among those aged 45-54, Black death rates are at least six times higher than that of whites, according to the Brookings Institution.

  • According to the COVID Racial Data Tracker, four of the top five counties with the highest death rates in the nation are all predominantly Black and in Georgia. 

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Fostering Change

Health officials state more must be done to address these issues during and after the pandemic. They cite the need for more implicit bias training, more diverse medical professionals and more collaboration with the Black community.

Requiring Implicit Bias Training

When Del Castillo worked to become a psychiatry-trained physician, implicit bias wasn’t discussed, she said. At Harvard University where she received her master’s degree in public health, implicit bias had gained notoriety because of Harvard’s implicit bias test.

Implicit bias training isn’t yet required at the Iowa medical college.

"That would be something that would be really nice to implement here," said Del Castillo, who helped organize White Coats for Black Lives.

Medical professionals must work to recognize their biases.

"There is evidence that once people are aware of their biases and receive training and feedback, they can change their behaviors," authors of the 2020 report stated.

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Creating a More Diverse Workforce

The AMA has called for increasing the number of people of color in medical school, residency, teaching and academic settings.

As a resident, Del Castillo said she also noticed areas of improvement, such as the need for Black deans, faculty and mentors.

Working with the Black Community

Del Castillo said medical professionals must work to build better relationships with the Black community.

"There’s been a lot of push toward health promotion and health education in barbershops, beauty salons and churches and trying to build those relationships with people and break down those barriers,” she said.

Morehouse School of Medicine in Atlanta will lead a 3-year, $40 million initiative to “strengthen efforts to link communities to COVID-19 testing, health care and social services and to best share and implement effective response, recovery and resilience strategies.”

Morehouse will “coordinate a strategic network of national, state, territorial, tribal, and local organizations to deliver COVID-19-related information to communities hardest hit by the pandemic.”

TAGS: #COVID-19 #UniversityofIowa #CarverCollegeofMedicine #GeorgeFloyd #AfricanAmericans #Health

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